5 Common Mental Health Medications Used in Workers’ Compensation
The incidence of mental health disorders has increased significantly over the last decade. The World Health Organization noted a 13% increase in reported mental health disorders over the past 10 years [1] while the American Psychological Association reported an increased demand for mental health treatment following the pandemic [2]. Certain mental health conditions such as Depression, Stress, Anxiety, and Post-Traumatic Stress Disorder (PTSD) are quite evident in the worker’s comp field [3].
The recovery period following a workplace injury can take a toll on a worker’s mental health due to socioeconomic stressors that arise from the inability to work. The incidence of mental health conditions also increases if workplace injuries are complicated with severe pain and comorbidities. In some cases, mental health issues arise after the return to work due to PTSD triggers within the workplace. The increase in worker’s comp claims with mental health related issues highlights the need for appropriate therapy.
This post will explore five key medications that have demonstrated safety and efficacy in addressing mental health disorders seen in worker’s comp cases alongside potential risks and issues with each.
1. Brand Name: Sertraline (Zoloft®)
Spotlight:
Brand Name: ZoloftGeneric Name: SertralineDrug Class: selective serotonin reuptake inhibitors (SSRIs)Common Uses: The SSRI class of medications is considered first-line therapy for depression, PTSD5, and anxietyCommon Side Effects: dry mouth, excessive sweating, drowsiness, dizziness, diarrhea, nausea, and decreased libido.Blackbox Warning: increased risk of suicidal thoughts and behaviors in pediatric and young adult patients
Sertraline belongs to a class of antidepressants known as selective serotonin reuptake inhibitors (SSRIs). This group of medications works on receptors in the brain to increase the amount of the neurotransmitter serotonin that is transmitted [4]. The increased activity of serotonin is what results in antidepressant effects. The SSRI class of medications is considered first-line therapy for depression, PTSD [5], and anxiety—all of which are commonly seen in worker’s comp cases [3]. Sertraline itself is FDA approved for the treatment of depression and PTSD while it is used off label for the treatment of PTSD and non-cardiac chest pain.
SSRI’s take approximately four to six weeks to feel the full effects of the drug. So there is a lag between when patients start taking the medication and when they begin to feel better. Some common side effects include dry mouth, excessive sweating, drowsiness, dizziness, diarrhea, nausea, and decreased libido. The dose of sertraline should be adjusted based on efficacy and tolerability. Typical doses range from 50 mg to a maximum of 200 mg orally per day. This medication does come with a black box warning for increased risk of suicidal thoughts and behaviors in pediatric and young adult patients, so close monitoring is essential in this patient population.
Additional counseling points include avoiding the use of alcohol and St. John’s Wort with sertraline [4]. Alcohol may counteract the effects of sertraline and worsen the symptoms of depression, anxiety, and PTSD. St. John’s Wort taken with SSRI’s can lead to excessively high amounts of serotonin in the body—a condition known as serotonin syndrome. This can result in seizures, muscle rigidity, and even death in extreme cases. Patients should also avoid activities involving mental alertness (i.e. driving or operating machinery) until drug effects are realized to avoid risk of injury.
2. Paroxetine (Paxil®)
Spotlight:
Brand Name: PaxilGeneric Name: ParoxetineDrug Class: Selective Serotonin Reuptake Inhibitor (SSRI)Common Uses: Depression, Anxiety, PTSDCommon Side Effects: Abnormal vision, Constipation, Diarrhea, Nausea, Sweating, Dry mouth, Decreased libidoBlack Box Warning: Suicidal thoughts and behaviors in pediatric and young adult populations
Paroxetine is another antidepressant belonging to the SSRI class. Like sertraline, this medication is also indicated for depression, anxiety, and PTSD [6]. While many other antidepressants are available for treatment, only sertraline and paroxetine are currently FDA approved to treat PTSD [5]. Since PTSD is commonly seen in worker’s comp cases [3], it is important to be aware of the few pharmacological therapies available at this time.
Paroxetine is typically dosed from 20 to 50 mg orally per day [6]. As with the SSRI class of medications, it can take approximately 4 to 8 weeks to feel the full effects of the drug. Some side effects include abnormal vision, constipation, diarrhea, nausea, sweating, dry mouth, and decreased libido. This medication also has a black box warning of suicidal thoughts and behaviors in pediatric and young adult populations so additional monitoring is necessary. Consumption of alcohol and St. John’s Wort should be avoided with paroxetine as well. NSAID pain medications such as ibuprofen and naproxen should be used with caution as it can increase the risk of bleeding when taken with paroxetine.
