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Medications can seem overwhelming. There are so many of them, so many possible side effects, and so much information that can be found online that may or may not be reliable.
While the nitty gritty details of pharmacology may feel daunting, learning exactly how medications do what they do can actually make it quite a bit easier to understand what their expected effects are—both positive and negative.
This post will give a quick rundown of the basics of some of the commonly used psychiatric medications.
Nerve Signalling in a Nutshell
Individual nerves in the brain, called neurons, pass messages between one another. Molecules called neurotransmitters act as chemical messengers for this neuron-to-neuron communication. Neurotransmitters released by Neuron A will then attach to receptors on the surface of Neuron B. This signaling process is where psychiatric medications act.
There are a few different ways they can do this. They can affect neurotransmitter receptors to alter how Neuron B will respond to the presence of the corresponding neurotransmitter. They can also affect "reuptake" of the neurotransmitter by Neuron A, part of the natural recycling process for neurotransmitters. Drugs can also affect this recycling process in other ways.
Antidepressants target the neurotransmitters serotonin, norepinephrine, and dopamine. The idea that depression comes from a serotonin deficit is not technically true, but signaling via these three neurotransmitters is involved in the illness process.
Many of the antidepressants target "reuptake" transporters. If we go back to the idea of Neuron A signaling to Neuron B, a drug that inhibits serotonin reuptake, for example, will stop Neuron A from sucking back up any leftover serotonin in the space between Neuron A and Neuron B. That means that more serotonin is available to do its thing with receptors on Neuron B.
There are a few different classes of drugs that target these reuptake transporters. Selective serotonin reuptake inhibitors (SSRIs) like citalopram target serotonin reuptake transporters, serotonin and norepinephrine reuptake inhibitors (SNRIs) like venlafaxine target both serotonin and norepinephrine reuptake transporters, and norepinephrine and dopamine reuptake inhibitors (NDRIs) like bupropion target norepinephrine and dopamine reuptake transporters.
Okay, so we've got more neurotransmitter hanging around in the spaces where neurons connect. What does that mean? Well, the good thing is it causes an antidepressant effect. The downside? There are multiple different kinds of receptors for each neurotransmitter that can cause a lot of different effects. Many of the side effects of psychiatric medications come from getting things moving in parts of the brain where we'd rather let sleeping dogs lie. One example? Serotonin gets involved in the gut. If it gets a little too active in that department, that can mean side effects. The various side effects of medications that may seem kind of random actually make more sense when you get to know more about the different kinds of receptors involved.
It takes some time for the receptors on the Neuron B side to adjust to a new medication. So, while that's happening there's a greater likelihood of side effects. Similarly, when coming off a medication it also takes some time for those receptors to adjust. So, there can be discontinuation symptoms if the drug is stopped too quickly.
In bipolar disorder, the goal of mood stabilizers is to both treat and prevent the highs of mania and the lows of depression. Different drugs have different levels of effectiveness when it comes to each of those roles.
Lithium is the original mood stabilizer, and it affects nerve cell signaling in multiple ways. There are also several anti-epileptic drugs that act as mood stabilizers. Although, the exact mechanism by which they do this isn't entirely clear. Increasingly, newer antipsychotic drugs are also being used as mood stabilizers. Many of the mood stabilizers require periodic bloodwork monitoring to ensure that blood levels of the medication are in the proper range. This is particularly important because of the potential for drug-drug interactions between mood stabilizers that are often used together.
What defines a drug as an antipsychotic is its activity at a certain type of dopamine receptor, the D2 receptor. There are four major dopamine signaling pathways in the brain. For antipsychotic effect, we only care about one of those pathways. Unfortunately, the D2 receptors in the psychosis-related pathway look exactly the same as the D2 receptors in the other pathways, so antipsychotic drugs can affect all four pathways. That means side effects. The newer, or "atypical" antipsychotic drugs have a sort of workaround, by affecting a specific type of serotonin receptor that tones down the dopamine effects in the non-psychosis-related pathways.
None of the antipsychotics just affect D2 dopamine receptors. They do a variety of other things. In some cases that's a good thing, such as mood stabilizing activity with the atypical's. In other cases, that's a bad thing, such as causing sedation and weight gain. The particular positive and negative effects are reasonably predictable based on the types of receptors a drug acts at.
Benzodiazepines like Ativan, Klonopin, and Xanax act at the receptors for GABA, a calming neurotransmitter. Benzos work very well in the short-term, but there are a few problems that go along with that:
- Tolerance: After using it for a period of time, a higher dose will be required to achieve the same effect that was obtained from the original dose.
- Psychological Dependence: This is the mental side of addiction, the thoughts and feelings that come with a sense of need for the drug to function.
- Physical Dependence: There will be physical withdrawal symptoms if the drug is stopped abruptly.
While they may sometimes seem to have totally random effects, there actually is a rhyme and a reason to what psych meds do, both good and bad. The more you know about your medication, the easier it is for you to be in the driver's seat when it comes to your own mental health.
Psych Meds Made Simple
Want to find out more? In my new book Psych Meds Made Simple, I go into much greater detail about the different classes of psychiatric medications. The goal is to empower you to make the best possible choices about your mental health. You can find it on Amazon.