How do antidepressants affect concentration?

Psychotropic drugs : No miracle pills

Psychopharmaceutical comes from ancient Greek and means "medicine of the soul". The basic idea of ​​this class of medication seems plausible: if you have a cold you take a cold spray, if you have a cough you take cough drops, if you have heart problems you take heart medication and if you feel depressed you take psychotropic drugs. But it's not that simple. On the one hand, the mode of action of psychotropic drugs is not quite as clear as that of a drug that decongests the mucous membrane or vasodilates. On the other hand, they are controversial because they interfere with our personality and feelings. Since the first antidepressant hit the market in the 1950s, psychotropic drugs have been charged with hopes, expectations and fears - which sometimes come true and sometimes don't. It is therefore impossible to make a general statement about whether psychotropic drugs are good or bad for the individual patient. Ultimately, everyone has to decide for themselves, depending on their life situation and in consultation with the treating doctor.

This is how anti-depressants work

Nerve cells communicate with each other via neurotransmitters. When a nerve cell receives a stimulus, it sends neurotransmitters, such as serotonin, into the synaptic gap. These attach to the receptors of the opposite cell, also known as the recipient cell. The antidepressant (SSRI) prevents serotonin from being collected again. As a result, it stays longer in the synaptic gap and excites the recipient cell for a longer period of time.

How are psychotropic drugs used?

There are a variety of psychiatric drugs that can be categorized in different ways. One way to do this is to organize them according to how they are used. This results in seven groups. Of these, two types are particularly important for the treatment of mental illnesses: neuroleptics, which are used for psychotic illnesses, and antidepressants, which, as the name suggests, are used to treat depression. According to the 2014 Drug Ordinance Report, the prescription rate for antidepressants more than doubled within nine years from 643 million daily doses in 2004 to 1,341 million in 2013. With this amount, statistically speaking, nearly 3.7 million people could be used a year swallow antidepressants every day for a long time. Neuroleptic consumption rose by about a third over the same period.

A third important group of psychotropic drugs are tranquilants, for example to relieve anxiety and tension. However, these are only prescribed in emergency situations and during crises because, since the 1980s, more and more studies had shown their high potential for addiction.

Antidepressants

The antidepressants are mainly used for depression. They should have a mood-enhancing effect. Depending on the drug, they can also have a drive-increasing or calming effect. Antidepressants do not work as quickly as neuroleptics. It takes up to two weeks for the body to adjust to the drug and for the drug to develop its antidepressant effect. The German Society for Psychiatry and Psychotherapy, Psychosomatics and Neurology (DGPPN) recommends giving antidepressants for unipolar depression (i.e. without manic phases) for four to nine months after the symptoms have subsided. With certain forms of the disease, for example if there have already been several periods of depression in the patient's life, even longer. In contrast to neuroleptics, which all work according to a relatively similar pattern, there are several subgroups of antidepressants. The currently most commonly prescribed drugs are called selective serotonin reuptake inhibitors (SSRIs).

Neuroleptics

Neuroleptics were primarily developed for use in psychotic disorders and schizophrenia. In acute psychosis, people are typically very afraid and have hallucinations. Another characteristic is that the environment is suddenly no longer experienced as usual. Things take on a multitude of meanings, which in extreme cases can lead to the patient no longer knowing what, for example, a glass or a pen is actually intended for. Neuroleptics are supposed to end this extreme condition. How quickly this happens depends, among other things, on the dose. How long neuroleptics should be given cannot be clearly stated. What is certain is that patients who have experienced psychosis often need a long time before they are considered healthy again. The psychosis itself usually lasts several weeks, the return to a self-determined and fear-free life several months or years.

How do psychotropic drugs work?

To understand how psychotropic drugs work, one must first understand how the brain works. As soon as one of the 86 billion nerve cells that make up the brain registers a stimulus, it sends out messenger substances, so-called neurotransmitters. These are called, for example, dopamine, serotonin or GABA. The neurostransmitters enter the synaptic gap, a minimal gap between the sending and receiving nerve cells. The surface of the cell on the other side of the synaptic gap is full of receptors to which the neurotransmitters can dock. The neurotransmitters then return to their original cell. This whole process happens very quickly. A nerve cell can fire up to 500 times in one second.

