EPQ (March 2015): Has the Use of Psychiatric Medication Improved the Treatment of the Mentally Disordered?

As a member of the 5th year academy at school, I was offered the opportunity to do an Extended Project Qualification a year early.

I chose the topic of psychiatry for my EPQ because I was and am very keen to study medicine at university, and have had a particular interest in psychiatry. I also find history, which I am studying as one of my A2 subjects, fascinating; therefore, linking the two to explore the recent history of psychiatry was an ideal choice for me. One of my principal interests is how the brain works, and the changes that medication exerts on it. Added to the complexity is the fact that as well as being one of the most contentious fields of medicine, psychiatry is one about which we know relatively little, which gave me plenty of scope for discussion and analysis.

My father’s work is concerned with the legal aspect of mental health, and consequently I have learnt a lot about the subject through him. A year before writing this project, I had a day’s work experience at Leigh House Hospital, an acute adolescent psychiatric ward, and as many of the patients were about my age it really affected me.

Although finding the time to write my project alongside my AS Levels was tough, I am very glad that I have done it and achieved an A*. The experience was enjoyable overall, and it was fascinating to research psychiatry (as well as several other unrelated areas on tangents) in great detail. Giving a PowerPoint presentation on my EPQ was also useful practice.

Here is a copy of my main essay of over 6,000 words (footnotes removed for reasons of layout):

Introduction

Since their development midway through the twentieth century, modern psychiatric drugs have provoked much controversy, raising a plethora of arguments for and against their use. Although medication is now very much the centrepiece in the treatment of the mentally disordered, by examining alternative methods, both preceding and current, I will evaluate the extent to which medication has been effective. In earlier times, methods of treatment that were ostensibly primitive and ineffective were used to treat mental disorders. The asylums in which most of this treatment took place, moreover, often now evoke feelings of disgust and shame. The word “bedlam”, derived from the Royal Bethlem Hospital, almost speaks for itself. Even twentieth-century practices such as electroconvulsive therapy (ECT) and lobotomy are regarded with the same hostility. Correspondingly, the perhaps simplistic popular perception is that:

Before the introduction of modern psychiatric medication, the treatment of the mentally disordered was primitive, and often barbaric.

Medication has resulted in extraordinary progress, and is by far the most effective and humane form of treatment for the mentally disordered.

There are numerous benefits to psychiatric medication, predominantly their efficacy at removing patients’ symptoms, and the way in which they allow many patients, who previously would have been permanently debilitated, to live a normal life. On the other hand, perhaps the most controversial issue with psychiatric drugs is that of side-effects. It is, furthermore, arguable that medication is merely another form of containment – sometimes given the sobriquet “chemical straightjacket” – and that other methods still have beneficial aspects.

Definitions

In order to appreciate fully the impact of the introduction of medication, it is important to clarify what is meant by “treatment”, “mentally disordered” and “psychiatric medication”. Under the Mental Health Act, the definition of treatment is very wide and somewhat ambiguous. It encompasses all “medical treatment which is for the purpose of alleviating or preventing a worsening of a mental disorder or one or more of its symptoms or manifestations”, with manifestations being the behaviour or actions of a patient, such as killing someone, that occur as a result of their disorder. Therefore, both medication and restraint, for instance, can be considered treatment; although it does not treat a patient’s symptoms, restraint can prevent a patient from causing harm to others.

The precise causes of mental disorders are much debated. Many mental disorders, such as schizophrenia, are hereditary, and susceptibility is passed on through abnormal genes. However, mental disorders can be precipitated by a number of other factors, such as infections, psychological trauma, head injury, or illicit drug abuse.

The term “mental disorders” includes mental illnesses, such as schizophrenia, bipolar disorder, and depression, but it also contains personality disorder, learning disabilities, and autistic spectrum disorders. Although psychiatric medication is predominantly used to treat mental illnesses, it is occasionally used for other disorders such as personality disorders (enduring, persistent disorders of inner experience that cause stress or severe impairment in social functioning). Therefore, I decided to focus on “mental disorders” to produce a more inclusive evaluation of the impact of psychiatric medication.

