A Brief Overview of Psychiatric Medication

 

A Brief Overview of Psychiatric Medication

Dr Jonathan Haverkampf

Psychiatric medication is used to treat a broad range of conditions that affect mental processes. They can be useful in cases of anxiety disorder, panic attacks, obsessive-compulsive disorder, depression, bipolar disorder, schizophrenia and many other psychiatric disorders. Many people who are “on medication” work in challenging jobs and take care of their families, work as artists and scientists, some cannot even get out of bed. In a number of cases medication can bring about real breakthroughs, in others it has more of a supportive role.

Medication should always be a component of an integrated therapy. Since we are dealing with mental processes, which process information coming in from various external and internal sources, there are three building blocks that play a significant role in the therapy of mental health problems:

  • Biological therapies, including medication
  • Psychotherapy
  • Social changes

They are not listed in the order of importance, but purely alphabetically. Even the sequence depends on the condition that presents itself to the clinician. In acute psychosis medication might be the only available starting point, while in an adjustment disorder often it requires the beginning of a strong therapeutic relationship to talk about medication. But in the end every cases needs to be assessed individually. In more severe cases, especially if there are other medical conditions, this may require a multidisciplinary approach.

Usually when one speaks of psychiatric medication, one refers to synthetically made chemical substances, which influence the neurotransmitter makeup in the vast network of nerve cells (neurons) that make up the brain. But in a limited range of less severe psychiatric conditions also substances from plants are used, often in the form of highly concentrated extracts. St John’s wort is an example of a ‘natural’ pharmaceutical used in some moderate forms of depression and anxiety. But at the present there is no substance with a clinically proven effect on a mental condition without side-effects, which also applies to plant extracts.

Medication and Psychotherapy

Medication and psychotherapy are not mutually exclusive. Psychiatric Medication has shown to be a great help at the beginning of a psychotherapy as a facilitator and support. Especially in cases where the symptoms make a psychotherapy impossible, for example, because the patient is mute or too agitated or too scared, medication makes outpatient treatment possible.

Medication has helped to treat conditions in outpatient settings that often required lifelong hospitalization not long ago. For the patient less time spent in a hospital means more time spent in familiar surroundings at home or with the family. In many cases, except for the most severe ones, this helps the psychotherapeutic process, because the social setting the patient lives in is where most of the communication comes from that influences how the patient deals with his or her problems.

Side-Effects

Every (psychiatric) medication has potential side-effects. Even water does in high doses, as people have committed suicide with water. Also, interactions are possible between psychiatric drugs and with non-psychiatric drugs. Particularly in the case of psychiatric drugs whether the patient notices a side-effect, and often even its shape and form, can differ substantially among individuals. Even many years of clinical experience make it guesswork, which, however, tends to get back over time. For example, a patient with severe anxiety disorder can virtually be ‘knocked out’ by a regular dose of the medication of choice, a serotonin reuptake inhibiting (SSRI) antidepressant. The approach in these cases is to go slow. In some cases, it might mean starting with 1/8 of a tablet and increasing it to ¼, ½ and 1 in daily or two-daily steps. This usually has to be done only once. Even after a pause of many years, one can begin again right away with one tablet, or in very anxious patients with half a tablet. But it is usually not an issue anymore when it is still the same or a very similar medication (citalopram vs escitalopram).

Safety

Many psychiatric drugs are quite safe as compared to other non-psychiatric medication. One reason may be that it is much more difficult to get registration for a substance to treat a ‘non-physical’ condition than for one that is used to treat severe medical conditions, even if both would have similar side-effects. People generally expect medication to treat mental health conditions, especially moderate ones, to be as close to “safe” as possible. Another reason for a high standard of safety is that the occurrence of adverse effects can potentially reduce drug compliance by the patient much more in cases of mental health conditions. This may not be entirely rational because the economic loss to the individual and society from sick leave or permanent disability in the area of  mental health is greater than in any other medical field, not to mention the often very long suffering that comes with psychiatric disorders.

There may also be ways to deal with the side-effects effectively. Some adverse effects can be treated symptomatically by using adjunct medications such as anticholinergics (antimuscarinics). In other cases, exercise, cognitive training or other non-pharmaceutical approaches can help.

In some cases, it is merely is an issue of how to begin or discontinue a medication. Some rebound or withdrawal adverse effects, such as the possibility of a sudden or severe emergence or re-emergence of psychosis in antipsychotic withdrawal, may appear when the drugs are discontinued, or discontinued too rapidly. [1] The antidepressant venlafaxine and the bipolar/antiepileptic drug lamotrigine should also be discontinued slowly.

Depression

Antidepressants are drugs used to treat clinical depression, and they are also often used for anxiety and other disorders. Most antidepressants interfere with the breakdown and ‘recycling’ of serotonin (SSRI) or norepinephrine (NRI) or both (SNRI). Some also have an effect on the dopamine neurotransmitter system. Most antidepressants have affinities for certain combinations of receptor classes. These patterns determine their effects and side-effects.

