Pharmaceuticals & Nutraceuticals.
In the Integrative Psychiatry blog, I described the phases of the Integrative Psychiatry approach. In phase 1, we typically consider symptomatic treatment options (usually pharmaceuticals and nutraceuticals). Several options are available to help manage symptoms while we explore underlying causes and contributing factors. Think of these options as Tylenol or Ibuprofen for the fever while we look for the source of the infection that causes it. Below, we will explore several pharmaceutical and nutraceutical options and some special considerations for the Integrative Psychiatry approach.
Skip to the end for important considerations beyond simple pharmaceuticals and nutraceuticals for symptomatic treatment!
Pharmaceuticals.
Pharmaceutical (medication) options are the mainstay treatment in conventional psychiatry practice. Pharmaceutical options all modify neurotransmitter activity. Because neurotransmitters are the communication molecule in the brain, a change at this level may translate to improved communication between brain regions. Neural integration, or appropriate communication between brain regions, is the overarching goal of most psychiatric treatments. There are several options divided into categories:
Selective Serotonin Reuptake Inhibitors (SSRIs). Selective serotonin reuptake inhibitors (SSRIs) block the reuptake of serotonin, increasing availability at the synapse. Modifying serotonin activity may improve symptoms of anxiety, depression, and trauma. Examples include fluoxetine (Prozac), sertraline (Zoloft), citalopram (Celexa), escitalopram (Lexapro), fluvoxamine (Luvox), and paroxetine (Paxil).
Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs). Serotonin-norepinephrine reuptake inhibitors (SNRIs) block serotonin and norepinephrine reuptake, increasing availability at the synapse. Modifying both serotonin and norepinephrine activity may improve symptoms of anxiety, depression, and trauma. Examples include duloxetine (Cymbalta), venlafaxine (Effexor), and desvenlafaxine (Pristiq).
Norepinephrine-Dopamine Reuptake Inhibitors (NDRIs). Norepinephrine-dopamine reuptake inhibitors (NDRIs) block norepinephrine and dopamine reuptake, increasing availability at the synapse. These options are commonly used for depression and executive impairment (e.g., attention-deficit/hyperactivity disorder). Bupropion (Wellbutrin) is the only pharmaceutical on the market that does this.
Tricyclic Antidepressants (TCAs). Tricyclic antidepressants (TCAs) function by inhibiting serotonin and norepinephrine reuptake, increasing the availability of these neurotransmitters at the synapse. Although similar in many ways to SNRIs, TCAs interact with acetylcholine and histamine receptors making their side effect profile different. These options tend to be more sedating. These options are commonly used for depression and anxiety. Examples include amitriptyline (Elavil), desipramine (Norpramin), doxepin, imipramine (Tofranil), and nortriptyline (Pamelor).
Monoamine Oxidase Inhibitors (MAOIs). Monoamine oxidase inhibitors (MAOIs) increase serotonin, dopamine, and norepinephrine availability by blocking monoamine oxidase, an enzyme that breaks down these neurotransmitters. MAOIs are typically used for depression, among other things. Still, they are less commonly used given the wide range of newer products available on the market that carry less side effect risk. Examples include isocarboxazid, phenelzine, stelegiline, and tranylcypromine.
First-Generation Antipsychotics (FGAs). First-generation antipsychotics are dopamine receptor blockers. These agents act on the receiving neuron (brain cell) to decrease the dopamine response. These agents are typically used in bipolar disorder, psychotic disorders, Tourettes, and autism spectrum, among other conditions. While still in use, these options carry a risk of extrapyramidal symptoms (EPS, movement disorders) such as dystonia, akathisia, and tardive dyskinesia. Examples include haloperidol (Haldol), chlorpromazine (Thorazine), fluphenazine (Prolixin), loxapine (Loxitane), perphenazine (Trilafon), pimozide (Orap), thiothexene (Navane), and trifluoperazine (Stelazine).
Second-Generation Antipsychotics (SGAs). Second-generation antipsychotics interact with serotonin receptors in addition to blocking dopamine receptors. These options are used for a range of conditions, including psychotic disorders, bipolar disorder, depression, trauma, and some forms of anxiety. These options are less likely to contribute to extrapyramidal symptoms (EPS) like dystonia, tardive dyskinesia, and akathisia compared with FGAs because the dopamine-serotonin balance in motor centers in the brain offsets the risk. Examples include clozapine (Clozaril), risperidone (Risperdal), olanzapine (Zyprexa), quetiapine (Seroquel), ziprasidone (Geodon), aripiprazole (Abilify), paliperidone (Invega), cariprazine (Vraylar), brexpiprazole (Rexulti), and lumateperone (Caplyta).
