Spring 2024 Issue

Psychotropic Medications
By Mark D. Coggins, PharmD, BCGP, FASCP
Social Work Today
Vol. 24 No. 2 P. 24

What Social Workers Need to Know to Help Clients With Mental Health Challenges

Social workers provide essential services and support to patients, caregivers, and their families. They’re also vital members of collaborative multidisciplinary health care teams and share a role with other disciplines committed to ensuring patients receive excellent health care services, including the appropriate management of medications. Social workers frequently assist clients in obtaining medication-related resources, monitoring them for potential medication-related issues, including compliance and side effects, and making referrals to health care providers. Clients who receive psychotropic medications used to treat mental illness often require additional support. By increasing their awareness and knowledge of psychotropics, social workers are better able to assist those who face mental health challenges.

Neurotransmitters
Neurotransmitters communicate signals from one neuron (nerve cell) to another target cell, such as another neuron, muscle, or gland. Neurotransmitter signaling helps our brains function and is involved in almost all bodily functions.

Classification of Neurotransmitters
A neurotransmitter can influence neurons in one of three ways: it can excite, inhibit, or modulate them.

Excitatory neurotransmitters such as epinephrine and norepinephrine excite the neuron, causing it to “fire” the message onto the target neuron.

Inhibitory neurotransmitters such as GABA and endorphins block or inhibit the message from being carried on further.

Modulatory neurotransmitters or “neuromodulators” such as dopamine and serotonin influence other neurotransmitters’ excitatory or inhibitory effects.

Specific Neurotransmitters
Certain neurotransmitters influence emotions, including mood, such as fear, pleasure, and joy. These include the following:

• Epinephrine: Responsible for the fight or flight response produced in stressful situations;

• Norepinephrine: Affects energy level and increases concentration;

• Dopamine: Responsible for pleasure and addiction, with people repeating actions to induce dopamine release;

• Serotonin: Involved in mood and contributes to well-being and happiness;

• GABA: Produces a calming effect by reducing the excitatory effect of neurons. High levels cause focus, while low levels increase anxiety;

• Acetylcholine: Involved in thought, learning, and memory;

• Glutamate: Involved in learning and memory; and

• Endorphins: Produce euphoria—a sense of well-being—and reduce pain.

Psychotropic Medications
When neurotransmitters become disrupted, symptoms of mental illness can occur. Psychotropic medications are used to treat mental health conditions by influencing the actions of various neurotransmitters in the brain.

Antidepressants
Antidepressants treat depression by helping correct the balance of neurotransmitters in the brain, especially serotonin and norepinephrine. Because it can take several weeks for antidepressant effects to be achieved, patients should be advised not to be discouraged if they don’t feel better right away.

Selective Serotonin Reuptake Inhibitors (SSRIs)
SSRIs are first-line medications for the treatment of depression and work by increasing levels of serotonin in the brain, which is believed to be diminished in people with depression. SSRIs are the antidepressant of choice across all ages and include fluoxetine (Prozac), citalopram (Celexa), escitalopram (Lexapro), paroxetine (Paxil), and sertraline (Zoloft). If a person cannot tolerate or doesn’t respond to the first SSRI tried, the use of a different SSRI may be appropriate.

SSRI side effects typically improve quickly (within one to two weeks) and include headache, abdominal pain, diarrhea and nausea, sleep difficulties, jitteriness, agitation, sexual side effects, and bruising. Persons taking any antidepressant—especially older adults—are at increased risk of falls. Another potentially severe side effect of antidepressants is “serotonin syndrome,” which can occur with high doses of SSRIs or when a combination of medications that increase serotonin are taken together. Symptoms can include agitation, confusion, and overheating (hyperthermia).

Serotonin-Norepinephrine Receptor Inhibitors (SNRIs)
SNRIs increase levels of serotonin and norepinephrine in the brain. If SSRIs are not effective or tolerated, SNRIs are often the next drug of choice. Common SNRIs include venlafaxine (Effexor), desvenlafaxine (Pristiq), and duloxetine (Cymbalta). SNRIs have similar effectiveness to SSRIs, but because they affect both serotonin and norepinephrine, they tend to have more side effects than SSRIs, including more dry mouth and increased blood pressure.

Atypical Antidepressants
“Atypical antidepressants” are those with mechanisms of action that don’t fit into the other main classes of antidepressants. Common atypical antidepressants include mirtazapine (Remeron), bupropion (Wellbutrin), and Trazodone (Desyrel). While these can be used alone for depression, they are more commonly used as addon (adjunct) agents with other classes of antidepressants.

Bupropion
Bupropion boosts dopamine and norepinephrine levels, which are involved in energy levels, motivation, and attention. It can be stimulating and is sometimes used to help improve symptoms such as oversleeping and fatigue. It can also improve concentration in people with depression or ADHD. A potential side effect of bupropion is weight loss, and it is used in combination with naltrexone in the weight loss medication Contrave. Bupropion can also help people quit smoking and can counteract a decrease in sex drive that is commonly seen with other antidepressants. As a result of its stimulating properties, bupropion’s side effects may include anxiety, agitation, and difficulty sleeping.

