MENTAL HOSPITALS ARE DRUGGING AMERICAN
KIDS TIL THEY’RE OUT OF THEIR SKULLS!
Psychotropic drugs Modern medicine’s alternative to purgatives, straitjackets, and asylums
by Frederick
Engstrom, MD says DRUGGING THE MENTAL PATIENTS IS WONDERFUL!
A
bewildering variety of therapies for mental illness—from exorcism to asylums,
from bloodletting to lobotomy, from tonics to talk therapy—have been tried over
the years, with limited success. During the past 50 years, after major
mid-century leaps in psychopharmacology, psychotropic drugs have taken
the lead among treatments for mental disorders such as depression and
schizophrenia. Chlorpromazine, lithium, and a host of modern newcomers have had
a significant impact on patients, physicians, medical practice, and society.
Severely psychotic patients can often be relieved of their frightening symptoms
and enabled to live in the community. Physicians have tools for treatment that
are efficacious and cost-effective; at the same time, the availability of these
medications may cause shifts in the physician’s role in mental healthcare. Both
psychiatry and psychotherapy are changing in response to the insights provided
by the use of medications and the questions it raises. The stigma of having a
mental illness has lessened considerably. It’s been nothing less than a
treatment revolution.* Demons or black bile? Mental illness has always been a
part of the human experience, and so has the quest to understand and treat it.
As in other medical fields, the preferred treatments for mental illness have
gone hand in hand with changing theories about its causes. Some ancient
civilizations, including the Babylonians and the early Egyptians, attributed
mental illness to demonic possession; their “cures” combined magic
incantations, religious ritual, and a veritable pharmacopoeia of natural
substances. The ancient Greeks believed that “hysteria” was caused by incorrect
positioning of the uterus; such eminent medical men as Hippocrates and Galen
advocated fumigation of the vagina to draw the uterus back into place. Then, as
at later points in history, the simple fact of being female was considered a
risk factor for mental illness (1).Hippocrates also theorized that depression,
which he called melancholia, was caused by black bile and hence could be cured
with purgatives.Several centuries later, the Roman writer Cicero (106-43 bc)
disagreed with the famous Greek’s physiological explanation. He proposed
instead that melancholia resulted from psychological difficulties and that
people were responsible for their own emotions, thus laying the foundations for
modern psychotherapy. Neither of these great thinkers could have predicted that
the conflict over the causes of mental illness would continue into the present
day.An ancient debate in the modern era During the centuries since the height
of the Greek and Roman civilizations, the debate over the causes of mental
illness has waxed and waned in response to the dominant intellectual and
religious movements. Successive intellectual movements such as rationalism,
romanticism, and humanism wrought parallel changes in the conceptualization of
mental illness, its causes, and its treatments. The 17th century saw
mental illness begin to move into the realm of physiology, aided by physicians
like Thomas Sydenham of England (1624-1689). He proposed that hysterical
symptoms could simulate many forms of organic disease—an important step toward
understanding the interdependence of body, mind, and brain (1). The debate
continued after the emergence of psychiatry in the mid-19th
century—not surprisingly, given the profession’s nature as a restless hybrid of
neurology and psychology. Advocates of physical causes for mental illness
recommended bloodletting, purging, cold-water immersion, and various tonics and
medications (primarily opium and opium derivatives) as treatments. Others
believed emotional disorders were caused by such problems as inappropriate
mothering; it was thought impossible for patients to recover while remaining at
home. Part of the treatment, then, was to place mentally ill patients in a
mental asylum. To simplify management, many of these patients were restrained
in straitjackets or manacles and chains.Despite the horror such restraints
evoke today, the state mental hospitals and insane asylums were themselves
built in response to a reform movement to replace the poorhouses of the 18th
and early 19th centuries. In poorhouses, the mentally ill who could
not be cared for by their families were not treated but merely confined, often
side by side with criminals, unwed mothers, the destitute, and the mentally
retarded (1). By 1870, 45,000 “known insane persons” were being treated in
America’s mental institutions, and by the turn of the century, 328 institutions
were caring for almost 200,000 patients (with surprisingly good outcomes, even
by today’s standards) (2). The number continued to rise, peaking in 1955 at
