July 13, 2022

Y ou reviewed two significant treatment modalities for mental illness: psychotherapy and psychopharmacotherapy. ?Use the information learned in this module to determine the best t

Y ou reviewed two significant treatment modalities for mental illness: psychotherapy and psychopharmacotherapy. Use the information learned in this module to determine the best treatment modality for the identified disorder and population. 3-4 paragraphs

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5791973/

CHAPTER 8

Essentials of Psychopharmacology and Treatment of Mental Health Disorders

Treatment Settings

Mental health services can be delivered via multiple different settings.

These settings may range from very restrictive (inpatient) to least restrictive (care delivered in the individual’s home).

Sometimes a combination approach may be required with home care combined with visits to a partial hospitalization program.

Inpatient Treatment

Only a small fraction of individuals with psychiatric illnesses are treated in hospital settings due to the high cost of inpatient treatment.

Inpatient hospitalization of an individual with a psychiatric condition may be voluntary or involuntary. It becomes necessary when:

A rapid deterioration in mental status renders an individual a threat to himself or herself or to others

The social environment or community of that individual cannot effectively support the emotional, physical, or psychological needs of that person

The Therapeutic Milieu

The term milieu is derived from the French words ma, meaning “my” and lieu, meaning “place.”

A therapeutic milieu is a structured group setting in which the existence of the group is a key force in the outcome of treatment.

Using the combined elements of positive peer pressure, trust, safety, and repetition, the therapeutic milieu provides an idealized setting for group members to work through their psychological issues.

Community-Based Treatment Settings

Community-based treatments can be roughly divided into the following categories:

Outpatient treatment

Partial hospitalizations

Home-based care

Partial Hospitalization Program (1 of 2)

A partial hospitalization program (PHP) is a type of mental health program used to treat mental illness and substance abuse. In the setting of partial hospitalization, the individual patient continues to reside at his or her home, but commutes to a treatment center up to 7 days a week.

Partial hospitalization programs are not employed for individuals who are an acute threat to themselves or others (such as acute suicidal depressed patients), because they are designed to focus on the overall treatment goals of the patient rather than safety issues.

Partial Hospitalization Program (2 of 2)

Two kinds of patients can best be managed in a PHP-type setting:

Patients recently discharged from a psychiatric hospital but who require close supervision and ongoing support from a clinical team

Mentally ill individuals residing at home or the homeless who need such a setting to avoid inpatient hospitalization

Telepsychiatry (1 of 4)

Telepsychiatry (a branch of telemedicine) is a specifically defined form of video conferencing that can provide psychiatric services to patients living in remote locations or otherwise underserved areas via the electronic transmission of images.

The first use of telepsychiatry dates to 1957.

Decreasing equipment and transmission costs and improvements in image quality have resulted in a wider adoption of telepsychiatry for particular populations.

Telepsychiatry (2 of 4)

Indications

It has been employed for diagnosis and assessment, medication management, and individual and group therapy.

Consultative services between psychiatrists, primary care physicians, and other healthcare providers have also been facilitated by telepsychiatry.

It has also been used in areas with a shortage of mental health practitioners for providing second opinions.

Telepsychiatry holds promise as a means of getting patients into treatment that they otherwise would not seek.

Some patients have actually found telepsychiatry more convenient and less costly than traveling to a therapist’s office.

Telepsychiatry (3 of 4)

Future

Patient surveys indicate a higher level of satisfaction with regard to patient–physician communication and a belief that this is a reliable form of practice. Overall, this new modality of care has helped in increasing access to services and has helped enhance the provision of services to families with homebound patients.

There is an urgent need for both further research into the field and randomized clinical trials of telemedicine applications.

A few barriers to providing telepsychiatry services exist. Reimbursement is still difficult to receive, especially through third-party payers, and licensure for practicing telepsychiatry may be difficult to obtain.

Telepsychiatry (4 of 4)

Four-pronged strategy to popularize telepsychiatry:

(1) integration into residency training

(2) involvement of academic health centers that have large concentration of psychiatrists

(3) enhancement of technology with iPhones, apps, etc.

