Psychotropic drugs.

Introduction Of the many patients with psychological illness or disorders in which emotional factors are important, a large proportion are given psychotropic drugs. Many improve because of this treatment and some despite it. The potent agents now available are liable to produce side-effects or toxic effects which have to be set against the potential benefits conferred by these drugs. If drug treatment is appropriate the problem is to choose the compound most liable to produce beneficial effects-regardless of whether weightfor-weight it is the most potent drug-which also has the least risk of unwanted effects (Lader, 1967). This is clearly a complex matter and to gather sufficient information to make a reasonable choice requires both adequate trials to demonstrate the drug's clinical efficacy and sufficient clinical experience to discover the incidence and nature of the side-effects. In clinical trials of psychotropic drugs all the problems of spontaneous change, the effect of concurrent environmental changes, the patient's relationship to medical staff, the potential bias of patient and doctor, the difficulty of assessing subjective changes and of measuring relevant objective changes, demand a careful design to the trial if the results are to have any significance. It is also necessary to verify that the subjects are taking the medication under trial, for it has ,been touid that among out-patients as many as 48% may not be taking the treatment prescribed (Wilcox, Gillan & Hare, 1965). Many doctors have pointed out that in their hands various psychotropic drugs prove to be more successful than results published even in satisfactorily controlled trials. Although this may be partially accounted for by their better intuitive selection of appropriate patients for particular treatments, it may well be that faith plays a large part. Faith may well move mountains, and enthusiastic approach can help certain patients who have had no benefit from the treatment of more cautious therapists. Unfortunately, when it comes to proving that faith has actually moved the mountain, the peak often remains obstinately far away unless the distance is assessed by the fervent practitioner free to move about in the haze appropriate to the altitude. In these circumstances, clinical enthusiasm is an unreliable basis for pharmacological knowledge or subsequent hypothesis. Periodic reviews of the toxicity of psychotropic drugs report unwanted side-effects, e.g. over-sedation, hypotension, or extra-pyramidal disorders, dangerous allergic responses, e.g. agranulocytosis, and toxic effects, e.g. liver necrosis or acute hypertension (Hollister, 1964). There are also the dangers of addiction and overdose. In any one year in Great Britain, each of the more popular drugs used in the treatment of anxiety, depression or schizophrenia is quite likely to feature in at least a million prescriptions. Even if the dangers are relatively infrequent, there are bound to be a number of occasions when drug toxicity will cause a patient (or the relatives) and the doctor to doubt if the original prescription was really justified. This clearly means that even familar drugs should not be prescribed without due consideration and to do so is to incur an unjustifiable risk. Moreover, if a popular sedative or anti-depressant drug is unthinkingly prescribed before making adequate enquiry into the patient's life, a potentially alterable cause of the emotional distress may be neglected. Unfortunately, it must be confessed that frequently the causes of psychiatric disorders are indeterminate or the circumstances so unfavourable that immediate radical cure is unlikely. In such cases the symptomatic relief which medication can provide is often a most useful alternative or accessory treatment.