Anti-war, or pro-peace, children’s books [via wood s lot; thanks!]

Author and psychologist Bruce Levine, interviewed on Salon, pummels psychiatry, psychotropic drugs and the role both may have played in the case of Andrea Yates. “The theory that depression and other disorders are caused by ‘chemical imbalances’ in the body that can be remedied by psychotropic medication is, according to Levine, ‘just that: a theory.’ Not only does he believe that psychotropic medication is, at best, ineffective; he also claims that the rush to solve social problems by medicating individuals is blinding us to the ways in which people are rebelling against an ‘institutional society’ that doesn’t meet human needs.”

“One of the greatest marketing feats of the past 20 years is use of pharmaceutical companies’ dollars to convince the mass media that psychiatrists who prescribe these companies’ drugs are basing their treatment on anything resembling science.”

But Levine, a non-medically-trained psychologist, not an MD, is guilty of basic mistakes in his understanding of the psychiatric theory he criticizes. For example:

All these new antidepressants — Prozac, Paxil, Zoloft — are SSRIs [selective serotonin reuptake inhibitors]; they all increase the level of the neurotransmitter serotonin in the brain. The theory is that this increase fixes depression.

But they’ve changed their theory every five or 10 years of which neurotransmitter fixes depression. So if you look back 20 or 30 years, they were talking about norepinephrine and that’s why they were giving out things like Tofranil and Elevil [sic; I don’t know if it is his misspelling or Salon‘s].

Not so. If you look back twenty or thirty years, they were talking about a biogenic amine theory of depression, the amines in question being both norepinephrine and serotonin. “Things like Tofranil and Elavil”, which are tricyclic antidepressants, are thought to affect both of these chemicals. They are still talking about both chemicals. The SSRIs are “selective” for serotonin, but they were developed and relied upon not because the prevailing theory changed so that it was only serotonergic dysfunction that was thought to be involved in depression. Far from it; our knowledge of the interactions of serotonin and norepinephrine have become far more sophisticated. In certain regions of the brain, serotonergic neurons may be “upstream” of and modulate the activity of norepinephrine. Furthermore, medications that modulate serotonin selectively tend to be more tolerable and safer (and, yes, more marketable). Norepinephrine was never forgotten. Newer drugs like venlafaxine (Effexor) and mirtazepine (Remeron) are, in fact, not selective, but thought to be combined serotonin/norepinephrine reuptake inhibitors, or SNRIs, with broader and arguably more effective action against depression. Even when psychiatrists were trying to treat everything with serotonin-specific drugs, it was clear that resistant cases often needed the addition of augmenting medications that would work on the norepinephrine side of the equation. So the theory never changed. This is so profound a misunderstanding, or rhetorical misrepresentation, of psychiatric theory that Levine’s observations lose all authority for me.

Levine is also a pitiful reductionist. He criticizes treatments that alter serotonin because serotonin is not necessarily the cause of the syndrome. This betrays a massive misunderstanding that medications rarely do just one thing (there are even basic debates within psychiatry about whether some effects certain medications have are unwanted side effects or part of their therapeutic benefit!) and a massive misunderstanding about the unimaginably complex interactions between the actions of the various neurotransmitters and the various anatomical regions of the brain. To treat through serotonin does not mean one is affecting only serotonin. Far from it. My guess is that Levine played hookey during the day or two that his psychological training addressed neurotransmitter theory, or that he was so angry about that take on things that he could not effectively learn the material. Here’s a quiz question for you, Dr. Levine — through what neurochemicals might your anger affect your ability to attend to and learn salient facts?

