The Role of Medication in Psychiatric Care

by Michael Schwartz, M.D.

The era of modern psychopharmacology began in the early 1950s with the discovery of the sedative, antidepressant and antipsychotic actions of known compounds that had already been developed for other medical uses. “Psychopharmacology” has come a long way in the past fifty years, and it still has a long way to go, but few would argue that the availability of medications to help people with emotional and behavioral symptoms has been one of the major advances in modern medical practice.

In the first half of the twentieth century, the psychoanalytic model of psychiatric treatment was dominant. Such a model relied heavily upon psychotherapy as a treatment modality. The doctor and patient worked together to better understand significant developmental factors in the patient’s life. The psychoanalyst and patient also worked together to uncover the unconscious mental processes that influenced the patient’s characteristic emotional responses and behaviors in response to the variety of interpersonal or circumstantial challenges he or she was likely to face in everyday life.

While the popularity and acceptance of psychotherapy benefited from the idea that problems could solved by “talking them out,” psychotherapy was often ineffective for more distressing emotional and behavioral symptoms. Psychotherapy was and continues to be ineffective for the symptoms of severe depression, manic-depressive illness, schizophrenia, some anxiety disorders, and many other conditions. Psychological models of behavior have always emphasized the role of learned behavior, and while learned behavior may account for a significant share of the behavior that human beings express, it is not the whole story. There is research that points to a significant role for genetically dictated differences from person to person in the way that the brain develops-with the net result of differences in brain structure and function. These differences may result in different vulnerabilities to stress and brain dysfunction, and the consequent manifestations of psychiatric symptoms and disorders. Some theoretical models suggest that, once the brain is partially or fully developed, infections, traumatic injuries, deterioration of brain cells, and acute or persistent emotional trauma may lead to changes in brain structure or physiological function that are manifest as emotional and behavioral symptoms which do not respond to psychological treatments.

The medications that are prescribed for psychiatric disorders work directly on the brain cells to correct the impaired physiological functioning of those cells. This “repair” work results in a reduction and often in a complete (though not permanent) resolution of distressing emotional and behavioral symptoms that an individual patient may be experiencing. The medications work by interacting with specific sites on nerve cells called “receptors” which allow the medication to “communicate” with the inner workings of the cell and to bring about subtle changes in cell functioning which have the net effect of improved brain function and symptom relief.

When working with their patients, psychiatrists may prescribe medications that relieve states of anxiety, depression, inattention or extreme irritability and anger. There are medications that relieve particularly distressing symptoms like hallucinations and disordered thinking. There are also medications that slow the decline of memory and thinking characteristic of Alzheimer’s disease and other kinds of dementia. As neuroscientists and psychiatric researchers learn more about the intricacies of brain structure and function, newer medications are being developed that are more refined both in terms of their therapeutic effects and their absence of side effects.

As remarkable as these medications are, they are not the whole answer to the treatment of psychiatric disorders. Often the most effective treatment combines medication and psychotherapy-targeting both learned behavior and the “mechanical” breakdown in brain function. Such treatment may be obtained in consultation with a psychiatrist and a non-MD psychotherapist, referred to as the ‘split-treatment’ model. Ideally, a psychiatrist who is skilled in both the medical (psychopharmacologic) and psychotherapeutic treatment models of emotional and behavioral problems, can provide the most efficient form of treatment.

Dr. Schwartz is the Director of Residency Training and an Associate Professor of Clinical Psychiatry at Stony Brook University School of Medicine.


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