July 24, 2000
Note from the Editor: The question of what it means to be human has existed, well, as long as have humans. Likewise, since the introduction of Prozac, a $2.5 billion per year drug prescribed for everything from depression to anxiety to obesity to general "well being", the controversy over the philosophical implications and physiological effects of such drugs persists. Contributor Antony Black has some pointed questions and strong opinions on these matters.
In the meantime, while scientific data is being amassed, our society continues to choose the quick-fix option over the more difficult long-term solutions to most problems. Witness the backlash against South Africa president Thabo Mbeki at the International AIDS Conference for focusing on the role of extreme poverty on the health of South Africans. The U.S. response to the rise of AIDS in Africa? To lend a billion dollars per year to sub-Saharan nations so that they can buy American drugs and medical supplies.
Yes, unfortunately the question remains: What does it mean to be human?
The last few decades have witnessed an explosion in the use of psychiatric medication. The omnipresence of legal brain altering drugs in our society is such that, nowadays, it is rare not to know someone who is on them - if we are not already taking them ourselves.
Contrary to popular perception, a marked increase in the practice of electro-shock therapy is accompanying this legal drug explosion. Prior to 1960 this biological psychiatric arsenal was confined mostly within the walls of the major psychiatric institutions. Since then, it has escaped the confines of the mental institution and taken up residence amidst the population at large.
One of the reasons for this psychiatric colonization of the normal stems from the increasingly intimate association between the multi-billion dollar a year psycho-pharmaceutical industry and institutional psychiatry. The latter's journals, conventions and professional associations are substantially underwritten by the former.
Another reason is the rapid growth in Western society of an overarching philosophy of biological reductionism. This notion posits that, in studying any higher organizational entity, the whole can be explained by the parts, the complex by the simple, the higher by the lower. If you are 'depressed', it is because you have a biochemical imbalance, rather than, perhaps, that your life has no meaning. If one goes to war it is because of individual 'aggressive genes', rather than your being the pawn of complex socio-political forces over which you have no control.
The idea that fundamentally new ontological properties and laws emerge at higher levels of an organization, each level of which demands its own language and theory for its description and analysis, is given short shrift in the reductionist paradigm.
A third and perhaps more ominous reason for the dramatic rise in the fortunes of biological psychiatry is that its proponents have waged a propaganda war on its behalf that is riven with pseudo-scientific claims and evidential suppression.
They continue to claim, for instance - against substantial research to the contrary - that shock therapy is harmless. Needless to say, no psychiatrists have ever volunteered to test this hypothesis themselves. In this they are probably wise, since the original animal research (of the 1940' and 50's), demonstrating undeniable brain damage, was damning in this regard, as has been much of the subsequent human clinical data. All of this evidence, however, as well as the vociferous condemnation by a legion of former patients, has done nothing to squelch the practice of this jealously guarded symbol of the psychiatric profession's medical and legal authority.
Particularly disturbing are the demographic trends for this controversial procedure. In Canada and in the United States, well over 100,000 people are subjected to the procedure every year. Over two thirds of these patients are women, and almost half are elderly.
Still, while ECT is one of the heavy weapons of the modern bio-psych arsenal, the more usual work-a-day armament is drug therapy. The first is targeted on a population of thousands. The second on millions.
Here again, proponents make a number of bold claims. Perhaps the most scandalous of these is that drug therapy is safe.
In 1980, twenty-five years after the introduction of neuroleptic (antipsychotic) medication, an American Psychiatric Association task force report finally, grudgingly confirmed what a number of previously neglected studies had attempted to call attention to, that roughly 40% of chronic users of these drugs went on to develop tardive dyskinesia, a Parkinsonian-like movement disorder indicative of permanent brain damage. Subsequent studies only amplified these fears by pointing the finger at other permanent brain disorders caused by the neuroleptics. These included tardive akithisia, a highly debilitating anxiety and hyperactive movement disorder. All told, the evidence now in supports rates of neuroleptic induced brain damage exceeding an astounding 5% per year of usage.
That for clearly psychotic patients there may be a cost-benefit tradeoff to consider with respect to whether or not to take these medications (perhaps, as a minimal, maintenance dosage), is rendered moot by the fact that few if any of the patients so prescribed are, or ever have been, told of the potential cost. Moreover, these drugs are routinely employed in institutional settings on clients that are patently not psychotic.
