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
“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
“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.”