Understanding Psychiatry Part 4: Taking Psychotropic Medication

Previous articles in the series on Understanding Psychiatry with Dr Sucheta Tiwari include a discussion of how to identify the need for help, the differences between a neurologist, psychiatrist and clinical psychologist, and what to expect in the first visit to a psychiatrist.

Psychotropic medication is that which works to alleviate our mental distress by influencing our brain chemistry.

There is a lot of resistance to taking psychotropic medication, which is disproportionately more than our resistance to any other medication. Instead of rejecting it outright, our attempt here is to gain the right information and make an informed decision about its potential benefits and risks for us. This is the focus of this article.


 

How does Psychotropic Medication Work?

Science today does not give us certain answers. Our minds and bodies create a unique combination along with our circumstances and environments, all of which come together to influence how psychotropic medication might work on/for each of us. However, some neurotransmitters and functions of brain chemistry have been understood enough to allow for management of mental distress through medication.

There are certain types of medications based on the way they function, what they treat and how they make us feel.

Antidepressants

Decreased quantity of serotonin – a neurotransmitter / brain chemical – is implicated in depression. Medications work to increase its quantity in our brain in two ways:

  1. by inhibiting the neurons from reabsorbing or up-taking the already released serotonin (hence the name, selective serotonin reuptake inhibitors or SSRIs)
  2. by increasing the production and release of serotonin

However, as with all medication, there may be associated side effects. These can include gastric upset, sexual difficulties, nervousness, drowsiness, problems with weight gain. We must note all beneficial and unwanted changes that occur when we take psychotropic medication and report these to our psychiatrist.

If you experience any side effects, make sure to visit your psychiatrist at the earliest. Do not stop the medication without informing your doctor.

Other than SSRIs, there is a long list of other anti-depressants such as tricyclic antidepressants (TCAs), Serotonin and norepinephrine reuptake inhibitors (SNRIs), Norepinephrine and dopamine reuptake inhibitors (NDRIs), and so on. Most of them work on serotonin along with norepinephrine or dopamine. All of these work in a variety of ways on different neurotransmitters in the brain, and they have been shown to help consistently with depression by impacting mood regulation.

Generally speaking – and it’s important to note that you may not experience any or all of these – their side effects include emotional numbness, dry mouth, urinary problems, or sexual difficulties.

Anti-anxiety or Anxiolytics

Depression and anxiety have different clinical presentations but the neurobiology overlaps. Therefore, the mainstay of treatment is more or less similar. Antidepressants are often prescribed for anxiety as well.

Particularly for calming us, a class of medicines called benzodiazapines are used. These are also called sedatives, hypnotics or anxiolytics. Anxiolytics tend to have a calming effect; they relax our mind and body, and can even make us sleepy.

The basic understanding is that these medications tranquilize the brain by increasing GABA (Gamma Aminobutyric Acid) activity, which is naturally produced in the body and responsible for our calm.

These are only to be taken in controlled doses, under medical supervision, as this class of drugs is known to cause dependence, and their use must be regulated by a qualified physician.

Obsessive Compulsive Disorder, or OCD, is a particular form of an anxiety disorder. SSRIs – the antidepressants discussed above – are helpful in treating it.

Balancing antidepressants and anxiolytics

It’s confusing. Antidepressants are meant to increase our energy levels, and anxiolytics are meant to decrease them. Given that there are similar treatments for depression and anxiety, how does this work?

The answer is found in adjusting the dosage (how much medicine) and the time at which are we are asked to take it (morning, night). A particular combination will work for us, and a balance will have to be found between which medicine works to produce energy or and which to produce calm, further regulated to produce this energy and calm at the times that best suit our body rhythms.

For example, if our job involves driving at night, we will either not be given an anxiolytic (a benzodiazapine) that can make us sleep at the wheel, or we will be asked not to drive at night. Similarly, people often complaint of their day routines getting disturbed due to fogginess or grogginess. In these cases, our night relaxant doses will be reduced and our anti-depressant, energy giving medication will be appropriately increased.

The key is to find the right balance that works for us, for which we need to take an active part in the medication process.

We should take note of our routine, the changes that occur with the medication, which doses and medicines make us feel better and worse and report this to our psychiatrist.

