This chapter introduces psychotropic medications. We’ll cover some of the basics, including how they generally work and what they’re used for. In the following chapters, we’ll look at specific types of medications such as antidepressants in more detail.
There’s a large amount of information about medications in this book compared with other types of treatments. This doesn’t mean that medications are more important or should be used more often. Rather, medications are some of the most poorly understood, complex, and frequently misused treatments available. At the same time, they are often readily available and can be very effective when used properly.
Let’s state the obvious. Recreational use aside, you don’t take any medication for the fun of it. You take it because the medical condition it’s supposed to treat is harming your health, life, and future. You hope the medication can fix this. Medications have the potential to greatly and quickly improve your mental health. The payoff can be huge, but so are the challenges. Your active involvement, using your living treatment plan, can tilt the odds in your favour and speed up your recovery.
We don’t think medications are for everyone, but hope you’ll approach these chapters with fresh eyes. We’ll do our best to get you up to speed as simply and quickly as possible. Our goal is to deliver a balanced and realistic overview to help you decide if they might have a place in your living treatment plan. Used properly, medications are powerful tools that can help you regain control of your life and improve your functioning. Used improperly, they are, at best, unhelpful, and, at worst, they can lead to many problems.
We’ll start with the basics. What are psychotropic medications and how do they work? We’ll also discuss why using them correctly is more complicated than using most other medications. People frequently abandon medications that would have improved their health due to some very avoidable mistakes.
We’ll cover five major types of psychotropic medications in the following chapters:
Antidepressants (e.g., Prozac, Effexor) are what most people think of when psychotropic medications are mentioned. Taken daily, they help with depression of course, but also anxiety and other conditions.
Sedatives and hypnotics (e.g., Valium, Ativan) help to quickly calm people down during stressful events. Some treat insomnia or are used until an antidepressant starts working.
Mood stabilizers (e.g., lithium, Epival) are most often used to smooth out the highs (mania) and lows experienced by people with bipolar disorders, but they can help people diagnosed with depression, too.
Antipsychotics (e.g., Seroquel, Risperdal) are used to treat psychosis in people with schizophrenia or in a manic episode. At lower doses, they complement other treatments for many mental illnesses.
Stimulants (e.g., Ritalin, Adderall) help people with Attention-Deficit Hyperactivity Disorder, treat fatigue, and improve concentration.
As we describe different medications, we’ll give you a basic overview of not only what they are used for, but also the neuroscience explaining how each medication works. It won’t surprise you that most medications affect the transmission of neurotransmitters (serotonin, norepinephrine, dopamine, GABA, glutamate, and others to lesser degrees).
There are dozens of different psychotropic medications. Predicting which one will work best with reasonable certainty is currently impossible. With many physical illnesses, after a quick exam or lab test, a doctor can prescribe a medication they know will probably help, such as an antibiotic for an infection. Unfortunately, mental health medications are more unpredictable. The science isn’t there yet.
You may have to try several medications to find one that works. If the first one didn’t work (or caused side effects), don’t conclude that psychotropic medications aren’t right for you. Similarly, because a medication was amazingly helpful for someone you know, don’t be disappointed if it doesn’t help you. If you’re going to try psychotropic medications, expect some trial and error.
Is picking the right medication simply guessing at random? Not at all. Doctors take into account many factors when selecting a medication for you to try. Your symptoms will guide them to a class of medications based on which neurotransmitters need to be targeted. Other symptoms tell them to stay away from medications targeting other neurotransmitters. How you’ve tolerated and responded to other medications also influences the decision. Genetics play a significant role, so if a close relative responded well to a medication there’s a greater chance you will too. Chronic health conditions raise the risk of some medications or make them less effective. Interactions with other medications or supplements can be a concern. Then there are issues such as cost, how and when the medication needs to be taken, how long it lasts, and more. Your doctor tries to keep up with all the new medications and lessons about existing ones, but it’s not easy.
