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 Acknowledgments
Many thanks to our publisher, Dr. Matthew McKay, and our editors, Leslie Tilley, Melissa Kirk, and Kayla
Sussell, for helping our ideas to take form.
To our families and friends, with deep appreciation, for their patience and encouragement throughout this
project.
Finally, heartfelt thanks to our students and our patients. May this book reach many and hopefully
contribute to our ongoing struggle to reduce emotional suffering.

8
 Part One

Understanding Psychopharmacology: The Basics

Part one of this book briefly covers the development of psychopharmacology from a historical and sociological
perspective and then goes on to provide an overview of neurobiology and pharmacology. The purpose of these
chapters is not to provide a comprehensive discussion of the fields of pharmacology or neurophysiology, but is
simply to familiarize you with the basic terminology and models of pharmacokinetics.

9
 1

Introduction
This book is intended primarily for mental health professionals and those in graduate training in psychology,
social work, psychiatric nursing, and counseling. The professional goal of most readers will be to provide
services that aim to reduce emotional pain, to promote psychological growth and healing, and to foster the
development of personal autonomy. To these ends, we in the field are trained in various theoretical
approaches that attempt to explain the development of maladaptive lifestyles and subjectively painful
psychiatric symptoms. These theories serve to give meaning and coherence to what we do in clinical practice
and, most importantly, lay a foundation of understanding so that interventions make sense and further the
goal of reducing suffering in ways that are effective.
Many schools of thought exist regarding the origins of mental health problems. As has been well
documented in the history of psychiatry, as schools of thought evolve, controversy, dogma, and empassioned
belief systems emerge. It may be inherent to the development and maturation of science that these
emotionally toned belief systems and the resulting debates occur.
From the mid-1960s through the 1970s, polarization occurred within psychiatry between those advocating
psychological theories (primarily psychodynamic and behavioral models) and those on the other side of the
fence using biological and medical models. The disagreements that emerged were more than differences of
opinion or dry debate. Each school attracted followers who had strong emotional investments in their
perspective.
For many years this division resulted in the development of barriers between groups of mental health
clinicians—and at times in fragmentation in care. Fortunately, during the past decade something has changed.
We are beginning to witness a shift in thinking, as increasing numbers of practitioners and training institutes
move away from egocentric and dogmatic positions and begin to embrace a more integrated approach with
regard to both theories of etiology and methods of treatment.

New discoveries in the neurosciences, refined technical advances in psychotherapy, and a large number of
outcome studies in both pharmacotherapy and psychotherapy have made it abundantly clear: People are
complex. Mental health problems spring from many sources; and reductionist, unidimensional models are
simply inadequate to explain the wide array of mental and emotional problems people experience. Likewise,
no single approach to treatment works for all problems. Certain disorders clearly respond better to certain
interventions, whereas others require alternative approaches.

In writing this book, although our primary focus is on psychopharmacology, we share a strong respect for
what will be termed integrative approaches to treatment: recognition of the importance of varied treatments
and collaboration among professionals from different disciplines.

We hope that you will find this book helpful as you engage in this most important profession and work
toward the goal of reducing emotional pain.

10
11
 History of Biological Psychiatry
In understanding psychopharmacology, it may be helpful if you are able to place it in a historical context. Let’s
take a brief look at this history as it unfolded.

