Some may find some the discussion at this site of interest.
“The flimsiness of the entire enterprise was brought home to me in devastating fashion in a conversation with Elliot Valenstein, a leading neuroscientist at the University of Michigan, and the author of three highly regarded and influential books on psychopharmacology and the history of psychiatry. I was talking to Valenstein about why today’s psychiatric drugs address only a very small proportion of the neurotransmitters that are thought to exist. Virtually all these drugs deal with only four neurotransmitters: dopamine and serotonin, most commonly, and also norepinephrine and GABA (technically known as gamma-aminobutyric acid). While no one knows exactly how many neurotransmitters there are in the humanbrain-indeed, even how a neurotransmitter is defined exactly can be a matter of debate-there are at least 100.
“So I asked Valenstein, "Why do all the drugs deal with the same brain chemicals? Is it because those four neurotransmitters are the ones understood to be most implicated with mood and thought regulation—that is, the stuff of psychiatric disorders?"
“ "It’s entirely a historical accident," he said. "The first psychiatric drugs were stumbled upon in the dark, completely serendipitously. No one, least of all the people who discovered them, had any idea how they worked. It was only later that the science caught up and provided evidence that those drugs influence those particular neurotransmitters. After that, all subsequent drugs were ‘copycats’ of the originals-and all of them regulated only those same four neurotransmitters. There have not been any new radically different paradigms of drug action that have been developed." Indeed, while 100 drugs have been designed to treat schizophrenia, all of them resemble the original, Thorazine, in their mechanism of action. "So," I asked Valenstein, "if the first drugs that were discovered had dealt with a different group of neurotransmitters, then all the drugs in use today would involve an entirely different set of neurotransmitters?"
“ "Yes," he said.
“ "In other words, there are more than a hundred neurotransmitters, some of which could have vital impact on psychiatric syndromes, yet to be explored?" I asked.
“ "Absolutely," Valenstein said. "It’s all completely arbitrary."
“The irony is that the shift to drug-oriented treatments has occurred even as the techniques of psychotherapy have improved dramatically. The old one-size-fits-all approach of long-term, fairly unstructured, verbally oriented psychoanalysis or dynamic psychotherapy has been replaced by a number of new approaches specifically geared toward particular kinds of patients.
“Traditional therapies can work well for highly verbal "worried well" patients with a fair degree of insight into their problems and motivation to do something about them. But such therapies clearly don’t work for many other people. Among the new, more tailored approaches developed during the past 20 years is cognitivebehavioral therapy (CBT), which gives patients the tools to examine the thoughts, feelings, and beliefs that lie behind their behavior, and develops the skills they need to enact change at a practical level. CBT has often been shown to be as effective as drugs in treating mild to moderate depression, with a significantly lower recurrence rate. It has also been used effectively to treat a broad variety of conditions, including bulimia, hypochondriasis, obsessive-compulsive disorder, substance abuse, and post-traumatic stress disorder, and it has even emerged as a means of reducing criminal behavior.
“Two other innovative treatment approaches-the Stages of Change model and Motivational Interviewing-have helped caregivers understand how to motivate (and help) people to change. These methods’ tenets, in a nutshell, are that change should be viewed as a cyclical rather than linear process; that the job of bringing about change is the responsibility of the patient, not the caregiver (a reversal of the centuries-old hierarchical construct of the doctor-patient relationship); and that the caregiver’s approach must vary according to the client’s "stage of change"-that is, the patient’s level of insight and motivation to move forward. The positive outcomes of these kinds of "psychosocial" approaches in addressing some of the most difficult human problems-including addiction and the resistance of people with mental and other illnesses to being drawn into -treatment have been shown repeatedly.
“These and other verbally oriented treatments are increasingly used by mental health professionals, but they have less appeal in the citadels of modern psychiatric thought. There, the biological model has triumphed, and not only because of the glittering promise it holds. Biopsychiatry is driven by a complex network of forces, not the least of which are the allure of treating patients expeditiously with drugs rather than time-consuming and sometimes-messy therapies, and the huge profits to be reaped from antidepressants, antipsychotics, and other psychoactive drugs. For patients, however, the benefits of the new paradigm are not nearly so unambiguous. By focusing so heavily on drugs, though they can be highly effective, particularly for severe conditions-we are neglecting to expose patients to the full array of treatments and approaches that can help them get better.
“If there’s any lesson to be gleaned from the recent history of psychiatry, it is, in the anthropologist Tanya Luhrmann’s words, "how complex mental illness is, how difficult to treat, and how, in the face of this complexity, people cling to coherent explanations like poor swimmers to a raft."
“We don’t know much, but we should know just enough to recognize how primitive and crude our understanding of psychiatric drugs is, and how limited our understanding of the biology of mental disorder. The unfortunate fact remains that the ills of this world have a tantalizing way of eluding simple explanation. Our only hope is to be resolute and careful, not faddish, in assessing new developments as they arise, and to adopt them judiciously within a tradition of a gradually but steadily growing arsenal in the fight against genuine human suffering.
“The part essay above is adapted from Charles Barber's new book, Comfortably Numb: How Psychiatry Is Medicating a Nation, which Pantheon will publish in February.”
Comfortably Numb: How Psychiatry Is Medicating a Nation by Charles Barber
Pantheon Books, 2008, hbk
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