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Chapter 5

Chapter Five.doc

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University of Toronto St. George

Chapter Five • Major sectors of mental health services • Speciality mental health sector: includes psychiatrists, psychologists, psychiatric nurses and psychiatric social workers who are trained specifically to treat people with mental disorders • General medical/primary care sector: includes health care professionals such as internists, paediatricians and nurse practitioners; may not be specifically trained in mental health treatment, but are often the initial point of contact or the only source of mental health services • Human services sector: includes social services, school based counselling services, residential rehabilitation services, criminal justice services and religious professional counsellors • Voluntary support network sector: self-help groups such as AA; growing component of mental health treatment; 3% of adult Canadian population have attended an AA meeting; 37% of Canadians who suffer from mental disorders or substance dependence use some kind of health care/community resource • Medication: prescribed by proponents of biological treatments • Psychotherapy: proposed by psychological and some social approaches; most involve therapist (psychiatrist, clinical social worker, etc) talking to client about symptoms and contributing factors; specific topic depends on therapist’s theoretical approach Biological treatments • Social impact: can treat people with severe psychological disturbances so can lead normal lives and not be warehoused; do not work for everyone; have significant side effects; worry that people will turn to drugs rather than deal with difficult issues in lives causing psychological problems; ethical issues of changing personalities with pills • Drug therapies: most discovered in roundabout ways; drugs thought to relieve psychological symptoms by correcting imbalances of neurotransmitters, compensating for structural deficits and effects of genetic abnormalities • Antipsychotic drugs: reduce symptoms of psychosis (loss of reality testing, hallucinations, delusions) • Chlorpromazine: discovery incited beginning of modern drug treatment; now used to treat symptoms of psychosis • Psychosis: loss of touch with reality, hallucinations and delusions • Phenothiazines: group of chemical compounds; chlorpromazine is one; first synthesized in 1883 by August Bernthsen, who was working to produce synthetic dyes; act as antihistamines and so initially useful in allergy treatment o 1940s: discover drugs can result in decrease in muscle tone, reduction of nausea, sometimes euphoria/sedation; began to use to calm agitated patients and reduce tremors in Parkinson’s patients o Post WWII: Henri Laborit uses these as pre-surgery drugs to reduce post- surgical shock (potentially fatal neuroendocrine response to stress); initially used promethazine but wanted drug with greater CNS effects so got recently synthesized chlorpromazine o 1950s: Jean Delay and Pierre Deniker found chlorpromazine reduces agitation, excitation, confusion and paranoia in psychotic patients; Delay labelled drugs neuroleptics, as they depress activity of the nervous system o 1954: Drug marked by Smith Kline and French under name Thorazine (little regulation of drug market so introduced before research into side effects) o Similar drugs: Thioridazine (Mellaril); trifluoperazine (Stelazine); Paul Janssen discovers butyrophenone (another class of drugs to reduce psychotic symptoms) and haloperidol (Haldol) starts being marketed in 1957 • Side effects: severe sedation, visual disturbances and tardive dyskinesia (neurological disorder characterized by involuntary movements of the tongue, face, mouth or jaw); atypical antipsychotics treat psychosis without some of those side effects (clozapine and risperidone) • How they work: drugs reduce levels of dopamine or influence receptors for dopamine in the brain; dopamine believed to increase or decrease salience to internal and external experiences to produce delusions and hallucinations • Antidepressant drugs: reduce symptoms of depression (sadness, loss of appetite, sleep disturbances) o Hydrazine: fuel used by Germans for rocket during WWII; in 1951, discovered that two hydrazine compounds (isoniazid and iproniazid) were effective in treating tuberculosis; euphoria side effect; Jean Delay suspected those compounds would be useful as antidepressants  MAOIs: monoamine oxidase inhibitors; compounds part of this class; trade names include Nardil and Parnate; drugs inhibit enzyme monoamine oxidase in the brain, resulting in higher levels of neurotransmitters like norepinephrine; side effects include headaches, jaundice, rise in blood pressure; other drugs prescribed more often o Tricyclic antidepressants: used most often until 1980s; Roland Kuhn discovers imipramine in 1950s which energizes patients and elevates mood; marketed as Tofranil in 1958; others include Elavil and Anafranil; seemed more effective and had fewer dangerous side effects that MAOIs; thought to work by inhibiting reuptake of norepinephrine, serotonin and dopamine; called “dirty drugs” as affect so many neurotransmitter systems o SSRIs: act more selectively on serotonin receptors than tricyclics; includes fluoxetine (Prozac), introduced in 1986, Zoloft and Paxil; very popular as side effects easier to tolerate (nausea, diarrhoea, headaches, etc); individual tolerability of antidepressant medications more important than specific antidepressant prescribed; useful for other psychological problems (anxiety, eating disorders, impulse control); newer drugs include venlafaxine (Effexor) and mirtazapine (Remeron) which target both serotonin and norepinephrine • Lithium: reduce symptoms of mania (agitation, excitement and grandiosity); metallic element present in ocean, natural springs, animal and plant