Mental Health Medications

Why Are Medications Used To Treat Mental Illness?

There is a common misconception that because there are often no visible signs, mental health conditions are “all in the head” and that they are easy to overcome. In actuality, mental health conditions are medical conditions, just like high blood pressure and high cholesterol, and have biological factors that contribute to their development.

For example, levels of serotonin are decreased in the spinal fluid of depressed individuals. Activity levels in different parts of the brain are also decreased in depression. Thus, it makes sense that there would be a biochemical treatment that would help address mental health conditions.

For some mental health conditions, medications are not required but can be helpful to speed up the process of recovery. Research consistently demonstrates that a combination of medications and therapy works best to address most mental health conditions. These conditions include depression and anxiety, which can be treated with medications alone, therapy alone, or a combination of the two. More severe presentations of depression and anxiety are more likely to benefit from the addition of medications.

Some other mental health conditions require medications to achieve remission or a reduction of symptoms. These include psychotic disorders, such as schizophrenia, and mood disorders, such as bipolar disorder.

What Are the Most Common Types of Mental Health Medications?

Antidepressants are the most prescribed mental health medications, but other common types of medications include non-antidepressant antianxiety medications and stimulants.

A 2024 study from AMA Psychiatry examined trends in incident prescriptions between 2018-2022 in the US, and it estimated 32 million antidepressant prescriptions in this timeframe. Approximately 16% of US adults reported filling one or more psychiatric prescriptions, with 12% of adults taking antidepressants.

What Drugs Are Used to Treat Depression?

Antidepressants are most commonly used to treat depression. Though they can help treat a wide variety of psychiatric conditions, including:

• Major depressive disorder
• Generalized anxiety disorder
• Post-traumatic stress disorder
• Obsessive-compulsive disorder
• Eating disorders
• Social anxiety disorder
• Premenstrual dysphoric disorder

Antidepressants also treat many nonpsychiatric conditions, including fibromyalgia, premature ejaculation, chronic pain syndromes, and postmenopausal symptoms like hot flashes.

There are five different classes of antidepressants used to treat depression. Each of these different classes works by affecting different chemicals in the brain.

Selective Serotonin Reuptake Inhibitors (SSRIs)

SSRIs primarily increase serotonin in the brain. These medications are the first-line treatment for depression and anxiety. They are widely available, inexpensive, and have fewer side effects compared to other antidepressant classes. Common mental health medications in this class include:

• Sertraline (Zoloft)
• Escitalopram (Lexapro)
• Citalopram (Celexa)
• Fluoxetine (Prozac)
• Paroxetine (Paxil)
• Vortioxetine (Trintellix)
• Vilazodone (Viibryd)

The last two medications on this list were developed to minimize sexual side effects associated with this class of medications.

Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs)

SNRIs increase serotonin and norepinephrine in the brain. They also treat nonpsychiatric conditions such as chronic pain and fibromyalgia. Common medications in this class include:

• Duloxetine (Cymbalta)
• Venlafaxine (Effexor)
• Desvenlafaxine (Pristiq)

SNRIs are a good initial choice for an individual suffering from chronic pain, depression, and anxiety, but they have more side effects compared to SSRIs.

Monoamine Oxidase Inhibitors (MAOIs)

MAOIs are an older class of antidepressants with an unclear mechanism of action. They are believed to increase serotonin, norepinephrine, and dopamine in the brain. They are very effective medications but are not used as often due to more severe side effects and are typically reserved for treatment-resistant depression. Some medications in this class require dietary restrictions due to complications when certain foods and drinks are taken with these medications. Common medications in this class include:

• Selegiline (Emsam, Zelapar)
• Phenelzine (Nardil)
• Tranylcypromine (Parnate)
• Isocarboxazid (Marplan)

MAOIs are better for atypical depression, which is characterized by mood reactivity, increased appetite, and feeling heavy and weighed down.

