Psychiatric Medications

This article is for informational purposes only and should not be construed as medical advice. Always consult with your healthcare professional (who may be a psychiatrist or other type of doctor, or who may be a nurse practitioner) when considering starting, changing, or stopping medications.

Medications can be part of a well-rounded treatment plan for mental health conditions. Psychiatric medications, also known as psychotropic medications, can affect your behavior, mood, thoughts, and perception. They might be used in combination with other treatment approaches like psychotherapy, electroconvulsive therapy (ECT), transcranial magnetic stimulation (TMS), and more. It is important to work with your healthcare professional to evaluate your needs and circumstances when determining which approach is best for you. 

Here are some general principles about psychiatric medications to keep in mind.

Naming: Psychiatric medications are commonly referred to using diagnostic categories (“antidepressant,” “mood stabilizer,” “anti-anxiety medication”, “antipsychotic”). But this approach can be misleading. Many decades of clinical use and research studies have demonstrated that certain medications can be useful for many different conditions. For example, the selective serotonin reuptake inhibitors (SSRIs) were initially developed to treat depression and are therefore called “antidepressants,” but they are also very effective for other conditions, like anxiety disorders, obsessive compulsive disorder, post-traumatic stress disorder, and traumatic brain injury (TBI). As another example, antipsychotics were initially developed to treat psychotic disorders like schizophrenia, but they can also be very helpful in treating bipolar disorder, as an additive treatment for depression, or for managing irritability or agitation in brain conditions like traumatic brain injury, neurodevelopmental disorders, and dementias. Many medications have multiple indications from the Federal Drug Administration (FDA) for various mental health conditions. 

Note: There is an international effort to change the naming of psychiatric medications to reflect their mechanism of action in the brain, instead of their common clinical use (“Neuroscience-based Nomenclature”). Although endorsed by many professional organizations, this naming system has not become popular yet, so we will still use the more commonly used categories below. 

What is the best mental health medication for me? 

As described above, there are different categories of psychiatric medications - you can think of them like families. Each category has its own set of similar medications - you can think of them like siblings. For any given psychiatric condition, there might be many medication options to choose from. The choice of specific medications depends on your unique circumstances. Before your healthcare professional starts or changes medications, they will want to know your medical history and a list of medications, supplements, and over-the-counter medications that you take, as well as any medication/drug allergies. If you have been on psychiatric medications in the past, it is helpful to provide a list of medications and, if you can remember, the dosage, length of time taken, level of benefit, and presence of side effects for each.

Sometimes, the medication that is first prescribed works well. Sometimes, the medication that is first prescribed does not work well or has intolerable side effects, and so another medication needs to be tried. It can take multiple trials to find a medication that works well for you. 

Most psychiatric medications take time to work. An adequate trial of a medication is generally considered about two months on an appropriate dose. Sometimes when people start a new medication or increase their dose, they may experience short-lived, minor side effects. Let your healthcare professional know if you have any concerns. Some medications have the possibility of rarer but more serious side effects, which your healthcare professional will discuss with you. Let your healthcare professional know if you are particularly sensitive to medications; sometimes starting at a much lower dose and increasing slowly can help. The purpose of medications is to help control your symptoms so that you can live your life to the fullest.

Medication Dosing

Most medications have a standard dosing range. Depending on the mental health condition being treated and your overall health, your healthcare professional may recommend a target dose at the lower or higher end of the dosing range. Some medications, like tricyclic antidepressants (TCAs) and mood stabilizers, require a blood test to ensure that you are taking an appropriate dose. Most psychiatric medications are tablets or capsules that are taken by mouth. Some medications are available in liquid form or as dissolvable tablets. Some medications, like antipsychotics, are available as an injection taken every few weeks or months. 

It is important to take the medications as prescribed. If you are having trouble taking your medications regularly, discuss the barriers with your healthcare professional. They can work with you to identify strategies that work with your lifestyle to increase adherence or suggest cost-effective alternatives if finances are an obstacle.

Timing

The length of time that you need to take a medication depends on the mental health condition being treated, the severity of your symptoms, and your overall progression over time. Some conditions are time-limited, whereas others last a lifetime and should be managed as a chronic health condition. 

Some people may need to take medication for a brief period of time. People with frequent and/or severe symptoms may benefit from long-term medications. Some people find they can reduce the dose or number of medications they take as they gain more stability. Some people might be able to participate more fully in psychotherapy and/or adopt behavioral changes in their life thanks to their psychiatric medications, but they still may need to temporarily increase the dose or add medications if symptoms worsen. 

