Chapter 1: The Naming Dilemma in Psychiatric Medications

Psychiatric medications face a significant issue with their labels. It's not about ridicule or mockery; rather, the terminology used fails to provide clarity and often misleads.

When discussing this topic, I'm not referring to the often convoluted and unpronounceable brand names that pharmaceutical companies create, which are often filled with peculiar combinations of letters. ("Ask your physician about the latest Mooodzoff!") Nor am I talking about the lengthy chemical names that generic versions carry. (Good luck with aripiprazole.)

Instead, the problematic terms include "antidepressants," "antipsychotics," and "mood stabilizers," which the mental health community employs to categorize these medications. Many psychiatric drugs, commonly labeled as psychoactive, are effective for various conditions beyond what their names imply.

This inconsistency can confuse patients who may not understand why they are prescribed medications that seem misaligned with their diagnosis. Such confusion can breed mistrust, particularly when a doctor prescribes an "antipsychotic" to address depression, anxiety, or sleep issues, potentially leading patients to feel they are being labeled as "crazy." These unhelpful labels can also affect prescribers, nudging them toward certain medications when better alternatives exist.

Neuroscientists advocate for a more descriptive approach, suggesting that medications should be named based on their effects on the brain. This mechanistic approach classifies psychiatric drugs by the neurotransmitters they influence, which could streamline the prescribing process.

While this method could reduce some confusion, it won't eliminate all issues surrounding the naming of medications. For instance, applying this mechanistic approach to what we currently refer to as "antidepressants" highlights some of its limitations.

Section 1.1: Understanding Mental Health Mechanisms

Many psychoactive medications can address a range of symptoms and conditions. This versatility arises from the overlap among various mental health disorders and shared genetic factors and neurochemical pathways.

However, this doesn't mean that all psychoactive drugs can be used interchangeably. It's essential to recognize that not every psychiatric medication will yield positive results for every individual. For example, while the antidepressant Prozac may also alleviate symptoms of panic and anxiety, it may not be effective for ADHD or delusions and could even exacerbate manic episodes.

We must acknowledge that our understanding of mental health conditions is still incomplete. Nonetheless, we know which brain receptors our medications interact with and the immediate effects of these interactions on neurotransmitters. Often, these effects are linked to mental health improvements, but more frequently, they initiate complex processes that alter neuronal interactions over time.

Subsection 1.1.1: Current Antidepressant Landscape

One term that aligns well with this mechanistic classification is serotonin selective reuptake inhibitor (SSRI). Introduced in the 1990s, SSRIs quickly became the primary choice for treating depression, remaining popular both in the US and worldwide. The SSRIs, in order of FDA approval, include: fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), fluvoxamine (Luvox), citalopram (Celexa), and escitalopram (Lexapro).

Despite their structural differences, SSRIs share significant similarities, primarily their strong binding to the serotonin transporter. These medications are considered "clean" because they predominantly target this transporter over others in the brain. However, given the lucrative nature of this market, pharmaceutical companies often emphasize trivial distinctions among SSRIs.

Recently, SSRIs have seen a decline in popularity due to the emergence of a newer class of antidepressants known as serotonin and norepinephrine reuptake inhibitors (SNRIs). SNRIs exhibit notable variations in their binding affinity for serotonin and norepinephrine transporters. The SNRIs, in order of FDA approval in the US, include: venlafaxine (Effexor), desvenlafaxine (Pristiq), duloxetine (Cymbalta), milnacipran (Savella), and levomilnacipran (Fetzima).

Before SSRIs, tricyclic antidepressants (TCAs) dominated the antidepressant market. These medications, named for their three-ringed chemical structure, were comparably effective to SSRIs but presented a higher rate of side effects, some of which were severe. The emergence of SSRIs, which are both safer and easier to dose, ultimately led to the decline of TCAs.

Chapter 2: The Evolution of Antidepressant Naming

In the video "Psychiatry & Big Pharma: Exposed - Dr James Davies, PhD," the complexities and implications of psychiatric drug classifications are explored in detail.

In recent years, the antidepressant landscape has transitioned from older SNRIs to SSRIs, and back again to new SNRIs. This evolution raises questions about whether this shift is due to fickleness among doctors or manipulative marketing by pharmaceutical companies.

By adopting a mechanistic labeling system, the distinctions between old and new SNRIs may become blurred. Both categories share similar mechanisms but differ significantly in efficacy and safety. The older SNRIs, or TCAs, are considered "dirty" as they interact with various neurotransmitter systems that may not contribute to their mood-enhancing effects while causing significant side effects.

For example, TCAs can cause sedation, weight gain, confusion, and dangerous heart-related issues. Even though they are less commonly prescribed than SSRIs, TCAs continue to be associated with numerous overdose fatalities.

Recent studies indicate that while TCAs may help with chronic pain and ADHD, these are often off-label uses. There is no evidence to suggest that TCAs outperform newer SNRIs, which are generally considered safer.

By consistently labeling TCAs as SNRIs, prescribers would be reminded of the availability of safer, equally effective alternatives. Although some patients respond well to TCAs, better options exist for most new patients, and a unified SNRI label could help clinicians remember this.

However, labeling medications solely by their beneficial actions can obscure their potential dangers.

In the video "Do Psychiatric Medications Fix 'Chemical Imbalances' in the Brain," the discussion delves into the misconceptions surrounding psychiatric medications and their effectiveness.

Determining the threshold for how strongly a drug must interact with a receptor to warrant a specific classification presents another challenge. For instance, I listed the newer SNRIs according to their market introduction, which corresponds to their binding affinities for serotonin and norepinephrine. Effexor, at low doses, primarily acts as an SSRI, while at higher doses, it functions as an SNRI.

These variations in binding strength can have significant clinical implications. Patients may experience heightened energy, increased anxiety, improved focus, or diminished side effects when the norepinephrine binding is stronger.

The complexities of drug interactions and their classifications lead to confusion. For example, should we classify low-dose Effexor as an SSRI and its higher doses as an SNRI? This classification is already in use for the TCA amitriptyline.

Insurance companies often operate under the assumption that all drugs within a mechanistic category are equally effective and safe, which is often not the case.

Pharmaceutical companies conduct extensive studies to demonstrate the safety and efficacy of medications before receiving FDA approval. However, once approved, doctors can prescribe these drugs for various purposes, leading to increased off-label use.

As a result, we may find ourselves using medications based on their actual actions rather than adhering to government-driven classifications.

The example of Luvox illustrates how marketing strategies can complicate medication designations. Although Luvox works effectively for depression, it is not officially approved for this indication. Similarly, Cymbalta was approved for depression and neuropathic pain, but its potential for treating ADHD has not been explored due to market competition concerns.

These examples highlight how FDA designations and marketing strategies can distort prescriber perceptions.

In conclusion, the diversity and complexity of psychoactive medications may render them too intricate for any classification system. As my brother-in-law says, "You can call me whatever you want. Just don’t call me late for dinner."