More modern antidepressants, such as the SSRI escitalopram, tend to show a higher selectivity for specific receptor subclasses. This might lead to less side-effects and in the best case also higher effectiveness.

SSRIs

A commonly used class of antidepressants are called selective serotonin reuptake inhibitors (SSRIs), which act on serotonin transporters in the brain that mediate the uptake and breakdown of these compounds. Since they reduce the recycling of serotonin they increase levels of serotonin in the synapse (the cleft between the nerve fibers from different cells). The SSRI revolution started with fluoxetine (Prozac®), which even made it on the cover of TIME magazine. The discussions and arguments that ensued, often about medical psychiatry in general rather than Prozac® in specific, were a result of it being prescribed in range and quantity unlike any medication before, maybe except for penicillin and Aspirin®. From today’s perspective the national and international debate seemed to have its merits, not matter how superficial and irrational it might have been.

SSRIs will often take 3–5 weeks to have a noticeable effect, as the density (number) of receptors in the cell membrane has to be regulated to a new level. This change in protein density in the cell membrane also explains a positive effect that can last after discontinuing the medication.

There are multiple classes of antidepressants which have different mechanisms of action. They do not only help against depression, but also against anxieties and in a number of other situations which I discuss in a different article. However, one rule should be that in the case of anxieties it is important to start with a low dose and that SSRIs are usually better tolerated by patients than NSRIs, which might even increase anxiety in the beginning.

Common antidepressants are (with common brands in the parathenses):

  • Fluoxetine (Prozac®), SSRI
  • Paroxetine (Paxil®, Seroxat®), SSRI
  • Citalopram (Celexa®), SSRI
  • Escitalopram (Lexapro®), SSRI
  • Sertraline (Zoloft®), SSRI
  • Duloxetine (Cymbalta®), SNRI
  • Venlafaxine (Effexor®), SNRI
  • Bupropion (Wellbutrin®), NDRI
  • Mirtazapine (Remeron®), NaSSA
  • Isocarboxazid (Marplan®), MAOI
  • Phenelzine (Nardil®), MAOI
  • Tranylcypromine (Parnate®), MAOI

Schizophrenia, Psychosis

Antipsychotics (Neuroleptic drugs) are drugs used to treat various symptoms of psychosis, such as those caused by psychotic disorders or schizophrenia.

Atypical antipsychotics are also used as mood stabilizers in the treatment of bipolar disorder, and they can augment the action of antidepressants in major depressive disorder.

There are two categories of antipsychotics: typical antipsychotics and atypical antipsychotics.  The atypical psychotics are called “atypical” because they appear to have a lesser risk of developing some of the extrapyramidal side-effects associated with the (older) class of typical antipsychotics.

Common antipsychotics are:

Typical antipsychotics

  • Chlorpromazine (Thorazine ® )
  • Haloperidol (Haldol®)
  • Perphenazine (Trilafon®)
  • Thioridazine (Melleril®)
  • Thiothixene (Navane®)
  • Flupenthixol (Fluanxol®)
  • Trifluoperazine (Stelazine®)

Atypical anipsychotics:

  • Aripiprazole (Abilify®)
  • Clozapine (Clozaril®)
  • Olanzapine (Zyprexa®)
  • Paliperidone (Invega®)
  • Quetiapine (Seroquel®)
  • Risperidone (Risperdal®)
  • Zotepine (Nipolept®)
  • Ziprasidone (Geodon®)

Anxiety, Panic Attacks

Basically medication with the same neurobiological mechanism is often used to help with sleep problems, anxieties and fears. They mostly belong to the group of benzodiazepines.

One problem with benzodiazepines is that they can be addictive and lead to withdrawal symptoms, although there is some discussion whether they are addictive in their own right or only in association with some other predisposing factors or negative behaviors. This is the reason why they are often only recommended for short term use. However, often an anxious patient can be helped by just carrying the tablet in his/her pocket. And benzodiazepines still play an important role in the treatment of anxieties and panic attacks. They are also used if first-line sleep medication, such as a sleep-inducing antidepressant or a z-drug in the short run, is not effective enough.

Some common benzodiazepines include:

  • Alprazolam (Xanax® ), anxiolytic
  • Chlordiazepoxide (Librium®), anxiolytic
  • Clonazepam (Klonopin®), anxiolytic
  • Diazepam (Valium®), anxiolytic
  • Lorazepam (Ativan®), anxiolytic
  • Nitrazepam (Mogadon®), hypnotic
  • Temazepam (Restoril®), hypnotic

Insomnia

The first line medication is a sleep-inducing antidepressant, especially if there are symptoms of depression and/or anxiety. Mirtazapine, for example, is am often prescribed sleep inducing antidepressant at lower doses (15 mg), but much less so at higher doses (45 mg).

