Psychopharmacology 101

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Psychopharmacological treatment of mental disorders is the direct outgrowth of the medical model within psychiatry, the biological revolution in psychiatry, and the biological and brain-based focus of psychology and the mental health fields. Psychiatry, for many years, was dominated by psychoanalytic formulations of mental disorders stemming to a large degree from Sigmund Freud and his followers. This is not to say that the biological and medical foundations of mental disorders were completely neglected during this era as is demonstrated by the influence of Kraeplin and Schneider. However, psychoanalysis was central to the treatment of mental disorders. About mid-twentieth century however, some findings with and applications of dopaminergic drugs in the treatment of psychotic symptoms in Schizophrenia ushered in what some historians of psychiatry call the biological revolution. This revolution saw the medical model brought to prominence in the understanding and treatment of mental disorders in psychiatry. Eventually, advances in neuropsychology, techniques in biological research in psychology, and imaging techniques and other related advances broadened this focus from mental disorder to psychology and human behavior and mental processes as a whole. This was reflected in the National Institute of Mental Health's (NIMH) research program of the 1990s, which was dubbed the decade of the brain.

Psychopharmacological treatment is based on the medical or biological model of mental disorders, with two primary assumptions (Gitlin, 1996): (1) mental disorders can be reliably classified according to diagnostic methods used in medicine before the introduction of laboratory tests and, (2) medications are effective in treating a variety of psychiatric disorders. I would add that both of these are built upon the assumption that mental disorders are, at their core, biological disorders and therefore alteration of the biological underpinnings constitutes treatment. This assumption is predicated on a monist view of the mind-body or mind-brain relationship. However, an alternative view of psychopharmacological treatment can be taken. That is, medications that successfully alleviate the symptoms of a mental disorder may not directly address underlying biological abnormalities but may instead influence the expression of symptoms or related systems that subsequently impact underlying biological abnormalities. For instance, I would suggest that medications used to treat seizures that are based on increasing the role and functioning of GABA in the brain do not indicate that seizures are a direct result of GABA dysfunction per se but, rather, are influential somewhere along the line of biological processes involved in the expression of neural dysfunction. More bluntly, if drinking alcohol helps me relax, this does not suggest that I have an alcohol deficiency disorder in my brain. This is important because as biological treatments are created and found to be helpful, we must not make the mistake of drawing causality from correlation!

General Goals of Pharmacotherapy

Psychiatrist Michael Gitlin (1996) identifies three general goals for pharma-cotherapy. Medications may be prescribed for the following reasons:

1. To treat an acute disorder and alleviate symptoms of an active disorder.

2. Prevent a relapse after clinical improvement.

3. Prevent future episodes, sometimes referred to as maintenance treatment.

Friedman, Davidson, Mellman, and Southwick (2000a) identify four major techniques used in pharmacotherapy: (1) selecting a drug to normalize the psycho-biological abnormalities associated with a disorder, (2) choosing the most appropriate drug with efficacy for particular symptoms or a comorbid disorder, (3) monitoring and readjusting the dosage in order to optimize efficacy and minimize side effects, and (4) recognizing an adequate therapeutic trial of a given drug in order to supplement with an additional drug or switch to a different drug.

It might be helpful to address just when someone, a friend, family member, client, or patient, might need a medication consultation with a medical doctor or prescribing psychologist. Gitlin (1996) outlines six factors or circumstances for such:

1. Significant psychiatric symptoms exist, such as sleep or appetite disturbance; fatigue; panic attacks; ritualistic behavior; cognitive symptoms, such as poor memory, concentration problems, and confusion; or psychotic symptoms, such as delusions and hallucinations.

2. Prominent physical symptoms or the presence of significant medical disorder such as headaches, abdominal pain, or clumsiness. A differential diagnosis may be in order!

