For New York Psychotherapy Group
By Claude Miller, MD
Ideally the function of medication in psychiatry is to help the patient be able to participate in psychotherapy. This may involve antidepressant and /or antianxiety preparations. The decision to inaugurate, change or terminate a given medication is made by the prescribing psychiatrist.
There have been many improvements in psychotropic medications in recent years so that many of the side effects that made patient compliance problematic have been decreased.
In addition to the preparations noted above, there are also antipsychotic medications to treat the major mental disorders or psychoses, primarily schizophrenia and manic-depression. These also act to render the patient accessible to psychotherapy but their use is far more critical than in the neuroses.
The dosage of a medication requires careful monitoring because too low a dose is ineffective and too high a dose can precipitate unpleasant side effects. The use of other systemic medications concomitantly with psychotropics must also be noted and controlled for.
The traditional antipsychotics for schizophrenia and manic-depression are often used and well studied. They act primarily by blocking postsynaptic receptors, and can effect a reduction in non-psychotic symptoms such as excitement, tension, aggression, hostility, uncooperativeness, restlessness, anxiety, irritability. There have been modest effects with the antipsychotics and low doses usually work. No antipsychotic has been found to be more effective than another. A physician should use a side effect profile as a guideline for selection.
There are certain families of medications that are extremely popular at the present time. One of these is the SRI’s (Serotonin Reuptake Inhibitors) which are used as antidepressants. The antidepressant, antiobsessive-compulsive, and antibulemic actions of fluoxetine are presumed to be linked to its inhibition of central nervous system neuronal reuptake of serotonin. Studies at clinically relevant doses in man have demonstrated that fluoxetine blocks the uptake of serotonin into human platelets. Studies in animals also suggest that fluoxetine is a much more potent uptake inhibitor of serotonin than of norpinephrine. These medications include Prozac. Another family that continues to be used comprises the tricyclics. An example of this is Elavil.
There are other medications formerly used to treat anxiety such as Valium and Quaalude which have fallen into disrepute because they are now classified as “Drugs of Abuse” which means they are habit forming. The family including Valium is called the Benzodiazapines.
As noted at the outset, the decision to begin psychotropic medication, at what dosage, and for how long, is a decision make jointly by the patient, the treating therapist and the consulting psychiatrist. In the right hands they can prove miraculous (as Lithium for Manic-Depressive Psychosis); conversely, in the wrong hands they can prove disastrous (as prolonged use of Valium for chronic anxiety.