Physical Treatments

Treatment by Drugs

The various drugs used in the treatment of psychiatric illness fall into four main categories: sedatives, stimulants, tranquillizers and antidepressants. They are all used empirically, that is, while they are known to have particular effects, the way in which they act is unknown or only partially known.

Of recent years many new drugs have been discovered and developed, notably the tranquillizers and the antidepressants. Some of them have greatly improved the management of many disorders and, in some illnesses, have appreciably altered the outlook. With other drugs, however, the initial optimistic claims have not been confirmed by medical experience. The greatest care is necessary in the close study of a new drug to establish its usefulness.

Sedatives. These are drugs which reduce the activity of the brain and the rest of the central nervous system. In small doses they reduce restlessness, feelings of anxiety and tension. In larger doses they induce sleep. In very large doses their effect is powerful enough to abolish breathing. Until the discovery of the tranquillizers they were the only medicaments available for the control of anxiety, restlessness and excitement.

They have certain disadvantages. They cause sleepiness, and sometimes depression in all but the smallest doses. There is a tendency for the system to become accustomed to them and larger doses may be required or addiction may develop.

This group includes many drugs having very similar effects, but which differ chiefly in the speed and duration with which they are effective. Medium and long-acting ones are used in relatively small doses for their calming effect. Medium and short-acting ones are used in larger doses to induce sleep in cases of insomnia or in sleep treatment.

Sedatives are usually taken by mouth, but they may be given by injection when a more marked and powerful effect results.

Tranquillisers. Tranquillisers have a calming effect in certain conditions and cause less drowsiness than the sedatives. They can therefore be used in larger doses, leaving the patient alert. They also have the advantage of not depressing respiration even in very large doses and they are to this extent safer than the sedatives. Tolerance and addiction are also much less likely to develop. Some tranquil lisers have a number of side-effects, including dryness of the mouth, fall in blood pressure and stiffness of the muscles.

Tranquillizers are frequently used in the treatment of anxiety or restlessness accompanying any psychiatric condition. The older tranquillizers are used chiefly in schizophrenia, mania and in organic states, being relatively ineffective in the psychoneuroses. Other tranquillizers, such as chlordiazepoxide (Librium) and thiopropazate (Dartalan) are more effective in these latter conditions.

In schizophrenia, these drugs may be strikingly effective in reducing disturbed behaviour, hallucinations, delusions and thought disorder.

Antidepressants. Their name is self-descriptive. Unlike the stimulants they have no effect on people who are not depressed. They may be used in cases where a mood of depression exists, whether in depressive illnesses or in neuroses with depression. They are frequently used for patients who would previously have been given electrical treatment .

Their side-effects include dryness of the mouth and fall in blood pressure.

Stimulants. These drugs, especially the amphetamines, produce increased wakefulness, postpone the need for sleep and may increase the flow of mental activity. They do not, however, markedly improve a mood of severe depression. They may produce or increase anxiety. Amphetamines are sometimes given as an aid to slimming, because they tend to diminish appetite. In large doses, usually over a period of weeks or months, acute toxic confusional psychoses may be produced.

Patients with unstable personalities may become addicted to stimulants. Amphetamines are often prescribed combined with a small dose of sodium amytal in the same tablet. This counteracts the tendency for anxiety to be produced.

Electroplexy

(Electroconvulsive Therapy)

The development of electroplexy arose out of the observation that spontaneous convulsions appeared to have a favorable effect on various sorts of mental illness. The supposed rarity of epilepsy in schizophrenia led to the conclusion that these two conditions were opposed to each other.

In 1936 the first attempts were made to treat schizophrenia with drug-induced convulsions. In 1938 the production of a convulsion using an electric shock was developed and this is the method commonly used now.

In modern techniques the treatment is usually administered under light anesthesia, such as may be used for dental extractions, and the muscular convulsion is reduced by a muscle-relaxant drug. The patient may sometimes be given this treatment as an outpatient. He receives an injection containing the anesthetic and the muscle relaxant, then an electric current of appropriate strength and duration is passed between two electrodes placed on his temples. The procedure takes a few minutes and the patient may be able to walk about after a short period of rest.

EIectroplexy is usually given two or three times a week, though in certain circumstances it may be given more frequently. Improvement usually begins after three or four treatments but a course of six to eight is usually necessary.

Electroplexy is used in the treatment of depressive illness, of mania and in schizophrenia. It is most effective in depressive illnesses, 80 per cent of cases making a complete and prompt recovery.

Insulin Coma Therapy

Insulin is a substance, produced in the pancreas, which controls the storage of sugar in the body. It is given by injection in the treatment of diabetes and in psychiatric treatments. One of its effects is to reduce the amount of sugar in the bloodstream and, in large doses, the reduction of blood sugar has the effect of producing coma.

Chance observations that a coma so produced had beneficial effects in cases of schizophrenia led to the use of insulin coma as a treatment for schizophrenia. The subsequent discovery of the tranquillizer drugs and of their efficacy in such illnesses, has reduced the need for insulin coma treatment, but it is still used for some patients.

Producing the Coma. Injections of increasing dosage are given on successive days until a coma is produced. Thereafter a coma is produced each day with the appropriate dosage until between 25 and 30 comas have been produced. Each coma is allowed to continue for half to one and a half hours, and is then interrupted by giving the patient sugar either by injection or by stomach tube.

Since great care is needed in order that the treatment may be given with the minimum of risk, insulin coma therapy is only given in special units under the supervision of specially trained staff. The best results are obtained in early acute cases of the disorder. There is usually a progressive improvement in schizophrenic symptoms and a steady gain in weight during the course of treatment.

Modified Insulin Treatment. Before the discovery of insulin coma treatment for schizophrenia, small doses of insulin given over a short period of time were known to have a sedative effect, to reduce tension, and to increase appetite and weight. Modified insulin therapy is therefore used in cases of psychoneurosis or mild depression where there is considerable tension and, in particular, if there has been weight loss. The treatment usually results in a general improvement in bodily health and in a feeling of well-being.

Prolonged Narcosis

(Sleep Treatment)

During attacks of severe anxiety or depression occurring in the course of a psychiatric illness, a period of continuous sleep is sometimes thought desirable. This can be induced by giving large doses of sedatives, or combinations of sedatives and tranquillizers, to achieve deep sleep for most of the day and night and heavy drowsiness for the remainder. The treatment may last for one or two weeks. It is necessary for the patient to be under close supervision in hospital.

Prolonged narcosis is usually given where the illness is reactive to extremely traumatic or painful circumstances which have become too much for the patient to cope with. It may tide him over the period of acute reaction. When this has been relieved, the patient is able to continue with other forms of treatment.

Brain Surgery in Psychiatry

Prefrontal Leucotomy (lobotomy) is the most commonly used of operations for the relief of psychiatric illness. Certain nerve fibers from the frontal lobes of the brain are cut, in order to reduce severe anxiety, tension, depression, or the excessive excitability and activity that occurs in some disorders. Various brain functions such as sensation or movement have been located in different part

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