Psychotropic medications: the classes and how they work

Transcript

SoheeFirst session with a new client. On the intake form, under current medications, she's written four names: Zoloft, Xanax, Abilify, and lithium.

RyanAnd you're not the prescriber. But you're the person who sees her every week. You'll be the one who hears it when she says she can't sleep, or she's gained weight, or her hands are shaking.

SoheeWelcome to EPPP Prep, the podcast. I'm Sohee.

RyanI'm Ryan. Today is the medication tour. Five classes: antidepressants, anti-anxiety medications, stimulants, antipsychotics and mood stabilizers. What each is for, how it works, how long it takes, and the side effects the exam likes.

SoheeOur main sources are the National Institute of Mental Health, or NIMH, and its page on mental health medications and the treatment chapter of the OpenStax psychology textbook. And a note up front: this is exam knowledge, not dosing advice. Medication decisions belong to the prescriber and the client.

RyanLet's start with antidepressants. NIMH lists three commonly prescribed types. Selective serotonin reuptake inhibitors, SSRIs. Serotonin-norepinephrine reuptake inhibitors, SNRIs. And norepinephrine-dopamine reuptake inhibitors, NDRIs.

SoheeOpenStax gives the logic. SSRIs increase the level of serotonin. SNRIs increase both serotonin and norepinephrine. And its brand-name examples for SSRIs are Paxil, Prozac and Zoloft. So our client's Zoloft is an SSRI.

RyanWhy are these the common choices? NIMH says they improve symptoms across a broad group of depressive and anxiety disorders, and they have fewer side effects than the older antidepressants, the tricyclics and the monoamine oxidase inhibitors, or MAOIs.

SoheeThough NIMH adds that those older drugs may be the best option for some people. Don't write them off on the exam.

RyanNow timing, which is a big one. NIMH says antidepressants usually take four to eight weeks to work. And problems with sleep, appetite, energy and concentration often improve before mood lifts.

SoheeThat's such a useful thing for a therapist to know. A client might say the pill isn't working, when the early signs are already there.

RyanSide effects. NIMH lists upset stomach, headache and sexual dysfunction as common for SSRIs and other antidepressants, generally mild and tending to fade. The OpenStax table adds nausea, weight gain, drowsiness and reduced sex drive for SSRIs.

SoheeAnd for the tricyclics, OpenStax names Tofranil and Elavil, with dry mouth, constipation, blurred vision, drowsiness and reduced sex drive.

RyanOne newer option to know. Esketamine is approved by the U.S. Food and Drug Administration, the FDA, for treatment-resistant depression, which may be diagnosed when symptoms don't improve after at least two antidepressants. It's a nasal spray given in a provider's office, clinic or hospital, and it often acts within a couple of hours.

SoheePause and think. Ten days after starting an SSRI, a client tells you he's sleeping a little better, but he still feels low and wants to quit the medication. What do you know that helps?

RyanAntidepressants usually take four to eight weeks, and sleep and energy often improve before mood. So his experience fits the usual course. The supportive move is to share that and encourage him to talk with his prescriber before stopping. NIMH is clear that people shouldn't stop a medication without a provider's help.

SoheeOn to anti-anxiety medications. First surprise for some people: NIMH says many antidepressants, including SSRIs and SNRIs, are used for anxiety too. For panic disorder or social anxiety disorder, providers typically start with SSRIs or other antidepressants, because they have fewer side effects.

RyanThen benzodiazepines. OpenStax lists Xanax, Valium and Ativan. They depress central nervous system activity. NIMH says they're used for short-term anxiety symptoms, and sometimes for generalized anxiety disorder.

SoheeAnd the key caution. Taking benzodiazepines over long periods may lead to tolerance or even dependence. So providers usually prescribe them for short periods and taper slowly, to reduce withdrawal or a rebound of anxiety.

RyanThen buspirone, the exam's favorite contrast. It can be used for anxiety over longer periods. But unlike benzodiazepines, it must be taken every day for three to four weeks to reach full effect, and it doesn't work on an as-needed basis.

SoheeAnd beta-blockers. Providers may prescribe them off-label for short-term anxiety, for example in a phobia like public speaking, to manage physical symptoms like a rapid heart rate, sweating and tremors. NIMH notes they generally aren't recommended for people with asthma or diabetes.

RyanPause and think. A client asks for something she can take only on the morning of a big presentation. Which is the poor fit: a beta-blocker or buspirone?

SoheeBuspirone. It has to be taken daily for weeks and isn't effective as needed. That's the tempting wrong answer, because it's an anti-anxiety drug. The as-needed options NIMH describes are benzodiazepines and beta-blockers.

