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6.5: Psychotherapeutics

  • Page ID
    110459
  • This page is a draft and under active development. Please forward any questions, comments, and/or feedback to the ASCCC OERI (oeri@asccc.org).

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    Learning Objectives
    • Differentiate the various classifications of Psychotherapeutic drugs based on their therapeutic action, effects on steps of neurotransmission, and neurotransmitter specificity
    • Compare and contrast the effectiveness and side effects of Psychotherapeutics

    Overview

    Psychotherapeutic medications can play a role in treating several mental disorders and conditions. Treatment may also include psychotherapy (also called “talk therapy”) and a variety of other medical and non-medical interventions. In some cases, psychotherapy alone may be the best treatment option. Choosing the right treatment plan should be based on a person's individual needs and medical situation, and under a mental health professional’s care.

    The National Institute of Mental Health (NIMH) also does not endorse or recommend any particular drug, herb, or supplement. Results from NIMH-supported clinical trials that examine the effectiveness of treatments, including medications, are reported in the medical literature. This section is intended to provide basic information about mental health medications. It is not a complete source for all medications available and should not be used as a guide for making medical decisions.

    Information about medications changes frequently. Check the U.S. Food and Drug Administration (FDA) website for the latest warnings, patient medication guides, or newly approved medications. Brand names are not referenced on this page, but you can search by brand name on MedlinePlus Drugs, Herbs and Supplements Drugs website. The MedlinePlus website also provides additional information about each medication, including side effects and FDA warnings.

    Psychotherapeutic Classification

    Much like the general classification of psychoactive drugs, there are multiple schemes of categorization that can be used. The most clear and useful system is based on the therapeutic purpose of the drugs rather than their synaptic mechanism of action or physiological effects (i.e. stimulant, depressant, etc.). Comprehensive information on various psychotherapeutic medications is available from the National Institute of Mental Health.

    Antidepressants

    Antidepressants are medications commonly used to treat depression. Antidepressants are also used for other health conditions, such as anxiety, pain and insomnia. Although antidepressants are not FDA-approved specifically to treat ADHD, antidepressants are sometimes used to treat ADHD in adults.

    The most popular types of antidepressants are called selective serotonin reuptake inhibitors (SSRIs). Examples of SSRIs include, Fluoxetine (Prozac), Citalopram (Celexa), and Escitalopram (Lexapro). Other types of antidepressants are serotonin and norepinephrine reuptake inhibitors (SNRIs). SNRIs are similar to SSRIs and include venlafaxine (Effexor) and duloxetine (Cymbalta). By inhibiting the reuptake of either serotonin or norepinephrine, these drugs enhance the activity of these systems by allowing these transmitters to stay in the synapse longer.

    Another antidepressant that is commonly used is bupropion. Bupropion is a third type of antidepressant which inhibits the reuptake of both norepinephrine and dopamine. Bupropion is also used to treat seasonal affective disorder and to help people stop smoking.

    SSRIs, SNRIs, and bupropion are popular because they do not cause as many side effects as older classes of antidepressants, and seem to help a broader group of depressive and anxiety disorders. Older antidepressant medications include tricyclics, tetracyclics, and monoamine oxidase inhibitors (MAOIs). For some people, these may be the best medications.

    How do people respond to antidepressants?

    According to a research review by the Agency for Healthcare Research and Quality, all antidepressant medications work about as well as each other to improve symptoms of depression and to keep depression symptoms from coming back. For reasons not yet well understood, some people respond better to some antidepressant medications than to others.

    Therefore, it is important to know that some people may not feel better with the first medicine they try and may need to try several medicines to find the one that works for them. Others may find that a medicine helped for a while, but their symptoms came back. It is important to carefully follow your doctor’s directions for taking your medicine at an adequate dose and over an extended period of time (often 4 to 6 weeks) for it to work.

    Once a person begins taking antidepressants, it is important to not stop taking them without the help of a doctor. Sometimes people taking antidepressants feel better and stop taking the medication too soon, and the depression may return. When it is time to stop the medication, the doctor will help the person slowly and safely decrease the dose. It's important to give the body time to adjust to the change. People don't get addicted (or "hooked") on these medications, but stopping them abruptly may also cause withdrawal symptoms

    Side Effects of Antidepressants

    Some antidepressants may cause more side effects than others. You may need to try several different antidepressant medications before finding the one that improves your symptoms and that causes side effects that you can manage.

