The word was easy to read even from my vantage point, upside down from the doctor’s view. In front of her lay a sheet of paper. Across the top, she’s written “antidepressants.” The word may have been followed by a question mark. And it was placed there because of what I’d shared. My son: didn’t like school, had few friends and seemed sorta sad. He was only ten years old. The offer came as a complete surprise. Don’t get me wrong, I’m not against antidepressants. In fact, I have taken them myself.
Fifteen years ago, a doctor troubleshooting gastrointestinal symptoms, prescribed me metoclopramide. A month into the planned six-week treatment, I experienced one of its “serious side effects,” namely, thoughts of suicide. A switch flipped inside my formerly rational brain. My thinking became conspicuously different. To counteract this medication-related symptom, another doctor prescribed a tricyclic antidepressant and a benzodiazepine. A few weeks later, when I started watching the clock between doses (impatient for the return to the feeling of uncaring calmness that came every time I popped another pill) I knew it was time to stop taking it (against my doctor’s advice). And did. The anxiety I experienced under withdrawal was many times higher than that that led me to it in the first place. Six months later, with the addition of talk therapy, my thinking returned to normal and my use of antidepressant ended.
My son’s neurotransmitters survived his teenage years without perturbation, but my daughter’s weren’t so lucky. She endured a mental health nightmare that we learned about in the fall of her junior year that continued for nearly fifteen months. I’m not at liberty to share the specifics, but the collateral damage was significant: she missed so much school that she had to transfer from the traditional to the alternative high school. The experience involved six trips to three different emergency rooms plus related care during which we had interactions with dozens of mental health care professionals in addition to repeated contact with a counselor and a psychiatrist. More often than not (except, for the most part, the staff at Seattle Children’s ER), these professionals’ actions and recommendations (or lack of): did not help, helped minimally, and/or made things worse. Too many times along this journey, we should have been given better advice. And my daughter, better care. When this scary scenario was over, her psychiatrist recommended a book with non-medication techniques to help her help herself with the symptoms. Although useful, it came 265 days late, thousands of dollars short and with an incomprehensible amount of irony.
As things returned to normal, I discovered Robert Whitaker’s Anatomy of an Epidemic. Within 24 hours, I’d read it cover to cover, highlighting helpful passages. Within a week, I’d read it again and ordered several copies to share. The biggest takeaway was two paragraphs (p 83) in which Whitaker elucidates neuroscientist Steven Hyman‘s paper Initiation and Adaptation: A Paradigm for Understanding Psychotropic Drug Action, ‘Antipsychotics, antidepressants, and other psychotropic drugs, he wrote, “create perturbations in neurotransmitter functions.” In response, the brain goes through a series of compensatory adaptations. If a drug blocks a neurotransmitter (as an antipsychotic does), the presynaptic neurons spring into hyper gear and release more of it, and the postsynaptic neurons increase the density of their receptors for that chemical messenger. Conversely, if a drug increases the synaptic levels of a neurotransmitter (as an antidepressant does), it provokes the opposite response: The presynaptic neurons decrease their firing rates and the postsynaptic neurons decrease the density of their receptors for the neurotransmitter. In each instance, the brain is trying to nullify the drug’s effects. “These adaptations,” Hyman explained, “are rooted in homeostatic mechanisms that exist, presumably, to permit cells to maintain their equilibrium in the face of alterations in the environment or changes in the internal milieu.”¶However, after a period of time, these compensatory mechanisms break down. The “chronic administration” of the drug then causes “substantial and long-lasting alterations in neural function,” Hyman wrote. As part of this long-term adaptation process, there are changes in intracellular signaling pathways and gene expression. After a few weeks, he concluded, the person’s brain is functioning in a manner that is “qualitatively as well as quantitatively different from the normal state.”‘
The content of Whitaker’s book opened my already skeptical of long-term-use-of psychopharmaceuticals eyes. I have since read, reread or revisited several books about mental illness and studied two new ones. Elio Frattaroli, MD, author of Healing the Soul in the Age of the Brain claims (p 394), “…dramatic changes in personality can be produced in three different ways: through the action of body-brain over mind, as typified by Prozac; through the action of spirit over mind, as typified by a religious conversion experience; and through the dialectical integration of body-brain, mind, and spirit as it occurs in the psychotherapeutic process. Of these three, I believe the one one that reliably produces genuine, deep, and lasting personality change is the psychotherapeutic process.” In Norman Doidge, MD’s absolutely fascinating The Brain that Changes Itself, the author dedicates an entire chapter to the use of psychoanalysis as a treatment for mental health issues and asserts that it leads to neuroplasticity.
I avoided going down the rabbit hole myself while all this was happening by a sort of self-psychotherapy that involves a combination of mindfulness and thinking about thinking, which I was surprised to see Susanna Kaysen explain in Girl, Interrupted (p 138), “There is thought, and then there is thinking about thoughts, and they don’t feel the same. They must reflect quite different aspects of brain function…The point is, the brain talks to itself, and by talking to itself, changes its perceptions.” This idea has worked for me and others who I care about and I hope that, with practice, it will work for my no longer medicated daughter.
During the past year and a half, I’ve learned more than I ever wanted to about psychopharmaceuticals, the mental health care system, mental health care professionals, and mental illness. While I believe that there is a place for short-term use of these medications (typically in conjunction with talk therapy), I think that doctors overprescribe them and patients, under-informed about potential pitfalls, over-expect (and accept) them. In hindsight, I wish that we had refused neurotransmitter perturbing medications to treat my daughter’s mental health condition. If we knew then what we know now, we would have. My advice to those considering the use of psychopharmaceuticals: read Anatomy of an Epidemic first, so that you can make your decision with eyes wide open.
Update: The Lancet recently published The Clinical effectiveness of setraline in primary care and the role of depression severity and duration. The most significant finding? There was “…no evidence that sertraline led to a clinically meaningful reduction in depressive symptoms at 6 weeks.” These results support the use of restraint when choosing psychopharmaceuticals for the treatment of mental health conditions.