3. Significant suicidality exists. In fact, any significant risk factor or issue such as danger to oneself (e.g., suicidality or self-mutilation), danger to others (aggression, violence, homicidal ideation, and even significant paranoia), and dysfunction in self-care, hygiene, and availing oneself of food, clothing, or shelter. This last one might also be particularly salient in situations where children are involved and their well-being is compromised as a result of mental disorder. A restoration or functioning is critical in such a situation.

4. Family history of a major psychiatric disorder exists.

5. Marked mood lability exists, especially in response to environmental events, with rage or depression. I would add irritability and even significant fear-reactions as is seen with PTSD to this factor.

6. There is nonresponse to psychotherapy. I would add to this factor those situations in which psychotherapy is either unavailable for any number of reasons or is very limited in scope and practice. Such is often the case for individuals with limited financial and health-insurance resources and in situations that have logistic challenges, such as rural settings, war zones, or even correctional or jail settings in which access to mental health services may be limited to contact with a psychiatrist, and psychotherapy is not feasible.

General Biological Bases of Psychopharmacology

As was discussed in Chapter 6, ultimately, what happens at the level of the neuron and, more specifically, at the level of the synapse, is critical in the biology of any mental process or behavior. One could take the ultimate reductionist approach and state that mental life and behavior is synonymous with synaptic functioning and its molecular biology. In either case, pharmacological treatment focuses on neural and synaptic functioning as the locus for action and effect. Medications used in the treatment of mental disorders work in at least one of the following ways: (1) mimicking a neurotransmitter and binding to a receptor site with subsequent stimulation of the receptor site, referred to as an agonist drug,

TABLE 14.1

Major Drug Classes for Mood and Anxiety

Antidepressants and anxiolytics

Common names

Neurochemical effects

Tricyclic and Tetracyclic drugs

Elavil

Sinequan

Tofranil

Serotonin reuptake blocking and norepinephrine reuptake blocking

Fluoxetine

Prozac

Serotonin reuptake blocking

Sertraline

Zoloft

Serotonin reuptake blocking

Paroxetine

Paxil

Serotonin reuptake blocking

Fluvoxamine

Luvox

Serotonin reuptake blocking

Monoamine Oxidase Inhibitors

Phenelzine

Enzyme production inhibition

Trazadone

Desyrel

Serotonin reuptake blocking

Nefazodone

Serzone

Serotonin reuptake blocking and norepinephrine reuptake blocking

Bupropion

Wellbutrin

Largely undetermined, possible noradrenergic and dopaminergic effects

Venlafaxine

Effexor

Serotonin reuptake blocking and norepinephrine reuptake blocking

Duloxetine and Milnacipran

Cymbalta & Ixel

Serotonin reuptake blocking and norepinephrine reuptake blocking

Klonopin

Ativan

GABA-benzodiazepine receptor complex

Buspirone

Buspar

Serotonin effects, varied and complex

Sedative-Hypnotics

Ambien

Benzodiazepine effects

(2) mimicking a neurotransmitter and binding to a receptor site with subsequent lack of or blocking of stimulation, referred to as an antagonist drug, (3) having a presynaptic effect leading to the increased release of a particular neurotransmitter, (4) having a partial agonist effect, causing the same effect but less so than the endogenous neurotransmitter, (5) blocking neurotransmitter reuptake back into the presynaptic neuron having the functional effect of increasing the level of a neurotransmitter's effects and enhancing the excitability of the postsynaptic neuron, (6) decreasing or increasing the sensitivity of receptors on postsynaptic neurons or the number of receptor sites, (7) altering the metabolism of a particular neurotransmitter, altering its availability within the system, and, finally, (8) altering the availability of a neurotransmitter by altering the availability of its precursor elements utilized in synthesis.

The classes of drugs used in psychopharmacological treatment are defined dually by the disorder and symptoms they are used for and targeting the underlying neurobiological effects and mechanisms. Table 14.1 summarizes the major classes of drugs used primarily in the treatment of depression and Anxiety Disorders including PTSD, with some examples and their underlying target neuro-chemical processes.

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