Apsychiatric orpsychotropic medication is apsychoactive drug taken to exert an effect on the chemical makeup of thebrain and nervous system. Thus, these medications are used to treatmental illnesses. These medications are typically made ofsyntheticchemical compounds and are usually prescribed inpsychiatric settings, potentiallyinvoluntarily duringcommitment. Since the mid-20th century, such medications have been leading treatments for a broad range of mental disorders and have decreased the need for long-term hospitalization, thereby lowering the cost of mental health care.[1][2][3][4] Therecidivism or rehospitalization of the mentally ill is at a high rate in many countries, and the reasons for therelapses are under research.[5][6][7][8]
A 2022umbrella review of over 100meta-analyses found that both psychotherapies and pharmacotherapies for adult mental disorders generally yield small effect sizes, suggesting current treatment research may have reached a ceiling and needs a paradigm shift.[9]
Several significant psychiatric drugs were developed in the mid-20th century. In 1948,lithium was first used as a psychiatric medicine. One of the most important discoveries waschlorpromazine, anantipsychotic that was first given to a patient in 1952. In the same decade,Julius Axelrod carried out research into the interaction of neurotransmitters, which provided a foundation for the development of further drugs.[10] The popularity of these drugs have increased significantly since then, with millions prescribed annually.[11]
The introduction of these drugs brought profound changes to the treatment of mental illness. It meant that more patients could be treated without the need for confinement in apsychiatric hospital. It was one of the key reasons why many countries moved towardsdeinstitutionalization, closing many of these hospitals so that patients could be treated at home, in general hospitals and smaller facilities.[12][13] Use of physical restraints such asstraitjackets also declined.
As of 2013, the 10 most prescribed psychiatric drugs by number of prescriptions werealprazolam,sertraline,citalopram,fluoxetine,lorazepam,trazodone,escitalopram,duloxetine,bupropion XL, andvenlafaxine XR.[14]
Psychiatric medications areprescription medications, requiring a prescription from aphysician, such as apsychiatrist, or a psychiatricnurse practitioner, PMHNP, before they can be obtained. SomeU.S. states andterritories, following the creation of theprescriptive authority for psychologists movement, have granted prescriptive privileges toclinical psychologists who have undergone additional specialised education and training inmedical psychology.[15] In addition to the familiar dosage in pill form, psychiatric medications are evolving into more novel methods of drug delivery. New technologies includetransdermal,transmucosal,inhalation,suppository ordepot injection supplements.[16][17]
Psychopharmacology studies a wide range of substances with various types of psychoactive properties. The professional and commercial fields ofpharmacology and psychopharmacology do not typically focus onpsychedelic orrecreational drugs, and so the majority of studies are conducted on psychiatric medication. While studies are conducted on all psychoactive drugs by both fields, psychopharmacology focuses on psychoactive and chemical interactions within the brain. Physicians who research psychiatric medications arepsychopharmacologists, specialists in the field of psychopharmacology.
A 2022umbrella review of over 100meta-analyses found that both psychotherapies and pharmacotherapies for adult mental disorders generally yield small effect sizes, suggesting current treatment research may have reached a ceiling and needs a paradigm shift.[18]
Psychiatric disorders, including depression, psychosis, and bipolar disorder, are common and gaining more acceptance in the United States. The most commonly used classes of medications for these disorders are antidepressants, antipsychotics, and lithium. Unfortunately, these medications are associated with significant neurotoxicities.
Psychiatric medications carry risk for neurotoxicadverse effects. The occurrence of neurotoxic effects can potentially reducedrug compliance. Some adverse effects can betreated symptomatically by using adjunct medications such asanticholinergics (antimuscarinics). Somerebound orwithdrawal adverse effects, such as the possibility of a sudden or severe emergence or re-emergence ofpsychosis in antipsychotic withdrawal, may appear when the drugs are discontinued, or discontinued too rapidly.[19]
Whileclinical trials of psychiatric medications, like other medications, typically test medicines separately, there is a practice in psychiatry (more so than in somatic medicine) to usepolypharmacy in combinations of medicines that have never been tested together in clinical trials (though all medicines involved have passed clinical trials separately). It is argued that this presents a risk of adverse effects, especiallybrain damage, in real-life mixed medication psychiatry that are not visible in the clinical trials of one medicine at a time (similar to mixed drug abuse causing significantly more damage than the additive effects of brain damages caused by using only one illegal drug). Outside clinical trials, there is evidence for an increase in mortality when psychiatric patients are transferred to polypharmacy with an increased number of medications being mixed.[20][21][22]
There are five main groups of psychiatric medications.
