In the previous chapter, we discussed one category of psychotropic medications: antidepressants. In the process, you learned a lot about neurotransmitters, dosing, metabolism, interactions, and more. We’ll try not to bombard you like that again.
But, that knowledge will be helpful in this chapter. Here, we’ll cover psychotropic medication categories including sedatives and hypnotics, mood stabilizers, antipsychotics, and stimulants and related medications. As before, we’ll discuss these in a general way. Details of individual medications can be found in Appendix C.
Sedatives, also called anxiolytics, are medications that reduce anxiety and help you feel calm. Hypnotics help you fall asleep or stay asleep. Many medications can be used for both purposes, depending on the dose. Examples of sedatives and hypnotics include alprazolam (Xanax), diazepam (Valium), clonazepam (Klonopin, Rivotril), and zolpidem (Ambien).
You’ve already learned that antidepressants are used to manage many different symptoms including anxiety. In fact, serotonergic antidepressants are the psychotropic treatment of choice for most forms of ongoing anxiety. While some people are almost always anxious, others have episodes of anxiety occurring only at certain times or when faced with loss or a stressful event. In this section, we’ll look at medications for such episodic anxiety. Most of these medications work quickly but aren’t intended for long-term use. This is in contrast with antidepressants which take several weeks to work and can be taken long term.
The most common sedatives and hypnotics are a class of medications called benzodiazepines (“benzos”). Though not technically benzodiazepines, some insomnia medications such as zopiclone and zolpidem (the “z-drugs”) work similarly. Note that other medications, made for entirely different purposes, can also manage anxiety-related symptoms.
Sedatives and hypnotics treat more than anxiety and insomnia. They can also decrease agitation, muscle spasms, seizures, and alcohol withdrawal.
Because many of these medications take effect very quickly, they can be used as needed1 during stressful situations. They can also be used regularly for up to a few weeks at a time. Ongoing, daily use of sedatives and hypnotics for long periods (months or years) is controversial. More on this shortly.
All benzodiazepines (and the z-drugs) work on the neurotransmitter GABA (gamma-aminobutyric acid). GABA is the primary inhibitory neurotransmitter. The more GABA bound to a neuron’s receptors, the less likely it is to send a signal to its connected neurons. This effect is the opposite of primarily excitatory neurotransmitters such as dopamine or glutamate. When those neurotransmitters bind to a neuron’s receptors, the neuron is more likely to send a signal. GABA helps to slow down and reduce signals travelling through the nervous system. It helps your body and mind calm down and relax.
Other sedatives and hypnotics use a variety of mechanisms. Some work on other neurotransmitters such as serotonin. Some blood pressure medications and antihistamines also fit into this category.
Medications such as benzodiazepines are much simpler to use than antidepressants. You’ll feel their effects only minutes to hours after taking each pill. There’s no lengthy period of adjusting to the medication or waiting weeks to see if it works. Yet, they can have side effects. If you’ve been on one for a while, you will need to stop it slowly to avoid withdrawal.
The most common side effects of sedatives and hypnotics are oversedation and fatigue. That’s probably not surprising given they promote relaxation. They may also cause dizziness, stumbling, and problems with coordination. Until you know how they affect you, use extreme caution when you must be alert and react quickly. Driving is a good example. Higher doses are associated with more severe side effects.
Cognitively, you may experience brain fog or forgetfulness. By slowing down the nervous system, benzodiazepines can worsen depressive symptoms over time. Other changes can include an increase in anxiety, aggression, hyperactivity, irritability, agitation, or anger.
You’ll likely find it harder to stop these medications the longer you’ve been on them and the higher the dose. You can develop a physical dependence, as with prolonged alcohol use. Withdrawal symptoms can be severe, even causing seizures. Don’t stop all at once! Decreasing too fast is a widespread problem. Work with your doctor to slowly lower the dose.
For people having difficulty decreasing benzodiazepines due to severe withdrawal, there are solutions. You read in the previous chapter that fluoxetine can smooth out antidepressant withdrawal. In the same way, diazepam (Valium) can reduce benzodiazepine withdrawal. It, too, remains in your system for several days. Switching to diazepam and then slowly reducing its dosage results in lighter withdrawal symptoms.2
All benzodiazepines have modest differences in their effects. They vary in strength, how long they take to start working, and how long their effect lasts. Like with other medications, you may react differently than someone else.
