In this week’s Mythbusters blog, guest contributor Dr Evangelos Vassos discusses the complex and important role of psychiatric drugs in the treatment of mental disorders.
Since the introduction of psychotropic drugs in the 1950s, a lot of discussions have taken place about their role in treating mental disorders. These range from simple questions about how well and how safely they work to queries about their long-term effect. This is something that can be neglected as most clinical trials only measure outcomes over 3-6 months. The most extreme opponents of medication believe that psychiatric drugs do not help individuals, and are used to control behaviours that do not conform to society’s norms. While exploring these beliefs, it is important to maintain a balanced view of the role of medication in psychiatry.
It is right that progress in pharmacology related to mental illness has been achieved through chance or trial-and-error findings rather than being the product of scientific evidence. For example, we know that antipsychotics modulate the dopaminergic systems and antidepressants mostly the serotoninergic systems. However, this knowledge did not actually drive drug discovery and was discovered later by studying the effect of these molecules after we knew they could help treat mental disorders. This is not uncommon in medicine, perhaps the most famous example is penicillin, which was discovered entirely by accident. An alternative to this trial-and-error approach is to discover new pathways of disease through genetics research, which aims to identify new molecular targets for drug manufacturing. Its success in psychiatry, however, remains to be proved.
It is also fair to question how useful psychiatric drugs are. Examples of where usefulness has been questioned include studies (with significant media coverage) suggesting that antidepressants have little effect in mild depression or that the long-term use of antipsychotics is associated with worse outcomes. Additionally, greater attention is being given to the side-effects of psychiatric drugs and has even led to changes in public policy. For example, the National Institute for Health and Care Excellence (NICE) has issued guidance to discourage the use of sodium valproate, an established mood stabiliser with good results in treating mania and bipolar disorder, in women of childbearing age due to risks of congenital malformations to the embryo. Another controversial area with passionate debates is the use of stimulants for ADHD in children. A large part of the public and many parents believe that these drugs are used to control “challenging” behaviours which should be treated with better parenting and improved educational conditions. However, there is cumulative evidence that, in most cases, these drugs, together with psychoeducation and behavioural modification have very positive effects.
There is thus some truth in the beliefs described above. However, psychiatric drugs do a lot more than simply control behaviours since a lot of people taking psychiatric drugs experience an improvement in their mental health. In particular, in depression and anxiety, antidepressants are among the most prescribed drugs in the NHS. They are usually prescribed by GPs rather than psychiatrists, and patients are happy to carry on with their treatment because they value the positive effects of medication. Beyond the subjective experience of the patients, benefits of medication are reflected in the reduction of the most severe conditions like catatonia, the reduction of recurrences of mental disorders and the lower levels of hospitalisation for mental health.
Even though psychological therapies are the first line of treatment for a variety of mental disorders, they are not available to everyone due to cost, availability of resources within the health care system and geographical limitations. In addition, many individuals cannot work psychologically or prefer a “biological” treatment, or the nature of their condition does not permit a long wait for the effect of treatment. Drugs are relatively inexpensive and can have faster action, which is very important, sometimes lifesaving. Finally, combined treatment of medication and psychotherapy is sometimes necessary as a reduction of the acute symptoms through drugs can be necessary for people to engage with psychological treatments.
You might also be interested in our previous blog about how medications for mental health conditions are more than just placebos.
In conclusion, it is important to be cautious, to avoid overprescribing drugs and to prioritise psychological treatment when appropriate, but we should not throw the baby out with the bathwater when evaluating the utility of mental health medication.