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Pharmacopsychiatry
The Complexity of Development Trends and
Decision-making in Pharmacopsychiatry
a report by
Hans-Jürgen Möller
Professor of Psychiatry, and Chairman, Department of Psychiatry, Ludwig-Maximilians University
The basis for decision-making in pharmacopsychiatry is not as simple psychiatric disorders.
2
In recent years, with researchers looking for
as one might think. It used to be believed that we have more or less associations with, for example, casual neurological parameters or
specific drugs with a more or less specific pharmacological mode of treatment, the question has been raised of whether syndromes
action for specific indications, such as schizophrenia, depression, etc. themselves are too complex and not meaningful entities.
2
However, the situation is much more complex, and clinical decision-
making is far from being that basic. Current developments of new Keeping in mind that van Praag’s ‘functional psychopathology’ focuses
psychopharmacatherapeutical compounds are taking one of two primarily on the serotonin system and disturbances of this system, such
directions: either broadening the indication for one compound or as obsessive–compulsive symptoms, aggression, etc., it should be
looking for subtypes of a more general indication. Some of these main noted that the neurobiological causation of symptoms is often
aspects will be discussed in this article. complex and involves more than one transmitter system. For example,
recent research has demonstrated that obsessive–compulsive
Nosological versus Syndromatological symptoms are apparently not only associated with disturbances of the
Psychopharmacotherapy serotonergic system, but that disturbances of the dopamine system
For a long time, evaluations of the different responses of various might also be involved.
disorders to certain types of drug treatment
1
appeared to justify the
traditional syndromatology and also partly the psychiatric nosology, at Two main streams can be defined in clinical psychopharmacology:
least as far as the rough classification was concerned. For example, the symptomatological/syndromatological approach,
3,4
which considers
lithium is primarily effective for prophylaxis in affective and symptoms/syndromes to be the main target for psychopharmacological
schizoaffective psychoses; electroconvulsive therapy is very effective interventions; and the nosological approach, which considers the illness
for ‘endogenous’ depression (major depressive disorder) but not for diagnosis to be the essential indication criterion.
5,6
These different
‘neurotic’ depression (dysthymia); and traditional neuroleptics clinical–theoretical positions are by no means unimportant for clinical
mainly influence the symptoms of schizophrenic psychoses, but do not practice, but they coin a prescription stereotype that complicates the
influence depression to a similar degree. permeation of the subject matter to be dealt with here. The basic
position of syndromatologically orientated psychiatrists means that they
However, this has to be viewed more critically in light of modern are always ready to apply a specific psychopharmacon to patients with
developments in psychopharmacology, where selective serotonin different diseases due to their respective symptoms/syndromes. In
re-uptake inhibitor (SSRI) antidepressants, for example, have contrast, nosologically orientated psychiatrists take up a ‘puristic’
demonstrated efficacy not only in depression but also in anxiety position, whereby, for example, neuroleptics are mainly applied to
disorders, and second-generation antipsychotics have shown efficacy schizophrenic psychoses and antidepressives mainly to (endogenous)
in treating not only psychotic but also depressive symptoms of depression. However, on a more broadly differentiated basis the
schizophrenic patients and even in acute bipolar as well as unipolar nosological approach can be used as a secondary decision-making
depression. Thus, response to psychopharmacological treatment does criterion to identify syndromatological indications.
not seem suitable for generating or validating a classification of
Very few empirical studies on syndromatological and nosological
information relevant for psychopharmalogical decision-making have
Hans-Jürgen Möller is a Professor of Psychiatry and
Chairman of the Psychiatric Department at the Ludwig-
been carried out. In two studies by Strauß et al.
7,8
examining the clinical
Maximilians University in Munich. He is also Chairman of International Classification of Diseases (ICD) diagnosis and the
the World Psychiatric Association’s Section on
contribution of dimensional, syndrome-related diagnosis to psycho-
Pharmacopsychiatry and Past President of the World
Federation of Societies of Biological Psychiatry (WFSPB)
pharmacological decision-making, two conclusions were drawn. First,
(1997–2001), as well as Chief Editor of the World Journal of
description of the indication of a therapy that names only the targeted
Biological Psychiatry and European Archives of Psychiatry and
Clinical Neuroscience and Editor of Der Nervenarzt and
symptom is incomplete; a complete description requires the diagnosis
Psychopharmakotherapie. Professor Möller is the author or co-author of more than 1,000 to be named, too. Second, diagnoses enhance the psychiatrist’s
original papers and reviews, and the author or editor of several books, including several
decision-making, as they provide an independent second opinion.
textbooks on psychiatry and psychopharmacology. His research interests are in the biological
psychiatry of schizophrenia and depression, clinical psychopharmacology, psychogeriatrics and
the methodology of clinical research in psychiatry.
Apart from these studies that specifically addressed the question of
E: hans-juergen.moeller@med.uni-muenchen.de
the relationship between syndromatological and nosological aspects
of decision-making in pharmacopsychiatry, there is a rich tradition of
70 © TOUCH BRIEFINGS 2008
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