Chapter 1: Introduction

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Welcome to our Deep Dive today.

We're going to be looking into this fascinating world of psychopharmacology.

Yes.

So how medications basically interact with our minds and the history behind this whole field.

And our guide for this is going to be the 9th edition of the Handbook of Clinical Psychopharmacology for Therapists.

Okay.

So it's a pretty dense book, but I think it's packed with some really interesting insights.

It is.

And I have a feeling you guys listening are going to be pretty surprised by some of the things we uncover.

Especially when you look back on the history of it.

Yeah, there's a lot of surprises.

So to even understand like where we are today,

we need to take a trip back in time.

What can you tell us about like the early days of even trying to understand and treat mental illness?

Well, like way back, like the late 1800s, psychiatry was very much influenced by what they called the medical model.

So thinking of mental illness in the same way you'd approach like a broken bone or a physical illness.

So they thought, you know, there's got to be some kind of biological disturbance that's causing these conditions.

So the focus was on finding that root cause in the brain.

Exactly.

Exactly.

And, you know, Emil Kraepelin, you know, he was kind of a pioneer in the field.

He was the one who developed this system of, you know, diagnosing mental illness that we still use today.

So he categorized things like schizophrenia and manic depressive psychosis.

But the problem was the treatment options were really limited back then.

So imagine like you finally understand what's wrong, but there's nothing you can do about it.

Exactly.

That must have been so frustrating for doctors and patients.

Absolutely.

Absolutely.

It fueled this search for like tangible evidence of brain pathology.

And, you know, they thought they would find like clear biological causes, but they kept coming up empty.

So they had the theory, but they didn't have the tools to really investigate it.

Exactly.

Yeah.

The science just wasn't there yet.

Right.

And then towards the end of the 1800s, there were a couple of discoveries that really seemed to like support their theories.

Okay.

They found that syphilis, right, which is a bacterial infection was actually causing psychosis and, you know, a good number of patients in asylums.

And in some cases, you know, mental symptoms were actually linked to thyroid dysfunction.

So that must have been a huge turning point.

Yeah.

Finally, there's some proof.

Exactly.

That some of these mental illnesses actually have a biological basis.

Right.

Right.

They finally had some, some like a real hard, real connection.

Yeah.

Did that lead to any changes in treatment then?

So while that did offer like this, this spark of optimism, it was pretty short -lived.

They couldn't really replicate those findings with other mental illnesses.

And then Sigmund Freud came on the scene and his psychodynamic theories.

And then that kind of shifted the focus away from the biological and more towards the psychological.

Freud.

The power of the unconscious mind and all that.

Exactly.

Exactly.

So psychoanalytic thinking came along, you know, offered this new way to understand and treat mental illness.

Right.

And by the 1940s, psychodynamic therapy was like the dominant force in American psychiatry.

Okay.

So instead of looking for a physical cause in the brain.

Right.

Now they're exploring like the complexities of the mind.

Right.

And how past experiences shape mental health.

Right.

Right.

Yeah.

Did that approach prove effective?

Well, you know, it had its, it had its merits.

Okay.

But it was largely ineffective when it came to severe mental illness.

Okay.

Like schizophrenia,

even Freud himself.

Really?

Acknowledged that.

Wow.

Yeah.

So they were like, okay, we need a different approach, you know, for these conditions.

So where did they turn next?

So while biological psychiatry was, you know, kind of struggling those early days, doctors were already using pharmaceuticals to manage symptoms.

Okay.

So they would rely on, you know, drugs like opium, morphine, even alcohol.

Wow.

To, you know, sedate highly agitated patients.

It's crazy how the tools have changed.

And then there were, you know, even more drastic somatic therapies.

Okay.

So things like malaria therapy.

Inflant shock therapy, lobotomies.

Wow.

Okay.

Yeah.

I've heard of lobotomies.

What is malaria therapy?

Yeah.

So they would actually infect patients with malaria on purpose.

Really?

The thinking was that the high fevers.

Oh, wow.

Would somehow alleviate the mental symptoms.

That sounds pretty radical.

Was it effective?

It was highly controversial and ultimately they abandoned it.

Okay.

But these early treatments, I think really highlight how desperate they were to find something, anything that could help.

