Jul 16 2009

Mental States

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Dr. Joanna Moncrieff is a psychiatrist and author of the book, “The Myth of the Chemical Cure.” She summarizes her position in a recent BBC article by the same name. Dr. Moncrieff takes a stand against drug therapy for psychiatric conditions. While there are certainly legitimate points to be made about the misuse or overuse of psychotropic drugs, I did not find Moncrieff article compelling or well reasoned. She creates a bit of a straw man regarding what she perceives to be a bias toward pharmacotherapy for depression and other mental disorders, and then attempts to replace it not with a more neutral or scientific view, but with her own biases against pharmacotherapy.

She writes:

People with schizophrenia and other conditions are frequently told that they need to take psychiatric medication for the rest of their lives to stabilise their brain chemicals, just like a diabetic needs to take insulin. The trouble is there is little justification for this view of psychiatric drugs.


Views about psychiatric drugs changed over the course of the 1950s and 1960s. They gradually came to be seen as being specific treatments for specific diseases, or “magic bullets”, and their psychoactive effects were forgotten.

Moncrieff makes two main points about the current attitudes toward mental illness – that they are conceived as imbalances in brain chemicals, and as specific diseases that can be cured with a specific treatment. In my opinion, both of these contentions are exaggerated to the point of being wrong – they are straw men.The “chemical imbalance” notion is often used as a shorthand explanation that physicians give patients, but it is an acknowledged oversimplification, not a working model. There is also sufficient truth to it to make it not unreasonable – but it is only part of the picture. Mental disorders, in some cases, result from underlying brain function, which is determined by the pattern of neuronal connections in the relevant brain regions and their level of activity. The level of activity is in turn determined by many factors, including the amount of neurotransmitter release, how quickly it is inactivated, and the sensitivity of various receptors.  In the last couple of decades we have also gained a deeper appreciation for the role of astrocytes (support cells) in modifying and regulating neuronal function.Of course it is an oversimplification to summarize all of this as a “chemical imbalance” but patient encounters often do not allow for an in-depth discussion of the latest neuroscience.

Moncrieff also implies that there is little or no evidence for the “chemical imbalance” view. I think this claim is misleading – “chemical imbalance” is an oversimplification, but it is not wrong. There is copious evidence for altered activity in various regions of the brain in many identified psychiatric syndromes – and this includes differing levels of neurotransmitter (chemical) activity.

I also disagree with Moncrieff’s use of the term “disease”. Frankly, this is a tactic I have seen from mental-illness deniers for years. Mental illnesses are not “diseases” in that there is no cellular pathology that can be identified. But this is irrelevant since that is not the model for most mental illness in any case. Brain function is determined by the pattern of neuronal connections and their neurotransmitter activity. If you change these patterns, you change mental function. If mental function is far enough outside of adaptive and healthy parameters, what you have is a mental disorder.

Mental disorders are often not discrete entities – because the brain is so complex, and each subsystem in the brain interacts with all the other subsystems and then the environment to create a complex net result. This leads to fuzzy classification systems based upon clinical signs and symptoms. However, it is the false continuum logical fallacy to claim that therefore these mental disorders do not exist. Schizophrenia is perhaps the worst example Moncrieff could have used since it is the most clear cut mental disorder, in my opinion, with strong evidence for altered brain function, specifically in the frontal dopamine regions.

Having slain her straw men, Moncrieff goes on to create her own equally biased and misleading view of  drug treatment for mental illness. She writes:

It is frequently overlooked that drugs used in psychiatry are psychoactive drugs, like alcohol and cannabis.

Psychoactive drugs make people feel different; they put people into an altered mental and physical state. They affect everyone, regardless of whether they have a mental disorder or not.

The claim that drugs used for psychiatric conditions are not seen as psychoactive drugs seems extraordinary to me, and is certainly at odds with my own experience. I often refer to the various classes of drugs that affect brain function explicitly as psychotropic drugs. Perhaps I am perceiving the difference between the experience of a neurologist and that of a psychiatrist, but I doubt that explains everything.