559,000 (3).In the late 1800s and early 1900s, as more and more mentally ill
persons were being housed in the nation’s mental institutions, new thinking led
to shifts in treatment. Mental illness came to be viewed as a medical problem,
with a new emphasis on brain disease as the cause. At the same time, Sigmund
Freud, one of psychiatry’s brightest stars, theorized that mental and emotional
disorders were caused by repressed instinctual drives and unconscious memories
from childhood. His dynamic work in neurology and psychology led to the
development of new psychotherapeutic methods, including free association, dream
interpretation, and psychoanalysis.Research continued into the 1930s and 1940s
on both the psychological and physiological fronts, resulting in rapid
proliferation of “talk therapies” as well as new medical treatments. Theories
about the interconnection of body and mind led to development of sleeping
cures, various forms of shock therapy, and psychosurgery, such as prefrontal
lobotomy. But many patients were unresponsive to these treatments, and
diagnosis and management remained hit-and-miss. The time was ripe for the
emergence of the first psychotropic drugs. The chemical revolution In 1947, the
year Postgraduate Medicine was first published, few people realized that
medicine was on the brink of important discoveries that would alter the way
patients with mental disorders were treated. But Dr Abraham Myerson, a
neuropsychiatrist long affiliated with Boston Psychopathic Hospital, had his
finger on the pulse. Quoted in the December 1948 issue, he predicted the future
focus of psychiatry with startling accuracy: “If I were asked to predict the
status of psychiatry 25 years from now, I would state without hesitation that
biochemistry, biophysics, [and] pharmacological therapeutics will hold the
center of the stage; that psychoanalysis will be present as a term, but
entirely different as a system of beliefs and principles; and that the social
phases of psychiatry with its genetic and social relationships will be of
fundamental importance (4).” Sedatives had appeared on the scene in the late
1800s, followed by barbiturates and amphetamines in the early 1900s. But it was
drugs such as chlorpromazine hydrochloride (Thorazine) and lithium, introduced
in the 1950s, that dramatically changed our thinking about mental illness.As
Harvard neurophysiologist and author Dr J. Allan Hobson recently summed it up,
“There is no doubt that the development of drugs that interact with the
brain-mind’s chemical system is the most important advance in the history of
modern psychiatry (5).” Some of the most far-reaching developments to date have
involved four main drug categories: antipsychotics, mood stabilizers,
antianxiety agents, and antidepressants.
Antipsychotics The
chemical revolution in treatment of psychoses, especially schizophrenia, began
with the release of chlorpromazine in May 1954. Originally designated as a
major tranquilizer, chlorpromazine was soon found to be more effective at
subduing the hallucinations and delusions of psychotic patients than any
previous treatment. Within 8 months of its appearance on the market, the drug
had been administered to over 2 million patients (3). Chlorpromazine allowed
many formerly hospitalized patients to be released to live in the community,
and it fostered the deinstitutionalization movement of the 1960s, 1970s, and
1980s, becoming known as “the drug that emptied the state mental hospitals
(6).” However, institutional populations were already declining before the
release of chlorpromazine, so it is probably more accurate to say that chlorpromazine
hastened a movement already in the making. Since the introduction of
chlorpromazine, it and other antipsychotics, including haloperidol (Haldol) and
clozapine (Clozaril), have transformed treatment of psychosis. The benefits for
patients who respond are clear: Frightening hallucinations are eliminated or
reduced, the patients feel more relaxed and in control, and a return to home
and family life is often possible. But, as with all psychotropic drugs, there
are downsides. Some patients complain of feeling drugged or lethargic. Others
experience restlessness, muscle rigidity, or dystonia. Negative symptoms, such
as social isolation and flat affect, often remain. In addition, these drugs do
not offer a cure; patients must continue to take them to maintain benefits. One
of the great problems with the mass closing of state psychiatric hospitals was
that many psychotic patients were released to situations that didn’t provide
structure or support. As a result, many patients stopped taking the
medications. Predictably, their symptoms recurred.Recent studies have found
that 30% to 40% of America’s homeless have severe mental illness, including
schizophrenia. And even now, after several decades of emptying and closing
state mental hospitals, patients with schizophrenia still occupy 40% of all
long-term hospital beds (3). Mood stabilizers Australian psychiatrist John F.