In the late eighteen hundreds, psychiatry was clearly rooted in the medical model and the neurology of the
day. Psychiatrists believed, almost exclusively, that mental illness could be attributed to some sort of biologic
disturbance. The earliest attempts to approach the understanding of mental illness in this era involved two
main areas of investigation.
On one front was the development of the first systematic nosologic system by Emil Kraepelin. This
pioneering work laid the foundation for all later diagnostic schema (such as the Diagnostic and Statistical
Manual of Mental Disorders, or DSM). And many of Kraepelin’s original notions about the classification of
major mental illness have stood the test of time. He was a brilliant investigator and the one most responsible
for ushering in descriptive clinical psychiatry. However, his endeavors must have been accompanied by a good
deal of frustration and impotence, since, despite the development of a systematic approach to diagnosis,
Kraepelin and other psychiatrists of his time had few, if any, methods of treatment.
At the same time, the hunt was on for evidence of brain pathology, which was presumed to underlie
mental illness. Research was conducted in neuroanatomy labs but yielded few concrete results. For example,
the famous French neurologist Jean-Martin Charcot believed that hysterical conversation symptoms were
undoubtedly due to some type of central nervous system lesion. He explained the fact that no demonstrable
pathology could be isolated on autopsy by saying it simply suggested that somehow the lesion mysteriously
disappeared at the time of death. We must bear in mind, however, that in all likelihood, these researchers and
clinicians were desperate to find causes and cures and went at it by the means best known to them (biology)
and using the scant technology available at the time.
Biological psychiatry got a shot in the arm in the late eighteen hundreds, as two discoveries were made. At
the time, probably one half of those housed in asylums suffered from a type of psychotic-organic brain
syndrome that ultimately was found to be caused by the Treponema pallidum bacteria (a central nervous system
infection seen in the late stages of syphilis). It was also eventually discovered that some organic mental
syndromes were due to pellagra (a disease associated with niacin and protein deficiency). These were
important discoveries, and they fueled enthusiasm in biological psychiatry. It was just a matter of time, it was
felt, before other biologic causes would be isolated and medical treatments developed. However, such
discoveries did not occur until the middle of the twentieth century. For practical purposes, biological
psychiatry came to a halt as it entered the nineteen hundreds.
The disappointments stemming from medical research on mental illness and the failure to develop any
effective treatment probably increased the receptivity of psychiatry to divergent approaches. At this same time
Sigmund Freud was assembling the basic notions of psychoanalysis. Freud’s initial theory was strongly
influenced by his own medical and neurological training (for example, his “Project for a Scientific
Psychology,” 1895), and many of his prevailing ideas continued to have their roots in biology, including drive
theory, instincts, and psychosexual development. However, his newly emerging theory and techniques of

12
treatment sparked interest in the use of novel, nonmedical approaches to treatment.

By the 1920s psychological (rather than biological) explanations for the development and treatment of
psychopathology had found their place in clinical psychiatry, and by the 1940s psychodynamic thinking had
permeated American psychiatry and become the dominant theoretical model. Yet these newly developed
approaches proved to be inadequate in the treatment of the more serious forms of mental illness, such as
schizophrenia and manic-depressive psychosis. In one of his last manuscripts, Freud himself admitted his
disappointment in psychoanalytic methods for treating schizophrenia. He hypothesized that eventually it
would be discovered that these grave mental disorders were due to some form of biologic abnormality, and
that perhaps drugs would eventually be found to treat these illnesses.

Somatic Therapies

In the days of Kraepelin, pharmaceuticals were used to treat mentally ill patients. Generally, the drugs
were prescribed to sedate wildly agitated psychotic patients. For example, Kraepelin listed in one of his
textbooks the following group of recommended medications (Spiegel and Aebi 1989):

Kraepelin noted, however, that none of these preparations cured mental illness, that they were for short-
term use, and that a number of them could lead to problems with addiction. All of these drugs achieved
behavioral control by sedating patients; none really affected psychotic symptoms per se, nor did they have any
impact on activating patients who were stuporous or clinically depressed.

Other somatic therapies were developed in the first half of the twentieth century, with variable results.
Malaria therapy was conceived in 1917, insulin shock in 1927, psychosurgery in 1936, and electroconvulsive
treatment (ECT) in 1938. All of these methods, as originally conceived, carried serious risks, and most
demonstrated marginal effectiveness. Psychosurgeries were carried out by the thousands in the 1940s,
resulting in rather effective behavioral control over agitated psychotic patients but at great human cost. Many,
if not most, lobotomized patients were reduced to anergic, passive, and emotionally dead human beings.

Electroconvulsive treatment, conversely, was quite effective in certain groups of patients, such as those
with psychotic depressive disorders. However, early methods of administration were fraught with dangerous
complications and side effects, and ECT was used on a widespread basis, indiscriminately. Many patients
were treated with it inappropriately and did not respond. (As shall be discussed later, in recent years
significant advances have been made in ECT, and it now affords a highly effective, safe treatment for selected
types of patients.)
Most severely ill patients in the late nineteenth and early twentieth centuries continued to be housed in

13
overcrowded state mental hospitals and were “treated” using tried and true methods of the day: seclusion,
restraint, and wet-sheet packs. Although seemingly inhumane procedures were employed, it may be important
to consider that the psychiatrists of that era were relatively helpless in the face of very severe mental illnesses
and that these approaches (although certainly misused at times) reflected their attempt to reduce the
horrendous human suffering seen in thousands of severely ill people.

