Types of Biomedical Therapy

Pharmacotherapy (Medication)

Biological therapies include four classes of psychiatric medications: antipsychotics, antidepressants, anti-cycling agents, and hypnoanxiolytics.

Learning Objectives

Discuss the various classes of psychotropic medications, the conditions they are used to treat, and their efficacy

Key Takeaways

Key Points

  • There are four classes of psychiatric medications: antipsychotics, antidepressants, anti-cycling agents, and hypnoanxiolytics. The first three groups of medications target specific problems such as mania or hallucinations.
  • Antipsychotics are used to treat schizophrenia, but may also be used for treating mania, delusional disorders, and other disorders. Antipsychotics have been found to work for as many as 70% of individuals with schizophrenia.
  • Antidepressants are used to treat major and bipolar depression, panic attacks, phobia, and obsessive-compulsive disorder. Antidepressants are effective in approximately 80% of individuals.
  • Anti-cycling agents, also called mood stabilizers, are drugs such as lithium. These drugs are used to treat bipolar disorder. Lithium is very effective and very fast working. The downside is that lithium has a number of serious side effects.
  • Hypnoanxiolytics include antianxiety agents, hypnotics, atypical anxiolytics, and atypical hypnotics. Hypnoanxiolytics have a general effect of calming individuals, alleviating anxiety, and causing sleep.
  • Many practitioners require that an individual be in therapy before they will prescribe a psychotropic substance, because therapy can increase the efficacy of psychiatric drugs.

Key Terms

  • bipolar disorder: A psychiatric diagnostic category, previously called manic depression, characterized by mood swings between great energy (mania) and clinical depression.
  • serotonin: An indoleamine neurotransmitter (5-hydroxytryptamine) that is involved in depression and is crucial in maintaining a sense of well-being and security.
  • dopamine: A neurotransmitter associated with movement, attention, learning, and the brain’s pleasure and reward system.
  • schizophrenia: A psychiatric diagnosis denoting a persistent, often chronic, mental illness affecting behavior, thinking, and emotion.

Defining Psychopharmacology

Psychopharmacology is the scientific study of the effects psychotropic substances have on mood, sensation, thinking, and behavior; psychopharmacotherapy is the medical application of these substances. A psychotropic substance is one that affects the mind or mental processes.

Psychotropic medications seek to address neurological imbalances in the brain that are thought to contribute to specific mental illnesses. The use of psychotropic medications is based on a philosophy held by biomedical therapists that the mind and body are connected, and that imbalances in the brain can be remedied to alleviate symptoms caused by these imbalances. That said, most practitioners prescribing medication for psychiatric symptoms require that their patient also be in psychotherapy with them or with another practitioner to further support the treatment and to provide closer supervision.

There are four major classes of psychotropic medications: antipsychotics, antidepressants, anti-cycling agents, and hypnoanxiolytics. The first three groups of medications target specific problems such as mania or hallucinations. If a “normal” individual took one of these medications they may notice little to no effect because the drugs are intended to target a specific problem that the normal individual does not suffer from. Hypnoanxiolytics, on the other hand, have general effects that work on all individuals.

Antipsychotics

Antipsychotics include drugs such as chlorpromazine and haloperidol. Antipsychotics are used to treat schizophrenia, but also may be used for treating mania, delusional disorders, and other disorders. Antipsychotic medications work primarily by blocking dopamine receptors. They have been found to work for as many as 70% of individuals with schizophrenia; however, approximately 30% of users develop serious side effects from using antipsychotics.

Antidepressants

Antidepressants come in several forms: tricyclics, selective serotonin reuptake inhibitors ( SSRIs, such as Prozac and Praxil), and monoamine oxidase inhibitors. Antidepressants are used to treat major and bipolar depression, panic attacks, phobias, and obsessive-compulsive disorder. The most commonly used antidepressants primarily affect the norepinephrine and serotonin (monoamine) neurotransmitter systems. Most antidepressants increase the available amount of norepinephrine or serotonin (or sometimes both) at the neuronal synapse, by decreasing the reuptake of these neurotransmitters into the pre-synaptic cell. They do this by inhibiting the norepinephrine transporter or the serotonin transporter, or by decreasing the metabolism of these neurotransmitters. Other antidepressants have direct effects on monoamine receptors. Antidepressants are effective in approximately 80% of individuals.

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Antidepressant: Antidepressants are used to treat depression, panic attacks, phobias, and obsessive-compulsive disorder.