Given this sobering tale, it might have been expected that biological psychiatry would exercise the cautionary principle in its future endeavours. This was not the case. Instead, the next round in psychiatry's legal drug trafficking campaign was launched on an unsuspecting public with all the same hubris, euphoria and woefully inadequate, experimental investigation as the first.
So began the anti-depressant revolution.
Actually, the word 'revolution' is slightly misleading here, for some of the anti-depressants, like the tricyclics and the monoamine oxidase inhibitors, have been around for quite a while. Long enough, in fact, to garner a shadowy reputation. Thus, the tricyclics, like Tofranil and Elavil, are known to have numerous side effects, induce severe withdrawal symptoms and be extremely lethal in overdose. The MAO inhibitors are so dangerous that the maintenance of a special diet is necessary to avoid life-threatening cardiovascular reactions.
The minor tranquilizers, like Valium, have also been around for decades and are probably the most widely prescribed psychiatric medication. Technically, they are considered apart from the anti-depressants by virtue of their central nervous system action. Nevertheless, they too are associated with a host of side effects in addition to being both highly addictive and lethal in combination with other drugs.
The word 'revolution', then, should rightly be reserved for the latest generation of anti-depressants, the so-called 'selective serotonin reuptake inihibitors' (SSRI's) and their hybrid kin. These include such brand names as Prozac, Paxil and Zoloft. What is revolutionary about them is less their mode of action, than the extraordinary media fanfare and scientific claims accompanying them. Though this is not the first time that a class of drugs has been alleged to specifically target the presumed biological cause of a complex psychological function (i.e. depression), they are the first to benefit from the notion that they might enhance the normal human condition as well.
The credibility of both these claims rests on the theory, widely embraced by the general public, that depression involves a well defined point source, or sources, in the brain upon which anti-depressant drugs act like magic bullets surgically targeting the offending region(s). Such a theory, however, seems never to have been burdened with the facts, for the overwhelming weight of clinical and physical evidence suggests that the drugs act, not by targeting any hypothetical 'depression center', but by simply blunting affect and emotion generally. They act, in other words, non-specifically to block emotional (limbic system) and higher cognitive (frontal lobe) connection. They don't 'target' anything other than a generalized splitting of psychic functioning.
Indeed, there is a clear line of reasoning that the sine qua non of their action is precisely their toxicity. In this they are related to alcohol, the pleasantly delirious effects of which derive largely from its toxicity and that, likewise, doesn't 'cure' or 'target' any mental dysfunction at all. In fact, a more telling analogy is to be seen in the comparison with cocaine and amphetamine, both of whose effects rely, in part, on their inhibition of the reuptake of serotonin. Ironically, it was cocaine that was first hailed as a miracle drug and panacea for psychic ills by Sigmund Freud at the turn of the century. That was until he personally discovered its physically destructive and addictive qualities.
The analogy can be carried further. Both cocaine and amphetamine impact additionally on the dopamine and adrenergic neurotransmitter systems. So do the SSRI's. Moreover, the claim that these drugs work functionally and specifically is further belied by the fact that the serotonin system itself ramifies throughout the brain and spinal cord.
Curiously, in light of the widespread concern about biochemical imbalances in the brain, the only known such imbalances (apart from a few hormonal conditions like Cushing's syndrome and Graves' disease) are those caused by the drugs themselves. Lack of appreciation of this fact leads routinely to travesties in assigning cause and effect. Thus, the inevitable rebound reactions which ensue upon cessation of medication, are often interpreted in circular fashion, by doctor and patient alike, as confirming evidence of the previously hypothesized biological abnormality.
It must be stated at this point, that none of the foregoing is meant to suggest that genes and biochemistry have nothing at all to do with moods and behaviour. Nor is it meant to espouse a belief in some sort of metaphysical mind/body dualism. The psyche is obviously based in a physical substrate and constitutional factors clearly influence everything from temperament to potential intellectual limits. But to see biological parameters as framing human potential is a far cry from believing that we have uncovered - or that there even exist - specific, localized chemical substrates of complex emotional and psychological states. It is, furthermore, naive to suppose that these drugs could ever act in a functionally specific (i.e. fine tuned) way given what we know of the neurophysiological complexity of even the most 'primitive' of brain processes (like temperature and water regulation, for instance).