RyanStimulants next. NIMH says they're prescribed for attention-deficit/hyperactivity disorder, ADHD, and narcolepsy. They increase alertness, attention and energy, and can raise blood pressure, heart rate and breathing. OpenStax examples are Adderall and Ritalin.

SoheeSide effects in the OpenStax table: decreased appetite, difficulty sleeping, stomachache and headache. And NIMH addresses a common parent worry. Evidence shows misuse or dependence is unlikely when stimulants are used as prescribed.

RyanNow antipsychotics, where the generations matter. The older, first-generation drugs are called typical antipsychotics, or neuroleptics. OpenStax says they were developed in the 1950s, names Haldol, Mellaril, Prolixin and Thorazine, and says they treat positive symptoms like hallucinations and delusions by blocking dopamine.

SoheeTheir signature long-term risk is tardive dyskinesia, involuntary movements of the arms, legs, tongue and facial muscles. NIMH describes it as uncontrollable muscle movements that can range from mild to severe.

RyanThe second generation, the atypical antipsychotics, came in the late 1980s per OpenStax, with examples Abilify, Risperdal and Clozaril. OpenStax says they treat negative symptoms like withdrawal and apathy by targeting both dopamine and serotonin receptors, and that newer ones may treat both positive and negative symptoms.

SoheeTheir signature risk is metabolic. OpenStax lists increased risk of obesity and diabetes and elevated cholesterol. So NIMH says providers may ask people on atypicals to take part in regular monitoring of weight, glucose and lipid levels.

RyanSo for our client, Abilify is an atypical antipsychotic. NIMH notes atypicals are sometimes used for bipolar depression, or for depression that hasn't responded to an antidepressant alone.

SoheeTiming again. NIMH says agitation and hallucinations typically go away within days, delusions usually within a few weeks, and full effects may take up to six weeks.

RyanAnd if usual antipsychotics don't help, a person may be prescribed clozapine. People taking clozapine must have regular blood tests, to check for a potentially dangerous side effect. We'll go deeper on that in the next episode.

SoheeOne more warning to know. The FDA requires all antipsychotics to carry a black box warning about increased rates of stroke and death in older adults with dementia.

RyanFinally, mood stabilizers. They're typically used for bipolar disorder. Lithium is approved for mania and bipolar disorder, and NIMH notes some studies indicate it may reduce suicide risk in long-term maintenance.

SoheeLithium requires regular monitoring of lithium levels, plus kidney and thyroid function. And some anticonvulsants are used as mood stabilizers. OpenStax lists Depakote, Lamictal and Tegretol alongside lithium.

RyanAnd here's a nice wrinkle on mechanism. OpenStax describes lithium as blocking norepinephrine activity at the synapse. But the FDA prescribing information says the mechanism of lithium as a mood stabilizer is unknown.

SoheeSo if a question asks how lithium works, be cautious. The safest framing is the label's: the mechanism isn't known.

RyanLet's name the classic traps. Buspirone as an as-needed drug. Benzodiazepines as a long-term first choice. Forgetting the four-to-eight-week lag for antidepressants. And mixing up the signature risks: the sources tie tardive dyskinesia to long-term use of the older typicals, and metabolic changes to the atypicals.

SoheeWith one caution on that last one. The FDA label for risperidone, an atypical, also warns that potentially irreversible involuntary movements can develop with antipsychotic drugs. So never pick an answer claiming the atypicals carry no movement risk at all.

RyanAnd back to our intake form. Zoloft is an SSRI, Xanax a benzodiazepine, Abilify an atypical antipsychotic, and lithium a mood stabilizer. So you'd listen for stomach upset or sexual side effects, drowsiness, weight change, and anything that sounds like a change in thirst or a new tremor, and you'd encourage her to bring those to her prescriber.

SoheeRecap. Antidepressants: SSRIs, SNRIs and NDRIs are the common choices, tricyclics and MAOIs are older, four to eight weeks to work.

RyanAnti-anxiety: SSRIs often first. Benzodiazepines short-term and tapered. Buspirone daily, weeks to work, not as needed. Beta-blockers for the physical symptoms of performance anxiety.

SoheeStimulants for ADHD and narcolepsy. Typical antipsychotics block dopamine and risk tardive dyskinesia. Atypicals act on dopamine and serotonin and need metabolic monitoring. Clozapine means blood tests.

RyanMood stabilizers: lithium with level, kidney and thyroid monitoring, plus anticonvulsants. And lithium's mechanism, per the FDA label, is unknown.

SoheeThis is one of those topics that rewards steady review more than cramming. You don't have to memorize every brand name today. Get the classes and the contrasts, and the details will settle in with practice.

RyanNext time, the side effects that become emergencies, starting with lithium. Thanks for listening to EPPP Prep.

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