3. Venlafaxine (Effexor®)
Spotlight:
Brand Name: Effexor®Generic Name: VenlafaxineDrug Class: Serotonin-Norepinephrine Reuptake Inhibitor (SNRI)Common Uses: Depression, Anxiety, Off-label use for PTSDCommon Side Effects: Similar to SSRIs: Abnormal vision, Constipation, Diarrhea, Nausea, Sweating, Dry mouth, and Decreased libidoBlack Box Warning: Increased suicidal thoughts and behaviors in pediatric and young adult populations
Venlafaxine belongs to the serotonin-norepinephrine reuptake inhibitor (SNRI) class of medications. This group of medications works similarly to SSRIs but increases the activity of two neurotransmitters: serotonin and norepinephrine. SNRIs are also considered first-line therapies for depression and anxiety. It can also be used off-label for the treatment of PTSD and neuropathic pain [7].
Venlafaxine is typically dosed from 37.5 mg to 225 mg per day. Like SSRIs, it can take between 4 to 8 weeks to feel the full effects of the drug. SNRIs have a similar side effect profile to SSRIs and similar interactions with alcohol, St. John’s Wort, and NSAIDs. This medication class also has a black box warning for increased suicidal thoughts and behaviors in pediatric and young adult populations. These patients should be monitored closely at initiation of therapy and with any dose changes that may occur [7].
4. Duloxetine (Cymbalta®)
Spotlight:
Brand Name: Cymbalta®Generic Name: DuloxetineDrug Class: Serotonin-Norepinephrine Reuptake Inhibitor (SNRI)Common Uses: Depression, Anxiety, Neuropathic painCommon Side Effects: Similar to SSRIs, which include abnormal vision, constipation, diarrhea, nausea, sweating, dry mouth, decreased libido; increased chance of urinary hesitancy and retentionBlack Box Warning: Increased suicidal thoughts and behaviors in pediatric and young adult populations
Duloxetine is another SNRI that is used for depression and anxiety. It cannot be used for PTSD as well. However, duloxetine is also beneficial for the treatment of neuropathic pain—another condition commonly seen in worker’s comp cases. This medication is particularly useful since it can be used to address mental health conditions and pain at the same time.
Duloxetine is typically dosed from 30 mg to 60 mg orally per day. Doses of 60 mg/day are recommended for the treatment of both depression, anxiety, and neuropathy8. It has a similar side effect and interaction profile to that of SSRIs. However, there is an increased chance of urinary hesitancy and retention with duloxetine. This medication should also be closely monitored in pediatric and young adult populations for signs of suicidal thoughts and behaviors. This risk was noted to decrease once patients were over the age of 25 years [8].
5. Alprazolam (Xanax®)
Spotlight:
Brand Name: Xanax®Generic Name: AlprazolamDrug Class: BenzodiazepineCommon Uses: Anxiety, Panic disorders, Off-label use for depressionCommon Side Effects: Abnormal coordination, Decreased blood pressure, Drowsiness, Constipation, Nausea, Impaired memoryBlack Box Warning: Potential for abuse, misuse, and addiction, especially when used with opioids
Alprazolam belongs to the benzodiazepine class of medications. This group of medications is used to treat anxiety and panic disorders. Alprazolam may also be used off-label for the treatment of depression in certain cases [9]. Benzodiazepines exert their effects by binding to receptors in the brain which are involved in anti-anxiety, anticonvulsant, and muscle relaxant actions.
Alprazolam doses for the treatment of anxiety begin at 0.5 mg orally taken three times daily. This may be increased up to 4 mg/day in divided doses9. Alprazolam doses for depression range from 2.5 to 3 mg orally taken in divided doses. Unlike SSRIs or SNRIs, the effects of alprazolam may be felt within 30 minutes of ingesting it. Some side effects of this medication include abnormal coordination, decreased blood pressure, drowsiness, constipation, nausea, and impaired memory. Due to side effects, activities involving mental alertness should be avoided until the drug effects are realized. Alcohol should also be avoided with this medication due to severe risk of CNS depression which can be fatal. This medication also has a black box warning for potential of abuse, misuse, and addiction when used with opioids. Extra monitoring is necessary if patients are on both benzodiazepines and opioid therapy concurrently or alternative therapies should be explored.
By Saloni Desai
PharmD Candidate (P4)
For questions, e-mail pharmd@prodigyrx.com
Citations
https://www.apa.org/news/press/releases/2021/10/mental-health-treatment-demand
https://www.claimsjournal.com/news/national/2024/04/18/322964.htm
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