tissue th o 19 century: used to treat rheumatism and gout; believed there was possible relationship between these disorders and mania; recommended by William Hammond o John Cade: observed onset of mania in fellow prisoners as Japanese POW and believed it might be excessive accumulation of metabolite; discovered lithium had powerful calming effect on guinea pigs; research largely went unnoticed o Mogens Schou: published series of studies on effectiveness of lithium in 1970 and only then was it legitimized as a treatment for mania o Downsides: severe side effects (including death); other drugs called anticonvulsants and calcium channel blockers used now (less side effects) • Anti-anxiety drugs: reduce symptoms of anxiety (fearfulness, worry, tension); anxiety and insomnia symptoms for which drugs most often prescribed o Barbiturates: introduced at beginning of 20 century; suppress CNS and decrease activity of variety of neurons; induce relaxation and sleep but are quite addictive; withdrawal can cause life-threatening symptoms, like delirium, convulsions and increased heart rate; ex: Nembutal o Benzodiazepines: discovered in 1940s but not widely available until 1960s when sold under names like Librium, Valium, Xanax and Serax; reduce symptoms of anxiety without interfering substantially with an individual’s ability to function in daily life; most often used as sleeping pills; recommended for short-term use but commonly used on long term basis; also highly addictive; active metabolites remain in body for days and can create toxic interaction effects with alcohol/other drugs • Herbal medicines: St. John’s wort (hypericum perforatum); European studies in mid-1990s suggested it was an effective treatment for depression; reasonable alternative in cases of mild/moderate depression but did not fare well in study of severe depression; can be bought without prescription; side effects less severe than that of antidepressant drugs; can interact with medications taken for medical ailments (heart disease, seizures, cancers); may also interfere with HPA axis and increase thyroid stimulating hormone (TSH) causing hypothyroidism • Phytomedicines: “natural” remedies for psychological problems; use dates back to beginning of civilization; regular part of modern mainstream medicine in Asia and parts of Western Europe; range from chamomile and peppermint to foxglove o Rauwolfia serpentine: used 3000 years ago by Hindu Ayurvedic healers th as treatment for insanity; rediscovered in 20 century and chemical analysis of the root extracts of R. serpentina led to discovery of dopamine and role in Parkinson’s and schizophrenia o Valerian: made from root of Valeriana officinalis, common herb native to Europe and Asia; safe, mild sedative o Kava: psychoactive member of the pepper family, widely used in Polynesia, Micronesia and Melanesia as a ceremonial tranquilizing beverage and in Europe/N.A for anxiety and insomnia; safe for short term relief from stress/anxiety; concerns over toxic effects on the liver • Concerns: expensive to do research; people using more potent substances without consulting physician; interactions with other drugs; botanicals not patentable and chemically very complex Electroconvulsive therapy • History: introduced in early 20 century originally as a treatment for schizophrenia; Ugo Cerletti and Lucio Bini; not effective for schizophrenia but effective for depression • Procedure: series of treatments in which brain seizure is induced by passing electrical current through patient’s brain; patients first anaesthetized and given muscle relaxants so they are not conscious when seizure hits and muscles don’t jerk; metal electrodes taped to head and current of 70-150 volts passed through one side of the brain for ½ a second; have a convulsion which lasts about one minute; consists of 6-12 sessions, which are brief and relatively innocuous • Concerns: still controversial; can result in significant and permanent cognitive damage; may be only effective alternative for some seriously depressed people who do not respond to medications Psychosurgery • History: early 20 century; Portuguese neurologist Antonio De Egas Moniz introduced a procedure in 1935 in which the frontal lobes of the brain were severed from the lower centers of the brain in people suffering from psychosis; developed into prefrontal lobotomy; severe and permanent side effects, including an inability to control impulses, extreme listlessness, loss of emotions, seizures and sometimes death • Psychosurgery today: used very rarely and only with people who have severe disorders that do not respond to other forms of treatment; neurosurgeons attempt to lesion, destroy or minute areas of brain thought to be involved with symptoms • rTMS: repetitive transcranial magnetic stimulation; patients exposed to repeated high intensity magnetic pulses, which are focused on particular brain structures; target left prefrontal cortex in depressed people; studies suggest people given rTMS daily for at least a week tend to experience relief • Process: electrical stimulation of neurons can result in long-term changes in neurotransmission across synapses, which can be enhanced or blunted depending on frequency of stimulation; fewer side affects and patients can remain awake; effective and safe alternative therapy Psychological therapies • Psychotherapy: effective alternative to drugs for some; can be combined with drug therapy • Psychodynamic therapies: help clients gain insight into unconscious motives and conflicts; help client recognize maladaptive ways in which they have been trying to cope and sources of their unconscious conflicts; integrate aspects of split off/denied personality • Free association: developed by Freud and others; client taught to talk about whatever comes to mind and try not to censor any thoughts; notice recurring themes and triggers; su
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