Psychiatric medication, also called psychotropic drugs, is indispensable in the treatment of mental health disorders. Psychotropic drugs influence neurotransmitters in the brain, thereby altering psychological conditions.
Psychiatric medications are used in treating mental health disorders, such as schizophrenia, bipolar disorders, OCD, depression, or anxiety. The use of modern psychiatric medication facilitates outpatient treatment, helping patient’s reintegrate into social and professional life.
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Psychiatric medications are typically divided into seven groups:
- Antidepressants
- Mood stabilizers (prophylactic agents)
- Antipsychotics (neuroleptics)
- Anxiolytics / Hypnotics
- Antidementia drugs
- Psychostimulants
- Other psychopharmaceuticals
Antidepressants
The term “antidepressants” refers to a group of medications designed to improve mood and normalize energy levels in cases of depression. They also alleviate common physical symptoms associated with depression, such as headaches, back pain, sleep disturbances, and gastrointestinal issues.
How Antidepressants Work
Antidepressants work primarily by balancing the metabolism of neurotransmitters like norepinephrine and serotonin in the brain, which are believed to be disrupted in depression. These neurotransmitters play a key role in transmitting nerve impulses. The mechanisms of action can vary widely among different antidepressants.
Types of antidepressants
Antidepressants are classified based on their chemical structure and mechanisms of action into the following main categories:
Tricyclic antidepressants (TCAs):
These first-generation antidepressants, named for their three-ring chemical structure (e.g., imipramine, amitriptyline, clomipramine, doxepin, trimipramine, desipramine, and nortriptyline), work by preventing the reuptake of norepinephrine and serotonin into their storage sites, thereby increasing their concentration at nerve endings. Some TCAs focus more on serotonin, others on norepinephrine, or both. Their effects range from stimulating to sedative or sleep-inducing.
Tetracyclic antidepressants:
With a four-ring chemical structure, these second-generation drugs (e.g., maprotiline) have effects similar to TCAs but are now considered secondary options.
Monoamine Oxidase Inhibitors (MAOIs):
MAOIs inhibit monoamine oxidase, an enzyme involved in breaking down norepinephrine and serotonin. A common reversible MAOI is moclobemide.
Selective Serotonin Reuptake Inhibitors (SSRIs):
SSRIs primarily increase serotonin levels in the brain by blocking the molecule responsible for returning serotonin to its storage. Examples include fluvoxamine, fluoxetine, paroxetine, sertraline, and citalopram.
Selective Norepinephrine Reuptake Inhibitors (SNRIs):
SNRIs selectively block norepinephrine reuptake, as seen with drugs like reboxetine.
Dual Serotonin-Norepinephrine Reuptake Inhibitors (SSNRIs):
SSNRIs a relatively new class (e.g., venlafaxine, duloxetine) that inhibit the reuptake of both serotonin and norepinephrine.
Noradrenergic and Specific Serotonergic Antidepressants (NaSSA):
NaSSA alpha-2 antagonists (e.g., mirtazapine) promote the release of norepinephrine and serotonin by blocking alpha-2 receptors that inhibit their release.
Antidepressants can also be categorized based on their effects into:
- primarily sedative (e.g., amitriptyline, doxepin, trimipramine, maprotiline, mirtazapine) or
- stimulating/energizing (e.g., escitalopram, clomipramine, venlafaxine) medications.
Use of antidepressants
Antidepressants play a central role in the treatment of depressive disorders. They are also successfully used for conditions such as anxiety, obsessive-compulsive disorders, and chronic sleep disturbances.
However, the effects of antidepressants are not immediate. While sedative or activating effects may appear relatively quickly, noticeable mood improvement in depression often takes several weeks of treatment. Changing medications too quickly due to initial unsatisfactory results could harm the patient. Importantly, antidepressants do not cause dependence, even with prolonged use.
Side effects of antidepressants
The side effects of antidepressants vary widely. Generally, they affect the autonomic nervous system, leading to issues like constipation or circulatory problems. Tricyclic substances may cause dry mouth, difficulty urinating, and drops in blood pressure. Selective serotonin reuptake inhibitors (SSRIs) are more likely to cause nausea, restlessness, sleep disturbances, and, in some patients, sexual dysfunction.
Antipsychotics
Antipsychotics primarily reduce psychotic symptoms like hallucinations, delusions, disorganized thinking, and sensory overload. These medications are essential in treating schizophrenia.