ICD10, the International Classification of Diseases in the tenth edition of the medical classification list by the WHO, is used for diagnosis of all diseases, as well as psychiatric ones. Although ICD10 is used as the basis for diagnosis, criteria for different diagnoses can overlap; therefore, it is often debatable as to what illness a patient has, and not necessarily definitive. For example, psychosis and delusions are present in patients with either paranoid schizophrenia, schizoaffective disorder, or drug-induced psychosis. Frequently, different psychiatrists will disagree over what illness a patient is suffering from. Therefore, patients could be unnecessarily bombarded with various medications, some with detrimental side-effects, that might not be treating their disorder.

“Psychiatric medication” encompasses drugs that have a specific effect on the brain and nervous system for the purpose of treating a mental disorder. There are six main types of psychiatric medication: antidepressants, antipsychotics, anxiolytics, depressants, mood stabilisers, and stimulants. Some basic drugs were used to treat the mentally ill in the nineteenth and early twentieth centuries, but the introduction of modern psychiatric drugs – initially developed in the mid-twentieth century from synthetic chemical compounds – revolutionised the treatment. It is these that I will be concentrating on.

History

In order to evaluate the impact of psychiatric drugs, one must consider the treatment methods that directly preceded them. Over the centuries, myriads of psychiatric treatment methods have been used, including trepanning (sawing or boring into the skull) and even exorcisms (using the invocation of holy names) – to release the evil spirit that supposedly caused mental illness – and bloodletting via leeches. For the sake of brevity, however, I shall only consider treatment that immediately preceded, and sometimes coincided with, the introduction of psychiatric medication.

Several non-pharmacological methods of treatment and restraint were used in nineteenth-century asylums; hydrotherapy, insulin coma therapy, and malaria therapy were all experimented with. Restraint and seclusion, however, were the mainstay. In 1814, Edward Wakefield, an author and leading advocate of lunacy reform, wrote of patient James (or William) Norris:

“. . . a stout iron ring was riveted about his neck, from which a short chain passed to a ring made to slide upwards and downwards on an upright massive iron bar, more than six feet high, inserted into the wall. . . . He had remained thus encaged and chained more than twelve years.”

This is a typical account of a visit to an early nineteenth-century asylum, and just one of a number of accounts of seemingly cruel mechanical restraint and poor conditions. Wakefield also described Bethlem’s conditions as being akin to “a dog kennel”.

Norris

James (or William) Norris in solitary confinement, Bethlem Asylum, 1814

There were inevitably some cases of violence and abuse in asylums shortly before medication was introduced. Moreover, in the days before the existence of the welfare state, there was a clear class divide. The rich could afford to go to the asylums with better conditions such as Bethlem, while many lower-class patients with serious illnesses were sent to county asylums, where conditions were often not much better than the workhouse, and from which few emerged. A large proportion of the mentally disordered were not given even this sort of rudimentary treatment. Those with what we now recognise as mental disorders might not even have been classified (in contemporary terminology which to modern ears is pejorative) as “lunatics” or “idiots” and therefore received no treatment at all.

The number of mentally disordered patients in England and Wales rose significantly from 1850, as awareness of mental disorders and increased diagnosis took place. Severely mentally disordered people who committed murder or other atrocities were sometimes simply hanged for their crimes, with no recognition of their mental condition, if they did not exhibit “frenzy or raving madness”.

The majority of asylums were, by definition, places of safety and refuge for patients who otherwise could have been left homeless, or ostracised. However, this view of asylums as places of “mystery [and] torture” has lingered and corrupted popular perceptions about conditions in the days before psychiatric medication. One such perception was that once patients went to an asylum, they were trapped and would never emerge. Although this might have been the case in nineteenth- and early twentieth-century county asylums, where severely ill, lower-class patients were sent, specialist asylums sought to challenge this view. In fact, in Bethlem from the 1860s, only those “presumed to be curable” were accepted for “maintenance and medical treatment”. Consequently, patients who showed no signs of improvement after a year were discharged – even if they were seriously ill – as soon as their families could make alternative arrangements.

