Psychopharmaceuticals are used to treat psychiatric disorders. They are prescribed subsequent to a diagnosis by a physician qualified to treat mental illness, but how does it work? In today's psychiatry, the benefits and risks of drug therapy will be considered for each patient. There are difficult issues that require sufficient knowledge of psychotropic drugs.
To be classed as a psychiatric medication, a chemical entity has to have as its primary function an effect on mentation. More specifically, psychopharmaceuticals are used to treat psychiatric disorders. They are prescribed subsequent to a diagnosis by a physician qualified to treat mental illness.
Modern ideas about psychiatric medications depend on a model of diagnosis and selection rather than, for instance, a general trial and error procedure to see what medication may be helpful – while the latter seems odd, without a clear understanding of what drugs were doing biologically, this has been the practice in the past.
Although medications have been used since antiquity to influence human behavior, it was not until the late 1950s that psychiatry moved toward the paradigm of biological remedy instead of symptom based medications. Before this, psychiatric drugs fell into two general classes – those that induced sedation and those that elevated mood. Opiates (along with barbiturates) and amphetamines were the staples of outpatient care and ‘talk therapy’ was the mainstay of treatment. For inpatients, dramatic ‘challenge’ treatments would include insulin shock therapy and electro-shock therapy, but neither falls into the category of medications as primary agents. (An interesting exception is the use of thyroid supplements to treat schizophrenia, subsequently found to be ineffective.)
Psychiatry has quite a history of failed treatments and medications. In the mid-20th century, psychopharmacology could be best classified as ‘ham-handed’. The most useful property of sedatives, for example, was in the control of unruly patients. The advent of chlorpromazine and the elucidation of neurotransmitters began to change the way psychiatrists viewed medications. This trend has continued and the search for more biologically rational (and physiologically based) medications continues today.
The model is a familiar one in other areas of medicine: Researchers find some anomaly (perhaps even a cause) that is associated with a condition and this new knowledge results in a drug meant to affect the biology of those afflicted. Primarily these are based on receptor sites in the brain that are either stimulated or attenuated by a medication.
Classes of Agents
While not all-inclusive, most psychiatric drugs can be classified into one of four areas. These are generally based on the conditions being treated. (A different classification would be based on mechanism of action or chemical moiety.)
- Anxiolytics, or anti-anxiety drugs, are prescribed to treat excessive anxiety or fear.
- Sedatives, or hypnotics – used to induce or enhance sleep and used to treat insomnia. Note there is some overlap in the drugs used for these first two categories. For instance, when patients cannot sleep because they are overly anxious.
- Antidepressants – These fall into two general classes, the tri-cyclic antidepressants (TCA) and the selective serotonin reuptake inhibitors (SSRI). Both are commonly prescribed, but the latter has fewer side effects and has become popular with doctors who are not psychiatric specialists to prescribe for mild/borderline depression.
- Anti-psychotics – these are the mainstay of treatment for schizophrenia, bi-polar disorder and other, serious mental conditions. Again, there is an overlap with other conditions and these agents may be used in lower dosages to treat depression.
This classification leaves out many conditions that a psychiatrist may treat. For instance, amphetamines are commonly prescribed for attention deficit hyperactivity disorder (ADHD). Also, some medications marketed for a specific diagnosis can find uses outside of these categories. Imipramine, the first tri-cyclic anti-depressant discovered, has found use in treating childhood bedwetting (nocturnal enuresis).
Like no other area of medical practice, psychiatry seems to beget criticism. Partially this is because treatments are often given without patient consent (and even against the wishes of a patient). Another criticism stems from the historical practice of a ‘chemical straitjacket’ – medications prescribed primarily to make a patient easier to handle. Psychiatry still suffers from a history that includes pre-frontal lobotomy and movement disorders induced by Thorazine.
Added to this is the fear most of us have about altering our own minds. The idea of reshaping ‘who we are’ in a fundamental way feels deeply invasive and unethical. For this reason, the diagnostic standard has become one of deciding if symptoms are severe enough to alter one’s normal lifestyle. In a real sense, this is how doctors decide if a condition rises to the level of necessitating intervention.
Some criticism is being leveled from within the psychiatric community itself. Doctor Joanna Moncrieff puts forth the idea that dependence on drug therapies has given psychiatrists an unsupported confidence and led to more and inappropriate treatments. Her paper, Drug Treatment in Modern Psychiatry: The History of a Delusion (2002) describes an overreliance on medications that do not help patients so much as they allow the practice of psychiatry to view itself as helpful.
To what extent are patients mentally diseased and to what extent are they merely ‘different’? The answer seems obvious with a patient who is clearly psychotic or dangerous. The case is less so when someone complains of depression or believes in other than ‘normal’ societal values. As late as 1970, homosexuality was considered by the American Psychiatric Association as a mental illness.
Psychiatrists often run up against the Hippocratic Oath’s dictum of primum non nocere (first, do no harm). They do not yet have the tools to look deeply into the neuropathology of a specific patient’s brain and correct aberrant conditions directly. There is always a risk of altering mentation in an unwanted direction or of a patient becoming addicted to a ‘remedy’. The risks are made greater because most drug treatments do not directly cure mental illness, but rather, are given chronically to control symptoms.
Medications are developed and tested statistically. But they are prescribed individually. The US Food and Drug Administration first started warning about increased risk of suicide in patients prescribed anti-depressants (both TCA and SSRI) in 2004. Further studies (2006) showed a doubling of risk for patients in the 18-25 year old group. This is the conundrum. To what extent will this patient be helped and at what risk?
The philosophical question revolves around what are ‘norms’ and how they are determined. The public seems keenly aware that medications may be misused to enforce societal norms in an unethical fashion. Prozac, an SSRI, has been hugely overprescribed simply to ‘make life more pleasant’. There is current controversy surrounding the use of methylphenidate (an amphetamine) for ADHD – the worry is that the drug isn’t helping young students so much as making them less disruptive in a classroom; aiding the teacher more than the patient.
Modern Goals of Psychiatry
Let us not forget that psychiatrists are first medical doctors. They are highly trained scientists involved in a difficult area of medicine. The ideal is to understand the physiological mechanisms that cause disease and find treatments (both drug and other therapies) that have meaningful and reliable outcomes. These are laudable goals. The deserved criticisms of psychiatry shouldn’t overlook the fact that the discipline has progressed and will continue to do so.
The hope is that continued research in neuro-anatomy and physiology will bring more cause and effect relationships to light. Meanwhile, psychiatrists will continue to diagnose and treat patients with both the art and the science available.