Antidepressants are drugs used to treatclinical depression, and they are also often used for anxiety and other disorders. Most antidepressants will hinder the breakdown ofserotonin,norepinephrine, and/ordopamine. A commonly used class of antidepressants are calledselective serotonin reuptake inhibitors (SSRIs), which act on serotonin transporters in the brain to increase levels of serotonin in thesynaptic cleft.[24] Another is theserotonin-norepinephrine reuptake inhibitors (SNRIs), which increase both serotonin and norepinephrine. Antidepressants will often take 3–5 weeks to have a noticeable effect as the regulation of receptors in the brain adapts. There are multiple classes of antidepressants which have different mechanisms of action. Another type of antidepressant is amonoamine oxidase inhibitor (MAOI), which is thought to block the action ofmonoamine oxidase, an enzyme that breaks down serotonin andnorepinephrine. MAOIs are not used as first-line treatment due to the risk ofhypertensive crisis related to the consumption of foods containing the amino acidtyramine.[24]
Common antidepressants:
Antipsychotics are drugs used to treat various symptoms of psychosis, such as those caused by psychotic disorders orschizophrenia.Atypical antipsychotics are also used asmood stabilizers in the treatment ofbipolar disorder, and they can augment the action of antidepressants inmajor depressive disorder.[24]Antipsychotics are sometimes referred to as neuroleptic drugs and some antipsychotics are branded "major tranquilizers".
There are two categories of antipsychotics:typical antipsychotics andatypical antipsychotics. Most antipsychotics are available only by prescription.
Common antipsychotics:
| Typical antipsychotics | Atypical antipsychotics |
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Benzodiazepines are effective as hypnotics, anxiolytics, anticonvulsants, myorelaxants and amnesics.[26] Having less proclivity for overdose and toxicity, they have widely supplantedbarbiturates, although barbiturates (such aspentobarbital) are still used foreuthanasia.[27][28]
Developed in the 1950s onward, benzodiazepines were originally thought to be non-addictive at therapeutic doses, but are now known to causewithdrawal symptoms similar to barbiturates andalcohol.[29] Benzodiazepines are generally recommended for short-term use.[26]
Z-drugs are a group of drugs with effects generally similar to benzodiazepines, which are used in the treatment of insomnia.
Common benzodiazepines and z-drugs include:
| Benzodiazepines | Z-drug hypnotics |
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In 1949, the AustralianJohn Cade discovered thatlithium salts could controlmania, reducing the frequency and severity of manic episodes. This introduced the now popular druglithium carbonate to the mainstream public, as well as being the first mood stabilizer to be approved by the U.S.Food & Drug Administration. Besides lithium, severalanticonvulsants andatypical antipsychotics have mood stabilizing activity. The mechanism of action of mood stabilizers is not well understood.
Common non-antipsychotic mood stabilizers include:
A stimulant is a drug that stimulates the central nervous system, increasing arousal, attention and endurance. Stimulants are used in psychiatry to treatattention deficit-hyperactivity disorder. Because the medications can be addictive, patients with a history of drug abuse are typically monitored closely or treated with a non-stimulant.
Common stimulants:
Professionals, such asDavid Rosenhan,Peter Breggin,Paula Caplan,Thomas Szasz,Giorgio Antonucci andStuart A. Kirk, sustain that psychiatry engages "in the systematic medicalization of normality".[30] More recently these concerns have come from insiders who have worked for and promoted the APA (e.g.,Robert Spitzer,Allen Frances).[31]: 185
Scholars such asCooper,Foucalt,Goffman,Deleuze andSzasz believe that pharmacological "treatment" is only aplacebo effect,[32] and that administration of drugs is just areligion in disguise and ritualistic chemistry.[33] Other scholars[who?] have argued against psychiatric medication in that significant aspects of mental illness are related to the psyche or environmental factors, but medication works exclusively on a pharmacological basis.
Antipsychotics have been associated with decreases in brain volume over time, which may indicate a neurotoxic effect. However, untreated psychosis has also been associated with decreases in brain volume and treatments have been shown improve cognitive functioning.[34][35][36][37]
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