New Discoveries

In the 1950s, three new discoveries heralded the beginnings of a new interest in biological psychiatry.
Interestingly, these three areas of investigation were conducted by separate groups of researchers, each with
little knowledge of the work being done by their colleagues (Kety 1975).

THORAZINE AND OTHER EARLY PSYCHOTROPIC DRUGS

Immediately after World War II, medical researchers and chemists working for pharmaceutical companies
were trying to develop a drug that would reduce the complications associated with shock following major
surgery. In early 1951, a compound initially labeled #4560 RP was developed and testing with surgical
patients was begun (Spiegel and Aebi 1989). The initial results were encouraging. Given preoperatively, it
relaxed patients, somewhat reduced postoperative shock, and proved to be a good antiemetic (preventing
postsurgical nausea). The finding that it produced noticeable sedation came as a surprise. In the aftermath of
field trials with surgical patients, the pharmaceutical company Laborit decided to try this medication with
restless, agitated psychiatric patients to help improve sleep, totally unaware that the drug would prove to have
more widespread effects on the psychiatric patients who were tested.
Initial clinical trials first reported in 1952 resulted in marked behavioral changes when given to manic and
schizophrenic patients. Not only did it produce a calming effect, but after a period of time it actually appeared
to reduce psychotic symptoms, such as delusions and hallucinations. Additional studies were carried out the
following year, and by 1954 the drug was approved for use. The new medication was given the generic name
chlorpromazine; in the United States it was marketed under the brand name Thorazine. It received immediate
acceptance, and by the end of 1954, for the first time ever, there was a marked decrease in the number of
patients incarcerated in state mental hospitals: the first major breakthrough in psychopharmacology.

Other psychotropic medications were discovered during the 1950s. The first antidepressant was developed
in 1952 (iproniazid, an MAO inhibitor), although clinical studies in humans did not take place until 1956.
The first tricyclic antidepressant, imipramine (Tofranil), was developed in 1954 and entered the market in
1957. The first minor tranquilizer, meprobamate, was released in 1955, followed shortly by the safer
benzodiazepine, chlordiazepoxide (Librium), in 1958. Finally, lithium carbonate, originally used as a sedative
by J. Cade in 1948, began to be used to treat bipolar disorder (formerly called manic-depressive illness) in the
early 1960s.
It is interesting to note that most of these psychopharmacological discoveries were accidental; that is, the
drug companies were developing medications to treat other medical illnesses and just happened to find that
the drugs could affect psychiatric symptoms. Also, these discoveries were made empirically; they were not
developed as an outgrowth of a particular theory of neurochemical dysfunction, nor was the mechanism of

14
action at all known. What was evident was that the medications worked and were far superior to any previous
treatments for severe mental illness.

THE SYNAPSE AND NEUROCHEMICAL TRANSMISSION

Although C. S. Sherrington inferred the existence of the synapse (the small space separating individual
nerve cells) as early as 1906, the specific details of synaptic transmission were not fully understood for many
decades thereafter. Sherrington’s ideas involved a sort of telephone switchboard model of the nervous system,
and neuronal messages were assumed to be transmitted via electrical stimulation. It was not until the 1950s
that neuroscientists realized that communication between nerve cells, although partially electrochemical in
nature, is largely due to the release of chemical substances. These chemicals, which transmit messages from
one nerve cell to another, are referred to as neurotransmitters; other chemicals that play an indirect role in
neurotransmission are called neuromodulators.
With this discovery, it became possible to imagine that certain neurologic dysfunctions might be caused by
chemical irregularities, and that therefore it might be possible to develop drugs that could influence or alter
neurotransmitter function.

GENETIC STUDIES

The third line of investigation involved both genetics and studies of familial patterns of mental illness.
The earliest research in this direction was ultimately criticized for numerous methodological flaws. Yet some
of the basic findings proved to be fundamentally correct. There is a strong genetic loading for certain mental
illnesses, in particular for schizophrenia and bipolar disorder. (In recent times evidence has been obtained
revealing genetic loadings for a number of mental disorders, although clearly the strongest evidence exists for
bipolar disorder, attention-deficit/hyperactivity disorder, and some types of schizophrenia.)

