Friday, June 21, 2019

Lauren Slater's Pharmacoepia

I don’t need to tell you, but I have no expertise whatever in psychotropic medication. Thus, I will continue my normal habit and not offer personal opinions on the subject.

Such is not entirely the case with Lauren Slater. A trained psychologist-- who no longer practices-- Slater has also had considerable experience as a patient taking psychiatric medication. If we want to be charitable we can say that she has had a mixed experience. She recounts it in her book Blue Dreams: The Science and Story of the Drugs That Changed Our Minds.

But, Slater is also a talented writer and researcher, and she serves as an excellent guide through the labyrinthine world of psychiatric medication. She understands full well that these medications have consistently been oversold. And she sees that the negative side effects must be evaluated in relation to the positive results. It’s not a simple picture at all.

So, we all remember when Prozac burst on the psychiatric scene in the 1980s. We recall that it was sold aggressively as a cure for depression and for just about anything else. As it happened Slater counted among those who first took Prozac. Maggie Jones's New York Times book review recounts Slater’s experience:

Thirty years since that first dose, neither Slater nor the drug has aged particularly well. Slater, who has spent much of her life wrestling with bipolar and obsessive-compulsive disorders, jumped from an initial prescription of 10 milligrams to 20 to 30 to 60, landing at 80 mg, which is where she left off in “Prozac Diary.” A doctor eventually upped her dose to 100 mg a day — 20 beyond what’s F.D.A. approved. But the drug that had “so magically removed the dead-weight symptoms so that my whole world became a gorgeous glimmer” ceased working once again. Many psychiatrists theorize that each relapse makes the brain more vulnerable to future episodes and leads to a lifetime of antidepressants for people who have had depressive episodes. At the same time, Slater notes, few studies have examined the long-term side effects of these serotonin boosters.

What else is Slater taking. The question seems to be: what hasn’t she taken. The pharmacopoeia in her medicine cabinet does not speak too well for the diagnostic ability of her psychitrists:

Slater’s current medicine cabinet includes the antidepressant Effexor, the antipsychotic Zyprexa, another antipsychotic, Abilify, the stimulant Vyvanse, the anti-anxiety medication Klonopin, as well as lisinopril to combat the high blood pressure caused by Effexor. Add in some of the other psychotropic medications she’s tried — Imipramine, Geodon, Risperdal, lithium — and it starts to read like a pharmacist’s daily fill list.

If I were to offer a modest critique here, I am wondering about these psychiatrists. Yes, they are credentialed professionals, but are we letting them off too easily? How good are they at doing differential diagnosis. I say this because the medications Slater has taken would have it that she suffers from every psychiatric disorder known to man. And, by the way, if she is bipolar, hasn't psychiatry long since known that it, which used to be called manic-depressive psychosis, is a metabolic disturbance?

Some of Slater's medications have some decidedly negative side effects:

But it’s Zyprexa and its side effect of increased appetite that particularly shadows Slater. Her mouth waters at the mention of food. She scoops marshmallow fluff out of a jar and downs several enchiladas at a time heaped with mole sauce. Now at 160 pounds on her 5-foot frame, she is diabetic and in kidney failure, her mouth thick with thirst and her urine thick with sediment. “A single warning from a single doctor when I was in the depths of despair,” she writes, “could not adequately convey the message that by swallowing this new drug I was effectively agreeing to deeply damage the body upon which I rely to survive.” Her attempts to withdraw from medications have proved disastrous: She once bought a gun and another time wrote suicide letters to her children, before retreating back to the blanket of meds again.

Of course, it is not entirely a horror show. Slater maintains a balanced attitude:

Just as important, her experience makes her a convincing travel guide into the history, creation and future of psychotropics. She is, understandably, not an uncritical cheerleader. But she resists the facile role of hard-charging prosecutor. And no wonder, really, given that the drugs have allowed her to have two children, write nine books, marry (and divorce) and hold dear friendships.

One does not know whether she would have had a better or worse life if she had not taken the medications, so one will refrain from commenting.

True enough, Thorazine and other neuroleptic drugs can produce some negative side effects. And yet, they were a godsend to many psychotic patients:

So, when she takes us back to the 1950s and the story of Thorazine, she doesn’t just give us a “One Flew Over the Cuckoo’s Nest” bag of horrors, but also a glimpse into doctors’ excitement when the drug quelled patients’ delusions and hallucinations and the once-comatose resumed living. A former barber, who had been in a haze for years and for whom all previous treatments failed, returned to shaving (his first customer: the doctor who gave him Thorazine). A juggler asked for billiard balls and began juggling again. And people on one psychiatric ward picked up musical instruments, used drills and saws, held conversations that had been unthinkable shortly before.

As for Prozac and the current love of SSRIs, apparently, the science about their effectiveness is far from settled:

But studies have never proved that depressed people suffer from low serotonin (some do, some have normal levels and others have high levels). And SSRIs often fare no better than placebos for mild to moderate depression. Still, doctors tend to talk about depression as if the science is settled, often telling patients: If you’re diabetic you take insulin; if you’re depressed you take a pill. The analogy, of course, doesn’t hold. There is no blood test, no X-ray, no urinalysis that pinpoints depression. It is a field, Slater writes, “still stuttering, with at best a slippery grasp on the science behind its pills and potions, a legion of medical men and women who can help you in one way but hurt you in another.”

By all measures, Slater seems to have written a valuable book. She has provided a balanced assessment of the value of psychiatric medication.

And yet, shouldn’t we also ask why we believe so completely that all emotional and mental health issues require medication? Surely, some do. Psychosis is most likely a brain disease, one that responds well to medication. And yet, depression and anxiety are part of everyday life. Do we really need to medicate them as much as we do? And do we really want to be a culture that wants to think that biochemistry is the answer for all human problems. And let's not forget: these medications are being prescribed by medical professionals who are certainly fallible themselves.


whitney said...

"A former barber, who had been in a haze for years and for whom all previous treatments failed, returned to shaving (his first customer: the doctor who gave him Thorazine). A juggler asked for billiard balls and began juggling again. And people on one psychiatric ward picked up musical instruments, used drills and saws,"

this reads like a Horror Story because it sounds like severely mentally ill people just picked up a bunch of weapons

David Foster said...

It's a little odd, when you think about it, that in a society which is suffused with *software* in almost all its aspects, that it should be so commonly thought that human behavior is almost totally a matter of the *hardware*.

trigger warning said...

Not strictly in defense of the psychiatrists, I think it worth noting that many patients walk in the door with a strong desire for the medications, believing - as the marketing, medico/psychological professions, insurance industry, and the pharmaceutical companies would have them believe - that salvation has been solved, and science says it's available from the corner drugstore. After all, the customer is always right, eh?

Stuart Schneiderman said...

True enough, many patients have learned to ask for certain medications. The problem, as I see it, is that they, perhaps like Slater, are receiving so many different kinds of medication that we can ask whether the psychiatrists are really prescribing as a function of a specific diagnosis or whether they are simply handing out pills... without very much discrimination.