(4) better coordination of services

Mental health educators can also explore possibilities similar to telepsychiatry in promoting their educational mission. It would entail keeping up with technological advancements and incorporating them in delivery of educational programs.

Involuntary Commitment (1 of 2)

Involuntary commitment is the practice of placing a person into a psychiatric hospital or ward against his or her will, in compliance with the mental health laws of the country.

Commitment is normally time-limited and requires reevaluation at fixed intervals.

Involuntary Commitment (2 of 2)

Even though the individual states differ in their involuntary commitment procedures, the most important and virtually universal criteria include the following:

Dangerousness to self

Dangerousness to others

Serious impairment leading to an inability to care for oneself as a result of mental illness

Psychopharmacology (1 of 3)

Psychopharmacology refers to the use of medications for the treatment of mental disorders.

Plant extracts and naturally occurring substances have been used for centuries to influence mood and anxiety, to adjust sleep and arousal, to create euphoria, and to alter consciousness.

Coffee, tea, and alcohol remain important examples of such substances.

Psychopharmacology (2 of 3)

The field of psychopharmacology underwent a rapid evolution during the second half of the 20th century.

A transformation of psychiatric treatment from a predominantly psychoanalytic to a biological orientation followed, leading to the discoveries of several medication classes.

Psychopharmacology (3 of 3)

Four main classes of psychotropic medications:

Antipsychotic medications

Antidepressant agents

Antianxiety agents

Mood stabilizers

Antipsychotic Drugs (1 of 5)

An antipsychotic (or neuroleptic) is a psychotropic agent primarily employed to treat psychosis.

First-generation antipsychotics have been around since the 1950s. Examples include haloperidol and perphenazine.

Most second-generation or atypical antipsychotics were developed much later, in the 1990s and thereafter, and include risperidone and olanzapine.

Antipsychotic Drugs (2 of 5)

Indications for use

Schizophrenia, bipolar disorder, schizoaffective disorder, delusional disorder, substance-induced psychotic disorder, and psychotic disorders secondary to a medical condition

Psychosis associated with a wide range of other diagnoses, such as psychotic depression

The off-label use of antipsychotic drugs has expanded, and they have increasingly been deployed as antidepressants; antianxiety drugs; mood stabilizers; cognitive enhancers; antiaggressive, anti-impulsive, and antisuicidal drugs; and hypnotic (sleep) medications.

Antipsychotic Drugs (3 of 5)

The prescription of antipsychotics involves:

Thorough assessment for need

Consideration of side effects

Choice of the best alternative

Titration of the dose of the chosen drug

Constant monitoring for side effects

Assessment of regulation of the dose over time as needed

Antipsychotic Drugs (4 of 5)

Side effects

Extrapyramidal reactions include movement disorders, impotence, lethargy, seizures, intense dreams or nightmares, and hyperprolactinemia (abnormally high levels of prolactin, a hormone primarily associated with lactation, in the blood).

Lowered life expectancy remains the most serious adverse effect.

Antipsychotics can alter the individual’s perceptions of pleasurable sensations and lead to a severe reduction in the feelings of desire and motivation. Detrimental effects on short-term memory have also been reported on high enough dosages.

Antipsychotic Drugs (5 of 5)

Typical (first-generation) versus atypical (second-generation) antipsychotics

The efficacy of typical and atypical antipsychotics is comparable.

Typical antipsychotics have a higher likelihood of side effects.

Atypical agents have higher costs in comparison with typical agents.

Antidepressant Agents

An antidepressant is a psychotropic agent used to treat mood disorders such as major depression and dysthymia. Antidepressants may also be used to treat anxiety disorders.

The most important classes of antidepressants include the monoamine oxidase inhibitors (MAOIs), tricyclic antidepressants (TCAs), tetracyclic antidepressants (TeCAs), selective serotonin reuptake inhibitors (SSRIs), and serotonin-norepinephrine reuptake inhibitors (SNRIs).