    The most common side effects listed by the FDA include:

    • Nausea and vomiting
    • Weight gain
    • Diarrhea
    • Sleepiness
    • Sexual problems

    Combining the newer SSRI or SNRI antidepressants with one of the commonly-used "triptan" medications used to treat migraine headaches could cause a life-threatening illness called "serotonin syndrome." A person with serotonin syndrome may be agitated, have hallucinations (see or hear things that are not real), have a high temperature, or have unusual blood pressure changes. Serotonin syndrome is usually associated with the older antidepressants called MAOIs, but it can happen with the newer antidepressants as well, if they are mixed with the wrong medications.

    Anti-Anxiety Medications

    Anti-anxiety medications help reduce the symptoms of anxiety, such as panic attacks, or extreme fear and worry. The most common anti-anxiety medications are called benzodiazepines which act to increase GABA function. Benzodiazepines can be effective in treating generalized anxiety disorder, but in the case of panic disorder or social phobia (social anxiety disorder), benzodiazepines are usually second-line treatments, behind SSRIs or other antidepressants.

    Benzodiazepines used to treat anxiety disorders include, Clonazepam (Klonopin), Alprazolam (Xanax), and Lorazepam (Ativan).

    Short half-life (or short-acting) benzodiazepines (such as Lorazepam) and beta-blockers (adrenaline inhibitors) are used to treat the short-term symptoms of anxiety. Beta-blockers help manage physical symptoms of anxiety, such as trembling, rapid heartbeat, and sweating that people with phobias (an overwhelming and unreasonable fear of an object or situation, such as public speaking) experience in difficult situations. Taking these medications for a short period of time can help the person keep physical symptoms under control and can be used “as needed” to reduce acute anxiety.

    Buspirone (which is unrelated to the benzodiazepines) is sometimes used for the long-term treatment of chronic anxiety. In contrast to the benzodiazepines, buspirone has both agonist and antagonist properties and effects serotonin and dopamine systems in complex ways. This drug must be taken every day for a few weeks to reach its full effect, thus, it is not useful for immediate treatment of anxiety symptoms.

    MDMA is an empathogen with both stimulant and hallucinogenic properties. As mentioned in Section 6.4, it was first used in the 1970s as an aid in psychotherapy but faced many legal and regulatory challenges in subsequent years that stalled both the research and clinical tests of its effectiveness. However, some researchers remained interested in its value in psychotherapy when given to patients under carefully controlled conditions. MDMA is currently in clinical trials as a possible treatment aid for post-traumatic stress disorder (PTSD); for anxiety in terminally ill patients; and for social anxiety in autistic adults. Recently, the FDA gave MDMA-assisted psychotherapy for PTSD a "Breakthrough Therapy" designation.

    How do people respond to anti-anxiety medications?

    Anti-anxiety medications such as benzodiazepines are effective in relieving anxiety and take effect more quickly than the antidepressant medications (or buspirone) often prescribed for anxiety. However, people can build up a tolerance to benzodiazepines if they are taken over a long period of time and may need higher and higher doses to get the same effect. Some people may even become dependent on them. To avoid these problems, doctors usually prescribe benzodiazepines for short periods, a practice that is especially helpful for older adults, people who have substance abuse problems and people who become dependent on medication easily. If people suddenly stop taking benzodiazepines, they may have withdrawal symptoms or their anxiety may return. Therefore, benzodiazepines should be tapered off slowly.

    Side Effects of Anti-Anxiety Medications

    Like other medications, anti-anxiety medications may cause side effects. Some of these side effects and risks are serious. The most common side effects for benzodiazepines are drowsiness and dizziness. For beta-blockers the common side effects include, fatigue, cold hands, dizziness or light-headedness, and weakness. Beta-blockers generally are not recommended for people with asthma or diabetes because they may worsen symptoms related to both. Possible side effects from buspirone include, dizziness, headaches, nausea, nervousness, lightheadedness, excitement, and trouble sleeping

    Stimulants

    As the name suggests, stimulants increase alertness, attention, and energy, as well as elevate blood pressure, heart rate, and respiration (National Institute on Drug Abuse, 2014). Stimulant medications are often prescribed to treat children, adolescents, or adults diagnosed with Attention Deficit, Hyperactivity Disorder (ADHD).