Some people may experience an increase in symptoms if they lower or stop their medication. If you want to decrease or stop your medication, please discuss the risks and benefits of doing so with your healthcare professional. Most medications are safe to stop on their own, though it is generally better to taper off slowly to ensure you do not experience a relapse as you lower the dose. Some medications may cause uncomfortable side effects if stopped suddenly from a higher dose (so-called “SSRI/SNRI Discontinuation Syndrome,” which a small percentage of people may experience). Other medications can be dangerous if stopped suddenly (like benzodiazepines if you have been on them for a long time or at a higher dose). Discuss with your healthcare professional the safest approach based on your specific circumstances. 

Special Considerations

People of all ages take psychiatric medications, but some groups must be given special consideration. 

For Children: Children may experience different reactions and side effects than adults. Your healthcare professional will ensure that any medication given to your child is both safe and necessary.    

For Older Adults: Adults over 65 years of age run a higher risk of drug-drug interactions, due to the likelihood of taking other medications. Older adults can also be more vulnerable to side effects of medications: as a person ages, their brain becomes more sensitive to sedating medications and their kidneys and liver may not process or eliminate medications as efficiently. Therefore, certain medications are not recommended in older adults, and the ones that are safe for use in older adults are often started at lower doses to minimize the risk of side effects.

For Pregnant and Postpartum People: Pregnancy and the postpartum period can be very vulnerable times. Hormonal changes as well as changes in usual life routines during these times can put people predisposed to developing psychiatric disorders at risk or cause worsening of preexisting psychiatric conditions. There can be risks associated with taking medications during pregnancy and immediately following delivery. These risks need to be balanced with the risks of untreated mental illness. Mental illness can affect a person’s ability to obtain or adhere to appropriate prenatal care. It can increase the risk of suicide and overall level of suffering a parent experiences. It could also decrease a parent’s capacity to bond with their baby, which can negatively impact the baby’s cognitive and emotional development. Certain medications are considered generally safe to take during pregnancy, while others require more extensive discussion of risks, benefits, and monitoring. The same is true for medication use during lactation. If you are planning to get pregnant or are already pregnant, work with your healthcare professional to review your medications and weigh the risks/benefits of continuing them, switching to another medication, or stopping. Helpful resources include: https://womensmentalhealth.org/resource-2/patient-support-services/ and https://www.fda.gov/consumers/free-publications-women/medicine-and-pregnancy

Common Classes of Mental Health Medications

Antidepressant Medications

Depressive disorders, such as depression and dysthymia, include negative thoughts (feelings of hopelessness, despair, and guilt; negative evaluations of oneself and the world; thoughts of suicide) and physical changes with the body (negative effects on sleep, appetite, and focus). There are many different types of medications that are traditionally referred to as antidepressants, described below. Most antidepressants take 4-8 weeks to work at any given dose. Some physical symptoms correlated with depression may improve before you experience an overall mood improvement. Antidepressants can trigger symptoms of mania or hypomania in people with bipolar disorder; treatment of a depressive disorder in the context of bipolar depression requires a different approach.  

People receiving treatment should be watched closely for increased suicidal thoughts or behaviors. The Federal Drug Administration (FDA) issued a warning on all antidepressants that use of antidepressants in children, adolescents, and young adults under the age of 25 may be associated with increased risk of suicidal thoughts or behavior, particularly during the first few weeks of treatment or with dose changes. This warning came from an analysis of several short-term trials of antidepressants, which showed a small increased risk of suicidal thoughts and behaviors relative to placebo in children and adolescents (there were no deaths by suicide). However, other analyses do not show this association. It is difficult to know how accurate this association is. This potential risk must be balanced with overall benefit: depression and other psychiatric conditions are associated with an increase in suicidality; therefore, treatment is important to not only reduce suffering but also to decrease the risk of suicide. If you or a loved one are experiencing suicidal thoughts or behaviors, visit Psychiatric Urgent Care or call 911.

Selective-serotonin reuptake inhibitors (SSRIs): SSRIs include citalopram, escitalopram, fluoxetine, paroxetine, sertraline, and others. Because of their overall efficacy and safety, they are considered first-line treatments for major depressive disorder, anxiety disorders, and obsessive-compulsive disorders. Most side effects are minor and resolve in a short period of time. SSRIs and many other medications increase the risk of serotonin syndrome. In a small percentage of people, SSRIs can cause sexual side effects, so it is important to speak with your healthcare professional about any potential sexual dysfunction prior to starting the medication and any changes in function while on the medication; there are several strategies that can be used to address sexual side effects if they occur. As discussed above, discontinuation symptoms can occur in a small number of people with certain medications. SSRIs were initially developed because in the mid-20th century, researchers hypothesized that imbalances in serotonin and other neurotransmitters caused depression. Modern research has shown that the chemical imbalance theory as a cause of depression is not accurate. This does not negate the fact that SSRIs still work. Decades of clinical use and research has shown that SSRIs are effective. Modern research has shown that SSRIs can normalize blood flow patterns in the brain, increase neuroplasticity, and increase mental flexibility. 

