The landscape of psychiatric medicine has evolved considerably in recent decades. New mental health medications are often more effective, while also offering fewer and/or less severe side effects.
It is important for prescribers and other mental health professionals to stay informed about the latest medications so they can share the information with colleagues and make the right decisions for patients. Herein, we will explore the potential impacts of various newer FDA-approved psychiatric medications and treatments.
Overview of the Changing Landscape
Broadly speaking, antidepressant treatments moved toward selective serotonin reuptake inhibitors (SSRIs) in the late 1980s with the introduction of fluoxetine (Prozac). Frequently, this was based on research suggesting that there is a chemical imbalance in the brain to be addressed (Hillhouse & Porter, 2016).
Although SSRIs remain an important tool, behavioral health practitioners often find that they are not as precise or effective for some patients. Lately, many new medications have emerged that may be more personalized and tailored for specific mental health conditions. These include treatment-resistant depression (TRD), severe postpartum depression, post-traumatic stress disorder (PTSD), and attention-deficit hypersensitivity disorder (ADHD) in adults.
Breakthroughs in New Mental Health Medications for Depression
Just in the past few years, at least 3 groundbreaking antidepressant medications and treatments have received approval from the U.S. Food and Drug Administration. For treatment-resistant depression (TRD), Spravato (esketamine) is a newly approved treatment that, via nasal spray, antagonizes the brain’s N-methyl-D-aspartate (NMDA) receptors to increase levels of a neurotransmitter called glutamate, as well as dopamine.
This is quite different and, for many patients, potentially more effective than other medications. Although this treatment requires at least several weeks of appointments at certified treatment centers where patients are observed for at least 2 hours, the time and cost can be worth it. Recent research (e.g., Sanacora & Katz, 2018) supports its effectiveness for severe depression in patients where other treatments have fallen short.Another promising new medication is a pill called
Auvelity that combines dextromethorphan with bupropion. The dextromethorphan portion of this medication is an NMDA receptor antagonist, like Spravato.
However, an oral NMDA antagonist has been elusive, because dextromethorphan is metabolized too quickly by an enzyme in the body (cytochrome P450 2D6) to be therapeutic. While Spravato gets around this by using a nasal route, treatment with Spravato is much less convenient than taking a pill.
Auvelity has addressed this by combining dextromethorphan into an extended-release oral tablet with bupropion (brand name: Wellbutrin), which inhibits production of the cytochrome that metabolizes dextromethorphan. Auvelity has achieved the distinction of “statistically significant antidepressant efficacy” within 1 week, compared to several weeks or longer with other medications (Khabir, Hashmi, & Asghar, 2022). Auvelity is an important advancement that can succeed where other treatments fail for major depressive disorder (MDD) and treatment-resistant depression (TRD).
Many new mothers are affected by post-partum depression, which can be especially difficult to treat. Fortunately, a new antidepressant named brexanolone (brand name: Zulresso), administered via intravenous route, offers new possibilities for relief.
This medication helps by rectifying a precipitous drop in a metabolite of progesterone that occurs after giving birth, as well as by increasing the activity of GABAA receptors (Cornett et al., 2021). Zulresso can be a lifesaving treatment, with the caveats that it requires 60 hours of continuous intravenous treatment in an inpatient setting and may prevent a new mother from breastfeeding.
Advancements in Antipsychotic Medications
Antipsychotic medications are used to treat psychosis. This often occurs in schizophrenia, and can also be featured in bipolar disorder, some forms of severe depression, and as a side effect of illicit drug use.
The original antipsychotic medications, such as haloperidol, were marred by the side effective of tardive dyskinesia, which is unwanted and uncontrolled muscle movements. This was especially common with extended use.
Second-generation “atypical” antipsychotic medications, such as olanzapine (Zyprexa), clozapine, and aripiprazole (Abilify), have fewer and less severe extrapyramidal side effects, and may also be more effective and therapeutic. In fact, these new mental health medications can sometimes be used for a broader range of conditions, even if the patient does not have psychosis.
Novel Treatments for Anxiety Disorders
Among antipsychotics, as of 2020, the only FDA-approved anxiety treatment is an older medication called trifluoperazine, which has the same problem with tardive dyskinesia following prolonged use (Garakani et al., 2020). However, medications have frequently been used “off-label” to treat anxiety, and some have gained FDA approval for one or more anxiety disorders.
Paroxetine (Paxil), an SSRI, stands out for treating panic disorder, social anxiety disorder, and generalized anxiety disorder. In addition, alprazolam (Xanax) is a benzodiazepine approved by the FDA for treating panic disorders and anxiety disorders. Currently, it is among the most prescribed psychotropic medications in the USA.
More recently, novel treatments for anxiety disorders have often included older drugs, and some have set themselves apart by focusing on glutamate pathways. For instance, ketamine and derivatives, such as Spravato, are undergoing research as anxiety treatments, although none have received FDA approval yet.
Newer SSRIs, such as vilazodone (Viibryd), were used off-label for anxiety in the 2010s. In the years since, these have been found to be less effective than older SSRIs such as paroxetine. Drugs that act on neuropeptides, such as oxytocin, remain an enticing future research direction. However, there are no current therapeutic formulations.
Although new mental health medications for anxiety are somewhat lacking, treatments that do not involve medications at all, such as cognitive behavioral therapy (CBT) and its extension, dialectical behavior therapy (DBT), can be efficacious for many anxiety disorders (Afshari et al., 2022), and also for ADHD in adults.
Patient Education and Communication
Patient education is vital, as successful treatment plans require understanding and buy-in to be followed properly. Communication strategies with patients should focus on the benefits of newer treatment options while being realistic about what it can accomplish for them.
As new pharmaceuticals come to market, they are heavily advertised on TV commercials and elsewhere to patients, with the instruction to “ask your doctor” about it. Unfortunately, patients may misunderstand, believing a medication that is not fit for them would be helpful.
You can address these concerns by explaining which new mental health medications would work best for their treatment plan and why, along with an acknowledgement that the commercials often paint an overly rosy picture of a particular medication.
Moreover, it is important to break down patient’s treatment plans into clear and consistent steps, explained verbally, in writing and visually. This helps ensure they take the right medications under the right conditions at the right times. Finally, encouraging your patients to keep a log of their general mood at multiple times per day can help assess whether the medication is working.
We hope this article offered some insights about the evolving landscape of new mental health medications and the importance of staying informed for providing optimal patient care. Embracing continuous learning, collaboration, and the use of the latest treatments go a long way towards improving outcomes.
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