Treatment of mental disorders

Mental disorders are classified as a psychological condition marked primarily by sufficient disorganization of personality, mind, and emotions to seriously impair the normal psychological and often social functioning of the individual. Individuals diagnosed with mental disorders are typically deemed unable to function in society. Mental disorders occasionally consist of a combination of affective, behavioral, cognitive and perceptual components. The acknowledgement and understanding of mental health conditions has changed over time and across cultures, and there are still variations in the definition, classification, and treatment of mental disorders.

History

Early glimpses of treatment of mental illness included dunking in cold water by Samuel Willard (physician), who reportedly established the first American hospital for mental illness. The history of treatment of mental disorders consists in a development through years mainly in both psychotherapy (Cognitive therapy, Behavior therapy, Group Therapy, and ECT) and psychopharmacology (drugs used in mental disorders). Psychotherapy is a relatively new method used in treatment of mental disorders. The practice of individual psychotherapy as a treatment of mental disorders is about 100 years old. Sigmund Freud (1856–1939) was the first one to introduce this concept in psychoanalysis. Cognitive therapy is a more recent therapy that was founded by Aaron T. Beck ( born in 1921), an American psychiatrist. It is a more systematic and structured part of psychotherapy. It consist in helping the patient learn effective ways to overcome their problems and difficulties that causes them distress. Behavior therapy has its roots in experimental psychology. E.L Thorndike and B.F Skinner were among the first to work on behavior therapy. Convulsive therapy was introduced by Ladislas Meduna in 1934. He induced seizures, by using pentetrazol, as a way to reduce depression. Meanwhile, in Italy, Ugo Cerletti substituted metrazol (which was used in Convulsive theory) with electricity. Because of this substitution the new theory was called Electro-Convulsive Therapy (ECT). Beside psychotherapy, a wide range of medication is used in the treatment of mental disorders. The first drugs used for this purpose were extracted from plants with psychoactive properties. Louis Lewin, in 1924, was the first one to introduce a classification of drugs and plants that had properties of this kind. The history of the medications used in mental disorders has developed a lot through years. The discovery of modern drugs prevailed during the 19th century.. Lithium was discovered as a treatment of mania, by John F. Cade in 1949, "and Hammond (1871) used lithium bromide for 'acute mania with depression'". In 1937, Daniel Bovet and Anne-Marie Staub discovered the first antihistamine (Neuroleptic). In 1950 the Paul Charpentier synthesized chlorpromazine (Neuroleptic). Different perspectives on the causes of psychological disorders arose including some that stated that psychological disorders are caused by specific abnormalities of the brain and nervous system and that is, in principle, they should be approached for treatments in the same way as physical illness (arose from Hippocrates's ideas).

Influences

There are numbers of practitioners who have influenced the treatment of modern mental disorders. One of the most important among them was the "Father of American Psychiatry", Benjamin Rush. Benjamin Rush (1746–1813) was considered the Father of American Psychiatry for his many works and studies in the mental health field. He tried to classify different types of mental disorders, he theorized about their causes, and tried to find possible cures for them. Rush believed that mental disorders were caused by poor blood circulation, though he was wrong. He also described Savant Syndrome and had an approach to addictions.

Other important early psychiatrists include George Parkman, Oliver Wendell Holmes, Sr., George A. Zeller, Carl Jung, Leo Kanner, and Peter Breggin. George Parkman (1790–1849) got his medical degree at the University of Aberdeen in Scotland. He was influenced by Benjamin Rush, who inspired him to take interest in the state asylums. He trained at the Parisian Asylum. Parkman wrote several papers on treatment for the mentally ill. Oliver Wendell Holmes Sr.(1809–1894) was an American Physician who wrote many famous writings on medical treatments. George H. Zeller (1858–1938) was famous for his way of treating the mentally ill. He believed they should be treated like people and did so in a caring manner. He banned narcotics, mechanical restraints, and imprisonment while he was in charge at Peoria State Asylum. Peter Breggin (1939–present) disagrees with the practices of harsh psychiatry such as electroconvulsive therapy.

Psychotherapy

A common form of treatment for many mental disorders is psychotherapy. Psychotherapy is an interpersonal intervention, usually provided by a mental health professional such as a clinical psychologist, that employs any of a range of specific psychological techniques. There are several main types. Cognitive behavioral therapy (CBT) is used for a wide variety of disorders, based on modifying the patterns of thought and behavior associated with a particular disorder. There are various kinds of CBT therapy, and offshoots such as dialectical behavior therapy. Psychoanalysis, addressing underlying psychic conflicts and defenses, has been a dominant school of psychotherapy and is still in use. Systemic therapy or family therapy is sometimes used, addressing a network of relationships as well as individuals themselves. Some psychotherapies are based on a humanistic approach. Some therapies are for a specific disorder only, for example interpersonal and social rhythm therapy. Mental health professionals often pick and choose techniques, employing an eclectic or integrative approach tailored to a particular disorder and individual. Much may depend on the therapeutic relationship, and there may be issues of trust, confidentiality and engagement.

To regulate the potentially powerful influences of therapies, psychologists hold themselves to a set of ethical standers for the treatment of people with mental disorders, written by the American Psychological Association. These ethical standards include:

• Striving to benefit clients and taking care to do no harm;
• Establishing relationships of trust with clients;
• Promoting accuracy, honesty, and truthfulness;
• Seeking fairness in treatment and taking precautions to avoid biases;
• Respecting the dignity and worth of all people.