Psychotropic medications operate on molecules, which then change how billions of electrical signals are transmitted. Depending on the pattern of signals, a change in mood occurs. The complexity makes it difficult to predict what medications will work. While genetic testing and advanced imaging can help somewhat, these tests are expensive and not in wide use. Researchers are busy working on other tools to make better predictions.
Most people don’t know what to expect when first prescribed a psychotropic medication. These medications often behave differently than other medications. For example, most antidepressants take weeks before you experience any effect. Many psychotropics are started below the effective dose so you can physically get used to them. If you aren’t told these things, it is normal to feel frustrated when you are not cured in a few days or weeks. Even medication side effects can be different because neurotransmitters are found in both your brain and other areas of your body. If nobody tells you what to expect, what to be concerned about, and what will likely disappear over time, you’re more likely to stop taking a medication long before it’s had a chance to work.
In this and the following chapters, you’ll learn what to expect from different types of medications. You’ll also learn the questions you need to ask and some ways you can find answers to your questions.
What problems can medications help with? Certainly not everything. They won’t help with relationship problems, unhealthy coping, or physical illness causing mental health symptoms. Even then, they can manage some symptoms, but you’ll need something else to fix the underlying problem.
Most people with severe mental illness, e.g., schizophrenia, need medications for daily functioning. Without them, they lose touch with reality, hearing or seeing things that aren’t there. They may believe they have superpowers or that the CIA has infiltrated their home. People suffering from severe depression need medication to decrease long-term suicidal thoughts. All of these have dangerous consequences.
Medications provide the stability needed for good self-care, to go to work or school, and maintain relationships. Other tools, such as psychotherapy, may help a bit, but, without medication, are not sufficient. While people with severe mental illness also have serious difficulties accessing effective care, their experiences, needs, and struggles are often very different than those of the people we expect to read this book.
Medications are often used to help get you back on your feet again. When you are depressed or anxious, they decrease your anxiety each morning, help you get out of bed, and prevent a panic attack. Medications help you regain your independence, so you rely less on friends and family. They improve your concentration and performance at work.
You may be faced with new stressors or have skeletons in your closet. You may have experienced some form of abuse, a chaotic family environment, a recent loss, or something that you know has deeply affected you. But, now is not the right time to deal with those problems. You know that medication can’t fix them, but it can shut off the worry so you can function well and meet your commitments.
People often seek treatment for mental health problems when they’re in the middle of a crisis. They have severe problems that are affecting them right now. Medication can be an effective tool to help end the crisis.
Like most people, you probably have had difficult experiences involving your relationships, your jobs, or in your childhood. Do you have enough emotional muscle to deal with them?
Counselling and psychotherapy can help you recognize problematic patterns of behaviour. You can then learn techniques or find new ways to deal with stressful situations. This takes a lot of hard work, learning new things, and practicing. You’re essentially rewiring your brain, replacing unhelpful behaviours and habits with healthier ones.
If you’re in crisis, you probably don’t have the emotional resilience needed to benefit from psychotherapy. You won’t grasp the techniques or retain what you’ve learned. You may be too scared or not have the energy to practice the skills. If you have a panic attack every time your therapist mentions an event from your past, you’re not going to get far.
In these situations, medications can help. They calm you down and increase your motivation and concentration. They build up your emotional armour so that you can handle the stresses that therapy brings. Sure, it’s a band-aid, but you may need to stop the bleeding before you can get to fixing the underlying problem.
After you’ve learned new habits, behaviours, and coping strategies, you may find that you don’t need the medications anymore. You can then be weaned off them if you and your treatment providers feel it makes sense. It’s important to follow your doctor’s instructions when stopping psychotropic medications. This is discussed in the following chapters.
It’s common for people to see multiple mental health providers. A psychiatrist might prescribe medications for you and a psychologist might provide psychotherapy. Each plays a different but necessary role in your treatment. It’s the combination that helps you reach wellness.
Medications can also be used long term. They aren’t only used when you are in crisis or when you need more resilience for psychotherapy. For many people, medications are a sensible approach to treatment over the long term. It seems almost ludicrous having to say that. Most people don’t feel a need to justify taking insulin if they have diabetes, taking anticonvulsants if they have epilepsy, or taking blood pressure medications for hypertension, even if it’s for the rest of their life.
