Editor’s Note: The Point blog is an opinion piece for current medical issues and does not always represent CMDA’s views. Please see the disclaimer at the end. This blog has featured issues in the past that have led to lively discussions with differing opinions, such as vaccines, government international spending and this issue of psychotropics. We ask that dialogue be respectful with an understanding of differing opinions.

 

I am a practicing psychiatrist with nearly 35 years of clinical experience in diagnosing and treating mental illness. I want to respond to Dr. Jeffrey Hansen’s recent article on The Point blog by first saying that I, along with my colleagues, appreciate the ongoing dialogue and the valuable contributions of psychologists like Dr. Hansen in the care of individuals facing mental health challenges. We believe open discussion, grounded in both research and clinical experience, is essential for advancing our understanding and treatment of mental illnesses. In that spirit, I would like to offer a further perspective on some of the points raised in his article.

 

Regarding the serotonin theory of depression, Dr. Hansen references Dr. Moncrieff’s review (published in Nature) as significant evidence against it. It is important to note this is an ongoing area of scientific debate, and subsequent responses, such as the one by Jauhar et al. (also in Nature) titled “A leaky umbrella has little value: evidence clearly indicates the serotonin system is implicated in depression,” present a different interpretation of the same data. The mechanisms of action of medications affecting the brain are complex and not yet fully understood, partly due to the limitations of animal models (try getting a PHQ 9 on a chimpanzee) and the ethical considerations surrounding human brain tissue research.

 

While it may be true there is a cultural narrative that “depression = low serotonin,” which has been potentially perpetuated or at least not adequately resisted by the field of psychiatry, the truth is too complex to be boiled down to a catchy soundbite. While we may not know the exact biological cause of depression, we do know that altering serotonin transmission in the brain does improve symptoms of depression in a significant portion of patients who take medications for this reason. To compound the suffering of those afflicted by depression by instructing that they should avoid potentially lifesaving medications simply because they are imperfect would violate the Hippocratic Oath that all doctors swear when they enter medical school: First, do no harm.

 

Dr. Hansen also posits that psychiatry has “turned normal human emotions into disorders” to prioritize profits. In my daily clinical experience, I encounter individuals suffering from severe conditions that go beyond the spectrum of normal human emotions, including delusions, hallucinations, mania and suicidal or homicidal thoughts. Tragically, some individuals do complete suicide, highlighting the critical need for effective interventions that will work on a timescale that therapy alone simply cannot accomplish. I shall never forget a statement made by the widow of one of my patients (after more than 50 years of a happy marriage on the mission field) soon after his suicide from a severe biological depression, “Doctor, he never would have done it in his right mind.” While I agree on the importance of avoiding overmedication, the reality of severe mental illness and the suffering it causes cannot be understated.

 

Dr. Hansen argues that increased sales of medications prove their illegitimacy. However, in healthcare, as in other sectors like technology (think Apple, Microsoft, Amazon), increased utilization can reflect patient needs and choices. Patients vote with their feet and pocketbooks, and while pharmaceutical marketing exists, it doesn’t equate to a mandate for psychotropic medications. Furthermore, considering other medical fields, such as oncology, where treatment costs and utilization have also risen significantly, the metric of sales alone does not inherently indicate illegitimacy. The average cost for a year of life gained from cancer drugs in the U.S. rose from $54,000 in 1995 to $207,000 in 2013.[1] I trust Dr. Hansen would not encourage a patient with cancer to avoid chemotherapy simply because the pharmaceutical industry is profiting from the multiple advances made in cancer research during the last several decades.

 

Dr. Hansen highlights the side effects of medications. I acknowledge that psychotropic medications, like all medical treatments, can have side effects, and these must be carefully considered and discussed with patients as part of the informed consent process. This process involves a thorough discussion of potential risks and benefits, as is also the case in other areas of medicine, such as chemotherapy for cancer. For individuals facing severe mental illness, where the risks of the illness itself are significant (e.g. suicide in schizophrenia), the potential benefits of medication in alleviating suffering and preventing adverse outcomes must be carefully weighed against the risks of side effects. For instance, clozapine, an antipsychotic with arguably some of the most severe side effects in its class, has such solid evidence for reducing the frequency of suicidal thoughts[2]^,[3],[4],[5] that its labelling reads, “Clozapine is indicated to reduce the risk of recurrent suicidal behavior….” These discussions with patients and their families are complex, balancing the significant risks of medications such as clozapine with the significant risk of suicide in schizophrenia (20 to 50 percent attempt and 5 percent complete suicide.[6]^,[7]

 

Dr. Hansen correctly notes that in much of the literature, but not all,[8] antidepressants may struggle to show a large difference from placebo in mild to moderate cases of depression. This fact is why I have told many patients, “You don’t need to see me. I am referring you to an excellent psychologist.” And it well might be Dr. Hansen, if I lived in Arizona (he has great Google reviews). Yet, many fall into the severe category, are treatment-resistant, have failed psychotherapy or have associated psychotic or catatonic features, requiring a biological intervention for an organic disease.

 

In summary, my experiences would caution avoidance of a myopic view on brain medications as espoused by Dr. Hansen. Bad theology and dogma frequently lead to unnecessary morbidity and mortality, be it Christian Scientist’s resistance to medicine in general, Scientologists’ war on electroconvulsive therapy or Jehovah’s Witness’ prohibition of transfusions.

 

[1] Howard et al “Pricing in the Market for Anticancer Drugs” Journal of Economic Perspectives, 29(1),139-162

[2] Meltzer et al “Clozapine treatment for suicidality in schizophrenia: international suicide prevention trial” Archives of General Psychiatry, 60(1), 82-91

[3] Tortorella et al. Clozapine reduces suicidal behavior: A review. Cochrane Database of Systematic Reviews, 2(1), CD006187

[4] Hennen and Baldessarini. Suicide risk in schizophrenia: clozapine as a protective factor. Harvard Review of Psychiatry, 13(3), 127-132

[5] Tiihonen et al. Effectiveness of antipsychotic treatments in a nationwide cohort of patients in Finland: A nationwide study. Lancet, 367(9527), 405-411.

[6] Schennach et al Suicidality in schizophrenia: a review and clinical treatment recommendations. Expert Opinion in Pharmacotherapy, 13(11), 1383-1398

[7] Palmer et al The lifetime risk of suicide in schizophrenia: a reexamination. Archives of General Psychiatry, 62(3), 247-253

[8] Gibbons, R. D., Hur, K., Brown, C. H., Davis, J. M., & Mann, J. J. (2012). Benefits from antidepressants: synthesis of 6-week patient-level outcomes from double-blind placebo-controlled randomized trials of fluoxetine and venlafaxine. Archives of General Psychiatry, 69(6)