Why psychopharmacology practice is poor, and how it can be improved

Nassir Ghaemi MD

The practice of psychopharmacology sometimes is seen as easy. Psychiatry training programs often spend a good deal of effort on teaching psychotherapies, but presume that medication knowledge will be obtained on the wards. To the extent that didactics are provided, they often involve basic pharmacology facts, such as mechanism, dosing, side effects, and pharmacokinetics.

In fact, the practice of psychopharmacology is complex, just as difficult as learning psychotherapies. Pharmacological facts about drugs are just the beginning, not the end. Besides learning the basic mechanisms, dosing, and pharmacokinetics of drugs, it is important to know when and how to use those drugs. Two aspects will be highlighted here: valid clinical definitions, and symptomatic versus disease-modifying treatment.

Standard psychiatric definitions for diagnosis are based on the Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association, which is the product of committee-based decisions. There is increasing experience and evidence that DSM diagnoses often are not valid scientifically, and have not promoted effective scientific research, especially in biological topics such as pharmacology. Thus, it is important to use clinical definitions that are not limited to, and may be different from, DSM definitions. Psychotropic drugs may be effective for non-DSM clinically defined syndromes, while failing for DSM constructs.

Another basic distinction about drugs in general is that they fall into two major categories: symptomatic or disease-modifying. Most psychotropic drugs are used symptomatically. They can improve symptoms, such as depression and anxiety, much as aspirin improves headache. But they often do not affect the underlying causes of those symptoms, such as diseases like schizophrenia or manic-depressive disease. There are exceptions: for instance, lithium has disease-modifying effects for manic-depression, preventing future mood episodes, while it has less acute symptomatic benefit.

It is important, then, for clinicians to distinguish whether they use psychotropic drugs for symptomatic, or for disease-modifying, purposes. If symptomatic, as is the case for most psychotropic drugs, then treatment should be low in dose if possible, and as time-limited as possible. Many clinicians do the opposite. They start psychotropic drugs and continue them indefinitely, partly perhaps on the assumption that they are having some disease-modifying effects, whereas clinical and biological research indicates that for most psychiatric syndromes, this treatment is symptomatic, not disease-modifying.

To achieve and emphasize disease-modifying practice, one has to use clinical diagnoses that reflect real underlying diseases, which again has not been the case with most DSM constructs.

In sum, the teaching and practice of psychopharmacology needs to go beyond simple facts about drugs, and examine the scientific evidence for valid clinical diagnostic phenotypes as targets, and pay special attention to symptomatic versus disease-modifying uses of drugs.