Right.

But a lot of these treatments were risky

and, you know, the results were inconsistent at best.

Right.

Right.

So even with the best of intentions, sometimes it's hard to find that right path.

Exactly.

So did this period of trial and eventually lead to any breakthroughs?

It did.

Okay, good.

The 1950s.

Okay.

You know, that decade brought this series of discoveries.

Okay.

That really rekindled that interest in the biological approach.

Okay.

And laid the groundwork for psychopharmacology as we know it.

Okay.

And it all started with Thorazine.

Thorazine.

Now I have heard that name.

Yeah.

Wasn't that one of the first anti -psychotic medications?

It was.

And what's really fascinating is that it was discovered completely by accident.

Really?

Researchers were trying to develop a drug to reduce post -surgical shock.

Okay.

And they noticed that chlorpromazine, which is the generic name for Thorazine,

had anti -psychotic effects.

Wow.

So they're working on one thing and they discovered.

Or a different.

This whole other use for this.

Yeah.

Wow.

You should wonder how many other groundbreaking discoveries are out there.

It does, yeah, yeah.

Just waiting.

Yeah.

It's, you know, you never know.

Research is unpredictable.

It really is.

Yeah.

But Thorazine wasn't the only breakthrough happening around that time.

There were two other major developments that really helped shape the field.

Okay.

I'm all ears.

What else was going on?

So the second one was this deeper understanding of the synapse and neurochemical transmission.

So for a long time, scientists thought that the communication between neurons, so the cells in our brains.

Right.

Was purely electrical.

Like an electrical circuit,

sending signals back and forth?

Yeah, exactly.

But then in the 1950s, they discovered that it was actually chemical.

Oh, wow.

Yeah.

So instead of these electrical impulses, it's.

Yeah.

It's more like a chemical language.

Exactly.

Yeah.

The brain is using to talk.

Yeah.

Yeah.

Wow.

Okay.

It's more complex.

And that was huge because it meant that certain neurological issues, potentially mental illnesses, could be caused by imbalances or irregularities in these neurotransmitters.

That makes sense because if the brain is trying to communicate, but the chemicals are off, then of course, that could affect mental health.

Exactly.

Okay.

What was the third big discovery?

So the third one was all about genetics.

Researchers suspected for a long time that there was a hereditary component to some mental illnesses.

Right.

But they were finally starting to gather some concrete evidence.

Right.

So they found that things like schizophrenia, bipolar disorder really tended to cluster in families, suggesting a strong genetic link.

So it's not just a matter of like, oh, you made bad choices.

Yeah.

Or there's a weakness.

There's actually something biological going on.

Right.

Right.

So by the early 1960s, you know, things were starting to fall into place.

You know, Thorazine showed that medication could actually have a huge impact on mental illness.

The discovery of neurotransmitters showed a possible mechanism.

Right.

And genetics provided an explanation for why some people were more vulnerable than others.

Okay.

So it sounds like they were finally on the right track, but I'm guessing that this newfound understanding of the biological underpinnings of mental illness wasn't without its controversy.

You're absolutely.

The use of psychotropic medications quickly became a really hot topic with very strong opinions on both sides.

Yeah.

I imagine.

Yeah.

What were some of the key points of contention?

Well, you had those who were staunchly pro Okay.

They argued that, you know, this offers a more scientific.

Okay.

And standardized approach to treatment.

Okay.

It worked quickly to alleviate the debilitating symptoms.

Right.

And it could even make patients more receptive to psychotherapy by reducing like overwhelming anxiety.

Right.

So medication was kind of seen as this like, yeah, game changer,

a way to help people in a way that maybe traditional talk therapy couldn't.

Exactly.

Yeah.

What about the other side?

So the people who were more in favor of psychotherapy.

Okay.

They argued that medications just masked the symptoms.

Okay.

They didn't address like the underlying psychological roots.

Okay.

So kind of like a band -aid solution.

Exactly.

Yeah.

They were also concerned about potential side effects.

Right.

The possibility of dependence.

Right.

And the idea that, you know, relying on medication might

discourage individuals from doing that, that work.

Okay.

Of, you know, therapy and personal growth.

Right.

Right.

So it sounds like both sides had some really valid points.

