Drug Therapy In Relation To Psychologicaltreatment

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No account of drug treatment strategies for psychiatric illness would be complete without consideration of psychological therapies. Psychotherapy is broad in content, ranging from simple counselling and 'supportive psychotherapy' sessions through ongoing formal psychoanalysis to newer techniques such as cognitive behavioural therapy.

As a general rule, psychotic illnesses (e.g. schizophrenia, mania and depressive psychosis) require drugs as first-line treatment, with psychotherapeutic approaches limited to an adjunctive role, for instance in promoting drug compliance, improving family relationships and helping individuals cope with distressing symptoms. By contrast, for non-psychotic depression and anxiety disorders such as panic disorder and obsessive-compulsive disorder, forms of psychotherapy are available which provide alternative first-line treatment to medication. The choice between drugs and psychotherapy depends on treatment availability, previous history of response, patient preference and the ability of the patient to work appropriately with the chosen therapy In many cases there is scope to use drugs and psychotherapy in combination.

Taking depression as an example, an extensive evidence base exists for the efficacy of several forms of psychotherapy. These include cognitive therapy (in which individuals identify faulty views and negative automatic thoughts and attempt to replace them with ways of thinking less likely to lead to depression), interpersonal therapy (which focuses on relationships, roles and losses), brief dynamic psychotherapy (a time-limited version of traditional psychoanalysis) and cognitive analytical therapy (another well structured time-limited therapy which combines the best points of cognitive therapy and traditional analysis).

Finally, it must be stressed that all doctors who prescribe psychotropic drugs engage in a 'therapeutic relationship' with their patients. A depressed person whose doctor is empathic, supportive and appears to believe in the efficacy of the drug prescribed is more likely both to take the medication and to adopt a mindset that might actually make him or her feel better than if the doctor seemed aloof and ambivalent about the value of psychotropic drugs. Remembering that placebo response rates of 30-40% are common in doubleblind trials of antidepressants, we should never underestimate the importance of our 'therapeutic relationship' with the patient in enhancing the pharmacological efficacy of the drugs we use.

Antidepressant drugs

Antidepressants can be broadly divided into four main classes (Table 19.1), tricyclics (TCA, named after their three ring structure), selective serotonin reuptake inhibitors (SSRIs), monoamine oxidase inhibitors (MAOIs), and novel compounds some of which are related to TCAs or SSRIs. Clinicians who wish to have a working knowledge of antidepressants would be advised to be familiar with the use of at least one drug from each of the four main categories tabulated. A more thorough knowledge base would demand awareness of differences between individual TCAs and of the distinct characteristics of the novel compounds. Since antidepressants are largely similar in their therapeutic efficacy, awareness of profiles of unwanted effects is of particular importance.

An alternative categorisation of antidepressants is based solely on mechanism of action (Fig. 19.1). The majority of antidepressants, including TCAs, SSRIs and related compounds are reuptake inhibitors. Certain novel agents including trazodone and mirtazapine are receptor blockers while MAOIs are enzyme inhibitors.

The first TCAs (imipramine and amitriptyline) and MAOIs appeared between 1957 and 1961 (Fig. 19.1). The MAOIs were developed from antituberculosis agents which had been noted to elevate mood. Independently, imipramine was synthesised from the antipsychotic drug chlorpro-mazine and found to have antidepressant rather than antipsychotic properties. Over the next 25

TABLE 19.) Classification of antidepressants


Selective serotonin reuptake inhibitors

Monoamine oxidase inhibitors

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