Mental Health: Pharmacotherapy and Talk Therapy I
Mental Health and the Brain:
Our seventh session and resulting on-line forum discussion considered issues of genetics and development in mental health in the context of our earlier discussions of the brain. This week, we will move on to begin to think about existing forms of mental health therapy in that context.
Readings for this week
- My adventures in psychopharmacology
- Sunny side up
- Big pharma and American psychiatry: the good, the bad, and the ugly
- Bitter pill
Relevant recent materials elsewhere
- The behavioral revolution
- Challenging the world in whispers, not shouts
- A psychologist helps repackage Democrat's message
- Your brains secret ballot
Where we've been ...
"if our mental life is solely the result of our physical brains and the interactions between the neurons/dominoes inside of them then I don't see how we can continue to believe that we have "free-will." ... MartinBayer
"As I try to review the observations and decide what is least wrong, I find myself faced with two stories. The first story attempts to explain all of our human intricacies, tendencies and abilities in terms of the intimidating complexity of the nervous system. The other story attempts to explain all our human intricacies, tendencies and abilities in terms of the intimidating complexity of the nervous system PLUS add on an immaterial self to the top of that which no one can really observe or say anything about. All other things being equal, why would I choose to believe that I have this immaterial self that is also interacting with my already bogglingly complex nervous system?" ... ryan g
"what I was suggesting was not simply that there are two stories that explain things equally well but rather we have two stories which attempt to explain the same thing to different degrees of success. Chemicals react in a specific way, they don't get to pick how they react. They respond to other chemicals in a determined way, and that is quite simply the whole story of a material brain. That does NOT explain our experience of free-will. So, I agree with you the immaterial self is a "posit" that we can't prove by pointing to some material thingy but it is a necessary one to explain our experience. " ... MartinBayer
"In appealing to the storyteller as a vehicle for reshaping meaning, is that not an act of free will? Is that not the very point of “creating meaning” that we have the capacity, the ability, the possibility, if not always the tools, to craft a new story?" ... Sophie F
"Can we perhaps find a more nuanced approach, one that will help people understand the gene story in a way that doesn’t ignore its power, while at the same time doesn’t promote false views of us as helpless automons condemned to march haplessly along a pre-determined path? ...adiflesher
" I'm worried that if we start making excuses for people based on their genes that people will be able to get away with anything." ... Ljones
"By targeting genes that influence detrimental behavior, we can at least give a genetically predisposed individual a small advantage in avoiding detrimental behavior." ... Paul B
"where does this sort of thing stop? What sorts of behaviors amount to things that make us unique and different, and what are pathologies?" ... ysilverman
" I believe that nature IS nurture and vice versa. One does not exist in isolation with out the other." ... akerle
"The model you have proposed (the interaction between genes and environment being dynamic and interactive) seems to be much more useful and makes more sense. The effect of nature/nurture on behavior seems like the perfect place to implement another "loop model." ... ryan g
"Perhaps I always thought of genes affecting an individual more physiologically that mentally or emotionally. And perhaps I believe that nurture is more important than nature, and this is incredibly shocking to me because I am a die-hard biology major and am writing a genetics thesis. So I’ll just stop here and try to figure out more ..." .... llamprou
"It is more “natural” for me to see the correlation between one’s environment and behavior rather than one’s genes and behavior, so I suppose I was clarifying for myself that the role of genes is something important to be taken into consideration." ... Sophie F
Pharmacotherapy discussion take off points
As for the drugs, there is no great mystery about the efficacy of antidepressants. We have access to the results of large-scale trials whose protocols were published in advance and whose data have been analyzed openly at every stage. Study after study shows a response rate on the order of 50 percent to 60 percent, where the response to a placebo pill is 35 percent to 40 percent. In general, most of the positive change occurs in the sicker patients. The more stringent the study, the more robust the outcome.
Just because it feels like, just because it sounds like, just because soaring drug company profits and obnoxious direct to consumer advertising seem to indicate that everyone around us is popping pills like mad doesn’t mean that they are doing so. Nor does it mean that we’re in the grip of some new, previously unheard-of, and uniquely epoch-defining social phenomenon.
People have been unofficially drugging themselves for as long as they’ve had the capability to do so. They smoked cigarettes to boost their concentration. They drank cocktails with lunch and dinner — and more — to deal with anxiety and despair. Prior to the modern era of F.D.A.-regulated prescribing practices, they slugged down untold quantities of tonics and bromides.
…perhaps most troubling, is the implication that a recent major loss makes it more likely that the person’s depressive symptoms will follow a benign and limited course, and therefore do not need medical treatment. This has never been demonstrated, to my knowledge, in any well-designed studies. And what has been demonstrated, in a study by Dr. Sidney Zisook, is that antidepressants may help patients with major depressive symptoms occurring just after the death of a loved one.
Don’t get me wrong; we have very effective and safe treatments for a broad array of psychiatric disorders. But in everyday clinical practice, we have little ability to predict which specific treatment will work best for you.
rarely does an antidepressant medication far exceed the placebo in effectiveness.
As biological psychiatry defines more and more human variation as abnormal, and as the choice of prescriptions grows, the result will be an increasing standardization of behaviors and feelings, and a reduction in freedom, as biological psychiatry inexorably circumscribes ever more tightly the range of acceptable emotions and actions.
Discovering that I had a recognized syndrome brought my parents tremendous relief. The news was comforting to me too. All I had to do, I thought, was pop a few pills and I’d be as focused and success-driven as everyone else in my school. I’d be normal.
Calls for increased funding for pediatric psychopharmacology research are ubiquitous within the child mental-health community. The pharmaceutical industry, which now sees a children's market large enough to justify the expense, is funding several large studies, hoping to obtain FDA approval for the tested drugs.
On the other hand, studies on psychosocial interventions provide no similar profit-driven initiative for investigation. The much lower funding for this kind of research comes primarily from government. However, with the profit-motive incentive to develop new drugs and the real-life pressures to medicate children these days, there is ever-increasing pressure to medicate.
When all you've got is a hammer, everything starts to look like a nail.
The fact is, we’re not allowed to prescribe placebos in our practices, and we have patients coming to us and banging down our doors because they are miserable,” says Carlat. “We can’t offer them a sugar pill, but we can offer an antidepressant even if its effect is 80 percent sugar pill. A lot of our patients are getting better. That’s why we prescribe antidepressants even in the face of this recurrent data.”
In 2001, Americans spent more than $12 billion on antidepressant medications, the equivalent of $43.85 for every man, woman, and child in the country.
…by insisting that disorders like depression and anxiety are primarily caused by malfunctioning brains, the proponents and practitioners of biological psychiatry ignore clear evidence about the psychological and social factors equally at the core of human emotions. There is a great loss in that. As ever-increasing numbers of Americans take psychotropic pills, we all begin to believe that more and more of our feelings—sadness, shyness, anger—are illegitimate and abnormal and require biological intervention to correct.
Diagnostic and Statistical Manual of Mental Disorders, or DSM, has been revised three times since 1953—in 1969, in 1987, and in 1994. The 1953 and 1969 editions offered classifications that accorded with the psychodynamic model prevalent at their time, when conditions warranting treatment were understood to be disorders of the mind. Then, in 1987, the language abruptly shifted, and diseases of the brain became the new currency. Whereas in 1953, the DSM had named 60 psychiatric disorders, the current DSM describes over 350 diagnoses. Surely, a 480 percent increase in identifiable psychiatric abnormalities cannot have resulted solely from dispassionate scientific discovery.