How psychotropic drugs are used; an explanatory paradigm

• Therapeutic uses of psychotropic medication can be allocated to a continuum between Psycho-antagonistic or Psycho-agonistic modes.
• Psycho-antagonistic mode: 25% e.g. prescribing hypnotic for treatment of insomnia.
• Psycho-agonistic mode: 74% e.g. prescribing Citalopram for treatment of Panic disorder.
• Due to the development of tolerance in long-term use, Psycho-antagonistic mode is preferred for treatment of acute/crisis situations.
• Due to the possibility of initial worsening, Psycho-agonistic mode with “lowest effective doses” is suitable for treatment of chronic illnesses.

Traditionally, two divergent approaches are used to explain the mechanism of action of psychotropic drugs. The dominant “Disease-centred” view emphasises the biochemical imbalance caused by ‘illnesses’. In contrast the “Drug-centred” view emphasises the psychoactive properties of these drugs and their ability to induce an ‘altered-state’ of mind. In this article we propose a new paradigm for classifying the therapeutic uses of psychotropic drugs based on the relation between their psychoactive effects and symptoms of indicated mental illness; as well as their clinical responses e.g. emerging tolerance, paradoxical initial worsening and being recommended for long/short term use. Based on this premise, therapeutic uses of psychotropic drugs can be placed on a continuum between two distinguishable modes. We define these modes as “Psycho-antagonistic” and “Psycho-agonistic”. 105 therapeutic uses of 85 psychotropic drugs are placed on this continuum; 74% on the Psycho-agnostic spectrum and 25% on the Psycho-antagonistic side. Hypnotic agents used for insomnia are clear examples of Psycho-antagonistic mode of use. Citalopram for treatment of Panic disorder is a clear example of using a drug in Psycho-agonistic mode. Only the therapeutic use of Lithium for bipolar affective disorder could not be allocated to any mode and considered as borderline. The paradigm highlights the possibility of initial worsening in majority of therapeutic uses of psychotropic drugs and importance of using lower doses. Further studies and clinical trials are needed to explore the full extent of the clinical implications of this paradigm in psychiatry and perhaps in other branches of medicine.

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