This post is part of the Psych Writer series on how psychopharmaceuticals work. They’re also called psychoactive or psychotropic. Those all mean the same thing: they’re medications that work to change your brain with what it’s missing so that you can get back your functioning.
This post is for educational purposes only, and doesn’t cover non-medicine modes of therapy. This being said, medication is not for everyone, but it is for many. Some people will need medication only, some will need talk therapy only, and still others will need a combination of the two for maximum effectiveness. This post deals with medication and how it works.
Now, onto the many, many, many psychotropic drugs and how they affect your brain.
You’ve probably heard of the podcast where they say “if you can’t make your own serotonin, store-bought is fine.” I wholeheartedly agree to that, and going further, it can apply to literally any medication. Try it: If you can’t make your own insulin, store-bought is fine. See how that works?
Your brain doesn’t always do what it’s designed to do, and that’s okay—the world of medicine can help you with that.
There are four major groups of psychotropic medications: antidepressants, antipsychotics, mood stabilizers (anti-cycling agents), and hypnoanxiolytics. Within those four groups, there are subgroups. With me so far?
There are hundreds of medications within these classes. Rather than go over each individual one, we’ll take a look at the sub-groups.
There are five sub-classes of antidepressants:
SSRIs: Probably the front-runner of antidepressants. This class is the first class that clinicians turn to in treating depression because so many people with depression and anxiety have problems with serotonin balance. SSRI stands for Selective Serotonin Reuptake Inhibitor. It increases serotonin in your brain by preventing, well, reuptake. By blocking the reabsorption, it keeps more serotonin in your system, making it available to your brain for the effect of less depression and anxiety. It’s important to note that vortioxetine (Trintellix) has been tossed into this class but is actually a serotonin modulator that repairs the brain’s white matter. White matter can atrophy with depression, and vortioxetine builds it back, unlike other SSRIs. It really belongs in a class of its own, but for now, here it is.
SNRIs: This is the next class practitioners will prescribe when SSRIs aren’t working and there is little to no anxiety present, or if the blood work comes back showing low norepinephrine in the system, or if your depression is also presenting with widespread pain. SNRI stands for Serotonin and Norepinephrine Reuptake Inhibitor. It is the same idea as an SSRI but also works on Norepinephrine.
Atypical: Like the name says, these medications don’t work like your typical SSRIs or SNRIs, etc. Bupropion (Wellbutrin) is probably the best known alongside mirtazapine. Sometimes with stubborn cases of depression, an add-on from the atypical class will be used. Think of it like a booster shot or a big brother standing behind the little brother with his arms folded, ready to beat your depression into a pulp if it doesn’t do what the little brother says.
Tricyclic: These are the oldest class and most tricky to use because there are too many wild side effects that it makes the prescription not worth it. However, if depression is severe and the other classes aren’t working, many people find it’s worth a try and to weather the side-effect storms. Amitriptyline and clomipramine are two of the most commonly prescribed in this class. Some people who have struggled with depression for a long time find that this is the only class that provides them with relief. Why? Because they work on three neurotransmitters in the brain—serotonin, norepinephrine, and dopamine.
If you are struggling and your meds aren’t working, and you’re seeing a general practitioner, seek the help of a psychiatrist who is more familiar with using tricyclic antidepressants for treatment.
MAOIs: These are Monoamine Oxidase Inhibitors. Monoamine refers to the system of that holy trinity of neurotransmitters you’ve come to know and love in fighting depression—serotonin, norepinephrine, and dopamine. Monoamine Oxidase is an enzyme that removes those neurotransmitters from the brain. MAOIs prevent this from happening, meaning you’ll have more of it left in your body. These are the final line in treating MDD because of the risk of serotonin syndrome as well as major, unpleasant side effects. The most commonly prescribed MAOIs are phenelzine and isocarboxazid.
Antipsychotics are used for several applications. They are prescribed for schizophrenia and related psychotic disorders, and sometimes are used with Bipolar Disorder and MDD with psychotic features. Yes, sometimes MDD can be so severe it causes psychosis.
Psychosis includes hallucinations which can be auditory, visual, or olfactory. It also includes delusions or fixed ideas. People with psychosis often demonstrate a lack of emotion or inappropriate emotion as well as severe lack of hygiene. These are known collectively as positive and negative symptoms. Think of it as active and inactive symptoms rather than positive as in good and negative as in bad. It’s more like go and stop. Positive symptoms would include hallucinations and delusions. Negative symptoms would include slowed thoughts or speech, loss of or inappropriate emotions, etc.
There are two classes of antipsychotic drugs: first generation and second generation. One is not actually better than the other. They just work differently. Some patients will find improvement with the first generation, and others with the second. There is no one-size fits all.
The first generation of antipsychotics is a blocker to the D2 receptor. This is a specific dopamine receptor. Your regular GP will not likely be the one prescribing this as it should be done by a specialist, such as a supervised Nurse Practitioner or psychiatrist. These first generation antipsychotics often reduce or eliminate the positive symptoms but can make negative symptoms worse or not affect them at all.
The second generation of antipsychotics work slightly differently: they block both the D2 receptor AND the specific serotonin receptor known as the 5HT2A receptor. Again, this kind of prescribing should be done by a specialist. The side effects are severe and it is not prescribed lightly. Additionally, the side effects stick around before the relief comes, so it’s hard to hang in there while the medicine does its work.
Mood Stabilizers (Anti-Cycling Agents)
Mood stabilizers are pretty self-explanatory—they take a cycling mood between mania and depression and even it out. They are in their own class. Typically what you will hear is “lithium and other mood stabilizers.” Mood stabilizers and anti-convulsants are the two kinds used in treating cycling disorders (Bipolar I, Bipolar II, and Cyclothymia).
These drugs affect a whole host of neurotransmitters, including (potentially) arachidonic acid (AA) enzymes, such as cytosolic phospholipase A2, cyclooxygenase-2 and acyl-CoA synthetase. Rather than go into it in great detail, if you are prescribed a mood stabilizer, ask your practitioner to explain which neurotransmitters this will affect in your brain. You can also ask your pharmacist. They are happy to take time out to talk to you about your medication, how it works, and what to expect.
These are the classes most US doctors are afraid to prescribe because they have a very poor understanding of addiction, so it is best up to a psychiatrist or specialist NP to prescribe. These are the medications that people do abuse for sedation effects, such as benzodiazepines like lorazepam and alprazolam.
Benzodiazepines will work fast and require a much lower dose than SSRIs. They enhance the action of the neurotransmitter Gamma Amino Butyric Acid, aka GABA. It causes a reduction in neuronal excitability—in other words, it slows you down.
Over time, the sedative effect will abate and some people mistake that as “not working.” The biggest question here is: are you getting panic attacks and anxiety again? If the answer is yes, then you will need an increased dose. If the answer is no, but it doesn’t make you sleepy anymore, then you have successfully treated your anxiety/panic with a benzo and you don’t need to have an increase. Remember, you’re not looking to go to sleep, you’re looking to handle your panic attack and still function.
Barbiturates and nonbenzodiazepines are rarely used for panic and anxiety disorders as they are better used for sedative and sleep effects.
Now that you have a basic knowledge of what these drugs are about and how they work, next time we will move on to part II of the Bazaar: what to expect when you’re first on psych meds, and how to tell if they’re working.
This post is not a substitute for professional medical advice. This post is for general informational purposes only and is not a substitute for professional medical advice. If you think you may have a medical emergency, call your doctor or (in the United States) 911 immediately. Always seek the advice of your doctor before starting or changing treatment.