The Impact of Psychopharmacology on Contemporary Psychiatry

Abstract

Modern clinical psychopharmacology can be dated from the introduction of lithium carbonate to treat mania by John Cade in Australia in 1949 or from the introduction of chlorpromazine as the first synthetic drug found to be effective in both mania and psychotic disorders in Paris in the early 1950s. Soon thereafter, the mood-elevating effects of the monoamine oxidase inhibitor, iproniazid, and the antidepressant effects of imipramine were reported. By 1960, haloperidol, the first butyrophenone antipsychotic, the first so-called atypical antipsychotic, clozapine, and the benzodiazepines also were introduced.1 That is, at least one agent from each major class of currently employed psychotropic drugs was known by the end of the 1950s. These new treatments brought about fundamental changes in the treatment of many major psychiatric disorders of unknown cause-notably, mania, depression, acute and chronic psychotic disorders, including schizophrenia, as well as severe anxiety disorders. These changes can fairly be considered revolutionary. Moreover, their impact extended far beyond improvements in treatment, and included fundamental changes in the conceptualization of most psychiatric disorders, in their diagnosis and categorization, on models for research into the nature of psychiatric illnesses, on psychiatric education, on methods and standards for experimental therapeutics, and on the organization of modern psychiatry as a clinical and academic medical specialty.In the first 2 decades of their introduction into psychiatric therapeutics, there was an intense struggle among the previous generation of psychiatrists who had been captivated by the psychodynamic and psychoanalytic tradition initiated by Sigmund Freud and his followers in the early 1900s. A common early assertion was that the new drugs might modify symptoms and limit pain and suffering, but leftundone much of what was required to bring about major and sustained changes in behaviour and thinking. Nevertheless, a new generation of more medically or biologically oriented psychiatrists came to dominate psychiatry internationally, and to replace their more psychologically minded colleagues in positions of influence, including most university chairs of psychiatry.This historical perspective is particularly timely for this issue of The Canadian Journal Psychiatry, aimed at a critical assessment of where clinical psychopharmacology and its impact on psychiatry now stand. Such sensitive questions arise as to whether the pharmacotherapeutic approach may have been overdone, with widespread degradation of standards for patient assessment and comprehensive care, as well as deeply affecting psychiatric education and the organization and functioning of psychiatric institutions and systems of care delivery.2,3 As noted by Dr David M Gardner4 and Dr Gustavo H Vazquez,5 there has appeared, in recent decades, a growing international inclination toward increasingly brief and routinized clinical encounters, with an emphasis on rapid but superficial diagnostic categorization and initiation of almost exclusively medicinal treatments. Even if such clinical practices were adequate, Dr Gardner4 emphasizes that they require extensive training, experience, knowledge, and judgment to be used effectively and safely. The argument can be made that heavy reliance on medicinal treatments with less emphasis on psychological approaches, and on symptom checklists rather than on thoughtful understanding of each patient has brought about fundamental changes in the theory and practice of modern psychiatry. These changes involve shifting the balance of tension between what has been labelled brainlessness versus mindlessness in psychiatry, in the biomedical direction.6,7 Such changes, in turn, are consistent with compelling efforts in recent decades to manage (limit) the costs of medical care of all types. Questions to be considered include whether this shiftmay be antithetical to comprehensive, thoughtful, and individualized care of people with psychiatric illness, and whether it provides an adequate model for psychiatric training. …