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Psychopharmacology Problem SolvingReview - Psychopharmacology Problem Solving
Principles and Practices to Get It Right
by F. Scott Kraly
W. W. Norton, 2014
Review by Maura Pilotti, Ph.D.
Mar 31st 2015 (Volume 19, Issue 14)

In Psychopharmacology Problem Solving: Principles and Practices to Get it Right, F. Scott Kraly advocates not the abandonment of psychotropic drugs for the treatment of psychopathology, but their judicious use.  What is to be defined as judicious use? The author defines it as a doctor-supervised administration of psychotropic drugs that considers the available scientific evidence on their effectiveness across diverse populations, their short-term and long-term undesirable effects, the feasibility of psychological and behavioral treatments, and the limits of our current knowledge of such drugs and their effects.  Of course, “judicious use” is a challenge that starts with patients who are often sensitive to the lures of a quick fix (e.g., a miracle pill that will address their concerns and entirely overcome their pain and suffering) and thus are easy prey of the advertisement produced by drug companies.  Some of the most troubling commercials are those openly encouraging patients to “ask their physician” whether a specific product is “right for them” as if a competent and ethical physician would not recognize by himself/herself the benefits of the product for his/her patients.  These commercials exploit the notion that knowledge of a given disorder and its treatment options makes patients educated consumers while they imply that the experience and advice of mental health professionals may need updating by cutting-edge drug manufacturers.  Equally troubling is the diagnostic fervor that targets children and adolescents who deviate from a putative normal range. Most of these children and adolescents are classified as suffering from specific forms of psychopathology which are assumed to be the source of behavioral problems experienced in school and at home.  Then drug therapies are presented to concerned families as appealing, cost-effective remedies which not only promise a fast resolution of problems, but also downplay or entirely ignore the long-term effects that psychotropic drugs may have on the chemistry of a developing brain.  Sadly, the latter is not an isolated event since precise and reliable information about long-term effects is largely unavailable to mental health professionals.

Mental health professionals and laypersons alike are likely to find the content of Psychopharmacology Problem Solving: Principles and practices to get it right not only helpful, but also insightful.  In practice, a “judicious use” of psychotropic treatments is an unavoidable necessity not only because most drugs’ long-term effects are often either unknown or not well understood, but also because their multiple-level interactions with the chemicals endogenous to the human brain remain largely a mystery.  Yet, how can “judicious use” become a practice when it contrasts with the needs for a quick fix that patients often desire? The author offers a set of common-sense principles upon which psychotropic drug therapy can and should rely.  These principles originate from the author’s acknowledgment that the human brain is a complex biological device whose mechanisms are not entirely understood.  In this scenario, psychotropic drugs are exogenous substances that alter its equilibrium.  The author reminds the reader that these drugs’ multiple effects are not easy to predict in any given patient.  He advocates a conservative approach to dosage, reminding the reader that if larger doses can be expected to produce effects of greater magnitude, such effects are likely to be both desirable and undesirable.  Given that each person is somehow a unique entity, a trial-and-error methodology, he argues, is generally to be adopted to identify the threshold dose and the dose that elicits the maxim effect in that person.  The author also warns the reader of the dangers of poly-pharmacy due to the current lack of knowledge and thus unpredictability of drug interactions.  He recommends reliance on small dosages at the start of treatment and progressive increases until the desired effects are achieved (i.e., relief of symptoms and minimal undesirable side effects).  He also recommends realistic expectations on the desired effects and undesired side-effects as no miracle cure exists. 

The author shares a broad set of recommendations for sensible decision-making in the clinical treatment of patients suffering from specific psychological disorders, such as schizophrenia, addiction (including food), mood disorders, and anxiety disorders.  If the reader conforms to the medical model and abstains from acknowledging that clinical labels are simply society’s value judgments on “normative standards”, then the goal of mental health can be narrowly defined as the absence or attenuation of undesirable symptoms obtained through a combination of both psychotherapeutic and psychotropic interventions.  The author appears to subscribe to this definition by advocating mental health professionals’ reliance on psychotherapy, behavioral interventions, and counseling, along with cautious use of psychotropic drugs.  He notes that the intake of exogenous substances that can alter the chemistry of the human brain may not be the only way of adjusting the chemistry of the brain to the desired levels.  In fact, the ability of the human brain, even an older brain, to adapt gives behavior modification and psychotherapy (when feasible) the ability to change brain functioning probably more predictably and lastingly than a psychotropic intervention can ever accomplish.  The author acknowledges the plasticity of the human brain while he shares his concerns regarding the use of psychotropic drugs for a variety of mental disorders.  The informed and cautious recommendations of the author regarding use of these drugs make his book an excellent read not only for mental health professionals and patients, but also for students who are considering a career in the field of mental health. 

The author’s acknowledgement of the merits of multi-dimensional therapeutic interventions recognizes that change at either the behavioral, cognitive, or biological level not only spreads to the other levels, but also is affected by it in a never-ending pattern of mutual influences. Consider, for instance, the need for attitude change in many areas of our social lives (e.g., prejudice).  People often neglect to note that not only can attitudes influence behavior (e.g., discrimination), but also behavior can influence attitudes.  Similarly, if psychotropic drugs are capable of altering behavior and cognition by means of changes in brain functioning, behavior modification and/or cognitive-behavior therapies can alter brain functioning by means of changes in conduct and thought. Of course, behavioral and cognitive interventions require more time and effort and are nothing like the quick and seemingly effortless fix that a pill appears to offer.  Their outcome is also less than guaranteed as they heavily depend on complex and delicate human interactions in and outside the clinical setting.  Yet, they rely on the natural plasticity of the human brain to adapt to changes and are those that represent a “healthy choice” for the treatment of a variety of forms of psychopathology.

 

© 2015 Maura Pilotti

 

Maura Pilotti, Ph.D., Ashford University


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