Anxiolytic Agents

An anxiolytic (antianxiety agent) is a drug used for the treatment of anxiety and its attendant psychological and physical symptoms.

Three classes of medications have gained prominence as anxiolytics:

Beta receptor blockers

Benzodiazepines

Certain antidepressants (both SSRIs and SNRIs)

Mood Stabilizers

A mood stabilizer is a psychotropic agent employed to treat mood disorders characterized by sustained and extreme shifts in mood states, seen usually in bipolar disorders.

Mood stabilizers prevent the swings between mania and depression.

These drugs are also used in the treatment of borderline personality disorder and schizoaffective disorder.

Examples are lithium, valproic acid, and carbamazepine.

Phases of Drug Development (1 of 3)

Drug development to support a viable marketing application advances in somewhat overlapping phases.

Nonclinical (also called preclinical) studies begin prior to human studies but continue throughout the clinical development period.

Prior to each phase of human testing, animal testing is done to ensure that the level of planned human exposure is safe.

Phases of Drug Development (2 of 3)

Phase I studies

Initial introduction of the new drug in humans. The studies are closely monitored, are conducted usually in healthy volunteers, and identify the properties of the drug and overt toxicities. These studies also establish tolerable doses for further testing.

Phase II studies

Phase II studies include carefully chosen patients with the disease or condition being studied. Optimal doses of the drug and safety data regarding common short-term side effects are also obtained during this phase.

Phases of Drug Development (3 of 3)

Phase III studies

Phase III studies help expand the information on the effectiveness and safety of the drug to assess the overall risk-to-benefit ratio. Study subjects are selected from a broader pool in comparison with phase II studies. These studies may include hundreds to thousands of patients.

Phase IV studies

Phase IV refers to the postmarketing activities that are conducted subsequent to the FDA approval of a drug.

Electroconvulsive Therapy (1 of 3)

The first electroconvulsive treatment or electroconvulsive therapy (ECT) course was administered to a delusional and incoherent patient in 1938. The individual improved with the first treatment and remitted after 11.

In 1940, the first use of ECT occurred in the United States.

Throughout the 1940s, ECT enjoyed popularity as a first-line therapy. Given the widespread use of pharmacological agents as first-line treatments for major psychiatric disorders today, ECT is currently more commonly employed for patients with resistance to those treatments.

Electroconvulsive Therapy (2 of 3)

Clinical indications

Major depression, both unipolar and bipolar

Psychotic depression in particular

Mania, including mixed episodes

Schizophrenia with acute exacerbation

Schizoaffective disorder

Diagnostic indications

Need for a rapid response on medical/ psychiatric grounds

Risks of alternative treatments outweigh benefits

Past history of poor response to psychotropics

Past history of good response to ECT

Patient preference

Failure to respond to medications in the current episode

Intolerance of pharmacotherapy in the current episode

Electroconvulsive Therapy (3 of 3)

Risks and side effects

Common side effects are confusion, memory loss, and physical side effects such as headache.

Memory loss secondary to ECT can manifest in different ways. Both retrograde and anterograde amnesia may occur.

Physical side effects such as nausea, vomiting, headache, jaw pain, muscle ache, or muscle spasms may occur.

During ECT, heart rate and blood pressure increase and, in rare cases, may lead to serious heart problems. If you have heart problems, ECT may be more risky.

Psychotherapeutic Approaches

Behaviorism

Cognitive behavioral approach

Psychoanalysis

Jungian therapy

Dialectical behavioral therapy

Interpersonal therapy

Group psychotherapy

Family and couples psychotherapy

Client-centered therapy

Transactional analysis

Behaviorism

Behaviorism is a philosophy of psychology based on the proposition that all actions taken by organisms can and should be regarded as behaviors.

A behavioral approach involves thinking about clinical symptoms as learned behaviors and developing treatment programs that help patients to learn new ways of behaving (and sometimes thinking) to reduce symptoms and improve quality of life.

Systematic desensitization is one application of the behaviorism approach.

