Drug and Other Medical Therapies

Dr. C. George Boeree

Drug therapy, also called pharmacotherapy, has become the fastest moving part of psychotherapy, with new developments occuring every year. Our knowledge of the chemistry of the nervous system is developing rapidly, and our knowledge of our genetic makeup even faster, and it is the hope of every psychologist that someday every psychological problem that has physiological roots will have a simple remedy in the form of a pill.

It is, of course, also understood that psychological problems have other roots as well, and that a pill won't solve all our problems. We will always need ways of teaching people to deal with stress more effectively and encouraging them to make the best of life. We also need a better understanding of the causes of stress and ways of modifying the world beyond the individual! These things move a bit more slowly.

We will also take a look at two more controversial therapies: Electroconvulsive therapy and the lobotomy. The first seems to be here to stay, at least for now; the second is already a historical relic.

Antianxiety drugs

Antianxiety drugs, also called anxiolytics, include such famous name brands as Valium and Librium. These drugs work by blocking GABA receptor sites, toning down central nervous system activity a bit like alcohol does. Although they help you to sleep, they do not cause the excessive sleepiness or grogginess that alcohol does.

They are a good temporary approach to anxiety problems: By calming a person, they allow talk therapy time to have an effect. But these drugs do encourage psychological dependence very quickly (they are very pleasant!) and anxiety often returns just as quickly when the patient stops taking them.

Obsessive-compulsive disorder has recently been successfully treated using the antidepressant drugs called SSRIs, described below. These may also help people suffering from panic attacks.

Antidepressant drugs

Antidepressants have made a great deal of progress in the last twenty years or so. The best known is the original one, Prozac (fluoxetine). Prozac is a member of a family of drugs called the SSRIs, which stands for selective serotonin reuptake inhibitors.

The name actually describes how they work: The drug prevents axon endings of seratonin neurons from completely "vacuuming up" excess seratonin from the synapse. Some seratonin always remains, and so it is easier for that neuron to stimulate the next neuron. It facilitates communications, you might say. Some of the drugs also do the same for norepinephrine. It is interesting to note that cocaine uses the same mechanism, only for dopamine.

For some people they give complete relief, for others none at all, but for most, the antidepressants "take the edge off" of depression. Again, this permits other therapy time to have an effect. They have a positive effect in about 70% of people with mild depression (Thase & Howland, 1995), but a much lower 20 to 40% effectiveness rate for people with more serious, psychotic depression (Spiker, 1985). But unlike the anxiolytics above, SSRIs are often prescribed for long periods of time, even for life. Their side effects are, for most people, minimal. The older antidepressants - called tricyclics and MAOIs - had quite a few.

Another drug has been found to be especially useful for people with bipolar disorder (manic-depression): Lithium, which is a light metal, seems to be a mood leveler, evening out people who suffer from highs and lows. It is also used to increase the effectiveness of antidepressants in people who don't respond well. It is hard on the liver, though, and so requires monitoring in the form of frequent blood tests.

Antipsychotic drugs

The best known antipsychotic drugs are the old drug chorpromazine and the newer drug clozapine. They both work by blocking dopamine receptors, thereby reducing a person's response to "irrelevant" stimuli, such as those that cause hallucinations and paranoia. The newer drugs such as clozapine also help a bit with various forms of withdrawal, as well as with anxiety and depression.

The older drugs in particular had a lot of side effects, making people sluggish and dopey, and giving them Parkinson's-like tremors. Perhaps you recall that people with Parkinson's disease seem not to develop schizophrenia, probably because they involve opposite neurochemical circumstances.

The antipsychotic drugs, even the newer ones, are "heavy" drugs, and have to be used with care. However, they have helped many people lead fairly normal lives, where before they would have been condemned to permanent institutionalization. Studies show that about 70% of patients improve with antipsychotic drugs, as compared with only 25% who were given a placebo (Kane, 1989; Kane and Marder, 1993).

Electroconvulsive therapy

Electroconvulsive therapy or ECT is what some people call shock therapy. It was invented in the 1930's by a team of Italian doctors, Ugo Cerletti and Lucio Bini. Originally, it was done with the patient conscious and was rightly considered a terrifying procedure.

Today, a lot has changed. Basically, it involves putting the patient under general anesthesia, providing them with a muscle relaxant so they won't have spasms that could hurt them, hooking up two electrodes to the temples or one temple and the forehead, and then applying 70 to 150 volts of electricity to the brain for a fraction of a second. Although this induces what are called grand mal seizures, the patient doesn't feel a thing and suffers no brain damage. The patient wakes up 15 minutes later with no memory of the ECT and possibly a few hours before the treatment. This procedure is done about three times a week, for three to 15 treatments. And, although no one really knows why, depression is significantly relieved for the majority of patients.

It is, of course, still not something we all line up for: Electroconvulsive therapy is only used for people with severe depression for whom other therapies, including drugs, have little or no effect. It is also used, with somewhat less effectiveness, for some forms of schizophrenia. Although the APA and other organizations view it as a humane and valuable therapy, there are many people who disagree, some very strongly.

Psychosurgery

The infamous lobotomy was invented by Antonio Egaz Moniz of the University of Lisbon Medical School. He found that cutting the nerves that run from the frontal cortex to the thalamus in psychotic patients who suffered from repetitive thoughts “short-circuited” the problem. Together with his colleague Almeida Lima, he devised a technique involving drilling two small holes on either side of the forehead, inserting a special surgical knife, and severing the prefrontal cortex from the rest of the brain.

Some of his patients became calmer, some did not. Moniz advised extreme caution in using lobotomy, and felt it should only be used in extreme cases where everything else had been tried. He was awarded the Nobel Prize for his work on lobotomy in 1949. He retired early after a former patient paralyzed him by shooting him in the back.

In 1936, Walter Freeman, an American physician, began performing lobotomies He was so satisfied with the results that he went on to do many thousands more,. He is famous for inventing what was called ice pick lobotomy: He found he could insert an ice pick-like instrument above each eye of a patient with only local anesthetic, drive it through the thin bone with a light tap of a mallet, swish the pick back and forth like a windshield wiper and - voilà - a formerly difficult patient is now a passive zombie.

Between 1939 and 1951, over 18,000 lobotomies were performed in the US, and many more in other countries except, curiously, the old Soviet Union, where it was banned back in the 1940s on moral grounds. It was often used on convicts, and in Japan it was recommended for use on “difficult” children. Thankfully, all that is really left of the lobotomy is sophisticated MRI-guided surgery used for people suffering from severe seizures.