Anti-Cycling Agents

Anti-cycling agents, also called mood stabilizers, are drugs such as lithium that are used to treat bipolar disorder. Lithium is very effective and very fast working: it eliminates the manic phase of bipolar depression, and once the manic phase is eliminated, the depressed phase usually stops as well. The downside is that lithium has a number of serious side effects.

Hypnoanxiolytics

Hypnoanxiolytics include antianxiety agents (also known as anxiolytics), hypnotics, atypical anxiolytics, and atypical hypnotics. Together, hypnoanxiolytics have a general effect of calming individuals, alleviating anxiety, and causing sleep. Unlike the other classes of psychomedication, hypnoanxiolytics have general effects that work on all individuals.

An anxiolytic is a drug that inhibits anxiety (in contrast to anxiogenic agents, which increase anxiety). Anxiolytic medications have been used for the treatment of anxiety, anxiety disorders, and their related psychological and physical symptoms.

Hypnotic drugs are a class of psychoactives whose primary function is to induce sleep and to be used in the treatment of insomnia, as well as in surgical anesthesia. Because drugs in this class generally produce dose-dependent effects, ranging from anxiolysis to production of unconsciousness, they are often referred to collectively as sedative-hypnotic drugs. Hypnotic drugs are regularly prescribed for insomnia and other sleep disorders, with over 95% of insomnia patients in some countries being prescribed hypnotics. Many hypnotic drugs are habit-forming and, due to a large number of factors known to disturb the human sleep pattern, a physician may instead recommend alternative sleeping patterns, sleep hygiene, and exercise, before prescribing medication for sleep.

The hypnotic medications benzodiazepine and nonbenzodiazepine also have a number of side effects such as daytime fatigue and cognitive impairments. However, benzodiazepines are often preferred over SSRIs for the treatment of anxiety disorders because they act more quickly and require a lower dose in order to be effective.

History of Psychopharmacology

Psychotropic substances have been used by humans for thousands of years. With the dawn of the Neolithic Age and the proliferation of agriculture, new plants with psychotropic effects came into use as a natural by-product of farming. Among them were opium, cannabis, and alcohol derived from the fermentation of cereals and fruits. Most societies began developing herblores, lists of herbs which were good for treating various physical and mental ailments. For example, St. John’s wort was traditionally prescribed in parts of Europe for depression (in addition to its use as a general-purpose tea), and Chinese medicine developed elaborate lists of herbs and preparations. These and various other substances that have an effect on the brain are still used as remedies in many cultures.

The dawn of contemporary psychopharmacology marked the beginning of the use of psychiatric drugs to treat psychological illnesses. It brought with it the use of opiates and barbiturates for the management of acute behavioral issues in patients. In the early stages, psychopharmacology was primarily used for sedation. Then with the 1950s came the establishment of chlorpromazine for psychoses, lithium carbonate for mania, and then in rapid succession, the development of tricyclic antidepressants, monoamine oxidase inhibitors, and benzodiazepines, among other antipsychotics and antidepressants. Defining features of this era include an evolution of research methods, with the establishment of placebo-controlled, double-blind studies, and the development of methods for analyzing blood levels with respect to clinical outcome and increased sophistication in clinical trials.

The early 1960s revealed a revolutionary model by Julius Axelrod describing nerve signals and synaptic transmission, which was followed by a drastic increase of biochemical brain research into the effects of psychotropic agents on brain chemistry. After the 1960s, the field of psychiatry shifted to incorporate the efficacy of pharmacological treatments, and began to focus on the uses and toxicities of these medications. The 1970s and 1980s were further marked by a better understanding of the synaptic aspects of the action mechanisms of drugs. However, the model has its critics—notably, Joanna Moncrieff and the Critical Psychiatry Network.

Efficacy of Psychopharmacology

Ideally, biological and psychosocial therapies should work together in a complementary fashion. For example, an individual with schizophrenia who is bombarded with visual, auditory, or other hallucinations, may find it difficult to focus in psychotherapy. With medication, the individual’s hallucinations can be eliminated or reduced to a level at which the individual can benefit from psychotherapy.

Different disorders respond to drug therapy differently. Some disorders are managed very effectively with biological therapies, others respond better to counseling, and some require the use of both. For example, the primary treatment of schizophrenia is antipsychotic medication, but it can be combined with psychosocial interventions like therapy. Eating disorders, on the other hand, are primarily treated through different types of psychotherapy, though medications related to weight gain or loss may be utilized. Depression is treated with therapy alone when possible to avoid the risks and side effects associated with drugs, but for some patients the combination of therapy and antidepressants is much more effective.

