Psychiatric Medications: Information & Specialists in Psychiatric Medications

The main groups of psychiatric medications are:

• Antidepressants: Medications primarily used to treat depression, but also to treat
  • anxiety disorders, 
  • obsessive-compulsive disorders,
  • personality disorders,
  • sleep disorders, 
  • addiction, and
  • chronic pain
• Mood stabilizers (phase prophylactics): Medications primarily used for the preventive treatment of episodic affective disorders, particularly bipolar disorder, i.e., manic-depressive illness
• Neuroleptics (antipsychotics): Medications used to treat schizophrenia and other psychoses
• Anxiolytics and hypnotics: Medications used, among other things, to treat anxiety and restlessness as well as sleep disorders
• Antidementia drugs: Medications used to treat dementia
• Alcohol withdrawal medications: Psychotropic drugs for the treatment of alcohol dependence

Antidepressants were formerly also known as thymoleptics. They are psychotropic drugs that improve mood and, depending on the specific medication, either increase energy levels or induce drowsiness.

Antidepressants are not addictive!

They are used to treat all types of depression. For mild to moderate depression, psychotherapy alone may be sufficient. However, psychotherapy does not take effect as quickly.

Herbal remedies such as St. John’s wort should only be used for mild depression. For severe depression, treatment with psychotropic medications is absolutely necessary!

It can take up to six weeks for an antidepressant to take effect. The first mood-lifting effects are usually expected after 7 to 10 days at the earliest. In approximately 70 percent of patients, depression resolves after 3 to 6 weeks of treatment.

Switching to other medications should only be considered after 4 to 6 weeks of unsuccessful treatment at a sufficiently high dosage.

Despite extensive research, the exact mechanisms of action of antidepressants are not yet fully understood. All antidepressants primarily affect the neurotransmitters serotonin and norepinephrine. This leads to changes in the brain’s regulatory circuits, which in turn alleviate depression.

What types of antidepressants are available?

The first substance found to be effective as an antidepressant was imipramine, discovered by chance in 1957. It is still available on the market today under the brand name Tofranil®. Around the same time, the antidepressant properties of the monoamine oxidase inhibitor iproniazid were also discovered. This active ingredient is used in the treatment of tuberculosis. Based on these substances, additional tricyclic and tetracyclic antidepressants and monoamine oxidase inhibitors were subsequently developed.

In the 1980s, selective serotonin reuptake inhibitors (SSRIs) were developed. While equally effective, they are generally better tolerated than tricyclic antidepressants. Tricyclic antidepressants cause a variety of side effects by binding to various other receptors.

This was followed by further innovations such as

• dual serotonin and norepinephrine reuptake inhibitors,
• alpha-2 antagonists, and
• selective norepinephrine reuptake inhibitors.

Depending on whether their effect profile tends to increase energy or cause drowsiness, antidepressants can also be classified into the following groups:

• Antidepressants that tend to cause drowsiness: e.g., amitriptyline, doxepin, trimipramine, mianserin, mirtazapine
• Antidepressants that tend to increase energy: nortriptyline, all SSRIs, reboxetine, venlafaxine, monoamine oxidase inhibitors

What side effects can occur with antidepressants?

In addition to their desired antidepressant effects, antidepressants can also cause side effects of varying severity. These typically occur during the first two weeks of treatment and often subside afterward.

Since mood improvement often hasn’t set in yet during this time, patience is key! Do not stop taking the medication, even if you haven’t noticed any positive effects yet.

The side effects of individual medications can be directly attributed to their impact on neurotransmitters and their binding sites:

• Anticholinergic side effects (especially tricyclic and tetracyclic antidepressants): dry mouth, constipation, difficulty urinating, rapid heart rate, blurred vision when reading
• Antiadrenergic side effects (primarily tricyclic and tetracyclic antidepressants and Edronax®): low blood pressure and circulatory disturbances (blackouts), irregular heartbeat, sweating
• Serotonergic side effects (especially certain tricyclic antidepressants, SSRIs, and Trevilor®): Nausea, possibly leading to vomiting; restlessness with sleep disturbances; sexual dysfunction
• Antihistaminergic side effects (especially certain tricyclic antidepressants, Tolvin®, and Remergil®): Fatigue, weight gain
• Other side effects: e.g., cardiac conduction disturbances leading to arrhythmias, muscle twitching, allergic rashes, changes in white blood cell count

Due to these side effects, regular follow-up examinations are necessary during antidepressant therapy. These include

• blood tests,
• ECG, and
• EEG.