The fact that such drugs affect everyone is also completely irrelevant. So does insulin – so do all drugs. Oddly stating this obvious fact implies that there is the belief that psychotropic drugs only affect the mentally ill – another straw man.

She wants to replace the “chemical imbalance” view of mental illness and psychiatric drugs with the “altered states” view. However, this view is as biased against rational pharmacotherapy as her straw man of “chemical imbalance” is in favor – and she entirely neglects the more nuanced and reasonable view in the middle that I described above  (therefore she creates a false dichotomy).

She writes:

In my view it remains more plausible that they “work” by producing drug-induced states which suppress or mask emotional problems.

Notice the scare quotes around “work.”  She is implying that psychiatric drugs put patients into an abnormal brain state that masks their real problems. While she acknowledges that such treatments may be useful in some cases in the short term, she implies it is not a real solution. She wants better informed consent from patients, but it seems that what she really wants is to scare patients off of pharmacotherapy.

Where I think this reasoning goes wrong is in the failure to recognize that we are all always in a “brain state.” Our brains are always in some state or another – wakefulness, drowsiness, sleep, arousal, panic, depression, etc. Being in a brain state is not an abnormal condition. Some people are in brain states that they find unpleasant and dysfunctional (or that others find dysfunctional – sometimes people lack insight into their own brain state). If someone is in a constantly depressed state to the point that they cannot function or enjoy life it is reasonable to alter their state if we can. If this can be accomplished with therapy, great. If not and pharmacology can work, that is a reasonable approach also.

Moncrieff wants to stigmatize psychotropic drugs as causing an abnormal brain state. But they just cause a different brain state, no more “normal” or “abnormal” than any other, although admittedly a pharmacologically forced brain state. The rational clinical approach is to give patients treatment trials  – if they like their brain state on a certain dose of a specific medication better than their brain state unmedicated, and they tolerate the side effects, use is appropriate and should not be stigmatized.

There are also many severe conditions like schizophrenia where some individuals do not have the ability to distinguish between reality and their paranoid fears. In this state they may become completely dysfunctional, even to the point of being catatonic in extreme cases. Tweaking their brain chemistry can make them functional, even if they do not recognize their own disorder, especially when in a psychotic state.

It is true that current pharmacological treatment for mental disorders is crude. We are hitting the entire brain with a chemical sledgehammer, when the patient may need a precise scalpel. That is just the current limitation of our technology.  We have made some incremental progress, targeting neurotransmitter subtypes, for example, but I consider our current best treatments to still be frustratingly crude. They can still be extremely useful, however, even life saving.

The rational middle in between Moncrieff’s false dichotomy, with her straw men characterization of psychiatry on one side and her anti-pharmacotherapy stigmatizing approach on the other, is to recognize the complexity of the brain and of mental disorders, to recognize that disorders are just that, and not discrete diseases, and to use pharmacotherapy judiciously and thoughtfully. The best practitioners do this, while of course there are those who don’t.

While I think we will make further incremental advances in pharmacotherapy, the paradigm is inherently limited. We have a limited ability to target specific brain functions, because evolution left us with a messy system. Different brain regions and functions use the same or similar neurotransmitters and receptors – therefore we cannot affect one without affecting the other, producing unwanted effects. Also, as I stated, brain chemistry is only part of the picture – the pattern of neuronal connections is another, and is most cases is probably the dominant factor.

But we are looking forward to new paradigms of treating brain disorders. We are already developing drug delivery systems that target specific brain regions. We may be able to affect brain structure and function directly with stem cells and genetic engineering. And we are rapidly developing the ability to interface computer chips and brain tissue. We will likely one day be able to actually change the pattern of neuronal connections in the brain, not just compensate for them.

Meanwhile rational pharmacotherapy is a reasonable option that should not be stigmatized. To do so is likely to cause unnecessary suffering and dysfunction among those with mental disorders that can be helped with the right drug treatment.

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