Tricyclic Antidepressants (TCAs)

TCAs are another older class of antidepressants that increase serotonin and norepinephrine in the brain. Like MAOIs, they are reserved for treatment-resistant depression due to more serious side effects. They are more commonly used in smaller doses to treat migraines, insomnia, and chronic pain. Common medications in this class include:

• Amitriptyline (Elavil)
• Nortriptyline (Pamelor)
• Imipramine (Tofranil)
• Doxepin (Silenor)

TCAs are better for melancholic depression, which is characterized by loss of pleasure in all activities, depression worse in the morning and early morning awakening, and significant weight loss.

Atypical Antidepressants

Atypical antidepressants don’t neatly fit into any of the other categories because they work differently by changing the levels of neurotransmitters like serotonin, norepinephrine, and dopamine.

This class includes bupropion (Wellbutrin), which primarily affects dopamine and norepinephrine, and mirtazapine (Remeron), which increases the release of norepinephrine and serotonin. This medication is popular in older adults due to having fewer side effects and drug-drug interactions.

What Drugs Treat Anxiety Disorders?

Many classes of medications are used to treat anxiety with a wide range of benefits and effects.

Antidepressants

Many antidepressants, like SSRIs and SNRIs, treat anxiety in addition to treating depression. Additionally, although bupropion is not classically used as a first-line treatment for anxiety, many physicians will prescribe it because it has been found to work on certain individuals.

Benzodiazepines

Because they work quickly, benzodiazepines are a class of medications used to treat anxiety in episodic situations, like for the treatment of panic attacks.

Benzodiazepines are intended to be used in the short term, as they have a high risk of physical dependence. They are best used for specific phobias, such as fear of flying or fear of needles, in single uses. They are also sometimes prescribed alongside antidepressants to be used on an as-needed basis while waiting for antidepressants to get into the system (typically take 4-6 weeks). Common medications in this class include:

• Alprazolam (Xanax)
• Lorazepam (Ativan)
• Clonazepam (Klonopin)
• Diazepam (Valium)

Buspirone

Buspirone is an anti-anxiety medication that doesn’t fall into any other class but has similarities to antidepressants. Its mechanism of action is unclear, but it has effects on serotonin. It can be taken as a scheduled, daily medication and on an as-needed basis but typically works better when taken daily. It can be taken as a standalone medication or in combination with an antidepressant to boost the anti-anxiety benefits of the antidepressant.

Off-Label Medications

There are a few other medications that are commonly used to treat anxiety that are not strictly psychiatric medications. Some of these medications do have an indication for the treatment of anxiety, and some are considered “off-label,” meaning they do not have the FDA indication for treating anxiety but are still effective in the treatment of anxiety.

One such medication is hydroxyzine (Atarax), an antihistamine that is usually used to treat anxiety at the moment. Some individuals benefit from taking it regularly for their anxiety when they do not respond to or cannot tolerate the side effects of other anti-anxiety medications. There is minimal risk of dependence with this medication. The primary side effects include drowsiness and dry mouth.

Another medication in this category is propranolol (Inderal), which is a blood pressure medication that is commonly used off-label for performance anxiety. It can be taken 30 minutes prior to a speech or presentation to reduce feelings of jitteriness, increased heart rate, and “mind going blank.” It is more commonly used as an adjunctive treatment for anxiety rather than a standalone medication.

Gabapentin (Neurontin) is an antiseizure medication that is also helpful in anxiety, sleep, chronic pain, and restless legs. This medication is also used for anxiety without a formal FDA indication. It can be beneficial in treating immediate symptoms of anxiety and, when taken daily, can help reduce overall baseline anxiety.

Pregabalin (Lyrica) is an antiseizure medication similar to gabapentin that also treats chronic pain and anxiety and similarly can be used in the moment for anxiety and also as a daily medication for anxiety.

What Medications Treat Psychotic Disorders?

