Psychotherapist's Guide to Psychopharmacology

In the last 20 years much work has been done on the influence of brain biochemistry on mood and behaviour and on pharmacological approaches to treating mental and emotional disorders. Partly as a result of this fact, a large proportion of patients who consult psychotherapists are already on medication of some sort. This book presents an overview of psychopharmacology for psychotherapists. It is designed to help them to treat patients in a way that takes into account the effects of the medication, and to recognize when some kind of pharmacological assistance might be useful in treating a disorder.

Chapter 1

Diagnosis and Treatment: Basic Principles

In the last thirty years, we in the mental health field have witnessed a veritable explosion of new information that has shifted the emphasis from the more psychoanalytically based models and treatments that dominated psychiatry and psychology for the preceding thirty years to descriptive and biological ones. The new approach is based on a number of assumptions, three of which are relevant to this book. The first is that psychiatric disorders can be reliably classified according to diagnostic methods used in medicine before the introduction of laboratory tests. The second is that pharmacological treatments -- medications -- are effective in treating a variety of psychiatric disorders. The third is that the efficacy of psychiatric therapies can be evaluated by empirical studies. Not surprisingly, the bulk of these treatment studies have involved medications. In this chapter, these three assumptions -- that psychopathology can be usefully described by symptom-based terms, that medications effectively treat psychiatric disorders, and that scientific methods can be applied to evaluate treatments -- will be discussed. The goals of medication treatment, some general principles of psychopharmacological treatment, and criteria for the selection of appropriate patients for psychopharmacological evaluation will then be presented.

DESCRIPTIVE PSYCHIATRY AND DSM-IV

Although the introduction of a descriptive, diagnosis-based approach to psychopathology was a radical shift from the etiologically based language of psychoanalysis, it was far from new. During the late nineteenth and early twentieth centuries, descriptive approaches dominated European psychiatry and resulted in the first diagnostic distinction between manic-depressive illness and schizophrenia (then called dementia praecox) on the basis of their differing clinical pictures. However, the descriptive approach fell into disfavor in this country for many decades, resurfacing only with the emergence of the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III) in 1980, the revised edition (DSM-III-R) in 1987, and DSM-IV in 1994. The goal of DSM-IV, as for any other diagnostic classification scheme is "to provide a helpful guide to clinical practice,...to improve communication among clinicians and researchers...,for improving the collection of clinical information and as an educational tool for teaching psychopathology" (DSM-IV, p. xv). By defining disorders consistently, both clinicians and researchers may better agree on what is meant by terms such as depression, thereby allowing better prediction of important clinical variables such as prognosis and treatment response.

Because the first half of this book is organized according to the DSM's classifications, it is worth reviewing their essential components.

The most important question in the descriptive approach used by DSM-IV is "what," in contrast to the centrality of "why" in psychoanalysis. It attempts (with only varying degrees of success) to be atheoretical with regard to etiology. Thus, when a 37-year-old man goes through a period of depressed mood with alterations in sleep, appetite, energy, and concentrating ability, the reason why is irrelevant for making the diagnosis of depression. Whether this patient's depression is best understood by his poor introject of a maternal object, depressogenic assumptions (using a cognitive framework), or by an alteration in the regulation of norepinephrine or serotonin in certain parts of the brain does not alter the diagnosis.

Among the objections to the descriptive approach is that patients are pigeonholed into diagnostic boxes and not understood for the unique constellation of intrapsychic, historical, and environmental variables that set each one apart from others. This objection is valid if clinicians view the patient's identity as synonymous with his diagnosis. Is the patient viewed as a person with manic-depressive disorder or is he a manic-depressive? The difference is far from semantic. Although the descriptive approach can be misused to objectify and distance patients, that is neither its purpose nor its proper use. DSM-IV classifies disorders, not individuals.

