Introduction:

CLASSIFICATION OF PSYCHOTROPIC DRUGS

In a medical context, psychotropic drugs refer to a class of prescription medications that primarily exert
their therapeutic effects on the central nervous system. Whether taken orally or administered
intravenously, psychotropic drugs are absorbed by the blood and transported into the brain. They pass
through the protective membrane, the blood brain barrier (BBB) and into the brain circulation.
The BBB comprises of capillaries made of tight junctions that do not allow free mixing of substances
contained within the blood with the extra cellular fluid. Most drugs cannot filter through the BBB and do
not affect brain function. Psychotropic drugs, on the other hand, are formulated especially to cross the
BBB and act directly on the brain to alter perception and mood, induce behavioral changes and affect
consciousness along with cognition [37].
The basic purpose of these drugs is to bring about the desired changes in mood and behavior to treat
and manage psychiatric disorders.
Classifying psychotropic drugs into particular groups that is universally acceptable is difficult and yet to
be done. Many of these medications have different primary functions but may eventually exert a wide
range of pharmacologic effects on the user. Many strategies have been proposed, however, a definite
classification with little or no overlap is yet to be defined. A Quick Reference to psychotropic medication
is available in Appendix A.
Psychotropic medications are generally categorized into the following:

 Antipsychotics
 Antidepressants
 Anxiolytics
 Mood stabilizers
 Prescription stimulants

 Sedative-hypnotics
 Miscellaneous drugs (e.g. herbal supplements)
Antipsychotics
This subgroup contains a large number of medications that are used to treat psychosis. Psychosis is a
generic term that encompasses disorders resulting from abnormal perception of reality accompanied by
a defective insight. Psychotic patients primarily experience these two characteristics:
 Hallucinations: Sensory perceptions without an actual stimulus being present

 Delusions: False beliefs about reality

Psychotic patients also present with social cognition impairments, personality changes and thought
disorders.
Antipsychotics are used in the treatment of mental illnesses such as schizophrenia, bipolar disorder,
delusional disorders, and also wide range of non-psychotic disorders such as Tourette syndrome,
autism, and dementia.
Antipsychotics work differently from regular medications in a way that they may not always produce
the same effect in different patients despite the similarities in their psychotic states. They may very well
exhibit different efficacies and duration of treatment across different patient groups. Interestingly,
some atypicals are prescribed in lower doses in people prone to weight gain and depression and
anxiety; they can also be used for pain management and insomnia in some patients. In short, they are
unpredictable, just like the disease they have been designed to manage.
Psychosis proceeds in an unpredictable pattern and symptomatic relief of a particular state is by no
means a criterion to discontinue an antipsychotic drug. Patients need to be thoroughly assessed by their
clinician before any changes to the dosage and timing of the medication can be taken. Additionally,
patients need to be educated about the need for these drugs to be tapered down slowly over a period
of time to avoid serious drug and manifestations of relapse such as insomnia, agitation and, motor
disorders can ensue and seriously undermine the progress made during the duration of treatment [38].
However, premature discontinuation is a reality and clinicians must then realign their treatment
strategies in order to accommodate the patient’s level of comfort regarding the therapy. Individuals
with sensitivities relative to their mental illness and medication management are a huge part of the
clinical follow up plan. Educating them and persuading them to follow the treatment strategy of
“starting low and going slow”, may be a challenge. Also, some people are attached to their routine drug
of choice, i.e. Ativan at bedtime or anti-depressant, and may be resistant to a change in medication and
its dosing schedule. In these individuals, resistance and self-sabotage to a newly improved drug therapy
often turns into a negotiation between the therapist and client.
Patients on antipsychotics need to be mindful of their diet and over the counter (OTC) medications or
nutrient product use (including “health” products) since they are notoriously known to interact with
many drugs including vitamins. The clinician’s opinion should be sought prior to commencing OTC
medications or products if the patient is already on

antipsychotics.

Antipsychotics are broadly classified into two subcategories i.e. typical and atypical (first generation and
second generation). The major difference between the two groups lies in their mechanisms of action. In
general, psychosis is believed to be a product of excessive dopamine activation and although all
antipsychotics mainly block the pathway leading to this, the atypical antipsychotics also act on the
serotonin receptors. The dual action results in fewer side effects.
The first atypical antipsychotic that gained FDA approval was clozapine in 1989 (39). It became the drug
of choice for the treatment of treatment-resistant schizophrenia and recurrent suicidal behavior in
schizophrenia. Not too long after its widespread acceptance and use, its most debilitating side effect,
agranulocytosis, began to surface.
When clozapine fell out of favor, other drugs of the same class emerged, namely risperidone and
olanzapine. Expert consensus agrees that atypical antipsychotics exhibit lower incidenceof
extrapyramidal effects and prolonged elevated prolactin levels. It blocks D4 at the mesolimbic pathway,
accounting for its efficacy in managing psychiatric symptoms minus the extrapyramidal symptoms (EPS).
Clozapine is a tricyclic benzodiapine with of 8-Chloro-11-(4-methylpiperazin-1-yl)-5H- dibenzo[b,e]
[1,4]diazepine. Its structure is shown below.

