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No psychiatry without psychopharmacology

  • Paul J. Harrison (a1), David S. Baldwin (a2), Thomas R. E. Barnes (a3), Tom Burns (a1), Klaus P. Ebmeier (a1), I. Nicol Ferrier (a4) and David J. Nutt (a5)...


The use of psychotropic medication is an important part of most psychiatrists' clinical practice. We propose here that psychiatry needs to give more prominence to psychopharmacology in order to ensure that psychiatric drugs are used effectively and safely. The issue has several ramifications, including the future of psychiatry as a medical discipline.

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Corresponding author

Paul J. Harrison, Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford OX3 7JX, UK. Email:


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Declaration of interest

P.J.H., D.S.B., T.R.E.B., I.N.F. and D.J.N. have received honoraria for lectures, chairing meetings or for attending scientific advisory boards, and grants for investigator-initiated research projects, from various pharmaceutical companies. P.J.H. has been Treasurer of the British Association for Psychopharmacology (BAP), and is a member of the Psychopharmacology Special Interest Group (PSIG). D.S.B. is Chair of PSIG and a member of BAP Council. T.R.E.B. is a former President of BAP, former Chair of PSIG, and is Joint Head of the Prescribing Observatory for Mental Health-UK. K.P.E. has received travel expenses from the Magstim Company and from Alzheimer UK, and funding from various pharmaceutical companies in support of training days for National Health Service colleagues. He is a member of BAP and PSIG. I.N.F.'s honoraria are all paid into a Newcastle University account for supporting research. He is President of the BAP and a member of PSIG. D.J.N. has grant support from, and holds share options in, P1Vital. He is President of the European College of Neuropsychopharmacology, a former President of the BAP, and President-Elect of the British Neuroscience Association. He is Editor of the Journal of Psychopharmacology and an advisor to the British National Formulary.



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No psychiatry without psychopharmacology

  • Paul J. Harrison (a1), David S. Baldwin (a2), Thomas R. E. Barnes (a3), Tom Burns (a1), Klaus P. Ebmeier (a1), I. Nicol Ferrier (a4) and David J. Nutt (a5)...


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No psychiatry without psychopharmacology

  • Paul J. Harrison (a1), David S. Baldwin (a2), Thomas R. E. Barnes (a3), Tom Burns (a1), Klaus P. Ebmeier (a1), I. Nicol Ferrier (a4) and David J. Nutt (a5)...
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The October 2011 BJP on Psychopharmacology

Nigel Bark, Supervising Psychiatrist
04 January 2012

Thank you for your October 2011 Edition on psychopharmacology, with original articles and stimulating and provocative Editorials. I strongly support Harrison et al's "No psychiatry without psychopharmacology"1 and would add that psychiatrists, being uniquely prepared for this, must take responsibility for the severely mentally ill, who nearly all need psychotropic medication. Every psychiatrist must be well trained in psychopharmacology to take on this responsibility and should be able to bean "avid psychopharmacologist"2. But one cannot take on this responsibility believing one's "prescription is a necessary evil..." that changes the relationship from "...a cooperative to a coercive one" to quote the odd and unfortunate remarks of the Editor2. If psychiatrists were better trained in psychopharmacology, part of which training must be the critical appraisal of articles, they would be able tolook at the data (which are not biased3) in articles and see through drug company's hype; then perhaps Kendall's diatribe4 against the pharmaceutical companies would be moot. However the story is more complicated and nuanced than Kendall4 suggests. It was not only drug companies that believed we had something new and better. We all did. I have been treating the severely mentally ill for over forty years and I know both the promise and the inadequacy of the antipsychotics. With clozapine and the promise of similarly acting second generation antipsychotics the early 1990s were an exciting time. (Yes, I disagree with the Editor2 again. I deliberately use 'second generation' because you know just what I mean and further classifying the 'first generation' antipsychotics into high and low potency drugs is a very good indicator of side-effects. Thus this classification is both meaningful anduseful.)We quickly realized we did not have a clozapine without the side effects and that none, not even clozapine, had significantly better effects on negative symptoms (once secondary negative symptoms were taken into account) or on cognition. In retrospect it's easy to see the biases but itwasn't at the time: the patients in those early studies were the first generation treatment failures; many of us working in State Hospitals thought the control haloperidol dose was too low! What we did have was the possibility of drugs without extra pyramidal side-effects (EPS). Patients wanted to be in these studies and would rather the side-effects of the second generation drugs than EPS5. The lack of EPShas held up3 and sitting in a ward meeting today is a different experiencefrom 20 years ago when half the patients would be leg-jigging, rocking, writhing or pacing. I am grateful for the choices the second generation antipsychotics give our patients but we desperately need better antipsychotics. The drug companies should hear from those treating the seriously mentally ill, of this need. I do not know where else but from drug companies, working with psychiatrists and basic scientists, new drugs will come. I am looking forward to them doing for schizophrenia what they did for AIDS where they turned a quickly lethal illness into a chronic lifelong manageable condition6.