Trazodone
Trazodone is both a serotonin modulator and an inhibitor of serotonin reuptake (increase serotonin levels in the brain). It’s a sedating antidepressant and is often prescribed for sleep. It’s less likely than many other antidepressants to cause problems with sexual dysfunction, insomnia, and anxiety. Common side effects include drowsiness, dizziness, dry mouth, orthostatic hypotension, and fatigue.

Mirtazapine
Mirtazapine increases both serotonin and norepinephrine levels. In addition to helping with depression, it can also improve sleep. At higher doses, it can help relieve depression and anxiety. Increased appetite and weight gain are common side effects. Therefore, mirtazapine is commonly used to help persons who may benefit from increased appetite or who need to gain weight. Other side effects can include dry mouth, sleepiness, and fatigue.

Tricyclic Antidepressants (TCAs)
TCAs are an older group of antidepressants that mainly increase norepinephrine and serotonin. Due to the potential for numerous side effects, TCAs are typically reserved for cases in which other antidepressants fail to treat depression adequately. Examples include amitriptyline (Elavil), imipramine (Tofranil), desipramine (Norpramin), and nortriptyline (Pamelor).

TCAs can cause “anticholinergic” side effects, including rapid heart rate, dry skin, dry mucous membranes, dilated pupils, constipation, ileus, difficulty urinating, and confusion or agitated delirium. Drugs like TCAs and others with significant anticholinergic properties can be especially concerning in older adults and should be avoided whenever possible.

Antidepressant Suicide Risk Warning
All antidepressants in the United States carry a warning about increased risk of suicidality (suicidal thinking and behavior) in children, teenagers, and adults younger than age 25. The warning does not mean that antidepressants should be avoided in these age groups, but rather that caution is required.

The pros and cons of using antidepressants in these age groups should be considered carefully, recognizing that young persons left with untreated depression are also at a much higher risk of suicide. The risk of suicidality appears to be highest during the first few months of treatment with an antidepressant and when the dose is increased or decreased. Those started on antidepressants should be closely monitored for suicidal warning signs such as talk of dying, self-injury, and increased withdrawal.

Antipsychotics
Psychotic symptoms such as hallucinations, delusions, and disordered thinking are thought to be due to an overactivity of dopamine. Antipsychotics work by regulating dopamine transmission in the brain. Antipsychotic medications are generally used to treat the symptoms of schizophrenia and other psychotic disorders but are sometimes used to treat bipolar disorder and treatment-resistant depression.

Classes
There are two classes of antipsychotics: first-generation antipsychotics (FGAs) and second-generation antipsychotics (SGAs).

FGAs
FGAs, or “conventional” antipsychotics, are an older class of antipsychotics that are dopamine antagonists (block dopamine’s effects). They’re associated with a higher risk of extrapyramidal side effects (EPSEs) and tardive dyskinesia. Extrapyramidal symptoms include abnormal movements of the face and body, tremors, slow movement, rigidity, restlessness, and irregular movements that can’t be controlled. In some cases, these side effects can become permanent. FGAs include haloperidol (Haldol), chlorpromazine (Thorazine), and fluphenazine (Prolixin).

SGAs
SGAs, or “atypical” antipsychotics, block dopamine and also affect serotonin. Atypical antipsychotics are associated with a lower risk of EPSE but have a higher risk of metabolic side effects (eg, increased cholesterol and increased blood sugar). SGAs include risperidone (Risperdal), quetiapine (Seroquel), olanzapine (Zyprexa), ziprasidone (Geodan), paliperidone (Invega), aripiprazole (Abilify), and clozapine (Clozaril).

Side Effects of Antipsychotics
While there’s less risk of EPSE with atypical antipsychotics, monitoring for EPSEs is appropriate for all antipsychotics. Atypical antipsychotics, especially olanzapine, can cause weight gain. Persons receiving antipsychotics should be monitored for metabolic side effects. Antipsychotics can also cause sedation, anticholinergic side effects, confusion, orthostatic hypotension, and increased infection risk, among others. Clozapine should be reserved for cases in which other antipsychotics have failed because it can cause neutropenia and requires routine monitoring of white blood cell counts.

All antipsychotics carry a black box warning due to an increased risk of death in older adults with dementia-related psychosis. The FDA requires that all antipsychotics include a black box warning stating that the medications are associated with increased rates of stroke and death in older adults with dementia.

Other Considerations
It’s not possible to predict which antipsychotic may work for a person, so it may take several trials of different antipsychotics to see which works best. Antipsychotics may help reduce symptoms of acute psychosis within several hours or days, but it can take four to six weeks to reach full effect. Persons receiving antipsychotics who are experiencing concerning side effects should be advised not to stop taking them without first discussing them with their doctors.

