Reducing the Brain, Ignoring the Soul

[finness]

Reducing the Brain, Ignoring the Soul

Grace E. Jackson, MD

December 5, 2002

There are at least five problems with the chemical imbalance model of mental disease:

1) the model ignores the reality that there has never been a consistently reproducible biological marker, to substantiate the levels of normal or abnormal neurotransmitters in the human nervous system

2) the model fails to respect the enormous complexity of neurotransmission in the human brain:

a) there are over five kinds of dopamine receptors which have been characterized to date, and even the best researchers know nothing about the D5 subtype

b) there are five separate kinds of cholinergic receptors

c) there are fifteen different kinds of serotonin receptors

d) neuroscientists do not yet understand the relationship between neuroreceptor density, sensitivity, or neurotransmitter turnover

3) the model fails to consider the fact that many of the neurochemicals which are presumed to be the basis of "mental disease" are, in fact, broadly distributed throughout the body. This fact casts doubt about our conceptualization of "brain tissue" (perhaps it is not limited to the cranial vault) and also raises questions about the reliability of serum or urine tests, as those assays may be capturing levels which reflect non-brain locations of neurotransmitter activity:

a) over 90% of the serotonin in the human body is made by the enterochromaffin cells of the stomach and small intestine, rather than the raphe nucleus of the midbrain and pons

b) a broad variety of cells in the human body possess receptors for many of the neurotransmitters, including white blood cells and platelets

4) the model fails to acknowledge the impossibility of measuring discrete events in the human brain, due to the speed of neurotransmission; and due to the relative bulk of our measuring devices, relative to the size and complexity of each synapse

5) the model fails to acknowledge the impossibility of explaining the brain in reductionistic terms. That is to say, the organic whole may so far exceed the sum of the component parts, that science will never be able to fully explain the workings of this magnificent system. Part of the problem here is that the brain is never capable of being studied in a vacuum - the system is forever open, due to the conscious, and unconscious, processes of the subject who is being observed. Part of the problem, too, arises from the phenomenon of diaschisis, or non-local effects, through which changes in one part of the brain reflect, and then precipitate, complex cascades of events in multiple locations throughout the nervous system. Thus, it is impossible to speak of serotonin or dopamine without analyzing the interactions of all complex chemicals, peptides, and amino acids upon each other, but far too little research has occurred to study the gestalt of these intercommunications.

[rached]

I'm nurse-liason for a psychiatrist, and do medication management for our patients once they have been stabilized. The bulk of our suburban practice is comprised of anxiety disorders (ocd being primary), bipolar disorders (mostly depressives), and to a lesser degree schizophrenia and other chronic thought disorders.

When patients initially come to us, it is usually because they or their families are desperate for help, and their situations are acute and intolerable. While CBT and other forms of talk therapy certainly have their legitimate and useful place in the treatment of mental/emotional illness......what these folks are looking for is NOT referral to a therapist, but relief from pain, and the sooner the better. Who can blame them? We can go on all day decrying that yes, we're a culture used to the "instant fix" but I think that psychotropic drug therapy gets a bum rap, frankly. Every single day I witness what I consider to be near-miracles primarily due to psych drugs; can't argue with that.

And yes, we do strongly encourage traditional talk therapy for every patient for whom it's appropriate. Generally speaking, that's most of them, once they're stabilized.

[lsyorke, RN]

Rached, it sounds like you work for a psychiatrist who takes the time to talk to patients. Thats how it should be. My gripe is with the doc who prescribes meds after a 15 minutes evaluation,then sees behavior that could be attributed to the medication given and instead of looking at the drug ,prescribes another drug to counteract the first one given. Since I've become involved in the SSRI problem I hear these stories over and over again. Case in point- 13 year old sees a psychiatrist for anxiety, gets paxil,does reasonably well at first and then gets aggressive. 2 years later is pulled off paxil(due to the FDA warning) and is put on zoloft. Psychotic symptoms start,suicidal violent,aggressive. Gets changed to Celexa. Psychotic symptoms continue.Add Seroquel to the mix and label her schizophrenic!! We need to educate doctors,families,and patients of the possible side effects of these drugs instead of saying"But they help so many other people". Do we ignore the ones who have problems? Do we fail to think that maybe the drugs can be bad for certain patients?Do those who are doing so well on SSRI's know that the withdrawal can in itself be a nightmare? Would I have let my son take an ssri knowing what I know now??ABSOLUTELY NOT!!

