Mental Health Medications / Psychotropic Medications

"Antidepressants are medications commonly used to treat depression. Antidepressants are also used for other health conditions, such as anxiety, pain and insomnia. Although antidepressants are not FDA-approved specifically to treat ADHD, antidepressants are sometimes used to treat ADHD in adults.

"The most popular types of antidepressants are called selective serotonin reuptake inhibitors (SSRIs). Examples of SSRIs include:

"Fluoxetine
"Citalopram
"Sertraline
"Paroxetine
"Escitalopram
"Other types of antidepressants are serotonin and norepinephrine reuptake inhibitors (SNRIs). SNRIs are similar to SSRIs and include venlafaxine and duloxetine.

"Another antidepressant that is commonly used is bupropion. Bupropion is a third type of antidepressant which works differently than either SSRIs or SNRIs. Bupropion is also used to treat seasonal affective disorder and to help people stop smoking.

"SSRIs, SNRIs, and bupropion are popular because they do not cause as many side effects as older classes of antidepressants, and seem to help a broader group of depressive and anxiety disorders. Older antidepressant medications include tricyclics, tetracyclics, and monoamine oxidase inhibitors (MAOIs). For some people, tricyclics, tetracyclics, or MAOIs may be the best medications."

"The most common side effects listed by the FDA include:

"Nausea and vomiting
"Weight gain
"Diarrhea
"Sleepiness
"Sexual problems

"Call your doctor right away if you have any of the following symptoms, especially if they are new, worsening, or worry you(U.S. Food and Drug Administration, 2011):

"Thoughts about suicide or dying
"Attempts to commit suicide
"New or worsening depression
"New or worsening anxiety
"Feeling very agitated or restless
"Panic attacks
"Trouble sleeping (insomnia)
"New or worsening irritability
"Acting aggressively, being angry, or violent
"Acting on dangerous impulses
"An extreme increase in activity and talking (mania)
"Other unusual changes in behavior or mood

"Combining the newer SSRI or SNRI antidepressants with one of the commonly-used "triptan" medications used to treat migraine headaches could cause a life-threatening illness called "serotonin syndrome." A person with serotonin syndrome may be agitated, have hallucinations (see or hear things that are not real), have a high temperature, or have unusual blood pressure changes. Serotonin syndrome is usually associated with the older antidepressants called MAOIs, but it can happen with the newer antidepressants as well, if they are mixed with the wrong medications. For more information, please see the FDA Medication Guide on Antidepressant Medicines

"Antidepressants may cause other side effects that were not included in this list. To report any serious adverse effects associated with the use of antidepressant medicines, please contact the FDA MedWatch program using the contact information at the bottom of this page. For more information about the risks and side effects for each medication, please see Drugs@FDA."

"Anti-anxiety medications help reduce the symptoms of anxiety, such as panic attacks, or extreme fear and worry. The most common anti-anxiety medications are called benzodiazepines. Benzodiazepines can treat generalized anxiety disorder. In the case of panic disorder or social phobia (social anxiety disorder), benzodiazepines are usually second-line treatments, behind SSRIs or other antidepressants.

"Benzodiazepines used to treat anxiety disorders include:
"Clonazepam
"Alprazolam
"Lorazepam

"Short half-life (or short-acting) benzodiazepines (such as Lorazepam) and beta-blockers are used to treat the short-term symptoms of anxiety. Beta-blockers help manage physical symptoms of anxiety, such as trembling, rapid heartbeat, and sweating that people with phobias (an overwhelming and unreasonable fear of an object or situation, such as public speaking) experience in difficult situations. Taking these medications for a short period of time can help the person keep physical symptoms under control and can be used “as needed” to reduce acute anxiety.

"Buspirone (which is unrelated to the benzodiazepines) is sometimes used for the long-term treatment of chronic anxiety. In contrast to the benzodiazepines, buspirone must be taken every day for a few weeks to reach its full effect. It is not useful on an “as-needed” basis."