1 Harrison PJ, Baldwin DS, Barnes TRE, Burns T, Ebmeier KP, FerrierNI, Nutt DN. No psychiatry without psychopharmacology. Br J Psychiatry 2011; 199: 263-5

2Tyrer P. From the Editor's desk. Br J Psychiatry 2011; 199: 350

3 Leucht S, Corves C, Arbter D, Engel RR, Li C, Davis JM. Lancet 2009; 373:31-41

4 Kendall T. The rise and fall of the atypical antipsychotics. Br J Psychiatry 2011; 199: 266-8

5 Rapid Response responses to: Geddes J, Freemantle N, Harrison P, Bebbington P. Atypical antipsychotics in the treatment of schizophrenia: a systematic overview and meta-regression analysis. BMJ 2000; 321:1371-1376

6 Bloom J. Whatever happened to AIDS? How the pharmaceutical industry tamed HIV. American Council on Science and Health. New York 2011

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Conflict of interest: I work in a state hospital with the severely mentally ill. I am proud to have been involved with new antipsychotic, industry supporeted, trials seeking better treatment for people with schizophrenia during the 1990s and early 2000s; the research (but not me) being supported by funds from many drug companies through the New York State Research Foundation of Mental Hygiene. I also did occasional Industry rating scale teaching and consulting; but not in the past five years.

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Scope of psychopharmacological psychiatry

swapna muthyapu, sho in psychiatry
04 January 2012

We are well aware of the various psychotropics available to date. These drugs are known to treat various range of mental illnesses includingdementia. Going through the history of psychiatry we have come a long way from chlorpromazine(traditionally known as largactil) in the 60s routinelyused to all psychiatric patients untill the asylums existed. We strongly believe there has been immense work done and huge contribution made to this field of psychiatry. we are sure that there is more to come in the near future. We as budding Psychiatrists should take initiatives to further our understanding in the receptor level.The British Association of Psychopharmacology(BAP) certainly talks about the the research to pharmaceutical development and clinical implication. It is vital that these modules taught in BAP should be incorporated as part of higher specialist training. Not to forget the importance of pharmacology in substance misuse department. Over the years we have recognised the various aspects of addictions and its impact on physical health. Needless to say that the major enduring mental illnesses in their acute phases heavily rely on psychopharmacology. i appreciate the fact that on the long run this may have limited input but yet an important role.

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Conflict of interest: None declared

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Psychiatrists should be well trained in psychopharmacology

D B Double, Consultant Psychiatrist
02 November 2011

As someone who may be seen as part of what has incorrectly been called the "anti-pharmacological lobby", I welcome Paul Harrison at al's call for psychiatrists to have a high level of knowledge and practice in psychopharmacology.[1] The problem is that they sem to have unquestioning faith in the efficacy of psychiatric medication (see href="" target="_blank">my critical psychiatry blog entry).Even the best quality clinical trials may not eliminate bias, particularly because of unblinding.[2] The small effect size in many clinical trials could be totally explained by bias introduced through unblinding.[3] Despite the difficulty of measuring bias, psychiatrists need to learn to be more critical of the evidence base.[1] Paul J. Harrison, David S. Baldwin, Thomas R. E. Barnes, Tom Burns, Klaus P. Ebmeier, I. Nicol Ferrier, and David J. Nutt. No psychiatry without psychopharmacology. The British Journal of Psychiatry 2011 199:263-265; doi:10.1192/bjp.bp.111.094334[2] Fisher S and Greenberg RP (eds) (1997) From placebo to panacea. Putting psychiatric drugs to the test. Chichester: John Wiley[3] Fergusson D, Glass KC, Waring D, Shapiro S. Turning a blind eye: the success of blinding reported in a random sample of randomised, placebo controlled trials. BMJ, doi:10.1136/bmj.37952.631667.EE ... More