    12th Night

Twelfth Night entertainment at Hanwell Lunatic Asylum, 1845

Life for a patient in an asylum was arguably more sociable with more available entertainment than in a modern psychiatric institution. Despite the focus being on restraint – because they lacked the facilities and treatment methods available now – the staff did recognise the importance of the warmth of human contact. Patients were given the opportunity to carry out unskilled labour, for which they were paid in the form of increased rations and better quality clothing. This, in turn, improved many patients’ quality of life, as well as helping them pass the time. So too did occasional plays, soirées, and balls, all of which the patients were involved in.

Following Wakefield’s account of 1814, conditions in asylums did gradually improve, aided by a number of pieces of legislation that were enacted in the nineteenth century. This is supported by an excerpt from a letter written in 1898 by Jonathan Lowe, a fifty-two-year-old labourer, describing his stay in Broadmoor.

“I am very comfirtable here. I am very kindely treted here: the superintend, the doctors and all the atendents are all very kind and respecfull to the patents. We have about five hours and half out in the gardens every day. There is books to read, periodicals; and the daily paper to read; billiards, bagatle, cards, demonios, chess, draphs, and everthing that is nessery for our amusement. Band plays out in the grounds, and there is plenty of musick amungst the patents themselves. We have our beer and tobaco and plenty of fruit: in fact, I am very comfortable.”

Non-pharmacological Treatments

Lobotomy

Lobotomy

An early advertisement for lobotomy, depicting a patient before and after the procedure, 1948

The next significant psychiatric development was lobotomy, first undertaken in 1935 by António Egnas Montiz. It is a highly contentious psychosurgical procedure that involves severing the nerve pathways to and from the prefrontal cortex (the cerebral cortex at the front of the brain, associated with cognitive control). Initially, it was hailed as a miracle cure, and subsequently some 50,000 lobotomies were performed in the 1940s and 1950s because it did cure most of the symptoms that it was designed to. These included schizophrenia and severe depression. Doctors continued lobotomies for over two decades; however, it became apparent that it created new, unintended impairment to replace those which it treated. Of the 75% of patients who did survive the lobotomy, they became either “dull and apathetic and zombie-like” or “uninhibited and euphoric”. An excellent summary of the diverse effects of lobotomy is: “There were some very unpleasant results, very tragic results and some excellent results and a lot in between.” The awarding of the Nobel Prize to Montiz in 1949 for the “discovery of the therapeutic value of leucotomy in certain psychoses” was almost as controversial as the practice for which he had won it.

While the lobotomy routinely had severe repercussions for those subjected to it, it did ease the serious issues of overcrowded psychiatric institutions and the expense of treating patients. Early in the twentieth century, the number of psychiatric patients occupying mental hospitals significantly increased, disproportionate to the availability of effective medical treatment. With all its defects, it is evident that lobotomy did, in a very limited sense, benefit society: without lobotomy, the overcrowding of mental hospitals and mixing of dangerous mental patients with the general population might have been worse. Walter Jackson Freeman, an American physician who specialised in lobotomy, held the utilitarian conviction that the lobotomy was a solution to the threat that mental illness posed to society. Therefore, lobotomy was seen to be a tool of social control, and the tide began to turn against it.

There was some overlap between the use of lobotomy and psychiatric drugs in the mid-twentieth century, but the practice of lobotomy has generally ceased since the 1970s. This is due to the fact that “the first wave of effective psychiatric drugs” has “fortunately” rendered lobotomy largely redundant. The psychosurgical method was superseded by what some people now denigratingly refer to as the “chemical lobotomy”.

Electroconvulsive therapy (ECT)

Alongside lobotomy, and before psychiatric mediation came into use, a separate form of treatment was often alternatively used. First implemented by the Italian neurosurgeon Ugo Cerletti in 1938, electroconvulsive therapy is still offered on the NHS, for “depressive illness, mania, catatonia and occasionally schizophrenia”, though it is used sparingly, usually when antidepressant drugs prove ineffective. When undergoing ECT, the patient is given a general anaesthetic and a muscle relaxant, before 800 milliamperes of electric current is briefly applied through the brain, thus inducing a seizure. This subsequently provides symptomatic relief, usually short-term.