Serotonin-norepinephrine reuptake inhibitors (SNRIs): SNRIs include desvenlafaxine, duloxetine, and venlafaxine. They are closely related to SSRIs and are helpful for major depressive disorder and certain anxiety disorders. Some SNRIs are also prescribed for chronic pain, migraines, and menopause-related symptoms.

Tricyclic antidepressants (TCAs): TCAs include amitriptyline, desipramine, doxepin, and nortriptyline. These were among the first antidepressants developed, starting in the 1950s. They are very effective for anxiety and depression. Some TCAs are also very effective for chronic pain. At low doses, some TCAs are used as sleep aides. TCAs can have more side effects or risks than SSRIs or SNRIs. Potential side effects include dry mouth, urinary retention, constipation, weight gain, and heart arrythmias. 

Monoamine-oxidase inhibitors (MAOs): MAOs include phenelzine, selegiline, and tranylcypramine. MAOs are also among the first antidepressants developed, starting in the 1950s. They have can serious drug-drug and food-drug interactions. The risk can be managed with appropriate oversight; however, because of this risk, they are often reserved for treatment-resistant depression when other classes of antidepressants with lower risks have not worked. Selegiline is available as a patch, which reduces some of the food-drug interactions.

Mirtazapine: Mirtazapine is an effective antidepressant and preventative treatment for anxiety. It has a different mechanism of action than SSRIs, SNRIs, and TCAs. Its side effects can include somnolence and weight gain, which is why it is often used in cases of insomnia and/or low appetite. At low doses, it can also treat nausea. 

Bupropion: Bupropion is effective for treating major depressive disorder, either on its own (monotherapy) or as an add-on to other antidepressants (augmentation). Its mechanism of action is similar to that of stimulants, so it can help with attention and is sometimes used to treat ADHD, but it can also cause side effects of increased heart rate or weight loss. It is not approved to treat anxiety; in some people, it can help with anxiety, but in others, it can worsen anxiety. It is also contraindicated in people with seizure disorders or people who are at risk of seizures. Bupropion comes in different formulations (short acting, longer-acting). One specific formulation has been approved by the FDA to help with smoking cessation.

Anti-Anxiety Medications

Anxiety disorders are characterized by difficult-to-control worry thoughts and feelings of fear, often with associated physical symptoms (like trouble breathing, chest pain, headaches, and/or gastrointestinal upset). There are two broad classes of anti-anxiety medications: preventative medications and “as needed” medications. 

Preventative medications help treat the underlying cause of anxiety to reduce anxiety over the long-term and prevent symptoms in the future. These medications generally take a few weeks to work. SSRIs are generally first line treatments for anxiety disorders. Other medications that work include SNRIs, TCAs, and mirtazapine. Buspirone can also work in this context if taken daily. 

“As needed” or “prn” medications are used to treat overwhelming anxiety in the moment, when coping strategies or therapy skills do not work. These medications are very helpful in stopping active symptoms of anxiety. These medications generally include benzodiazepines, gabapentin, pregabalin, hydroxyzine, and buspirone. In many cases, benzodiazepines are not recommended for long-term use because they can cause physical dependence and withdrawal (similar to alcohol), as well as increase the risk of falls and cognitive problems in older adults. Low-dose antipsychotics are sometimes used as “prn” medications too.

People with anxiety and phobias can experience intense physical symptoms like rapid heart rate, sweating, and tremors. Beta-blockers like propranolol can sometimes be used to help relieve these symptoms. 

Stimulants

Stimulants include amphetamine and methylphenidate. Stimulants are effective treatments for attention-deficit/hyperactivity disorder (ADHD). These medications increase alertness, attention, and energy. Potential physical side effects include elevated blood pressure, heart rate, and breathing as well as decreased appetite or insomnia. In vulnerable individuals, they can trigger addiction, mania, or psychosis, so they may not be appropriate choices for all people. Stimulants are safe when taken under a healthcare professional’s supervision and used as directed. 