Conflict of interest: None declared

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Psychopharmacology should be a priority in training

Sanjeewa A Jayakody, Specialty doctor
02 November 2011

I must be grateful for Harrison et al and BJPsyh for the article about psychopharmacology and psychiatrists. Unfortunately we are in era, people preaching that psychotropic medications should be the last option in managing almost every psychiatric illness and they are the most toxic chemicals used in medicine. I think if psychiatry to progress like other fields of medicine we should change this and rather encourage people learnand prescribe more appropriately.

As a trainee who completed my membership recently I am always concerned about little knowledge in psychopharmacology I ended up at the end of training. I do not feel we need to know in depth knowledge in psychopharmacology to pass membership exams in UK and most my colleagues will agree with me on this.

There are several methods that I feel that we can improve the knowledge of trainees hence the future psychiatrists. I have attended fourMRCPsych courses around country during my training days. They allocate very little time to teach psychopharmacology and but few I had in Bristol about depression and schizophrenia were very fascinating and I have them still with me. In fact they are the only lecture notes from MRCPsych courses kept safely by me. In a survey of all child psychiatrists who graduated from U.S. child psychiatry residencies between 1996 and 1998 (392 of 797 responding), psychopharmacology was rated most relevant to their current practices. Psychopharmacology education was rated among the most important aspects of the training experience 1

I feel there should be more emphasis on psychopharmacology in membership exams and it is one of the most effective ways to increase the trainees' knowledge. We all try to learn minimum need to pass the exams toprogress in our career but at least this will make sure the future trainees will read more of psychopharmacology like we read statistics now as it is almost half of MRCPsych paper 3. As psychiatrists who are mainly but not only professionals who prescribe medication we should have in depth knowledge of every aspect of few medications we prescribe to our patients.

Credibility of psychiatry and psychiatrists among general public and especially among medical students will only improve with more effective use of medication. Other wise every body will look at psychiatrist as if we are doing nothing but talking as I was told many times by my colleaguesin other specialties.

Treating psychiatric patients is the only way forward as we have reached ceiling effect with psychotherapy. As a trainee I don't see psychotherapy will change the way dramatically we treat patients but definitely psychopharmacology. So it is important psychiatrists now emphasis more on psychopharmacology and it will attract more medical students to psychiatry and younger psychiatrist will be interested in research in psychopharmacology leading to find more effective medication in treating psychiatric problems. It is not only trainees but practicing psychiatrists should be up to date in order to prescribe as well as teach students and trainees. It will be important that supervision is not limited to ensuring that the trainees is prescribing the "right" medication, but also that the rationale (i.e., clinical and neurobiological foundations and patient preferences) be consistent with the principles learned in the classroom2.

Dr Jayakody S A, MRCPsych

1. Harrison PJ, Baldwin DS, Barnes TRE, Burns T, Ebmeir KP, Ferrier, IN, Nutt DJ. No psychiatry without psychopharmacology. Br J Psychiatry 2011; 199: 263 - 265.

2. Steven L. Dubovsky, M.D. Who Is Teaching Psychopharmacology? Who Should Be Teaching Psychopharmacology? Academic Psychiatry 29:155-161, June 2005

2. Carlos Blanco, M.D., Ph.D., Juan Jos? Luj?n, M.D. and Edward V. Nunes, M.D. Education and Training in Psychopharmacology

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Conflict of interest: None declared

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Psychopharmacology and the molecular genetics of schizophrenia and autism

Feargus F O'Croinin, Psychiatrist
02 November 2011

Harrison et al correctly highlight the importance of psychopharmacology for patient care (1). One of the problems with psychopharmacology is the incomplete understanding of the neurochemical foundation on which to base treatment for disorders such as schizophrenia and autism. Current research in molecular genetics may provide some of theanswers.