Often, several different treatment approaches would be sensible. It then becomes a matter of weighing the costs and benefits of each. Some people find that medication is the most practical way to manage their symptoms. If taking a pill each day keeps you well, that’s pretty convenient.
We know what psychotropic medications are and what kind of mental health problems they are ideally suited for. We now want to turn to a slightly different question: why are they used?
In other words, if you’ve got several different tools to pick from that might reasonably address your symptoms, e.g., medication and counselling, why might you choose medication? It’s not always because medication is the best tool for the job.
Medications are used to treat mental health problems because they work. That is, when an appropriate medication is used to help with an appropriate problem, it has been shown to be very effective. Compared with many medical treatments, that means if your doctor starts you on a psychotropic medication, there’s a very good chance (albeit with a bit of trial and error) that medication will help.
How effective are psychotropics compared to other medications? One way to compare is by asking how many people you’d need to give the medication to before you saw a positive result. That would be “10” if on average one out of ten people saw a result, and “1” if everyone saw a result.1
To prevent one heart attack with low-dose aspirin: 1,500-2,000
To prevent one heart attack with statins: 40-100
To prevent a second seizure with anti-epileptic medications: 10
To recover from depression with antidepressants: 4
Yes, four! This shows antidepressants are incredibly effective. Studies for various types of psychotropics and appropriate illnesses frequently show numbers in the single digits.
Yet, some people who have tried one or more medications haven’t found them helpful. Sometimes this is a result of an incorrect diagnosis, missing other problems, or completely inappropriate medication choices. More often, this happens when medication trials aren’t run well. We’ll talk more about this later.
Limited access to alternatives is one reason that medication may be used more than other treatments. At times, they are used for problems they really aren’t intended to solve.
Accessibility comes down to the issue of providers’ availability, time, and resources. If you go to your family doctor for help with mental health, you’re more likely to leave with a prescription. Consider the alternatives. They don’t have the time to provide you with extensive psychotherapy. Trying to connect you with the right therapist is difficult and time-consuming, particularly if you’re on a tight budget. Helping with complex issues is impractical during a short doctor’s appointment.
Being able to afford treatment plays a huge role in being able to access it. In places such as Canada, everyone can visit a family doctor at no cost. In contrast, professionals such as psychologists aren’t generally covered by basic health insurance. Unless you’re lucky enough to have a publicly funded clinic available with the services you need, you may not be able to pay for treatment.
Coverage for the cost of medications varies, too. For example, Canada has universal healthcare but not universal pharmacare. Paying for medications often costs less than paying for therapy. Depending on the medication, a month’s worth of medication could cost the equivalent of ten minutes of therapy.
Without the cash to pay for medication, there are usually a few options:
Employer or other group benefits programs often have medication coverage.
Some provincial or state governments offer for-fee group benefit plans open to anyone in that province.
For those with somewhat lower income, some governments have programs that cap the amount you have to pay for medication.
For those who are very low income, social assistance programs may provide some form of medication coverage.
Many pharmaceutical companies offer compassionate programs and can provide their specific medication to people who need it, but who can’t afford it and can’t access other programs.
Pharmaceutical sales reps often give samples to doctors to make it easier to try people on their medication. Sometimes they can provide enough samples to “float” one or more patients long term.
If you’re having trouble paying for medication, talk to your doctor about it. They may not know the price of the medication they are prescribing. They may be able to prescribe similar alternatives that are more affordable. Your pharmacist will be able to tell you what different medications cost. They may know of programs that you are eligible for that could reduce the cost.
We started this chapter by saying that nobody takes medication for fun. Taking medication is a better option than doing nothing to improve your health. There are things that many people like even less than taking a medication. Depending on the person, these might include
spending hours in therapy confronting uncomfortable thoughts and feelings;
engaging in increasingly scary activities to overcome a fear or phobia;
reading and practicing techniques from a workbook; and
exercising, eating healthier, or cutting back on caffeine or alcohol.