Working mechanism of antipsychotics
In acute psychoses, antipsychotics help organize perception and thought processes. Their primary target is the neurotransmitter dopamine, a chemical messenger crucial for transmitting impulses between nerve cells. Antipsychotics block dopamine receptors (D-receptors), reducing the activity of nerve cells that use dopamine for communication. Newer antipsychotics also act on other receptors, such as serotonin receptors.
Types of antipsychotics
Antipsychotics are classified into two main groups: typical (classic) and atypical (modern) antipsychotics:
Typical/Classical Antipsychotics
These are older, first-generation antipsychotics (e.g., Haloperidol) that, in addition to their antipsychotic effects, can cause significant motor side effects.
Atypical/Modern Antipsychotics
Second-generation antipsychotics are highly effective in reducing positive symptoms like delusions and hallucinations. They have a different side effect profile compared to classical antipsychotics, with less pronounced motor disturbances. However, they often cause metabolic changes, which can lead to weight gain. Examples include Risperidone, Olanzapine, Clozapine, Quetiapine, Ziprasidone, and Aripiprazole.
Previously, antipsychotics were categorized as high-, medium-, or low-potency based on the degree to which they blocked a specific dopamine receptor (D2). A stronger blockade meant greater reduction of psychotic symptoms, classifying the drug as high-potency (e.g., Haloperidol). Recent discoveries of other dopamine receptors have shown their relevance, particularly in the effects of atypical antipsychotics. Low-potency antipsychotics, which primarily have calming and sleep-inducing effects, are often used for psychomotor agitation. Examples include Chlorprothixene and Pipamperone.
Use of antipsychotics
Antipsychotics are used as supportive treatment for psychotic disorders, particularly schizophrenia, as well as for managing various types of agitation. They are also applied in treating mania, bipolar disorders, behavioral problems in children, and restlessness or sleep disturbances in elderly patients caused by psychoses. Additionally, antipsychotics are used in pain management and to treat nausea after surgery. However, their use outside of schizophrenia treatment should be approached cautiously. Antipsychotics do not cause dependency, even with long-term use.
Side affects of antipsychotics
In addition to potential changes in blood counts and a slight drop in blood pressure, typical (classical) antipsychotics can cause extrapyramidal motor effects. These involve disruptions in the nerve pathways responsible for fine motor coordination, leading to muscle cramps, restlessness, involuntary movements, and general slowing down. Atypical antipsychotics cause fewer motor-related side effects but can lead to other issues, such as weight gain.
Anxiolytics and hypnotics
Substances with anxiety-relieving (anxiolytic) or calming (sedative) effects are known as anxiolytics or sedatives. The term “tranquilizers” (calming agents) was also commonly used in the past. These substances often have an additional sleep-inducing effect, which is why they are also called hypnotics.
Working mechanism of anxiolytics and hypnotics
Anxiolytics and hypnotics relieve anxiety and tension by enhancing the inhibitory function of certain nerve cells regulated by the neurotransmitter gamma-aminobutyric acid (GABA). GABA acts like “brake” in the brain. These drugs influence the receptors of neurotransmitters at synapses (connections between nerve cells), causing ion channels to open. This increases the electrical charge of the nerve cell, making it more inhibited in its activity.
Classification of anxiolytics and hypnotics
Benzodiazepines:
The most important drugs in this group not only relieve anxiety and have a calming effect but also relax muscles and have anti-seizure (anticonvulsant) properties. These effects vary depending on the specific drug profile. Examples of benzodiazepines include Bromazepam, Flunitrazepam, Flurazepam, Lorazepam, Nitrazepam, Oxazepam, and Tetrazepam.
A major drawback of benzodiazepines is their significant risk of both physical and psychological dependence. Secondary dependence is also common, especially in individuals with a history of drug or alcohol addiction. For this reason, benzodiazepines are not suitable for long-term treatment and require strict medical supervision.
Non-Benzodiazepines:
These drugs (e.g., Zopiclone, Zaleplon, Zolpidem) are relatively new substances that act similarly to benzodiazepines despite having a different chemical structure. They carry a slightly lower risk of dependency but should also only be prescribed for short durations. They are not recommended for individuals with a history of addiction, such as alcohol or benzodiazepine dependence.
Hypnotics also include so-called barbiturates, whose effects range from mild sedation to deep anesthesia and respiratory arrest, depending on the dose. Due to severe side effects, drug interactions, and a high risk of addiction, barbiturates are no longer used.
Use of anxiolytics and hypnotics
The primary use of anxiolytics and hypnotics is to treat symptoms of anxiety, agitation, and sleep disturbances, regardless of their cause. Certain substances (e.g., Tetrazepam) are also effective for treating muscle tension.