Clozapine blocks weakly D2-receptor and D1-receptor. It primarily acts on the D4-receptors, a specificity
that accounts for its lower incidence of EPS. It also exhibits of anticholinergic, antiserotoninergic, and
antihitaminic activity. The latter is responsible for the adverse effects it has on sleep patterns.
Clozapine has a 50-60% bioavailability following oral administration, reaching a peak plasma
concentration of 102-771 ng/mL within 1.5-2.5 hours. It is excreted both in the urine and feces.
Risperidone is another example of atypical antipsychotic drug. Its exact mechanism of action is not
completely understood but studies show that it is also a serotonin and dopamine receptor antagonist.
Its antidopaminergic and antiserotonergic activities stem from its blockade of the D2 and 5-HT2
receptors in the brain, respectively. Dopamine receptor blockade rarely results in neuroleptic malignant
syndrome, a fatal neurological disorder characterized by muscle rigidity, fever and autonomic
instability. Neuroleptic malignant syndrome is most commonly associated with the typical (older)
antipsychotics.

Risperidone has also been found to possess antiadrenergic and antihistaminergic properties. Aside from
schizophrenia, it is prescribed as an adjunct to lithium in patients with acute manic episodes associated
with bipolar disorder [40, 41], and treatment of irritability and behavioral problems associated with
autistic disorders [42].
The chemical formula of Risperidone is 3-[2-[4-(6-fluoro-1,2-benzisoxazol-3-yl)-1- piperidinyl]ethyl]-
6,7,8,9-tetrahydro-2-methyl-4H-pyrido[1,2-a]pyrimidin-4-one. Its molecular formula is C23H27FN4O2
and its chemical structure is shown below.

Most drugs when passing the liver via the blood stream undergo the first pass effect or hepatic
metabolism. Risperidone, when given orally, is almost completely absorbed. One/third of the drug
undergoes hepatic metabolism, with its primary metabolite, paliperidone, exhibiting as much efficacy as
its parent drug. This is the reason why the bioavailability of risperidone is close to 100%. Its mean half-
life is between 19-23 hours; the diverse number is attributed to the variability in the CYP26D group of
enzymes that metabolize it. It reaches steady state concentration within 5-6 days from the start of
therapy. It is primarily excreted in the urine. Initially, risperidone is given to adults in a dose of 2 mg/day
(either once or twice daily tablet). The dosage can be increased to up to 4 mg on the second day with
further increments as required. Severe side effects are expected with higher doses of the drug.
Generally, doses above 10 mg/day have not been proven to be more efficacious than lower doses and
since they are associated with serious side effects, they should only be administered when the clinicians
deem its benefits to outweigh its risks.

Risperidone is the first antipsychotic approved by the FDA for the treatment of schizophrenia in
adolescents aged 13-17. When used in the elderly, the starting dose should not be more than 1 mg/day.
It carries a FDA black box warning because of its propensity to cause death in patients with dementia-
related psychosis. Additionally, risperidone is best avoided in patients with renal and hepatic
impairments. More than 900 medications are believed to interact with this drug and 46 of those have
serious consequences. A detailed medication history should be taken to check for possible interactions
prior to start of therapy.
Another novel atypical antipsychotic is quetiapine. Quetiapine is also indicated in the treatment of
psychotic disorders. Anecdotal evidence points to its effectiveness in manic disorders as well, although,
no multicenter control trials have been found to support it. It is considered a first line drug for bipolar
disorders [43].
Quetiapine is a diabenzothiazepine derivative that also possesses dopamine antagonistic effects
responsible for its antimanic properties. Its antiserotonergic and antiadrenergic properties give this
drug its antidepressant effects. Its molecular formula is C21H25N3O2S, and its chemical structure is
shown below.
The drug is rapidly absorbed following oral administration and takes about 1.5 hours to reach peak
plasma levels. Compared to risperidone, quetiapine reaches steady state concentration faster i.e.
approximately 2 days. The liver metabolizes quetiapine extensively to produce inactive metabolites. Its
average half-life is 2-3 hours.

