Side-effect Russian roulette?

March 25, 2009 3:12 PM

I've just been prescribed propranolol, a beta-blocker, as prophylaxis against migraines, which I've been getting every 1-2 weeks and are pretty bad. But I'm scared as hell that the side effects sometimes include clinical depression. I'm already not in the best of places, emotionally speaking, and have been in therapy for a year and a half, but I don't think I've ever been clinically depressed. Should I fill the prescription?

I'd already raised concerns about insomnia associated with beta-blockers, and turned down another medication because depression was among the possible side-effects. I'm in therapy as an attempt to tackle my general gloom along with the occasional bout of suicidal mess, but I've always managed to keep my life just about together in a structural way. I don't want these pills to knock me down to a place I can't get up from. I don't know how much of this is a rational fear.

A previous doctor put me on Amitriptyline, which I was OK with the side-effect profile for, but admittedly my headache frequency does suggest that that isn't really working.

I'll be seeing the doctor again in a month, supposedly to discuss the effects of the propranolol. I imagine a knee-jerk response may be that I should leave actually taking anything until after I've discussed it with him again. But I'm a bit embarrassed about how fussy I've been about possible side-effects already, and about the sense I have that I'm wasting my doctor's time. (The NHS is wonderful, but god does it make me guilty sometimes.) Plus, I can only take so much time off work - not because of holidays, but because it isn't easy to do my job in less than a full week. Also, my GP doesn't know the full story about the therapy and the problems that led to it, and I'm not sure I'm all that enthusiastic about explaining it to him.

I really need advice.

posted by Acheman to health & fitness (14 answers total)

I only have anecdotal advice -- I've taken beta blockers for over 15 years (propranolol was my first) and they don't have any negative side effects for me. Zero.

Beta blockers are really safe, commonly prescribed drugs that have been around for ages. This is one of the least scary new-to-you drugs your doc could have prescribed, and I think you just start taking it without worry.

Again, all this is anecdotal.
posted by mudpuppie at 3:26 PM on March 25, 2009

@Acheman,

this is where I would start.

Google the name of your drug and prescribing information and you will find the documention; this summarizes the efficacy and safety findings from clinical studies.

Although depression is reported as an adverse event, look at tables that compare placebo to the drug. Even if you see an adverse event listed as common, compare that to placebo. For example, 10% of weight gain in placebo vs drug group would not indicate a danger to me.

The table for this drug cites diziness and constipation as over 3% and slightly more prevalent than the placebo group (and even then, very low).

If it were me, I would not be concerned re:depression.

Moreover, think of the pathway. A beta blocker prevents is not directly disrupting a serotinergic type receptor, which would make me think - may alter risk of depression.

Hope this helps. I do think you are taking the right approach (think and ask about adverse events). Also, a pharmacist would probably have this info and be more than willing to help and explain this to you, too. Just consider that as another resource,
posted by Wolfster at 3:36 PM on March 25, 2009

Obviously I didn't proofread.

I meant if it is the same in each group, drug and placebo, not a problem.

A beta blocker does not alter the serotinergic pathway.

Wolfster needs caffeine
posted by Wolfster at 3:38 PM on March 25, 2009

Big fat zero. Based on my experience with it - I'm giving you that slightly frowny ...what?? look right about now :)

I was taking it for a while, with other stuff/ by itself/ on and off and not once ever noticed it doing anything except perhaps exactly what it was intended to.
It's a non-event :)
posted by mu~ha~ha~ha~har at 4:00 PM on March 25, 2009

Sounds to me your on/off depression is likely linked to your serious migraines, at least to a good extent. Any physician worth his salt knows that severe unmitigated pain can lead to major depression and suicidal ideation. So the focus should be primarily on hitting the migraine; since you mention a trial of amitritylene (a third-line drug) I assume first-line therapy (i.e. triptan drugs) have been tried without success. Refractory headache and migraine are, believe it or not, a specialty area and you may do better under the care of a neurologist with an interest in this area. If it affects your life so critically I would consider the money a private consultation may cost a good investment; after the first one or two consultations in order to obtain an expert opinion and start treatment based on this assessment, a return to NHS care (ideally under the same consultant) should be possible.

Propranolol is indeed an old (i.e. well-established) drug which is now "old hat" in its original usage for blood pressure control but is still used for refractory migraine. It has a long list of potential side effects (as do pretty much all antihypertensives), but most of these are either uncommon or disappear once the body "gets used to" the drug. Depression is, to my knowledge, not a major worry - cold hands & feet, reduced libido and possible masking of hypoglycaemia symptoms are far more likely to be noticed. But its efficacy for migraine is not brilliant either. It's very much a matter of "suck it and see".

Many migraine sufferers eventually succeed in identifying precipitants, be they foodstuffs, allergens or behavioural patterns - that's why every expert will demand you keep a detailed log of not only symptoms but also what you eat and do every day of the week, and of work/home stresses.

The advice about consulting a knowledgeable pharmacist is good. And browse the net but give more credence to official sites, e.g. government health advice and national patient support groups, than to personal blogs and private sites.

