H U M A N PSYCHOPHARMACOLOGY, VOL. 2, 195-196 (1987)

E D I T 0 RIAL

Psychopharmacology in the Real World

The real world is the world of reality, the world of the patient’s normal environment in contrast to the alien surroundings of the hospital ward or outpatient department. When it comes to the prescribing of psychotropic drugs, this is the domain of the general practitioner, doctor and patient alike being involved in the same milieu. This is the milieu in which the majority of psychotropic drugs are prescribed and so it is appropriate to consider the ways in which such prescribing may be affected by the necessity of meeting the demands of the real world.

The treatment of major depression with antide- pressant drugs can be considered as a paradigm. General practitioners are often accused of using such drugs in too low a dosage with consequential poorer results. Rather than starting with doses normally accepted as being within the therapeutic range, in general practice it is often customary to prescribe a smaller dose and then work up to that range, although seldom exceeding its lower level. For example, amitriptyline might well be pre- scribed in a dose of 35mg for the first week, increasing to 50mg in the second week and only the accepted minimal dose of 75 mg thereafter. Whilst it is true that better results are undoubted- ly obtained by starting with 75mg the general practitioner has to face the problem of the patient’s compliance in drug taking. Under these circumstances, some effect is better than none at all.

All antidepressant drugs suffer from the dis- advantage of a slow build-up of therapeutic effect over 10-14 days and an appreciable incidence of unpleasant (although not usually serious) side- effects, which in contrast to the therapeutic effect may be immediate and are dose-dependent. In other words, the patient at home is likely to abandon treatment and refuse to reinstate it, when he or she (or more importantly family members) do not perceive any immediate im- provement. Symptoms may in fact appear to become worse, because of the supervention of side-effects. By starting with a small dose and

working upwards, these problems can to some extent be overcome and the patient’s confidence maintained in persevering with treatment until the therapeutic effect becomes apparent.

In the real world, an important aim of treatment is to enable the patient to continue with as near a normal life as possible, both at work and in the home. Even minor side-effects can seriously interfere with these objectives. Take for example, the man who is using a telephone all day long and suffers from dry mouth, a common side-effect with many psychotropic drugs. This may then become a major inconvenience and may result in the patient omitting doses or taking smaller amounts than those prescribed. Patients treated in the community are unsupervised and so the reliability of medication may be called in question. The supervised patient in hospital receives his drug doses regularly at stated times and in the requisite amounts. The unsupervised patient at home or at work may easily forget to take doses, interpret dosage instructions incor- rectly, and, when doses are given frequently, may even forget whether or not he has taken them. Another adverse aspect is that when questioned by his physician, he may staunchley affirm that he has not departed from the instructions on the bottle, in order to avoid giving the impression that he is letting his doctor down. An even more serious possibility is that, having forgotten to take a dose at the right time, in order to make up for this he takes double the dose next time, with the possibility of producing even more pronounced side-effects.

It is important to explain the rationale of treatment to the patient, since many individuals equate all psychotropic drugs with addiction- producing tranquillizers. A simple explanation that depressive illness is due to a lack of certain chemicals in the brain (‘chemical messengers’) and that the aim of treatment is to stimulate the body to produce these chemicals in the right amounts again, can be helpful in obtaining patient co-operation. It is important to emphasize that

0 1987 by John Wiley & Sons, Ltd.

196 D . W1i E ATLF Y

either therapeutically or prophylactically and then need not be repeated until the situations recur. From the point of view of long-term treatment, most stress situations that provoke anxiety are encountered during the working days of the week, when anti-anxiety drug treatment can be administered, and then omitted at the week-end when further stresses are unlikely to be encountered. Although there are reports (mostly anecdotal) that the shorter acting benzodiazepine compounds (for example, lorazepam) are more likely to cause withdrawal symptoms, these drugs are more useful to provide these drug-free periods.

Lack of sleep, when prolonged for any appreci- able period, may insidiously undermine the sufferer’s health, influencing not only his or her whole life but also exerting an adverse effect on his physical well-being. Since the present range of benzodiazepine hypnotics includes compounds of much shorter duration than their anxiolytic equivalents, there would seem to be little justification for withholding them, provided they are wisely prescribed. For example, an ultra- short-acting drug such as triazolam with a 2 4 hours duration of action is particularly suitable for patients who take a long time to fall asleep for, as the effect of the drug wears off, natural sleep supervenes, with little likelihood of any adverse effects the next morning. Likewise, short-acting compounds such as temazepam and lormetazepam with a duration of effect of 5-6 hours are particularly suitable for patients suffer- ing from periods of wakefulness during the night.

The current development of new non- benzodiazepine anxiolytics and hypnotics may once again provide the general practitioner with an acceptable form of treatment for ailments that produce considerable morbidity in the com- munity.

Succcssful psychopharmacology in the real world must take into account the impact of that real world on the patient and his treatment and modifications to accepted practice sometimes become necessary in order to enable psychophar- macology to be practised at all.

DAVID WHEATLEY

the course of antidepressant drug therapy is given for a defined period only and an analogy can be made to, say, the treatment of acute bronchitis with an antibiotic. When the bronchitis resolves, the course of antibiotic is concluded and the situation with depression is just the same: when the depression has been lifted, then treatment can be omitted, although it may take a little longer than in the case of a respiratory infection. It is also important to explain to the patient the ‘lag period’ before the effects of treatment will be felt and the phrase ‘it is necessary to become worse before getting better’ can sometimes be used to advantage.

The other main field for psychopharmacology in general practice is in the management of anxiety disorders including panic attacks, and the treatment of insomnia. Owing to adverse media publicity, there is a considerable reluctance at the present time for general practitioners to prescribe benzodiazepine anxiolytic and hypnotic drugs and, indeed, on the part of the patient to take them. When considering the three main categor- ies of anxiety disorders listed in DSM 111, namely phobic, anxiety states and post-traumatic stress disorder, the decision is a clinical one. The physician must balance any possible adverse effects from the drug prescribed against the harm to the patient if the illness remains untreated. However, further problems may arise when the physician is confronted with a patient with physiological anxiety. This may take two main forms: an acute situational anxiety and continuing anxiety or chronic symptoms in an individual with an anxious personality. For an example of the former we might consider an individual who is afraid of flying and for whom the short-term prescription of an anxiolytic may enable him or her to make a journey that would otherwise prove impossible. Under the latter heading are those individuals who continually react to the normal minor stresses of life with exaggerated and inappropriate anxiety symptoms. We also have to consider the various psychosomatic disorders of which anxiety often constitutes an integral and inseparable component.

When anxiety-provoking situations arise at irregular intervals, anxiolytic drugs can be taken