Antipsychotic medications treat psychotic disorders by blocking the effects of dopamine in specific areas of the brain.

There are two classes of antipsychotics — first-generation, or typical antipsychotics, and second-generation, or atypical antipsychotics.

These medications help reduce hallucinations and delusions, stabilize the mood, and make thoughts clearer.

First-Generation Antipsychotics

First-Generation Antipsychotics are older medications with an increased likelihood of causing involuntary movement disorders. They are reserved for more treatment-resistant psychotic conditions due to side effects. This class includes:

• Chlorpromazine (Thorazine—this brand name is now discontinued in the US)
• Thioridazine (Mellaril)
• Haloperidol (Haldol)
• Fluphenazine (Prolixin)
• Loxapine (Loxitane)
• Perphenazine (Trilafon)
• Pimozide (Orap)

The one antipsychotic medication on this list that is still used routinely is haloperidol, as it is available in many different formulations and works quickly to treat agitation and aggressive behavior. It is used in inpatient psychiatric settings and critical care units in the hospital, where patients can sometimes experience confusion and aggressive behavior in the setting of acute medical illnesses.

Second-Generation Antipsychotics

Second-Generation Antipsychotics are a newer class of antipsychotic medications that are less likely to cause abnormal movement disorders. They are considered equally effective to first-generation antipsychotics, except for clozapine, which is known to be beneficial in treatment-resistant schizophrenia. Common medications in this class include:

• Aripiprazole (Abilify)
• Asenapine (Saphris)
• Brexpiprazole (Rexulti)
• Cariprazine (Vraylar)
• Clozapine (Clozaril)
• Iloperidone (Fanapt)
• Lumateperone (Caplyta)
• Lurasidone (Latuda)
• Pimavanserin (Nuplazid)
• Paliperidone (Invega)
• Quetiapine (Seroquel)
• Risperidone (Risperdal)
• Ziprasidone (Geodon)
• Olanzapine (Zyprexa)

More recent developments in this class of medications have activity at serotonin receptors and reduce the likelihood of abnormal movement disorders. These medications are increasingly effective, with a decreased likelihood of adverse effects like weight gain and drowsiness.

What Drugs Treat Attention Deficit Hyperactivity Disorder?

The medications that treat attention deficit hyperactivity disorder (ADHD) fall into two categories: stimulants and nonstimulants.

Stimulant medications are the first-line treatment for ADHD as they are more effective than non-stimulant medications. Some individuals get significant side effects on stimulant medications or may not be the right candidate for a stimulant medication (for example, someone with a history of severe stimulant use disorder). In these instances, non-stimulant medications are used.

Stimulant medications fall into one of two types: methylphenidate-based or amphetamine-based. Both types of stimulants have an equal likelihood of being effective in a certain individual. However, there is some suggestion that children and adolescents may do better with methylphenidate-based stimulants, and adults may do better with amphetamine-based stimulants.

Stimulant medications help improve focus and make it easier to get back on track if distracted. They help slow down all the different thoughts rushing through the head and make it easier to follow a thought to the finish. They have a calming effect and are more likely to make someone with ADHD feel sleepy. They help reduce overthinking and the ability to get past the point of “analysis paralysis” to get started on a task.

Potential side effects include:

• Elevated blood pressure
• Palpitations
• Decreased appetite
• Increased risk of hot weather injury (such as heat exhaustion, heat stroke)
• Difficulty falling asleep, particularly if taken too late in the day

Common methylphenidate-based stimulants include:

• Methylphenidate extended-release (Concerta), a long-acting, once-a-day medication
• Methylphenidate immediate-release (Ritalin), a quick, short-acting medication that needs to be taken 2-3 times a day to cover a full work or school day
• Methylphenidate mixed extended and immediate-release (Metadate), which contains 30% of immediate release and 70% extended release
• Dexmethylphenidate (Focalin), a newer, extended-release medication that is more potent than regular methylphenidate

Common amphetamine-based stimulants include:

• Dextroamphetamine-amphetamine sulfate extended and immediate release (Adderall)
• Dextroamphetamine (Dexedrine)
• Lisdexamfetamine (Vyvanse)

The extended-release formulation usually lasts for eight hours and is taken once a day. The immediate-release formulation usually lasts an average of four hours and must be taken 2-3 times daily. It kicks in within 30 minutes but can have more “wearing off” effects of fatigue and irritability.