Let’s face it: a lot of people either don’t have the time or would rather do other things with their time. They would rather take a pill each day.
If you haven’t already, you’ll likely encounter a few people with strong negative feelings about psychotropic medications and, often, psychiatry as a whole.
Some people may tell you all mental health problems are overreactions. They do not represent illness. Or, they may say that people who rely on medication are too lazy to eat well and exercise. They’re just not trying hard enough. That’s nonsense!
Many of these people have had bad personal experiences. Some may have even been given potent medications against their will while involuntarily committed to a hospital. You’ll find these individuals gathered in psychiatric survivor groups. Some identify as anti-psychiatry and hold the extreme view that the field of psychiatry should be abolished. The internet has given these people a louder voice.
There are legitimate concerns associated with taking any medication. But when people start telling you that “mental illness isn’t real,” medications are a means of “state control,” and that it’s all a profit-driven scheme by “Big Pharma” to get you addicted, they’re crossing the line between legitimate concern and paranoid conspiracy.
Yes, pharmaceutical companies have more influence than they probably should. Understanding of some of the underlying neurobiological mechanisms is still advancing. And, involuntary psychiatric treatment for extreme circumstances is never ideal. We’re not discounting skepticism, but it has to have some basis in a broad-based reality.
We want to caution you that when people share their experiences, remember that their circumstances are not necessarily yours. Everyone is different, especially when it comes to mental health. Be wary of all-or-nothing views, regardless of the source. If you have concerns, speak with your doctor or other mental health professionals.
As with any health issue, learn as much as you can in order to help improve your mental health. Consider any credible, evidence-based treatment that is appropriate for your circumstances. Choose the ones that best meet your own unique needs. Any treatment decisions will involve trade offs, costs, and benefits. Remember that neglecting your symptoms has costs, too.
We’ve already stated that medications may help with certain problems but not others. They may assist you in getting the most out of other treatments such as psychotherapy. But before looking at any lengthy treatment, ruling out other physical causes of your symptoms (as we discussed in the Physical Illness chapter) is a must.
For many with mild to moderate anxiety or depression, lifestyle choices can have a similar impact to an antidepressant. And there are countless other benefits of regular exercise, improving your diet, getting proper sleep, and cutting back on alcohol and caffeine that we’ve talked about previously.
It’s not unusual to try improving lifestyle choices to see if your symptoms improve. You can then decide whether adding medication makes sense. Some people choose to forego alternatives if they are available and prefer to take medication. Your illness, goals, and timeframes may influence your choices. There’s no right or wrong answer.
Medications, used well, can be a useful part of your overall treatment. We hope this and the following chapters help you make an informed choice.
Psychotropic medications include antidepressants, sedatives and hypnotics, mood stabilizers, antipsychotics, and stimulants.
Psychotropics work on neurotransmitters and can take time before they start working. Side effects when starting are common. Finding the right medication often involves some trial and error, but a good trial takes time.
Medications can help with severe mental illness, improve short-term functioning, build emotional resilience to help with psychotherapy, or provide long-term symptom management.
Despite conspiracy theories to the contrary, psychotropics can be effective and affordable options. They may be the only effective option for some situations or one of several treatment options, each with benefits and risks.
The formal name for this measure is the number needed to treat (NNT). It’s a frequently used measure of effectiveness in evidence-based medicine. The corresponding measure for treatment safety is the number needed to harm (NNH). A group of doctors have scoured studies to collect NNT data on a wide range of medical conditions and interventions.
https://thennt.com
Their site is unfortunately short on data surrounding psychiatric treatments (and a few other areas) but is a great resource to put specific NNT data in context (e.g., compare your treatments with others). Data on specific treatments for specific conditions, mental health and otherwise, can easily be found by searching Cochrane reviews and Google Scholar.↩
Now Available! A MSP-supported live course for BC residents based on the book. [Mar/2023]
While you can read it for free online, there are conditions on sharing it with others (see below). You can also still purchase copies in paperback or e-book (PDF, Kindle, Kobo, etc.).
Now Available! A MSP-supported live course for BC residents based on the book.
