A New Nomenclature for Psychotropic Drugs

How pharmacology can aid in the diagnosis of mental disorders

The precise diagnosis of mental disorders constitutes a formidable problem. Mental disorders are currently diagnosed based on clinical symptoms, which are often subjective. Various drug classes, traditionally referred to as "antidepressants," "antipsychotics" and "mood stabilizers" are then used empirically to treat affected patients. The previous decade has witnessed an increasing extension of the use of drug classes beyond their traditional indications (e.g., "antidepressants" in the treatment of anxiety disorders). Therefore, we would like to initiate a discussion in the pharmacological and psychiatric research communities on an alternative classification of mental disorders: Instead of using the traditional categorical classification of mental disorders physicians should rather diagnose symptoms (e.g., anhedonia) without bias to a traditional categorization (e.g., depression). The appropriate most effective drugs are then selected based on these symptoms. Depending on the responsiveness of the patient towards a given drug X, the disease should be classified, e.g., as drug X-responsive disease. This approach will also help us elucidate the still poorly understood molecular mechanisms underlying mental disorders, i.e., drugs can also be viewed and used as molecular diagnostic tools. In several fields of medicine, drugs are already used as molecular diagnostic tools. Thus, there is already precedence for the concept proposed here for mental disorders.

Effects of Current Psychotropic Drugs on Inflammation and Immune System

The immune system and inflammation are involved in the pathological progression of various psychiatric disorders such as depression or major depressive disorder (MDD), generalized anxiety disorder (GAD) or anxiety, schizophrenia, Alzheimer's disease (AD), and Huntington's disease. It is observed that levels of inflammatory cytokines such as tumor necrosis factor-α (TNF-α), interleukin-1β (IL-1β), and other markers are highly increased in the abovementioned disorders. The inflammation and immune component also lead to enhance the oxidative stress. The oxidative stress and increased production of reactive oxygen species (ROS) are considered as important factors that are involved in pathological progression of psychiatric disorders. Increase production of ROS is associated with excessive inflammation followed by cell necrosis and death. The psychotropic drugs are mainly work through modulations of neurotransmitter system. However, it is evident that inflammation and immune modulation are also having important role in the progression of psychiatric disorders. Rationale of the use of current psychotropic drugs is modulation of immune system by them. However, the effects of psychotropic drugs on the immune system and how these might contribute to their efficacy remain largely unclear. The drugs may act through modification of inflammation and related markers. The main purpose of this book chapter is to address the role of current psychotropic drugs on inflammation and immune system. Moreover, it will also address the role of inflammation in the progression of psychiatric disorders.

Individual Differences in Response to Antidepressants: A Meta-analysis of Placebo-Controlled Randomized Clinical Trials

Importance

Antidepressants are commonly used to treat major depressive disorder (MDD). Antidepressant outcomes can vary based on individual differences; however, it is unclear whether specific factors determine this variability or whether it is at random.

Objective

To investigate the assumption of systematic variability in symptomatic response to antidepressants and to assess whether variability is associated with MDD severity, antidepressant class, or study publication year.

Data Sources

Data used were updated from a network meta-analysis of treatment with licensed antidepressants in adults with MDD. The Cochrane Central Register of Controlled Trials, CINAHL, Embase, LILACS database, MEDLINE, MEDLINE In-Process, and PsycInfo were searched from inception to March 21, 2019. Additional sources were international trial registries and sponsors, drug companies and regulatory agencies' websites, and reference lists of published articles. Data were analyzed between June 8, 2020, and June 13, 2020.

Study Selection

Analysis was restricted to double-blind, randomized placebo-controlled trials with depression scores available at the study's end point.

Data Extraction and Synthesis

Baseline means, number of participants, end point means and SDs of total depression scores, antidepressant type, and publication year were extracted.

Main Outcomes and Measures

Log SDs (bln σ̂) were derived for treatment groups (ie, antidepressant and placebo). A random-slope mixed-effects model was conducted to estimate the difference in bln σ̂ between treatment groups while controlling for end point mean. Secondary models determined whether differences in variability between groups were associated with baseline MDD severity; antidepressant class (selective serotonin reuptake inhibitors and other related drugs; serotonin and norepinephrine reuptake inhibitors; norepinephrine-dopamine reuptake inhibitors; noradrenergic agents; or other antidepressants); and publication year.

