Section 1: Introduction -- The Prescriptions Nobody Reviews

A 67-year-old woman in Montego Bay has been on diazepam 5 mg at night for twelve years. It was started for "nerves" after her husband died. Nobody has reviewed it since. She also takes amitriptyline 25 mg at night -- unclear whether it was started for insomnia, neuropathic pain, or depression. Her daughter reports increasing confusion, two falls in the past month, and difficulty finding words.

Her anticholinergic burden score is 3 from the amitriptyline alone. Combined with the sedative load from the diazepam, she is on two CNS-active drugs that individually warrant review and together produce a compounding risk of cognitive impairment, falls, and functional decline.

This is not unusual. Psychotropic drugs -- benzodiazepines, antidepressants, antipsychotics, and mood stabilisers -- are among the most commonly continued medications in Caribbean practice. They are started for valid clinical reasons and maintained indefinitely without reassessment of whether the original indication still applies, whether the drug is still the best option, or whether the patient's age and comorbidities have changed the risk-benefit calculation.

1.1 Mental health prescribing in the Caribbean context

Four features of Caribbean clinical practice shape psychotropic prescribing:

Limited specialist access. Psychiatric services in many Caribbean territories are concentrated in a small number of facilities. Primary care clinicians initiate and maintain psychotropic prescriptions without specialist review. The drugs prescribed reflect what is available on the formulary and what the clinician is familiar with -- which may not align with current evidence.

Formulary constraints. First-generation antipsychotics (haloperidol, chlorpromazine) remain on Caribbean essential medicines lists and are prescribed where second-generation agents with more favourable side effect profiles might be preferred. Older antidepressants (amitriptyline, imipramine) are more widely available than SSRIs in some territories.

Stigma and underreporting. Mental health stigma in Caribbean communities affects both presentation and treatment. Patients may describe psychological distress in somatic terms -- headaches, poor sleep, "nerves," fatigue -- leading to symptomatic prescribing (a benzodiazepine for sleep, a tricyclic for "nerves") rather than formal psychiatric assessment.

Continuation without review. Psychotropic drugs, once started, tend to remain on the medication list permanently. The original prescriber may have retired or moved. The indication may no longer be documented. The patient continues the drug because "the doctor put me on it" and nobody has suggested stopping.

1.2 What this report covers

This report profiles psychotropic drug classes commonly encountered in Caribbean practice -- benzodiazepines, antidepressants (tricyclics, SSRIs, SNRIs), antipsychotics (first and second generation), and mood stabilisers -- with a focus on drug interactions, Beers Criteria flags, anticholinergic burden, prescribing cascades, deprescribing opportunities, and the specific risks that emerge when psychotropic drugs are prescribed alongside the cardiovascular, antidiabetic, and analgesic medications that dominate Caribbean polypharmacy.

Section 2: Benzodiazepines -- The Drugs That Never Stop

2.1 The Caribbean benzodiazepine problem

Diazepam is on the Jamaica VEN list and the OECS EML. It is available, inexpensive, and familiar. It is also the drug most likely to be started "temporarily" and continued indefinitely.

Tolerance to the anxiolytic and hypnotic effects of benzodiazepines develops within 2-4 weeks. After that period, the drug is no longer producing the effect for which it was prescribed. But stopping it produces withdrawal symptoms -- anxiety, insomnia, irritability, tremor -- that are indistinguishable from the original condition. This creates a cycle: the drug stops working, withdrawal mimics relapse, the drug is continued.

Beers Criteria (Report 1): All benzodiazepines are flagged for adults aged 65 and older. Associated with cognitive impairment, delirium, falls, hip fractures, and motor vehicle accidents.

Deprescribing (Report 4): Diazepam, alprazolam, and lorazepam are covered as Drugs 3, 4, and 5 in Report 4. Taper schedules, communication scripts, and the distinction between withdrawal and relapse are detailed there.

2.2 Key interactions

2.3 The benzodiazepine-opioid combination

This combination warrants specific attention. The FDA issued a boxed warning in 2016 for concurrent benzodiazepine and opioid prescribing. The risk of respiratory depression is not simply additive -- it is synergistic. In the Caribbean, this combination is encountered when a patient on chronic diazepam is prescribed tramadol or codeine for pain, or when a patient on opioid analgesia is given a benzodiazepine for anxiety or sleep.

ElesRx flags this combination as a major interaction with specific guidance on risk reduction.

Section 3: Antidepressants -- The Interactions That Accumulate

3.1 Tricyclic antidepressants -- Amitriptyline, Imipramine, Nortriptyline

Amitriptyline is one of the most prescribed drugs in Caribbean primary care -- often at low doses (10-25 mg) for indications other than depression: insomnia, neuropathic pain, headache prophylaxis, "nerves."