It’s important for your doctor to match the medication to your specific needs. Short-acting ones (e.g., lasting about an hour) help you fall asleep but not stay asleep. They treat panic attacks. Long-acting ones (e.g., lasting up to a day or more) are best for ongoing anxiety. You’d need several doses of a short-acting one during the day to help with ongoing anxiety, and if not taken at regular intervals, you may experience an anxiety spike or withdrawal leading up to each dose.
There are several dozen different sedatives and hypnotics. Besides benzodiazepines, many other medications also help with certain forms of anxiety. Some are even safe for long-term use. Many of these medications were created for other purposes, e.g., lowering blood pressure or reducing pain. Appendix C describes some of the most common ones.
As mentioned, long-term daily use of benzodiazepines and similar medications is controversial. Most can be addictive. You can develop tolerance, needing a larger dose to achieve the same effect, and dependence, making them hard to stop. Using them for a short period or even occasionally over a long period does not carry the same risks.
Benzodiazepines are readily available and cause feelings of well-being and relaxation. This makes them some of the most commonly abused prescription medications. People often mix them with other substances, prescribed or otherwise, that also relax or slow body systems. These include opioid painkillers, alcohol, and illicit drugs. Combining these can be dangerous. Other medications can also compound this effect. Too much of any of these can slow your respiratory system to the point you stop breathing. You are at greater risk if you have a lung condition like asthma or sleep apnea. The opioid crisis has highlighted the dangers of accidental overdose deaths from respiratory depression.
Benzodiazepines can cause other dangers related to oversedation. These include falls and accidents while driving or operating machinery. Sedation worsens with age, making it a serious problem in seniors who are already at much higher risk of harm from falls. Long-term benzodiazepine use can also lead to memory impairment. This is again of increasing concern as people age. They increase the risk of depression and mood problems such as emotional blunting (feeling numb and unable to experience a full range of emotions).
These challenges are partly why antidepressants and other medications are the primary long-term treatments for anxiety.
The next medications we’ll discuss are mood stabilizers. These help with bipolar disorders, illnesses consisting of both depressive episodes and hypomanic or manic (high) episodes. During a high, you may need less sleep, have racing thoughts or excess energy, or undertake risk-taking behaviours for several days. The previous chapter includes a full list of symptoms.
Mood stabilizers include lithium, valproic acid (Depakote or Epival), carbamazepine (Tegretol), and lamotrigine (Lamictal). Many other medications are used as mood stabilizers, including many antipsychotics. We’ll cover these separately later in this chapter.
While antidepressants can help treat depressive episodes in bipolar disorders, their use raises the risk of hypomania or mania. Mood stabilizers help keep you from developing a mood episode, either high or low. This neutral state is known as euthymia. Treatment to keep you euthymic is called maintenance. If a mood episode develops, higher doses of mood stabilizers and other medications are briefly used to achieve remission.
Less commonly, mood stabilizers help people with unipolar depression, i.e., who have never had a hypomanic or manic episode. Some people who don’t improve with antidepressants respond well to mood stabilizers.
Let’s first examine some of the biological changes associated with bipolar disorders. We know depression can result from reduced transmission of serotonin, norepinephrine, and dopamine. Too much of these, particularly of the latter two, can contribute to hypomania or mania. But other neurotransmitters are also involved during a high. Two excitatory neurotransmitters, glutamate and aspartate, act to rev up various body systems. Think of these as the reverse of GABA that you read about earlier. Finally, chemical reactions involving sodium, calcium, and potassium can put neurons into overdrive. This increases the transmission of all neurotransmitters.
Mood stabilizers work on many of these substances. Interestingly, aside from lithium, the major mood stabilizers are all anticonvulsants. Their main use is to prevent seizures in people with conditions such as epilepsy. They all affect sodium or calcium in the neuron, which changes transmission rates and reduces glutamate and aspartate. Some may also boost GABA or serotonin. The exact mechanisms by which these medications work for bipolar disorders are not fully known.
A bipolar disorder can be one of the more challenging illnesses to treat. The inherent mix of low and high mood states requires a complex balancing act. Finding an effective medication regime can be tricky and often takes a combination of medications.
Like antidepressants, the dosage of mood stabilizers can only be increased in small increments. Some may take weeks to have full effect. Increasing too quickly boosts the chances of having side effects. You may need lab tests before starting and more to find the right dose. Doctors often prescribe antipsychotics and benzodiazepines to manage your symptoms in the interim. Both take effect quickly.
Mood stabilizers have similar side effects to antidepressants, including gastrointestinal problems, dizziness, and headache. Weight gain and sedation can also be problematic. Your doctor should help you watch and manage these. Each medication also has rare but potentially dangerous side effects. Make sure you know what to look out for.
