Psychopharmacology and Biologically-Based Interventions: Medications and Related Approaches

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Psychopharmacology and Biologically-Based Interventions: Medications and Related Approaches

Abnormal Psychology · Chapter 24: Therapeutic Approaches in Mental Health PracticeSection 24.3 · lesson 92 of 9717 min · free with a free account

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In this lesson

Classes, decisions, and debates - by class and function only.

  • Describe the main medication classes and their general mechanisms
  • Explain how prescribing decisions are made, reviewed, and shared
  • Describe non-medication biological interventions accurately
  • Evaluate the debates: efficacy, over-prescribing, industry influence, withdrawal

Transcript

Everything said in the video, section by section (2,234 words). Read along, or search it.

Therapeutic Approaches in Mental Health Practice

Psychopharmacology and Biological Interventions

This section covers psychopharmacology, and other biologically based interventions. It describes the main classes of psychotropic medication and their general mechanisms, and how prescribing decisions are made, reviewed, and shared with the person. And it evaluates the principal debates about psychiatric medication, including efficacy, over-prescribing, and industry influence.

Before You Begin

Not Medical Advice

This material is educational. It is not medical advice, and no reader should change any medication on the basis of it. Medication is described here by class and clinical function only. No drug names, doses, regimens, or protocols appear anywhere in this course. Prescribing, monitoring, and any change, including stopping, are decisions made with a prescriber. And abrupt discontinuation can be harmful.

Where Medication Sits

One Option Among Several - Not the Default

Psychopharmacology is one option among several, rather than the default. That has to be said, because service structures often imply otherwise. Medication is often the most available intervention, and the quickest to start. It is the one a person can be offered when nothing else can be provided. And availability is easily mistaken for indication. One correction from section three point two needs restating, because it shapes how medication is explained to people. Symptom change from a drug does not establish that a deficiency caused the condition. A treatment acting on a system may help, without that system being the origin of the problem. So describing medication as correcting an imbalance goes beyond what the evidence supports.

Vocabulary

7 Terms for Reading About Medication

A few terms make the rest of this section readable. An agonist activates a receptor, producing an effect like the system's own signaling. An antagonist occupies a receptor without activating it, blocking that signaling. Reuptake inhibition slows the removal of a neurotransmitter from the synapse, so its signaling continues longer. Half-life is the time for the amount of a substance in the body to fall by half. It governs how quickly effects arrive, and fade. The therapeutic window is the range in which a medication gives benefit without unacceptable adverse effects. Narrower windows need closer supervision by a prescriber. Tolerance is a reduced effect with continued exposure. And dependence is physical adaptation, so that stopping produces a characteristic disturbance. As section eighteen point one established, that is different from a substance use disorder.

Onset and Response Lag

Benefit Trails the Biochemistry

For several classes, symptomatic benefit trails the drug's immediate biochemical action, sometimes by weeks. That matters for two practical reasons. First, a person who expects benefit within days may conclude the treatment has failed, and stop. That is one of the most common reasons a treatment appears not to work. Second, the lag is itself evidence against the simplest mechanistic accounts. If the effect were a direct result of the immediate synaptic change, it would arrive with it.

Table 24.3.1 - The Classes (1)

By Mechanism and Function - No Names, No Doses

This table describes the classes by mechanism and function. Notice that no column contains a name, a dose, or a comparison between classes. And read the side-effect column as a category, not as a prediction for any individual. Antidepressant classes act on monoamine signaling, chiefly through reuptake or receptor effects. They are used for depressive presentations and several anxiety-related conditions, and benefit typically trails the biochemical effect. Anxiolytic and sedative classes enhance inhibitory signaling. They give short-term relief of severe anxiety. Their onset is rapid, which is part of their dependence liability. Mood-stabilizing classes have varied mechanisms, several incompletely understood. They are used for bipolar presentations, under specialist supervision. And antipsychotic classes act on dopamine signaling, with wider receptor effects in the second grouping. Side effects fall into metabolic, movement-related, sedative, and hormonal categories. There is some effect early, and a fuller effect over weeks.

Table 24.3.1 - The Classes (2)

Attention, Cognition, and Substance Use

Stimulant and non-stimulant classes act on dopamine and norepinephrine signaling, for attentional presentations. Onset is rapid for stimulants, and slower for non-stimulants. Agents used in cognitive conditions act on cholinergic and glutamatergic signaling. Their symptomatic benefit is modest, at best. And agents used in substance-related conditions reduce craving, block reinforcing effects, or provide maintenance. They are described by function, and prescribed by specialists. Two class-level points deserve separate statement. The anxiolytic and sedative classes carry a dependence liability, as section eighteen point two described. That is why prescribing practice for them changed substantially, and why short-term use is the general position. And the antipsychotic classes act more on positive symptoms than on negative or cognitive ones. That limitation matters, because negative and cognitive features drive functional outcome more strongly.

