Risks of sedating

It is wise not to be too censorious about the treatment of disorders of which the aetiology is still largely unknown, but to bear in mind that ’it may well be that in a hundred years current therapies, psychotherapies as well as physical therapies, will be looked upon as similarly uncouth and improbable’ (Kiloh 1988).

Historically, physical treatments can be divided into two main classes: * those that were aimed at producing a direct change in a pathophysiological process, usually by some alteration in brain function; » those that were aimed at producing symptomatic improvement through a dramatic psychological impact.

A less arduous regimen was the use of continuous warm baths, often given in combination with cold packs.

This treatment was recommended by clinicians as distinguished as Connolly (1794-1866) and Kraepelin (1856-1926), and was still in use at the Bethlem Hospital in the 1950s.

This view is erroneous in so far as schizophrenia-like illnesses are actually more common in patients with temporal lobe epilepsy than would be expected by chance (see p. Astute clinical observation, in combination with controlled trials, has shown that ECT is effective 1934 Insulin coma treatment (Sakel) 1936 Frontal leucotomy (Moniz) 1936 Metrazole convulsive therapy (Meduna) 1938 Electroconvulsive therapy (Cerletti and Bini) 1949 Lithium (Cade) 1952 Chlorpromazine (Delay and Deniker) 1954 Benzodiazepines (Sternbach) 1957 Iproniazid (Crane and Kline) 1957 Imipramine (Kuhn) 1966 Valpromide (valproate) in bipolar disorder (Lambert etal.) 1967 Clomipramine in obsessive-compulsive disorder (Fernandez and Lopez-Ibor) 1971 Carbamazepine in bipolar disorder (Takezaki and Hanaoka) 1988 Clozapine in treatment-resistant schizophrenia (Kane in the acute treatment of severe mood disorders.

Thus, even though the rationale for the introduction of ECT was incorrect and its mode of action remains unclear, controlled trials have confirmed that, in carefully defined clinical situations, ECT is a safe and effective treatment (see p. The action of lithium in reducing mania was a chance finding by Cade (1949) who had been investigating the effects of urates in animals and had decided to use the lithium salt because of its solubility.

The last 30 years have brought a period of consolidation in psychopharmacology.

Clinical trials have been widely used to refine the indications of particular drug treatments and to maximize their risk:benefit ratios.

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Also, the assessment of efficacy depended almost entirely on uncontrolled clinical observation.

The latter interventions were often based on philosophical theories about the moral basis of madness.

For example, many physicians appear to have followed the proposal of Heinroth (1773-1843) that insanity was the product of evil and personal wrongdoing.

This study was published about the time when chlorpromazine was introduced, and both factors led to a rapid decline in the use of insulin coma treatment.

It should be noted that the controlled studies did not exclude the efficacy of insulin treatment in some circumstances, and a number of workers continued to maintain that it was effective.

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