Even more naive, however, is to suppose that tampering, on a daily basis for perhaps years, even decades, on end, with the most delicate, complex and evolved organ in the known universe, is not inherently dangerous. Certainly our experience with the neuroleptics suggests otherwise.
Equally worrying is that basic neurophysiological principles clearly argue for the potential of permanent changes in physiology when the brain's dynamic homeostasis is chronically altered or upset. A number of animal studies involving amplification of the serotonin system have already demonstrated a compensatory down-regulation of serotonin receptivity resulting in the permanent loss of serotonin receptors.
Also worrying is a recent report in the British medical journal the Lancet, describing how a group of scientists in the United States had scanned human brains and found damage to serotonin neurons, caused, they believe, by the street drug Ecstasy. Studies with monkeys have reinforced these results. Ecstasy is thought to work, at least in part, by boosting the serotonin system.
Still, biological psychiatrists will argue, and most people believe, that the SSRI's have undergone a rigorous battery of independent tests, trials and experimental protocols under the auspices of the American FDA to insure their efficacy and safety. Nothing could be further from the truth.
First of all, the experimental studies for these drugs are constructed, financed, and supervised entirely by the drug companies themselves. Their vaunted independence is a complete myth.
Second, the timelines of the trials are so unreasonably short as to fly in the face of the most elementary scientific reasoning. Prozac, for instance, was released onto the market with only six weeks of clinical trials. In essence, anyone now taking the drug for more than six weeks is involved in one's own study into its long-term effects.
Third, the experimental protocol and statistical design of many of these studies are a complete scandal in their own right. In the case of Prozac, among other statistical shenanigans: data were pooled from different sources, then manipulated into shape; relevant clinical groups were eliminated from participation; additional confounding medications were administered simultaneous to the test drug; the dropout rate of roughly 50% - and the reasons for - were never factored into the final results; finally, the total number of subjects that actually finished a placebo-controlled study was a mere 286.
It is natural to ask at this point, why, given their potential danger, we haven't witnessed an epidemic of adverse reactions and brain damage related to these new generation drugs.
As far as the latter effect is concerned, 'witnessed' is the operative term. The serotonin neurotransmitter system, unlike the dopamine system upon which the neuroleptics principally act, is not linked directly to the body's motor system, therefore any damage that may occur is likely to be much less visible over the short and intermediate run. Moreover, any emotional scarring or loss that does take place is likely, again, to be interpreted as part of the original hypothesized 'biological' disorder. That said, it must be noted that the SSRI's do, in fact, also effect the dopamine and adrenergic systems, and, like the neuroleptics, they can be expected to exert a malign, if peripheral, influence on these structures as well. Evidence to this effect has already been documented.
In terms of bad reactions, the case against the SSRI's is on much firmer clinical ground. Following its release in 1988, for instance, a flood of Prozac horror stories hit the media. A deluge of lawsuits quickly followed, whilst Eli Lilly, its manufacturer, embarked on a massive lobbying and propaganda campaign to protect its $1 billion a year (1993) Prozac market.
Among the many pathological effects that Prozac appeared to induce or exacerbate were: paranoia, compulsion, depression, suicidal ideation and violence. Numerous bizarre and gratuitous murders and suicides were credited to its influence, and a number of august journals including the Lancet and the British National Formulary came out with confirming warnings about 'suicidal ideation' and 'violent behaviour'. Interestingly, this symptom cluster is typical of amphetamine psychosis, a, by now, well-known result of protracted stimulant overdose. Like amphetamine, Prozac is functionally a stimulant.
Apart from safety, yet another claim routinely made by proponents of the biological psychiatric paradigm is that the long-term effectiveness of medication for neurotic disorders is superior to that of traditional psychotherapy. Once again, a claim with little or no clinical evidence to back it up. Actually, a number of comprehensive reviews over the past decade have come out decisively in favour of psychotherapy. Commonsense would hardly dictate otherwise for, by suggesting to people that they are merely biologically defective mechanisms capable of handling their emotional/psychospiritual crises only with the aid of a technological crutch, many of the fundaments and principles of psychological healing are completely undermined. Encouraging patients to give up on personal growth and understanding in favour of pills is, apart from being a philosophy of despair, a recipe for emotional disaster. Thus, helplessness is substituted for mastery, dependency for autonomy, and an unexamined life takes the place of self-discovery.