Viewing schizophrenia as a disorder of DNA damage and repair as previously suggested (2) helps explain the recent finding that de novo mutations account for more than half of the sporadic cases of schizophrenia (3). As yet there is no drug therapy to reduce the genesis of mutations. Further research in the area of molecular genetics is neededto move psychopharmacology into the area of prevention.

Another area where molecular genetics could contribute more to drug development is the field of autistic spectrum disorders. Brains of patients with autism show altered expression of genes relating to normal synapse development. Abnormal synaptic mRNA splicing assembly of many genes is found in autism (4). Interestingly, abnormal mRNA splicing is also found in familial dysautonomia, with a remarkable impact on mRNA splicing fidelity recently shown by plant cytokinin kinetin (5). Thus suggesting a role for plant cytokinins in autism.

These two examples lend support to the need for more funding of basicresearch as it relates to molecular genetics and the psychopharmacology ofmental illness. Having an accurate neurochemical foundation on which to base treatment would confirm the central role of psychopharmacology in thetreatment of mental illness.

(1) Harrison PJ, Baldwin DS, Barnes TR, Burns T, Ebmeier KP, Ferrier N and Nutt DJ. No psychiatry without psychopharmacology. BJPsych; 199,263-265 2011

(2) O'Croinin FF, Schizophrenia, a distinct genetic entity? eletter, BJPsych. March 2011

(3) Xu B, Louw Roos J, Dexheimer P, Boone B, Plummer B, Levy S et al.Exome sequencing supports a de novo mutational paradigm for schizophrenia.Nat Genet. Vol 43; 9, 864-868 Sep 2011

(4) Voineagu I, Wang X, Johnston P, Lowe J, Tian Y, Horvath S et al: Transcriptomic analysis of autistic brain reveals convergent molecular pathology. Nat; Vol 474, 380-384 June 2011

(5) Slaugenhaupt SA, Mull J, Leyne M, Cuajungco MP, Gill SP, Hims MM et al, Rescue of a human mRNA splicing defect by the plant cytokinin kinetin. Hum. Mol. Genet. 13(4): 429-436, 2004

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Conflict of interest: None declared

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Importance of Psychopharmacology in Psychiatry

Gurdaval Singh, ST6 in General Adult Psychiatry
21 October 2011

Harrison et al1 wrote a highly informative editorial on psychopharmacology in psychiatry. We fully support the authors' view that theoretical and practical knowledge of psychopharmacology is a fundamentalattribute which all psychiatrists should possess. Most psychiatrists will have a penchant for, or specific training in, a particular treatment modality, whether it is a biological, psychological or social treatment approach. However, regardless of their preference, sound knowledge and practical experience of using psychotropic medication is paramount. It is disappointing that the Royal College document on Roles and Responsibilities of the Consultant in General Adult Psychiatry2 only devoted a few lines to the subject of pharmacology. We believe this embodies how little emphasis is placed on this important and complex aspect of psychiatry.

Most medical students encounter psychopharmacology for the first timeduring their psychiatric placements. We believe the emphasis on the importance of this subject area should be established during undergraduatemedical training. We agree with the authors that there should be more clarity and emphasis on psychopharmacology during core and higher psychiatry training. However, we would like to emphasise that any formal training courses should supplement rather than substitute for learning psychopharmacology from day-to-day clinical practice, private study and guidance from senior colleagues. The issues outlined by the authors clearly highlight the importance of life-long learning and training in thetheoretical and practical aspects of psychopharmacology. Without this, psychiatrists will not only lose a fundamental skill that largely sets them apart from other mental health professionals, but put patients at risk due to deficient or out-of-date knowledge in this key area of psychiatric practice. As the authors highlight, there are multiple ramifications for psychiatrists if they do not have sound up-to-date theoretical and practical knowledge of psychopharmacology including litigation due to inadequate or out-of-date knowledge in this area.