J. Cade’s 1949 discovery of the beneficial impact of lithium on
manic-depressive disorder was a major leap in psychopharmacology for two
reasons: effectiveness and specificity. Many patients with bipolar illness
responded well to the medication, often being freed from incapacitating mood
swings that may have led to such personal difficulties as uneven productivity,
ruined careers, and marital break-ups. Equally important, however, was the fact
that patients with schizophrenia did not respond to lithium, leading
psychiatrists to a degree of diagnostic precision that was previously not
possible. Recently, some antiepileptic medicines—valproic acid (Depakene) and
carbamazepine (Epitol, Tegretol)--have also been used to treat bipolar
illnesses. While lithium remains the treatment of choice for classic (bipolar
I) manic-depressive disorder, newer drugs have proved useful for bipolar
variants, such as rapid cycling bipolar disorders. These medications are often
prescribed in conjunction with standard antidepressant and antipsychotic drugs.
Antianxiety agents- Anxiety is one of the most common and most important
emotions, an internal switch that can turn on the fight-or-flight reaction and
hence an indispensable tool of survival. However, when anxiety is severe,
prolonged, and apparently causeless (for example, when a person suffers
recurrent panic attacks at a shopping mall), it can be debilitating. Many pharmacologic
agents have been used to alleviate anxiety. The first were barbiturates, widely
prescribed before the 1960s. But they were highly sedating and addictive and
didn’t always work. Chlordiazepoxide (eg, Librium) and the other benzodiazepine
anti-anxiety agents developed from the 1960s to the 1980s rapidly replaced
barbiturates, for some very good reasons. The benzodiazepines proved to be more
effective, to have fewer side effects, and to be less dangerous in overdose.
They have remained popular too; as recently as the early 1990s, six of the 25
top-selling prescription drugs in the United States were benzodiazepines (7).
While many patients have been relieved of their anxiety or panic symptoms, some
critics would say that not all anxiety ought to be treated. It’s worth
remembering the 1950s and 1960s phenomenon of “mother’s little helper,” when
barbiturates and other antianxiety drugs were prescribed for masses of
discontented housewives. A number of thinkers, philosophers, and writers have
accorded anxiety a valued place in the pantheon of emotions. Their recognition
that anxiety may serve a useful function by enhancing our understanding of the
human condition and the ways in which our lives are out of joint brings an
unusual perspective to the modern concern over whether to prescribe
anxiolytics. One such thinker is novelist Walker Percy, who was trained in
medical pathology and strongly influenced by existentialist philosopher Søren
Kierkegaard and who has written extensively about psychiatry and the self.
Echoing a dominant tradition in psychology, he suggests that anxiety may be
important to the individual’s journey of self-discovery.If an anxious
individual is medicated, he or she may be “protected” from a painful but
essential human experience (6). While Percy’s point of view needs to be
balanced by the evidence of grateful patients whose anxiety disorders once
prevented them from driving, sleeping, working, performing, and even leaving
home, his concerns about the impact of drugs on creativity, personality, and
human development are not easily dismissed. Antidepressants In any given
6-month period, about 3% of adult Americans experience severe depression (7).
Because of its widespread incidence, depression has been called the “common
cold” of the psychiatric profession. Everyone experiences a depressed mood in
response to common life events such as sickness, death of a loved one, or
divorce. For the millions whose depressed mood becomes a clinical syndrome,
though, psychotropic therapy is one way to relieve the symptoms. From the 1930s
to the 1950s, electroconvulsive therapy (ECT) was the most effective, widely
used treatment for serious depression. Then, in the mid-1950s, iproniazid, an
antitubercular agent, was found to give patients energy and a sense of
well-being (6). Although later withdrawn because of concern over its side
effects, it was prescribed to about 400,000 depressed patients in its first
year and earned a reputation as the first modern antidepressant. Now
antidepressant drugs are the first choice for treatment, and ECT is used, for
the most part, only when a patient does not respond to pharmacotherapy. The
tricyclic imipramine hydrochloride (Tofranil), developed during the late 1950s
and introduced during the early 1960s, was the first of the now-available
antidepressants and still is often prescribed (6). Current theories attribute
depression to psychological causes (eg, low self-esteem, important losses in
early life, history of abuse) and biological causes (eg, imbalance of neurotransmitters,
including serotonin and dopamine; disruptions in the sleep-wake cycle) as well
as experiential and social factors. The various classes of
antidepressants—tricyclics, MAOIs, serotonin-specific agents—and individual
drugs including nefazodone (Serzone), mirtazapine (Remeron), venlafaxine
(Effexor), and bupropion hydrochloride (BuSpar) target the biological causes.