When treating sleep disorders, doctors generally distinguish between prescription sleep aids (e.g., benzodiazepines, non-benzodiazepines) and over-the-counter mild to moderate sleep aids (e.g., antihistamines, herbal remedies). Due to their high addiction potential, benzodiazepines are only used for acute treatment of severe sleep disturbances. For chronic sleep disorders, calming antidepressants such as Trimipramine or Trazodone may be prescribed. These sleep-inducing antidepressants have the advantage of not causing dependency.
Side effects of anxiolytics and hypnotics
All hypnotics generally reduce reaction time. Long-term use can lead to decreased motivation, drowsiness, dizziness, and a general emotional numbness. A cumulative effect is also common, where the drug doses are administered faster than the body can metabolize them, resulting in the accumulation of toxic substances.
Regular use of benzodiazepines carries a high risk of dependency, and sudden discontinuation can lead to significant withdrawal symptoms.
Mood stabilizers
Mood stabilizers, also known as phase prophylactics, are primarily used for bipolar disorders to reduce the risk of relapse into a new episode or, ideally, to prevent it entirely. The most commonly used substances are Lithium and various anticonvulsants, such as Carbamazepine, Lamotrigine, and Valproic Acid. These medications were originally approved for treating epilepsy.
Working mechanism of mood stabilizers
Mood stabilizers balance mood during depressive and manic phases. Despite its decades-long successful use as a mood stabilizer, the exact mechanism of action for Lithium remains unclear. It triggers various reactions in the body and works similarly to the neurotransmitter serotonin, which is essential for transmitting certain nerve signals. Lithium also affects the body’s internal clock, regulating day and night cycles, and is believed to be involved in signal transduction mechanisms (cascade reactions that transmit many hormonal signals and sensory stimuli). The precise mood-stabilizing mechanisms of anticonvulsants such as Carbamazepine, Valproic Acid, and Lamotrigine are also not yet fully understood.
Use of mood stabilizers
Lithium treatment must be tailored individually to each patient. Any treatment decision requires careful consideration of the potential risks and benefits. When using Lithium (e.g., for bipolar disorders), the doctor must adjust the dose to the patient’s specific needs. It is equally crucial that the patient reliably takes the medication exactly as prescribed. Since the therapeutic range is narrow—meaning the effective dose is close to the potentially toxic dose—regular blood serum level checks are necessary. The optimal blood level must be determined in consultation with the doctor.
Anticonvulsants like Carbamazepine are often used when Lithium therapy has been unsuccessful. Lamotrigine is primarily used to stabilize mood in unipolar depression. Mood stabilizers do not cause dependency, even with long-term use.
Side effects of mood stabilizers
The most common side effects of Lithium, especially in cases of overdose, include thirst, nausea, diarrhea, weight gain, memory problems, and an enlarged thyroid gland. Tremors may also occur. Lithium is excreted through the kidneys, and overdose can lead to dehydration symptoms and sodium deficiency. With further overdose, more severe tremors, uncoordinated movements, speech difficulties, and even drowsiness may develop. Therefore, Lithium levels in the blood must be regularly monitored by a doctor, along with kidney function tests.
Common side effects of Carbamazepine include dizziness, movement disorders, drowsiness, skin reactions, and vision problems, particularly during the early stages of treatment.
Lamotrigine is generally well-tolerated, but rare allergic reactions can occur. For this reason, the dosage of Lamotrigine is increased very gradually over several weeks.
Psychostimulants
Psychostimulants are substances that increase energy levels and, in the short term, enhance performance and concentration. This group of drugs, which includes caffeine, varies significantly in chemical structure. The most important substances are amphetamine derivatives (e.g., Methylphenidate), which affect the activity of nerve cells that use the neurotransmitters dopamine and norepinephrine.
In practice, psychostimulants are mainly used to treat attention deficit hyperactivity disorder (ADHD) and excessive daytime sleepiness (narcolepsy). Treatment for ADHD should only be conducted by a specialist.
Anti-dementia medications
Antidementia medications (acetylcholinesterase inhibitors, glutamate antagonists) are drugs that can improve cognitive functions, such as memory, concentration, learning, and thinking. By doing so, they can reduce the disease-related limitations in daily social activities. As the name suggests, they are primarily used in the treatment of dementia.
Additionally, there are so-called nootropics, such as Ginkgo biloba, Nicergoline, Nimodipine, and Piracetam, which are believed to enhance brain functions. However, their effectiveness is not scientifically proven, and their mechanisms of action are not fully understood.
