The Complexities of Psychopharmacology

When Socrates was compelled to drink hemlock, he became what the ancient Greeks called a pharmakon, the root of our word, “pharmacology.” Pharmakon is a protean term, variously translated as “cure,” “poison,” and-in Socrates' case-“scapegoat.” The articles that follow suggest that the Greeks were prescient in anticipating the complexities of modern psychopharmacology.

In this issue's Special Report, Dr Gerhard Grnder explores the hypothesis that plasma drug concentrations directly reflect concentrations of psychotropics in the brain. Citing recent positron emission tomography (PET) studies, Grnder argues that PET occupancy measures “have approached the status of surrogate markers for probable drug effectiveness.” He believes that these research developments may ultimately decrease the number of medication nonresponders, reduce the incidence of drug-related side effects, and decrease the total cost of drug therapy.

Dr S. Nassir Ghaemi and Megan M. Filkowski review the controversial area of antidepressant use in bipolar disorder (BD). While acknowledging that antidepressants are sometimes needed, the authors urge a cautious and conservative approach. Analyzing new data from randomized trials, they argue that in the long term, antidepressants are clearly effective in only about 15% to 20% of patients with BD. Furthermore, antidepressants may lead to a worsened course of illness in those with rapid cycling BD.

Drs Amit A. Shah and Thomas E. Finucane argue that the pharmaceutical industry has systematically distorted the classic scientific paradigm in ways that have not served the best interest of patients. The authors opine that some pharmaceutical companies have “medicalized” normal experiences such as social anxiety; exaggerated the prevalence of some psychiatric disorders; and effectively excluded from the published literature those studies that do not support their product claims. However, the authors acknowledge that “by itself, industry sponsorship does not mean that a clinical trial is flawed” and that patients have benefited from treatments promoted by the pharmaceutical industry. Nevertheless, the authors argue for the registration of all clinical drug trials and more stringent rules concerning disclosure of conflict of interest.

Drs Emilio J. Sanz and Carlos De las Cuevas review the complex risk-benefit calculations involved in psychopharmacologic treatment during pregnancy. They acknowledge the increased risk of obstetric complications and congenital malformations with prenatal use of some psychotropics. However, they pointedly warn that untreated psychiatric illnesses pose “a tremendous threat” to the fetus, owing to potentially risky maternal behaviors. Clearly, each case requires a careful, individualized risk-benefit assessment.

It seems that psychopharmacology, like the pharmakon, is complex indeed, and that only by understanding the risks and benefits of psychotropic agents will we truly be of help to our patients.

Dr Pies is clinical professor of psychiatry at Tufts University and Science Content Editor of Psychiatric Times. His most recent books include Creeping Thyme, a collection of poetry (Brandylane Publishing); Zimmerman's Tefillin, a short story collection (PublishAmerica); and Handbook of Essential Psychopharmacology, 2nd edition (American Psychiatric Publishing).