Ensuring patients adhere to medication is a significant problem in all medical specialties and psychiatry is certainly no exception. Without a sound understanding and up-to-date knowledge of psychopharmacology, encouraging patients to adhere to psychotropic medication might sound unconvincing. Appropriate knowledge of psychopharmacology amongst psychiatrists is fundamental not only when prescribing patients psychotropic medication but also when deciding not to prescribe such medication. For example, the NICE guidelines for borderline personality disorder3 recommend that psychotropic medication should not be used specifically for the disorder or for the individual symptoms or behaviour associated with it. This example illustrates how an awareness of the evidence base behind this recommendation avoids unnecessary polypharmacy despite the temptation to prescribe in these circumstances at times.

A large proportion of our patients have several physical and psychiatric co-morbidities, particular lifestyle choices and are on multiple psychotropic and non-psychotropic medications. An up-to-date and detailed knowledge of psychopharmacology is required in order to ensure that all the aforementioned factors are accounted for when deciding to prescribe a patient psychotropic medication. An example to illustrate thispoint includes being aware that smokers taking clozapine require up to double the dose of clozapine compared with non-smokers to achieve an equivalent plasma concentration secondary to smoking's metabolic inductioneffects.4 Another example would be having an awareness of caffeine's metabolic inhibitory effect in individuals taking clozapine.5 Both these examples demonstrate the importance of having detailed knowledge of psychopharmacology. Without it, detrimental clinical ramifications may ensue. Certain psychotropic medications including lithium, clozapine, antipsychotics and mood stabilisers are almost exclusively prescribed by psychiatrists. Psychiatrists require a detailed understanding of these medications in order to guide other professionals as to whether their use is appropriate, how they may interact with other medications and how they may impact on an individual's physical and mental health. This level of expertise should be expected of all psychiatrists working with patients taking psychotropic medications and is hopefully one of several cogent arguments to support psychiatry remaining a medical discipline.


1.Harrison PJ, Baldwin DS, Barnes TRE, Burns T, Ebmeir KP, Ferrier, IN, Nutt DJ. No psychiatry without psychopharmacology. Br J Psychiatry 2011; 199: 263 - 265.

2.Royal College of Psychiatrists. Roles and Responsibilities of the Consultant in General Adult Psychiatry (Council Report CR140). Royal College of Psychiatrists, 2006.

3.National Institute for Health and Clinical Excellence. Borderline personality disorder: treatment and management (Clinical Guideline CG78). London: National Institute for Health and Clinical Excellence, 2004.

4.Rostami-Hodjegan A, Amin AM, Spencer EP, Lennard MS, Tucker GT, Flanagan RJ. Influence of dose, cigarette smoking, age, sex, and metabolicactivity on plasma clozapine concentrations: a predictive model and nomograms to aid clozapine dose adjustment and to assess compliance in individual patients. J Clin Psychopharmacol 2004; 24(1):70 - 8.

5.H?gg S, Spigset O, Mj?rndal T, Dahlqvist R. Effect of caffeine on clozapine pharmacokinetics in healthy volunteers. Br J Clin Psychopharmacol 2000; 49(1), 69 - 73.

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Conflict of interest: None declared

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Correspondence re: No psychiatry without psychopharmacology

Ben Sessa, Psychiatrist
21 October 2011

I read with baited breath the editorial from Paul Harrison et al, No Psychiatry without Psychopharmacology'1, alert for any hint of Cartesian duality. Alas the old adage was there.

Whilst I support what the authors say about the continued value of drugs in clinical practice and the high levels of scientific objectivity that accompanies their use, I was disheartened that an article dedicated to stressing the importance of psychopharmacology for the future of psychiatry entirely failed to mention the issue of acute drug-assisted psychotherapy. In this area of research psychotherapy and psychopharmacology are not considered as distinct entities but rather the drugs are used acutely to directly enhance the psychotherapeutic experience. This subject may prove to have an increasingly important role in our profession in coming years and deserves attention.

The drugs Psilocybin and MDMA have a unique psychotherapy-enhancing quality increasingly recognised by contemporary clinical studies. A recentUK-based fMRI study suggests psilocybin improves access to emotional memories2 and, mediated by oxytocin release3, MDMA increases levels of empathy and therapeutic engagement between therapist and patient, which may make it well-placed as an adjunct for trauma-focused psychotherapy4. Arecent pilot study suggests MDMA-assisted psychotherapy dramatically reduces rates of treatment-resistant PTSD far exceeding those seen with traditional SSRI and psychotherapy alone5.

