A reader asked me what I thought about Peter Breggin’s longstanding critique of modern psychiatric practice, as reflected in this review of one of his recent books. My first reaction was, “Oh, no, Breggin again.” I have such difficulty with his argument with psychiatry (and such curiosity about what personality factors and life experiences congealed as such rabid fervor in him) that I usually just dismiss him. But (sigh) this reader, concerned by the antimedication arguments here, asked for a response.
As the reviewer encapsulates it, this book “neatly summarizes many of the best arguments against biological psychiatry”, and that is precisely the problem. They are simply arguments against, with no balanced deliberations. Breggin feels it is a mistake to view depressed feelings as a disease; in doing so, he is reacting to an outmoded version of psychiatric theory which had not demonstrated the structural and functional brain changes we now can see in untreated severe depression. Admittedly, the dividing line between ‘normal’ depressed feelings — which are a part of everyone’s mood variations — and the pathological process is difficult to draw, but that is the challenge every mental health practitioner faces, some better than others at refraining from pathologizing the ‘normal variants’ but on everybody’s minds. I actually join Breggin in criticizing those of my colleagues who have lost their perspective on the distinction completely, and the trend toward what Peter Kramer MD (in Listening to Prozac) has called ‘cosmetic psychopharmacology’, which has its sources in both conceptual confusion on the part of prescribers and the vested interests in the field which want to widen the scope of permissible prescribing targets. But to castigate the entire field for the excesses of its least perspicacious would deprive those clearly suffering from a correctable physiological disturbance bringing them ongoing distress and dysfunction (which worsens if not treated) a scientific and systematic approach to alleviating their suffering.
I would also join Breggin in his criticism of those for whom medication is the end-all of their treatment attack, but, again, that is not the norm in the field. It is well acknowledged that the best treatment approach to most mental illnesses such as, say, depression as Breggin discusses it here, is a combination of therapy and medication, so much so that a non-medical therapist who fails to recognize the indications for medication and make the recommendation to her/his severely depressed patient can be sued for malpractice. I like to tell my patients that medication is like a bicycle — the most efficient human-powered vehicle to get from point A to point B, but you still have to pedal. The analogy only goes so far, however, because when you get there there is still much more work to do when and if you dismount.
Breggin also faults the field for the fact that we do not know how medications work on a cellular level; this is true. But is naive to assert that all the speculation about how the medications work is designed solely to promote the drugs. We know the medications work, empirically; people feel better and get better when they are treated with them, as established (contrary to breggin’s assertion) by countless studies meeting the gold standard of scientific method — the double-blind placebo-controlled methodology. There are examples throughout medical science of medications being used because they have been shown to be beneficial, while the explanation of their mechanism remains purely speculative. The dirty secret for all of medicine is that the emperor often has no clothes when s/he speaks authoritatively in certainties about the mechanism of action of the magic bullets s/he dispenses. Arguably, healing, no matter in what medical subspecialty, depends in large measure on what has been called the priestly function of the physician, enlisting the supplicant by authority and charisma into a shared belief system which mobilizes the patient’s own mind’s and body’s best resources for the restoration of their health — with physiological help from medication effects.
The mechanisms of most drugs that affect complex physiological systems such as the cardiovascular are, on some level, opaque to analysis, although Breggin is right to be more troubled about the issue with neuroscience and psychiatry than with other medical fields. He ignore two simple facts with the most profound significance. First, in brain disease, the affected organ is the very same one that is the vehicle for perceiving and describing the dysfunction, unlike what patients can tell us relatively unimpeded when their heart, lungs or abdominal organs are malfunctioning. Secondly, by and large (this is not fully true, but enough for my argument here) there is no animal model for human consciousness, so experimental methods to establish pathophysiology or the effects of medication upon that pathophysiology are inherently impossible. There is no adequate animal model for any psychiatric disease for that reason, researchers’ arguments to the contrary. So, Dr. Breggin, the brain will always be a black box. But that doesn’t mean we have no way of knowing how effective our treatment approaches are; don’t confuse the two different epistemological realms.
His next point, that the psychiatric drugs “impair our emotional awareness and our intellectual acuity”, and thus “impede the process of overcoming depression”, that that is all they do, is patently absurd. But the crux of the argument comes in his next assertion, that “If a drug has an effect on the brain, it is harming the brain,” i.e. that psychiatric drugs are, plain and simple, poisons. In particular, he works himself into a fever pitch about imagined “potential hazards” of SSRIs for which there is no substantiation. And to claim that “there are so many… that no physician is capable of remembering all of them” (and thus no patient adequately informed by their physician) makes me glad he does not himself use his medical license to treat patients, with such seemingly scarce memory capacity. As readers of FmH know, I have discussed at length the bogus claim that SSRIs provoke or worsen suicidality, or promote interpersonal violence. Breggin would do well to criticize careless use by inattentive or undertrained personnel, as I have written, but not to throw the baby out with the bathwater. His argument is rife with misinformation, distortion and selective attention to prove an a priori conclusion, and logical and epistemological fallacies. His constituency is the rather small absolutist anti-psychiatry movement, the members of which it shold be pointed out have mostly been motivated to object to not antidepressants but antipsychotic medications, for which the evidence of damaging effects, impairing judgment, equivocal effctiveness, and use as tools of social oppression has far more ‘teeth’ than anyone reasonable asserts for antidepressants.
I think there is a role in the psychiatric profession for a histrionic gadfly like Breggin (just as there is a role in the medical debate over assisted suicide for Jack Kevorkian!), if his polemic forces a reexamination and acknowledgement of the grain of much exaggerated truth at its core. But his irresponsible reductionism and overgeneralization leave him without the credibility to take his role responsibly. I’ll go back to just dismissing him, I suppose. As Malcolm Lowry once said, “How many wolves do we feel on our heels, while our real enemies go in sheepskin?”