"Like other medications, anti-anxiety medications may cause side effects. Some of these side effects and risks are serious. The most common side effects for benzodiazepines are drowsiness and dizziness. Other possible side effects include:
"Nausea
"Blurred vision
"Headache
"Confusion
"Tiredness
"Nightmares

"Tell your doctor if any of these symptoms are severe or do not go away:
"Drowsiness
"Dizziness
"Unsteadiness
"Problems with coordination
"Difficulty thinking or remembering
"Increased saliva
"Muscle or joint pain
"Frequent urination
"Blurred vision
"Changes in sex drive or ability (The American Society of Health-System Pharmacists, Inc, 2010)

"If you experience any of the symptoms below, call your doctor immediately:
"Rash
"Hives
"Swelling of the eyes, face, lips, tongue, or throat
"Difficulty breathing or swallowing
"Hoarseness
"Seizures
"Yellowing of the skin or eyes
"Depression
"Difficulty speaking
"Yellowing of the skin or eyes
"Thoughts of suicide or harming yourself
"Difficulty breathing

"Common side effects of beta-blockers include:
"Fatigue
"Cold hands
"Dizziness or light-headedness
"Weakness
"Beta-blockers generally are not recommended for people with asthma or diabetes because they may worsen symptoms related to both.

"Possible side effects from buspirone include:
"Dizziness
"Headaches
"Nausea
"Nervousness
"Lightheadedness
"Excitement
"Trouble sleeping

"Anti-anxiety medications may cause other side effects that are not included in the lists above. To report any serious adverse effects associated with the use of these medicines, please contact the FDA MedWatch program using the contact information at the bottom of this page. For more information about the risks and side effects for each medication, please see Drugs@FDA."

"Patients stopping serotonin reuptake inhibitor (SRI) antidepressants are susceptible to SRI withdrawal, a constellation of somatic and cognitive-emotional symptoms usually occurring within 24–48 hours of stopping or reducing dosages. The syndrome may follow a protracted course and is often associated with substantial morbidity and functional impairment.1,2 Systematic reviews have reported the incidence of antidepressant withdrawal to be 33%–56%, based on short-term studies.3,4

"In recent years, the high rates of SRI withdrawal despite ostensibly gradual taper protocols have been explained by positron emission technology (PET) radioligand neuroimaging data. These studies show that about 80% occupancy of the serotonin transporter (SERT) occurs at minimum therapeutic doses of SRI antidepressants, with considerable occupancy even at subtherapeutic doses, as represented by a hyperbolic curve (Table 1).5–7 To avoid precipitous changes in SERT occupancy, which are thought to induce neurobiological instability, dosage reductions should respect this hyperbolic relationship. Progressively lower subtherapeutic doses must be incorporated into an SRI taper to maximally attenuate the risk of withdrawal symptoms.5–9"

"Currently, available dosage strengths in standard drug formularies are too limited to support gradual SRI tapers (Table 2). For instance, the lowest marketed dose of duloxetine (20 mg) averages at least 70% SERT occupancy with short-term treatment, 9 and 10 mg of citalopram averages at least 60% SERT occupancy. 9 Discontinuation at these dosages is a precipitous and high-risk discontinuation strategy. Several selective SRIs (SSRIs) are available in prepackaged prescription liquid form, but newer SRIs — including the serotonin–norepinephrine reuptake inhibitors (SNRIs), vilazodone, and vortioxetine — are not available as liquids (Table 2). To obtain dosages at lower SERT occupancies, patients often split small unscored tablets, open capsules to count beads or weigh powder, self-manufacture liquid dilutions, or rely on a compounding pharmacy.