Antianxiety Medications
Medications used to treat anxiety are referred to as “anxiolytics.” Serotonin and norepinephrine play a role in both depression and anxiety. As such, antidepressants (eg, SSRIs and SNRIs) are used to treat both depression and anxiety. Other anxiolytics include benzodiazepines (BZDs) and buspirone (Buspar).

Antidepressants
Anxiety is common among persons with depression, and SSRIs are considered to be the drugs of choice for anxiety disorders due to concerns of addiction and tolerance that develop with BZDs.

BZDs
BZDs are a class of central nervous system depressants with hypnotic, muscle relaxant, and anticonvulsant activity. BZDs work by potentiating the effects of the neurotransmitter GABA. Common BZDs include alprazolam (Xanax), lorazepam (Ativan), clonazepam (Klonopin), and others. Tolerance to BZD’s anxiolytic effects and dependence on them occurs quickly (in as little as one month), with many persons experiencing significant withdrawal symptoms when the BZD is stopped. For this reason, BZDs may be used short-term (two to four weeks) to relieve anxiety but are not recommended to be given long term. Prolonged use of BZDs is associated with dependence, substance use disorder, and increased death, especially when taken with other central nervous system depressants (eg, alcohol, opioids). Common side effects include drowsiness, confusion, dizziness, impaired coordination, depression, increased anxiety, vision problems, and slowed breathing.

Buspirone
Buspirone is a novel anxiolytic medication with a unique structure and pharmacologic profile. It’s a serotonin agonist, meaning it can bind to the same receptor as serotonin. It’s structurally unrelated to BZDs, barbiturates, and other anxiolytics. Unlike BZDs, buspirone has little abuse potential and is intended to be used long term. However, it may take three to four weeks before full antianxiety effects are achieved, and it’s therefore not used for acute anxiety episodes. Common side effects of buspirone include nausea, headache, changes in dreams, drowsiness, and dizziness or feeling lightheaded.

ADHD Medications
ADHD is a common neurological disorder characterized by persistent problems of inattention, hyperactivity, and impulsive behavior. ADHD symptoms begin in childhood and, for many, will continue into adolescence and throughout adulthood. Medications used to treat ADHD target dopamine and norepinephrine, which are involved in attention and concentration. Both stimulants and nonstimulants are used to treat ADHD symptoms.

Stimulants
Stimulants, including methylphenidate (Ritalin) and amphetamine-dextroamphetamine (Adderall), are the preferred treatment options for ADHD due to their proven efficacy and ability to provide rapid and dramatic improvement in helping persons with ADHD. However, stimulants are controlled substances and have the potential for abuse. Side effects may be troublesome for some persons and include decreased appetite, weight loss, difficulty sleeping, anxiety, tics, and increased blood pressure and heart rate.

Nonstimulants
Nonstimulants used to treat ADHD include atomoxetine (Strattera), antidepressants (eg, TCAs, venlafaxine), and blood pressure medications (eg, clonidine, guanfacine). Nonstimulants take longer to work than stimulants and may take three to four weeks to achieve full effects. Nonstimulants may be prescribed when stimulants aren’t effective, when side effects from stimulants are intolerable, in persons with concerns for abuse of stimulants, and also in combination with stimulants to increase their effectiveness.

Straterra
Straterra is a nonstimulant that was developed specifically for ADHD. It works by increasing levels of norepinephrine in the brain. Strattera often doesn’t work as well as stimulants. Common side effects include nausea, constipation, difficulty sleeping, and weight loss.

Antidepressants for ADHD
Antidepressants, including TCAs (eg, amitriptyline, nortriptyline), bupropion, and SNRI antidepressants (eg, venlafaxine), are sometimes used for ADHD. These antidepressants can help with the symptoms of ADHD and can help with comorbid depression and anxiety, which are common in persons with ADHD.

Blood Pressure Medications
Clonidine (Catapres) and guanfacine (Tenex) are blood pressure medications that can help persons with ADHD by stimulating receptors in the brain’s prefrontal cortex to alter processes implicated in ADHD symptoms. The most prominent side effects of both drugs are sedation and orthostatic hypotension. Sudden discontinuation of these drugs can also result in rebound hypertension.

Takeaways
Social workers provide essential support to clients, many of whom suffer from mental illness conditions that require the use of psychotropic medications. Social workers who increase their awareness and knowledge of psychotropics are in a unique position to assist persons with mental health issues by both referring them to appropriate health care providers and also by monitoring for potential psychotropic side effects and compliance issues.

— Mark D. Coggins, PharmD, BCGP, FASCP, is a long term care expert and corporate pharmacy consultant for Touchstone-Communities, a leading provider of senior care that include skilled nursing care, memory care, and rehabilitation for older adults throughout Texas. He’s a past director of the American Society of Consultant Pharmacists and was nationally recognized by the Commission for Certification in Geriatric Pharmacy with the Excellence in Geriatric Pharmacy Practice Award.