As happened with the practice of lobotomy, those who performed ECT travelled around the world to promote it. But many doctors and the public alike became opposed to ECT; in their eyes, it was brutal and crude. One particularly scathing polemic, The Brutal Reality: Harmful Psychiatric “Treatments”, denounces “the ECT procedure itself [as] no more scientific or therapeutic than being hit over the head with a bat”. Though this is certainly hyperbolic, there was some basis for this criticism. Initially, neither modern anaesthetic nor muscle relaxant was used on patients (because it did not exist), provoking violent seizures. Patients and families were often poorly informed by doctors and nurses, who did not explain what ECT was, or the potential risks which accompanied it. There is also evidence to suggest that ECT was used to “‘stun’ noisy patients into submission”, rather than to treat them. Although its use has actually increased in Scandinavian countries, its perceived reputation has lessened its use in other countries. Consequently, the implementation of ECT has more than halved between 1985 and 2000, largely being displaced by psychiatric drugs.

ECT

A newspaper article revealing the optimistic atmosphere surrounding ECT, 1940

Ken Kesey’s novel (and later film) One Flew Over the Cuckoo’s Nest, about a patient who fakes insanity to serve a sentence in hospital rather than prison, was largely responsible for the received opinion that ECT is “dangerous, inhumane and overused”. Written in 1975, it actually depicts a type of ECT being performed on the main character that was “already nearly 20 years obsolete” by 1975.

The vast majority of hospitals in England at the time were using modified ECT with muscle relaxants such as succinylcholine from 1951, and anaesthesia, significantly reducing any potential discomfort. However, by the 1950s, when psychiatric drugs were beginning to replace ECT, the damage had already been done. It remains in use, but lingering concern about ECT treatment is reflected in section 58A of the Mental Health Act 1983 – reinforced by the Code of Practice published in 2008 – under which a patient with capacity who refuses ECT cannot be forced to undergo it.

Psychotherapy and other therapies

The current treatment of the mentally disordered is not confined to medication and ECT; other methods of treatment are also used. The main alternative is psychotherapy. In psychotherapy, a patient talks to a trained therapist in order to help them understand the emotions, ideas, and behaviours that contribute to their illness, and thus how to deal with them.

Probably the earliest form of psychotherapy was psychoanalysis, principally associated with Sigmund Freud. Freud coined the term “psychoanalysis” in 1896, and then spent the rest of his life delineating its main features. The aim of the therapy was to remove neuroses and thereby cure the patient. A psychoanalytic therapist would typically encourage the “analysand” – or patient under analysis – to express whatever thoughts pass through their mind, including dreams, fantasies, so-called Freudian slips (parapraxes), and free associations. From this, the psychoanalyst would form hypotheses about the patient’s past and present experiences. When both the patient and the psychoanalyst came to the same conclusion about the psychological processes that contributed to the mental illness, they were – according to Freud – cured. Since Freud, psychoanalysis has evolved, but remains fundamentally similar.

Cognitive behavioural therapy (CBT) is an alternative form of psychotherapy that retrains the patient’s method of thinking and consequent behaviour to help him or her deal more effectively with stress. New therapies are still being developed, and existing therapies refined.

While largely safe, however, there is the possibility that psychotherapy may – like any other treatment – “make things worse if it is misapplied”. Dr Philip Cushman strongly believes that psychotherapy has been complicit in inducing illnesses that it was supposed to cure, and that it “perpetuates the social problems that caused the patient’s wounds in the first place”. Moreover, the applicability of psychotherapy is limited, because it can only be used in moderate cases, or when a patient has made significant improvement in their condition. This is because patients have to be compliant, and able to focus and engage with the psychotherapist.

Also available to patients is a wide variety of more specific individual and group therapies. These deal with areas such as sex offending, relapse prevention and insight development.

