Psychotropic drugs, such as opium, had been used since the origins of the medical treatment of psychiatric patients. During the nineteenth and the first half of the twentieth century, synthetic drugs such as the bromides, the barbiturates, and the amphetamines were developed. Some of them, especially the sedatives and hypnotics, had a real but in practice marginal value in alleviating some symptoms. They had never constituted an effective treatment of mental disorders. Modern psychopharmacology not only initiated what has been rightly called a therapeutic revolution in psychiatry but also gave a powerful new impulse to the biological perspective. Its date of birth is usually considered to be 1952 when the remarkable activity of chlorpromazine on the symptoms of schizophrenia and mania was discovered. This had been preceded in 1949 by the demonstration of the value of lithium salts in manic states. A few years later it was shown that the continuous administration of lithium salts prevented the recurrence of manic and depressive phases in the mood disorders. This was followed by the introduction of drugs acting on the depressive manifestations (imipramine and the monoamine oxidase inhibitors in 1957) and on anxiety (including chlorediazepoxide, the prototype of the benzodiazepines, in 1960). In one decade clinicians had empirically discovered the fields of application of the main classes of psychoactive drugs—the neuroleptics, the antidepressants, the anxiolytics, and the mood stabilizers—which had been synthesized by biochemists and previously tested by pharmacologists on animal models. The scale and rapidity of the spread of their use had major repercussions.
The first was a modification of the image of psychiatry. The layman generally expected a physician to prescribe drugs to treat the disease from which he suffered. In part because it did not conform to the expected therapeutic behaviour, psychiatry had been seen as an atypical and almost non-medical specialty. In addition to the specificity of the institutions in which it was generally practised, psychological techniques were unknown in the rest of medicine, and even the recently introduced biological techniques (the shock therapies and the lobotomy) had a somewhat strange and frightening character. The establishment of pharmacotherapy contributed strongly to modifying this perception, even if it did not completely remove the traditional prejudices.
The second consequence was even more important. There were, at least initially, controversies about the roles of pharmacotherapy and of the new social perspectives in the restructuring of the mental health care system. In fact, the number of inpatients in psychiatric hospitals began to decrease from 1955 on, and it seems obvious that the main cause was the therapeutic efficacy of the drugs. They reduced the mean length of hospitalization and eventually even made it unnecessary. Although some types of patients did not benefit from them and the mental state of others was only improved, many who had previously been condemned to long stays in the hospital were able to return to the community, with their treatment eventually being continued in rehabilitation settings and often on an ambulatory basis. Pharmacotherapy had made possible the practical implementation of social trends. In addition to this basic contribution to the 'deinstitutionalization' movement, pharmacotherapy was an essential factor in the growth of private practice. The success of psychotherapy had been one contribution to this, but the complexity of its techniques, the length of the treatment, its applicability to only a few types of disorder, and he uncertainty of the results limited its use to a relatively small number of selected patients, even in the United States during the period of the greatest popularity of psychodynamism. Pharmacotherapy could be used much more easily, on a much larger number of patients, and did not require a long and complex training. Some of the drugs, such as the anxiolytics, had an immediate symptomatic effect, and others (the antidepressants and the neuroleptics) could attenuate or suppress the pathological manifestations in a few weeks and, outside the acute phase requiring hospitalization, could be used on an ambulatory basis. It was not only private psychiatrists who were able to treat many of their patients successfully; general practitioners also began to prescribe psychotropic drugs on a large scale.
The third consequence was the explosive development of biological research in psychiatry. The first therapeutic discoveries were largely empirical, but new biochemical techniques allowed some of the modes of action of the drugs to be elucidated. From 1960 on, studies of the influence of these drugs on various aspects of neurotransmission in the brain stimulated hypotheses about the abnormal biochemical mechanisms considered to be the physical substrate of the mental disorders. Meanwhile new methods had been introduced for examination of morphological modifications of the living brain and even of the nature and localization of the biochemical processes taking place in its different parts. The discovery by Watson and Crick in 1953 of the chemical basis of heredity and the subsequent spectacular advances in molecular biology gave a fresh impulse to psychiatric genetics, which had been partly discredited by their misuse by the National Socialist regime. Under the name of neurosciences, these new fields of enquiry progressively acquired a dominant role in psychiatric research at the same time as the introduction of an ever-increasing number of drugs, eventually more potent, usually with less inconvenient side-effects, and sometimes with new therapeutic indications.
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