Antipsychotics

Antipsychotic medications were initially developed to treat symptoms of psychosis. Psychosis is a hallmark symptom of schizophrenia and schizoaffective disorder, but it can also occur in the context of mood disorders like major depression and bipolar disorder, alcohol/drug use or intoxication, and certain other medical or neurological conditions. Antipsychotics have a wide dosing range, and at lower doses are used for other indications besides psychotic disorders. They can be a first- or second-line treatment for bipolar disorder, a helpful add-on treatment for depression or anxiety that has not responded to the traditional treatments, and effective in managing symptoms of agitation in the context of TBI, neurodevelopmental conditions, or dementia. 

Antipsychotics are generally grouped into first-generation antipsychotics—these were the first medications that were developed, and they have a high affinity for the dopamine receptors in the brain. Examples include haloperidol, chlorpromazine, and fluphenazine. 

The second-generation antipsychotics have more wide-ranging effects on different receptors in the brain; these include olanzapine, risperidone, paliperidone, quetiapine, aripiprazole, pramipexole, and ziprasidone. Clozapine is a very effective antipsychotic that is used in treatment-resistant schizophrenia and psychosis but requires frequent blood draws for monitoring. 

As a category, antipsychotics have certain potential side effects, described below. However, each specific medication within this category has a slightly different side effect profile, and certain antipsychotics carry a lower or negligible risk of specific side effects relative to other antipsychotics. Antipsychotics can cause metabolic side effects, such as weight gain, increased blood glucose levels (leading to or worsening diabetes), and increased cholesterol levels. Antipsychotics can also cause neurological movement disorders in vulnerable individuals. In the immediate setting, this can be restlessness (“akathisia”) or an “acute dystonic reaction” (a sudden stiffening of one muscle group, like of the arm, the neck, or the eyes, which is a time limited reaction that responds to diphenhydramine or benztropine). With long-term use in individuals with certain risk factors, it can cause uncontrollable muscle movements like tardive dyskinesia. All antipsychotics also carry a warning for QTc prolongation, though many other medications (including certain heart medications and antibiotics) can also prolong the QTc. The QTc is a measure of electrical activity of the heart. If this measure gets too long, it increases the risk of cardiac arrythmias, including sudden death. Antipsychotics increase the QTc a small amount, so generally this is not a concern unless there are other risk factors as well, such as underlying heart disease, genetic conditions causing QTc prolongation, abnormal electrolyte levels, or the presence of other medications that also prolong the QTc. 

Your healthcare professional will monitor you for the development of any potential side effects using screening questions, physical examination, blood laboratory tests, and/or electrocardiogram. If you develop these side effects, they can be managed with lifestyle modifications, addition of new medications to treat the side effects, or a switch to a different medication.

Mood Stabilizers

Mood stabilizing medications are used to treat bipolar disorder. They can also be used in other conditions, like unipolar depression and traumatic brain injury. Some mood stabilizers are also effective as add-on treatments for major depression. Certain mood stabilizers are used by neurologists as seizure treatment. Many of these medications carry certain risks of fetal abnormalities; therefore, use of birth control is recommended for ovulating persons, and discussion with your healthcare professional (or consultation with a specialist in reproductive psychiatry) about risks and benefits is recommended if planning to become pregnant.

Lithium is one of the most effective psychiatric treatments available and works for all phases of bipolar disorder (acute mania, acute depression, and prevention of mania and depression). Lithium is different from many other medications you might be familiar with because it is dosed based on blood levels in the body. The target blood levels vary depending on the condition being treated. It is important to get the right dose—if the level of lithium is too low, then you might not get effective relief of your symptoms; if the level of lithium is too high, you could get signs and symptoms of lithium toxicity, which can be life-threatening. Potential side effects include weight gain, tremors, increased thirst/urination, and—with long-term use—kidney or thyroid dysfunction. These are all things your healthcare professional can monitor you for with screening questions and laboratory studies. 

Valproic acid is another medication used in the treatment of bipolar disorder, though it is used in other contexts as well. It is particularly effective at treating mania in bipolar disorder, but patient blood levels need to be checked using a laboratory test to ensure it is at the right dose. Potential side effects include weight gain, tremor, and hair loss. Rarely, it can cause pancreatitis, liver dysfunction, or decreased production of platelets and blood cells. These are things your healthcare professional can monitor you for with screening questions and laboratory studies. 