The z-drugs are not benzodiazepines but seem to work on the same receptors in the brain and have similar effects as the benzodiazepines. They are mostly used to help with sleep, but are also potentially addictive, and should thus be only used in the short run.

Common Z-drugs include:

  • Eszopiclone (Lunesta®)
  • Zaleplon (Sonata®)
  • Zolpidem (Ambien®, Stilnox®)
  • Zopiclone (Imovan®)

Bipolar (manic-depressive conditions)

The history of the mood stabilizers is quite interesting. Famously, in 1949, the Australian John Cade discovered that lithium salts could control mania, reducing the frequency and severity of manic episodes. People living in a lithium rich area had a lower likelihood of manic-depressive episodes (as bipolar disorder were called formerly). Lithium became the first mood stabilizer approved by the FDA (the U.S. Food & Drugs Administration).

In addition to lithium, several anticonvulsants and atypical antipsychotics have mood stabilizing activity.

Common mood stabilizers:

  • Lithium carbonate (Carbolith®), first and typical mood stabilizer
  • Carbamazepine (Tegretol®), anticonvulsant and mood stabilizer
  • Oxcarbazepine (Trileptal®), anticonvulsant and mood stabilizer
  • Valproic acid, and salts (Depakine®, Depakote®), anticonvulsant and mood stabilizer
  • Lamotrigine (Lamictal®), atypical anticonvulsant and mood stabilizer
  • Gabapentin, atypical GABA-related anticonvulsant and mood stabilizer
  • Pregabalin, atypical GABAergic anticonvulsant and mood stabilizer
  • Topiramate, GABA-receptor related anticonvulsant and mood-stabilizer
  • Olanzapine, atypical antipsychotic and mood stabilizer

ADHD (formerly ADD)

 Stimulants are frequently used to treat attention deficit-hyperactivity disorder. A stimulant is a drug that stimulates the central nervous system, increasing arousal, attention and endurance. Because the medications can be addictive, patients with a history of drug abuse are typically monitored closely or treated with a non-stimulant. It is argued that the risk of addiction in patients diagnosed with ADHD is much lower or even non-existant.

There are also some antidepressants that have stimulant effects. Methylphenidate is a noradrenaline-dopamine reuptake inhibitor

Common stimulants include:

  • Methylphenidate (Ritalin®, Concerta®), a norepinephrine-dopamine reuptake inhibitor
  • Dextroamphetamine (Dexedrine®), the dextro-enantiomer of amphetamine
  • Dexmethylphenidate (Focalin®), the active dextro-enantiomer of methylphenidate
  • Lisdexamfetamine (Vyvanse®), a prodrug containing the dextro-enantiomer of amphetamine

There are also mixed amphetamine salts, such as Adderall®, a 3:1 mix of dextro/levo-enantiomers of amphetamine.

The Combination with Psychotherapy

As mentioned, psychiatric drugs can support psychotherapy. Psychotherapy, if done correctly, is always more specific than any chemical compound that floods the brain and affects all information transmission mediated by a certain class of neurotransmitters and receptors. But in order for psychotherapy to work, the individual has to be receptive to the information and the interaction offered by the therapist, and if the condition is severe or in situations of psychological stress this may not be possible without proper medication.

If a patient suffering from depression cannot sleep anymore or has lost any motivation to communicate, psychotherapy may only be of limited effectiveness. If a patient is completely detached from reality because of a psychosis or from the after-effects of a severe trauma, medication may help to establish a rapport between patient and therapist.

Over the medium- and long-run the indication for medication, just like for psychotherapy, needs to be evaluated regularly. Also, as with any medication, a somatic inventory should be done, potential interactions kept in mind and certain blood and other tests, such as ECGs or even EEGs, carried out regularly, if the substance warrants it.

© Dr Christian Jonathan Haverkampf

jonathanhaverkampf@gmail.com

Dublin, Ireland

Websites on Psychotherapy, Counselling and Communication Coaching: www.jonathanhaverkampf.com; www.jonathan-haverkampf.com; www.jonathanhaverkampf.ie; www.wordnets.com

This paper is solely a basis for academic discussion and no medical advice is given. Always consult a professional if you believe you might suffer from a medical condition. The lists of drugs have not been checked for accuracy.

Trademarks belong to their respective owners. Even if a word is not marked as such, it may still be trademarked. No checks have been made, whether a name is trademarked or not.

References

[1] Moncrieff, Joanna (23 March 2006). “Does antipsychotic withdrawal provoke psychosis? Review of the literature on rapid onset psychosis (supersensitivity psychosis) and withdrawal-related relapse”. Acta Psychiatrica Scandinavica. John Wiley & Sons A/S. 114 (1): 3–13. doi:10.1111/j.1600-0447.2006.00787.x. ISSN 1600-0447. PMID 16774655. Retrieved 3 May 2009.

[2] Stahl, S. M. (2008). Stahl’s Essential Psychopharmacology: Neuroscientific basis and practical applications. Cambridge University Press.