Lambert here: I missed being drugged in grade school, for good or ill. A big generational difference!
By Joshua C. Kendall, a Boston-based journalist and author. His reporting on psychiatry, neuroscience, and health policy has appeared in numerous publications, including BusinessWeek, The Boston Globe, The New York Times, The Los Angeles Times, The Daily Beast, Scientific American, and Wired. Originally published at Undark.
About 40 years ago, Daniel Bergner’s younger brother, Bob, then 21 and a college dropout, had a psychotic break. He became delusional; he was convinced that he might be the messiah and that he could cure their grandfather’s Alzheimer’s disease. Worn down by insomnia, Bob was also neglecting his personal hygiene. Out of desperation, the brothers’ parents arranged to have Bob committed to a locked psychiatric unit, where he was soon pumped up on a heavy dose of Haldol, an antipsychotic medication.
Shortly after Bob was hospitalized, their father handed Daniel a popular book by the late Ronald Fieve — first published in 1975— on mood disorders. According to this prominent psychopharmacologist, psychiatry was undergoing “a third revolution,” which was leading to new and highly effective drug cures for major mental disorders, including schizophrenia, bipolar disorder, and major depression. This book, notes Daniel Bergner in “The Mind and the Moon: My Brother’s Story, The Science of Our Brains, and the Search for Our Psyches,” gave his parents hope that his brother’s condition could be treated. “It was as if they had ingested the book’s sentences and elevated its paragraphs to articles of faith,” he writes. “They were immediate converts.”
As Bergner, a contributing writer for The New York Times Magazine, emphasizes in his moving narrative, the chief claim contained in that bestseller of yesteryear — that mental illnesses are diseases for which there exist chemical cures — ended up gaining a lot of traction. But Bergner himself has long harbored reservations about such biological reductionism.
As he reports in this deep dive into the history of psychiatric treatments over the last century — which features interviews with leading neuroscientists and psychiatrists, as well as profiles of people like Bob who have waged long battles with psychiatric problems — the biological revolution in psychiatry has not come close to living up to its grandiose promises.
Medication can indeed reduce emotional suffering. Bergner cites research suggesting that about half of people who take selective serotonin reuptake inhibitors, or SSRIs — a category of popular antidepressants that includes the mega-selling Prozac — do experience some symptom relief “if comparison with placebos is disregarded.” But while the number of Americans taking psychiatric drugs has been steadily increasing over the past 20 years (more than 40 million adults and as many as 40 percent of college students, according to recent estimates), drug treatment, he stresses, often does not work at all and sometimes is harmful due to noxious side effects. For example, SSRIs, can cause both sexual dysfunction and withdrawal symptoms, both of which, Bergner notes, their manufacturers have minimized. And antipsychotics can cause weight gain and increase the risk of diabetes; according to internal records of pharmaceutical company Eli Lilly, 16 percent of patients taking its blockbuster drug Zyprexa gained more than 66 pounds.
The triumph of biological psychiatry, Bergner suggests, has everything to do with the close ties between Big Pharma and academic psychiatry and little to do with compelling scientific evidence. As he notes, an opinion article in The New England Journal of Medicine declared in 2019 that “psychiatric diagnoses and medications proliferate under the banner of scientific medicine, though there is no biologic understanding of either the causes or the treatments of psychiatric disorders.”
Take the chemical imbalance theory — as deeply embedded in the contemporary cultural firmament as Freud’s tripartite theory of the mind was a couple of generations ago — which posits that a serotonin deficiency can cause depression. Psychiatrist Steven Hyman, a former director of the National Institute of Mental Health, who now directs a center for psychiatric research at the Broad Institute of MIT and Harvard, suggests that this idea is just marketing double-talk. As he explains to Bergner, “How people could think that mediocre — important, but mediocre — drugs like the SSRIs could give us any comprehension is beyond me. The logic is like saying, I have pain so I must have an aspirin deficiency.”
Likewise, Eric Nestler, a professor of psychiatry, neuroscience, and pharmacological sciences at the Icahn School of Medicine at Mount Sinai, tells Bergner that it would be easy to argue that psychopharmacology has run into a dead-end, noting that “there hasn’t been a truly new mechanism for the treatment of any psychiatric disorder in over a half a century.”