Moreover, at precisely the time of greatest need, the patient-cum-psychic adventurer is delivered up to a zombie-like state devoid of both mental acuity, and the capacity for deep feeling, self-awareness and self-empathy.
That biological psychiatry could so blithely trample underfoot such granite pillars of therapeutic commonsense is chilling.
Even more chilling is the fact that the biological paradigm has expanded well beyond the confines of the adult population. For though most medicated adult patients can be said to be nominally voluntary, medicated children can in no way be so considered. In an era deluged with an avalanche of new statistics detailing the pervasiveness of childhood poverty, neglect, and abuse, it is curious that the psychiatric profession has chosen to ignore the obvious psychosocial causes of most childhood behavioural disorders. Instead, the profession has opted to crusade for the wholesale drugging of this involuntary population on the basis of totally unsubstantiated theories of biological causation.
Thus, there is hardly a shred of experimental evidence to buttress such trendy childhood 'disease' entities as Minimal Brain Dysfunction, Learning Disorder, or Attention-Deficit Hyperactivity Disorder. No underlying local organic malformation, physiological malfunction or chemical basis has ever been clearly demonstrated for these syndromes and no well-controlled clinical studies have ever unequivocally supported them either. This has not stopped the escalating prescription of such stimulants as Ritalin and Dexedrine despite a host of negative side effects including, tics, spasms, growth suppression, and chronically elevated heart rates and blood pressure.
Naturally, the same dangers, the same potential for permanent damage, apply with respect to these medications as they do to all the others, with the added complication that, here, the potential for harm is compounded by virtue of the drugs' interaction with the developing brain.
Increasingly, Prozac is also being given to children despite them never having been part of the original experimental protocol. The license for such practice derives from the fact that, once the FDA has approved a drug, there are few restrictions on how or to whom a doctor can prescribe it. In line with this practice, the anti-depressants in general have become a jack-of-all-trades medication prescribed for everything from insomnia to migraine headache.
In stark contrast to this massive state-sanctioned drug laundering operation is the harshly punitive 'war' the state wages against illegal drugs. Though beyond the scope of this commentary, this fascinating (perhaps to some, transparent) paradox does point up the concluding need to confront some of the broader social implications of the biological psychiatric paradigm.
As part of its general philosophical stance this paradigm is an ideological formation with an implicit, highly ideological portrayal of the nature of 'human nature'. In this sense it is aimed at us all. For at the heart of any political philosophy is found a biased conception of what it means to be human; and it is just this conception that the reductionist psychiatric model seeks to address in a manner which is neither progressive nor in any way new. Indeed, it is entirely politically and culturally reactionary.
Politically, the notion that the laws of human behaviour and mental functioning should be phrased predominantly in terms of biological parameters ineluctably invokes the specter of social Darwinism. For if our behaviour is thought to be strictly biologically determined then it is immutable, our fates inevitable, and the status quo merely reflects the 'laws of nature'. It is then but a short step to the rationalization of the manifest inequalities of societal wealth and privilege, a sort of updated version of the Divine Right of Kings in pseudo-scientific jargon.
Culturally, the notion that we should conceive ourselves primarily as biochemical mechanisms is not only dangerously dehumanizing and spiritually stunting, it leads inevitably to both a dismissive and escapist attitude towards many genuine psychological and social problems.
In other words, in having induced a substantial proportion of the population into believing that their behaviours are dictated by their genes and their biochemistry, biological psychiatry has set back the psychological paradigm many years. It has also fanned the flames of a simplistic, reductionist view of human nature and of human society.
Psychiatry may have festooned itself with self-congratulatory laurels vis-�-vis its increasingly 'scientific' and 'objective' orientation but, ironically, it has moved ever further away from the true meaning of those terms. Having jettisoned the language and level of analysis necessary for an appropriate dialogue with its clientele, it is no longer even capable of seeing itself in any remotely objective way.
Possessed by the reductionist daemon, psychiatry remains blind to its own historical contingency, to its own social, cultural, economic and political conditioning. Unable to see that it too has a case history, it remains insensible to its own, quite advanced pathology.
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