Psychotropic drugs ---Modern medicine’s alternative to purgatives, straitjackets, and asylums but also ARE NUTHOUSES OVER MEDICATING SCHIZOPHRENICS? by Frederick Engstrom, MD, guest editor.

MENTAL HOSPITALS ARE DRUGGING AMERICAN KIDS TIL THEY’RE OUT OF THEIR SKULLS!

Psychotropic drugs Modern medicine’s alternative to purgatives, straitjackets, and asylums

TOP paragraph by Frederick Engstrom, MD who says that DRUGGING THE MENTAL PATIENTS IS WONDERFUL! SECOND, DR BREGGIN (BELOW) says PSYCH MEDS ARE THE WORST!

A bewildering variety of therapies for mental illness—from exorcism to asylums, from bloodletting to lobotomy, from tonics to talk therapy—have been tried over the years, with limited success. During the past 50 years, after major mid-century leaps in psychopharmacology, psychotropic drugs have taken the lead among treatments for mental disorders such as depression and schizophrenia. Chlorpromazine, lithium, and a host of modern newcomers have had a significant impact on patients, physicians, medical practice, and society. Severely psychotic patients can often be relieved of their frightening symptoms and enabled to live in the community. Physicians have tools for treatment that are efficacious and cost-effective; at the same time, the availability of these medications may cause shifts in the physician’s role in mental healthcare. Both psychiatry and psychotherapy are changing in response to the insights provided by the use of medications and the questions it raises. The stigma of having a mental illness has lessened considerably. It’s been nothing less than a treatment revolution.* Demons or black bile? Mental illness has always been a part of the human experience, and so has the quest to understand and treat it. As in other medical fields, the preferred treatments for mental illness have gone hand in hand with changing theories about its causes. Some ancient civilizations, including the Babylonians and the early Egyptians, attributed mental illness to demonic possession; their “cures” combined magic incantations, religious ritual, and a veritable pharmacopoeia of natural substances. The ancient Greeks believed that “hysteria” was caused by incorrect positioning of the uterus; such eminent medical men as Hippocrates and Galen advocated fumigation of the vagina to draw the uterus back into place. Then, as at later points in history, the simple fact of being female was considered a risk factor for mental illness (1).Hippocrates also theorized that depression, which he called melancholia, was caused by black bile and hence could be cured with purgatives.Several centuries later, the Roman writer Cicero (106-43 bc) disagreed with the famous Greek’s physiological explanation. He proposed instead that melancholia resulted from psychological difficulties and that people were responsible for their own emotions, thus laying the foundations for modern psychotherapy. Neither of these great thinkers could have predicted that the conflict over the causes of mental illness would continue into the present day.An ancient debate in the modern era During the centuries since the height of the Greek and Roman civilizations, the debate over the causes of mental illness has waxed and waned in response to the dominant intellectual and religious movements. Successive intellectual movements such as rationalism, romanticism, and humanism wrought parallel changes in the conceptualization of mental illness, its causes, and its treatments. The 17^th century saw mental illness begin to move into the realm of physiology, aided by physicians like Thomas Sydenham of England (1624-1689). He proposed that hysterical symptoms could simulate many forms of organic disease—an important step toward understanding the interdependence of body, mind, and brain (1). The debate continued after the emergence of psychiatry in the mid-19^th century—not surprisingly, given the profession’s nature as a restless hybrid of neurology and psychology. Advocates of physical causes for mental