During his initial hospital stay in 1983, Bob was diagnosed with bipolar disorder and told that he would need to take lithium for the rest of his life. After three or four years, he could no longer stand the side effects — a tremor in his hands and a feeling as if a blanket had been placed over his brain. After another stint in a psychiatric hospital, he was shuttled off to a homeless shelter. But after Bob stopped taking the medication and distanced himself from both his parents, he succeeded in rebuilding his life. He got married to “the love of his life” and now works as a pastor. “I’m just lucky,” Bob says to his brother, “that I’m crazy enough to have refused being crazy.”
Bergner also tells the story of Caroline, who, as a young girl, began hearing a slew of different voices. One warned her that various family members were in danger. Another, which she identified as Miss Kathy, repeatedly castigated her, and told her that her clothes smelled. By the age of 9, Caroline was taking a daily cocktail of antipsychotics to treat her troubling symptoms. But the drugs didn’t help much, and she became obese.
As a teenager, Caroline added to the mix a few recreational drugs such as heroin and ecstasy, which she would later pay for either with sex or by selling her prescription pills on the street. After dropping out of college, she stayed in residential facilities such as a therapeutic farm and a group home. She turned her life around though when she got off all the drugs and became a roller derby star. Caroline found a job with a nonprofit that involved working as a peer counselor with the Hearing Voices Network (HVN), an international movement that offers support by helping people accept their voices rather than try to suppress them. While her own voices have not gone away, Caroline has since become a national leader in the HVN.
Bergner tries to discuss what might be going on in Caroline’s brain with Donald Goff, a schizophrenia expert and professor of psychiatry at New York University. Goff’s immediate reaction is to ask Bergner if she had “been tried on clozapine” — an antipsychotic reserved for severe cases due to its particularly dangerous side effects. Goff’s response shocks Bergner. “It skipped the question of what life might currently be, for Caroline, free of medication,” he writes. “It was spoken with the presumption, the principle, that medication was the correct and best way to go.”
While Bergner’s critique of the disease model of mental illness may sound unduly harsh, it accords with the growing scholarly view that psychiatry’s current assortment of somatic treatments — namely, its numerous drugs for major mental illnesses — have not served patients all that well. This disappointing track record is also emphasized in “Desperate Remedies: Psychiatry’s Turbulent Quest to Cure Mental Illness,” a recently published history of the field by sociologist Andrew Scull. Like Bergner, Scull highlights how much severely distressed people need those who care for them — both their doctors and their loved ones — to do a better job of listening to exactly what is going on inside their hearts and minds. They are not merely diseased brains.
As Bergner argues, just as there are various pathways to mental illness, there are also various pathways to recovery; and while medication can be a useful tool, it is not a sine qua non. Psychiatry, he writes, needs to evolve because at present, “the profession’s reflexive reaction to distress and to divergent realities, to life’s agonies and its precipices, is to provide whatever medication is available, and to urge its long or permanent use, no matter how flawed the drugs, no matter how often futile, and no matter how potentially damaging.”
Sadly, as Bergner shows in his well-crafted narrative, the longstanding belief that there is a pill (or a drug cocktail) for every psychiatric ill is little more than a widely shared delusion, which can sometimes make life even harder for those who turn to psychiatry for relief from their mental anguish.
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My wife has mental health issues. She is able to live a normal life thanks to medication and good doctors care.It was a long difficult struggle.You need a good doctor to figure out what medications work. It takes time for this to happen. Also a person need periodic counseling to make sure their medications are working and to monitor any side effects. She will have to take medication for her life time. Medications can work for some people.Fortunately my wife is one of them.
I’ll repeat my brush with “official” pharmacopsychiatrics.
While clinically depressed a few decades ago, I sought help from the Parish Mental health clinic. They evaluated me, a two hour battery of tests and a “professional conversation,’ and put me on Prozac. A week later I was a functioning Zombie, (similar to a functioning alcoholic but without the fun of drinking all day.) I felt like the top of my head was missing, literally. Cognition was perceptably slowed. (I still could remember the ‘before’ state of my mind.) My motor skills were degraded. (For someone who worked in construction, that was a big problem.) Finally, my attention span had shrunk to nanoseconds.