Your doctor will provide you with detailed information about the treatment and the follow-up examinations.

Mood stabilizers are used to stabilize depressive and/or manic mood swings associated with affective and schizoaffective disorders. They are also called phase prophylactics and are intended to prevent relapses.

With the exception of lamotrigine, mood stabilizers are also used for the acute treatment of certain forms of bipolar disorder.

What mood stabilizers are available, and where are they used?

The following mood stabilizers are currently in clinical use:

• Lithium (e.g., Quilonum®, Hypnorex®): relapse prevention (prophylaxis) of recurrent depression and mania, and depression in bipolar disorders; acute treatment of euphoric mania
• Valproic acid (e.g., Orfiril®, Ergenyl®): Acute treatment of mania and prevention of manic episodes in bipolar disorders; treatment of rapid cycling
• Carbamazepine (e.g., Tegretal®, Timonil®): Acute treatment of dysphoric/irritable mania; treatment of rapid cycling
• Lamotrigine (e.g., Elmendos®): Prevention of recurrence of depression in bipolar disorder

What side effects can occur with mood stabilizers?

Lithium (e.g., Quilonum® or Hypnorex®)

Lithium is a salt that has been used successfully for decades. It is dosed so that the blood level is typically between 0.6 and 0.8 mmol/l. Regular blood level monitoring is necessary because

• at lower levels, the relapse-preventing effect is lost, and
• at higher levels, side effects become more pronounced.

Side effects primarily include

• tremors of the hands,
• increased urination,
• weight gain,
• gastrointestinal problems, and
• thyroid dysfunction.

Various medications taken at the same time can lead to increased blood levels and even toxicity. Therefore, patients should inform every doctor that they are taking lithium!

The acute effect of lithium in the treatment of mania often begins within a few days. The relapse-preventing effect often becomes apparent only after several months.

Valproic acid (e.g., Ergenyl® or Orfiril®)

Valproic acid was originally developed as a treatment for epilepsy but is also effective for bipolar disorder. It is dosed to achieve blood levels of 50 to 125 µg/ml.

Overall, valproic acid is well tolerated. The most common side effects are

• fatigue,
• elevated liver enzymes,
• temporary hair loss, and
• weight gain.

Carbamazepine (e.g., Tegretal® or Timonil®)

Carbamazepine is also an antiepileptic drug. It is used when lithium is ineffective or the patient cannot tolerate it. This medication is also titrated based on blood levels (6 to 12 µg/ml).

The most common (usually temporary) side effects are

• fatigue,
• dizziness,
• unsteady gait,
• skin rashes,
• elevated liver enzymes, and
• abnormalities in white blood cell counts.

Lamotrigine (e.g., Elmendos®)

Lamotrigine must be titrated very slowly to avoid dangerous skin and mucosal reactions. The patient receives 25 mg per day for the first two weeks, then 50 mg for the next two weeks. This is followed by an increase of 50 to 100 mg every two weeks.

If certain other medications are being taken, the dose may need to be adjusted.

Neuroleptics have a sedative effect on

• agitation,
• aggressive behavior, and
• psychotic experiences such as hallucinations, delusions, and disturbances of the sense of self.

These psychotropic drugs are therefore also referred to as antipsychotics. Strong neuroleptics are primarily used in the treatment of schizophrenia and other psychotic disorders. In 75 percent of cases, they lead to a significant improvement in psychosis.

Mild, sedating neuroleptics are also used for

• restlessness,
• agitation, and
• sleep disturbances

.