Quetiapine is given as a daily dose of 25 mg once or twice daily which can be increased up to a
maximum of 400 mg per day. However, some clinical trials showed that doses above 300 mg/day did
not exhibit superior efficacy to lower doses. Dosage adjustment is indicated in patients with hepatic
impairment. Age, gender, ethnicity and smoking do not affect its
pharmacokinetics. Like risperidone, quetiapine has also been linked to early death in elderly patients
with dementia [44] and likewise carries a black box warning on its label.
The black box warnings against the use of risperidone and quetiapine (Seroquel) in dementia-related
psychosis in geriatric patients are due to their fatal adverse effects on the cardiovascular and
respiratory systems. Patients have reportedly died suddenly because of heart failure and pneumonia.
In 2009, quetiapine joined risperidone as an FDA-approved monotherapy for the treatment of
schizophrenia in adolescents aged 13 to 17 years and as an adjunct to both lithium and valproic acid for
acute manic episodes in children and adolescents aged 10 to 17 years with bipolar disorder.
The older (typical) antipsychotics first emerged in the 1950’s, some 40 plus years before clozapine came
into the picture. These drugs act on the dopamine receptors (D2) of the CNS, essentially blocking the
endogenous dopamine from binding with them and exerting their normal physiological effects. The
older antipsychotics initially fell out of favor because of their propensity to cause extrapyramidal
symptoms (EPS). This adverse effect stems from the drug’s antidopaminergic action on the basal
ganglia. EPS includes the following movement dysfunctions:
 Akinesia
 Akathisia
Additionally, typical antipsychotics also exhibit other adverse effects such as:
 Parkinsonism (tremors, rigidity)

Bradykinesia

Erectile dysfunction
Haloperidol was developed in 1958 and approved for antipsychotic use by the FDA in 1967. It is also
indicated for the treatment of schizophrenia and has been found to be effective in treating the vocal
utterances in Tourette’s syndrome. It belongs to the butyrophenone class of drugs that include
droperidol, a neuroleptanalgesic anesthesia and sedative and, domperidone, an antiemetic. Its chemical
structure is shown below.Haloperidol is available in oral and injectable forms. The IM formulation
contains the active drug haloperidol along with lactic acid, an excipients, used to stabilize the pH of the
formulation. It is also given intravenously. As expected, its onset of action and response is very rapid
with a bioavailability of 100%. When administered as an infusion, its pharmacological effects are
sustained over a long period of time.

Haloperidol is believed to cause QT prolongation and should be given with extreme caution to patients
suffering from conditions that cause prolonged QT intervals, patients who are receiving drugs that cause
electrolyte imbalances, and critically ill patients [45]. Coadministration with carbamazepine decreases its
plasma concentration, thus, requiring dose adjustment in such cases [46]. Haloperidol is absolutely
contraindicated in patients with stroke, cardiac conditions, known hypersensitivity to the drug, and
severely intoxicated with alcohol and other central nervous system depressants. Just like the atypical
related psychosis.antipsychotics, haloperidol carries the risk of early death in elderly patients with
dementia withdrawal responses associated with their sudden discontinuation. Withdrawal symptoms

A psychotropic describes any drug that affects behavior, mood, thoughts, or perception. It’s an umbrella
term for a lot of different drugs, including prescription drugs and commonly misused drugs.

We’ll focus on prescription psychotropics and their uses here.

The Substance Abuse and Mental Health Services Administration (SAMHSA) National Survey on Drug Use
and Health data found that in 2018, 47 million adults over age 18 reported a mental health condition.

This is around 1 in 5 adults in the United States. More than 11 million reported serious mental illness.

Mental health and well-being affect our daily lives. Psychotropic medications can be an important part
of the tools available to help keep us well.

Fast facts about psychotropic drugs

Psychotropics are a broad category of drugs that treat many different conditions.

They work by adjusting levels of brain chemicals, or neurotransmitters, like dopamine, gamma
aminobutyric acid (GABA), norepinephrine, and serotonin.

There are five major classes of legal psychotropic medications:

anti-anxiety agents

antidepressants

antipsychotics

mood stabilizers
stimulants

Some can cause very serious side effects and have special monitoring requirements by healthcare
providers.

Indications of psychotropic drugs

Some conditions psychotropics treat include:

anxiety

depression

schizophrenia

bipolar disorder

sleep disorders

These medications work by altering neurotransmitters to improve symptoms. Each class works a bit
differently, but they have some similarities, too.