It all came to a head one afternoon while driving to the corner store for something for Phyllis. I neglected to stop at a fully signed and very personally familiar street corner. (We lived at the end of one of the streets involved.) I dinged a neighbour’s car. (Later said neighbor tried to con me into paying for a new car, but that’s another story.)
The next morning I threw away the remaining doses of Prozac and have never looked back. It took me several weeks to return to “normal.” I discovered that I preferred to be depressed to being in thrall to that Demon Drug. I was lucky in that Phyllis agreed with my decision and helped all she could to ease the transition back to the status quo ante.
Having people around you who care enough to put aside their own needs and desires for a while to focus on helping you is paramount. I will be willing to state that this category generally does not include paid assistance. With the accelerating atomization of society and the financialization of the medical field, expect the cohort of psychiactically “challenged” persons to grow quite large.
We all know that psychotropics are grossly over prescribed, like most of Pharma’s products. When the only tool you know how to use is a hammer, everything looks like a nail. While it is possible in some cases for people to manage serious mental illness without medication, that is exceptional.
Having said that, our son experienced 3 psychotic breaks, first one at the end of the first year in university. Each resulted in hospitalization (mental health wards are awful places!). He was diagnosed with schizophrenia. Twice he gradually tapered off his medication under medical supervision and family support. Both times after 6 months, despite his heroic efforts the delusions returned. In spite of this he actually got good grades. But at the end of the semesters things were unmanageable for all concerned. The good intentions of his parents and therapists couldn’t halt the downward spiral.
Over the ensuing 12 years, he has been on at least 8 antipsychotics. All have undesirable side effects, a couple were quite serious. He has been on clozapine for 7 years now. Yes, in 2% of cases it can cause a blood disorder (agranulocytosis). For the first 6 months FDA requires weekly blood tests, biweekly for the next 6, then monthly. Psychiatrists don’t like the management of clozapine for this reason. However it has proven to be one of the most effective treatments. Clozapine is the drug of choice in many countries, including China, but generally blood tests end in a few months.
For our son, All of us agree without clozapine he wouldn’t have a decent life. Clozapine allowed him to finish a degree in molecular biology and have a semi-normal life. But he remains disabled. He’d require a compassionate, tolerant, mentoring employer. How many workplaces are like that in the Covid era?
The problem is stigma… mentally ill persons scare normals. There are rare incidents of violence, but most often the mentally ill are victims. Funding and services are threadbare; handing out pills is cheap while therapy and work/study assistance is expensive. Providers are difficult to find and are grossly overworked. Safe housing is difficult and many mentally ill do not live with family. Supported housing in Central New York is pretty gruesome and NYS does a better job than most.
> “there hasn’t been a truly new mechanism for the treatment of any psychiatric disorder in over a half a century.”
Doesn’t that say it all? How many disabling diseases, injuries, acute illnesses are there were treatment options haven’t changed in half a century? As a society we simply do not care about the mentally ill. We wish they would “go away” and not be seen at all.
Sometime in the 80’s I read “Is there no place on earth for me?“, Susan Sheehan’s chronicle of a woman’s experience of schizophrenia. The book also described how the appearance of antipsychotic drugs had led to widespread changes in public policy regarding mental health treatment and funding, promoting the idea that institutions then housing and caring for people suffering from schizophrenia and other illness could be shutttered, and their patient populations released into the general community. The account was painful to read, casting in plain terms the self-abuse and neglect these people suffered. They need help and care: there are no silver bullets here.
The date for this change might be pushed back a little further. The fall of 1970, my senior year in high school, was interview season for colleges. These interviews included meetings with local alums of the colleges to which I applied, and one of these proved to be quite interesting from my standpoint. At the time, I was both naive and interested in psychiatry. The alum interviewer was a businessman, but his brother was a psychiatrist. When I started talking about Freud, Jung and Menninger, he told me that his brother said that psychiatry was going the chemical route. Talking to patients was on the decline.
