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Article Excerpt
A number of literature reviews exist that support the use of psychotropic medications. This article provides a review of the disconfirming literature regarding psychopharmacology use. Comparing the first review of psychopharmacology published in the counseling field two decades earlier to what is known currently, I examine recent developments in psychopharmacology research focusing on the safety, efficacy, side-effects, and theoretical assumptions of various classes of psychotropic medications. This article concludes by addressing counselor identity, practice and training concerns vis-a-vis psychiatric medications and the medical model.
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Ponterotto (1985) published the first article review of psychopharmacology within the counseling literature. He proposed that counselors must become familiar with the current medications (i.e., antipsychotics, antidepressants, anti-anxiety, and lithium salt agents) used to treat psychiatric disorders, especially given these medications' "increased technology," "more sophisticated empirical validation procedures," and "treatment efficacy" (p. 109). Although many new medications have come onto the market since 1985, more recent literature reviews (e.g., King & Anderson, 2004) discuss the benefits of the use of psychotropic medications with very little discussion addressing the conflicting evidence.
Although Hansen (2005) recently discussed the role of the medical model within the counseling profession and the impact that this adoption will have on our future identity as counselors, there is little discourse concerning the problems associated with psychotropic medications and the adoption of psychopharmacology practices as part of the professional counselor agenda. In this article, I address this problem and encourage counselors to call into question the uses of technology (e.g., brain scans), research methodology, and treatment efficacy of these medications based on the examination of the existing research. Specifically, I suggest counselors investigate rigorously the uses and consequences of these medications regardless of their support or skepticism. In this effort, this article serves as a review of the disconfirming literature of psychopharmacology for mental health counselors to consider. As a caveat, I admit that this article is inherently biased and does not provide supportive evidence for psychopharmacology, which is written elsewhere.
In keeping with the organization of Ponterotto's (1985) article, this article provides counselors with access to information about the safety, side-effects, and efficacy problems regarding the classes of psychotropic medications he presented (i.e., antipsychotics, antidepressants, antianxiety, and lithium salts). In addition, I discuss misconceptions about the mental illnesses these medications treat. I also provide information about the critical skills counselors need to have to examine psychopharmacological research, and I offer guidelines for counselors concerned with the role of psychopharmacology in practice. I first address the major assumption used in the support of psychopharmacology.
The Major Assumption
Before discussing the use of psychotropic medications in general, one must consider the major assumption on which the uses of these medications are based: psychiatric disorders must have a specific biological etiology--neuropathological, neurochemical, or genetic explanation (Double, 2004; Kendler, 2005; Stahl, 2000). However, no valid diagnostic tests exist to determine a physical disease process for the great majority of diagnoses found in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), text-revision (American Psychiatric Association [APA], 2000) (Ducommun-Nagy, 2003; Valenstein, 1998). Those disorders listed in the DSM-IV-TR for which a clear, undeniable disease process is present (e.g., Alzheimer's disease and other various forms of dementia) or a clear genetic defect has been located (i.e., Rett's disorder) fall under the purview of neurology, not psychiatry (Ducommun-Nagy, 2003; Encyclopedia of Mind Disorders, 2005; Glasser, 2003). Psychiatrist Kenneth Kendler (2005), co-editor-in-chief of Psychological Medicine, stated, "We [psychiatrists] have hunted for big, simple neuropathological explanations for psychiatric disorders and have not found them. We have hunted for big, simple neurochemical explanations for psychiatric disorders and have not found them. We have hunted for big, simple genetic explanations for psychiatric disorders and have not found them" (pp. 434-435).
Despite the lack of clear evidence for neuropathological, neurochemical, or genetic explanations for psychiatric disorders, the beliefs in such are heavily perpetuated by psychopharmacologists and physiological psychiatrists (Valenstein, 1998), who differ from the declining number of psychiatrists and psychiatric nurse practitioners who appreciate the contextual factors affecting mental health. Psychopharmacologists and physiological psychiatrists believe that mental health problems reduce down to chemical and electrical exchanges between brain cells (neurons). With this philosophy, psychotropic medications are marketed aggressively and prescribed indiscriminately (Rosenheck, 2005; Schultz, 2004, Wazana, 2000) with the message that these medications will correct alleged brain defects related to psychiatric disorders. The following sections draw on existing psychopharmacological literature on common medications to examine this orthodoxy.
ANTIPSYCHOTIC (NEUROLEPTIC) MEDICATIONS
In this section, I address the claims made by Ponterotto (1985) regarding antipsychotic medications in his original article. I also discuss recovery issues related to schizophrenia. Ponterotto stated the following regarding antipsychotic medications:
1. Antipsychotic medications have been "proven effective in the management of various psychotic disorders, including psychotic depression, manic-depression, and particularly schizophrenia [italics added]" (p. 109).
2. Antipsychotic medications serve as prevention and to decrease pre-existing symptoms from emerging.
3. Antipsychotic medications restore normal cognitive functioning, decrease psychotic thinking, projection, suspiciousness, perplexity, delusional thoughts, hallucinations, illogical thought processes, the inability to separate relevant from irrelevant details, excitement, rambling, tangential speech, and impulsive behavior; and restore normal psychomotor activity.
4. Antipsychotic medications are safe, non-addicting, and non-lethal.
Efficacy
Current psychiatric texts (e.g., Textbook of Psychiatry [1999], the Massachusetts' General Hospital Handbook of General Hospital Psychiatry [1997], and Principles and Practice of Psychopharmacology [1993]) highlight the benefits of antipsychotics that Ponterotto (1985) mentioned. Often these texts attribute the decline of admissions into psychiatric hospitals to the benefits of antipsychotic medications, despite evidence to the contrary (Whitaker, 2004). (1) For example, only 30% to 50% of clients on antipsychotic medications experience any level of remission of psychotic symptoms (Jackson, 2005; Whitaker, 2002), and up to 74% of clients discontinue their medication within 18 months (Lieberman et al., 2005).