    Two of the most common stimulants used to treat ADHD are Methylphenidate (Ritalin), and Amphetamine/Dextroamphetamine (Adderall)

    Stimulants are also prescribed to treat other health conditions, including narcolepsy, and occasionally depression (especially in older or chronically medically ill people and in those who have not responded to other treatments).

    How do people respond to stimulants?

    Stimulants have the potential to cause excessive activity and physiological activation, however, for individuals with ADHD the opposite is true in that it can have a calming and “focusing” effect. Stimulant medications are safe when given under a doctor's supervision. Some children taking them may feel slightly different or "funny."

    Some parents worry that stimulant medications may lead to drug abuse or dependence, but there is little evidence of this when they are used properly as prescribed. Additionally, research shows that teens with ADHD who took stimulant medications were less likely to abuse drugs than those who did not take stimulant medications. Despite the findings noted above, there is also research indicating the risk of "diversion" of prescribed stimulants for nonmedical uses between students at educational institutions. This diversion could put individuals at a higher risk for stimulant abuse.

    Side Effects of Stimulants

    Most side effects are minor and disappear when dosage levels are lowered. The most common side effects include:

    • Difficulty falling asleep or staying asleep
    • Loss of appetite
    • Stomach pain
    • Headache

    Less common side effects include:

    • Motor tics or verbal tics (sudden, repetitive movements or sounds)
    • Personality changes, such as appearing “flat” or without emotion

    Antipsychotics

    Antipsychotic medicines are primarily used to manage psychosis. The word “psychosis” is used to describe conditions that affect the mind, and in which there has been some loss of contact with reality, often including delusions (false, fixed beliefs) or hallucinations (hearing or seeing things that are not really there). It can be a symptom of a physical condition such as drug abuse or a mental disorder such as schizophrenia, bipolar disorder, or very severe depression (also known as “psychotic depression”).

    Antipsychotic medicines do not cure these conditions. They are used to help relieve symptoms and improve quality of life.

    Older or first-generation antipsychotic medications are also called conventional "typical" antipsychotics or “neuroleptics”. Most of the drugs in this class act as potent dopamine antagonists primarily effecting the dopamine D2 receptor. This antagonistic effect reduces the dopamine overactivity found in psychotic disorders, such as Schizophrenia. Some of the common first-generation antipsychotics include:

    • Chlorpromazine
    • Haloperidol
    • Fluphenazine

    Newer or second generation medications are also called "atypical" antipsychotics. These drugs act on various neurotransmitters systems in addition to dopamine and, as such are not as potent in their dopamine antagonism. Some of the common atypical antipsychotics include:

    • Risperidone
    • Olanzapine
    • Quetiapine

    Both typical and atypical antipsychotics have been shown to work to treat symptoms of schizophrenia and the manic phase of bipolar disorder. In addtion, several atypical antipsychotics have a “broader spectrum” of action than the older medications, and are used for treating bipolar depression or depression that has not responded to an antidepressant medication alone.

    How do people respond to antipsychotics?

    Certain symptoms, such as feeling agitated and having hallucinations, usually go away within days of starting an antipsychotic medication. Symptoms like delusions usually go away within a few weeks, but the full effects of the medication may not be seen for up to six weeks. Every patient responds differently, so it may take several trials of different antipsychotic medications to find the one that works best.

    Some people may have a relapse—meaning their symptoms come back or get worse. Usually relapses happen when people stop taking their medication, or when they only take it sometimes. Some people stop taking the medication because they feel better or they may feel that they don't need it anymore, but no one should stop taking an antipsychotic medication without talking to his or her doctor.When a doctor says it is okay to stop taking a medication, it should be gradually tapered off— never stopped suddenly. Many people must stay on an antipsychotic continuously for months or years in order to stay well; treatment should be personalized for each individual.

    Side Effects of Antipsychotics?

    Antipsychotics have many side effects (or adverse events) and risks. The FDA lists the following side effects of antipsychotic medicines:

    • Drowsiness
    • Dizziness
    • Restlessness
    • Weight gain (the risk is higher with some atypical antipsychotic medicines)
    • Dry mouth
    • Constipation
    • Nausea
    • Vomiting
    • Blurred vision
    • Low blood pressure
    • Uncontrollable movements, such as tics and tremors (the risk is higher with typical antipsychotic medicines)
    • Seizures
    • A low number of white blood cells, which fight infections

    The older, typical antipsychotic medications can also cause additional side effects related to physical movement, such as:

    • Rigidity
    • Persistent muscle spasms
    • Tremors
    • Restlessness

    Long-term use of typical antipsychotic medications may lead to a condition called tardive dyskinesia (TD). TD causes muscle movements, commonly around the mouth, that a person can't control. TD can range from mild to severe, and in some people, the problem cannot be cured. Sometimes people with TD recover partially or fully after they stop taking typical antipsychotic medication. People who think that they might have TD should check with their doctor before stopping their medication. TD rarely occurs while taking atypical antipsychotics.

