Adjuvant Therapy With β-Adrenergic Blockers in Psychiatry

Abstract

Beta-adrenergic blockers (b-blockers), notably propranolol, are commonly deployed in psychiatric practice to address a multitude of clinical indications. 1 These include, inter alia, performance anxiety, posttraumatic stress disorder, schizophrenia, mood disorders, neurodevelopmental disorders [autism spectrum disorder (ASD), ID, Tourette syndrome [TS], and attention-deficit/hyperactivity disorder], episodic dyscontrol, lithium-induced tremors, clozapine-induced tachycardia, akathisia, alcohol detoxification, organic brain syndrome, dementia, and traumatic brain injury (TBI). Here, we brief the clinical use of b-blockers in such diverse indications while examining the extant evidence. It should be borne in mind that all these are off-label uses, and b-blockers are currently not FDA-approved for any psychiatric indication. Moreover, trend of clinical use seems to have fallen into disfavor in the 21st century with the rampant introduction of newer more nuanced psychotropic agents on the market. A major setback is the bulk of literature on psychiatric uses of b-blockers, that dates back to the eighties when its use was pretty popular but sorely where methodological flaws have crept into these studies. Cautious interpretation is then highly warranted.b-blockers are competitive antagonists of norepinephrine (NE) and epinephrine at b-adrenoceptors. They are peripherally sympatholytics. They lack direct sedation or abuse potential. They differ regarding their selectivity (eg, propranolol is nonselective while atenolol is more b 1 antagonist), lipophilicity (eg, propranolol has high lipophilicity while atenolol has lower lipophilicity), half-lives (eg, propranolol 3-6 hr and atenolol 6-9 hr), and route of elimination (eg, propranolol has hepatic while atenolol has renal clearance). For those with COPD, a more selective b 1 antagonist, for example, atenolol, is preferred. Use is also cautioned in diabetics as b-blockers could mask hypoglycemia. It should be withheld if blood pressure is less than 90/60 or heart rate is below 55 bpm.

Attention-Deficit/Hyperactivity Disorder–Associated Impulsive Aggression

“…If patient exhibits autonomic hyperarousal (eg, tachycardia, perspiration …) during this episodic dyscontrol, this might hint on norepinephrine and reasonable choices would include β-blockers 7 (eg, propranolol), α 2 agonists 8 (eg, clonidine), mirtazapine, 9 or lithium. 10 β-blockers are more helpful in the setting of neurotrauma (eg, traumatic brain injury).…”