[finness]

yes, to some patients, chemical intervention is crucial. for others, it is ineffective, fruitless, and yes, even dangerous. it is the responsibility of a competent psychiatrist to determine the appropriate therapeutic intervention...be it chemical or traditional talk analysis. one of the pitfalls of psychiatry is that treating a patient with extreme depression, ocd, mania, personality disorders, or anxiety is not as exact as setting a broken arm. psychiatry, for better or worse, is highly dependent upon vigilant, skillful professionals providing the care best suited to the patient. may we all be involved in the process of healing...

[Thunderwolf, MSN, RN]

Interesting topic. I believe, from my own past professional and personal experience, meds have their place, but also does counseling/psychotherapy. Research has shown that they have a synergic effect on each other (1+1=3, not 2), improved results for each when combined. I agree, there are some docs who pass out the pills too much or too LITTLE, without taking the adequate time to talk to the person. This is where nursing comes in. Meds have their place, but they are not the magic pill. Illness does not happen in a vaccuum. You can take the healthiest person, lump enough stress, and push the person over his/her threshold. Seen it. Had it. Helped others through it. Counseling has its place. However, I've seen the benefits of meds too. I have found it helpful to explore with others their symptoms as listed in the DSM criteria, using it as a brief benchmark of understanding how relief from meds/counseling will help, coming back to it later to measure progress. For many, this has been helpful. It is also helpful for the person to monitor or measure how his/her meds and/or counseling has not been helpful thus far. Medication teaching has to be present, the good and the bad, for the person to be informed on their meds. The benefits and disadvantages. All meds have side effects. Take any med, long enough and/or strong enough, there will be side effects. The more the person is informed, the better off he/she is. I also believe in letting the person know what the medication or counseling WILL NOT fix or cure. I believe this is important to not build false hope or set up false expectations. This is what it is, this is what we can do about it, and this is what we can genuinely expect at this time and down the road. Meds can take a significant edge off symptoms, allowing the person to benefit more fully from counseling/therapy and move on in his/her life.

[CliveUK]

There is next to no evidence for the effectiveness of "counselling". And seeing as "counsellors" don't even need to be licensed or registered to set their service up, you could be allowing rank amateurs to have access to your brain. Give me the drugs any day of the week.

[Thunderwolf, MSN, RN]

CliveUK, in the USA...Counseling is a regulated, title protected, profession in many of our states here (just like nursing). In these particular states, it is illegal for a person (professional or non-professional) to hold themselves out as a "counselor". Many of these states require a Masters degree "in" Counseling and require sitting for boards with ongoing contact hours for education in order to maintain the license. A counselor can focus his/her practice in developmental counseling (dealing with life stress, life promotion, and life management...non-psychiatric) OR focus in clinical counseling (dealing with psychiatric conditions). In our country, however, any one can call themselves a therapist (a nurse, a psychologist, a psychiatrist, a counselor, a social worker, a priest, a plumber, or who ever). A therapist here is a catch-all term. I do not know how it is so in Great Britain. However, people do benefit from counseling. So, I guess I disagree, but that is my bias.

[CliveUK]

Over here, the counselling and therapy industry is totally unregulated, except through informal, voluntary regulation by organisations representing therapists of various flavours. This is why I have a healthy dose of scepticism about therapy and therapists.

The only therapies with any proven efficacy are cognitive behaviour therapy and solution-focussed therapy. There is virtually no convincing evidence for the benefit of psychoanalysis, Rogerian counselling, psychodynamic approaches and all the other ever more obscure schools of brain-fiddling. I think most of it is a con, frankly, unintentionally perpetrated by well-meaning people who have swallowed the therapy myths hook line and sinker. Belief in some schools of therapy is more akin to religious belief than anything else.

If I had depression, I'd be asking them to give me the drugs then try and get me a CBT therapist but don't let them "humanistic" counsellors loose on me please!!

[StuPer]

Hi CliveUK,

As an ex-pat from the UK I know what the counselling situation is like in the UK, however I cannot agree with your cynical interpretation of counselling. Certainly there are people who are prepared to abuse the trust of vulnerable individuals and claim skills where none exist, but there is a lot of evidence in support of counselling. CBT as you mention has evidence, but only because its structured format make it easier to quantify than other forms of counselling, as is DBT.

But you seem to believe that medications offer a safer and better alternative, when if you look at the research often presented by the drug companies themselves, most antidepressants have only a marginal improvement over placebo, certainly not enough to make you throw your mouth open with eager anticipation. Happy pills are a misnomer, they at best mildly improve your ability to cope and I would suggest the psychological comfort of knowing your on a 'pill' accounts for a lot of improvement, however the cognitive tools taught in a number of counselling disiplines, give longer term strategies that can literally change your life.