Criticisms of Psychopharmacology

A somewhat controversial application of psychopharmacology is “cosmetic psychiatry.” This is when people who do not meet criteria for any psychiatric disorder are nevertheless prescribed psychotropic medication. For example, the antidepressant Wellbutrin might be prescribed to increase perceived energy levels and assertiveness while diminishing the need for sleep, instead of its intended use, alleviating symptoms of depression. The antihypertensive compound Inderal is sometimes chosen to eliminate the discomfort of day-to-day, “normal” anxiety. Prozac in not-depressed people can produce a feeling of generalized well-being. Mirapex, a treatment for restless leg syndrome, can dramatically increase libido in women. These and other off-label lifestyle applications of medications are controversial and not uncommon. Although occasionally reported in medical literature, no guidelines for such usage have been developed.

There is also a potential for the accidental misuse of prescription psychoactive drugs by elderly persons, who may have multiple drug prescriptions.

Electroconvulsive Therapy

Electroconvulsive therapy (ECT) is a treatment method sometimes used for psychiatric disorders that do not respond to other forms of treatment.

Learning Objectives

Discuss the goals, techniques, and efficacy of electroconvulsive therapy for various psychological disorders

Key Takeaways

Key Points

  • It is unclear exactly how ECT works, but research suggests that it helps by shocking the brain and reducing the number of neural connections involved in depression or other illnesses, thereby stimulating the creation of new connections in other areas of the brain.
  • Some research suggests that ECT may stimulate an increased production of neurotrophic growth factors such as brain derived neurotrophic factor (BDNF) causing migration and proliferation of progenitor cells and growth of new neurons in the hippocampus.
  • ECT is currently used in the treatment of major depressive disorder, mania, schizophrenia, and catatonia, and has a reported success rate of around 80%. It should only be considered when other treatments such as therapy and pharmacological treatments are ineffective.

Key Terms

  • myalgia: Muscular pain or tenderness.
  • convulsion: An intense, paroxysmal, involuntary muscular contraction.
  • pharmacological: Of the medicinal characteristics of a specific drug, such as its uses and effects.

Defining Electroconvulsive Therapy

Electroconvulsive therapy (ECT) is a treatment method that is sometimes used to treat psychiatric disorders, such as major depression, that do not respond to other forms of treatment (psychotherapy or pharmacological treatments).

During treatment, a convulsion, or seizure, is induced by the application of electrical current to the brain. It is unclear exactly how ECT works, but research suggests that it helps by shocking the brain and reducing the number of neural connections involved in depression or other illnesses, thereby stimulating the creation of new connections in other areas of the brain. Some research suggests that ECT may stimulate an increased production of neurotrophic growth factors such as the brain derived neurotrophic factor (BDNF), causing migration and proliferation of progenitor cells and growth of new neurons in the hippocampus. The average treatment requires 2–3 sessions a week. The total number of treatments may vary, but generally between 6 and 12 total treatments are recommended.

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ECT machine: The Thymatron IV is a machine used for electroconvulsive therapy.

History of Electroconvulsive Therapy

Convulsive therapy was introduced in 1934 by Hungarian neuropsychiatrist Ladislas J. Meduna, who is widely considered to be the father of convulsive therapy. However, Meduna used camphor, and later metrazol, rather than electricity, to induce seizures. Italian professor of neuropsychiatry Ugo Cerletti, who had been experimenting with using electric shocks to produce seizures in animals, developed the idea of using electricity as a substitute for metrazol in convulsive therapy. In 1937, he and his colleagues tested electroconvulsive therapy for the first time on a person. Once they started trials on patients they found that after 10 to 20 treatments patients had improved greatly, though they experienced memory loss. This had benefits, however, as patients could not remember the treatments and had no ill feelings toward them. ECT soon replaced metrazol therapy all over the world because it was cheaper, less frightening, and more convenient.

The steady growth of antidepressant use along with negative depictions of ECT in the mass media led to a marked decline in the use of ECT, or “shock therapy” as it was sometimes called, during the 1950s to the 1970s. The U.S. surgeon general stated there were problems with electroshock therapy in the initial years before anesthesia was routinely given, and that these (now obsolete) practices were causing misperceptions about the way ECT was used.