One issue not discussed is the role of insurance reimbursements. There is no parity for psychiatric treatment under private insurance, the fees are abysmally low, especially for therapy alone. During the biological psychiatry movement in the 1980’s, psychiatrists embraced biological psychiatry for many reasons. At the same time we were concerned with a big legal case in which a psychoanalyst was sued and lost when treating the patient with depression with therapy alone (pt had a bad outcome). The treating psychiatrist was blamed for not prescribing meds. This landmark case led to some defensive prescribing to treat depression. Then prozac hit the scene and changed the world. If insurance paid MD’s equally for therapy alone vs therapy and meds or med management alone, psychiatrists would more readily provide more therapy instead of medicating only and referring out patient’s for therapy, imho. Meds can be a life saver, but psychiatrists have been pushed into the role of “prescriber only” by many forces, and we have complied with this transition. Now nurse practitioners are being placed in the same role to replace psychiatrists in many medical centers. Just one opinion and no offense intended towards my very dedicated colleagues. A more holistic approach to treatment including diet, exercise, meditation, therapy, etc… really is best for many patients but we hardly have the time to address these things under the current treatment model of 15 minute visits. Of course corporate medicine has made it even harder. People who can do this work (which is time consuming) often avoid insurance contracts in order to get paid appropriately.
But is anything more than 15 minute visits possible when psychiatrists, like all MDs, insist on getting pay that puts them in the top 1-2% of incomes?
Medical school costs 50k+ per year. Lots of debt…
One aspect of this issue is how some organizations advocating for the mentally ill, such as NAMI, the National Alliance for the Mentally Ill are heavily funded by the pharmaceutical industry. Medication is sometimes necessary and helpful but is vastly oversold, and the possible negative consequences (suicide, violent outbursts, weight gain, suppression of creativity), are minimized or ignored.
Many borderline people can be helped by modifying their social circumstances, and creating an environment that allows them to function in a positive way. We’re not all able to spend so much time sitting at a desk doing what is so often pointless work. That’s the real craziness.
gotta love the weird dichotomy/paradox that we’ve built into medicine here: if you have an unrecognized yet chronic condition that can’t be seen or accounted for in labwork of various kinds and is resistant to basic pain meds or muscle relaxants or whatever, it’s “in your head” and then when you go to the Head Shrinker, he says it’s “in your body” and hands you…different drugs.
fluoxetine just made me sleep. i wasn’t “depressed” any longer because i wasn’t conscious long enough to be depressed. the rigmarole to quickly get this into my system was done at a free county health clinic. they quickly worked through the bureaucratic gyrations of that and then told me that getting into a counselling group (no individualized, just group) would take waiting on a list for possibly up to a year.
essentially, most people are not going to be still depressed within a year, drugs or no. some significant percentage of people move through their depression without interventions at all (because it is situational, and life goes on. i am not talking about clinical depressives, which i believe i have been nearly my entire life). so i got the message: “take these drugs and go away, please. if you’re still here in a a year, maybe we will do something then”.
by the time they called me for the group counselling, i had moved out of the state entirely.
At first, when the big seeming advances came about–schizophrenia, for instance, being amenable to drug therapy, lithium as a wonder drug, it did seem as if a breakthrough had come. Yet the years since also make it evident that drug therapy for mental illness is just a cheap treatment to keep complaints from being too costly. It isn’t just boys being diagnosed en masse and drugged for ADHD. It is also those mythical centrist suburban white woman gobbling anti-anxiety drugs.
One of the most famous cases of antiquity is Aelius Aristides. Reading about him and his trips to the temples of Asclepius is eye-opening indeed. The practice of Incubatio, “temple sleep,” is remarkable. The diagnosis would be revealed in part in dreams–something C.G. Jung learned later, and Jung even notes some dreams that predicted death.
The temples had physicians and priests on staff. So you would have a medical doctor to talk to and a priest to talk to. [The sacred dogs that licked wounds are remarkable, as are the resident (nonvenomous) temple snakes. We still see sacred dogs in images of St. Roch / Rocco, a plague saint, and snakes are still considered good luck in places like Greece.]
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)60471-2/fulltext
Was Aelius Aristides just some nutso? In spite of his illnesses, he lived to age 62 or so. For much of his life, he had a flourishing career. Maybe, Aelius Aristides was like Bob Bergner, just crazy enough not to want to be crazy.