Ponterotto (1985) looked promisingly into the future when he mentioned that new antipsychotic medications were on the horizon. His prediction that within the next five years new medications would be available has now come to fruition. A number of medications, including Riserdal (resperidone), Zeldox (ziprasidone), Seroquel (quetiapine), Zyprexa (olanzapine), and Abilify (aripiprazole) have since come on the market, each touting how it is better than the other. On September 19, 2005, however, the National Institute of Mental Health (NIMH) concluded that the newer atypical antipsychotic medications did not perform any better than the older conventional antipsychotic medications. Moreover, Jackson (2005) outlined how the newer medications produce many of the same side-effects associated with conventional medications. Unfortunately, it is the side-effects of these medications that may have given us our perception of psychotic people. Whitaker (2002) wrote:
The image we have today of schizophrenia is not that of madness--whatever that might be in its natural state. All of the traits that we have come to associate with schizophrenia--the awkward gait, the jerking arm movements, the vacant facial expression, the sleepiness, the lack of initiative are the symptoms due, at least in large part, to a medication-induced [italics added] deficiency in dopamine transmission (p. 164).
Recovery from Psychosis
The World Health Organization (WHO) examined the success rates for the treatment of major psychotic disorders, specifically schizophrenia. Left, Sartorious, Jablensky, Korten, Ernberg (1992) performed a 5-year follow-up of clients diagnosed with schizophrenia in the following cities using standard DSM criteria: Aarhus, Denmark; Agra, India; Cali, Colombia; Ibadan, Nigeria; London, Moscow, Prague, and Washington, D.C. Clients in developing countries (i.e., Columbia, India, and Nigeria) experienced a higher rate of recovery from schizophrenia than those in developed countries (e.g., The United States). Although the WHO study did not identify the cause for the discrepancy, the study did allude to the differences in psychiatric treatment. In the developing countries, only 16% of clients were maintained on antipsychotic medication versus 61% of clients maintained on these medications in the developed countries (Whitaker, 2004). Regarding outcomes, measured by symptomatic status at time of follow-up, time spent in a psychotic episode and pattern of course, clients from Agra and Ibadan faired better than clients from the cities in developed countries, especially with regards to good social outcomes (Left et al., 1992).
Contrary to what some may expect, up to 68% of clients diagnosed with schizophrenia experience partial to full recovery (Bleuler, 1974; Ciompi, 1988; Harding, Brooks, Ashikaga, Strauss, & Breier, 1987; Harrow, Grossman, Jobe, & Herbener, 2005; Huber, Gross, Schuttler, 1975; Mathews, Basil, Mathews, 2006; Tsuang, Woolson, Fleming, 1979) and an estimated 25% to 40% of acute psychotic clients recover without any antipsychotic medications (Bola & Mosher, 2002). The greatest predictors of who recovers include little or no medication, emphasis on hope, assistance in non-hospital environments, closer proximity to home, and a supportive environment (Bola, Mosher, & Cohen, 2005; Mosher, 1999).
Relapse Prevention and Latent symptoms
The success of a medication is often based on its ability to prevent relapse. However, neuroleptics may increase the likelihood of relapse and worsen symptoms (Gut, Maany, Mozley, Swanson, Biker, & Gur, 1998; Zarate & Tohen, 2004). For example, antipsychotic medications are known to increase the number of dopamine receptors or neuronal receptors' sensitivity to dopamine (Davis & Rosenberg, 1979; Moore, 1986) thus creating neurological changes in the brain (Chakos, 1994; Gur et al., 1998; Harrison, 1999; Jellinger, 1977). The neurons grow additional dopamine receptors to compensate and adapt to the excessive dopamine in the brain caused by the medication. If a client with schizophrenia discontinues taking neuroleptic medication, the brain no longer has the increased level of dopamine that accommodated the increase number of receptors; in short, there is a deficiency of neurotransmitters for the number of receptor cells perhaps increasing the likelihood for future psychotic behavior (i.e., discontinuation syndrome).
Such anatomical changes (i.e., changes in size, density, and properties of neurons and glia, especially within the striatum and frontal cortex, and significant enlargement and scarring in the caudate) may account for the differences, as measured by brain scans, between the brains of schizophrenic clients who have been medicated for years, and a control group which has not been medicated (Double, 2004; Jackson, 2005a, 2005b). Given that within the United States, the psychiatric community adheres to a strict biochemical explanation for schizophrenia and psychotic behavior, and medicates as a first line of defense, such treatment may inadvertently lead to greater chronicity (Whitaker, 2002; 2004) by increasing the rate of relapse due to the brain's response (i.e., neuroplasticity) to neuroleptics. Cultures that do not appear to maintain clients on neuroleptic medications (as in the WHO study) evidence higher rates of recovery.
When clients discontinue medication, they may experience complications (e.g., tardive psychosis; Silvestri et al., 2000). Pharmacological researchers report that the complications upon discontinuation of the medication are a return of the psychotic symptoms (Gitlin et al., 2001). The client is then remedicated. However, studies suggest that the symptoms are just as likely due to withdrawal from the medications--known as neuroleptic discontinuation syndrome (Tanter & Healy, 1998). Such evidence of neuroadaptation within the brain precisely meets the definition of addiction (Shafer & Albanese, 2005). Moreover, Zarate and Tohen (2004) found that clients maintained prophylactically on antipsychotic medication demonstrated more detrimental effects than those who discontinued the medication, such as more depressive symptoms, higher rates of dysphoria and parkinsonism, and greater discontinuation rates.
Psychopharmacologists...
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