Anticholinergic burden (Report 1): ACB Score 3 -- the highest category. Associated with dry mouth, constipation, urinary retention, blurred vision, tachycardia, cognitive impairment, delirium, and -- with long-term use -- an association with increased dementia risk.

Beers Criteria (Report 1): Flagged for adults aged 65 and older. The combination of anticholinergic burden and sedation makes tricyclics among the highest-risk psychotropic drugs in older adults.

Key interactions:

Deprescribing (Report 4): Low-dose amitriptyline is Drug 6. If the original indication has resolved, taper 25% every 2-4 weeks. Alternatives for neuropathic pain: gabapentin (with renal adjustment). Alternatives for insomnia: melatonin, sleep hygiene.

3.2 SSRIs -- Sertraline, Fluoxetine, Paroxetine, Escitalopram, Citalopram

SSRIs are the first-line antidepressants for depression and anxiety in current guidelines. They have a substantially lower risk profile than tricyclics -- no significant anticholinergic burden, lower cardiac risk, and a wider therapeutic index.

Key interactions:

Paroxetine-specific concern (Report 4): Paroxetine has the most severe discontinuation syndrome of any SSRI. Dizziness, electric shock sensations, nausea, insomnia, irritability. Frequently mistaken for relapse, leading to reinstatement. If an SSRI switch is planned, sertraline or escitalopram have more favourable discontinuation profiles.

SSRI + NSAID: This combination is common in Caribbean practice -- a patient on sertraline for depression who takes ibuprofen OTC for pain. Both drugs independently increase GI bleeding risk through different mechanisms. Together, the risk is clinically significant, particularly in older adults or those with a history of peptic ulcer disease.

3.3 SNRIs -- Venlafaxine, Duloxetine

Venlafaxine: Serotonergic at lower doses; noradrenergic at higher doses. Discontinuation syndrome is severe -- second only to paroxetine. Must be tapered slowly. Causes dose-dependent hypertension at higher doses -- blood pressure monitoring is required.

Duloxetine: Effective for depression and diabetic neuropathic pain (Report 7, Report 8). Contraindicated at CrCl below 30 (Report 2). In the diabetic patient with CKD and neuropathic pain, duloxetine may not be an option -- gabapentin (with renal adjustment) is the alternative.

Section 4: Antipsychotics -- First Generation and Second Generation

4.1 First-generation antipsychotics -- Haloperidol, Chlorpromazine

These remain on Caribbean essential medicines lists and are prescribed for schizophrenia, acute psychosis, agitation, and -- inappropriately -- for insomnia and anxiety.

Haloperidol:

Chlorpromazine: Same risk profile as haloperidol plus significant anticholinergic burden (ACB Score 3), orthostatic hypotension, photosensitivity, and hepatotoxicity.

Beers Criteria (Report 1): Both flagged for older adults. The combination of sedation, anticholinergic effects, extrapyramidal symptoms, and QT prolongation makes first-generation antipsychotics among the highest-risk drugs in geriatric prescribing.

Deprescribing (Report 4): Haloperidol started in hospital for acute agitation and continued after discharge is Drug 18. If the acute episode has resolved and the patient is not on haloperidol for a chronic psychiatric condition, taper 25-50% every 2-4 weeks.

4.2 Second-generation antipsychotics -- Quetiapine, Risperidone, Olanzapine

Lower extrapyramidal risk than first-generation agents, but carry metabolic risks:

Quetiapine for insomnia: Quetiapine at low doses (25-50 mg) is increasingly prescribed for insomnia, particularly in patients where benzodiazepines are being avoided. This is an off-label use. The metabolic risks -- weight gain, glucose dysregulation -- apply at all doses and may not be justified for insomnia alone.

Antipsychotics in dementia: Antipsychotics are associated with increased mortality in elderly patients with dementia-related behavioural disturbances. The FDA issued a boxed warning in 2005. If antipsychotic use is initiated for behavioural symptoms in dementia, it should be time-limited with a clear plan for reassessment and discontinuation.

Section 5: Mood Stabilisers -- Lithium, Valproate, Carbamazepine, Lamotrigine

5.1 Lithium

Lithium has the narrowest therapeutic index of any commonly prescribed psychotropic drug. The therapeutic range (0.6-1.0 mmol/L) is close to the toxic range (above 1.5 mmol/L). Small changes in renal function, hydration, or co-prescribed drugs can shift a stable patient into toxicity.