Yeah.

Was there any common ground?

Some advocated for a more integrated approach.

Okay.

So acknowledging that medication and psychotherapy could work together.

Okay.

You know, rather than being seen as like these

opposing forces.

Okay.

So the best approach might be to use both.

Exactly.

Yeah.

But even that wasn't universally accepted.

Okay.

And it's important to remember that these weren't just like theoretical debates.

Right.

This was playing out.

Right.

You know, in the real world.

Right.

How did the public react to this growing use of these medications?

So it was a bit of a mixed bag.

You know, public perception was really being influenced by media.

Right.

And there were concerns about like the over prescription of drugs like Valium and Librium.

Right.

You know, mother's little helper.

Right.

The anxiety just medicated away.

Exactly.

And some people, some critics argue that these were just being used for social control, you know, rather than genuine medical need.

Okay.

And it actually sparked like this anti psychiatry movement that saw the medicalization of mental health as a form of oppression.

So cultural and political factors can really shape.

Oh yeah.

People's acceptance.

Yeah.

For sure.

Of the treatments.

Yeah.

Absolutely.

And these weren't just like isolated debates.

Right.

They had, you know, real consequences.

There were some high profile cases involving Mitalin.

Okay.

You know, used to treat ADHD.

Right.

And Prozac.

Right.

Which is an antidepressant.

Right.

Where negative media coverage and lawsuits led to a decline.

Oh wow.

In their prescription.

Even though.

Wow.

Research supported.

So even when there's evidence.

Yeah.

It doesn't always.

Exactly.

Public perception can have a powerful influence.

That's amazing.

Okay.

So it seems like this period was this real push and pull.

Yeah.

Between like the biological and psychological.

Yeah.

Approaches.

It really was.

And both sides had very, very strong points.

Exactly.

Yeah.

A time of great change and discovery, but also.

Right.

A lot of debate.

A lot of controversy.

Yeah.

Okay.

Well, I think that's a great place to maybe pause.

Okay.

For now.

We'll come back and talk about how those debates evolved and the emergence of these more integrated approaches.

Great.

So stay tuned.

We'll be right back.

So as we move into the 1980s.

Okay.

The landscape of mental health care kind of starts to shift in some interesting ways.

So this was when the field started to move towards a more integrated approach, right?

Combining medication and psychotherapy.

That's exactly right.

It was a real shift away from this either or debate, you know, and realizing they both have valuable roles to play.

What do you think contributed to that change in thinking?

Well, I think one of the newer medications were being created that had fewer side effects.

Oh, that makes sense.

Yeah.

Because if the medications are causing a lot of problems.

Yeah.

People are going to want to take them.

Exactly.

So better medications probably really help.

Yeah.

It really encouraged people to consider that option.

Right.

And we also saw the discovery of new medications for things like panic disorder and OCD.

Okay.

Which really expanded the treatment options available.

Right.

Right.

And importantly, research really started to demonstrate the benefits of using medication and therapy together.

So the research was kind of catching up to what exactly a lot of clinicians were seeing in practice.

Yeah.

Like, hey, this combined approach actually seems to work better for some people.

Exactly.

Exactly.

Okay.

And so while that was happening on the medication front,

psychotherapy was also going through some changes, right?

It was.

New approaches like cognitive behavioral therapy, CBT, and interpersonal therapy, they came onto the scene.

Okay.

And they proved very effective for certain conditions.

So it wasn't just that the medications were getting better.

Right.

But the therapy was also becoming more targeted and effective.

Exactly.

And these newer therapies, they were more structured and standardized, which made it easier to really study them and teach them to other therapists.

So it seems like there was this simultaneous advancement in both medication and psychotherapy.

Yeah.

Okay.

But I'm guessing even with all this progress.

Yeah.

There were still some challenges.

Uh huh.

Right.

Especially when it came to access.

For sure.

Treatment.

Yeah.

One major challenge was managed care.

Okay.

You know, in the influence of insurance companies.

Right.

Because that's all about being cost effective.

Exactly.

Right.

Finding those cost effective solutions.

Right.

But that can sometimes be at odds with

providing comprehensive mental health care.

Right.

So you've got what's medically necessary.

Yeah.

Versus what's.

Financially feasible.