Medication

The treatment of the mentally disordered was revolutionised by the development of modern psychiatric drugs in the 1950s. “The introduction of these drugs heralded truly revolutionary developments in the management of mental illness”; they were innovatory because they provided pharmacological treatment for disorders that were previously resistant to therapy. Therefore, many patients who had been rendered incapacitated by their disorder were now relieved of it, and able to live largely settled and productive lives.

In the early nineteenth century, there had been very little in the way of drug treatment for mental patients. Drugs were by and large naturally occurring, such as the depressant laudanum (derived from opium), and could only be given orally; therefore, consent was required from the patient, and manic/deluded patients would not receive treatment. It was not until the invention of the hypodermic syringe in the 1850s that medication could be given forcibly, injecting drugs into the patient intravenously or intramuscularly. It is evident from records held at the Maudsley and Bethlem hospitals that drugs such as barbiturates and Paraldehyde were used as treatment in the 1930s and 1940s.

The real breakthrough came on 11 December 1950, when the French chemist Paul Charpentier produced the compound chlorpromazine. Having been tested extensively, it was found to induce a calming and shock-reducing effect. It was subsequently introduced in 1954 under the trade name Thorazine, and used as an antipsychotic for treating paranoid schizophrenia. Chlorpromazine became the benchmark drug for schizophrenia by controlling the symptoms, without the incapacitating side-effects associated with previous drugs. Chemists soon began to experiment with the derivatives of chlorpromazine, which led to the development of tricyclic antidepressants. These, together with chlorpromazine were the “first truly effective psychotropic drugs”.

Chlorpromazine

An American poster advertising Thorazine (chemical name chlorpromazine), 1962

Despite a strong opposition to any psychiatric medication in some quarters, medication is now largely regarded as the mainstay in the treatment of mental disorders. However, the rate of advance in psychiatric medication has slowed. Medication has been converted from intramuscular medication to pill forms and vice versa, but there have been relatively few recent developments in psychiatric treatment with drugs, in comparison to, for example, physical treatment.

Controversy

What is a mental disorder? One fundamental criticism of psychiatry is that there is no proof to support the common belief that mental disorder is a biological disease. In a series of interviews, psychiatrists were asked at the 2006 American Psychological Association convention how many patients they had cured. The answer was almost exclusively in the negative, or “I have cured none of my patients”, as one psychiatrist bluntly replied. While diseases such as diabetes or cancer can be diagnosed in a laboratory, psychiatrists “unfortunately rely primarily on symptoms to make [their] diagnoses”. Elliot Valenstein, author of Blaming the Brain, asserts that there are “no tests available for assessing the chemical status of a living person’s brain”. The theory that mental illness derives from chemical imbalances in the brain – on which psychiatric drugs are based – is “unproven opinion, not fact”.

Some sceptics strongly believe that psychiatric medication is a sham perpetuated by the financially motivated corporate world. The results of many drug trials can be manipulated to present ostensibly beneficial effects, leaving us with “a distorted picture of any drug’s true effects”. Furthermore, drug manufacturers are perfectly able to censor trials yielding results that would reduce potential commercial success. Therefore, both the positive and negative effects of medication have to be viewed sceptically. Some medication may not only be causing harmful side-effects, but also failing to treat symptoms effectively.

Positive aspects

Unlike antibiotics, which are used to destroy bacteria, psychiatric drugs treat the symptoms of – rather than curing – the illness. There are only speculations as to how this happens, the more accepted disease-centred model being that the medication effects changes to the brain and nervous system that correct underlying biochemical abnormalities.

How effective are psychiatric drugs? A study by the Royal College of Psychiatrists in 2012 suggested that psychiatric drugs are “as effective as other drugs” – that is, drugs such as statins and antibiotics. Therefore, the study implied that the psychiatric drugs work as well at treating mental disorders as general medical drugs do for physical illnesses.

The placebo effect – replacing medication with a sugar pill, for example – would suggest that it is not necessarily solely the chemical content of the medication that has an effect on the recipient. In a study in 2000 designed to determine the extent of the placebo effect, patients with depression were treated either by antidepressants, or by placebo. Symptom reduction for placebo treatment was at 30.9%, but for the patients treated with antidepressants, it was around 10% higher.