Key interactions:

Caribbean Practice Note: The Caribbean climate creates a specific lithium risk. Tropical heat, inadequate fluid intake, and gastroenteritis -- all common -- reduce renal lithium clearance. Patients on lithium in the Caribbean require explicit counselling on hydration and should have lithium levels checked more frequently during hot weather or acute illness.

Pregnancy (Report 5): Lithium crosses the placenta. Associated with Ebstein's anomaly (cardiac malformation) in first-trimester exposure, though the absolute risk is lower than historically estimated. Breastfeeding is generally not recommended -- lithium enters breast milk at 30-50% of maternal serum levels.

5.2 Valproate

Pregnancy (Report 5): The most teratogenic commonly prescribed drug. Contraindicated in women of childbearing potential unless no alternative exists and a pregnancy prevention programme is in place.

Hepatotoxicity (Report 2): Valproate is hepatotoxic. LFTs should be checked before starting and periodically during treatment.

Key interaction: Valproate inhibits the metabolism of lamotrigine, approximately doubling lamotrigine levels. If both are co-prescribed, lamotrigine dose must be reduced by 50%.

5.3 Carbamazepine

CYP3A4 induction: Carbamazepine is one of the most potent CYP enzyme inducers in clinical use. It reduces the levels of dozens of co-prescribed drugs:

Auto-induction: Carbamazepine induces its own metabolism. Levels decline over the first 2-4 weeks, requiring dose adjustment.

5.4 Lamotrigine

Lower teratogenic risk than valproate (Report 5). Preferred mood stabiliser in women of childbearing age. Key risk: Stevens-Johnson syndrome, particularly with rapid dose titration -- start low, titrate slowly.

Section 6: Prescribing Cascades in Mental Health

Recognising the cascade allows removal of the trigger drug, which may resolve the symptom and allow the secondary drug to be stopped.

Section 7: The Monitoring Checklist -- Mental Health Edition

Section 8: About ElesRx

ElesRx flags psychotropic drug interactions, anticholinergic burden from co-prescribed agents, Beers Criteria alerts for benzodiazepines, tricyclics, and antipsychotics in older adults, prescribing cascades involving psychotropic drugs, and the serotonin syndrome risk when tramadol or other serotonergic agents are combined with antidepressants.

The tool is available at elesrx.com. ElesRx is a product of PIPPS Smart Apps, a division of J.C. Epiphany Limited (Jamaica, est. 1998).

Section 9: Methodology and References

9.1 Data sources

Psychotropic drug interaction and safety data is drawn from the ElesRx clinical database, verified against DailyMed, the European Medicines Agency, Health Canada, and published clinical guidelines. This report consolidates mental health-relevant content from Reports 1-10 and supplements it with additional class-specific pharmacology.

9.2 Limitations

This report covers outpatient psychotropic prescribing as encountered in Caribbean primary care and general adult psychiatry. Specialised areas -- clozapine monitoring, electroconvulsive therapy, substance misuse pharmacotherapy, child and adolescent psychopharmacology -- are beyond its scope.

9.3 Author and conflict of interest disclosure

This report was authored by Juliet Duncan, BPharm, founder of J.C. Epiphany Limited and developer of ElesRx. The author has a commercial interest in ElesRx. This report is published without an access gate as a contribution to Caribbean clinical education. No external funding was received.

9.4 Citation

Duncan J. The Mental Health Prescribing Report: Psychotropic Drug Safety in Caribbean Practice. ElesRx Clinical Reports, Report 11. Published 2026 at elesrx.com/reports/mental-health-prescribing-report/. J.C. Epiphany Limited, Jamaica.

References

1. American Geriatrics Society 2023 Updated AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2023;71(7):2052-2081. doi:10.1111/jgs.18372

2. FDA Drug Safety Communication. FDA warns about serious risks and death when combining opioid pain or cough medicines with benzodiazepines. US Food and Drug Administration. 2016.

3. Leucht S, Cipriani A, Spineli L, et al. Comparative efficacy and tolerability of 15 antipsychotic drugs in schizophrenia: a multiple-treatments meta-analysis. Lancet. 2013;382(9896):951-962. doi:10.1016/S0140-6736(13)60733-3

4. Correll CU, Detraux J, De Lepeleire J, De Hert M. Effects of antipsychotics, antidepressants and mood stabilizers on risk for physical diseases in people with schizophrenia, depression and bipolar disorder. World Psychiatry. 2015;14(2):119-136. doi:10.1002/wps.20204

5. Taylor DM, Barnes TRE, Young AH. The Maudsley Prescribing Guidelines in Psychiatry. 14th ed. Wiley-Blackwell; 2021.