The type or class of medication a doctor prescribes depends on the individual and specific symptoms.
Some medications require regular use for several weeks to see benefits.

psychotropic drugs and their uses.

Classes and names of psychotropic drugs

Class Examples

Typical antipsychotics chlorpromazine (Thorazine);

fluphenazine (Prolixin);

haloperidol (Haldol);

perphenazine (Trilafon);

thioridazine (Mellaril)

Atypical antipsychotics aripiprazole (Abilify);

clozapine (Clozaril);

iloperidone (Fanapt);

olanzapine (Zyprexa);

paliperidone (Invega);
quetiapine (Seroquel);

risperidone (Risperdal);

ziprasidone (Geodon)

Anti-anxiety agents alprazolam (Xanax);

clonazepam (Klonopin);

diazepam (Valium);

lorazepam (Ativan)

Stimulants amphetamine (Adderall, Adderall XR);

dexmethylphenidate (Focalin, Focalin XR);

dextroamphetamine (Dexedrine);

lisdexamfetamine (Vyvanse);

methylphenidate (Ritalin, Metadate ER, Methylin, Concerta)

Selective serotonin reuptake inhibitor (SSRI) antidepressants citalopram (Celexa);

escitalopram (Lexapro);

fluvoxamine (Luvox);

paroxetine (Paxil); sertraline (Zoloft)

Serotonin-norepinephrine reuptake inhibitor (SNRI) antidepressants atomoxetine (Strattera);

duloxetine (Cymbalta);

venlafaxine (Effexor XR); desvenlafaxine (Pristiq)

Monoamine oxidase inhibitor (MAOI) antidepressants isocarboxazid (Marplan);

phenelzine (Nardil);

tranylcypromine (Parnate);

selegiline (Emsam, Atapryl, Carbex, Eldepryl, Zelapar)

Tricyclic antidepressants amitriptyline;

amoxapine;

desipramine (Norpramin); imipramine (Tofranil);

nortriptyline (Pamelor); protriptyline (Vivactil)

Mood stabilizers carbamazepine (Carbatrol, Tegretol, Tegretol XR);

divalproex sodium (Depakote);

lamotrigine (Lamictal);

lithium (Eskalith, Eskalith CR, Lithobid)

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Major classes of psychotropic drugs, their uses, and side effects

We’ll briefly cover the classes and some of the symptoms psychotropics treat.

Always talk to your doctor about the specific symptoms you’re experiencing. They’ll find the best
treatment options available to help you feel better.

This includes nonmedication options, such as cognitive behavioral therapy.

Some medications, such as antipsychotic medications, may take up to 2 weeksTrusted Source to help
with symptom relief. It’s important to give the medicine a chance to work before stopping it.

Anti-anxiety agents

Anti-anxiety agents, or anxiolytics, can treat different types of anxiety disorder, including social phobia
related to public speaking. They can also treat:

sleep disorders

panic attacks

stress

Mechanism of action

This class is known as benzodiazepines (BZD)Trusted Source. They’re recommended for short-term use.
BZDs work by increasing GABA levels in the brain, which causes a relaxing or calming effect. They have
serious side effects, including dependence and withdrawal.

Side effects

Side effects of BZDs include:

dizziness

drowsiness

confusion

loss of balance

memory problems

low blood pressure

slow breathing

Caution

These medications may be habit-forming if used long term. They’re not recommended for more than a
few weeks.

SSRI antidepressants

SSRIs are mainly used to treat different types of depression. Among them are major depressive disorder
and bipolar disorder.

Depression is more than feeling sad for a few days. It’s persistent symptoms that last for weeks at time.
You may also have physical symptoms, like sleep issues, lack of appetite, and body aches.

Mechanism of action

SSRIs work by increasing the amount of serotonin available in the brain. SSRIs are the first choice of
treatment for many types of depression.

Side effects

Side effects of SSRIs include:

dry mouth

nausea

vomiting

diarrhea

poor sleep

weight gain

sexual disorders
Caution

Some SSRIs can cause elevated heart rate. Some can increase your risk for bleeding if you’re also using
blood thinning medications, such as nonsteroidal anti-inflammatory drugs like aspirin or warfarin
(Coumadin, Jantoven).

SNRI antidepressants

Mechanism of action

SNRIs help treat depression but work a bit differently than SSRIs. They increase both dopamine and
norepinephrine in the brain to improve symptoms. SNRIs might work better in some people if SSRIs
haven’t brought improvement.