Cognitive Behavioral Therapy (CBT)

Cognitive behavioral therapy is a form of psychotherapy that attempts to treat problems concerning dysfunctional emotions, behaviors, and cognitions through a goal-oriented, systematic approach.

A central tenet of the cognitive theory of emotional disorders is its stress on the cognitive triad, the psychological significance of people’s beliefs about themselves, their personal world (including significant others), and their future.

When people experience maladaptive subjective emotional distress, the cognitive behavioral approach links it to their problematic, stereotypic, biased interpretations pertinent to this cognitive triad of self, world, and future. These biased interpretations are often called cognitive distortions.

Psychoanalysis

Psychoanalysis involves a body of ideas developed by Austrian neurologist Sigmund Freud that has continually evolved in the decades that followed.

The major application of psychoanalysis is to the study of human psychological functioning and mental illnesses.

Psychoanalysis has three main components:

A method of investigation of the mind and the way one thinks

A systematized set of theories about human behavior

A method of treatment of psychological or emotional illness

Jungian Therapy (Analytical Psychotherapy)

Based on integrating the conscious and unconscious parts of the mind to help the individual feel balanced and whole

Helpful for those struggling with low self-esteem, depression, anxiety, phobias, grief, or relationship issues, or recovering from trauma

The therapy entails dream journaling, indulging in creative experiences, and word association tests (in which the response time to a word indicates hidden emotions and issues).

The therapy explores deep-rooted causes of unresolved problems and blockages in emotions to achieve “individuation,” or wholeness.

Dialectical Behavior Therapy

Dialectical behavior therapy (DBT) is a form of psychotherapy that was originally developed for the treatment of individuals diagnosed with borderline personality disorder (BPD).

DBT was formulated by Marsha M. Linehan, a psychology researcher at the University of Washington.

The technique of DBT combines standard cognitive behavioral techniques for emotion regulation and reality-testing with concepts of distress tolerance, acceptance, and mindfulness. Some of these tenets have been derived from Buddhist meditative practice.

Treatment strategies in DBT are based on the fusion of principles from behavioral learning theories with those of acceptance found in Eastern mindfulness and Western contemplative spiritual practices.

Interpersonal Therapy

Interpersonal therapy (IPT) is a time-limited psychotherapy that focuses on interpersonal dynamics and on building interpersonal skills.

The basic premise on which IPT is based is the belief that interpersonal factors may contribute significantly to psychological problems. IPT aims to change an individual’s interpersonal behavior by promoting adaptation to current interpersonal roles and situations.

IPT helps individuals identify and address interpersonal problems within four major social domains: grief, interpersonal role disputes, role transitions, and interpersonal deficits.

Group Psychotherapy

Group psychotherapy is an approach that employs a professionally trained therapist who organizes and guides a group of members to work together toward the maximal attainment of the goals of each individual in that group and of the group itself.

Certain properties that are integral to a group, such as mutual support, can be exploited to help provide relief from psychological suffering.

The group may also serve to provide a form of peer support to help offset the feeling of isolation experienced by many individuals who seek psychiatric help.

Family or Couples Psychotherapy (1 of 2)

A kind of psychotherapy that focuses on families and couples to foster change and development

Emphasizes family relationships as an important factor in psychological health

Family therapy focuses on the underlying dynamics within the family and visualizes change in terms of the interaction among different family members (or spouses in case of couple therapy). Such changes in interpersonal interaction can help an individual cope more effectively.

Family therapy is an assortment of many techniques, all of which have the final goal of direct alteration of maladaptive family processes.

Family or Couples Psychotherapy (2 of 2)

Indications for family therapy

Problems across generational boundaries (e.g., conflicts between two generations; more than one generation living in the same space)

Serious medical or mental illness in a family member

Familial stress secondary to cultural or religious differences or societal differences (e.g., interracial or same-sex partnerships)

Sibling issues beyond parental control

A child or adolescent being treated for a psychiatric illness and having behavioral issues

Indications for couple therapy

Specific psychosocial stressors for couples, termination of partnerships, communication issues

Client-Centered Psychotherapy

Client-centered psychotherapy is a fairly widely used model of psychotherapy wherein the therapist creates a relaxed, nonjudgmental environment by demonstrating genuineness, empathy, and unconditional positive regard toward his or her patients while using a nondirective approach. This helps the individual undergoing therapy to generate solutions to his or her problems. The model was created by Carl Rogers, a psychologist, in 1940.

