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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)...
Summary

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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Copyright
Corresponding author
Paul J. Harrison, Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford OX3 7JX, UK. Email: paul.harrison@psych.ox.ac.uk
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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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References
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2 Royal College of Psychiatrists. Roles and Responsibilities of the Consultant in General Adult Psychiatry (Council Report CR140). Royal College of Psychiatrists, 2006.
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14 Royal College of Physicians. Innovating for Health: Patients, Physicians, the Pharmaceutical Industry and the NHS. Report of a Working Party. Royal College of Physicians, 2009.
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16 Craddock, N, Antebi, D, Attenburrow, M-J, Bailey, A, Carson, A, Cowen, P, et al. Wake-up call for British psychiatry. Br J Psychiatry 2008; 193: 69 [and responses: 193: 510–7].
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21 Denman, C. A modernised psychotherapy curriculum for a modernised profession. Psychiatrist 2010; 34: 110–3.
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  • EISSN: 1472-1465
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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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eLetters

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 http://www.bmj.org/cgi/content/full/321/7273/1371 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="http://criticalpsychiatry.blogspot.com/2011/10/psychiatrists-should-know-what-theyre.html" 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 http://lujancirugia.com/education_training.html

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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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