At present the selective serotonin reuptake inhibitors (SSRIs) hold center
stage, and fluoxetine hydrochloride (Prozac) is in the spotlight.The result of
years of focused research and design, fluoxetine was rapidly accepted and
prescribed to millions within a few months after its introduction in December
1987 (7). Some patients have shown such a dramatic response to this
antidepressant that, as author and psychiatrist Dr Peter D. Kramer (6) notes in
his national bestseller Listening to Prozac, they “are not so much cured of
illness as transformed.” Indeed, the drug, which became both the media’s
darling and its victim during the early 1990s, often relieves lifelong
depression, leading to improvements in self-image, confidence, self-esteem,
sensitivity to conflict, and awareness of the needs of others (6). Tales of
transformation raise fascinating questions about the potential for this family of
drugs. Fears or hopes that the SSRIs might be able to change personalities
through “cosmetic psychopharmacology (6)” have not been fulfilled. But the
dramatic responses that some patients have to the SSRIs raise that possibility
for future generations of drugs. Will we be able to provide a “psychological
makeover” to a patient’s personality of choice? Who will address the ethical
issues?
Until solid answers to the many difficult questions are available,
physicians are making decisions about whether and when to prescribe
psychotropic drugs on the basis of current knowledge and their own clinical
experience. In The Chemistry of Conscious States, Dr Hobson (5) describes his
personal exploration of the fascinating relationship between mind and brain
chemistry and comes to a measured, conservative conclusion: “Drugs are a
powerful aid to changing the brain-mind states of the mentally ill, but we must
use them with appropriate caution.” Citing concerns about our still-infant
state of knowledge about drug interaction with brain chemistry, as well as side
effects and the potential for abuse and overuse, Hobson calls himself a
reluctant prescriber. Today, tomorrow, and beyond Things are changing rapidly
in the field of psychopharmacology. In last month’s issue of Postgraduate
Medicine, for example, Dr Leslie Citrome (8) discussed the latest developments
in antipsychotic medications. He noted that two new agents introduced within
just the last few years—risperidone (Risperdal) and olanzapine
(Zyprexa)--promise to be as effective as clozapine for positive symptoms and
more effective for negative symptoms of schizophrenia. Sertindole (Serlect),
quetiapine (Seroquel), and ziprasidone are “on deck” in the testing and
approval process. Research is also under way to develop and evaluate new SSRIs,
monoamine oxidase inhibitors, and other drugs for treating depression and other
mental disorders.* The US Food and Drug Administration is in the process of
approving expanded roles for existing drugs too. For example, in January 1997,
it approved the SSRI sertraline hydrochloride (Zoloft) for treatment of
obsessive-compulsive disorder and approved fluoxetine for treatment of
bulimia.* Advances on other psychopharmacologic fronts are on the
horizon.Researchers are exploring new methods of drug administration, such as
small pumps that can inject drugs directly into the brain and electrical
devices that stimulate discrete brain regions. Another intriguing possibility
is dose sequencing, in which special, intermittent dosing may prove more
effective than daily regimens in treatment of some psychiatric disorders
(7).*Developments in drug therapies will also be accompanied by advances in
adjunct therapies. For instance, light therapy has proved effective treatment
for seasonal affective disorder; perhaps it will prove useful in treating other
depressive disorders too. And continued study of the biologic causes of mental
illness on the genetic level may one day yield genetic diagnoses and treatment.
Who knows? As Dr Kramer (6) speculates, perhaps one day physicians
will advocate early detection of depression the way they now advocate early
detection of cancer, and treatment of very minor conditions will take on a
standard preventive function.*Abraham Myerson, who was honored as a pgm “Man of
Medicine” in 1948, once wrote that it puzzled him that both philosophers and
some scientists would talk about the mind “as if it were too lofty to have any
direct dependence upon the structure of the brain (4).” Today, modern science
is affirming Myerson’s 50-year-old conviction that “chemistry and mind and
brain have become knit as finely together as any chain of cause and effect in
this world of ours.” For example, recent positron-emission tomography studies
at the UCLA School of Medicine have revealed that both fluoxetine and cognitive
therapy “can actually restore normal function in the obsessive-compulsive brain
(9).” The idea that either a drug or a learning experience can change the way
nerve cells interact is strong evidence for the close-knit brain-mind
connection that should spark exciting new directions for treatment.*As the
brain is coaxed to reveal its secrets on the molecular level, emerging
information can guide efforts to create new drugs that target particular forms
of mental illness. For now, as primary care physicians take an increased role
in treating patients with mental illness, physicians and patients alike will
continue to evaluate the promise of a better life through chemicals.*At the
forefront Daniel G. Blazer, MD, PhDDuring his 20 years of practice, Daniel G.
