Clinical Implications of the Drug-Centered Approach
This chapter outlines applications of the drug-centered approach to the practice of psychiatry. Some psychiatrists who are critical of the contemporary focus on pharmacotherapy might argue for psychiatrists to return to the era when their primary role was as psychotherapists. That is not the position taken here. Rather, the author proposes that psychiatry should remain the medical specialty whose expertise is in understanding and prescribing psychoactive substances but that its members do so from the perspective of the drug-centered model articulated in Chap. 4. The implications of a drug-centered, as opposed to disease-centered, approach to medications are examined for several major classes of psychoactive compounds. Similar themes emerge: (1) short-term efficacy with increased relapse risk when drugs are stopped, combined with a conceptualization of mental disorders as chronic, commonly leads to recommendations for long-term pharmacotherapy; (2) considerations of possible withdrawal effects are frequently ignored; and (3) each class of drugs is prescribed for ever-widening lists of indications. These factors have contributed to growing numbers of people taking multiple drugs for indefinite durations. The benefits of shifting to a drug-centered approach are explored and the chapter concludes with suggestions for integrating such an approach into psychiatric practice.
KeywordsPsychopharmacology Antipsychotics Antidepressants Psychostimulants Benzodiazepines
- 1.Insel T. Words matter; 2012. https://www.nimh.nih.gov/about/directors/thomas-insel/blog/2012/words-matter.shtml. Accessed 19 Aug 2018.
- 2.Gøtzsche PC. Deadly psychiatry and organized denial. Artpeople. ISBN 978-87-7159-623-6; 2015.Google Scholar
- 3.Whitaker R. Anatomy of an epidemic. New York: Crown; 2010.Google Scholar
- 4.Robinson TE, Becker JB. Enduring changes in brain and behavior produced by chronic amphetamine administration: a review and evaluation of animal models of amphetamine psychosis. Brain Res Rev. 1986;11(2):157–98.Google Scholar
- 7.Moncrieff J. The bitterest pills. London: Palgrave Macmillan; 2013.Google Scholar
- 8.Nasrallah HA, Tandon R. Classic antipsychotic medication. In: Schatzberg AF, Nemeroff CB, editors. The American psychiatric publishing textbook of psychopharmacology. Washington, DC: American Psychiatric Publishing, Inc.; 2009. p. 533–54.Google Scholar
- 11.Sisti D, Segal AG, Emanuel EJ. Improving long-term psychiatric care: bring back the asylum. J Am Med Assoc. 2015;313(3):243–5.Google Scholar
- 18.Wunderink L, Nieboer RM, Wiersma D. Recovery in remitted first-episode psychosis at 7 years of follow-up of an early dose reduction/discontinuation or maintenance treatment strategy. JAMA Psychiat. 2013;70(9):913–20.Google Scholar
- 23.Bola JR, Mosher L. Treatment of acute psychosis without neuroleptics: two-year outcomes from the Soteria project. J Nerv Ment Disord. 2003;191(4):219–29.Google Scholar
- 24.Center for Disease Control. Selected prescription drug classes used in the past 30 days, by sex and age: United States, selected years 1988–1994 through 2011–2014; 2016. https://www.cdc.gov/nchs/hus/contents2016.htm#080. Accessed 05 Aug 2018.
- 25.Pratt LA, Brody DJ, Gu Q. Antidepressant use among persons aged 12 and over: United States, 2011–2014 NCHS Data Brief 283; 2017. https://www.cdc.gov/nchs/data/databriefs/db283.pdf
- 26.Cipriani A, Furukawa TA, Salanti G, et al. Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: a systematic review and network meta-analysis. Lancet. 2018;17:32802–7.Google Scholar
- 27.Moncrieff J, Kirsch I. Efficacy of antidepressants in adults. Br Med J. 2005;331(7509):155–7.Google Scholar
- 28.Vittengyl JR. Poorer long-term outcomes among persons with major depressive disorder treated with medication. Psychother Psychosom. 2017;86:302–4.Google Scholar
- 32.Sharma T, Guski LS, Freund N, et al. Suicidality and aggression during antidepressant treatment: systematic review and meta-analyses based on clinical study reports. Br Med J. 2016;27(352):i65.Google Scholar
- 37.Billioto de Gage S, Moride Y, Ducruet T, et al. Benzodiazepine use and risk of alzheimer’s disease: case-control study. Br Med J. 2014;349:1–10.Google Scholar
- 38.Kahneman D. Thinking, fast and slow. New York: Farrar, Straus and Giroux; 2011.Google Scholar
- 39.American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Arlington: American Psychiatric Publishing; 1994.Google Scholar
- 40.American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Arlington: American Psychiatric Publishing; 2013.Google Scholar