Wednesday, February 24, 2010

The Uses and Misuses of Psychiatric Medication

Many moons ago, when I was training to become a psychoanalyst, my supervisor told me that since I was not a physician I should not be offering an opinion about psychiatric medication.

The advice was sound then; it is sound now.

My supervisor had good reason to insist on this point. As I was learning, any time anyone declares that psychiatric medication is bad for you, the people who are quickest to latch on to the message are those who need it the most: schizophrenics and paranoiacs, thus, psychotics.

When I was training many people were enraptured by the anti-psychiatry of R. D. Laing and David Cooper. As it happened, Laing and Cooper were physicians. Yet, when they encouraged psychotics to refuse treatment they caused far more harm than good.

For the record, Laing and Cooper felt that schizophrenics were not insane; they were expressing truths that had been repressed by capitalist-imperialist-warmongers. They believed that psychiatrists wanted to medicate schizophrenics to shut them up, to silence their inconvenient truths.

The issues surrounding the use and misuse of psychiatric medication are difficult to grasp because we often do not make the most important distinctions.

On one side psychiatrists deal with psychotic patients whose problems, current research suggests, derive from defective brain structure. Schizophrenia and paranoia would thus not be psychological disorders.

Psychiatrists also treat those who suffer from bipolar illness, which is now considered to be a metabolic disorder, not a psychological disorder.

In those situations medication is imperative; no psychological treatment has ever been shown to work. No one should ever suggest that these patient groups should ever forgo medication.

Aside from these extreme cases, psychiatrists also treat patients whose conditions have a biochemical component, and thus, that can often respond to medication, but that can also respond to other forms of treatment.

Take the example that opens Louis Menand's New Yorker article: "Head Case: Can Psychiatry Be a Science?" (link here.) A man has been laid off from his job. He becomes withdrawn, demoralized, and dysfunctional.

From a psychiatric perspective he is suffering from depression. If you hook him up to a PET scan you will discover that his depression manifests itself in inhibited brain functioning. We will grant that there are medications that will alter the chemical composition of his brain to the point that he will feel better.

(As Menand explains, the last point is controversial. For the sake of argument, I will grant it.)

It is true that medication might help this man. But then again, so will a new job. Since inactivity and joblessness are an important cause of depression, Dr. Richard Mollica of Harvard Medical School once famously asserted that: "the best anti-depressant is a job."

Let's say that for someone who is jobless a new job will cure depression. We might even add that for someone who is socially disengaged, a new circle of friends, a new group membership, coupled with activities might produce the same effect.

Let's imagine that such "cures" produce an improvement in brain chemistry.

But what about the patient who cannot, of his own volition, get off the couch and start looking for a job. Perhaps his depression is so severe that it must be medicated. But it might also be the case the he has been taught by the culture that if he does not feel that he really wants to start looking he should not force himself to get up and get out.

I have said it many times before, this piece of accepted cultural wisdom makes an important contribution to the persistence of depression.

Of course, a job is not the only thing that can produce an improved biochemical balance in brain chemistry. If I recall correctly, cognitive treatment can also produce these effects, while improving mood, attitude, focus, and concentration. We also know that aerobic exercise also improves mood, attitude, focus, and concentration. And finally, many forms of psychotherapy have also been shown to ameliorate a depressive condition.

(I will mention in passing that therapy helps depressed patients if the patient and therapist make a human connection, if they converse and show each other mutual respect. Dare I say that classical psychoanalysis would never allow such a thing, so that when someone like Menand says that psychoanalysis can help a depressed patient, he should have added that this is only true if the psychoanalyst (or the therapist, for that matter) is functioning more like a life coach and less like a therapist.)

These thoughts raise some pertinent questions. If a job is the best antidepressant for a man who has just lost his, why would Prozac not be part of his treatment? Surely, it might have a place, but it does not function in the same way that a job does.

Prozac will make the man feel better whether he has a job or not, and we can ask ourselves whether that will make him more or less likely to do what it takes to find work.

Even if we grant that Prozac will improve your mood, it does not supply you with social skills. It does not contain a program that will naturally impel you to do the right things in your job search. You may need medication to get up off the couch, but you will surely need a clearer action plan if you are going to solve your unemployment problem.

Anyone who imagines that Prozac alone will cure you of joblessness or of social isolation and anomie is simply being naive. It is simply not true that social and work skills are lying dormant in your mind, only needing the prod of Prozac to be awoken and put into action.

I would add that taking pills is basically a passive experience. You are not doing what you must do to get a job, and thus feeling that you have earned your better mood. When you rely on Prozac you are passively allowing a chemical substance to induce an improved mood that has nothing to do with your own efforts. Then we might ask that a cheery attitude that you have not earned by working for it, whether on the job or following a plan for improving your life, is really yours.

If Prozac provides people with the impetus to go out and do what they have to do, then it surely has a place. If it works wonders for people who do not respond to anything else, then, well and good. But if it creates a false impression that taking a pill is all you have to do, and that it will help you to feel good about being unemployed, then it is not working for you. It is working against you.

1 comment:

Dr. Larry Deutsch said...

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