(going anonymous for this one)
Brilliant. Thanks for this and the link.
I’ve had some success with various medications for the roller coaster of depression, and if I find myself there again, I’ll not hesitate to follow my very good shrink’s sound advice. I think the best thing I did was TMS. Really brought things down to the point where I could deal with the breakdowns and anxiety by adjusting my lifestyle slightly. YMMV
Many thanks, DJG, Reality Czar.
A bit off-topic, but it may be interesting to mention that the image of the sacred dogs licking the wounds and helping with the healing of the sick was adopted in Cuban popular Catholicism, and it appears always as part of the iconography of San Lázaro. Since Cuban Catholicism is often blended with Afrocuban religions, this Catholic saint is syncretized with Babalu Aye, an African orisha or god. Here is a link (English and Spanish; the English version isn’t bad but is not perfect).
https://www.thecubanhistory.com/2012/04/babalu-aye-and-san-lazaro/
I was hospitalised four times for bipolar disorder, including two times against my will, until I managed to stabilise on lithium treatment. Some people have bad side effects from lithium; I don’t have any. It doesn’t work for everyone; but it works very well for about 50% of patients, including me. Thanks to the drug, I’ve been able to lead a normal life for 22 years. The only drug that can completely cure bipolar is lithium, but the only mention of it here is negative. People might refuse to take lithium after reading this article, and that could ruin their lives.
Thanks for this book link!
I have Schizoaffective Bipolar Disorder, three suicide attempts, four hospitalizations. I also have an autoimmune disease. I am no longer on psychiatric medications because they are no different than heroin to me. They shut me off but they are no cure and trade one set of symptoms fro another.
What I have discovered in myself and what has helped me is knowing that mood disorders are immune disorders and not neurological disorders. In my opinion, it is the immune system that changes the neurobiology.
But these medications, when used correctly, can save lives in the short term. They saved my life quite a few times and klonopin still saves me when I need it. But since the causes of mood disorders are so so many different genetic and environmental causes we will never find a magic medication for any of these disorders. It will come down to personalized medicine.
And Paul, a comment on lithium, it did nothing fro me but I still know that does not means it will not work for others. The literature is clear on this, that there are lithium responders and non-responders. Lithium has been know for a long time to effect the immune systems as well.
So what am I saying? Basically there is an in between. Psychiatric medications should be used as a treatment until they find out what is going on with the immune system. But this is the opposite to what has been happening. They just pump you full of meds and forget about you.
Thanks, JAC. I don’t know enough about the immunology of mental “Dis-Ease” to agree or disagree with your very interesting theory, but everything else in your comment strikes me as the wisdom and enlightenment that comes only to someone who has walked this path.
JAC, I agree with the immune disorder theory, and I sometimes see articles about it. Around 1999, I took the interferon/ribavarin treatment they pushed, at the time, as a ‘cure’ for HepC. Interferon was well known to cause depression and suicide. I had to sign statements saying I had never attempted suicide and there were no suicides in my family. (Interferon is an immune chemical, the exact cytokine that causes pain and it was ‘pain in a bottle’.) The idea is to crank up your immune system and kill the virus. It didn’t seem to have much effect on the HCV, but I developed some kind of depression/anxiety that put me in such a state of terror, I knew couldn’t live that way. It was unfocused, just sheer gibbering terror but I never let on how bad I felt. I stopped the treatment, and drank lots of water, hoping I could wash it out. I did not want even more chemicals! The worst of it cleared up in a few weeks, but it took years to straighten out the anxiety. So, I think there is a clear connection, there.
Three insights on psychoneuroimmunology of mood disorders to be taken from the COVID-19 pandemic
In the civliization fomerly known as Christendom, superstitous reaction to scientific discoveries is more influential in forming understanding of ‘disease’ than scientific discoveries in medicine. Reaction to Newton and Darwin as much as to, for instance, germ theory.
The results can be very strange. ‘Disease’ is invoked both to absolve the sufferer of moral taint, but even more often, to attaint suffering. The idea that homosexuals are diseased was once enlightened thinking.