Lamotrigine is generally a well-tolerated medication that works for treatment of bipolar depression and prevention of depression/mania in bipolar disorder. It can also cause a rash in up to 10% of people. Most of the time, this rash is not dangerous, but in a small subset of people (less than 1%) it can be a sign of a life-threatening condition called Stevens-Johnson Syndrome, which affects the skin and mucous membranes. Certain genetic profiles predispose a person to the risk of Stevens-Johnson Syndrome. The risk of Stevens-Johnson Syndrome can be mitigated by starting at a low dose and increasing it very slowly (every 1-2 weeks). Therefore, getting on a therapeutic dose of this medication takes months, as opposed to weeks with the other mood stabilizers. You can check blood levels of lamotrigine, but generally the dose is adjusted based on usual dosing ranges and clinical response to the medication, not by tracking the blood levels closely.

Carbamazepine can treat and prevent mania in bipolar disorder. The biggest side effect of carbamazepine is risk of drug-drug interactions, reducing the efficacy of other medications that are metabolized by the liver (specifically, by 3A4 enzyme in the liver). Rarely, it can cause liver dysfunction, decreased production of platelets and blood cells, and Stevens-Johnson Syndrome. 

Sleep Aides

Sleep can be disrupted in many psychiatric conditions. Sleep aides may be used to facilitate sleep until the underlying psychiatric treatment begins taking effect. Sleep aides are meant to be used in the short-term setting. Melatonin is a hormone that our bodies naturally produce to signal sleep, and it is available as an over-the-counter supplement. Other prescribed sleep aides include: low-dose antidepressants (like trazodone and mirtazapine), low-dose antipsychotics (like quetiapine), sedative-hypnotics (like zolpidem and eszopiclone), benzodiazepines, and antihistamines (like diphenhydramine). Long-term use of sedative-hypnotics, benzodiazepines, and diphenhydramine can have negative effects on cognition. If sleep continues to be a problem despite adequate treatment of the underlying condition, then a sleep study or a course of Cognitive Behavioral Therapy for Insomnia may be helpful. 

Medication Assisted Treatment (MAT) for substance use disorders

MAT is helpful in treating alcohol and substance use disorders. 

Opioid Use Disorders

Buprenorphine and methadone: Buprenorphine and methadone are FDA approved methods of treating opioid use disorder. Both have been shown to promote abstinence, improve adherence to treatment, and reduce deaths in people with opioid use disorder. They both act on the opiate receptors in the brain, similar to the way that opioid drugs do. Buprenorphine is a "partial agonist" and methadone is a "full agonist." Because of that difference, buprenorphine is less likely to cause overdose and has a much lower risk of respiratory depression. Other benefits of buprenorphine are that is does not carry the same risk of QTc prolongation as methadone and it has fewer drug-drug interactions. Buprenorphine must be prescribed by a qualified healthcare provide who has received a special prescribing waiver; it can be picked up at a pharmacy. Methadone is dispensed from specialized programs, and, initially, people must come get the dose every day in the clinic. Both buprenorphine and methadone are considered first-line treatments for opioid use disorder.

Naltrexone is FDA approved for both alcohol use disorder and opioid use disorders; it is sometimes used off-label for other compulsive behaviors. Naltrexone is considered first-line treatment for alcohol use disorder. Naltrexone works by blocking specific naturally occurring opiate receptors in the brain that are responsible for the reward circuit of the brain. In that way, it reduces the cravings and pleasure associated with alcohol or opioid use. Naltrexone is generally well tolerated, though can sometimes cause nausea. It is available in tablet form or monthly intramuscular injection. It cannot be taken within 7-10 days of opioid use because it can trigger opioid withdrawal. 

Alcohol Use Disorders

First-line treatments for alcohol use disorder include naltrexone (described above) and acamprosate. These medications are FDA approved to treat alcohol use disorder. They help reduce cravings and promote sobriety. Acamprosate is a tablet that is taken three times a day once someone has stopped drinking. Acamprosate cannot be taken by people with severe kidney disease. 

Second-line treatments for alcohol use disorder include disulfiram and gabapentin. Disulfiram is FDA approved to treat alcohol use disorder. Alcohol is eliminated from the body after first being broken down into other chemicals (acetaldehyde and then acetate). Disulfiram acts by blocking the conversion of acetaldehyde into acetate, thus increasing the blood concentration of acetaldehyde and causing an uncomfortable physical reaction (sweating, flushing, nausea) after drinking alcohol. In this way, disulfiram acts as a deterrent to drinking. It should not be used in people with coronary artery disease or psychosis. It works best when taken in a supervised setting. Gabapentin is sometimes used off-label to treat alcohol use disorder. It has been shown to reduce cravings at higher doses and can help with alcohol detoxification. 

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