PSYCHIATRY UPDATE Psychopharmacology Editor Kamal N Kalita Co-editor Angshuman Kalita ii PSYCHIATRY UPDATE: Psychopharmacology Editor Kamal N Kalita Co-editor Angshuman Kalita Published by Department of Psychiatry, LGBRIMH, Tezpur-784 001 on behalf of Organising Committee, 28th Annual Conference Indian Psychiatric Society, Assam State Branch in association with Bhabani Books, Guwahati, Assam ISBN: 978-93-87494-14-5 © Publishers All rights reserved. Except for brief quotations in critical articles or reviews, no part of this work may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior written permission of the publishers. Printed in India at Bhabani Offset & Imaging Systems Pvt. Ltd. 7 Lachit Lane, Rajgarh Road, Guwahati-781 007 Phone: (0361) 2524056, 2528155 e-mail: [email protected], web: www.bhabani.com iii Preface Kamal N Kalita, Angshuman Kalita To understand how any external agent including psychotropic works one has to know details of the process of healing. Wayne Jonas’ in his book ‘How Healing Works: Get well and Stay Healthy using Your Hidden Power to Heal’ has described many events that help to have broader view of the process of healing and the science involved in it along with a view how little has been known till date. Modern psychopharmacology can be told to be developed serendipitously in 1950s bringing revolutionary changes in treatment of disorders of the mind. Evolving Psychopharmacology changed the conceptualization of most psychiatric disorders in terms of a) their diagnosis and categorization, b) on models for research in the nature of psychiatric illnesses, c) on psychiatric education, d) on methods and standards for experimental therapeutics, and e) on the organization of modern psychiatry as a clinical and academic medical specialty. Consequently a new generation of more biologically oriented psychiatrists came to dominate psychiatry internationally, and to replace their more psychologically minded colleagues in positions of influence. Initial rapid response to medications made us over optimistic and the shift of care for asylums were seen towards community and general hospitals. Thus the economics of health care was a new unfolded chapter in psychopharmacology. Some scholars like Dr Gardner1 and Dr Vazquez 2are critical of recent trends of a growing international inclination toward increasingly brief and routinized clinical encounters, with an emphasis on rapid but superficial diagnostic categorization and initiation of iv Psychiatry Update: Psychopharmacology almost exclusively medicinal treatments. They advocate even if such clinical practices were adequate they require extensive training, experience, knowledge, and judgment to be used effectively and safely. The argument can be made that heavy reliance on medicinal treatments with less emphasis on psychological approaches, and on symptom checklists rather than on thoughtful understanding of each patient has unfolded a chapter involving fundamental changes in the theory and practice of modern psychiatry. These changes involve a tug of war of what has been labelled brainlessness versus mindlessness in psychiatry. Recent advancement of technology giving birth to neurosciences, neurogenetics, neuroimaging etc with new drug development technologies are not giving any conclusive view in regards to psychiatric conditions. It is expected as most of such conditions are still considered idiopathic. Some scholars criticize the pharmacocentric neurotransmitter related theories to be too simplistic for psychiatric disorders. Baldessarini in his editorial for Canadian Journal of Psychiatry 2014 August issue has even criticized this to e neuromythology. Again over emphasis on statistically significant results with manipulated research methodology and statistical methods influencing the evidence based mental health having different conflicts of interest is a dark chapter unfolded3. Global market for psychotropic was estimated to be 88.3 billion USD in 2015 the rise is steeping in last 10 years. But it is interesting that the market for antipsychotic and antidepressant showed declining trend and raising trend for neurocognitive agents, hypnotics, antiepileptics. Similar was the result in India as published in Acta Medica International 2016 vol 3 (GS Poduri). These findings open a different platform for discussion along with the impact of marketing on patient care. Thus we see Psychopharmacology has unfolded many chapters in Psychiatry and many are yet to be unfolded. In this edition of ‘Psychiatry Update: Psychopharmacology’ we have tried to give a glimpse into different arena in this regards. To start with Psychiatry Update: Psychopharmacology v Brahma described about the different nomenclature