Mood Stabilizers. Mood stabilizers stabilize neuronal (brain cell) membranes to control firing (message sending). These options do this by adjusting mineral activity in the brain (e.g., sodium, magnesium, calcium, etc.). These options are used for mood stabilization in bipolar disorder and trauma and can be used for anxiety as well. Examples include lithium, divaloproex (Depakote), carbamazepine (Tegretol), and Lamotrigine (Lamictal).
Anxiolytics. Several anxiolytics have various mechanisms of action. Benzodiazepines (e.g., lorazepam [Ativan], diazepam [Valium], clonazepam [Klonopin], alprazolam [Xanax]) modify gamma-aminobutyric acid activity. In contrast, some options modify histamine (e.g., hydroxyzine), and others interact with beta-adrenergic receptors (e.g., propranolol, clonidine). All of these options help manage anxiety symptoms.
Psychostimulants. Psychostimulants enhance the uptake of dopamine and norepinephrine in the brain by increasing availability through pre-synaptic (before the synapse) brain cell blockade. These options are generally used to improve focus and attention-deficit/hyperactivity disorder. Examples include amphetamine (Adderall), lisdexamfetamine (Vyvanse), and methylphenidate (e.g., Ritalin, Concerta, and several others).
Non-stimulant Medications. Some non-stimulant medications are used to treat attention-deficit/hyperactivity disorder (ADHD). Unlike psychostimulants, these options are not controlled substances and, therefore, do not carry an addiction potential. They differ in their binding strength and mechanism. Non-stimulant options for ADHD, such as atomoxetine (Strattera) and viloxazine (Qelbree), primarily block norepinephrine reuptake, increasing availability in the brain.
You’ll notice that among these options, there are several indications, meaning that you can use several agents for the same condition. A skilled psychiatric provider can help you navigate your unique circumstances and determine which option may be the most appropriate based on your symptomatic experience.
Nutraceuticals.
Nutraceutical (herbal, botanical, and supplement) options are considered in Integrative Psychiatry. Like pharmaceuticals, these options can modify neurotransmitter activity. While some may believe these options are less effective, several well-conducted research trials have been done on several nutraceutical options. Some of the most well-supported options include:
Monoaminergic Alternatives. These options are all potential alternatives to monoaminergic medications (e.g., SSRIs, SNRIs, TCAs, and MAOIs). Options include s-adenosylmethionine (SAMe), rhodiola, 5-hydroxytryptophan (5-HTP), L-tryptophan, Saint John’s Wort, and Saffron.
Anxiolytic Alternatives. These options are all potential alternatives to anxiolytic medications (e.g., SSRIs, SNRIs, TCAs, MAOIs, and pharmaceutical anxiolytics). Options include magnesium, lavender, inositol, L-theanine, ashwagandha, holy basil, N-acetylcysteine, Glycine, Kava, lithium orotate, and Passionflower.
Executive Functioning Alternatives. These options are all potential alternatives to medications for attention-deficit/hyperactivity disorder (ADHD) and cognitive decline. Examples include bacopa, ginkgo biloba, pycnogenol, saffron, acetyl-l-carnitine, L-theanine, lion’s mane, rhodiola, zinc, and phosphatidyl serine.
Mood Stabilizer Alternatives. These options are not quite as potent as pharmaceutical options, but can produce a mood stabilizing effect for those experiencing mood dysregulation
While these options are widely available without the need for a prescription, it is strongly advised to consult a psychiatric specialist or medical provider for recommendations based on your unique situation. As with pharmaceutical options, nutraceutical products have risks, side effects, and contraindications (i.e., situations where the agent should not be used). Also, as with pharmaceutical agents there are several overlapping indications for nutraceutical options. Your Integrative Psychiatry specialist can help you navigate through options to help you decide on the most appropriate option for your unique situation.
Beyond Symptomatic Control.
If our goal is neural integration (i.e., healthy communication between brain regions) and neurotransmitter activity modification through pharmaceuticals and nutraceuticals enhances this at a biochemical level, we should ask an important question. How are neurotransmitters made in the first place?
It turns out that several vitamins, minerals, and other cofactors are required for adequate neurotransmitter activity. For example, vitamin D, iron, B12, magnesium, etc., are all required for neurotransmitter synthesis. Optimizing these levels is a common approach by the Integrative Psychiatry specialist. Taking this a step further, we now need to ask why these requirements are imbalanced in the first place.
This leads the Integrative Psychiatry specialist to examine several bodily systems to identify and treat abnormalities. Knowing how these internal systems are working provides a window into external systems and lifestyle factors that can be modified to optimize the internal environment for resilience and wellness.
Book an appointment now to go beyond symptomatic control and get to the root causes of your symptoms!
In the next blog, I will discuss the internal systems considered in Integrative Psychiatry and some of the methods used to evaluate them in more detail.