Medication

Psychiatric medication is also widely used to treat mental disorders. These are licensed psychoactive drugs usually prescribed by a psychiatrist or family doctor. There are several main groups. Antidepressants are used for the treatment of clinical depression as well as often for anxiety and other disorders. Anxiolytics are used, generally shorter-term, for anxiety disorders and related problems such as physical symptoms and insomnia. Mood stabilizers are used primarily in bipolar disorder, mainly targeting mania rather than depression. Antipsychotics are used for psychotic disorders, notably in schizophrenia. However, they are also often used in smaller doses to treat anxiety. Stimulants are commonly used, notably for ADHD.

Despite the different conventional names of the drug groups, there can be considerable overlap in the kinds of disorders for which they are actually indicated. There may also be off-label use. There can be problems with adverse effects and adherence.

Antipsychotics

In addition of atypical antipsychotics in cases of inadequate response to antidepressant therapy is an increasingly popular strategy that is well supported in the literature, though these medications may result in greater discontinuation due to adverse events. Aripiprazole was the first drug approved by the US Food and Drug Administration for adjunctive treatment of MDD in adults with inadequate response to antidepressant therapy in the current episode. Recommended doses of aripiprazole range from 2 mg/d to 15 mg/d based on 2 large, multicenter randomized, double-blind, placebo-controlled studies,4,5 which were later supported by a third large trial.6 Most conventional antipsychotics, such as the phenothiazines, work by blocking the D2 Dopamine receptors. Atypical antipsychotics, such as clozapine block both the D2 Dopamine receptors as well as 5HT2A serotonin receptors. Atypical antipsychotics are favored over conventional antipsychotics because they reduce the prevalence of pseudoparkinsonism which causes tremors and muscular rigidity similar to Parkinson’s disease. The most severe side effect of antipsychotics is agranulocytosis, a depression of white blood cell count with unknown cause, and some patients may also experience photosensitivity.

Antidepressants

Early antidepressants were discovered through research on treating tuberculosis and yielded the class of antidepressants known as monoamine oxidase inhibitors (MAO). Only two MAO inhibitors remain on the market in the United States because they alter the metabolism of the dietary amino acid tyramine which can lead to a hypertensive crisis. Research on improving phenothiazine antipsychotics led to the development of tricyclic antidepressants which inhibit synaptic uptake of the neurotransmitters norepinephrine, dopamine, and serotonin. Later research on this class of antidepressants focused mostly on the effects of norepinephrine. These drugs share many similarities with the tricyclic antidepressants but are more selective in their action. The greatest risk of the SSRIs is an increase in violent and suicidal behavior, particularly in children and adolescents. In 2003 antidepressant sales worldwide totaled $15 billion USD and as of 2006 antidepressants accounted of seven of the 100 most prescribed drugs.

Other

Electroconvulsive therapy (known as ECT) is used, for example in prolonged mood disorder unresponsive to other interventions. Psychosurgery, including deep brain stimulation, is another available treatment for some disorders.

Creative therapies are sometimes used, including music therapy, art therapy or drama therapy.

Lifestyle adjustments and supportive measures are often used, including peer support, self-help and supported housing or employment. Some advocate dietary supplements. Many things have been found to help at least some people. A placebo effect may play a role.

Services

Main article: Services for mental disorders

Often an individual may engage in different treatment modalities and use various mental health services. These may be under case management (sometimes referred to as "service coordination"), use inpatient or day treatment, utilize a psychosocial rehabilitation program, and/or take part in an Assertive Community Treatment program. Providing optimal treatments earlier in the course of a mental health disorder may prevent further relapses and ongoing disability and has led to a new early intervention in psychosis service approach for psychosis.

Mental health services may be based in hospitals, clinics or the community.

Some approaches are based on a recovery model of mental disorder, and may focus on challenging stigma and social exclusion and creating empowerment and hope.

In America, half of people with severe symptoms of a mental health condition were found to have received no treatment in the prior 12 months.

Fear of disclosure, rejection by friends, and ultimately discrimination are a few reasons why people with mental health conditions often don't seek help.

The UK is moving towards paying mental health providers by the outcome results that their services achieve.

List of treatments

• Somatotherapy (type of pharmacotherapy; biology-based treatments)
  • Psychiatric medications (psychoactive drugs used in psychiatry)
    • Antianxiety drugs (anxiolytics)
    • Antidepressant drugs
    • Antipsychotic drugs
    • Mood stabilizers
  • Shock therapy also known as convulsive therapies
    • Insulin shock therapy (no longer practiced)
    • Electroconvulsive therapy
  • Psychosurgery
    • Leukotomy (prefrontal lobotomy; no longer practiced)
    • Bilateral cingulotomy
    • Deep brain stimulation
• Psychotherapy (psychology-based treatment)
  • Cognitive Behavior Therapy
  • Psychoanalysis
  • Gestalt Therapy
  • Interpersonal psychotherapy
  • EMDR
  • Behavior Therapy

Further reading

• Mind, Brain, and Personality Disorders Am. J. Psychiatry 1 April 2005: 648-655.
• General Psychiatry JAMA 16 September 1998: 961-962
• The practice of medicinal chemistry, Camille Georges Wermuth
• Theories of Psychotherapy & Counseling: Concepts and Cases, Richard S. Sharf
• Cognitive behavioural interventions in physiotherapy and occupational therapy, Marie Donaghy, Maggie Nicol, Kate M. Davidson
• Key concepts in psychotherapy integration, Jerold R. Gold