Rogerian psychotherapy is based on the idea that each person has the ability to solve psychological problems and that feeling understood and highly appreciated helps the forces within to solve those problems.

Transactional Analysis

The underlying premise of transactional analysis is that human beings seek intimacy, comfort, or recognition through social interactions. They get such intimacy and recognition through mutual exchanges that Berne called “strokes.”

Harmonious and realistic transactions foster mental health, whereas transactions rooted in ulterior motives lead to discomfort and disharmony.

Because it focuses on communication, transactional analysis has also been successfully applied in the analysis of organizations and systems.

Hypnosis and Self-Hypnosis

Franz Mesmer (1734–1815) is considered the father of hypnosis.

Hypnosis is a trance or an altered state of awareness in a person induced by a therapist who uses suggestions to extinguish undesirable behaviors or form desirable behaviors. When the person himself or herself gives these autosuggestions, this process is called as self-hypnosis.

Some of the applications of hypnosis are for control of pain and hot flashes; changing undesirable behaviors (such as bed wetting, insomnia, smoking, overeating, etc.); counteracting cancer chemotherapy side effects; and in mental health illnesses that include anxiety, phobias, and post-traumatic stress disorder.

Newer Approaches (1 of 3)

Transcranial magnetic stimulation (TMS)

The application of a rapidly changing magnetic field to the superficial layers of the cerebral cortex, thereby inducing locally changing small electric currents called eddy currents

TMS exemplifies the noninvasive stimulation of focal regions of the brain and can be used for research or therapeutically without the need for anesthesia.

TMS is being studied for the treatment of depression and schizophrenia.

Newer Approaches (2 of 3)

Two more recent additions to brain stimulation methods, deep brain stimulation (DBS) and vagus nerve stimulation (VNS), were introduced about a decade following the first trials of TMS.

VNS subsequently received FDA approval for the adjunctive long-term treatment of chronic or recurrent depression in adults.

In addition, human studies designed to validate the efficacy of DBS in the treatment of depression and obsessive-compulsive disorder are under way.

Newer Approaches (3 of 3)

Eye movement desensitization and reprocessing (EMDR)

A comprehensive, integrative psychotherapy approach, described as an eclectic approach that combines elements of many different psychotherapy styles in structured protocols that are designed to maximize treatment effects.

EMDR psychotherapy attends to the past experiences that have set the groundwork for pathology; the current situations that trigger dysfunctional emotions, beliefs, and sensations; and the positive experience needed to enhance future adaptive behaviors and mental health.

Costs Associated with Mental Health Care (1 of 3)

Advances made in the field of psychotropic agents used to treat depression, schizophrenia, and bipolar disorder have predictably led to huge increases in expenditures on psychotropic medications.

From 1996 to 2001, spending on psychotropic drugs almost tripled from $5.9 million to $14.7 million.

However, a study done in 2016 found that due to patent expirations, the spending is growing more slowly over the period 2012–2020, at an average annual increase around 3.0% per year.

Costs Associated with Mental Health Care (2 of 3)

Generic drugs

A generic drug is identical—or bioequivalent—to a brand-name drug in dosage form, safety, strength, route of administration, quality, performance characteristics, and intended use. Generic drugs cost much less than brand-name drugs.

Antidepressants available as generic drugs include Prozac, Celexa, and Remeron.

Antipsychotics available as generic drugs include Haldol, Prolixin, and Thorazine.

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Y ou reviewed two significant treatment modalities for mental illness: psychotherapy and psychopharmacotherapy. ?Use the information learned in this module to determine the best t

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