The mechanism of action of neuroleptics is not yet fully understood. They block binding sites (receptors) for neurotransmitters such as dopamine. This triggers a whole series of subsequent reactions that then lead to the antipsychotic effect.

Neuroleptics are not addictive!

What types of neuroleptics are there?

A distinction is made between strong and weak neuroleptics. The group of strong neuroleptics is further divided into classic and atypical neuroleptics.

Potent Neuroleptics

Classic neuroleptics have been on the market for decades and are safe to use. They are highly effective as antipsychotics. They can be administered both as tablets and via intramuscular injection. However, they often cause motor side effects.

Atypical neuroleptics include

• Solian®,
• Abilify®,
• Leponex®,
• Zyprexa®,
• Seroquel®,
• Risperdal®, and
• Zeldox®.

They cause few or no motor side effects and are therefore referred to as “atypical.” In most cases, they are better tolerated than classic neuroleptics. For this reason, they are increasingly being used today as first-line treatment for acute schizophrenia.

There are essentially no differences in efficacy between the individual drugs. Therefore, the choice of medication is based on criteria such as efficacy in previous treatment or side effect profile.

Only the atypical antipsychotic clozapine (Leponex®) has been shown to be superior in treating schizophrenia that does not respond to other antipsychotics.

Antipsychotics should be administered at an adequate dose for at least 4 to 6 weeks. If no effect is observed, a switch to another medication is only possible after this period.

Mild Antipsychotics

Weak neuroleptics are used to treat restlessness and sleep disturbances. For the treatment of schizophrenia, they are often combined with strong neuroleptics.

Examples of these drugs include Eunerpan®, Dipiperon®, and Atosil®.

What side effects can occur with neuroleptics?

The most significant side effects of classic neuroleptics affect motor function. These include

• so-called early dyskinesias, which set in very quickly (tongue, mouth, and eye spasms, approx. 20 percent),
• restlessness (inability to sit still, or akathisia, approx. 30 percent),
• parkinsonism (muscle stiffness and hand tremors, approx. 20 percent), as well as
• late dyskinesias, which develop as a long-term consequence after months to years of chronic use (e.g., tongue rolling, grimacing, etc., approx. 20 percent).

However, atypical antipsychotics also cause side effects. Motor side effects are much less common, however, or do not occur at all. The most important side effects include

• fatigue (e.g., Zyprexa®, Seroquel®),
• weight gain (especially Zyprexa® and Leponex®),
• cardiac conduction disturbances (e.g., Zeldox®),
• lactation,
• sexual dysfunction (e.g., Solian®), and
• often changes in blood counts (especially Leponex®).

Therefore, regular medical checkups are necessary. In rare cases, Leponex® can cause a significant decrease in white blood cell count. Therefore, a complete blood count must be performed during the first 18 weeks.

Mild neuroleptics are generally characterized by very good tolerability.

What are anxiolytics and hypnotics?

Anxiolytics are psychotropic drugs that relieve anxiety and tension. Hypnotics (sleeping pills), on the other hand, are all psychotropic drugs that induce sleep. In the past, these psychotropic drugs were also referred to as sedatives or tranquilizers.

The most important class of anxiolytics and hypnotics is the benzodiazepines. Their use is problematic primarily because of their high potential for abuse and dependence.

The main groups of medications are:

Benzodiazepines

These include, for example,

• Lorazepam (Tavor®),
• Diazepam (Valium®),
• Alprazolam (Tafil®), and
• Oxazepam (Adumbran®).

Their effects are

• anxiolytic and emotionally relaxing, as well as
• induce drowsiness (sedative) and promote sleep (hypnotic).

In addition, they have a muscle-relaxing effect. For this reason, Musaril®, for example, can also be used to treat severe muscle tension and spasticity.

Because of their effectiveness against seizures, they are also used in neurology as antiepileptic drugs.

In psychiatry and psychotherapy, benzodiazepines are used for the acute treatment of

• anxiety and panic attacks,
• severe depression accompanied by anxiety and restlessness,
• severe anxiety and agitation associated with schizophrenia or mania, and
• for the treatment of sleep disorders

.