Off-Label Prescribing

Lawful, Often Reasonable - With 2 Questions

Off-label prescribing is the use of a medication outside the indications for which it was formally approved. It is common in this field. Approvals lag behind clinical practice, children and older adults are under-represented in the trials, and some presentations have no approved treatment at all. It is lawful, and often reasonable. But it raises two questions. The evidential question is what supports the use. An approval is one form of evidence, and its absence does not mean there is none. The ethical question is whether the person knows. Consent to a treatment includes knowing that it is being used outside its approved indication, and what that does and does not imply.

Table 24.3.2 - Adherence

A Shared Decision Problem, Not a Patient Failure

The reframing from section nineteen point five applies to all prescribing. Adherence is a shared decision problem, rather than a patient failure. A person who stops taking something is usually acting on a reason, and the clinical task is to find out what it was. Side-effect burden is a trade-off the person has judged unacceptable, which is their judgment to make. Review it with the prescriber, and take it seriously. Disagreeing with the diagnosis is a difference about what is wrong. A person who does not accept the premise will not take the conclusion. Feeling better is a reasonable inference that the problem has resolved. So discuss maintenance and relapse in advance, before the person feels well. Cost or access is a practical barrier, and will not respond to explanation. Stigma, what taking medication is felt to mean, is rarely volunteered, and frequently decisive. Name it. And lack of benefit may be real. Given the response lag, check whether enough time has passed, and then reconsider. Notice that only one row is about the medication not working.

Adverse Effects and the Symptom Problem

Separated Chiefly by Timing

Telling an adverse effect from a symptom of the condition is a recurring difficulty, because the two overlap. Sedation may be a drug effect, or the condition. Agitation may be either. So may changes in appetite, sleep, or concentration. What separates them is chiefly timing and course. An adverse effect typically begins after a change in treatment, and follows it. A symptom follows the condition. Getting this wrong in one direction means the treatment is increased, in response to its own effect. Getting it wrong in the other means a treatable symptom is blamed on the drug, and left. Both are common. And both are addressed by asking what changed, and when, rather than by inference from the picture alone.

Physical Health Monitoring

Part of What Prescribing Is

Long-term prescribing carries a monitoring responsibility. The reason is in section nineteen point one. The mortality gap in serious mental illness is largely due to physical health conditions, and inadequate physical healthcare. And some medication classes add to that risk directly, through metabolic and cardiovascular effects. It is stated here as a clinical duty, and nothing further. Monitoring belongs to whoever is prescribing, and it is not optional. The failure here is rarely a decision. It is an assumption. The mental health service assumes primary care is monitoring, primary care assumes the specialist service is, and nobody is. The correction is explicit allocation. Whose responsibility it is, recorded, and told to the person, so they know what should be happening, and can ask. Given the mortality gap, this is not a peripheral part of prescribing. It is part of what prescribing is.

Special Populations

Thinner Evidence, Harder Judgments

Three groups require specialist consideration. For each, the evidence is thinner than for the general adult population, and the judgments are correspondingly harder. Children and adolescents are under-represented in the trials most prescribing rests on, with added considerations about development and consent. Older adults handle medication differently, take more co-prescribed treatments, and are more sensitive to several kinds of effect. The points about polypharmacy and anticholinergic burden from section twenty point four apply. And pregnancy and breastfeeding involve two sets of considerations at once. The evidence is limited by the ethics of trials in this group, and the risks of untreated illness weigh in the balance too. No specific guidance of any kind appears here. These are specialist decisions, and a general answer does not exist.

Combining and Sequencing

Together Often Beats Either Alone

The general evidence is that medication and psychological therapy together often outperform either alone. That varies by condition and severity, and it is not universal. Sequencing depends on the presentation. Medication comes first where severity or acuity makes psychological work impracticable. Therapy comes first where the person prefers it, and the presentation permits. And either can come first where both are reasonable. Preference belongs inside that decision, not alongside it. As section twenty-four point one established, it predicts engagement, and engagement predicts outcome.

Figure 24.3.3 - Shared Decision-Making

The Option of Taking Nothing

Shared decision-making needs the person to have information about likely benefit, likely adverse effects, and the alternatives. And it needs the option of no medication, inside the discussion, not raised only if the person happens to think of it. Look at the marked box. Taking nothing is one of the options being discussed. A conversation that leaves it out is not a shared decision, however thoroughly the rest is covered. The options are then weighed against the person's own priorities. And the decision comes with a plan B, for if the first choice does not suit.