Controversy

By the early 1960s then, it had been discovered that synaptic activation is chemical in nature; certain
illnesses seem to be genetically passed on from generation to generation (and genetic factors are expressed
biochemically); and newer drugs could significantly reduce psychiatric symptoms. The triangulation of this
data provided rather strong support for a renewed interest in biological psychiatry. There was new hope for
the millions of patients suffering from serious mental illness, and psychiatry had begun to step back into “real
medicine” again.
However, despite the advances, these new treatments were plagued by a host of side effects—some
unpleasant, some actually dangerous. These potent drugs were also often overused or were misused in certain
treatment settings. Consequently, controversy began to arise, both among professionals, and in the lay public
and mass media.

Medications and the Media

15
 Research studies and clinical experience certainly influence prescribing
practices. However, in recent years the media has had a profound effect on
public opinion and ultimately on clinical practice.

In the late 1980s, negative attention was focused on the drug Ritalin
(methylphenidate), a widely prescribed stimulant used in the treatment of
attention-deficit/hyperactivity disorder (ADHD). Andrew Brotman,
summarizing the work of Safer and Krager (1992), states, “The media attack
was led by major national television talk show hosts and in the opinion of the
authors, allowed anecdotal and unsubstantiated allegations concerning Ritalin
to be aired. There were also over twenty lawsuits initiated throughout the
country, most by a lawyer linked to the Church of Scientology” (Brotman 1992,
audiotape).

In a study of the effects of this negative media and litigation blitz,

conducted in Baltimore County, Maryland, Safer and Krager (1992) found that
the use of Ritalin had dropped significantly. From 1981 through 1987, the use
of Ritalin had increased fivefold. However, in the two-year period during and
just following the negative media attention, there was a 40 percent decrease in
prescriptions for Ritalin. And this decrease occurred at a time when research on
ADHD and stimulant treatment continued to strongly support the safety and
efficacy of such medications. The authors go on to state that 36 percent of
children who discontinued Ritalin experienced major academic maladjustment
(such as failing grades or being suspended), and an additional 47 percent who
discontinued encountered mild to moderate academic problems. Concurrently,
as Ritalin use (especially new prescriptions) decreased, there was a significant
(fourfold) increase in the prescription of tricyclic antidepressants among
ADHD children. It is important to note that tricyclics, although often used to
treat ADHD, tend to have more troublesome side effects than Ritalin, and
have been implicated in six reports of cardiac fatalities. Brotman (1992)
concludes, “When there are reports in the media that lead to stigmatization of a
certain drug … there tends to be a move to other medications which have less
notoriety, even if they may, in fact, be more problematic.”

16
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 More recently, following wide acclaim as a new “breakthrough drug for
depression” (Cowley et al. 1990), Prozac (fluoxetine) came under attack by
consumer groups and, again, the Church of Scientology. The negative attention
was sparked by a single article (Teicher, Glod, and Cole 1990) documenting
the emergence or reemergence of suicidal ideas in six patients treated with
Prozac. The six patients had been diagnosed as suffering from severe depressive
disorders, and in no case were there actual suicide attempts following the onset
of treatment with Prozac. But suddenly Prozac was thrust into a very
unfavorable light and was the next drug in line to find itself the topic of
television talk shows.

Subsequent studies have failed to find any evidence that Prozac is more
likely to be associated with suicidal feelings than any other antidepressant (Fava
and Rosenbaum 1991; Beasley and Dornseif 1991). In fact, in one study the
incidence of suicidal ideations was greater in patients treated by placebo or
imipramine (a tricyclic antidepressant) than by Prozac (Beasley and Dornseif
1991).

The Church of Scientology attempted to convince the Federal Drug

Administration (FDA) to pull Prozac from the market. However, the FDA
ruled against taking such action because there was no scientific evidence to
support the claims made by the Church of Scientology (Burton 1991).

All medications produce some side effects. Reports of adverse effects, even
if very infrequent, must be taken seriously and investigated systematically.
There is a place for skepticism and scrutiny. However, one must consider the
negative effect of unsubstantiated reports in the lay press. For example, the risk
of Prozac-induced suicide appears to be extremely low, and the suicide rate in
untreated major depression is reported to be 9 percent. Clearly, failure to treat
carries the graver risk.

It is very likely that many seriously depressed people and parents of ADHD
children have been understandably, and unnecessarily, frightened by negative,
sensationalistic reports in the media. To quote Brotman (1992) again,

17
 “Pharmacotherapy does not exist in a social and political vacuum.”