"Although a number of leading guidelines clearly recommend hyperbolic tapering of SRIs (which can involve transitioning to liquid formulations to obtain the needed doses), for some, these methods can be prone to error, time consuming, and expensive.6,12 Certain patients may lack the physical or cognitive capacity to consistently carry out extemporaneous tapering methods. Psychiatric providers often receive limited training in deprescribing psychotropics, including hyperbolic tapering as a means of safely and successfully deprescribing SRIs.8

"In light of current deprescribing challenges at the level of the pharmaceutical formulary, patient, and clinician, there is a clear need for novel antidepressant tapering approaches that are safe and effective but also practical and easy to implement for patients."

"Psychiatric disorders are the most common conditions affecting women of childbearing age1,2. The prevalence of psychiatric disorders has increased, with recent data indicating that approximately 30% of women in developed countries are affected2, and estimates place the prevalence of psychiatric disorders during pregnancy at approximately 20%3,4,5,6. This trend has led to more pregnancies complicated by psychiatric disorders, presenting serious challenges in clinical practice3,5,7. Numerous reports show that such pregnancies are associated with an increased risk of obstetric complications, such as gestational hypertension and diabetes, and adverse neonatal outcomes, such as preterm delivery and low birth weight1,2,6,7.

"Pregnancy is a period of heightened psychological vulnerability characterized by a higher risk of mental instability2,3. During the postpartum period, maternal psychiatric instability may adversely affect child development through neglect and abuse. To mitigate these risks, many pregnant women with psychiatric disorders require pharmacological interventions, often involving multiple psychotropic medications2,7,8. The proportion of psychotropic polytherapy continues to rise and 70–80% of exposed women received antipsycotics in polytherapy8."

"This study investigated the effect of psychotropic medication use during pregnancy on short-term neonatal outcomes, focusing on the implications of non-opioid psychotropic polypharmacy and co-exposure. The incidence of adverse events was not clearly increased in newborns exposed to one or two maternal psychotropic medications compared to unexposed infants. However, in cases involving maternal use of three or more psychotropic medications, a higher frequency of short-term respiratory support and NAS-related symptoms was observed, although the number of such cases was limited. We also found no consistent trends linking maternal psychiatric diagnoses to their medications and neonatal adverse outcomes. Moreover, psychotropic drugs that inhibit CYP2D6 worsened short-term neonatal outcomes in cases of multiple psychotropic medications.

"This study found that taking three or more psychotropic medications during pregnancy worsened short-term outcomes in full-term singleton newborns. Numerous studies have investigated the effects of in utero exposure to individual psychotropic medications on obstetric and neonatal outcomes2,3,7,18,19. However, limited research has examined the impact of psychotropic polypharmacy during pregnancy on neonatal or obstetric outcomes, specifically regarding co-exposure or the number of psychotropic medications used8,9,10. Huybrechts et al. reported that in utero exposure to two or more psychotropic medications with opioids doubled the risk of NAS9. They observed that NAS severity was higher in neonates exposed to both opioids and psychotropic drugs compared to those exposed only to opioids. However, their study did not examine neonatal adverse effects beyond NAS or the outcomes of in utero psychotropic polypharmacy without opioid exposure9. As previous studies investigating the effects of non-opioid medication during pregnancy, Sadowski et al. reported higher NICU admission rates in neonates exposed to polytherapy compared to monotherapy (29% vs. 16%) when analyzing second-generation antipsychotics with other psychotropic medications, though this difference was not statistically significant8. Frayne et al. also found higher NICU admission rates in newborns of women with severe mental illness on psychotropic medications but no significant difference between the monotherapy and polytherapy groups for those on antidepressants or antipsychotics10. In addition to these evidences8,10, our study identified infants exposed to three or more non-opioid psychotropic drugs during pregnancy as a high-risk population. As untreated maternal mental health problems pose significant risks, the decision to use psychotropic medications during pregnancy should be made on an individual basis after a thorough risk/benefit analysis. The adverse effects of prenatal exposure to psychotropic drugs on newborns must be balanced against the benefits of mental health treatment for both the mother and infant20. Appropriate neonatal care should be prioritized for infants exposed to three or more psychotropic drugs during pregnancy."