Are You Ready to Change the Way You Think About Psychiatric Medication?

Columbia University

As our understanding of the utility of the medications used in psychiatric practice expands, it has become apparent that the way we think about and refer to many of these medications is suboptimal.

For instance, many medications originally developed for the treatment of depression—which we commonly call “antidepressants”—are known to produce anxiolytic and analgesic effects; likewise, the medications classified as “second-generation” or “atypical” antipsychotics have been shown to produce antidepressant effects in some patients.

As a result, many of us have found ourselves on the receiving end of the question, “Doctor, do you think I am psychotic?” after prescribing an antipsychotic to a patient with depression, and other similar questions.

The Neuroscience-based Nomenclature initiative (NbN) is an effort to change the way we refer to medications, shifting the conversation away from an indication-based nomenclature toward the pharmacological mode of action of a given molecule. At this year’s Annual Meeting, I joined with several members of the NbN Task Force to describe the plan to change the way we think and talk about psychiatric medication.

As we discussed at the presidential session titled “New Nomenclature for Medicines,” changing the way we classify medications could prove beneficial for patients and clinicians alike. For patients and their families, clearly stressing the biological action of psychiatric medications emphasizes the fact that these illnesses are not moral failings or the patients’ “fault,” but rather the outcome of disturbed neurocircuitry, amenable to pharmacologic or behavioral interventions. Such a shift could contribute to decreasing stigma about psychiatric disease and perhaps enhance adherence as patients and their families understand the goals of pharmacotherapy more clearly.

Referring to medications based on the mode of action also encourages clinicians to take a more nuanced, precise view of pharmacologic treatments when considering the next “pharmacological step” for patients.

The NbN categorizes medications in terms of their pharmacologic targets and mode of action—listing the approved indications by the Food and Drug Administration (FDA) and/or by the European Medicines Agency (EMA) as well as medication side effects and efficacy, neurotransmitter actions, physiological effects, and effects on neurocircuitry as documented in preclinical and human studies.

The following examples demonstrate several ways the NbN might stimulate clinicians to think more precisely about pharmacologic action:

• Diazepam: Originally developed as an anxiolytic, this medication is FDA approved for the treatment of muscle spasms, status epilepticus, and alcohol withdrawal. Most psychiatrists know it works at the benzodiazepine receptor. As NbN notes, diazepam is a GABA PAM, a sobriquet reflecting its effects: positive allosteric modulation of the γ-amino butyric acid-A receptor, meaning it enhances effects of molecules binding to the receptor.

• Carbamazepine: Commonly thought of as an anticonvulsant and mood stabilizer, carbamazepine is approved for bipolar disorder and epilepsy by several agencies. It has anti-manic, anti-epileptic, and analgesic properties (for neuropathic pain). As noted in NbN, carbamazepine has anti-glutamatergic actions—specifically, it blocks voltage-gated sodium and calcium channel blockers leading to an alteration of glutamatergic tone.

• Mirtazapine: Developed as an antidepressant, mirtazapine has anxiolytic, anti-insomnia and antiemetic properties. NbN lists mirtazapine as a norepinephrine multifunctional (NEmF) drug acting as an antagonist at the norepinephrine alpha-2, 5-HT2A, 5-HT2C, and 5-HT3 receptors, leading to increases in extracellular dopamine and norepinephrine and increasing mRNA of neurotrophins while decreasing expression of pro-apoptotic proteins.

The NbN initiative has received robust support from some of the leading neuropsychopharmacology associations. It is the brain child of a group of scientists from the European College of Neuropsychopharmacology, the American College of Neuropsychopharmacology, the Asian College of Neuropsychopharmacology, the International College of Neuropsychopharmacology, and the International Union of Basic and Clinical Pharmacology.

This approach has the potential to shift the way we conceptualize our psychopharmacological interventions. Are we ready? ■