illness recommended bloodletting, purging, cold-water immersion, and various tonics and medications (primarily opium and opium derivatives) as treatments. Others believed emotional disorders were caused by such problems as inappropriate mothering; it was thought impossible for patients to recover while remaining at home. Part of the treatment, then, was to place mentally ill patients in a mental asylum. To simplify management, many of these patients were restrained in straitjackets or manacles and chains.Despite the horror such restraints evoke today, the state mental hospitals and insane asylums were themselves built in response to a reform movement to replace the poorhouses of the 18^th and early 19^th centuries. In poorhouses, the mentally ill who could not be cared for by their families were not treated but merely confined, often side by side with criminals, unwed mothers, the destitute, and the mentally retarded (1). By 1870, 45,000 “known insane persons” were being treated in America’s mental institutions, and by the turn of the century, 328 institutions were caring for almost 200,000 patients (with surprisingly good outcomes, even by today’s standards) (2). The number continued to rise, peaking in 1955 at 559,000 (3).In the late 1800s and early 1900s, as more and more mentally ill persons were being housed in the nation’s mental institutions, new thinking led to shifts in treatment. Mental illness came to be viewed as a medical problem, with a new emphasis on brain disease as the cause. At the same time, Sigmund Freud, one of psychiatry’s brightest stars, theorized that mental and emotional disorders were caused by repressed instinctual drives and unconscious memories from childhood. His dynamic work in neurology and psychology led to the development of new psychotherapeutic methods, including free association, dream interpretation, and psychoanalysis.Research continued into the 1930s and 1940s on both the psychological and physiological fronts, resulting in rapid proliferation of “talk therapies” as well as new medical treatments. Theories about the interconnection of body and mind led to development of sleeping cures, various forms of shock therapy, and psychosurgery, such as prefrontal lobotomy. But many patients were unresponsive to these treatments, and diagnosis and management remained hit-and-miss. The time was ripe for the emergence of the first psychotropic drugs. The chemical revolution In 1947, the year Postgraduate Medicine was first published, few people realized that medicine was on the brink of important discoveries that would alter the way patients with mental disorders were treated. But Dr Abraham Myerson, a neuropsychiatrist long affiliated with Boston Psychopathic Hospital, had his finger on the pulse. Quoted in the December 1948 issue, he predicted the future focus of psychiatry with startling accuracy: “If I were asked to predict the status of psychiatry 25 years from now, I would state without hesitation that biochemistry, biophysics, [and] pharmacological therapeutics will hold the center of the stage; that psychoanalysis will be present as a term, but entirely different as a system of beliefs and principles; and that the social phases of psychiatry with its genetic and social relationships will be of fundamental importance (4).” Sedatives had appeared on the scene in the late 1800s, followed by barbiturates and amphetamines in the early 1900s. But it was drugs such as chlorpromazine hydrochloride (Thorazine) and lithium, introduced in the 1950s, that dramatically changed our thinking about mental illness.As Harvard neurophysiologist and author Dr J. Allan Hobson recently summed it up, “There is no doubt that the development of drugs that interact with the brain-mind’s chemical system is the most important advance in the history of modern psychiatry (5).” Some of the most far-reaching developments to date have involved four main drug categories: antipsychotics, mood stabilizers, antianxiety agents, and antidepressants.