The greatest problem, as with many complex conditions, is that you feel so isolated. So submitting a query to the hive mind is just the tonic! Good luck, and keep up the spirit.
posted by kairab at 4:02 PM on March 25, 2009

The evidence that propranolol and other beta-blockers may lead to depressive symptoms is largely limited to anecdotes and small case reports. The best inquiry into this association in the medical literature was a meta-analysis of trials including 35,000 patients and this study found that for every 1,000 patients taking such drugs, only 6 more had an annual risk of reporting depressive symptoms as compared to folks not taking these drugs.¹ Moreover, that association failed to reach statistical significance (it may have been due simply to chance alone). In other words, if there is a link between depression (symptoms bothersome enough for patients to either report them and/or discontinue therapy) and these drugs at all, it's a relatively rare occurence.

That certainly doesn't entirely rule out the possibility that it might still happen in your case. But perhaps thinking of it like "Russion roulette" is a touch too melodramatic, particularly when you are clearly free to stop the medication at any time and for any reason including intolerable side-effects (which in this case, should resolve with discontinuation). Keep in mind that in the UK alone, over 2,000,000 people take drugs within the same class.
posted by drpynchon at 4:13 PM on March 25, 2009

I'm a pharmacist. Propranalol doesn't stay in your system that long. You certainly could try it - if it made you feel depressed, just stop taking it, and you'll be your old self in a day or so. Depression's a pretty rare side effect for this drug.

Feeling depressed as a side effect of a drug is not the same as being permanently plunged into depression. Stop the drug and the depression will stop.

That said, if you are worried about hurting yourself, you need a plan to make sure you stay safe. Are you seriously considering suicide? Do you have a plan for how you would commit suicide? If so, I would be concerned. If you are not suicidal now, and you have a friend you could call if you started to feel suicidal, I would try the propranalol.
posted by selfmedicating at 4:17 PM on March 25, 2009

Or, what drpynchon said.
posted by selfmedicating at 4:17 PM on March 25, 2009

Make sure your therapist knows you're taking it, Anon, and that he or she should be monitoring you for sudden mood changes. I tend to think drpynchon and selfmedicating have the right of it here and you've got very little to worry about, but you could probably use the psychological reassurance of knowing that your therapist is keeping a closer watch on you.

Anecdotally, it didn't do much to me when I was taking it for migraines, and it didn't alter the depression I had at the time, either. My reason for discontinuing it (under doc's orders) had to do with it working too well, and giving me an overly-low BP of 80/50, which was making standing up safely a problem. That's something you'd notice right off, trust me. Good luck; I wouldn't be too scared in your shoes, especially with a pro looking out for me.
posted by fairytale of los angeles at 6:30 PM on March 25, 2009

I'm also on propranolol, prescribed by my psychiatrist who is treating me for anxiety. (In-office quip: 'Any medication whose name ends in "lol" has to be good.') She often prescribes this medication as a short-acting drug to bring down the blood pressure of someone who has a performance-related anxiety that causes a high blood pressure spike, where the alternative would be a potentially habit-forming sedative.

As selfmedicating pointed out, the drug is incredibly short-acting. It's in your blood for four to six hours at most. If you take the drug, and feel depressed, don't take another one. Simple as that.
posted by SpecialK at 7:16 PM on March 25, 2009

The main thing that jumps out at me about your post is that you have not told your GP, the doctor prescribing your medication, about your emotional health problems. I can understand you being reluctant to share such personal information, but depression is nothing to be ashamed of, and someone who is prescribing you medication NEEDS to know everything that could influence your reaction to it. This is part of your GP's job, and you should give yourself every advantage you can by keeping him/her well informed.

I struggled with depression all my life until I got on a combination of lamictal and selexa, so I definitely understand your reluctance to do anything that might exacerbate your mood problems. I was prescribed lamictal on an as-needed basis for test anxiety, and it has done wonders for me--I only take one every couple of months, but if anything I have found that it makes me feel better because it reduces stress (and doing well on exams feels good too.) Of course I am a sample size of one, and I do not take it regularly as you are considering doing, but based on my experience I would not be worried. Good luck!
posted by Cambrian_Sea at 9:07 PM on March 25, 2009

More anecdotal advice: I took beta blockers for about twenty years, also for migraines; they did lessen the severity and frequency of my migraines considerably. I did not experience any mood-related or other side effects. Also, they do not seem to be difficult to stop taking, should they not be helpful for you.
posted by violette at 8:08 AM on March 26, 2009

I was on the drug for migraines. It really worked quite well for that. The side effects I had were
1. Being much, much cooler all the time (kind of nice for FL weather)
2. Heart beating at same rate most all of the time (why I quit)
3. Depending on your blood pressure dizziness (another reason I quit)
4. An amazingly better sex life (just kidding)

Hope this helps. Have a great one!
posted by gibbsjd77 at 1:15 PM on March 26, 2009

I was on nadolol, another beta blocker, for over two years, and in my experience it was extremely safe and side-effect free. I did have gibbsjd77's experience of extremely consistent heart rate, even when exercising, which was kind of strange. I also had some dizziness, but that came later with a big change in lifestyle, so may well not have been the drug.

So, another vote for not being worried.
posted by rustcellar at 9:07 AM on March 27, 2009