Medication Safety & Psychiatric Oversight

Medications Used in Psychiatric Oversight

There are many classes of psychiatric medications used for different conditions. They have different mechanisms of action, which is why the side effects they cause can also vary. Broadly, you’ll come across the following types of psychiatric medications: 

Antidepressants 

The most commonly used antidepressants are the selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs). These are the first-line pharmacological treatments for depression due to their well-established efficacy. 

Common SSRI medications include: 

• Sertraline.
• Escitalopram.
• Paroxetine. 

SNRIs, like venlafaxine and duloxetine, are better indicated for moderate to severe depression. Research suggests that patients who have failed to reach remission with an SSRI may benefit from treatment with an SNRI.^[1]

The clinical response to SSRIs usually begins to show up after 2-4 weeks of treatment initiation, but maximum benefits often do not occur until about 8-12 weeks of therapy.

SSRIs need to be monitored for their sexual side effects. Many people on SSRIs report: 

• Decreased libido.
• Erectile dysfunction.
• Delayed orgasm. 

If this is the case, either their dose is adjusted or they are shifted to an atypical antidepressant, like bupropion or mirtazapine, which does not have these effects. 

Anti-Anxiety Medications 

SSRIs and SNRIs also work for anxiety. However, benzodiazepines are another class of anti-anxiety medication that targets gamma-aminobutyric acid (GABA) neurotransmission instead of serotonin or norepinephrine. 

A meta-analysis of 54 articles with 12,655 participants found that benzodiazepines were superior to SSRIs and SNRIs in treating generalized anxiety disorder.^[2] 

Anti-anxiety meds are used to treat: 

• Generalized anxiety disorder.
• Panic disorder.
• Social anxiety disorder. 
• Phobias, like animal phobias, situational phobias, natural environment phobias, and so on.
• Agoraphobia, which is an intense fear of situations where escape may be difficult and could lead to panic symptoms.

Benzodiazepines, however, have a degree of misuse potential. So, SSRIs and SNRIs are preferred for long-term anxiety management because they address anxiety without the risk of misuse. 

Mood Stabilizers 

These are the medications used to treat extreme mood fluctuations, such as mania and hypomania, that happen as part of bipolar disorder. They target serotonin, dopamine, and glutamate receptors in the brain.

Lithium is the most extensively studied mood stabilizer with the strongest evidence base. Other FDA-approved mood stabilizers include: 

• Lamotrigine.
• Valproate.
• Quetiapine. 
• Olanzapine. 

However, mood stabilizers, lithium in particular, require regular blood monitoring to ensure therapeutic safety. 

Although they are best used for bipolar disorder, mood stabilizers can also be used for: 

• Schizoaffective disorder.
• Severe, treatment-resistant depression.
• Aggression, severe irritability, and explosive behavior.
• Borderline personality disorder.

Antipsychotics 

Antipsychotics are a class of psychiatric prescription medications primarily used to treat psychosis. There are two types of antipsychotics: 

1. Typical (first-generation) antipsychotics. They block dopamine (D₂) receptors in the brain, and although quite effective, they have a higher risk of movement-related side effects. Examples of these drugs include haloperidol and chlorpromazine. 
2. Atypical (second-generation) antipsychotics. They affect both dopamine and serotonin receptors and are first-line psychiatric treatments for psychosis because of the lower risk of movement disorders. They include risperidone, olanzapine, quetiapine, aripiprazole, and lurasidone. 

The Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) was a double-blind study sponsored by the National Institute of Mental Health (NIMH).^[3] It compared the effectiveness of atypical and conventional antipsychotic drugs in schizophrenia treatment and found them to have equal efficacy. 

Clozapine is the drug of choice for treatment-resistant schizophrenia (TRS), but it requires blood monitoring due to the risk of causing an extremely low white blood cell count. 

Stimulant Medications 

The FDA has approved the stimulant medications methylphenidate and amphetamine for attention-deficit hyperactivity disorder (ADHD). These medications improve dopamine and norepinephrine availability in the brain. 

A study surveying 133 clinical trials that included 14,000 children and teens and 10,000 adults concluded that stimulants were effective for ADHD in both children and adults.^[4] However, methylphenidate tends to work better in children, while amphetamines are preferred in adults. 

People on stimulants get their heart rate and blood pressure checked at each visit to ensure medication safety. 

Medications for Suicide Prevention

Intranasal esketamine is FDA-approved for treatment-resistant depression and for those with acute suicidal ideation. Research found that a single ketamine infusion was associated with significantly lower suicidal symptoms at 24 hours compared with control treatment.^[5]

Ketamine and esketamine need to be monitored for two hours post-administration. Common adverse effects of ketamine infusions include: 

• Transient dissociation.
• Dizziness.
• Nausea.

Medications Used for Substance Detox

The FDA has approved methadone, buprenorphine, and naltrexone for the treatment of opioid use disorder (OUD). All of these drugs reduce cravings and the euphoric effects of illicit opioids. 

The medications used for psychiatric oversight of alcohol use disorder are: 

• Acamprosate.
• Disulfiram.
• Oral naltrexone.
• Extended-release injectable naltrexone.

Use of alcohol use disorder medications is associated with increases in the rate of abstinence and reductions in: 

• The risk of heavy drinking.
• Number of drinking days.
• Amount of alcohol consumed per drinking day.
• Cravings. 

Buprenorphine is the safest drug for treating opioid use disorder. This is because it has a lower overdose risk than methadone. It comes as sublingual tablets, sublingual film, buccal film, and subcutaneous implants and injections.