system of pharmaceutical products. It has become more important when there is ongoing debate of generics Vs branded medicines. To understand how a psychotropic acts we have to know its pharmacokinetics and dynamics. Aziz etal wrote on its emerging concepts while Kalita enumerated roles of drug monitoring. Bhandari etal and Chakravarty described on ethnic differences in psychopharmacology and the changes in PK across life cycle. The article on treatment modalities of Indian System Medicine by Sarma has added a new flavour in modern psychopharmacology. People seem to be more concerned about side effects of psychotropics than its effects; Deb has seen it from a different angle. Although behavioural modalities remain main treatment options for child and young people there is a growing trend of prescribing psychoactive agents as reflected in market surveys. Behere etal, Linganna etal and Islam etal described use of pharmacotherapy in this age group with various problems. Use of hormonal drugs is still in infancy in psychiatry and Talukdar describes it with brevity. Sexual disorders still remains a taboo in our society and we see many quack taking advantages of this stigma and ignorance. Manohar etal and Tripathy etal have looked into the use of different agents in this area. Regarding emerging trends in management of anxiety and bipolar depression have been effectively depicted by Ghosh and Chakraborty etal. Chetia discusses the pharmacogenetic factors influencing antidepressant response and this may become pertinent in future patient care approaches. Psychiatry and psychopharmacology will never be complete if we do not include schizophrenia. But very few volunteered to contribute an article in this regard. We have mentioned about decreasing trend of sale of antipsychotic globally. Perhaps there is transient lack of affinity in this specific illness among the professionals probably due to inherent complicacies associated with this illness with no significant positive news in its care and research. vi Psychiatry Update: Psychopharmacology Pandey etal, Dutta and Borkotoky etal have lucidly narrated specific areas in this regard. Substance use disorders are getting more emphasis in current psychiatry and the market presence of medications in this area are getting significant attention along with increasing investment in research. Joseph etal, Dutta, Rahman etal, Shantaram etal, and Mukherjee etal have made the chapter on addiction in this edition of ‘Psychiatry Update’ interesting. With the world getting more elderly people across different countries the health problems of elderly are getting significant attention. Probably this increased attention is associated with the good response from contributors in this area. Management of cognitive problems have been enumerated by Avinash, Kishore etal, Kumar. Das wrote about use of Z drugs in insomnia of elderly while anxiety management is discussed by Sharma etal. Agarwal etal described the age old problem of delirium along with its management strategies. Bordoloi etal described the various regulating agencies for Pharma industry in India in their short writing effectively. Das has put forward his view on the emerging trends on different treatment strategies in which agriculture may have significant role. Finally Gogoi deals with a very controversial subject of Polypharmacy fabulously. Defining rationality in an area which is described irrational by conventional textbooks is a daunting task. But polypharmacy has become rule rather than exception. Judicious use is what needs to be learnt and practised till we get better instrument to deal with mental health conditions. While planning this book we tried for best representation of contributors from different institutions of Assam and a few from outside. Different chapters were planned to ensure coverage of different spectrum of psychopharmacology. The basic research in this area could not be covered well and we apologize for that. Editing this book has been a nice experience and I am grateful to the contributors. I thank Angshuman for his energetic role and the employees of Bhabani Offset & Imaging Systems Pvt. Ltd. for their support and suggestion. Psychiatry Update: Psychopharmacology vii REFERENCES 1. Gardner DM. Competent psychopharmacology. Can J Psychiatry. 2014;59 (8): 406–411 2. Vázquez GH. The impact of psychopharmacology on contemporary clinical psychiatry. Can J Psychiatry. 2014;59(8):412–416 3. Baldessarini RJ. American biological psychiatry and psychopharmacology 1944–1994. Chapter 16. In: Menninger RW, Nemiah JC, editors. American psychiatry after World War II (1944–1994). Washington (DC): American Psychiatric Press; 2000. p 371–412. For the term pharmacocentric