Non-stimulant medications used to treat ADHD include:

• Atomoxetine (Strattera)
• Guanfacine (Intuniv)
• Viloxazine (Qelbree)
• Bupropion (Wellbutrin)

Both atomoxetine and viloxazine increase norepinephrine and are similar to antidepressants. Guanfacine is more commonly used in children for the treatment of hyperactivity. Bupropion is an antidepressant that can increase focus.

Sometimes, stimulants are combined with nonstimulants in individuals who only partially respond to stimulant medications.

What Drugs Treat Mental Illness in Children?

All psychiatric medications used to treat adults can also be used to treat children. However, there are more limited studies in children, and fewer psychiatric medications have an FDA indication for use in children. This does not mean the medications are not safe or effective in children, and medications are often used off-label in children.

Since there are more concerns about long-term risks in conditions such as depression and anxiety, the preferred form of treatment for those with mild to moderate symptoms would be therapy.

Antidepressants have the most reassuring data in children. There is a black box warning on all antidepressants about a rare side effect that occurs more commonly in adolescents and young adults. This rare side effect is the increased risk of suicidal thoughts with antidepressant use in children and adolescents. The overall risk is still low, and in children who have severe depression and anxiety, medication is more likely to improve and reduce their symptoms.

Other mental health medication options for children include:

• Anti-anxiety medications such as benzodiazepines are seldom used given the potential for dependence and are only used when symptoms are very severe and do not respond to other treatments.
• Schizophrenia and bipolar disorder would require medications for treatment and would include the same antipsychotics and mood stabilizers used in adults.
• Stimulant medications are still considered first-line in the treatment of ADHD in children and are more likely to improve the long-term trajectory of the condition. Undertreated and untreated ADHD can lead to the development of additional depressive and anxious conditions, substance use disorders, and eating disorders.

With any medication selection, the risks and benefits are carefully considered in the context of the individual. Medications are selected based on the likelihood of response balanced with potential side effects.

Are Mental Health Medications Right for Me?

The decision to start mental health medications is not an easy one. Speaking with your doctor about your symptoms is a good place to start so you can make a well-informed decision. One factor that goes into the decision-making is the severity of your symptoms, which can be measured through questionnaires, and the overall impact on your ability to function. If you prefer to try therapy first and there are no urgent symptoms that require more immediate treatment, it is reasonable to hold off on starting medications.

There are some situations where it might make sense to start a medication sooner, such as attending therapy for at least three months and have not seen any improvement. Or maybe you have severe symptoms, which could include:

• Serious thoughts of ending your life
• An inability to work or function
• Unusually cloudy thoughts and slow movement
• Hallucinations and delusions
• Inability to take care of yourself (meaning you are not eating, bathing, managing your hygiene)
• Worsening physical and mental symptoms

The use of mental health medications is a invaluable tool in the treatment of mental health conditions. Not only can they greatly speed up your recovery and reduce the need for hospitalization, they can also prevent you from going through the same cycle of symptoms year after year. You can have a better quality of life and have the time and energy to spend on other things, like relationships, hobbies, and activities you enjoy.

It is not a sign of weakness to take medication for a mental illness, and starting a medication does not always mean you will need to stay on it long-term. A typical timeframe for a first episode of treatment for depression and anxiety is 9-12 months. If remission is achieved after that period, it is reasonable to taper off the medication.

Speak to your doctor today to see if you might benefit from a medication evaluation.