Psychiatric medication has enabled people to come to terms with their illness, and to live with dignity in a way which would have been impossible for most of their nineteenth-century predecessors. Capacity and rationality can be restored to patients, allowing them to live essentially normal lives. For those patients who will always use illicit drugs in the community, psychiatric medication has a protective effect, allowing them to live without psychotic symptoms.

In spite of the fact that there are generally side-effects to medication, they are arguably outweighed by the benefits. Although the side-effects of antidepressants may, for example, include anxiety, sickness, or dizziness, effective treatment of crippling symptoms might be a beneficial compromise to the patient.

Negative aspects

The side-effects inextricably linked with the positive effects vary in intensity and type between different varieties of medication. Psychiatric drugs are sometimes pejoratively referred to as “chemical lobotomies” or “straitjackets”. One patient who took chlorpromazine told his psychiatrist how “six weeks later . . . [he] felt like [his] mind had been put through a meat grinder”. The NHS lists forty-seven possible side-effects of chlorpromazine, including potentially fatal heart, respiratory, and liver problems. Indeed, patients on chlorpromazine have to undergo frequent blood tests.

Many psychiatric drugs have been taken off the market for being too harmful; chlormezanone is an example that was removed from the EU, the US, and many other countries in 1996. It had been linked with hepatotoxicity (chemically induced liver damage) and toxic epidermal necrolysis (an acute, life-threatening dermatological disorder). Furthermore, there are both illnesses and patients for whom psychiatric medication proves ineffective, particularly those with severe depression and bipolar and personality disorders.

Even more modern psychiatric medication designed to reduce negative repercussions, including those regarded as miracle drugs, do have severe side-effects. Clozapine, probably the safest antipsychotic for treating paranoid schizophrenia, commonly results in constipation, hypotension (low blood pressure), and weight gain; acute, life-threatening conditions such as agranulocytosis (which reduces the number of white blood cells, increasing susceptibility to infection), and circulatory collapse (failure of blood circulation) are also a risk. Consequently, life expectancy is usually significantly reduced.

For many patients, furthermore, the administration of medication can be as unpleasant as the side effects. Intramuscular injection of medication into the buttocks, as is usually the case, is painful and humiliating.

Patients can also develop a dependence on, or even addiction to, psychiatric drugs such as anxiolytics or antidepressants. Consequently, withdrawal symptoms can ensue after ending a course of psychiatric medication, because the patient needs time in order to overcome the drug’s effect on the mind and body.

An indirect consequence of the advent of modern psychiatric drugs in the mid-twentieth century was an exodus of patients into the community. On the one hand, this was beneficial, because it gave many patients the freedom and responsibility to live normal lives. It was planned that community-based facilities would be available, should any ex-patients need it. On the other hand, however, it became clear that thousands of discharged patients were incapable of living independently, whether they were taking medication or not. Many psychiatric institutions closed down, some 76,000 beds being lost between the 1950s and 1980s. Exacerbated by a lack of poor housing and inadequate follow-up care, many patients became homeless. In this sense, psychiatric medication indirectly worsened the position of many mentally ill patients.

It is arguable that taking psychiatric drugs does increase the likelihood of “cases of violence, suicide, and crime”. The correlation between psychiatric medication and suicide is uncertain, with various studies either suggesting or disputing it. A patient taking medication in the community has a greater opportunity to take an overdose.

Has medication superseded non-pharmacological treatment?

The short answer to this is no; the importance of non-pharmacological treatment is underestimated, and often chosen before medication. Non-pharmacological treatment is especially important for dealing with personality disorders, which are often refractory to psychiatric medication.

Although obsessive compulsive disorder is largely treated effectively with medication such as antidepressants, it is not completely potent in all cases; therefore, types of psychosurgery similar to the lobotomy are still used. Between 1991 and 1995, a team of Harvard investigators performed several variations of lobotomies, cingulotomies, designed to minimise abnormal behaviour and emotional distress by using an electric current to create lesions in the cingulate gyrus of the brain. Just over a third of patients indicated “major clinical improvement”, deeming cingulotomy “a viable treatment option for patients with severe treatment-refractory OCD”.