While withdrawal symptoms from mood stabilizers tend to be milder than with antidepressants, they do occur. Decreasing the dose gradually often helps. If you’re at all prone to seizures, a sudden stop increases this risk. Also, suddenly stopping carries a high risk of developing a mood episode. This is particularly the case if you’ve been on the medication for a long time.
As with all psychotropic medications, you need to watch for specific side effects and be aware of mood changes. Mood stabilizers, except for lamotrigine, also require periodic lab monitoring.
Doses for antidepressants (and lamotrigine) are based on how well they manage your symptoms (or produce side effects). For other mood stabilizers, the level of medication in your bloodstream is critical. Blood tests check if the concentration is within a certain therapeutic level. In general, below that level, the mood stabilizer is unlikely to have much effect. Above the therapeutic level, it can be toxic.
Besides medication levels, each can potentially have side effects when used long term. Regular monitoring of weight, blood chemistry, kidneys, liver, etc. can detect problems before they become dangerous. Each medication has a protocol outlining what needs to be monitored and how often. Make sure your doctor doesn’t forget this part.
Lithium was first used to treat bipolar disorders more than 50 years ago. Options for mood stabilization have multiplied since then. While lithium is still used today, so are many other agents, alone, or in combination. The mood stabilizers listed in Appendix C are part of that mix, but so are various antipsychotics and sometimes antidepressants.
Your physical health may preclude the use of some medications. Your pattern of mood episodes may favour some medications as a starting point. You will likely undergo some trial and error before you find the best medication regime. For many people, no regime is ideal, and they struggle with a balancing act between highs, lows, and side effects. Keep track of your symptoms and medication changes. This can prevent your doctor from changing your medication based solely on how you’re feeling the day of your appointment.
When a doctor suggests you take an antipsychotic, you may question why you require the same hardcore medication used for a severe illness such as schizophrenia. You’re not alone. In truth, doctors use antipsychotics even when psychosis isn’t an issue. They treat depression, anxiety, bipolar disorders, PTSD, OCD, and some personality disorders.
Doctors use antipsychotics for mild to moderate mental illness differently than for severe illness. Doses tend to be much smaller. High doses are used rarely and for short periods, if at all. Examples of antipsychotics include quetiapine (Seroquel), risperidone (Risperdal), and olanzapine (Zyprexa).
Antipsychotics operate primarily on dopamine. Some also affect norepinephrine and serotonin. But they do so via a wider variety of mechanisms than antidepressants. This makes them uniquely capable of being added to antidepressants or other medications. They can treat problems that the “main” medication didn’t fully correct. Let’s look at a few uses.
Acute episodes. Antipsychotics are often used to quickly control symptoms of an acute mood episode. They take effect within days, and their dose doesn’t need to be slowly increased over weeks. Once you are no longer in crisis, they can be decreased or stopped altogether.
Transitional agents. Antidepressants and mood stabilizers take weeks before they take full effect. Antipsychotics can manage your most bothersome symptoms until then. Their purpose here is similar to using benzodiazepines to manage anxiety in the short term.
Augmenting agents. Interestingly, low doses of some antipsychotics can improve the effectiveness of antidepressants. Say your antidepressant helped you feel 80-90% better. However, you can’t increase the dose further. Maybe you’re at the maximum or have too many side effects. Adding a small dose of an antipsychotic may give it enough of a boost to help you feel 100% well.
Symptom management. Your antidepressant or mood stabilizer may have helped with most of your symptoms. Antipsychotics can target symptoms that your main psychotropic medication isn’t resolving. For example, quetiapine can help with sleep and nightmares, while risperidone can help with racing thoughts or anger. Unlike benzodiazepines which are addictive, antipsychotics may be better for long-term use.
Some people with mood problems have tried every antidepressant and mood stabilizer in the book. Even so, they can’t find one (or a combination) that they can both tolerate and that treats their symptoms. An antipsychotic may fit the bill when other medications haven’t worked.
Antipsychotics can affect several neurotransmitters. All reduce dopamine transmission by blocking one type of dopamine receptor (D2). The second-generation or atypical antipsychotics also block one type of serotonin receptor (5HT2A). Some medications increase or decrease the transmission of other neurotransmitters and receptors.
While antipsychotics are a mainstay for treating many symptoms of mental illness, you need to proceed with caution.