PROFESSIONAL DISSENTION

Within professional ranks, debate issued from two fairly discrete theoretical camps: those who were
promedication and those who were pro-psychotherapy. Each group amassed impassioned arguments not only
in favor of its own point of view, but also against the other school of thought, as set out below.

PROMEDICATION (ANTIPSYCHOTHERAPY)—ARGUMENTS IN FAVOR OF MEDICATION TREATMENT AS THE

TREATMENT OF CHOICE:

Because of its quantifiable nature—that is, the ability to monitor dosage—medication treatment can
be studied much more systematically than psychotherapy.

Medications act quickly to reduce painful and debilitating symptoms.

The quicker response seen with medications can help to restore hope and reduce demoralization.

Treatment with medications can be conducted in a much more systematic and standardized fashion,
whereas psychotherapy relies heavily on the individual skill of the psychotherapist.

Rapid and effective symptom relief can potentially reduce suffering to such an extent that the patient
is better able to engage productively in psychotherapy. Likewise, the reductions of drive strength
afforded by some psychotropic medications may operate to free up more psychic energy, which could
then be channeled into adaptive ego functions.

Medications can provide help to patients who have limited intellectual capacity, poor ego strength, or
both; that is, drugs may be effective with people for whom psychotherapy is inappropriate.

Psychotherapy is often prolonged and expensive, may be unavailable to many people, and is of
unproven effectiveness (this was the case especially in light of the very limited psychotherapy outcome
studies available in the 1950s and 1960s). Thus medications are much more cost-effective and more
readily available to the general public.

Finally, those strongly wedded to a biochemical model of psychopathology contended that social,
behavioral, and psychological approaches simply could not correct the underlying biologic abnormality
responsible for major mental illnesses. Recent studies, however, have cast doubt on this hypothesis.

PRO-PSYCHOTHERAPY (ANTIMEDICATION)—ARGUMENTS IN FAVOR OF PSYCHOTHERAPY AS THE

TREATMENT OF CHOICE:

Only psychotherapy, not medications, can address the complexity of human psychological
functioning. Medications only treat symptoms, whereas psychotherapy focuses on the whole person or

18
 psyche.

Psychotherapy aims toward personal growth and autonomy, whereas drugs are likely to foster
dependency, either on the doctor or on the drug itself.

Drugs can interfere with autonomy and expressions of free will, whereas psychotherapy honors these
processes. The prescription of medications may, at least at an unconscious level, communicate the
message that the drug will do the work, you don’t have to. (Numerous documented instances of
overuse of tranquilizing medications to achieve behavioral control provided fodder for this argument.)

Medications may reduce anxiety and other forms of suffering to such an extent that people will be less
motivated to engage in psychotherapy.

Many drugs have undesirable or dangerous side effects, and some can lead to dependence and abuse.

Medications ultimately do not solve problems, teach adaptive coping skills, mend broken hearts, or
fill empty lives (Menninger 1963).

Although this debate continued throughout the 1960s and 1970s, clearly there were also a number of what
G. L. Klerman (Beitman and Klerman 1991) calls “pragmatic practitioners”—those mental health
professionals who used whatever approaches seemed to work. Certainly it was, and is, reasonable to consider
that some disorders are best treated by psychotropic medications, others by psychotherapy, and it often makes
sense to use a combination of both modalities.

PUBLIC OPINION

A parallel to the professional debate began to occur within the general public. In institutes of higher
education, the humanistic movement began to permeate not only departments of psychology but the global
academic community as well. The post-McCarthy social climate was ripe for new attitudes that challenged
political and social control and applauded the expression of free will, self-expression, and self-actualization.
Reports began to surface regarding the abuse of psychiatric medication by the medical profession. Opponents
to drug treatment accused the psychiatrists of using medications to achieve control. The term “chemical
straitjacket” became popularized.