In the Clinic

What a Shared Decision Actually Involves

A shared decision is not consent obtained after a recommendation. It is a conversation in which the options are set out, with what is known and not known about each. The person's own priorities are drawn out, and the decision is made against those priorities. Two things make it real, rather than performed. The clinician must be prepared for the person to choose differently from what they would have recommended. And the conversation must cover what to do, if the first thing tried does not suit them. Without that, the plan has only one branch. The evidence is that shared decisions improve adherence and satisfaction. That is not circular. A person who has weighed the trade-offs has already decided the thing they would otherwise decide alone, three weeks later, when the first adverse effect arrives.

Non-Medication Biological Interventions

Evidence Versus Reputation

Electroconvulsive therapy is described accurately, as in section three point five. In modern practice, it is given under anesthesia with muscle relaxation, as a course of treatments. It is used principally for severe depressive presentations that have not responded to other treatment, and for some acute presentations where speed matters. Its evidence for those uses is good. Its adverse effects include cognitive effects, named here at category level. The gap between that evidence and its public reputation is substantial. The reputation comes largely from historical practice and dramatic portrayal, rather than from current use. Non-invasive brain stimulation is established for some depressive presentations, less so elsewhere, and a growing rather than settled area. And light-based approaches are referenced from section twelve point two, with no self-administration guidance anywhere.

Table 24.3.4 - The Debates

Read Across Each Row

This table sets out the principal debates about psychiatric medication. Read across each row. The claim of over-prescribing rests on prescribing rising without a matching change in outcomes, and on modest average effects. The counter is that under-treatment does greater harm, and the criticism can reflect stigma. Still unsettled is whether the average effect is the right measure, when responses vary so widely between people. Publication bias in trials is documented, as section two point three described. The counter is that registration and reporting reforms, driven from within the field, have changed this. How far they have worked is unsettled. On industry influence, design choices, comparators, and marketing are documented concerns. The counter is that influence is not fabrication, and independent replication exists for the main classes. And withdrawal effects were under-recognized. Recognition and guidance have since improved, but their frequency and duration are still actively disputed. Reading only the supporting column makes a case for abolition. Reading only the counter column makes a case for complacency.

Withdrawal and Deprescribing

An Instructive History

Withdrawal and discontinuation deserve their own statement, because the history is instructive. For some classes, discontinuation effects were described for years as mild and brief. And the accounts of people who experienced otherwise were not taken seriously. That position has changed. The clinical statement here is the one required throughout. Stopping or changing any medication is a decision made with a prescriber, and abrupt discontinuation can be harmful. No protocol content appears in this course. Deprescribing is the planned reduction or stopping of medication that is no longer indicated. It carries the same specialist framing. It is worth naming, because prescriptions build up more readily than they are reviewed, particularly across crises, and across services.

Summary

One Option, Decided Together

To summarize. Psychopharmacology is one option among several, and availability is easily mistaken for indication. Symptom change from a drug does not establish that a deficiency caused the condition. Benefit often trails the biochemical action, which makes treatments appear to fail. Adherence is a shared decision problem, and only one common reason for stopping is lack of benefit. Adverse effects and symptoms are separated chiefly by timing. Physical health monitoring is a duty of prescribing, and it fails through assumption. Shared decision-making includes the option of no medication. Electroconvulsive therapy has good evidence for specific uses, and a reputation drawn from the past. And the debates about over-prescribing, trial evidence, industry influence, and withdrawal are live. They are not resolved here.

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About Psychopharmacology and Biologically-Based Interventions: Medications and Related Approaches

Why do antidepressants take weeks to work?
Antidepressants take weeks to work because their symptom benefit trails their immediate biochemical action, and the reason for that lag is not fully settled. The effect on synaptic signaling arrives quickly, so the delay suggests benefit depends on slower downstream changes rather than on that immediate effect. Practically, a person expecting relief within days may conclude the treatment failed and stop, one of the most common reasons a treatment seems not to work.
What is shared decision-making about psychiatric medication?
Shared decision-making is a conversation in which the options, including taking no medication, are set out with what is known and not known about each, and the decision is made against the person's own priorities. It is not consent obtained after a recommendation. The clinician must be prepared for the person to choose differently, and the plan should cover what to do if the first choice does not suit. Shared decisions improve adherence and satisfaction.
What is off-label prescribing in psychiatry?
Off-label prescribing is the use of a medication outside the indications for which it was formally approved. It is common and lawful in psychiatry, partly because approvals lag behind practice, children and older adults are under-represented in trials, and some conditions have no approved treatment. It raises two questions: what evidence supports the use, and whether the person knows the medication is being used off-label.
Is electroconvulsive therapy still used today?
Yes, electroconvulsive therapy is still used and has good evidence for specific purposes. In modern practice it is given under anesthesia with a muscle relaxant, as a course of treatments, mainly for severe depression that has not responded to other treatment and for some acute presentations where speed matters. Adverse effects include cognitive effects. Its frightening reputation comes largely from historical practice and dramatic portrayals.

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