Financially feasible.

Right.

What kind of impact did that have on treatment decisions, do you think?

Well, there was concern that medication only treatment was often favored by managed care because it was seen as cheaper.

Right.

Even if it wasn't the best option for the person.

Wow.

So that raises some real ethical dilemmas.

It does.

Right.

Like, people getting the best care.

Right.

Or just the most affordable care.

It's a tough question.

Right.

And we need to be mindful.

Yeah.

Of the potential for overuse.

Okay.

Of medication.

And also the importance of accurate diagnosis.

Right.

So it's not just about throwing pills at a problem.

Exactly.

It's about really understanding the root of.

Uh huh.

The mental distress.

Exactly.

And then going from there.

Yeah.

It's really important.

It is.

Okay.

And this actually brings us to another important point.

Okay.

Even with all the amazing developments we've talked about.

Okay.

Medication is not a magic bullet.

You're saying there's limitations.

There are.

Absolutely.

To what medication can achieve.

While medications can be so effective.

Okay.

Alleviating symptoms.

Yeah.

They don't address every aspect of psychological suffering.

So it might manage the symptoms.

Right.

But it's not necessarily getting at the root cause.

Exactly.

Of why those symptoms are there in the first place.

Right.

Okay.

And that's really where psychotherapy comes in.

Right.

It provides that safe space.

Right.

To explore those deeper issues.

Right.

Work towards lasting change.

So really understanding the problem.

Uh huh.

And not just.

Yeah.

Trying to get rid of the symptoms.

Exactly.

There are things that medication just can't address.

Okay.

You know the complexities of relationships.

Right.

Past experiences, the way we think and feel about the world.

Okay.

So it seems like what we're learning is that both medication and psychotherapy have their strengths and limitations and often the best approach.

Yeah.

Is the one that uses both.

You got it.

Is that kind of what the handbook.

That is the handbook's perspective.

It emphasizes this integrated model of care.

Okay.

Recognizing the value of both.

Right.

So it's not about seeing them as competing.

Right.

It's about seeing them as working together.

Working together.

Yeah.

To achieve.

Yeah.

The best possible outcome.

That common goal.

Exactly.

Okay.

Treatment should always be.

Yeah.

Individualized.

You know.

Right.

And not based on you know.

Right.

Ideology or cost cutting.

Right.

Right.

It's about finding the right balance for that person.

There's really no one size fits all approach.

No.

Which makes sense right.

Everyone's different.

Everyone is different.

Everyone has different needs.

Uh huh.

This has been really interesting.

Yeah.

I feel like we've seen this kind of gradual shift.

We have.

From this focus on either or.

Uh huh.

To this understanding that we really need to.

Yeah.

Like bring in both of these approaches.

It's been a journey for sure.

Right.

Lots of twists and turns.

Full of breakthroughs.

Yes.

But this journey's still.

It is.

Unfolding.

It is.

So where do we go from here?

Well.

What are some of the takeaways you want our listeners.

Yeah.

To have from this deep dive.

I think the biggest takeaway is that mental health care isn't static.

Right.

It's a dynamic field.

Right.

Always evolving.

Always changing.

Always new discoveries.

New discoveries being made.

Yeah.

So stay curious.

Stay curious.

Yeah.

Stay open.

Yeah.

But always.

Critical.

Critical thinking.

Yeah.

Evidence based practice.

Absolutely.

That's so important.

It is.

It is.

Okay.

So what do you see on the horizon for psychopharmacology?

Well with all the advancements in neuroscience.

Right.

We're seeing all this research on the brain.

Uh huh.

You know particularly with these neuroimaging techniques.

Right.

Like PET scans and spec scans.

So those allow us to see what's happening.

Yeah.

In the brain.

Exactly.

It's like a window into the mind.

It is.

It's revolutionary.

Right.

It's giving us a much clearer picture of what's happening.

Right.

Which can help us develop more targeted treatments.

Like we have a roadmap now.

Yeah.

It's a great analogy.

Yeah.

You know.

But we're still just scratching the surface.

Right.

The brain is so complex.

It really is.

There's so much we don't know.

Right.

So we've made progress but there's still so much miscare.

Absolutely.

Yeah.

That's what makes it exciting.