Working mechanism of antidementia medication
Like other psychotropic drugs, antidementia medications influence neurotransmitters in the brain, particularly acetylcholine and glutamate. Most antidementia drugs have been tested for Alzheimer’s disease. Acetylcholinesterase inhibitors (e.g., Donepezil, Galantamine, Rivastigmine) play a significant role since Alzheimer’s patients often have reduced levels of acetylcholine. These drugs inhibit the enzyme acetylcholinesterase, which breaks down acetylcholine in the body. Galantamine also acts on nicotinic receptors, enhancing the binding of acetylcholine to nerve cells.
Glutamate antagonists (e.g., Memantine) take a different approach. They block glutamate receptors at synapses (connections between nerve cells), reducing the overexcitation of nerve cells regulated by glutamate.
Use of anti-dementia medications
Although antidementia medications cannot permanently halt the degeneration of nerve cells, acetylcholinesterase inhibitors can slow the decline in cognitive function in mild to moderate dementia for a short period, and in rare cases, even improve it. Early treatment is crucial for better outcomes. Glutamate antagonists are recommended for severe forms of dementia.
Overall, antidementia medications can improve the quality of life for patients and their families and slightly delay disease progression. However, not all patients respond to the treatment, meaning the medication may not have any effect on some individuals.
As with all psychotropic drugs, it is especially important to combine medication with psychosocial support. Antidementia medications do not cause dependency, even with long-term use.
Psychotropic medication used in withdrawal
Clomethiazol:
This calming and sleep-inducing drug can also help relieve epileptic seizures. It is primarily used to treat alcohol delirium, which can occur in chronic alcohol consumption. Additionally, it plays a role in treating older patients with psychomotor agitation. Due to its high potential for dependence, Clomethiazol is prescribed only as a short-term therapy, lasting a maximum of two weeks. Patients with lung diseases should not take Clomethiazol.
Acamprosate:
This relatively new substance is used to reduce relapse rates in alcohol-dependent individuals, particularly in the critical months following physical detoxification. However, it is not suitable for treating acute withdrawal. Although its effectiveness has been demonstrated, relapses can still occur during treatment.
Disulfiram:
Disulfiram is also used in the treatment of alcohol dependence. It works by blocking the enzyme aldehyde dehydrogenase, which is essential for breaking down alcohol in the body. When this enzyme is inhibited, the toxic byproduct acetaldehyde accumulates in the blood, causing unpleasant reactions like nausea, dizziness, and rapid heartbeat. The goal of this therapy is to create an aversion to alcohol consumption by making the experience highly uncomfortable. However, the treatment requires strong motivation from the patient.
Use of psychotropics during pregnancy and breastfeeding
Women planning to conceive, pregnant women, and breastfeeding mothers should consult their doctor thoroughly regarding the use of psychotropic medications. Stopping prescribed medication should only be done under medical supervision. Some drugs are considered safe and can be taken during pregnancy and breastfeeding. Often, the worsening of a mental illness poses a greater risk than continuing medication. If the currently prescribed drug is unsuitable (contraindicated) for this period, a specialist will provide alternative options. Close coordination with the gynecologist is essential.
Misuse and dependency on psychotropic drugs
The potential for dependency on certain psychotropic drugs is debated among scientists. However, there is consensus that antidepressants, antipsychotics, mood stabilizers, and antidementia drugs do not cause dependency. In contrast, benzodiazepines and many sleeping pills can lead to habituation within just four weeks and, over time, to dependency. Older individuals are particularly at risk—approximately 10% regularly take benzodiazepines without a clear medical prescription. Benzodiazepines can also cause dependency at low doses, which can develop after long-term use, even with minimal amounts. Preventing this dependency and managing its risks within the overall treatment plan for mental illnesses is a key responsibility of physicians.
In general, prescribing and dosing psychotropic drugs should be handled by a specialist, and regular medical checkups are essential during their use.
Psychotropic drugs in older adults
Treating mental disorders in older adults often requires psychotropic drugs, just as in younger and middle-aged individuals. Their effectiveness in clinical outcomes is generally comparable across age groups. However, for many approved medications, there is limited research data for older populations. This makes it essential for treating physicians to carefully monitor effectiveness and adjust doses as needed, relying on their expertise in managing older patients with mental illnesses.
As in other life stages, psychopharmacological therapy is a cornerstone in the complex treatment of mental disorders. This approach must integrate sociotherapeutic and psychotherapeutic interventions of varying intensities, depending on the type and stage of the illness.
