Psychiatric drugs: do they really do what we're told they do?

Today I want to tell you about a book I’m reading at the moment. Although I’m only halfway through, I have no hesitation in recommending it: Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America by Robert Whitaker. The author is a journalist who specialises in medicine, and in this book he speaks very frankly about the so-called psychopharmacological revolution, that is, the moment psychiatric drugs arrived in our lives. It isn’t a dense book full of statistics; it’s very readable and flows easily. He explains how these drugs were discovered by chance (“magic bullets”), why the theories that supposedly explain how they work don’t have the scientific backing they should, how different historical and economic periods greatly shaped the way mental disorders were understood and the importance society gave them (the old asylums…), and countless other fascinating things, all of them backed by references to the scientific literature (although it’s worth knowing that some of his interpretations are disputed by other researchers). In my view, it’s quite an achievement to write a book on this subject and still make it an easy read. In this article I’m going to highlight some of the points I consider most important from what I’ve read so far, things I believe we should all know, because nowadays these drugs are handed out almost like sweets and, in my opinion, are given the status of a cure-all. And they’re not.

I want this to be a light read despite the subject, so I won’t include statistics or references, but if you’re interested you’ll find them all in detail in the book.

Let’s get started…

To begin with, you would expect that the number of people with mental illness would have dropped significantly since this “psychopharmacological revolution” began, but that hasn’t been the case. In fact, the number of people diagnosed with a mental disorder has soared in recent years. What’s more, this rise seems to coincide with the arrival of Prozac (in case you didn’t know, one of the star antidepressants of recent decades) and of other psychiatric drugs. Another fact worth mentioning is that the numbers have shot up not only in adults but also in children. So what’s going on? Does this mean psychiatric drugs don’t work? The medications used for mental disorders have shown a certain effectiveness; that’s beyond dispute, because many people benefit from them and, thanks to them, are able to lead a functional life. Even so, the figures above raise questions that, at the very least, lead us to consider some important issues.

If we go back to the early days of psychiatry, we’ll all remember how techniques such as electroshock, induced diabetic coma or lobotomy were once used to “cure” mental disorders (in fact, if you’re interested in the subject, a few years ago Netflix released a series set in the psychiatric world of that era, Ratched, which shows all these treatments and is, at heart, a social critique of everything that was done back then), not to mention the stigma of mental illness, the appalling state of the so-called asylums and the way patients were treated. After the Second World War, with all the veterans coming home and everything that entailed, mental health and the care and condition of the people living in those institutions started to become a priority. That was when research into psychiatric medicine as we know it today began, and the first anxiolytics, antidepressants and antipsychotics were synthesised.

At that point in history, the scientific community was asking two questions:

1. Whether people with mental illness had a real chemical imbalance that medication corrected.
2. Whether the drugs developed on that assumption really “cured” that chemical imbalance.

Let’s see what the evidence says about these two questions…

1) On the first question: do people with mental illness have a real chemical imbalance?

The serotonin theory (the one researchers rely on to explain how most antidepressants work) has been surrounded by a great deal of controversy over the years: some studies supported it, others dismissed it… It was much the same with the dopamine theory (the one used to explain how antipsychotics work in the treatment of schizophrenia): while many researchers supported it with their studies, just as many rejected it.

An important point we should always keep in mind: the fact that a drug improves or reduces the symptoms of a disorder doesn’t necessarily imply a cause-and-effect link. In other words, the fact that a drug produces some improvement (as antidepressants and antipsychotics did in depression and schizophrenia, respectively) doesn’t mean it is necessarily targeting the biological cause of the disorder. To this day there is no scientific proof that clinical depression or schizophrenia are caused by a biological deficit.

2) On the second question: if it hasn’t been shown that a chemical imbalance in the brain causes mental disorders, what do psychiatric drugs actually do if they’re not correcting an imbalance in brain chemistry?

The drug, for instance an antidepressant such as fluoxetine (the active ingredient in Prozac, a serotonin reuptake inhibitor), acts on the brain of a patient who, until proven otherwise, has normal brain chemistry. At first the corresponding changes take place and the patient’s mood improves, but, according to the author, in the medium to long term the serotonin system would adapt, for example by making the postsynaptic neurons, which are the ones that pick up serotonin once it has done its job, less sensitive. Whitaker argues that something similar happens with antipsychotics, although the clinical significance of these adaptations is still debated.

If this is right, then, as the author asks in his book, do psychiatric drugs help or harm patients in the long run? The author discusses several follow-up studies of people with schizophrenia, some taking antipsychotics on a permanent basis and others who weren’t medicated, in which the unmedicated patients showed better day-to-day functioning, fewer symptoms and fewer hospital admissions in the long term than the group that was permanently medicated. For Whitaker, this suggests that in the short term antipsychotics “work”, because they’re useful in reducing symptoms, but that in the long term they may be more harmful to the course of the disorder and to the patient’s quality of life. Put simply, he argues that the medication may increase the chances of turning the patient into a chronic patient. It’s worth saying that this interpretation is not a scientific consensus: these are mostly observational studies, in which the people who were able to stop medication probably had a better prognosis to begin with, and other studies show that continuing antipsychotic treatment reduces the risk of relapse. Even so, the question of what the best long-term strategy is for each patient remains open and is still being researched. The author links these results to what I explained a few lines above: antidepressants and antipsychotics produce changes in the corresponding pathway in the brain that improve symptoms, but in the long run, according to his hypothesis, they could disrupt that system and contribute to some patients with schizophrenia or depression getting worse over time. It’s an interesting hypothesis, but it hasn’t been proven.

I’d like to come back to this subject once I’ve read further into the book, because I think all of us, professionals in related fields and ordinary people alike, need a better level of pharmacological literacy, and that’s really what this author is aiming for: to open our eyes through the data, no more and no less. Let everyone read it and draw their own conclusions.

Highly recommended.

Important: if you take medication, don’t stop it or change the dose on your own. Any change should be made with your doctor or psychiatrist.