ECT, moreover, is still crucial for treating medication-resistant psychotic illness, as well as depression. The UK ECT Review Group found in 2003 that “treatment with ECT was significantly more effective than pharmacotherapy”. Around 90% of patients who have ECT for depression have positive results; in contrast, only 70% respond so well under antidepressants alone. The main side-effect is memory loss, but this – like other less common repercussions including confusion and concentration problems – usually subsides within a few days. Shocking stories of people suffering long-term amnesia, such as a patient who couldn’t “remember a bloody thing”, are very rare. The majority of prospective ECT patients are content to consider treatment. Correspondingly, one patient, though lamenting over her “long-term memory deficits”, had no regrets over her choice of “ECT over a life of psychic agony”. By and large, the decline of ECT and the rise of psychiatric drugs to replace it did not improve the treatment of the mentally disordered. In fact, the revival of ECT in the 1980s proved a great benefit to the mentally ill, because many who suffered enduring and persistent illness could consequently be treated. ECT treatment is not an enduring cure, but works almost without exception in the short term.

Psychotherapy, despite having potential, if slim, risks – and it can in some cases be fundamentally ineffective – does help improve the treatment of the mentally ill. This is because it offers an alternative to other, more radical treatment methods. Psychotherapy is usually used in conjunction with an exercise regime, sleep and stress management, and psychiatric medication. Therefore, it can be difficult to determine precisely which aspect of the treatment is relieving the patients; however, it is usually clear that the combination does yield beneficial effects. Therapy is also very useful in bringing about further improvement in patients who have been treated successfully with medication or ECT. Some mental illnesses, such as cannabis-induced psychosis, are triggered by illicit drug abuse, and may resolve spontaneously in the absence of such substances; no medication is required. Psychotherapy, though, has an important role in creating avoidance strategies to help people eradicate this problem.

Nursing, restraint and seclusion

While restraint is usually temporary, seclusion – even in intensively nursed high-security institutions like Broadmoor Hospital – can last for a long time, especially if patients are prone to a “violent outburst”. Consequently, nursing – the quality of which has improved over the years – will also always be necessary. Despite being used only as a “last resort”, the need for occasional restraint or seclusion indicates that psychiatric medication is sometimes not sufficient by itself.

While ECT and psychotherapy do amount to medical treatment, in that they prevent the worsening of symptoms, it is important to consider restraint, which also treats mental disorders by inhibiting their manifestations. Although drugs have significantly reduced the need for restraint and seclusion on psychiatric wards, that is not to say that they have been eliminated. There are concerns about the levels of violence and quality of treatment in some psychiatric wards, predominantly non-secure ones.

Methods of restraint practised by the police are not regularly used to control patients on wards, yet still appear from time to time, as indicated by the Care Quality Commission, an organisation that inspects and regulates health and social care services in England. In their “Monitoring [of] the Mental Health Act in 2012/13”, they found that 22% of wards investigated had reported the police use of Tasers, CS spray, handcuffs, and tape or binding. Throughout the respective securities – high, medium, low, and non-secure – most cases occurred on non-secure wards.

Stigma

Newspaper

A tabloid newspaper indicating the stigma of mental disorders, 1999

With respect to mental disorders, stigma is still a large problem; 87% of people with mental health problems report the detrimental repercussions of stigmatisation and discrimination. The Oxford Handbook of Psychiatry defines stigma as “the sense of collective disapproval and group of negative perceptions attached to a particular people, trait, condition, or lifestyle.” While those who suffer from mental disorders are undoubtedly subjected to much unjustified prejudice, there is evidence to suggest at least some link between severe mental illness, such as paranoid schizophrenia, and violence towards others. There is also the real problem that mental disorder may be genetically linked and therefore passed down the generations.