Changes in the body’s reactions with age
Brain changes:
The brain becomes more vulnerable to metabolic or circulatory disturbances with age and may react more sensitively to medications not primarily classified as psychotropic (e.g., antibiotics).
Altered metabolism:
The aging body’s metabolism changes and declining organ function affects the effectiveness, tolerability, and elimination of medications.
Body composition:
The body’s water content decreases by about 40%, while fat content increases by approximately 35%. This significantly affects the distribution and breakdown of medications, particularly those that are water-soluble (hydrophilic) or fat-soluble (lipophilic).
Increased multimorbidity:
Older patients often have multiple chronic conditions (multimorbidity), each requiring treatment with specific medications (polypharmacy). On average, older adults have five medical conditions and take two to six prescribed medications, along with one to two self-administered drugs. This increases the risk of adverse interactions and side effects, necessitating regular reviews of medication necessity and compatibility.
Principles of treatment in older adults
Treating older adults with psychotropic drugs requires careful consideration of their physical changes, comorbidities, and potential drug interactions. Regular monitoring, gradual dosage adjustments, and open communication among healthcare providers are essential to ensuring effective and safe treatment. Psychotropic drugs are a key component of integrated care, alongside psychosocial and therapeutic approaches tailored to each patient’s condition and stage of illness. Changes in the aging body lead to specific guidelines for medication use in older adults:
Start low, go slow:
Dosages should begin low and increase gradually. While product information may not always provide specific recommendations, decisions should rely on the prescribing physician’s experience with older patients. In some cases, drug absorption issues in the digestive system may result in lower-than-expected blood levels, potentially requiring higher doses. Monitoring drug blood levels can help guide therapy.
Avoid overdose risks:
Medications with active metabolites, slow metabolism, or prolonged half-lives increase the risk of overdose and toxicity in older adults. These drugs require close monitoring.
Monitor drug interactions:
Potential interactions with other medications must be identified and checked regularly.
Gradual changes:
Both starting and stopping medications or switching to a different drug should be done slowly to avoid adverse effects.
Ensure compliance:
Adherence may be influenced by the form of medication, such as splitting tablets or counting drops, which can be challenging for elderly patients. Adjusting the form of medication—such as prescribing smaller doses or alternative formats—can help ensure compliance, even if these options are less cost-effective.
Review therapy regularly:
With polypharmacy and multimorbidity common in older adults, therapy plans should be regularly evaluated. Communication among prescribing physicians and expertise in geriatric pharmacotherapy is essential.
Use of Psychiatric medication. Summary
Psychotropic medications are prescribed based on the mental health condition and the associated symptoms.
Antidepressants:
These drugs improve mood, normalize motivation, alleviate cognitive symptoms, and reduce physical symptoms such as pain, sleep disturbances, or gastrointestinal issues. They are also effective for anxiety and obsessive-compulsive disorders (OCD).
Antipsychotics:
used primarily to treat psychoses, delirium, psychotic symptoms in depression or dementia, and aggression in dementia. The choice of antipsychotic depends on its sedative and antipsychotic potency. Side effects vary and may include an increased risk of falls due to sedation. Long-term use may be necessary for psychoses to prevent relapse, but treatment for delirium or dementia should be as short and low-dose as possible. Some antipsychotics have been linked to vascular risks or movement disorders, which require careful consideration.
Mood stabilizers:
Lithium is used for acute and long-term management of bipolar disorder and as an adjunct in severe recurrent depression. Regular monitoring of kidney and thyroid function is crucial. Discontinuing lithium after long-term use requires careful consideration and transition to alternative treatments if needed.
Antiepileptics:
These are used in the acute phase of mania or depression and for relapse prevention. Monitoring kidney and liver function is essential, as older adults may develop delirium with dosage adjustments.
Antidementia drugs:
These slow dementia progressions are approved for Alzheimer’s, mixed dementia, and Parkinson’s dementia. Cholinesterase inhibitors (e.g., Donepezil, Galantamine, Rivastigmine) are used for mild to moderate dementia, while NMDA receptor antagonist Memantine is used for moderate to severe stages. Rivastigmine is also used in Parkinson’s dementia.
Benzodiazepines:
These relieve anxiety, promote sleep, relax muscles, and prevent seizures. However, they carry a high risk of dependency and should only be used for short durations with short-acting options (e.g., Lorazepam, Oxazepam). Risks include worsening sleep apnea, respiratory depression, and balance issues, which increase fall risk in older adults.