Because of this backlash, national institutions reviewed past practices and set new standards. In 1978, the American Psychiatric Association released its first task-force report in which new standards for consent were introduced and the use of unilateral electrode placement was recommended. The 1985 NIMH Consensus Conference confirmed the therapeutic role of ECT in certain circumstances. The American Psychiatric Association released its second task-force report in 1990, where specific details on the delivery, education, and training of ECT were documented. Finally in 2001, the American Psychiatric Association released its latest task-force report. This report emphasizes the importance of informed consent, and the expanded role that the procedure has in modern medicine.

Efficacy of Electroconvulsive Therapy

ECT is a safe procedure with a mortality rate calculated to approximately 0.2 per 100,000 treatments. It is currently used in the treatment of major depressive disorder, mania, schizophrenia, and catatonia. It has different levels of efficacy depending on the disorder it is called on to treat.

Major Depressive Disorder

For major depressive disorder, ECT is generally used only when other treatments have failed, or in emergencies, such as imminent suicide. A meta-analysis done on the effectiveness of ECT in unipolar and bipolar depression was conducted in 2012. Findings showed that, although patients with unipolar depression and bipolar depression responded to other medical treatments very differently, both groups responded equally well to ECT. Overall remission rate for patients with unipolar depression after a round of ECT treatment was 51.5%, and 50.9% in those with bipolar depression. When ECT was followed by treatment with antidepressants, about 50% of people relapsed by 12 months following successful initial treatment with ECT, with about 37% relapsing within the first 6 months. About twice as many relapsed with no antidepressants.

Catatonia

ECT is generally a second-line treatment for people with catatonia who don’t respond to other treatments, but is a first-line treatment for severe or life-threatening catatonia. There is a lack of clinical evidence for its efficacy but it has been used successfully in the treatment of this disorder.

Mania

ECT is used to treat people who have severe or prolonged mania; however, it is recommended only in life-threatening situations or when other treatments have failed.

Schizophrenia

ECT is rarely used in treatment-resistant schizophrenia, but is sometimes recommended for schizophrenia when short-term global improvement is desired, or the subject shows little response to antipsychotics alone.

Criticisms of Electroconvulsive Therapy

In the past, ECT was called “electroshock therapy” and “shock treatments.” For many years it was distrusted as a form of therapy because of its early years, in which it was a very traumatic experience. A major contributor to the public’s mistrust of ECT was the film (and the novel it was based on) One Flew Over the Cuckoo’s Nest, which portrayed ECT as dangerous and cruel.

Today, ECT is generally more well-regarded, and controversies surrounding its use are due to its side effects. The physical side effects of ECT include short-term nausea, headaches, muscle pain, dental injuries and oral lacerations, and myalgia. These effects seem to be short-lived and respond to symptomatic treatment. Of much more concern are the cognitive side effects and transient confusion that have been reported. Memory loss and problems forming new memories, word-finding difficulties, and deficits in memory may continue for longer periods of time, making this approach to treatment highly controversial. Memory loss occurs to some extent in almost all ECT recipients. The American Psychiatric Association report acknowledged in 2001 that ECT can lead to “persistent or permanent memory loss.” It is the effects of ECT on long-term memory that give rise to much of the concern surrounding its use today.

Psychosurgery

Psychosurgery, a group of procedures aimed at disrupting neural pathways, has declined over the years due to better psychiatric medications.

Learning Objectives

Discuss the goals, techniques, and efficacy of various types of psychosurgery

Key Takeaways

Key Points

  • ” Psychosurgery ” is the name for a group of neurosurgical treatments including cingulotomy, subcaudate tractotomy, limbic leucotomy, and corpus callosotomy. In each of these procedures, a part of the brain is damaged or destroyed.
  • Psychosurgery was used primarily for depression, obsessive-compulsive disorder, and medical conditions such as epilepsy. Only 30–50 percent of patients show significant improvement after psychosurgery.
  • The reason for the decline of psychosurgery was not only related to ethical concerns and the low percentage of effectiveness; it was also related to the advancement of more effective and minimally invasive treatments such as psychiatric medications.

Key Terms

  • palliative: Minimizing the progression of a disease and relieving undesirable symptoms for as long as possible, rather than attempting to cure the (usually incurable) disease.
  • psychosurgery: Surgery of the brain to treat or alleviate mental illness.
  • lesion: A wound or injury.
  • epilepsy: A medical condition in which the sufferer experiences seizures (or convulsions) and blackouts.