Blazer, MD, PhD, has found psychotropic drugs to be “wonderful tools” in the
treatment of mental illness. Dr Blazer, who is the J. P. Gibbons Professor of
Psychiatry and Dean of Medical Education at Duke University Medical Center, Durham,
North Carolina, has watched the evolution of psychotropic drugs carefully. Like
many other physicians, he supports the use of medications together with other
forms of therapy.* “The emerging thought is that a combination of cognitive or
behavioral therapy with an antidepressant, for instance, is superior to either
one alone. Intuitively, psychiatrists have known that for years, but now there
is good evidence for it. Using the two concurrently is more effective,
especially if you broaden the concept of nonpharmacologic therapy to include
relating effectively with the patient and working closely with the patient’s
family.”* As more primary care physicians deal with mental illness in their
everyday practice, their experiences may raise questions about the effects of
psychotropic drugs on the personality and the self. Such questions, Dr Blazer
notes, are now being addressed by “neurophilosophers.”*“Individuals like Paul
and Patricia Churchland, Jerry Foder, Richard Rorty, Ed Hundert, and Owen
Flanagan are philosophers who also have an excellent knowledge of
neurophysiology and neurobiology. They have pushed the envelope in bringing
together the study of neurobiology and human behavior and in looking at what
sciences can inform psychiatry, leading to new approaches in therapy for
psychiatric disorders. Their writings will stimulate new types of research.”*
Looking to the future, Dr Blazer predicts the development of drugs that give
greater control over specific conditions. “They’ll have fewer side effects and
be more targeted—for example, we know now that valproic acid is particularly
effective for manic episodes in patients who’ve had strokes. We’ll also know
more precisely what a drug will do and what its side effects will be. And that
will help primary care physicians be better able to manage mental illnesses.”
This is just my MORNING dose.
Night dose twice as large!
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The greatest critic of insane asylums, Dr. R.D. Laing, has written amply on the sick psychiatrist syndrome. His website: offers much to read, and his books are a dollar each at ABEBOOKS.COM
Dr. Peter Breggin agrees with LAING in "TOXIC PSYCHIATRY." KIRKUS REVIEWS SAYS: "He is a psychiatric reformer who takes aim and blasts away with both barrels. Breggin (author of the novels The Crazy from the Sane, 1971, and After the Good War, 1972) launches a full-scale attack on the popular view that neuroses and psychoses are diseases with biochemical and genetic causes best treated by drugs--even by electroshock and incarceration. He advocates not pills but psychotherapy, which ideally provides a ``caring, understanding relationship--made safe by professional ethics and restraint.'' Treating mental disorders as chemical imbalances to be corrected primarily by chemical intervention is, he claims, an outrageous hazard to health, damaging the brains of a high percentage of those subjected to it. Breggin notes that the medical training of today's bio-psychiatrists ill-equips them for any other approach: They are taught to make diagnoses and prescribe medical treatments; their communication skills are undeveloped, and they know little about the art of listening to patients' problems. Their penchant for prescribing drugs, according to Breggin, is encouraged by a too-cozy relationship between the medical profession and the pharmaceutical industry, which generously funds research into the biochemical and genetic basis of mental disorders, and whose claims for its products are insufficiently scrutinized by either the FDA or the medical profession. Breggin also has harsh words for health insurers that reimburse for drugs and psychiatric hospitalization but not for psychotherapy and social rehabilitation; coming under fire as well are schoolteachers who seek chemical solutions to classroom discipline problems, and parents who are unwilling to accept any blame for the psychological problems of their children. Although Breggin's preference for nonmedical intervention is clear, he remains skeptical about much of what's available today, warning that ``the buyer of psychotherapy must be extremely cautious.'' A one-sided but forceful caveat emptor for anyone seeking mental-health services.
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If you have any first hand information on this, please write anita sands, astrology@earthlink.net