Due to the high risk of developing dependence, these medications should only be used for a short period of time. The standard treatment duration is a maximum of 6 weeks.

However, they are still prescribed rather indiscriminately, even though other therapies have proven to be effective. Additional side effects include difficulty concentrating and slowed reaction times, which is why the ability to drive is impaired!

Non-Benzodiazepines

These medications, used exclusively as sleep aids, include

• Ximovan® (used for its relatively long duration of action in cases of difficulty falling asleep and staying asleep),
• Stilnox® and Bikalm® (used for their shorter duration of action in cases of difficulty falling asleep), and
• Sonata® (which, due to its very short duration of action, can also be taken if you wake up during the night).

Overall, these medications are less likely to lead to the development of dependence. They are generally very well tolerated, but should always be taken only temporarily.

Other anxiolytics and hypnotics

Beta-blockers are primarily used for anxiety that

• are accompanied by pronounced physical symptoms or
• are situation-dependent, e.g., exam anxiety or stage fright (Dosage: e.g., 10 to 120 mg of propranolol (Dociton®)).

There is no risk of developing dependence. Antidepressants (primarily selective serotonin reuptake inhibitors) are also used to treat anxiety disorders. For mild sleep disturbances, behavioral changes and herbal preparations (hop and valerian preparations) are often sufficient.

Over-the-counter hypnotics also include certain antihistamines, such as

• diphenhydramine (Dolestan®, Emesan®, Vivinox®) or
• doxylamine (Gittalun®, Sedaplus®).

Their sleep-inducing effect is relatively mild compared to that of true hypnotics. They are therefore suitable only for mild sleep disturbances.

Chloral hydrate (Chloraldurat®) can also be used as a sleep aid. Its sleep-promoting effect begins at a dose of 0.5 to 2 g and lasts for about 5 hours. Tolerance develops quickly with regular use. Patients with gastrointestinal, liver, or heart conditions must not take chloral hydrate. Dependence may develop.

What are anti-dementia drugs?

Antidementia drugs are various types of psychotropic medications that help improve

• memory,
• attention, and
• concentration

in cases of organic mental disorders, particularly dementia.

There are three distinct groups of substances:

• acetylcholinesterase inhibitors
• Glutamate modulators
• Other nootropics

What side effects can occur with anti-dementia medications?

Acetylcholinesterase inhibitors include

• Aricept®,
• Exelon®, and
• Reminyl®,

which are used to treat mild to moderate Alzheimer’s dementia. The main side effects at the beginning are usually limited to

• diarrhea,
• nausea and vomiting, as well as
• muscle cramps

. Occasionally, a slow heart rate may occur, increasing the risk of falls. This risk is particularly high when beta-blockers are administered concurrently. Acetylcholinesterase inhibitors should be used with extreme caution in patients with

• severe asthma,
• known cardiac arrhythmias, and
• benign prostatic hyperplasia

.

Memantine (e.g., Ebixa®) is a glutamate modulator. It is used to treat moderate-to-severe Alzheimer’s dementia and other forms of dementia. Tolerability is relatively good. Although rare,

• hallucinations,
• confusion,
• dizziness,
• headaches, or
• fatigue.

Nootropics include various substances such as

• ginkgo supplements (e.g., Tebonin®),
• piracetam (e.g., Nootrop®),
• nicergoline (e.g., Sermion®), or
• vitamin E,

which have virtually no side effects. The effectiveness of these substances in treating dementia has not been conclusively demonstrated.

Among psychotropic medications used to treat alcohol dependence, a distinction is made between

• medications used to support alcohol withdrawal and
• medications intended to prevent alcohol relapse.

During alcohol withdrawal, medication with Distraneurin® is necessary in approximately 50 percent of cases. This medication may only be used during detoxification treatment at a specialized clinic.

Campral® is available on the market as a relapse-prevention medication; it must be taken daily. It reduces the craving for alcohol. It should always be administered in conjunction with psychotherapy.