Defining Psychosurgery

Psychosurgery is a treatment in which brain tissue is destroyed with the aim of alleviating the symptoms of a psychological disorder. It has also been called “functional neurosurgery.” Psychosurgery is a drastic step typically only taken in the absence of any other successful treatment (and sometimes not even then), because it is a major challenge to remove harmful tissue without impacting the brain tissue necessary to retain full neural function.

There are many types of psychosurgery. Many end in “-omy,” the Latin root used in surgeries to indicate the removal of something.

Cingulotomy

Cingulotomy is a surgical procedure that severs the supracallosal fibers of the cingulum bundle, which pass through the anterior cingulate gyrus. This surgery is used to treat obsessive-compulsive disorder (OCD) and depression.

Subcaudate Tractotomy

Subcaudate tractotomy is a surgery to sever the fibers connecting the orbitofrontal cortex to the hypothalamus. It is used primarily for depression and OCD.

Limbic Leucotomy

The limbic leucotomy combines the cingulotomy and subcaudate tractotomy procedures. It was hypothesized that making two lesions would produce better results, but the rate of effectiveness is still approximately the same as the subcaudate tractotomy procedure alone.

Corpus Callosotomy

Corpus callosotomy is a palliative surgical procedure for the treatment of seizures, as seen in epilepsy. Because the corpus callosum is critical to the spread of epileptic activity between brain hemispheres, the goal of this procedure is to eliminate this pathway. The corpus callosum is severed, after which the brain has much more difficulty sending messages between the hemispheres, although some limited interhemispheric communication is still possible.

Deep-Brain Stimulation

In deep-brain stimulation (DBS), a device like a pacemaker is implanted into a part of the brain to send electrical impulses to that area of the brain. It is used primarily for Parkinson’s disease, essential tremor, and major depression, although it has been used for a number of other disorders as well.

History of Psychosurgery

This treatment approach began in the late 1800s under the Swiss psychiatrist Gottlieb Burckhardt, and continued into the mid 1930s under Portuguese neurologist Antonio Egas Moniz with the leucotomy. A leucotomy is the cutting of white nerve fibers in the brain, and is also known as a prefrontal lobotomy. In the United States, neuropsychiatrist Walter Freeman and neurosurgeon James W. Watts devised what became the standard prefrontal procedure and named their operative technique “lobotomy.” In spite of Moniz’s Nobel Prize in 1949, the use of psychosurgery declined during the 1950s. By the 1970s the standard lobotomy was very rare, but other forms of psychosurgery were occurring on a smaller scale.

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Lobotomy: Dr. Walter Freeman, left, and Dr. James W. Watts study an X-ray before a psychosurgical operation. Freeman and Watts developed a lobotomy technique that became the standard.

Efficacy of Psychosurgery

Psychosurgery has a low rate of efficacy relative to the risks of the procedures. For example, cingulotomies have been found to be only about 30% percent effective. Subcaudate tractotomies have been found to be effective about 50% of the time, as have limbic leucotomies.

Advances in surgical techniques have greatly reduced the incidence of death and serious damage from psychosurgery. However, the risks include but are not limited to seizures, incontinence, decreased drive, personality changes, cognitive problems, and affective problems. Currently, interest in the neurosurgical treatment of mental illness is shifting to deep-brain stimulation (DBS), in which the aim is to stimulate areas of the brain with implanted electrodes.

Criticism of Psychosurgery

Psychosurgery has always been highly controversial. In 1977 the US Congress, during the presidency of Jimmy Carter, created the National Committee for the Protection of Human Subjects of Biomedical and Behavioral Research to investigate allegations that psychosurgery—including lobotomy techniques—were used to control minorities and restrain individual rights. The committee concluded that some extremely limited and properly performed psychosurgery could have positive effects. However, public opinion of psychosurgery is wary at best, and literary and film works such as One Flew Over the Cuckoo’s Nest have portrayed lobotomies as dangerous forms of punishment rather than useful treatments.

The reason for the decline of psychosurgery was not only related to ethical concerns and the low rates of efficacy; it was also related to the advancement of more effective and minimally invasive treatments such as psychiatric medications. Through the use of some psychiatric medications, the same areas of the brain are able to be targeted and suppressed without the need to surgically create lesions or remove parts of the brain. Psychiatric medications also are able to provide effective treatment in a number of other ways, such as stimulating neural pathways.

There have been calls in the early 21st century for the Nobel Foundation to rescind the prize it awarded to Moniz for developing the lobotomy, a decision that has been called an astounding error of judgment at the time and one that psychiatry might still need to learn from, but the foundation declined to take action and has continued to host an article defending the results of the procedure.