It is true that the best evidenced way of improving a persons depressed mental state is a combination of antidepressants and CBT, that does'nt mean other forms of counselling are ineffective, rather they do-not and cannot be easily fitted into a research format. Imagine how you would meansure improvement in the 'humanistic' model of counselling when its guiding principle is to see the world of the client rather than impose your view of the world on the client... by default the only person who can measure improvement in that setting is the client.

I'm not saying your completely wrong, far from it, as I said there are a lot of people who give counselling a bad name. Let me give you one reason, true counselling specifies a number of sessions in which the objectives the client sets are met, this is rarely supposed to go above 10-12 sessions. Now if you were a counsellor and your livelihood was dependant on a certain number of clients coming through your doors on a weekly basis, how encouraged would you be to end a series of sessions if you were not making enough to live on?

All in all, in recent times I have seen research which demonstrates neither CBT (counselling) or pharmocology (antidepressants) improve outcomes to the point where you counld heartily recommend either, that is improved by combining both systems, but a salient point is that many people simply recover from depression without input from either.... the old 'time as a healer' therapy.

Sorry I havent evidenced a lot of this, but you really want I'll dig it up, I'm just tired and basically too lazy....

regards StuPer

[CliveUK]

StuPer - it is rather convenient, isn't it, that certain schools of counselling/therapy consider themselves too mysterious and unquantifiable to be researched adequately? Which allows them to get away with the self-proclaimed tales of their efficacy - a bit like religion, really: "we can't prove it one way or the other, you just have to believe". I imagine Rogerian counselling could lend itself to - at the very least - a qualitative review. And given that Dissociative Identity Disorder and False Memory Syndrome are both creatures of the consulting room, artefacts of the therapist/client relationship, then I would say that certain forms of therapy are actually more damaging than anti-deps.

In contrast to some of my earlier statements on this forum, I have become more and more convinced of biological theories of depression, which is why I believe (and research tends to back me up) that neurotransmitter modification and the kind of neuromodulation which effective therapies like CBT provide are the only truly proven effective measures.

[lsyorke, RN]

There's a BIG contradiction here Clive!! If you choose to believe the "chemical imbalance" cause of depression you must look at the success parameters. They too are based on someone elses determination of success, just like therapy. There is no measurement of neurotransmitters that is available. No "serotonin level" to be drawn. Just subjective or objective result reporting. Calling it a chemical imbalance removes the stigma attached to depression, but doesn't make it absolute. Now add in to the mix what are the other ramifications of altering neurotransmitters. The human body is one big feedback system. If you change the serotonin level believing that that is the cause of depression you have to realize that that will effect how the adrenal glands work, the pituitary gland, production of liver enzymes,thyroid function etc...... It's not as simple as it is made out to be. Now add in the placebo effect of a "miracle" drug group that have been marketed for everything from depression to shyness. That's a powerful stimuli !

[StuPer]

I would also add that there is a chicken and egg issue, if the 'chemical imbalance' was precipitated by a non-pharmaceutical change (reactive to social situation etc), why is the only proven restoration by giving the brain an alien drug. The fact that imbalance is caused without chemical addition definately lends weight to the idea it can be restored without drugs, don't you think?

The use of antidepressants maybe easier, and more convenient, but I cannot recall a patient who recovereed from a clinical depression by pills alone.. not one. They have their place but are certainly not the answer, and as I said their efficacy is far (according to company stats) from glorious. The point Isyorke makes is also extremely important, not even the most ambitious neurologist, psychiatrist, etc would claim to have a complete understanding of the way the brain works, or what impact medications have on the individual, hence all the side-effects discovered after the approval of a drug. Lastly is'nt that use of antidepressants and other psychotropic medications a 'leap of faith', we may know some direct benefits, but not the multivarious other possible implications, Clozapine being a case in point.

As I said counselling maybe a mixed bag, and thats why when recommending couonselling to a patient I ensure they are aware of the pit-falls and the need to find someone who they relate to and how there maybe a need to swap counsellors a few times to meet their needs..... just like trying to find an antidepressant that works for an individual client.

regards StuPer

[lsyorke, RN]

"As I said counselling maybe a mixed bag, and thats why when recommending couonselling to a patient I ensure they are aware of the pit-falls and the need to find someone who they relate to and how there maybe a need to swap counsellors a few times to meet their needs..... just like trying to find an antidepressant that works for an individual client"

Well put Stuper!! There are good counselors/therapists/psychologists and there are bad. I was lucky to find one for my son who has been wonderful. Recognizing the paxil withdrawal and at the same time working on what caused the paxil to be prescribed for in the first place. My son is in a MUCH better place now because of this mans interventions. I can't say the same about my son's experience with paxil.