Side effects

Side effects of SNRIs include:

headache

dizziness

dry mouth

nausea

agitation

sleep problems

appetite issues

Caution

These drugs can increase blood pressure and heart rate. Your liver function must be monitored while on
these medications as well.

MAOI antidepressants

These drugs are older and aren’t used very often today.

Mechanism of action

MAOIs improve symptoms of depression by increasing dopamine, norepinephrine, and serotonin levels
in the brain.

Side effects

Side effects of MAOIs include:

nausea

vomiting

dizziness

diarrhea

dry mouth

weight gain

Caution

MAOIs taken with certain foods that have the chemical tyramine can increase blood pressure to
dangerous levels. Tyramine is found in many kinds of cheese, pickles, and some wines.

Tricyclic antidepressants

These are one of the oldest classes of antidepressants still available on the market. They’re reserved for
use when newer medications haven’t been effective.

Mechanism of action

Tricyclics increase the amount of serotonin and norepinephrine in the brain to improve mood.

Doctors also use tricyclics off-label to treat other conditions. Off-label use means a drug is used for a
condition that doesn’t have Food and Drug Administration (FDA) approval for that condition.

Off-label uses for tricyclics include:

panic disorder

migraine

chronic pain

obsessive-compulsive disorder

Side effects

Side effects include:

dry mouth

dizziness

drowsiness

nausea
weight gain

Caution

Certain groups should avoid tricyclics. This includes people with:

glaucoma

enlarged prostate

thyroid issues

heart problems

These medications can raise blood sugar. If you have diabetes, you may have to carefully monitor your
sugar levels.

Typical antipsychotics

These drugs treat symptoms associated with schizophrenia. They may also be used for other conditions.

Mechanism of action

Typical antipsychotics block dopamine in the brain. The first antipsychotic drug in this class,
chlorpromazine, was introduced more than 60 years agoTrusted Source. It’s still in use today.

Side effects

Side effects of antipsychotic drugs include:

blurred vision

nausea

vomiting

trouble sleeping

anxiety

drowsiness

weight gain

sexual problems

Caution

This class of drugs causes movement-related disorders called extrapyramidal side effects. These can be
serious and long lasting. They include:
tremors

uncontrolled facial movements

muscle stiffness

problems moving or walking

Atypical antipsychotics

These are the next generationTrusted Source of medications used to treat schizophrenia.

Mechanism of action

drugs work by blocking brain chemicals dopamine D2 and serotonin 5-HT2A receptor activity.

Doctors also use atypical antipsychotics to treat symptoms of:

bipolar disorder

depression

Tourette syndrome

Side effects

Atypical antipsychotics have some serious side effectsTrusted Source. These include an increased risk of:

diabetes

high cholesterol levels

heart muscle–related problems

involuntary movements, including muscle spasms, tremors

stroke

Side effects of atypical antipsychotics include:

dizziness

constipation

dry mouth

blurred vision

weight gain
sleepiness

Caution

Aripiprazole (Abilify), clozapine (Clozaril), and quetiapine (Seroquel) have a black box warning for
specific safety concerns. There’s a risk of suicidal thoughts and behaviors in people under the age of 18
who take one of these medications.

Mood stabilizers

Doctors use these drugs to treat depression and other mood disorders, like bipolar disorder.

Mechanism of action

exact way mood stabilizers work isn’t well understood yet. Some researchers believe these medications
calm specific areas of the brain that contribute to the mood changes of bipolar disorder and related
conditions.

Side effects

Side effects of mood stabilizers include:

dizziness

nausea

vomiting

tiredness

stomach problems

Caution

The kidneys remove lithium from the body, so kidney function and levels of lithium must be regularly
checked. If you have poor kidney function, your doctor may need to adjust your dose.

Stimulants

These drugs mainly treat attention deficit hyperactivity disorder (ADHD).

Mechanism of action

Stimulants increase dopamine and norepinephrine in the brain. The body can develop dependence if
used long term.

Side effects
Side effects of stimulants include:

problems with sleep

poor appetite

weight loss

Caution

Stimulants can increase heart rate and blood pressure. They may not be the best option if you have
heart or blood pressure problems.

Risks and black box warnings for psychotropics

The FDA requires boxed warningsTrusted Source for certain medications or classes of medications.
These can be for three main reasons:

The risk of a dangerous adverse reaction must be weighed over its benefits before use.

A dose adjustment might be needed for safe prescribing.

A specific group of people, such as children or pregnant women, might need special monitoring for safe
use.

