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The use of pharmacological tools in the treatment of a plethora of mental health issues has been going on for centuries. The use of different pharmacological interventions is also closely tied to present theory about the mechanisms that underlie different mental health difficulties. Thus, treatment has the ability to inform theories about the aetiology of different psychological disorders. A good example of this is the serotonin hypothesis of depression, which has been strongly influenced by the success of drugs such as selective serotonin reuptake inhibitors in managing the symptoms of depression. Since the use of pharmacological interventions in the treatment of mental health issues in increasing (Zuvekas, 2005) despite the fact that it is a relatively young science, this means that commonly used treatments are subject to change. Furthermore, their use is fundamentally based on the assumption that psychological disorders are analogous to physical disorders in that they have some fundamental underlying cause that can be treated. This fairly controversial notion became prevalent in the 19th and 20th centuries for a number of cultural, political and professional reasons but Boyle (2002) points out that there is no real empirical evidence that indicated that this is the case. This essay will discuss pharmacological treatments for mental health issues and how they came about, and consider implications for the treatment of mental health issues. I will focus particularly on depression and schizophrenia.
Zuvekas (2005) found that spending on psychotropic medications, the main type of treatment for most mental health disorders as well as substance abuse problems, has risen significantly in the US. He points out that data from the National Institute for Health Care Management Research and Educational Foundation (2002) with regard to the retail sale of drugs indicate year on year increases for anti depressants, which represent the largest pharmacological therapeutic category among all prescription drugs in terms of expenditure. Furthermore, there are increases of up to 30 per cent for antipsychotic medications, which are used to treat schizophrenia among other mental health issues. Recent retail drug sales data document annual increases of 20 percent for anti-depressants, the single largest therapeutic category among all prescription drugs ranked by expenditures, and as much as 30 percent a year for antipsychotics. The vast majority of the growth in spending on pharmacological interventions for mental health issues between 1996 and 2001 was explained by selective serotonin reuptake inhibitors, used mainly in the treatment of depression, and other, newer, antidepressant medications and atypical antipsychotics. This indicates that these are two of the mental health issues that are treated most commonly using pharmacological methods.
Zuvekas also notes that the numbers of people who used selective serotonin reuptake inhibitors and other antidepressants showed an increase between 1996 and 2001 from 7.9 million users to 15.4 million. The number using older antidepressant pharmacological treatments such as tricyclics fell from 2.3 million to just 1.2 million over the same period. He concludes that this is due to the newer treatments replacing the older drugs, but also due to the fact that much higher numbers of people are in receipt of treatment using antidepressants. Furthermore, spending on the newer types of antidepressant increased by a massive 18.5 percent annually. In a similar way, the numbers of people who used atypical anti psychotic medications increased between 1996 and 2001 from 0.3 million users to 1.6 million users. Further, Zuvekas notes that the number who used older types of antipsychotic decreased by more than half. This suggests again that atypical psychotics, a relatively recently discovered pharmacological intervention, are being used as a substitute for older medicines and also that more people are being prescribed these interventions.
In terms of demographic features, Zuvekas also reported that women were more likely to access treatment for mental health issues, in particular prescription drugs. In addition to this, the gender difference increased from 1996 to 2001. He also notes that “whites were much more likely than other racial and ethnic groups to use… [mental health] services and prescription drugs in both years. As with differences by sex, the differences between whites and other groups grew in 1996 – 2001” (p. 200). It seems likely that this fact is related to the fact that people whose family income fell below the poverty line were more likely to use these services than people with higher family incomes, and the poorer groups tended to receive other types of treatment relatively cheaply in comparison to the high cost of pharmacological interventions. Zuvekas noted that mental health issues have tended to be greatly under rated throughout history. Epidemiological studies carried out in the 1980s and 90s (see Kessler et al, 1994; Narrow et al, 1993) showed that under a third of people suffering from severe mental health issues actually received any treatment and so the rise suggests that this gap is being reduced. However, the U.S. Department of Health and Human Services (1999) highlighted questions with regard to the use of pharmacological interventions in the treatment of mental health issues. There are concerns about the over use of pharmacological methods of treating mental health issues at the expense of other kinds of treatment, which can mean that patients do not receive other kinds of help that could prove useful.