The more profound sin of his broadside, which is shared with most of the other so-called radical critiques of modern psychopharmacology, is to assume that the fact that the theory — the biogenic amine theory or whatever — is inadequate, that we really do not understand how the brain works, is grounds to conclude that we should not use the medications. Psychiatrists will be the first to agree that we do not have anything like a complete theory of the actions of the medications we use. It is a deep misunderstanding of basic pharmacology to think we need to know precisely, to the molecular level, how a medication works before we can assert that it is effective. By that standard, there would be almost no therapeutics anywhere in medicine at all. We would not use aspirin, we would not use narcotics, we would not use insulin or any cardiac drugs. Think how absurd it would be, in other fields, to warn consumers not to buy technologies whose basic theory is not completely understood. Praxis and theory are dialectically related, not linearly…

The process of drug discovery, about which I would venture a guess Dr. Levine knows little, illustrates this. Often, it is serendipitous observation that first suggests a certain substance (in nature or in the laboratory) will control a certain symptom, to be later confirmed by clinical trials. The theory of how a drug works chemically often guides me in drug choice and understanding of side effects and results of combining it with other medications, but it is never lost to me that we discovered rather than invented the drug and its effectiveness (although we may be at the dawn of the often-promised era of ‘rational drug design’). Readers know that I often remind you that the CNS is a ‘black box’ whose inner workings are still largely opaque to us. It is in fact usually our investigation of the mechanism of action of a medication known to be effective that illuminates how the brain (at least in pathology) works, rather than an understanding of the brain that illuminates how the drug works. The process of drug development builds on the original serendipity to invent basically similar, if more refined, versions of the same compound by analogy.

This is a more serious critique of psychiatry; that the lens through which we understand the chemistry of a mental state has been determined by coincidence or accident, and that different ways of understanding (and different, potentially efficacious medications that work by novel mechanisms) are so much harder to discover. Substances with many modes of chemical action in the brain (or, for that matter, elsewhere in the body) might be effective against depression, for example, but we haven’t happened upon them yet, except for those that work on the familiar neurotransmitters serotonin and norepinephrine. Furthermore, it may only be by accident that we think they work on those neurotransmitters. That activity may be an epiphenomenon distant from the therapeutic effect (although probably correlated with it).

In fact, evidence is emerging that there may be totally different mechanisms of the known antidepressant drugs that contribute to their therapeutic effectiveness, such as modulation of nerve growth factors and neuroprotective benefits. Again, these discoveries about the actions of the molecules feed back to influence our understanding of the workings of the brain and the ‘lesion’ in depression; a new model is emerging involving damage to neurons probably mediated by stress hormones which neatly explains some aspects of depression (including its chronicity, its relationship to loss and stress, and some physical findings in depressed patients) and complementing the amine mechanisms.

The truth about investigating the workings of the brain is something like the parable of the blind men and the elephant. Just because the appreciation by each blind man in the parable of the true and complete essence of an elephant was incomplete and inaccurate does not mean that they should not interact with the beast. But I wouldn’t expect Levine to understand this…

It was a mixed blessing, but my stomach was strong enough to go on with the interview with Levine, because I was curious about what he had to say about Yates. Although I suspect he and I would differ greatly in the details, we probably actually agree that irresponsible psychiatric treatment should bear much of the culpability for the deaths of those five unfortunate children, I reasoned. Suddenly, I come upon this:

When people are taken off Haldol, they routinely become really agitated, they feel completely out of control. Sometimes people can’t even keep food down; if they haven’t eaten for a while, they often experience dry heaving.

This is absolutely inaccurate, thoroughly irresponsible grandstanding. Not only not “routinely”, but never, have I seen a reaction like this, and I have prescribed alot of haloperidol during my career. Honestly, I don’t know where he gets this stuff, although it makes good press and may sell books. And they want to give nonmedically-trained psychologists like him the right to prescribe?

But while he goes drastically wrong in his criticism of drug-based treatment, Levine makes a crucial point with which I agree. Focusing on brain disease has certainly put the blinders on the field of psychiatry. As a whole, it is as deeply reductionistic as I’ve just finished accusing Levine of being from the other side. While psychiatric disorders appear to be proliferating, it is not merely the pharmaceutical industry’s profit-hungry marketing pressures that are to blame, even though it is true that if the only tool you have is a hammer, you will tend to see nails everywhere. He says:

Psychiatry is part of the problem in that it is exploiting this situation, but it is also diverting people from taking a true look at what is happening in the culture to cause all of these problems. Our society is perhaps the most economically successful culture in the history of the world, materially. But in our one-dimensional quest for productivity, consumption and efficiency, we have forgotten about a whole bunch of things that people need to stay human — like community, autonomy, diversity. All of those things have shrunk.