Here are a few drugs and classes with boxed warnings. This isn’t a full list of warnings. Always ask your
doctor or pharmacist about specific drug side effects and risks:

Aripiprazole (Abilify) and quetiapine (Seroquel) aren’t FDA approved for use in anyone under age18 due
to the of risk suicidal thoughts and behavior.

Antipsychotic medication use in older adults with dementia-related psychosis can increase the risk of
death.

Antidepressants can worsen suicidal thoughts and behavior in children and adolescents.

Stimulant drugs may cause dependence and addiction.

Benzodiazepines taken with opioid medications can increase the risk of overdose.

Clozapine (Clozaril) can cause agranulocytosis, a serious blood disorder. You need to have blood work
done to monitor your white blood cell count. It can also cause seizures as well as heart and breathing
problems, which can be life threatening.

Avoid mixing psychotropic drugs with alcohol. Some classes, like BZDs, antidepressants, and
antipsychotic medications, have greater sedating effects with alcohol. This can create problems with
balance, awareness, and coordination. It can also slow or stop breathing, which may be life threatening.
Drug interactions

Psychotropic drugs have many interactions with other drugs, food, alcohol, and over-the-counter (OTC)
products. Always tell your doctor and pharmacist all the medications and supplements you’re taking to
avoid adverse reactions.

Stimulant drugs like amphetamine interact with:

SSRIs

SNRIs

MAOIs

tricyclics

lithium

Combining these drugs can cause a serious reaction called serotonin syndrome. If you need to take both
types of medications, your doctor will modify the doses to avoid adverse interactions.

SPECIAL WARNINGS FOR CHILDREN, PREGNANT ADULTS, AND OLDER ADULTS

Children. Some psychotropic drugs have a higher risk of side effects in children and aren’t FDA approved
for use in children. Your doctor will discuss risks versus benefits of specific medications.

Pregnancy. There’s limited information on the use of psychotropics during pregnancy. The benefits and
risks must be carefully considered for each person and each drug. Certain drugs, such as BZDs and
lithium, are harmful during pregnancy. Some SSRIs can increase the risk of birth defects. SNRI use in the
2nd trimester can cause withdrawal symptoms in babies. doctors must carefully monitor you and your
baby if you’re using any psychotropics.

Older adults. Certain drugs can take longer for body to clear if liver or kidney aren’t working well. may
be taking more medications, which can interact or increase the risk of side effects or adverse reactions.
dose might need an adjustment. Before starting any new medications, be sure to discuss all medications,
including OTC drugs and supplements, with the doctor.

Legal issues surrounding psychotropic drugs

BZDs and stimulants are controlled substances because they can cause dependence and have the
potential for misuse.

Never share or sell r prescription medications. There are federal penalties for selling or illegally buying
these medications.

These medications can also cause dependence and lead to substance use disorders.
For support and to learn more about substance use disorders, reach out to these organizations:

Narcotics Anonymous (NA)

National Institute on Drug Abuse (NIDA)

Substance Abuse and Mental Health Services Administration (SAMHSA)

When to seek emergency care

Psychotropic medications can have serious side effects. In some people, side effects can be severe.

SEEK EMERGENCY TREATMENT

Call your doctor or 911 right away if you have any of these symptoms:

your symptoms are getting worse (depression, anxiety, mania)

thoughts of suicide

panic attacks

agitation

restlessness

insomnia

increased heart rate and blood pressure

feeling irritable, angry, violent

acting impulsively and any other dramatic changes in behavior

seizures

antidepressants

Antidepressant medications are a first-choice option for treating major depressive disorder (MDD),
according to guidelines from the American Psychiatric Association. They can also help to treat anxiety
conditions, including generalized anxiety disorder.
There are different types of antidepressants, based on how they work within the brain. Some are better
for treating certain conditions and symptoms. But they all come with potential side effects.

Generally, each type causes somewhat different side effects, but there can still be some variance within
a single type.

People can also respond differently to antidepressants. Some people may have no troubling side effects,
while others may have one or more serious side effects. This is why may need to try a few different
medications before find the right fit.

Selective serotonin reuptake inhibitors (SSRIs)

SSRIs affect serotonin, which is a neurotransmitter that plays a role in many things, including the mood.
Neurotransmitters act as chemical messengers within the body.

When brain releases serotonin, some of it is used to communicate with other cells, and some of it goes
back into the cell that released it. SSRIs decrease the amount of serotonin that goes back into the cell
that released it, leaving more available in brain to communicate with other cells.

Experts aren’t completely sure about the role serotonin plays in depression. But many believe that low
levels of serotonin are a contributing factor.