The second essential feature of the DSMs is their mulfiaxial approach. Patients are rated along five axes simultaneously, each of which utilizes different types of information. Psychiatric disorders are listed on Axes I and II while Axes III, IV, and V describe associated medical conditions, psychosocial and environmental stressors, and level of functioning. Axis I disorders comprise all clinical syndromes except for personality disorders and developmental disorders arising in childhood, which are listed on Axis II. Thus, Axis II disorders are, in general, more stable and long lasting. When a clinician describes a patient as having an Axis I disorder, he is referring to the presence of a symptombased disorder, such as depression, phobias, or schizophrenia. Describing an adult patient as having an Axis II disorder is equivalent to saying he has a personality disorder. Among the goals of separating Axis I from Axis II is to encourage clinicians to conceptualize coexistent disorders. Instead of deciding whether the patient suffers from major depression or narcissistic personality disorder, the clinician can diagnose both disorders. This approach makes evaluation more difficult, but also more accurate. In this way, either/or formulations can be replaced by richer, more complex models.

It is in the evaluation and diagnosis of personality disorders that the descriptive approach of DSM-IV is most problematic. Inherently, personality features are difficult to describe using the language of symptoms and signs. As an example, criteria used to diagnose personality disorders such as lack of empathy or persistent identity disturbance simply do not fit well into a classification system that is defined as atheoretical and descriptive. Compounding the problem of classifying personality disorders in the DSMs is the use of a categorical system in which patients either meet criteria for a diagnosis (a category) or they don't. Another type of diagnostic system describes patients along a number of dimensions without specific cutoffs demarcating normal from abnormal (or having a disorder vs. not having it). It is especially in the diagnosis and description of personality disorders that a dimensional system has the strongest and most persuasive proponents -- and that the categorical system has the most difficulties (see chapter 7 for more details about dimensional approaches to personality).

It is rather easy to criticize, with merit, the entire DSM system. Three different manuals -- DSM-III, III-R, and IV -- have been published over the short span of fourteen years, an insufficient time to gather enough new data to warrant many of the diagnostic definitions and changes in the new editions (Zimmerman, 1990). Disorders are defined and undefined in successive DSM editions without obvious justification. As an example, a manic episode precipitated by an antidepressant was diagnosed as bipolar disorder in DSM-III-R. In DSM-IV, that same episode would be called substance-induced mood disorder and specifically prohibited from contributing to a diagnosis of bipolar disorder, despite a lack of published data supporting or refuting either definition in the last six years. Furthermore, it continues to be difficult to use DSM-IV to describe patients with milder disorders, such as those with low self-esteem or heightened rejection sensitivity without significant depressive symptoms.

Additionally, the DSMs have done a better job at defining disorders reliably (can three clinicians agree that a certain patient has these specific symptoms and therefore meets specified criteria for a diagnosis?) than in demonstrating validity (do these diagnostic criteria have practical value with regard to prognosis, family history, treatment responsiveness, and so on?). Since for clinicians reliability is far less important than validity, the utility of the diagnostic system is not always apparent.

Despite these valid criticisms, the DSMs have accomplished a great deal and fill a vital need for mental health professionals. They have forced us to become more precise in our terminology, fostering both clearer thinking and clearer communication between ourselves and with those governing the finances of health care. Each succeeding DSM edition has been increasingly based on data and changes have often been made in response to feedback from the clinical community. If mental health professionals are to be taken seriously in our chaotic, rapidly changing system of health care (whatever its ultimate form), it is mandatory that we have clear definitions of disorders -- even if those definitions change somewhat over time -- and that we be able to perform the large-scale studies demonstrating both the prevalence and morbidity of these disorders. The DSMs foster these goals in ways that other systems might not.

Another major stumbling block for the acceptance of the descriptive approach as used in DSM-IV has been an understandable concern that this new model would replace and discount all other ways of understanding psychopathology. Descriptive models, however, should never preclude other ways of understanding psychological phenomena. For any clinical disorder, for any individual patient, different models will each have advantages and disadvantages in explaining the psychopathology. The clinical phenomenon of acute mania may be best viewed using the descriptive model, while adjustment disorders or narcissistic personalities will be better understood by an interpersonal or psychoanalytic perspective. A patient with a mild to moderate depression triggered by a loss, however, might be best understood using both descriptive and psychological concepts, with each model clarifying only a piece of the puzzle. It would be redundant and disruptive to point out continually in this text that other ways of understanding patients are helpful and, at times, mandatory. The use of multiple conceptual models should be considered a basic prerequisite for the full understanding of patients.