At this early stage there are promising suggestions that drug-assisted psychotherapy may be particularly efficacious for several anxiety-based conditions that present with significant levels of treatment resistance for traditional drug and psychotherapeutic techniques. Further recent controlled clinical studies include psilocybin-assisted psychotherapy for anxiety6 and OCD7 and there is an on-going study underway with using LSD-assisted psychotherapy8. There is also an emergingindication that psilocybin could have a positive and long-lasting effect on altering previously assumed rigid personality traits9.

In all these studies quoted the drugs have been delivered with significant positive outcomes, no lasting adverse psychological or physiological problems and no risks of drug dependency. Although research in this field continues to be slowed down by controversy10 we may be on the eve of a clinical psychedelic research project beginning in the UK.

With drug-assisted psychotherapy we see the direct influence of an acutely administered psychotropic drug being guided by an attendant psychotherapist to directly focus attention on the patient's psychologicalmaterial of greatest importance. In this respect the approach is a directchallenge to Dualism, suggesting there is a viable substrate in which 'mind' and 'body' can interact.

Such research still has some way to go before acceptance by mainstream psychiatry, but if it does bear fruit we owe as much to the population of patients with treatment-resistant anxiety disorders to at least keep the topic of debate on the table when thinking about the futureof psychopharmacology in psychiatry.

Yours SincerelyBen SessaConsultant Child and Adolescent Psychiatrist, Taunton, UK.


1.Harrison, P. Et al (2011) BJP No Psychiatry without Psychopharmacology. British Journal of Psychiatry, 199, 263-265.2.Carhart-Harris, R et al (2011) Psilocybin augments subjective and neural responses to autobiographical memory cues: An fMRI study with implications for psychedelic-assisted psychotherapy. Unpublished / under review with BJP.3.Thompson MR et al (2007) A role for oxytocin and 5HT(1A) receptors in the pro-social effects of 3,4, methylenedioxyamphetamine ("ecstasy"). Social Neuroscience Volume 4, Pages 359 - 3664.Sessa, B. (2011) Could MDMA Be Useful to enhance Psychotherapy for PTSD? Progress in Neurology and Psychiatry. (Accepted September 2011 and in print).5.Mithoefer, M. et al (2010) The safety and efficacy of 3,4-methylenedioxymethamphetamineassisted psychotherapy in subjects with chronic, treatment resistant posttraumatic stress disorder: the first randomized controlled pilot study. Journal of Psychopharmacology. 0/0 pp1-14.6.Grob, CS et al (2011) Pilot Study of Psilocybin Treatment for Anxiety in Patients With Advanced-Stage Cancer. Arch Gen Psychiatry. 2011;68(1):71-78.7.Moreno FA, et al (2006) Safety, tolerability and efficacy of psilocybinin 9 patients with obsessive-compulsive disorder. J Clin Psychi 67: 1735-1740.8.Protocol for on-going LSD-Psychotherapy study cab be found at: A. MacLean, M. W. Johnson, R. R. Griffiths (2011) Mystical Experiences Occasioned by the Hallucinogen Psilocybin Lead to Increases inthe Personality Domain of Openness. Journal of Psychopharmacology, 2011; DOI: 10.1177/026988111142018810.Sessa B, Nutt DJ (2007) MDMA, politics and medical research: Have we thrown the baby out with the bathwater? J Psychopharmacol 21: 787-791

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Conflict of interest: None declared

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sanjit k koul, specialty doctor
05 October 2011

This study has been long awaiting to be published. One of the main reasons for medical students and young doctors not to choose psychiatry iswhat they see as no role of pharmacology or pharmacological treatment in treating psychiatric disorders.we know that pharmacological options are still the best in treating disorders like psychosis or bipolar affective disorder where it is becoming more and more clearer that chemical imbalance is the most probable causative factor of these disorders and hence treating that chemical imbalance is the best way forward.Using the drugs in day to day clinical practice and seeing the result objectively ,hopefully will change the perspective and vision of psychiatry of these budding brains to work and practice as psychiatrists.

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