SSRI antidepressants include:

citalopram (Celexa)

escitalopram (Lexapro)

paroxetine (Brisdelle, Paxil, Pexeva)

fluoxetine (Prozac)

fluvoxamine

sertraline (Zoloft)

SSRIs are the most common choice for treating MDD, but they can also help with:

generalized anxiety disorder

panic disorder

social anxiety disorder

premenstrual dysphoric disorder

post-traumatic stress disorder

obsessive-compulsive personality disorder

hot flashes

Common side effects

The more common side effects of SSRIs include:

headaches

nausea

trouble sleeping

dizziness

diarrhea

weakness and fatigue

anxiety

stomach upset

dry mouth

sexual problems such as low sex drive, erectile dysfunction, or ejaculation problems

SSRIs are more likely than some antidepressants to cause sexual side effects. They can also increase
appetite, potentially leading to weight gain.

Serotonin-norepinephrine reuptake inhibitors (SNRIs)

Like SSRIs, SNRIs are often used to treat MDD. Similar to SSRIs, SNRIs prevent cells in your brain from
reabsorbing certain neurotransmitters. This leaves more of them available to communicate with other
cells.

In the case of SNRIs, the neurotransmitters affected are serotonin and norepinephrine.

SNRI antidepressants include:

desvenlafaxine (Khedezla, Pristiq)

duloxetine (Cymbalta)

levomilnacipran (Fetzima)

milnacipran (Savella)

venlafaxine (Effexor XR)

SNRIs are often used to treat depression, but they can also help with:

nerve damage caused by diabetes

fibromyalgia

generalized anxiety disorder

hot flashes

Common side effects

The more common side effects of SNRIs include:

headaches

nausea

insomnia

drowsiness

dry mouth

dizziness

loss of appetite

constipation

sexual problems such as low sex drive, erectile dysfunction, or ejaculation problems

weakness and fatigue

sweating

SNRIs can cause sexual side effects, but not as often as SSRIs. Some people who take SNRIs may also gain
weight, but weight loss is more common.

In some cases, people taking SNRIs may notice increased blood pressure.

Tricyclic antidepressants (TCAs)

TCAs are an older group of antidepressants. Like SNRIs, they help to increase levels of norepinephrine
and serotonin your brain. But they also decrease the effects of another neurotransmitter called
acetylcholine.
This impact on acetylcholine increases the risk of certain side effects. As a result, TCAs are typically only
used if SSRIs and SNRIs don’t work well .

Some common TCAs include:

amitriptyline (Elavil)

clomipramine (Anafranil)

desipramine (Norpramin)

doxepin

imipramine (Tofranil)

nortriptyline (Pamelor)

In addition to treating depression, many TCAs are used for other conditions, including:

nerve pain caused by shingles

nerve damage caused by diabetes

social anxiety disorder

fibromyalgia

migraine headache

bedwetting in children

Common side effects

The more common side effects of TCAs include:

headaches

dry mouth

blurred vision

digestive issues, such as stomach upset, nausea, and constipation

dizziness

drowsiness

trouble sleeping

memory problems
fatigue

weight gain

sexual problems such as low sex drive, erectile dysfunction, or ejaculation problems

trouble urinating

fast heart rate

sweating

The side effects of TCAs are similar to those of SSRIs and SNRIs, but they tend to occur more frequently
and can be more bothersome.

TCAs are also much more likely to cause certain side effects, including:

dry mouth

blurred vision

constipation

trouble urinating

weight gain

drowsiness

In rare cases, TCAs can also cause potentially dangerous heart-related side effects, such as:

low blood pressure when standing up

high blood pressure

abnormal heart rate or arrhythmia

Monoamine oxidase inhibitors (MAOIs)

Like TCAs, MAOIs are an older group of medications. Today, they’re not commonly used for depression,
but your healthcare provider might suggest them if others aren’t offering relief.

MAOIs work by preventing your body from breaking down certain neurotransmitters. This causes an
increase in your levels of serotonin, norepinephrine, and dopamine.

Some common MAOIs include:

isocarboxazid (Marplan)

phenelzine (Nardil)
tranylcypromine (Parnate)

selegiline (Eldepryl, Emsam)

In addition to depression, some MAOIs are used for other conditions. Phenelzine and tranylcypromine
are sometimes used for panic disorder and social anxiety. Selegiline is used for Parkinson’s disease.

Common side effects

The more common side effects of MAOIs include:

low blood pressure

nausea

headaches

drowsiness

dizziness

dry mouth

weight gain

stomach pain

confusion

diarrhea

runny nose

sexual problems such as low sex drive, erectile dysfunction, or ejaculation problems

MAOIs are more likely to cause low blood pressure than other antidepressants. These medications can
also interact with foods containing tyramine and cause dangerously high blood pressure.