Antidepressants

According to experts, the balance of messenger substances in the brain is disturbed in depression, according to an information from the Institute for Quality and Efficiency in Health Care (IQWiG) based in Cologne. Depending on the type of drug, psychotropic drugs influence this ratio of messenger substances, for example by disrupting the transport system that brings the "fired" serotonin back into the sending nerve cell. This hinders the resumption of serotonin (see graphic). This function gave the group of selective serotonin reuptake inhibitors their name. The most frequently prescribed active ingredient of these is citalopram. But what is the point of influencing the serotonin metabolism in such a way? Well: This means that the serotonin stays longer in the synaptic gap and can come into contact with the receptor more often. In this way, the availability of serotonin is increased. The affected nerve cells react with appropriate adaptation mechanisms over the course of two weeks. Only then does the antidepressant effect arise at all. In the first few days of taking the drug, however, patients typically only notice unpleasant effects such as nausea or slight restlessness, but these disappear again as the body adapts to the drug.

Neuroleptics

The neurotransmitter dopamine plays an important role in psychosis, as it regulates perception, alertness, reward and concentration, among other things. Doctors assume that a psychosis is caused by an excessive reaction of the cells to which the dopamine docks. Typical neuroleptics therefore inhibit the docking of dopamine with the recipient cell and thus dampen the reactions. So-called atypical neuroleptics, which have been developed in the last few decades, often also influence the serotonin balance, which led to a change in side effects. As with antidepressants, the organism also adapts to the effects of neuroleptics.

What side effects are possible?

Like all drugs, psychotropic drugs can have undesirable effects. These differ depending on the drug, dose and from patient to patient. Typical general side effects of psychotropic drugs include: weight gain, dry mouth, stomach and intestinal problems, sleep disorders, headaches, blood pressure problems, cardiac arrhythmias and loss of libido. Many patients complain, especially at higher doses, of a certain sluggishness, listlessness and a very narrow field of interest. The most extreme form of this is "standing beside you", that is, an alienation from your own self.

Antidepressants

Particular caution should be exercised with antidepressant types whose drive-enhancing effects set in faster than their mood-enhancing effects, as they may increase the risk of suicide. Children and adolescents in particular need to be particularly well looked after when they are given this drug in order to counteract such a risk.

Neuroleptics

At high doses or when doses are too high for a long time, all neuroleptics actually cause motor disorders, such as a stiff gait or involuntary facial twitches. Some of these side effects may persist and do not go away even after you stop taking the medication.

What do the critics say?

Jann E. Schlimme is a resident psychosis psychotherapist and until spring 2015 led a consultation hour to reduce or discontinue psychotropic drugs at the Charité. He criticizes that the problem of addiction to antidepressants and neuroleptics is often ignored. It must be said that "addiction" to antidepressants and neuroleptics means something different from alcoholism, for example. It is not about the patient developing an addiction and demanding more and more of the drug. The problem lies in the adaptation of the organism, including the brain metabolism, to the effects of the drugs. For example, after stopping serotonin reuptake inhibitors, there is less serotonin available in the receiving nerve cell than when taking medication. Because it is suddenly transported back into the sending cell much faster. As a result, it is very likely that withdrawal symptoms will occur if the drug is suddenly discontinued, says Schlimme.

How long it takes for such dependency mechanisms to appear cannot be clearly stated and varies from person to person. "From the age of six months you can be pretty sure that withdrawal symptoms will occur when you stop or reduce the dose," says Jann Schlimme.

These discontinuation effects can be particularly uncomfortable for a depressed or psychotic patient because the withdrawal symptoms can easily be confused with the actual symptoms. "If you leave the medication off, you don't even know what's going on," says Schlimme. “Is it withdrawal symptoms? My original depression? «In any case, it is important that a reduction should only take place in small steps and that it should be accompanied therapeutically.

A fundamental debate about psychotropic drugs concerns their effectiveness or the question of whether other treatment methods might not work just as well or better. With antidepressants, the more severe the depression, the more likely it is that an antidepressant will benefit. The guidelines of the German Society for Psychiatry, Psychotherapy and Neurology (DGPPN) also provide for the treatment of mild depression without psychotropic drugs. In the case of moderate depression, the guidelines are not entirely clear as to whether psychotherapy or drug therapy is more recommended; in the case of severe depression, a combination of both should be used.