Anti-Psychotic Medication

Psychosis is diagnosed when there is a break from reality. With psychosis, there is often a significant reduction in self care, social relations, ability to work and so on. Biochemically, an excess of dopamine is linked with some symptoms of psychosis such as hallucinations and delusions. (Dopamine is not the only chemical implicated in psychosis, but has proved to be one of the possible ways psychosis has been alleviated).

For other symptoms such as blunted emotions, there are fewer available medications, and traditional antipsychotics don’t always work. However, there are some newer medications affecting other neurotransmitter systems as well as antidepressant medication that can be useful in addition to usual therapy in some cases.

The role of psychosocial rehabilitation in the recovery from schizophrenia and other psychoses cannot be overemphasized.

An integrated biological, social, and psychological recovery program goes a long way in ensuring an improved quality of life.

There are many more medications out there, falling into different categories and working in different ways. The ones discussed here are the most common types and are generally what we might encounter the most.


Cocktail of Medication

This is a phrase we often hear in popular culture to refer to psychiatric medicine. It makes us wary of psychotropic medication; makes us feel like we’re running blind, like we’re ingesting pills without knowing what’s really going on. More than anything, it makes it hard for us to trust the psychiatrist.

This is understandable, but surmountable.

We know that neuroscience is not at a point where we can pinpoint chemicals to an exact location, quantity, or function and have medication work on those exact specifics. Psychotropic medicines do not – as yet – provide “targeted therapy” which has become commonplace in the treatment of many physical illnesses such as cancer. However, through a multitude of ways, psychotropic medications, either alone or in combination, work very well. We also know that all medications have side effects, including our over the counter paracetamol and ibuprofen.

To add to this, there are treatment protocols for different disorders. For example, depression by itself is treated very differently from depression that comes within bipolar disorder.

There is only one way to do this:

Trust our body in the ways it responds to the medication. But also trust our psychiatrist, once we’ve decided to trust our treatment with them.

Just as we are experts in matters of our bodies, they too are experts in their field, with a lot of experience and see cases similar to ours (even if not exactly the same) everyday.

Psychiatric diagnosis and medication must be a collaborative practice.


Pros and Cons of Psychotropic Medication

There are of course some drawbacks that can make us resist psychotropic medication.

  • Most psychotropic medication takes about 2-4 weeks to start showing effect. Benzodiazapines act much quicker, within minutes or hours.
  • It may act in unknown and sometimes unpredictable ways in various combinations.
  • It can have side effects that sometimes outweigh the benefits, such as dulling our emotions, making us sleepy or zombie-like, decreasing our energy levels or sex drive.

Despite these drawbacks, psychotropic medication has some advantages.

  • It works faster than any talk based psychotherapy
  • It can help people who are in states when they are unable to communicate
  • It helps in emergency responses
  • It can bring us to a state of calm or cognizance such that we may undertake other activities that can aid our recovery, be it talk therapy, exercise or professional work

Overall, when going through a mental health crisis, please do consult a psychiatrist and if possible, a clinical psychologist.

In order to aid the recovery process, when we feel it possible, we should try and exercise, maintain a routine, get enough sleep, eat well, meet friends, and go to work.

These sound like clichéd advice, but the importance of these continued efforts cannot be stated enough. This does not mean that these actions can substitute for medication, but rather they can aid the medication in working better, in releasing serotonin naturally, in keeping other parts of us healthy, and in helping us be more a part of our own recovery and illness management process.

Armed with the knowledge that medication is only there if there is a shared decision about the diagnosis, the treatment possibilities, and evaluating the need for medication, we can play an active role in our medication regimen and overall recovery.

In the next article, we will discuss the three principles of prescribing psychotropic medication. These can be the guiding fundamentals that ensure that we know and participate in the process of our mental health recovery.


If you have particular questions or concerns and we’ll do our best to help you resolve them. writein@theshrinkingcouch.com
This article has information only. Please do not consider this to be a substitute for medical advice.

sucheta tiwari
Dr. Sucheta Tiwari is in the final year of her psychiatry residency. She has received her medical education from the University of Delhi and also has a masters degree in Global Health from the University of Oxford, UK. She hopes to work with mental health issues both with individuals as well as the communities they live in.