Results

In the 91 eligible trials (18 965 participants), variability in response did not differ significantly between antidepressants and placebo (bln σ̂, 1.02; 95% CI, 0.99-1.05; P = .19). This finding is consistent with a range of treatment effect SDs (up to 16.10), depending on the association between the antidepressant and placebo effects. Variability was not associated with baseline MDD severity or publication year. Responses to noradrenergic agents were 11% more variable than responses to selective serotonin reuptake inhibitors (bln σ̂, 1.11; 95% CI, 1.01-1.21; P = .02).

Conclusions and Relevance

Although this study cannot rule out the possibility of treatment effect heterogeneity, it does not provide empirical support for personalizing antidepressant treatment based solely on total depression scores. Future studies should explore whether individual symptom scores or biomarkers are associated with variability in response to antidepressants.

Attitudes and behaviour towards psychotropic drug prescribing in Swedish primary care: a questionnaire study

Background

The prescribing of psychotropic drugs, i.e. antidepressants, sedatives (anxiolytics, hypnotics), and antipsychotics is considerable and a large proportion is prescribed by general practitioners (GPs). There are concerns about dependency and medicalisation, and treatment decisions in psychiatry may appear arbitrary. Increased knowledge of GPs’ opinions on the prescribing of psychotropics may lead to more rational use of these drugs. We aimed to quantify GPs’ attitudes, beliefs and behaviour towards various aspects of psychotropic drug prescribing.

Methods

A questionnaire was distributed to physicians in all 199 GP practices in Region Västra Götaland, Sweden. The questions concerned determinants of psychotropic drug prescribing that had been identified in a previous, qualitative study.

Results

Questionnaires from 516 physicians (64% of whom were specialists in family medicine, 21% interns in family medicine, 15% others) at 152 GP practices (59% of which were state owned, 72% in an urban area, with a median of 7808 registered patients) were returned (estimated response rate: 48%). A majority – 62% – of GPs found it easier to start prescribing psychotropic drugs than to stop (95% confidence interval, 57%, 66%) vs. 8% (6%, 10%). Most GPs considered psychotherapy more suitable than psychotropic drugs in cases of mild psychiatric disease: 81% (77%, 84%) vs. 4% (3%, 6%). The problems treated with psychotropic drugs were considered to be mostly socioeconomic, or mostly medical, by similar proportions of physicians: 38% (34%, 42%) vs. 40% (36%, 45%). GPs were on average satisfied with their levels of antidepressant and sedative prescribing in relation to medical needs. More GPs regarded their prescribing of antipsychotics as being too low rather than too high: 33% (28%, 39%) vs. 7% (4%, 10%).

Conclusions

This study illustrates the complexities of psychiatric drug treatment in primary care and identifies potential drivers of increased prescribing of psychotropics. The manifold factors, medical and non-medical, that affect prescribing decisions may explain a sense of arbitrariness surrounding psychotropic drug treatment. This notwithstanding, GPs seem mostly content with their prescribing.

Electronic supplementary material

The online version of this article (10.1186/s12875-018-0885-4) contains supplementary material, which is available to authorized users.

Hearing the Unheard: An Interdisciplinary, Mixed Methodology Study of Women's Experiences of Hearing Voices (Auditory Verbal Hallucinations)

This paper explores the experiences of women who "hear voices" (auditory verbal hallucinations). We begin by examining historical understandings of women hearing voices, showing these have been driven by androcentric theories of how women's bodies functioned leading to women being viewed as requiring their voices be interpreted by men. We show the twentieth century was associated with recognition that the mental violation of women's minds (represented by some voice-hearing) was often a consequence of the physical violation of women's bodies. We next report the results of a qualitative study into voice-hearing women's experiences (n = 8). This found similarities between women's relationships with their voices and their relationships with others and the wider social context. Finally, we present results from a quantitative study comparing voice-hearing in women (n = 65) and men (n = 132) in a psychiatric setting. Women were more likely than men to have certain forms of voice-hearing (voices conversing) and to have antecedent events of trauma, physical illness, and relationship problems. Voices identified as female may have more positive affect than male voices. We conclude that women voice-hearers have and continue to face specific challenges necessitating research and activism, and hope this paper will act as a stimulus to such work.