Schizophrenia is a psychosis, and its symptoms are often divided into positive, which are marked by their presence, and negative, which are marked by their absence. Positive symptoms include hallucinations, delusions and thought disorder while negative symptoms include flattened affect, poverty of speech and anhedonia. Atypical antipsychotic drugs such as clozapine have high efficacy despite lower levels of blockade to D2 dopamine receptors. Thus suggests that action at other dopamine receptors and possibly other transmitter systems, such as serotonin, may be important (Van Tol et al, 1991). Atypical antipsychotics are also better at treating negative symptoms and produce fewer motor side-effects (Stip, 2000). This is probably due to the reduced D2 blockade. Although the disorder is commonly treated with drugs, the efficacy of which are undeniable (Schwartz et al. 1993), Pilling et al (2002) point out that pharmacological interventions alone are rarely enough to give the best outcome for the patient. cognitive behavioural therapy assumes that schizophrenia may have an underlying biological origin but that symptoms are influenced by somatic, environmental and behavioural factors. Pilling et al looked at the efficacy of family and cognitive behavioural therapy and concluded that family therapy had a clear preventative effect on the likelihood of readmission and psychotic relapse among patients, as well as increased compliance with medication. Cognitive behavioural therapy also resulted in increase ‘important improvement’ in patients’ mental state as well as improvements on continuous measures when follow up investigations were carried out. There were also lower drop out rates. This strongly indicates that the benefits of pharmacological interventions should in the vast majority of cases be paired with a ‘talking’ therapy, which can even increase the likelihood of the patient agreeing to take their medication as prescribed.
Depression is an affective disorder, which is characterised by intense feelings of lowered mood, sadness or melancholia. For a diagnosis of major depressive disorder, The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994) states that the patient must be in a consistent state of anhedonia or depressed mood for a period of at least two weeks. In the 1950s, it was found that iproniazid, classified as a monoamine oxidase inhibitor (Selikoff & Robitzek, 1952), and imipramine, which is a tricyclic (Kuhn, 1958), had the side-effects of improving the mood of the patients to whom they were given. Since the discovery that both types of drug increase the levels of the monoamines noradrenaline and serotonin, many different neurotransmitters have been suggested as aetiological factors in depression, although one should always note that it is difficult to infer causation, particularly in patients who have been at the receiving end of pharmacological interventions for long periods of time. The discovery that these drugs reduced depressive symptoms was a major contributory factor in the ‘serotonin hypothesis’ (in which regard Schildkraut (1965) is a seminal paper) of depression, which posits that abnormalities in this neurotransmitter among patients is a major factor in depression. Thus, pharmacology can inform theory about different mental health issues with a view to discovering their underlying cause and, hopefully, more successful treatments.
Boyle (2002) argues that psychiatric diagnosis can distort research by putting emphasis on form at the expense of a proper consideration of content. The argument can also be said to apply to treatment using pharmacological interventions. For example, hallucinations are often taken to be a symptom of schizophrenia without the practitioner questioning what the hallucination related to, or the reason for which a person is experiencing depression might be overlooked. Using a different kind of intervention might encourage the practitioner to consider these issues more closely, but the use of drugs treats the symptom in general without any consideration of the significance of content. Boyle also points out that there is a lot of evidence that indicates that behavioural problems and emotional distress are understandable responses to negative life situations and relationships (e.g. Albee, 1986; Read et al, 2005; Wilkinson, 2005). This means that the disorder can be seen as a result of the individual’s circumstances rather than being inherent in the individual per se. The implications of this are often masked by a presentation of negative relationships and situations as consequences arising from the disorder rather than causes. People who question this presentation can be accused of ‘family blaming’. Inserting something like ‘innate vulnerability’ between the individual and their environment allows a shift in the focus from the environment to the vulnerability.
Boyle (2002) argues that diagnosis can be a barrier to mental distress being prevented. This is because an important aspect of prevention is an understanding of the causes of the entity that needs preventing. However, if the causes – whether they are biochemical, hormonal or genetic – of mental health difficulties remain elusive, this means that is nothing in the model on which prevention can be based. Again, this can be said to be true of pharmacological interventions. They can prevent some symptoms for occurring but they cannot ‘cure’ mental health issues without an understanding of what has caused them. For this, a ‘talking’ therapy should be used, perhaps in conjunction with drugs, in order to try and reach a fuller understanding of the patient and their behaviour.
In conclusion, pharmacology is a very important element of the treatment of mental health conditions and this is indicated by the fact that use and spending on such drugs has seen significant increases in the past few years. Although more and more efficacious pharmacological interventions continue to be discovered, tested and implemented, it is important to take into account the fact that in a large proportion of mental health cases, drugs alone are not enough to see positive gains for the patient; they should be used in combination with other kinds of therapy that take into account the circumstances in which the patient lives as well as the content of their illness. This approach has been shown to be the most likely to present real results for the patient and those who know them. Aside from helping patients, pharmacology has also been important in scientific theorising about the causal factors that may underlie different mental health issues. Although research has thus far indicated that the causes are wide ranging and that there may be no simple cure-all drug for mental health disorders, at least this points researchers in the correct direction for new treatment options. This is related to the fact that decades of research seem to indicate that disorders of the mind are not necessarily comparable to disorders of the body, and so simple treatments that work for all may never be a reality.
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