Better Living through Chemistry

"If all the drugs were thrown into the ocean, it would be all the worse for the fishes and all the better for mankind."
Oliver Wendell Holmes


What would you give for a pill that made you happy or thin or helped erase the pain of losing a loved one?

As anyone who reads a newspaper knows, some of these pills already exist, others are on the way. Is it wrong to take a pill to change the way you feel, any more than to change your blood pressure or treat an infection? Does it make us somehow less ourselves, less human?

There are legitimate concerns about our knowledge of psychotropic medications (i.e. medications that affect the brain). However, those who take the position that this is an either/or proposition fall into the same reductionistic trap that they are criticizing. The fact that medications are not as effective, or as benign, as advertised on TV or touted in popular journals and magazines is hardly news. It takes very little effort to find information that contradicts every claim of efficacy and safety. Dig a little deeper and one can enter the slightly paranoid world of ‘antipsychiatry’. In fact the debate about the efficacy or otherwise of psychotropic medications is as old as the field of psychopharmacology itself.

Some people, however, conclude that all medications cause serious problems and that their benefits are entirely a placebo effect (i.e. the medicine itself is causing no appreciable benefit; rather it is the patient’s perception that helps them).
Are these conclusions any more scientific than what they are criticizing?

It’s true that our knowledge of mental functions is, in fact, extremely rudimentary and the current tools at our disposal, crude. The basic building blocks of the central nervous comprising the brain and spinal cord system are cells called Neurons. The number of neuronal connections in the brain exceeds several billion and the possible combinations of each are several orders of magnitude greater than that.

Is it any wonder that we are mostly in the dark about how our brains function? On the other hand, compared to even 20 years ago, we have come a long way towards a basic understanding of neurochemistry and neurophysiology. We know more today about neurotransmitters, localization of brain functions, effects of trauma on the brain and the effect of degenerative changes on brain structures and function than we have ever known and our knowledge is accumulating at an accelerating pace.

I often describe medication for mental illness with an analogy of a broken TV. You can unscrew the back panel, get inside and fix what’s wrong or you can give it a swift kick on the side and hope for the best. Our current approach to psychotropic medications is, at the moment, more akin to the latter.

This does not mean that using medications for mental illness is a useless exercise. There are strong and ever growing research data on the effectiveness of these medications. Also, the placebo effect is not confined to medicines only for psychiatric or emotional illness, it occurs with drug trials for all kinds of medicines including those which are, at least to the lay person, beyond reproach, e.g. antibiotics and pain medications.

I have seen again and again in my practice that medications do help, albeit for a short time and sometimes with unpleasant side-effects. The ‘poop-out’ syndrome is a common occurrence in all patients taking psychiatric medications. It refers to the phenomenon that happens with a majority of antidepressant medication (particularly the SSRIs or Serotonin Specific Reuptake Inhibitors like Prozac, Zoloft etc. It is also being increasingly recognized in newer medications such as Effexor etc). Most people on these medications for more than a few months will, at some point, experience a diminishing effect on the same dose of medication, even though they may be taking it religiously.

The issue of non-compliance aside, there is a perfectly reasonable scientific explanation for this. The principle of homeostasis is a well known one. It refers to the tendency for the human body to attempt to move towards equilibrium in the face of an applied stress. This is the reason muscles grow bigger if exercised regularly. It stands to reason then, that if we alter brain chemistry by introducing foreign chemicals into the body, the brain will attempt to compensate by trying to move towards homeostasis. If the baseline (i.e. usual) state of brain functioning has been depression, anxiety or what have you, it will move back towards that state in spite of medications.

This is the reason that non-medication interventions such as psychotherapy, exercise, social skills training etc are crucial. Medication provides a ‘window of opportunity’ which can be anywhere from a few weeks to a few months during which the patient has to try and change the factors in their life that led them to the dysfunctional state in the first place. This may mean psychotherapy to deal with past abuse and trauma, marital or individual therapy to deal with relationship or occupational problems or group therapy to deal with socialization or substance abuse problems etc. The problem arises if people assume medication to be the end per se, rather than a means to an end. It is this group of people who will make endless rounds of doctors for more and different medications.

Regarding the research that claims that medications cause brain damage, irreversible and/or disabling side effects etc, once again, one needs to have some perspective. The commonly prescribed antidepressants are some of the most widely prescribed medicines in the world. In the US, of the ten most prescribed drugs across any specialty (not just Psychiatry), three are antidepressants. This translates into millions of people taking these medications at any given time. Prozac was first approved in the US in 1987. This means we are in year 20 of the SSRI era. If we add the older antidepressants (which came out in the late 50s) into the mix, the antidepressant era has now been around for close to a half century. Of course people have experienced side effects, some quite serious but the proportion of these is small compared to the number of people who have taken these medicines. One needs to be circumspect about drawing premature conclusions.

The same can be said about the other major classes of psychiatric medications, the so-called antipsychotics, used for more severe mental illnesses like Schizophrenia and Bipolar disorder, the benzodiazepine group or ‘nerve medicines’ like Valium, Xanax etc and the most recent group, the ‘mood stabilizers’ like Lithium, Depakote etc.

So, do medicines help people or not? The answer is a qualified yes. If a person is willing to work hard to change the factors that led to their illness in the first place medicines can provide the necessary initial impetus to get a person moving in the right direction. Subsequently with continued hard work in therapy, groups, vocational training, avoidance of drugs and alcohol etc, the illness can be kept at bay. However, mental illness, I often tell my patients, is more akin to other chronic illnesses like Diabetes and Hypertension rather than acute illness. It can be controlled but usually not eliminated.

Our goals with therapy and medications are the same. Remodeling and refining those neuronal connections in the brain that control certain emotional states, hopefully eliminating or greatly reducing the negative ones and allowing the positive ones to flourish. Both psychotherapy and medications accomplish the same goal albeit in a different way and with different time frames (one can also argue that meditation, prayer, yoga, exercise, talking to close friends and loved ones etc can have similar effects).

Psychiatric medications can be a useful means to an end. They can help people begin their path to recovery and, used judiciously, can be lifesavers. However, as with everything else in life, ‘Caveat Emptor’.