07 Psychiatric Medications

How psychiatric medications are grouped

Psychiatric medications are commonly grouped according to the symptoms or disorders they treat. Examples pair generic names with familiar U.S. brand names and typical uses, but brand availability and approved uses can vary by formulation.

Medication choice depends on the person. Medicines should not be started, changed, or stopped without guidance from a qualified clinician.

Antidepressants

Antidepressants are used for depression and are also commonly prescribed for anxiety disorders. Many take several weeks to provide their full benefit.

Common antidepressant groups

• SSRIs: Selective serotonin reuptake inhibitors include fluoxetine (Prozac), sertraline (Zoloft), escitalopram (Lexapro), citalopram (Celexa), and paroxetine (Paxil). They are used for depression and several anxiety disorders. Common effects include nausea, sleep changes, and sexual dysfunction. Abrupt discontinuation should be avoided because stopping can cause withdrawal-like symptoms.

• SNRIs: Serotonin-norepinephrine reuptake inhibitors include venlafaxine (Effexor XR) and duloxetine (Cymbalta). They are used for depression and anxiety; duloxetine is also used for some pain conditions. Venlafaxine may cause discontinuation symptoms if stopped suddenly.

• NDRI: Bupropion (Wellbutrin), a norepinephrine-dopamine reuptake inhibitor, is used for depression and may be selected when avoiding some SSRI-associated sexual effects. It can increase seizure risk, especially in susceptible patients.

• Other antidepressants: Mirtazapine (Remeron) and trazodone (Desyrel) are used for depression. Sedation is common, so they may also be used when sleep symptoms are present.

• TCAs: Tricyclic antidepressants include amitriptyline (Elavil) and nortriptyline (Pamelor). They are used for depression and, for some agents, pain or other conditions. Important cautions include anticholinergic effects, sedation, and cardiac toxicity in overdose.

• MAOIs: Monoamine oxidase inhibitors include phenelzine (Nardil) and tranylcypromine (Parnate). They are usually used for depression when other options have not worked. Drug and food interactions, including interactions with tyramine-rich foods, can be serious; medication changes require clinician guidance.

Anxiolytics

Anxiolytics reduce anxiety. SSRIs and SNRIs are often used for ongoing anxiety treatment, while other medicines may be used in particular situations or for short-term symptom relief.

• Benzodiazepines: Lorazepam (Ativan), alprazolam (Xanax), clonazepam (Klonopin), and diazepam (Valium) can rapidly relieve some acute anxiety symptoms. They can cause sedation and impaired coordination. Tolerance, dependence, and withdrawal are concerns, particularly with prolonged use, so they are generally limited to short-term use.

• Buspirone: Buspirone (Buspar) is used for ongoing anxiety treatment. It takes time to work and is not an as-needed medicine for rapid relief.

• Beta blocker: Propranolol (Inderal) is sometimes used off-label for physical symptoms, such as tremor or a racing heart in performance situations. It does not treat every aspect of anxiety.

Antipsychotics

Antipsychotics are used mainly for psychosis, including schizophrenia. Some are also used for bipolar disorder or as add-on treatment for depression.

• First-generation (typical): Haloperidol (Haldol) and chlorpromazine (Thorazine) are used for psychosis and other specific indications. They have greater risk of movement-related adverse effects. Monitor for extrapyramidal symptoms (EPS), such as stiffness, tremor, and restlessness, and for tardive dyskinesia with longer-term use.

• Second-generation (atypical): Risperidone (Risperdal), olanzapine (Zyprexa), quetiapine (Seroquel), and aripiprazole (Abilify) are used for schizophrenia and, depending on the drug, bipolar disorder or as depression augmentation. Weight, glucose, and lipid monitoring may be needed; metabolic effects are an important concern for this group.

• Atypical with special monitoring: Clozapine (Clozaril) is used for treatment-resistant schizophrenia. Blood monitoring is required because of the risk of dangerously low white blood cells.

Antipsychotics carry a boxed warning about increased risk of death in older adults with dementia-related psychosis. They are not FDA-approved for that use.

Mood stabilizers

Mood stabilizers are used to treat or prevent mood episodes in bipolar disorder. Some anticonvulsants and atypical antipsychotics also serve as mood-stabilizing treatments.

• Lithium: Lithium (Lithobid) treats and helps prevent mania and other bipolar mood episodes. Monitoring of blood lithium level, kidney function, and thyroid function is required; toxicity can be serious.

• Anticonvulsants: Divalproex/valproate (Depakote), lamotrigine (Lamictal), and carbamazepine (Tegretol) are used for selected bipolar mood episodes or prevention. Valproate has important liver, pancreas, and pregnancy-related risks. Lamotrigine must be increased gradually because of the risk of serious rash, especially if increased too quickly. Carbamazepine can be used for manic or mixed episodes.

• Atypical antipsychotics: Quetiapine (Seroquel) and olanzapine (Zyprexa) are examples. Depending on the medication, some are used for acute mania, bipolar depression, or maintenance. Monitor for drug-specific movement or metabolic adverse effects.

Antidepressants, when used for bipolar depression, are generally not used alone because of the risk of triggering mania or rapid cycling.

Medications for attention disorders

ADHD medicines are divided into stimulants and nonstimulants. Both groups include medicines used for ADHD, but the nonstimulants differ from one another in how they work and how quickly they take effect.

• Stimulants: Methylphenidate (Ritalin, Concerta), mixed amphetamine salts (Adderall), and lisdexamfetamine (Vyvanse) are examples. Some stimulants are also used for narcolepsy. Possible effects include reduced appetite, insomnia, and increased heart rate or blood pressure. Misuse can cause serious harm; stimulants should be used only as prescribed. Misuse and dependence are risks.

• Nonstimulants: Atomoxetine (Strattera), guanfacine ER (Intuniv), clonidine ER (Kapvay), and viloxazine ER (Qelbree) are examples. Guanfacine and clonidine can cause sleepiness and lower blood pressure.

FDA-approved ADHD medicines include both stimulants and nonstimulants, including methylphenidate, amphetamine products, atomoxetine, guanfacine, clonidine, and viloxazine.

Medications for sleep disorders

Sleep medicines may be used for insomnia, but the choice depends on whether the main problem is falling asleep, staying asleep, or another sleep condition. Some medicines can cause next-day impairment, dependence, or unusual sleep behaviors.

• Non-benzodiazepine hypnotics (“Z-drugs”): Zolpidem (Ambien), zaleplon (Sonata), and eszopiclone (Lunesta) are used for insomnia. They can cause next-day drowsiness and, rarely, complex sleep behaviors such as sleep-driving. Avoid combining them with alcohol or other sedatives unless specifically directed. Zolpidem has a warning for serious complex sleep behaviors.

• Melatonin-receptor agonist: Ramelteon (Rozerem) helps with sleep onset and is generally not considered a benzodiazepine-type sedative.

• Orexin-receptor antagonist: Suvorexant (Belsomra) is used for insomnia, including difficulty falling or staying asleep. It may cause sleepiness and impaired alertness.

• Sedating antidepressants: Low-dose doxepin (Silenor) and trazodone (Desyrel) are sometimes used for insomnia. Trazodone is also an antidepressant. Sedation and next-day grogginess may occur.

Zolpidem, zaleplon, eszopiclone, and ramelteon are commonly used prescription hypnotics.