However, there is little doubt that the extent of stigmatisation has reduced over the years, and is still decreasing, due to both increased awareness and psychiatric medication. Before psychiatric medication was introduced, people with mental disorders displayed manifest evidence of their illness, and were therefore branded as “crazy” or taken away to an asylum – or “mad house” – which had pejorative connotations. Access to psychiatric medication has allowed many patients to suppress their symptoms and live everyday lives; it is then often almost impossible to distinguish between those with and without mental illness.

Moreover, the taking of medication has become more widely accepted due to the increased prevalence of all types of medication, whether it be contraceptives or antibiotics. Stigma has also been mitigated by increased awareness and anti-stigma campaigns, such as Time to Change, which has coincided with increased use of psychiatric medication. While there are still examples of newspapers reinforcing stigma, the media has helped by raising awareness.

Patients’ views of psychiatric medication

Despite the reduction in symptoms brought about by medication, many patients lack the insight to understand that the medication has helped. Instead, they attribute the benefits to other factors that have improved the quality of their life. Consequently, many patients are detained under the Mental Health Act because they refuse to consent to administration of medication. Many patients do feel debilitated and humiliated by the side-effects of medication, which can result in weight gain or decreased life expectancy. In spite of this, bad as the side-effects may be, most patients undoubtedly regard their psychotic symptoms – such as hearing incessant voices urging them to kill themselves – as so handicapping that the side-effects are a price worth paying.

Even so, some patients do demonstrate that they can live untreated with the symptoms of their mental disorder. For instance, the beliefs of a patient with persistent delusional disorder – who perhaps believes incorrectly that she is distantly related to the Royal Family – do not significantly affect their daily life. Medication is often not taken by patients, whether it be accidental or deliberate. In many cases, this is because they don’t want to and can make the decision not to, either because of fear of side-effects/cost/availability/stigma/dependency, or because they have a delusion whereby they think that they are not mentally ill, and therefore do not need any medication. This can be a problem with uncompliant, potentially dangerous patients who are discharged from psychiatric wards under the understanding that they will take their medication. Moreover, cognitive impairment or severe depression can render the patient unwilling to take medication that potentially would make them feel better, leading to a vicious circle.

Conclusion

Overall, having completed my research, I concluded that psychiatric medication has undoubtedly improved the treatment of the mentally disordered. Beforehand, I believed that psychiatric medication exclusively had improved the treatment of the mentally disordered. Although as a result I have come to the firm conclusion that medication has improved treatment, this project has broadened my perspective about other psychiatric treatments, and helped me recognise their respective merits. Other factors – such as improved nursing and care standards, and therapeutic techniques – have also had a positive influence on the treatment of the mentally disordered.

Modern psychiatric drugs constitute a far more effective and ethical method of treatment than – for example – lobotomy, which was generally used to control the patient, rather than treat his or her symptoms. They have, furthermore, reduced stigma and restored dignity to those who previously would have been ostracised or confined in an asylum. Psychiatric medication has allowed patients to live comparatively normal lives in the community.

Having looked into the history of treatment methods, I realise that there certainly was some abusive and ineffective treatment of the mentally disordered in the past – and this has not been entirely eradicated nowadays. But a close examination of the history of treatment in the days before modern psychiatric medication does leave one with a sense of admiration for doctors of those days. Without the resources which we now take for granted, many of them cared compassionately and effectively for their patients. Those doctors would have been astonished by the improvements brought about by modern psychiatric medication.

There is of course no panacea, and psychiatric drugs frequently produce severe side-effects. Successful treatment still requires that medication should be supplemented by non-pharmacological treatment which not only builds upon past experience, but is continuously reviewed and updated. A balance between pharmacological and non-pharmacological treatment must be achieved to suit patients’ individual needs.

Without medication, however, psychiatry would still be in its infancy.

Reflections

In researching and writing my EPQ I learnt a great amount of information and broadened my perspective on types of psychiatric treatment and the effects that they can have on patients’ lives. As I’m hoping to do a degree in medicine – which would require me to do a great deal of independent research and write it up to a tight schedule – this has given me a useful insight into what would be required. Overall, researching and writing up my EPQ was a useful and interesting experience.

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