Serotonin antagonist and reuptake inhibitors (SARIs)

SARIs are also known as serotonin modulators or phenylpiperazine antidepressants. They’re sometimes
considered atypical antidepressants because they work differently. SARIs can help treat:

depression

anxiety

panic disorder
Like most other antidepressants, SARIs help to increase the amount of available serotonin — and
sometimes other neurotransmitters — in your brain. But they do so in different ways from other
antidepressants.

Some SARIs include:

nefazodone

trazodone (Oleptro)

Common side effects

The more common side effects of SARIs include:

drowsiness

dry mouth

headaches

dizziness

nausea

fatigue

vomiting

blurred vision

diarrhea

constipation

low blood pressure

confusion

Many people taking SARIs experience drowsiness or sleepiness. This makes them a potentially good
option for people with insomnia, especially if they also have depression.

Atypical antidepressants

Some antidepressants simply don’t fit into any of the main group, usually because of the way they work.
These are known as atypical antidepressants.

Bupropion (Wellbutrin)
Unlike most other antidepressants, bupropion doesn’t increase serotonin. Instead, it works to increase
norepinephrine and dopamine. It’s sometimes classified as a norepinephrine-dopamine reuptake
inhibitor.

In addition to being used for depression, bupropion is also used to help people quit smoking.

The more common side effects of bupropion include:

trouble sleeping

headaches

irritability or agitation

dry mouth

constipation

loss of appetite

weight loss

nausea

vomiting

sweating

dizziness

anxiety

Compared with other antidepressants, bupropion is less likely to cause weight gain. In fact, weight loss is
a common side effect.

Bupropion is also less likely to cause sexual problems. As a result, it’s sometimes prescribed alongside
other antidepressants to reduce their sexual side effects.

But it’s more likely than some other antidepressants to cause insomnia and anxiety. In rare cases,
bupropion can cause seizures, especially when used in high doses.

Mirtazapine (Remeron)

Mirtazapine increases the effects of norepinephrine, serotonin, and dopamine in brain in a different
way than other antidepressants. It’s sometimes classified as a noradrenergic antagonist-specific
serotonin antagonist.

The more common side effects of mirtazapine include:

drowsiness

dry mouth

increased appetite

weight gain

high cholesterol

constipation

weakness and fatigue

dizziness

Like SARIs, mirtazapine may cause sleepiness or drowsiness. As a result, mirtazapine may be used for
those who have depression and trouble sleeping.

Mirtazapine can also cause increased appetite, making it more likely to cause weight gain than other
antidepressants.

Vilazodone (Viibryd)

Vilazodone increases serotonin’s effects in the brain in ways both similar to and different from SSRIs. It’s
sometimes called a serotonin partial agonist reuptake inhibitor.

The more common side effects of vilazodone include:

diarrhea

nausea

dizziness

dry mouth

trouble sleeping

vomiting

Vilazodone is less likely to cause weight gain than many other antidepressants, such as SSRIs and TCAs.
Some people who take vilazodone have sexual problems, such as low sex drive or erectile dysfunction,
but this seems to be less common with vilazodone compared to SSRIs and SNRIs.

Vortioxetine (Trintellix)
Vortioxetine is sometimes called a multimodal antidepressant. It functions somewhat like an SSRI, but
has additional effects on serotonin levels.

The more common side effects of vortioxetine include:

sexual problems, such as orgasm or ejaculation problems

nausea

diarrhea

dizziness

dry mouth

constipation

vomiting

Vortioxetine is more likely to cause sexual side effects than many other antidepressants. But it’s less
likely to cause weight gain.

This chart only includes common side effects. Some antidepressants may have less common, more
serious side effects, including increased suicidal thoughts.

Side effect SSRIs SNRIs TCAs MAOIs SARIs bupropion mirtazapine vilazodone
vortioxetine

headache X X X X X X

diarrhea X X X X X X

dry mouth X X X X X X X X X

fatigue X X X X X X X

sweating X X X X

dizziness X X X X X X X X

blurred vision X X X

sexual issues X X X X X X

drowsiness X X X X X X X

insomnia X X X X X

weight gain X X X X X
weight loss X X X

Suicidal thoughts and behaviors risk

Some antidepressants, including SSRIs, may cause an increase in suicidal thoughts or actions. This risk is
higher in children, teenagers, and young adults. It’s also higher within the first few months of treatment
or during dosage changes.