The drug prescription report also cites studies that fundamentally question the effectiveness of antidepressants. They show that the effect that an antidepressant has is not very different from the effect of a placebo. IQWiG has published similar information on the Internet. The drug's effect is often tested by dividing a group of patients into two parts: one part receives the drug, the other an ineffective dummy drug (placebo). According to IQWiG, such studies have brought this result with antidepressants: With antidepressants, the symptoms improved in 40 to 60 out of 100 patients within six to eight weeks. With the placebo in 20 to 40 patients. That is, the medication improved symptoms in an additional 20 people. “But it can also be the case that expectations of treatment and regular care played a role in the studies,” write the IQWiG experts.

Jann Schlimme is of the opinion that even acute psychoses do not necessarily require medication with neuroleptics. Without it, however, it would only work if alternative treatment methods were available - for example in the Berlin »Soteria«, a comfortably furnished special ward that also offers a protected room in which the patient can stay together with a trained contact person. Another problem for recovery after an acute psychosis is that there has long been a consensus that psychotic patients are fundamentally too fragile for psychotherapy and that medication is therefore the only long-term treatment option. "The argument was that the patient already experienced an oversupply of meanings during the psychosis and that psychotherapy would only confuse him there." This belief is no longer so vehemently advocated. In Berlin there is also a network of psychotherapists who specialize in psychoses, but the offer is still insufficient, says Schlimme.

Another advantage for the patient with drug-free therapy is the strengthening of self-efficacy. "If the patient notices that I can get away with it without medication, it will most likely help him through the next crisis." On the other hand, if you have the feeling that you need the pill and have only just made it because of it, then kick this effect is not one.

So should all patients better avoid psychotropic drugs? No, says Schlimme, especially if you've been taking the medication for a long time. "There are patients who would like to do without pills, but notice during the reduction that it is too exhausting for them." Neuroleptics, for example, ensure that the environment is only perceived as filtered. If you have got used to it for several years, it is difficult to adjust to more influences again. With some, for example, the voices that have been suppressed by neuroleptics come back and are difficult to bear.

The question of when psychotropic drugs are useful cannot therefore be answered unequivocally. "I also don't think it's right to see it as an isolated problem," says Jann Schlimme. It is not just about the question of whether psychotropic drugs are yes or no, but about which treatment environment can be offered to the patient. And adds: "When meeting your best friend in the afternoon for coffee, it's not the caffeine in the coffee that is the decisive factor in this event."

You can read more about this in the magazine for medicine and health in Berlin "Tagesspiegel Gesund".

Further topics of the edition:Fact check. Exciting information about mind and soul; You have a tit. When is the psyche really sick ?; Brain research. What neuroscience can and cannot do; Psychosomatic. Body and mind are an inseparable unit; The path to healing. Outpatient, inpatient, rehab? The navigator shows the treatment route; Help in life crisis. Berlin addresses for emergencies. DEPRESSIONS: Get out of the bladder. The way back to life can succeed; Still live well! A victim reports from her everyday life; Winter depression. How artificial light helps against seasonal mood lows; BURNOUT: Illness with chic? Why burnout is just a fad for some; Shut down. A ski jumping legend talks about sport and illness; Burned out. A comedian tells about the dark side of success; ADDICTION: Life without drugs.Weaning is hard work; Children of addicts. A picture book deals with the effects of alcohol addiction on the family; Drug. What drugs are there and how they work; SCHIZOPHRENIA: Flood of stimuli. When the dopamine balance in the brain is out of joint; Family affair. Author Janine Berg-Peer on life with a schizophrenic daughter; MENTAL DISORDERS: Live fearlessly. A sick fear is curable; Doctor's letter. How obsessive-compulsive disorder is treated; Eating disorder. When enjoyment is lost; SLEEP DISORDERS: Self-experiment. Slumbering in the laboratory; Dream research. What our nightly head cinema reveals; SERVICE: A comparison of clinics and doctors; Column. Helmut Schümann advises you to take your psyche seriously

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