    Mood Stabilizers

    Mood stabilizers are used primarily to treat bipolar disorder, mood swings associated with other mental disorders, and in some cases, to augment the effect of other medications used to treat depression. Lithium, which is an effective mood stabilizer, has a broad spectrum of action including the inhibition of dopamine and glutamate systems and increased GABA action (Malhi, et al., 2013). Lithium is approved for the treatment of mania and the maintenance treatment of bipolar disorder. Additionally, a number of cohort studies describe anti-suicide benefits of lithium for individuals on long-term maintenance. Because mood stabilizers work primarily by decreasing abnormal activity in the brain they are also sometimes used to treat:

    • Depression (usually along with an antidepressant)
    • Schizoaffective Disorder
    • Disorders of impulse control
    • Certain mental illnesses in children

    Anticonvulsant medications that primarily act as agonists to GABA neurotransmitter systems are also used as mood stabilizers. They were originally developed to treat seizures, but they were found to help control unstable moods as well. One anticonvulsant commonly used as a mood stabilizer is valproic acid (also called divalproex sodium). For some people, especially those with “mixed” symptoms of mania and depression or those with rapid-cycling bipolar disorder, valproic acid may work better than lithium. Other anticonvulsants used as mood stabilizers include:

    • Carbamazepine
    • Lamotrigine
    • Oxcarbazepine

    Side Effects of Mood Stabilizers

    Mood stabilizers can cause several side effects, and some of them may become serious, especially at excessively high blood levels. These side effects include:

    • Itching, rash
    • Excessive thirst
    • Frequent urination
    • Tremor (shakiness) of the hands
    • Nausea and vomiting
    • Slurred speech
    • Fast, slow, irregular, or pounding heartbeat
    • Blackouts
    • Changes in vision
    • Seizures
    • Hallucinations (seeing things or hearing voices that do not exist)
    • Loss of coordination
    • Swelling of the eyes, face, lips, tongue, throat, hands, feet, ankles, or lower legs.

    Some possible side effects linked to anticonvulsants (such as valproic acid) include:

    • Drowsiness
    • Dizziness
    • Headache
    • Diarrhea
    • Constipation
    • Changes in appetite and/or weight
    • Agitation
    • Mood swings
    • Abnormal thinking
    • Uncontrollable shaking or movement of a part of the body
    • Loss of coordination
    • Blurred or double vision
    • Ringing in the ears
    • Hair loss

    Summary

    It should be clear that psychotherapeutic medications have been proven effective at treating a wide variety of psychological disorders, with only a few major types reviewed here. The drugs that treat depression, anxiety, psychosis, and various other disorders of mood and cognition do so by a variety of means. Each category of psychotherapeutic drug can include various different drugs with different actions at the synaptic and neurotransmitter levels. Many other drugs not referenced here, such as hallucinogens and marijuana have also been studied for their potential effectiveness in treating disorders, such as Post Traumatic Stress Disorder, Anxiety, and depression. Some positive outcomes have been found, but more definitive research is needed in order to validate these findings.

    Attributions

    Adapted from "Mental Health Medications." Authored and Provided by the National Institute of Mental Health. .  License: Public Domain: No Known Copyright

    References

    Malhi GS, Tanious M, Das P, Coulston CM, Berk M. (2013) Potential mechanisms of action of lithium in bipolar disorder. Current understanding. CNS Drugs. Feb;27(2):135-53. doi: 10.1007/s40263-013-0039-0. PMID: 23371914.

    Vrecko S. (2015). Everyday drug diversions: a qualitative study of the illicit exchange and non-medical use of prescription stimulants on a university campus. Social science & medicine, 131, 297–304. https://doi.org/10.1016/j.socscimed.2014.10.01


    This page titled 6.5: Psychotherapeutics is shared under a mixed license and was authored, remixed, and/or curated by Multiple Authors (ASCCC Open Educational Resources Initiative (OERI)) .