Taken together, this may help to explain why so many kids are being diagnosed with attention deficit disorder and all these other various childhood disorders. The largest increases we have seen in new illnesses are the ones that affect children.

…We have created that. And that is what we, as a culture, don’t want to admit: We’ve created fewer and fewer places for different kinds of personalities to feel good about themselves and to make a living.

Stay with that thought, Dr. Levine; psychiatry needs to hear it (and be pummelled).

“Modern antidepressant drugs which have made billions for the pharmaceutical industry will be banned from use in children today because of evidence, suppressed for years, that they can cause young patients to become suicidal.

The Medicines and Healthcare Products Regulatory Agency (MHRA) told doctors last night not to prescribe all but one of the antidepressants known as selective serotonin reuptake inhibitors (SSRIs).

The exception is Prozac, which is licensed for use in depressed children in the US. But the MHRA will warn that, at best, it helps only one child in 10.” —Guardian.UK

I have written extensively about the thoughtful psychiatrist’s balancing act in the face of the rapacity of Big Pharma on the one hand and the somewhat histrionic overreaction on the other of those with sometimes good and sometimes bent intentions to protect psychopharmacological patients, sometimes from the care they need. This decision was prompted by public outcry and throws the baby out with the bathwater. Based on my own practice standards, I have said all along that the best antidote to adverse outcomes of drug treatment is prudent responsible doctoring, not regulation, but, I don’t know, I suppose I should not speak for the profession as a whole. It may serve society’s interests better to prevent harmful bad practice than rely on good. It is indicative of the sorry state of modern medical practice to be at the mercy of both market forces and hysteria and not steer through the currents with any authority or respect.

Two of the SSRI class of drugs have already been banned – or, technically, contra-indicated in children – by the agency.

The first, in June, was Seroxat, which goes by the generic name paroxetine (Paxil); the second, in September, was Efexor (venlafaxine) (Effexor); joining them now will be Lustral (sertraline) (Zoloft), Cipramil (citalopram) (Celexa), Cipralex (escitalopram) (Lexapro) and Faverin (fluvoxamine) (Luvox).

[I have added in italics the corresponding trade names of these drugs in the US. — FmH]

If this British pronouncement works anything like analogous decrees in the US, it is worth pointing out that it does not have the force so much of law as of recommendation (“technically, contraindicated”, rather than “banned”), and will serve to give prescribers but more importantly patients or parents, pause. It is just another eddy being introduced into the marketplace. When alarm in the US last year resulted in a recommendation that one SSRI, Zoloft (sertraline) not be prescribed for children, I am not sure it changed prescribing practices much. I would be interested in the data.

It may influence GPs more than psychiatrists. As you know, I feel that the proper source of consumer concern over adverse effects of psychiatric medications is the fact that they are mismanaged by poorly prepared general practitioners who have been the major targets of Pharma’s marketing efforts over the twenty years since the SSRIs were introduced. That shift in targeting strategy has been, I am convinced, the biggest cause of the change in the landscape of modern psychiatry during my practice, and I have fought bitterly against it. The single most helpful thing to do to insure maximal benefit from psychopharmacological treatment is to take your loved one, or yourself, to a reputable psychiatric specialist rather than allow your medication to be prescribed by your general practitioner.

Now, turning to the other claim, that antidepressants may not be very effective in children, that should rightly prompt profound consumer skepticism when a doctor reaches for a prescription pad, especially to treat a child. There is an epidemic of both overdiagnosis and overprescription for conditions in which medication may not be effective. However, I am dubious about the 1:10 claim. I am not a child psychiatrist but I know that my colleagues in that end of the field have far greater success rates than 10%, when diagnosis is properly performed and prescribing is targeted and prudent. A truly depressed child is at considerable risk of morbidity and mortality, and prudent antidepressant use has an invaluable role in ameliorating her/his suffering and preventing a dire outcome. It just has to be managed by someone properly trained, adequately experienced, well-intentioned, and not in the pockets of the drug companies.