The 1970s saw the proliferation of new tranquilizers, and pharmaceutical companies reaped fortunes from
the sale of well-known pills such as Valium and Librium. The vast majority of prescriptions written for minor
tranquilizers (more than 90 percent) were written by family practice doctors, not psychiatric specialists. The
“drugged state” was the fastest growing state in the union (Bly 1990). The inappropriate use and abuse of
tranquilizers gained increasing public attention and even found its way into popular songs (the Rolling Stones’
“Mother’s Little Helper”) and movies (I’m Dancing as Fast as I Can).
In the 1960s, the Church of Scientology was successfully sued by the American Psychiatric Association. In
retaliation, it began a long, embittered assault on American psychiatry. Initially the Church of Scientology
launched a negative campaign against the use of Ritalin, a psychotropic medication used to treat attention-
deficit disorder. More recently it has orchestrated a move to shed negative light on the antidepressant Prozac

19
(see box on page 8).
Biological psychiatry was under attack. Although clearly there was a good deal of abuse and misuse of
psychoactive drugs, there also continued to be decreasing numbers of people living in mental hospitals, and
drug companies were at work developing newer and “cleaner” psychotropic medications, medications with
fewer side effects.

Rapprochement: Biological and Psychological Perspectives

During the 1980s, a shift began in which increasing numbers of mental health practitioners and
researchers widened their previously narrow views on etiology and treatment of mental illness. Increasingly, it
became recognized that unidimensional models, whether psychological or biological, fell short of explaining
the tremendous complexities of human psychological functioning and psychopathology. This transition to
more complementary and integrated views of cause and cure can be attributed to several new developments:

Psychopharmacology and the “Managed Care” Dilemma

Since the advent of newer-generation psychotropic medication, many

millions of people are receiving more effective treatment for a host of
psychiatric conditions. For this we are grateful. However, it also has become
abundantly clear that the effects of psychiatric drugs are limited. Under the best
of all circumstances such treatments do not have an impact on all aspects of
psychological suffering.

In our view, successful psychiatric treatment should always include

psychotherapy. Only in the context of a healing relationship may many aspects
of psychological dysfunction be adequately addressed. Numerous interpersonal,
intrapsychic, spiritual, and existential dimensions of human functioning simply
are not amenable to pharmacologic treatment.

In this book we acknowledge the many benefits of drug treatment; however,

we must also share a concern: In these days of cost containment and managed
care, individual human lives and quality-of-life issues are often ignored. It is a
real concern that an automatic, knee-jerk reaction will be just to prescribe pills,

20
 when so much more is needed. We are treating people, not just nerve cells.

However, given the rising cost of pharmaceuticals, the most recent cost-
containment strategies are as likely to focus on the use of psychiatric medication
as well as on psychotherapeutic interventions. Paradoxically, perhaps as
psychotropic drugs begin to account for an ever-increasing percentage of total
health care expenditures, we will see best-practice guidelines influenced in a
way that will support psychotherapy.

We hope that critical questions will be raised. Are medication treatment

failures completely an effect of the drugs not working? Or could the relative
lack of psychotherapeutic modalities be a contributing factor? Similarly, as the
prescribing of psychotropics has become the first step in treatment, has that
first step been taken before an accurate diagnosis was made? Are we medicating
out of habit, when it is not really indicated? If the patient would benefit more
from psychotherapy, are we doing more harm than good?

We remain hopeful that the pendulum will swing back to support what
most practicing clinicians know to be true: the best outcomes result from
appropriately balanced treatment that includes therapy and medications.

Human beings and their life problems are enormously complex. And it is
the highly trained clinician who must ultimately decide which combinations of
treatments are best suited for each individual client (not insurance companies,
treatment manuals, or untrained technicians)!

The side effects of medications historically resulted in very poor compliance rates among psychiatric
patients, and the most effective medication available is useless if the patient doesn’t take the drug as
prescribed. Compounds introduced in the 1980s and early 1990s have yielded effective medications
with much more user-friendly side-effect profiles.

Discoveries have been made in which new medications and newer uses for existing medications

21
 provide very good results in treating certain types of mental illnesses, such as panic disorder and
obsessive-compulsive disorder. This greatly increases the psychiatrist’s arsenal of effective
medications.

A growing body of well-controlled research studies (double-blind, randomized, placebo-controlled)

lend convincing support to the efficacy of psychotropic drugs.

Neuroimaging techniques, such as PET and SPECT scans, allow researchers to view metabolic
activity in the living brain. These technologies have been able to isolate localized brain abnormalities
in certain mental disorders, including major depression, schizophrenia, ADHD, and obsessive-
compulsive disorder. They can provide data on particular sites of drug action or binding, and can
illustrate changes between the pre- and post-treatment status of particular brain structures. Imaging
techniques have added considerable “hard data” to various theories of biochemical etiology in selected
mental illnesses.