PHARMACOTHERAPY AND ITS IMPLICATIONS FOR OTHER THERAPIES

The second assumption of the medical model in psychiatry, that some psychiatric disorders are effectively treated by medications, has been established through the astonishing amount of research over the last forty years devoted to the discovery, development, and documentation of psychopharmacologically active drugs. Initially used for severe depressions and psychotic disorders, medications have now been demonstrated to be useful for at least some patients with a wide variety of disorders. The simple existence of two editions of this book is testimony to the extent to which medications have been established as a treatment modality for psychiatric disorders. Despite the dramatic effect of medications in reducing or preventing psychopathology, however, their limitations have tempered some of the early, unrealistic hopes of the more biologically oriented clinicians. In a variety of disorders, medications are profoundly effective, yet still leave untouched some core aspects of the disorder which must be treated with other modalities. These limitations are most obvious in schizophrenia (see chapter 5), but are apparent also in panic disorder, bipolar disorder, and others.

Since 1987, with the release of fluoxetine (Prozac) as the first of the powerfully serotonergic antidepressants with fewer side effects than the older antidepressants, an increasing number of individuals with relatively mild psychiatric disorders and difficulties have taken one of these new medications. As an example, through early 1995, approximately 16 million patients had taken fiuoxetine alone (Dista, 1995). The rapid proliferation of these medications in psychiatric treatment has led many therapists and interested laypeople to be concerned that prescribed drugs would soon become the quick fix for all problems, that a patient suffering distress would be given a medication to feel better at the risk of ignoring psychological and psychosocial factors. ("I just want to be more assertive with my girlfriend" or "I want to be bolder and more creative.") The explosion of media interest in these new medications has only exacerbated the problem, as exemplified by one Newsweek cover that pictured a Prozac capsule (labeled by its trade name and not its generic name) and by the controversy surrounding Peter Kramer's book Listening to Prozac (1993). (See chapters 3 and 7 for more detailed discussions of the serotonergic antidepressants for mild depressions and personality disorders.)

It is likely that some individuals have been prescribed one of the serotonergic antidepressants with little clinical justification. However, a great number of people with mild psychiatric disorders, many of whom have worked hard in psychotherapy but are still symptomatic, have greatly benefited from one of these newer medications. Moreover, in the treatment of the more serious psychiatric disorders, extraordinary numbers of patients continue to go untreated. In the most recent epidemiological study, only 42 percent of those with a psychiatric disorder had ever sought treatment for that disorder (Kessler et al., 1994). Of those with an active psychiatric disorder within the last year, less than 30 percent had received any type of treatment (Regier et al., 1993; Kessler et al., 1994). There is even evidence that only one quarter of chronically anxious patients use tranquilizers (Uhlenhuth, Balter, Mellinger, Cisin, and Clinthorne, 1983). Finally, of those patients with a severe mental illness as defined by psychosis or marked functional impairment, almost 40 percent sought no treatment within a one-year period (National Advisory Mental Health Council, 1993). Together, these studies suggest that, even now, we continue to be more of an undertreated than an overtreated society.

Another concern of psychotherapists about the advent of medications was their implication for the etiology of psychiatric disorders. There is a natural assumption that if medications are helpful, they must be correcting some biochemical abnormality which would then be viewed as the sole cause of the disorder. With the simplistic information promulgated in the press, patients come to their primary care physicians claiming that they know they have a serotonin deficiency and that they want a medication to fix this problem! Despite a remarkable amount of research over the last twenty-five years, however, there is still no definitive biological explanation for any psychiatric disorder (see chapter 2). Furthermore, even if a biological cause might be found for one or a number of disorders, it would not, by itself, imply the proper or effective methods of treatment. For example, coronary artery disease culminating in heart attacks has genetic and biological causes. Yet its course and outcome can be altered by life-style changes, such as diet, smoking, exercise, and the like. Similarly, even if depression or rejection sensitivity were shown to be caused by a specific neurotransmitter abnormality, this would have no necessary implication for the efficacy of psychotherapy in treating it.

In summary, just as descriptive models of psychopathology, as exemplified by DSM-IV, must be supplemented by other models to best understand our patients' problems, pharmacotherapy never precludes other methods of treatment. For some disorders, such as mild to moderate depression or obsessive compulsive disorder, there may be a variety of different, valid therapeutic approaches. As disc...