Antipsychotics have side effects, especially when used long term. Weight gain is more common and more pronounced than with some antidepressants. Other risks include poor blood sugar control (which can lead to diabetes), increased cholesterol, movement disorders (tics or tremors), hormone changes, cardiac rhythm changes, and drowsiness. Remember that just because these can happen, it does not mean they will.
Other than for acute mood states, they’re probably not the first tool to reach for. Still, based on your symptoms and response to other medications, adding an antipsychotic to your regime may be the best choice. Before starting, most people should have baseline measurements done (e.g., weight, abdominal circumference, ECG, glucose, lipids, liver, kidneys). Your current health may also be a factor. Ongoing monitoring, typically not long after starting and then every 6 to 12 months, should pick up any changes. The risks to your overall health, the benefits of the medication, and ways to minimize side effects should be considered.
The final class of psychotropic medications we’ll look at are stimulants, along with some related non-stimulant medications. They are used to treat Attention-Deficit Hyperactivity Disorder (ADHD). Examples include amphetamine (Adderall), methylphenidate (Ritalin), and atomoxetine (Strattera).
Stimulants boost transmission of dopamine (primarily) and norepinephrine. That results in increased attention, focus, and cognitive skills.
Broadly, there are two main types of stimulant medications. The first type derives from the stimulant amphetamine and includes Dexedrine, Adderall, and Vyvanse. The other type derives from the stimulant methylphenidate. It includes Ritalin, Concerta, and Biphentin/Aptensio. Most people find that one type or the other works better.
Otherwise, medications differ depending on how long their effects last and how they are released into your system. Some deliver a sizeable hit within the first hour that declines with time. Others release medication more equally over eight hours, so their effect stays constant.
Stimulants also help with some symptoms of depression such as poor concentration and fatigue. They do, however, tend to worsen anxiety.
Though not a concern when used as prescribed, stimulants are often abused and can be addictive. Some people take large doses or crush some extended-release pills to receive a massive hit right away. The result is similar to taking cocaine, which also delivers a sudden dopamine boost. Sometimes they are mixed with other medications. People without ADHD obtain them to use as cognitive enhancers. Their use by university students during exam preparation is widespread.
There are non-stimulant treatments for ADHD which have less potential for abuse. Atomoxetine (Strattera) helps with many ADHD symptoms. It works on norepinephrine rather than dopamine. Another non-stimulant option is extended-release guanfacine (Intuniv), which also affects norepinephrine. Both can cause hypomania or mania if you are at risk.
All these medications can interact with other medications and illicit drugs. They can increase blood pressure, decrease weight, change heart rhythms, affect hormones, and cause glaucoma. Take them only under medical supervision.
We’ve discussed antidepressants, benzodiazepines, mood stabilizers, antipsychotics, and stimulants and related medications. These are the main classes of psychotropic medications used today.
Sometimes, medications made for entirely different uses can help with psychiatric symptoms. You already read that many anticonvulsants work as mood stabilizers. Some blood pressure medications (e.g., propranolol, prazosin) can reduce nightmares. Some antihistamines (e.g., hydroxyzine) work as well as benzodiazepines for anxiety or sleep, with less risk of addiction or dependence. There are many other examples.
Different medications are used to deal with the side effects of psychotropic medications. We’ll discuss those in the next chapter.
Sedatives and hypnotics help with anxiety and sleep. The majority are benzodiazepines. They can cause tolerance, dependence, oversedation, and cognitive problems if used long term.
Mood stabilizers prevent both depressive and hypomanic or manic episodes. They are used to treat bipolar disorders but also unipolar depression. Some of them need periodic monitoring to avoid long-term health problems.
Antipsychotics in high doses help with psychotic illnesses. In lower doses, they can be used for other illnesses. They can help in the short term before an antidepressant starts working. They can boost the effectiveness of antidepressants or help long term with symptoms such as insomnia, anger, or rumination.
Stimulants help with attention, focus, and other cognitive skills associated with ADHD. They can help treat some symptoms in other illnesses such as depression.
Healthcare workers refer to medications you take only when needed (rather than on a regular schedule) as p.r.n. medications. This is from pro re nata, the Latin translation of “when needed.” This is the extent of your Latin lessons!↩
Dr. Heather Ashton maintains a very useful website about benzodiazepines, covering a range of topics. It includes step-by-step protocols to gradually reduce and stop benzodiazepines. The first steps are converting other benzodiazepines to their equivalent dose of diazepam. The long half-life of diazepam helps minimize withdrawal as it is reduced. You can find more information at:
https://benzo.org.uk↩
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.
