Chapter 8: Medication for Mental Disorders

Today, most people with mental disorders are treated with powerful psychoactive medications.  While not a cure, these medications do reduce symptoms, suffering, and health care costs.  Their use is controversial in some cases, however, and they do have side effects.

The medical model views mental illness as a type of biological disorder or dysfunction.  Although this model has been widely criticized, the use of psychotherapeutic drugs is often discussed in the context of the model.  A first step in the model is to identify symptoms and provide a diagnosis, but diagnosing mental disorders on the basis of behaviors is both difficult and controversial.  The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders provides a standard diagnostic approach that is used in many settings.

Mental disorders are often divided into several major groups.  Anxiety disorders are those characterized by excessive worry, fears, or avoidance.  Panic disorder, phobias, and obsessive-compulsive disorder are examples of anxiety disorders. Psychosis is a serious mental disorder involving loss of contact with reality. Schizophrenia is characterized by long-term psychosis and such symptoms as delusions, hallucinations, and disorganized speech and behavior.  Finally, mood disorders involve manic or depressive episodes.  Major depression carries a risk of suicide, while a person with bipolar disorder may cycle between depression and mania.

Prior to the development of antipsychotic drugs, patients were often hospitalized for long periods and treated with powerful sedatives, insulin shock, and convulsive therapies.  The introduction of the first antipsychotics in the mid-1950s started a revolution in mental health care and increased interest in psychopharmacology. The antipsychotics help control symptoms in most people with schizophrenia, and they are thought to affect several different neurotransmitters.  While generally safe, they often have side effects, including movement disorders that can resemble Parkinson's disease.  Recently developed drugs known as atypical antipsychotics tend to be more effective at reducing some of the symptoms of schizophrenia while also having fewer or less severe side effects.

Drugs have also been developed to treat mood disorders.  The major types of antidepressant drugs are the monoamine oxidase inhibitors, the tricyclics, and the selective serotonin reuptake inhibitors.  Antidepressants are thought to act by increasing the availability of norepinephrine or serotonin, but the time lag between administration of the drugs and the antidepressant effect indicates that we don't yet completely understand how they work.  While antidepressants have been found to be more effective than a placebo, they don't work for everyone and do have side effects, including an increased risk for suicidal thoughts among children and teens. Bipolar disorder can also be treated with drug therapy, usually in the form of lithium or a type of anticonvulsant medication.  These mood stabilizers prevent both manic and depressive episodes.

Despite their widespread use, drugs are not always the most effective treatment. Electroconvulsive therapy is still in use for severely depressed or suicidal patients because it is more effective than antidepressants and has an immediate benefit.

In addition to changing how mental disorders are treated, the development of psychotherapeutics also had many social effects. Following the introduction of antipsychotics, the number of people occupying beds in mental hospitals declined dramatically. The new model focused on treating people as outpatients in community-based mental health clinics.  Treatment emphasis also shifted from psychotherapy to psychotherapeutic drugs.  However, problems can occur when patients do not take prescribed medications and are not able to care for themselves. Currently, there are more mentally ill people in jail than in hospitals, and people with serious mental illnesses make up a significant proportion of the homeless.