Neuroimaging techniques have been accompanied by a host of new laboratory procedures that allow
neuroscientists to assay the neurochemical by-products found in spinal fluid. Although early
psychopharmacology was implemented without any real knowledge of the underlying
pathophysiology, in the past decade, biochemical theories have gained scientific support.

These new developments in psychiatry and the neurosciences have been hard to ignore. Many formerly
hard-line psychotherapists have been won over by the flood of research findings and their personal experiences
in treating people with psychoactive drugs.
During this same period, important advances were made in the theory and practice of psychotherapy.
During the late 1970s and 1980s the first truly well-controlled psychotherapy studies emerged (including the
now popular meta-analyses). The results of these studies cast doubt on the findings of early research that had
suggested that psychotherapy was ineffective (Eysenck 1965, for example). Of the many forms of
psychotherapy that have been developed, the meta-analyses suggest that no single school of therapy is clearly
superior and that psychotherapies across the board are often much more effective than no treatment.
Also during this time we witnessed the development of novel treatment approaches, such as cognitive
behavioral psychotherapy (Beck 1976) and interpersonal psychotherapy (Klerman et al. 1984) as a treatment
for particular disorders, such as depression and panic disorder. These approaches have appeal, in that they can
be somewhat systematically applied (some even provide “canned” formats or “cookbooks”). Also, the
methodology is a bit less reliant on the personal characteristics of the therapist. These approaches then lend
themselves to a short-term format and can often be conducted in groups. And, finally, these psychotherapies
can be more easily studied. Both cognitive behavioral and interpersonal psychotherapies have a solid track
record of effectiveness (as is discussed further in the next chapter).

Finally, both clinical-anecdotal and research studies have emerged that support the combined use of
pharmacotherapy and psychotherapy in the treatment of particular disorders. At times, the combined
treatments have been shown to be superior to either single treatment alone.
For many in the mental health community, the writing on the wall has become far more legible: A single

22
model for understanding and treating mental disorders is too narrow and is simply inadequate. As we shall be
discussing in subsequent chapters, current evidence suggests that particular disorders do respond best to
certain medical treatments, and for these, medications are the treatment of choice. Other disorders have little
to do with biochemical dysfunction, and medications play little or no role in their treatment. And still other
disorders require the skillful integration of biological and psychotherapies.

As the saying goes, when you only have a hammer, every problem looks like a nail. Fortunately, at the
present time, mental health professionals have access to a “toolbox” of approaches that can, if employed
appropriately, dramatically increase our effectiveness in reducing emotional suffering and promoting mental
health.

23
 Why Learn About Psychopharmacology?
In the United States, the majority of mental health services are provided by nonmedical therapists. Likewise,
the majority of prescriptions for psychotropic medications are written by family practice and primary care
physicians (see figure 1-A). Thus, even though psychiatrists represent the branch of medicine that specializes
in psychopharmacology, they are directly responsible for providing only a fraction of professional services to
the mentally ill. Consequently, it is becoming increasingly important for all mental health clinicians to have a
basic familiarity with psychiatric medication treatment.
Many nonmedical psychotherapists are or will become strongly and rather directly involved in medication
treatment. In some settings psychologists and social workers assume a major role in monitoring client
responses to psychotropic medications. As primary therapist, these practitioners are in most frequent contact
with clients and are in the best position to observe symptomatic improvement, side-effect problems, and issues
involving medication adherence. When consulting with primary care physicians, or as a staff member in some
HMO settings, nonmedical therapists who are well-versed in the use of psychiatric medications can play an
active (albeit collaborative) role in recommending particular medications and dosage adjustments. In addition,
the Department of Defense, in response to an inadequate number of psychiatrists available in the military,
implemented a program to train a small number of psychologists so that they are able to prescribe a limited
formulary of psychiatric medications. Currently, properly trained psychologists can become licensed to
prescribe psychiatric medications in the states of New Mexico, Illinois, and Louisiana. These various activities
reflect quite direct involvement in medication treatment by nonmedical therapists.

In contrast, many nonmedical therapists have little to do with drug treatment. In some cases this may be
due to the nature of their position in a particular treatment setting; in others it may have more to do with their
own preferences and biases, such as opposition to medication treatment. However, we believe that, regardless
of the degree of involvement and interest in medication treatment, it is increasingly important that all mental
health therapists become acquainted with some basic notions regarding psychopharmacology.

