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Chapter 8

Medication for Mental Disorders

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Model:

symptoms  diagnosis  determination of cause  treatment  cure

Criticisms of model:

Usually the only symptoms of mental disorders are behavioral

Behaviors are varied and can have many causes

Model guides much of current thinking

Psychoactive drugs are used to control symptoms of mental illness

Researchers seek to identify chemical imbalances associated with specific mental disorders

Mental Disorders: The Medical Model

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Classification of Mental Disorders

Diagnostic and Statistical Manual of Mental Disorders (DSM-5)

Developed by the American Psychiatric Association

Provides diagnostic criteria and definitions for hundreds of disorders

Widely used classification system

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Anxiety disorders

characterized by excessive worry, fears, or avoidance

DSM-5 anxiety disorders

Specific Phobia

Social Anxiety Disorder

Panic Disorder

Agoraphobia

Generalized Anxiety Disorder

Mental Disorders

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Psychosis

a serious mental disorder involving loss of contact with reality

DSM-5 schizophrenia

Chronic psychosis characterized by two of the following (including at least one of the first three):

delusions

hallucinations

disorganized speech

disorganized behavior

lack of emotional response

Causes significant interference with social and/or occupational functioning

Mental Disorders

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DSM-5 mood disorders

Characterized by depressed or manic symptoms

Major Depressive Disorder

Bipolar I Disorder

At least one manic episode and possible alternating depression

Individuals don’t always fit neatly into diagnostic categories

Mental Disorders

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General paresis

Syphilitic infection of the nervous system that causes psychosis

“Malaria therapy”

Fever associated with malaria was thought to improve the condition

Later antibiotics were developed that cured syphilis

Early Treatment of Mental Disorders

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Early pharmacotherapy

“Narcosis therapy”

depressants used to induce sleep for a week or more

Intravenous thiopental sodium (“truth serum”)

used during psychotherapy to help patients express repressed thoughts

Insulin-shock therapy

Used to treat schizophrenia

Ineffective

Electroconvulsive therapy

Ineffective to treat schizophrenia

Still used to treat severe depression that doesn’t respond to medication

Early Treatment of Mental Disorders

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Phenothiazines

An early group of drugs used to treat psychosis

Reduced psychotic symptoms without sedation

Initially called tranquilizers or neuroleptics

Now called antipsychotics

Following introduction of drug therapy for schizophrenia

Restraints and convulsive therapies were reduced or discontinued in psychiatric hospitals

Atypical antipsychotics

Mechanism of action differs from phenothiazines

All recent antipsychotics are atypical

Antipsychotics

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Typical antipsychotics

Dopamine antagonists

Block D2 receptors

Produce pseudoparkinsonism

Time delay in drug effects indicates that the mechanism of action is probably more complex

Atypical antipsychotics

Serotonin-dopamine antagonists

Block both D2 dopamine and 5HT2A serotonin receptors

Produce less pseudoparkinsonism

Antipsychotics: Mechanism of Action

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Generally safe

Do not produce drug dependence

Difficult to use to commit suicide

Side effects

Some allergic reactions

jaundice, skin rashes

Photosensitivity

Agranulocytosis

low white blood cell count

Pseudoparkinsonism

tremors, muscle rigidity, shuffling walk, masklike face

Tardive dyskinesia

most serious complications of drug treatment

Antipsychotics: Side effects

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Long-term effectiveness appears to be considerably lower than short-term

75% of patients discontinue use by 18 months

No clear evidence that atypical antipsychotics work better than conventional

Use in special populations

Children: high risk of weight gain and metabolic changes that signal increased risk for diabetes and cardiovascular problems

Elderly: significant increase in death risk from cardiovascular and other problems

Antipsychotics: Effectiveness

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Monoamine oxidase inhibitors

Examples: phenelzine, tranylcypromine

Tricyclics

Examples: amitriptyline, doxepin, nortriptyline

Selective reuptake inhibitors

Examples: fluoxetine, sertraline, paroxetine

Antidepressants

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MAO inhibitors

Discovery: iproniazid (tuberculosis drug) also elevated mood

Mechanism of action

Increases the availability of serotonin, norepinephrine, and dopamine in synapse by inhibiting enzymatic breakdown

Limited use due to side effects and toxicity

Examples: hypertension and “cheese reaction”

Monomamine Oxidase Inhibitors

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Discovery

Imipramine: search for better phenothiazine antipsychotic resulted in a drug that elevated mood

Mechanism of ation

Increases the availability of serotonin, norepinephrine, and dopamine in synapse by interfering with reuptake

Not effective in all patients

But they reduce the severity and duration of depressive episodes

Tricyclic Antidepressants

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Types of selective reuptake inhibitors

SSRI (serotonin reuptake inhibitors)

SSNRI (serotonin and norepinephrine reuptake inhibitors)

Mechanism of action

Increases the availability of serotonin and/or norepinephrine in synapse by interfering with reuptake

Safer than tricyclic antidepressants, less likely to lead to overdose deaths

However, FDA warning about increased risk of suicidal tendencies in children and adolescents

Selective Reuptake Inhibitors

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ECT (electroconvulsive shock therapy)

Most effective treatment for severe depression

Best treatment choice in cases with a risk of suicide

Can be used in conjunction with drugs

Compared to pharmacotherapy

ECT relieves symptoms faster

ECT may be more effective

Electroconvulsive Therapy

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Lithium

A drug used to treat mania and bipolar disorder

Acceptance slow in United States

Previous history of lithium poisonings

Perception that mania is not a serious problem

Impossible to patent a basic chemical element

Thus, no financial incentive

Can be safe or toxic

Blood levels must be monitored

High rate of patient noncompliance

Mood Stabilizers

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Lithium normalizes mood in bipolar patients

Preventing both mania and depressed mood swings

Ultimate mechanism of action is unknown

Little effect in treating unipolar depression

Other mood stabilizers are anticonvulsant drugs

valproic acid

carbamazepine

lamotrigine

Mood Stabilizers

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Following the introduction of antipsychotics

Number of patients in psychiatric hospitals declined dramatically

Consequences of Pharmacotherapy

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Source: American Hospital Association, Hospital Statistics, 2012

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Changes for psychiatrists

Less time spent doing psychotherapy

Priority and emphasis on establishing an appropriate drug regimen

Consequences of Pharmacotherapy

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Civil rights issues

Indefinite commitment to a hospital deemed unconstitutional (1975)

Periodic review of a patient’s status helps determine if patient presents a danger to self or others

Patient is released if there is no danger

Concerns

Patients may have well-controlled symptoms while on medication in a hospital

But may stop taking medication upon release

Unmedicated patients, although not overtly dangerous, may still be too ill to care for themselves

Consequences of Pharmacotherapy

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Imprisonment and homelessness

More mentally ill persons are jailed each year than are admitted to state mental hospitals

About one-third of all homeless people have some form of serious mental illness

Consequences of Pharmacotherapy

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