Right.

Yeah.

Okay.

Well as we kind of wrap up.

Yeah.

As part of our deep dive.

I do have one final question.

Okay.

For you.

Okay.

If the majority of mental health services are provided by you know non -medical therapists.

Uh huh.

Like psychologists and social workers and counselors.

Right.

Why is it so important for them to have this understanding of psychopharmacology?

That's a great question.

Yeah.

Because you know even though they're not prescribing they're often the ones who are working directly with people who are taking medications.

So they need to be able to recognize the effects.

Exactly.

Talk to the prescribing physician.

Yeah.

Really be advocates for your clients.

Yeah.

In that sense.

It's just be realistic.

A lot of people aren't comfortable.

Right.

Seeing a psychiatrist.

Right.

So they might have concerns about stigma.

Right.

Or they might just prefer to work with someone.

Right.

They already know.

And so in those cases you know the therapist might be the one to recommend.

Okay.

A referral to a physician who prescribes.

So having that basic understanding can really help them be better advocates.

Better advocates.

Yeah.

Yeah.

It bridges the gap.

Right.

Between the disciplines.

Right.

So it's not about you know therapists versus psychiatrists.

Right.

It's about working together.

To help the client.

Exactly.

Okay.

This has been really fascinating.

It has.

I feel like we've really um.

Yeah.

We've seen how this whole field has evolved.

Yeah.

And this interplay between psychology and biology.

For sure.

And how valuable both medication and therapy can be.

Yeah.

Yeah.

I think.

Yeah.

It does sound like we're on the edge of like all these big breakthroughs.

Yeah.

But I also imagine with that comes some ethical concerns.

Oh yeah.

As we get more advanced.

Yeah.

And as our understanding of the brain deepens you know.

Right.

Especially in the area of genetics we might be able to identify people.

Right.

Who are predisposed to certain mental illnesses.

Right.

And that brings up all these questions about privacy and discrimination.

Right.

And you know how will genetic testing be used.

Right.

Right.

You know.

It's a lot of power.

It is.

It is.

Okay.

Right.

It's a lot of responsibility.

To have that knowledge.

It is.

And to use it responsibly.

Yeah.

And then even as we develop more advanced technologies.

Right.

What about personal autonomy.

Exactly.

Freedom of thought.

Freedom of thought.

Yeah.

So it's really it's really fascinating.

It is.

Like we're kind of in this science fiction.

It feels like it sometimes.

It does.

It does.

Where it's like okay the technology is amazing.

Yeah.

But.

But there's always that potential for misuse.

Right.

So it's like this constant balance.

Yeah.

Finding that.

Moving forward.

Uh huh.

But also making sure we're protecting ourselves.

Absolutely.

It's but it's an exciting time.

Right.

It really is.

Okay.

Well this has been a very enlightening time.

Good.

Good.

Deep dives I think.

Yeah.

You know we've we've really traced the evolution.

We have.

Of this field from the very beginning.

Yeah.

To where we are today.

It's cutting edge.

With all this research and.

Yeah.

It's amazing how far it's come.

It really is.

Yeah.

And I think what I've really taken away from this is.

Yeah.

You know this idea that it's not just one at the other.

Right.

It's it's both.

It's both.

Finding that sweet spot.

Finding that sweet spot.

Yeah.

What what would you say is the one key takeaway.

The one key takeaway.

You want people to.

You know I think it's that we need a holistic.

Okay.

Approach to mental health care.

Okay.

One that considers the person's individual needs.

Mm hmm.

You know their biology.

Their psychology.

Their experience.

The whole person.

The whole person.

Yeah.

Not just the symptoms.

Not just the symptoms.

You know and as science continues to you know.

Yeah.

Unlock these mysteries.

I have no doubt we're gonna.

Yeah.

You know discover even more effective and personalized treatments.

So exciting.

It is.

It's.

I feel like it's a very hopeful.

Yeah.

Very hopeful.

To be in this field.

Yes.

Yes.

Well thank you so much for.

You're welcome.

Taking this deep dive with us.

It's been my pleasure.

And thank you to all of you.

Yes.

For listening.

Thanks for joining us.

And be sure to join us next time.

Yes.

For another deep dive.

See you then.