Convincing evidence now exists that certain mental disorders are either caused or accompanied by

24
neurochemical abnormalities. The failure to appropriately diagnose and medically treat such conditions can
result in the use of ineffective or only partially effective treatments and hence in prolonged suffering. Aside
from the obvious cost in human terms, prolonged inappropriate treatment results in excessive financial
burdens for clients, their families, and the health care system.
In addition, to date there have been successful malpractice suits brought against therapists who failed to
treat or refer for treatment patients suffering from particular disorders known to be generally responsive to
medication.
All mental health professionals must be able to, at the very least, diagnose mental disorders that require
psychotropic medication treatment so that appropriate referrals can be made. Differential diagnosis will be
discussed in detail in this book.

In many cases, clients may not choose to see a psychiatrist, even when told by their therapists that
medication treatment is indicated. This may be due to financial concerns or to the negative stigma some
people believe is attached to psychiatric treatment. A viable alternative, in some cases, is referral to the family
practice doctor. Many people suffering from emotional distress see their family physician first. This doctor
may begin treatment with psychotropic medications and may also refer the patient for psychotherapy. In such
cases, the nonmedical therapist may be in a key position to supply information regarding diagnosis and
treatment response. Increasingly, family practice physicians and nonmedical therapists become partners
collaborating on the treatment of many clients—especially those suffering from fairly uncomplicated
depressive and anxiety disorders.
Effective consultation with family practice doctors and psychiatrists alike is enhanced by the nonmedical
therapist’s ability to accurately communicate and discuss diagnosis, target symptoms, presumed etiology, and
possible treatments. We hope this book will provide a solid grounding in basic issues to help improve
communication and cooperation between professionals.
Mental health treatment has moved increasingly toward greater acceptance of multidisciplinary and
integrated treatment modalities. As sophistication in the diagnosis and medical treatment of mental disorders
continues to develop, it will be important that mental health professionals not take a step backward. The
polarization of models and professional “turf battles” of the 1960s and 1970s may have sparked useful and
lively debate, but they also often resulted in a fragmentation of care. Ongoing knowledge of and respect for
diverse models and collaborative involvement hold promise for increasingly effective efforts in treating mental
illness. If you are an instructor interested in using this book in courses you teach, visit
http://www.newharbinger.com/39256 for classroom adoption resources.

25
 2

Integrated Models
The decision about whether to use psychotropic medications in the treatment of psychiatric disorders is
influenced by a number of factors. Unfortunately, often the decision is based largely on the clinician’s a priori
view toward treatment, deriving from his or her theoretical perspective. As we shall argue, the critical variable
in this decision is more appropriately based on the diagnosis, and in particular on the presence or absence of
key target symptoms that suggest the patient is experiencing some form of neurochemical disorder.
In broad and extremely heterogeneous groups of disorders, such as mood disorders, some may be largely or
exclusively caused by biological factors. Other disorders in such groups share some symptoms with biologic-
based mental illness, yet their etiology stems largely or exclusively from nonbiologic sources, for example,
emotional, psychosocial, or cognitive sources. Thus a very important question to address when making a
diagnosis and subsequent decisions about treatment is, “Is there any evidence to suggest that this person’s
problems are due to some form of biologic disturbance?” However, all too often this question is framed overly
simplistically: “Is the disorder biological or is it psychological?”
The distinction between what is psyche and what is soma is ambiguous at best. Invariably, there is a
complex interaction between psychological and biological factors in all cases of emotional disorder. This
complexity will be the focus of this chapter.

26
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 Transcriber’s Note:
Punctuation has been standardised.
Changes to the original publication are as
follows:

Page 76
spoke argumentively and there
changed to
spoke argumentatively and
there
Page 135
Don broke in the assist her
changed to
Don broke in to assist her
Page 185
look in the faces o’ them
childern changed to
look in the faces o’ them
children
Page 269
fiancè. I can see no changed to
fiancé. I can see no
Page 280
and there were afforded an
changed to
and they were afforded an
Fourth page of book catalogue
designs by Dan Sayre Grosbeck
changed to
designs by Dan Sayre
Groesbeck
Seventh page of book catalogue
Aero-Plane changed to
Aeroplane
*** END OF THE PROJECT GUTENBERG EBOOK PHOEBE DARING: A
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