Thank you for the book review Lambert, and for bringing up this important topic. I will read the book.
For those interested in further reading along the same lines, I can recommend Gary Greenberg’s 𝘔𝘢𝘯𝘶𝘧𝘢𝘤𝘵𝘶𝘳𝘪𝘯𝘨 𝘋𝘦𝘱𝘳𝘦𝘴𝘴𝘪𝘰𝘯: 𝘛𝘩𝘦 𝘚𝘦𝘤𝘳𝘦𝘵 𝘏𝘪𝘴𝘵𝘰𝘳𝘺 𝘰𝘧 𝘢 𝘔𝘰𝘥𝘦𝘳𝘯 𝘋𝘪𝘴𝘦𝘢𝘴𝘦. Published in 2010, it is exceedingly well-written and spiced with humor and wit.
https://www.amazon.ca/Manufacturing-Depression-Secret-History-Disease/dp/1416569804
Greenberg is a practicing psychiatrist who also hasn’t bought into Big Pharma’s decades-long campaign to “pathologicalize” unhappiness and turn it into the very profitable Disease of Depression. All the while, as the writer of the book reviewed here points out, it has downplayed the addictive properties and side-effects of its psychotropic drugs and virtually ignored placebo effects in its clinical trials.
This kind of thinking is every bit as dangerous as the idea that pharma can cure anything. Depression is neither a “modern disease,” nor is some kind of chronic unhappiness. The last thing we need is more pop psychology.
He recognizes that depression is and can be a serious disease. He questions, though, whether unhappiness, short-term or prolonged, is clinical depression. That’s what the pharmaceutical industry would have us believe, on very slight evidence.
Just took 45 mins out of an insanely busy and stressful day to look up some info on Greenberg (preparing to take sick kitty to vet in the morning, first time in 7 years, because last visit nearly killed him). For starters, this book is outdated; the science has advanced by light years since then, some of the research has been mentioned on NC, IIRC (including studies of neurological changes in the brain caused by COVID).
Secondly, pharma’s role as pusher, aided and abetted by consulting firms, insurance companies, PE, and goddess knows who else, is well-documented and also a frequent topic here. Thirdly, after reading interviews in which he does some major backpedaling, my takeaway was a rambling mess of vague opinions by a writer who needed something “important” to write about and who overstated his case to market his book — ironically, not much different from the drug companies. For sure, he has valid points, but I doubt much of it is news to NC readers. Speaking for myself, I wouldn’t waste any more time on this book.
My older sister was depressed all her life, likely due to sexual abuse at an early age. She was “functional” from the standpoint of finding and keeping jobs; relationships were another matter entirely. She flat out refused to take antidepressants out of fear they would change her personality. A few days after turning 45, she committed suicide. She had planned and elaborately prepared for it months in advance, without giving so much as a hint to the psychotherapist she’d been seeing for years.
Of the six remaining siblings (both of our parents were long gone), I was the only one who wasn’t angry with her. Having been clinically depressed myself from childhood, I
had some clue what she was suffering. I chose at one point to try Prozac — it was just short of miraculous, but the ramp-up was traumatic, and after six months, the side effects became debilitating, so I couldn’t fault her for not wanting to go that route. Moreover, I respected her right to end her own life. The only sibling who ever spoke to me again was my younger brother, and even then, it took him ten years.
Is anyone evaluating the usefulness of psychedelics?
It seems to me that this is something new.(to that aim)
from mushrooms/psilocybe
or even ketamine. and cannabis
One thing that does sound clear; is that there is no ONE anything. no one disease. no one experience. the spectrum of reality, as to the: cause, severity of experience, treatment, life path, etc… all seems to be individual. So it seems that these other options, which may work for some. should be allowed to try.
End the prohibition.
Thank you for spreading info about that issue, it’s very important.
I’ve not read that book yet, but it for sure will do!
Thanks for the interesting article. I find a lot of the material curious. I previously studied psychology at the University of Maryland and wrote about it on a student resource https://studymoose.com/university/university-of-maryland in an article about application essay samples. I think that such practices will only help people in the future. Modern science is moving forward and I am glad that many fields are evolving.
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