Antipsychotics The chemical revolution in treatment of psychoses, especially schizophrenia, began with the release of chlorpromazine in May 1954. Originally designated as a major tranquilizer, chlorpromazine was soon found to be more effective at subduing the hallucinations and delusions of psychotic patients than any previous treatment. Within 8 months of its appearance on the market, the drug had been administered to over 2 million patients (3). Chlorpromazine allowed many formerly hospitalized patients to be released to live in the community, and it fostered the deinstitutionalization movement of the 1960s, 1970s, and 1980s, becoming known as “the drug that emptied the state mental hospitals (6).” However, institutional populations were already declining before the release of chlorpromazine, so it is probably more accurate to say that chlorpromazine hastened a movement already in the making. Since the introduction of chlorpromazine, it and other antipsychotics, including haloperidol (Haldol) and clozapine (Clozaril), have transformed treatment of psychosis. The benefits for patients who respond are clear: Frightening hallucinations are eliminated or reduced, the patients feel more relaxed and in control, and a return to home and family life is often possible. But, as with all psychotropic drugs, there are downsides. Some patients complain of feeling drugged or lethargic. Others experience restlessness, muscle rigidity, or dystonia. Negative symptoms, such as social isolation and flat affect, often remain. In addition, these drugs do not offer a cure; patients must continue to take them to maintain benefits. One of the great problems with the mass closing of state psychiatric hospitals was that many psychotic patients were released to situations that didn’t provide structure or support. As a result, many patients stopped taking the medications. Predictably, their symptoms recurred.Recent studies have found that 30% to 40% of America’s homeless have severe mental illness, including schizophrenia. And even now, after several decades of emptying and closing state mental hospitals, patients with schizophrenia still occupy 40% of all long-term hospital beds (3). Mood stabilizers Australian psychiatrist John F. J. Cade’s 1949 discovery of the beneficial impact of lithium on manic-depressive disorder was a major leap in psychopharmacology for two reasons: effectiveness and specificity. Many patients with bipolar illness responded well to the medication, often being freed from incapacitating mood swings that may have led to such personal difficulties as uneven productivity, ruined careers, and marital break-ups. Equally important, however, was the fact that patients with schizophrenia did not respond to lithium, leading psychiatrists to a degree of diagnostic precision that was previously not possible. Recently, some antiepileptic medicines—valproic acid (Depakene) and carbamazepine (Epitol, Tegretol)--have also been used to treat bipolar illnesses. While lithium remains the treatment of choice for classic (bipolar I) manic-depressive disorder, newer drugs have proved useful for bipolar variants, such as rapid cycling bipolar disorders. These medications are often prescribed in conjunction with standard antidepressant and antipsychotic drugs. Antianxiety agents- Anxiety is one of the most common and most important emotions, an internal switch that can turn on the fight-or-flight reaction and hence an indispensable tool of survival. However, when anxiety is severe, prolonged, and apparently causeless (for example, when a person suffers recurrent panic attacks at a shopping mall), it can be debilitating. Many pharmacologic agents have been used to alleviate anxiety. The first were barbiturates, widely prescribed before the 1960s. But they were highly sedating and addictive and didn’t always work. Chlordiazepoxide (eg, Librium) and the other benzodiazepine anti-anxiety agents developed from the 1960s to the 1980s rapidly replaced barbiturates, for some very good reasons. The benzodiazepines proved to be more effective, to have fewer side effects, and to be less dangerous in overdose. They have remained popular too; as recently as the early 1990s, six of the 25 top-selling prescription drugs in the United States were benzodiazepines (7). While many patients have been relieved of their anxiety or panic symptoms, some critics would say that not all anxiety ought to be treated. It’s worth remembering the 1950s and 1960s phenomenon of “mother’s little helper,” when barbiturates and other antianxiety drugs were prescribed for masses of discontented housewives. A number of thinkers, philosophers, and writers have accorded anxiety a valued place in the pantheon of emotions. Their recognition that anxiety may serve a useful function by enhancing our understanding of the human condition and the ways in which our lives are out of joint brings an unusual perspective to the modern concern over whether to prescribe anxiolytics. One such thinker is novelist Walker Percy, who was trained in medical pathology and strongly influenced by existentialist philosopher Søren Kierkegaard and who has written extensively about psychiatry and the self. Echoing a dominant tradition in psychology, he suggests that anxiety may be important to the individual’s journey of self-discovery.If an anxious individual is medicated, he or she may be “protected” from a painful but essential human experience (6). While Percy’s point of view needs to be balanced by the evidence of grateful patients whose anxiety disorders once prevented them from driving, sleeping, working, performing, and even leaving home, his concerns about the impact of drugs on creativity, personality, and human development are not easily dismissed. Antidepressants In any given 6-month period, about 3% of adult Americans experience severe depression (7). Because of its widespread incidence, depression has been called the “common cold” of the psychiatric profession. Everyone experiences a depressed mood in response to common life events such as sickness, death of a loved one, or divorce. For the millions whose depressed mood becomes a clinical syndrome, though, psychotropic therapy is one way to relieve the symptoms. From the 1930s to the 1950s, electroconvulsive therapy (ECT) was the most effective, widely used treatment for serious depression. Then, in the mid-1950s, iproniazid, an antitubercular agent, was found to give patients energy and a sense of well-being (6). Although later withdrawn because of concern over its side effects, it was prescribed to about 400,000 depressed patients in its first year and earned a reputation as the first modern antidepressant. Now antidepressant drugs are the first choice for treatment, and ECT is used, for the most part, only when a patient does not respond to pharmacotherapy. The tricyclic imipramine hydrochloride (Tofranil), developed during the late 1950s and introduced during the early 1960s, was the first of the now-available antidepressants and still is often prescribed (6). Current theories attribute depression to psychological causes (eg, low self-esteem, important losses in early life, history of abuse) and biological causes (eg, imbalance of neurotransmitters, including serotonin and dopamine; disruptions in the sleep-wake cycle) as well as experiential and social factors. The various classes of antidepressants—tricyclics, MAOIs, serotonin-specific agents—and individual drugs including nefazodone (Serzone), mirtazapine (Remeron), venlafaxine (Effexor), and bupropion hydrochloride (BuSpar) target the biological causes. At present the selective serotonin reuptake inhibitors (SSRIs) hold center stage, and fluoxetine hydrochloride (Prozac) is in the spotlight.The result of years of focused research and design, fluoxetine was rapidly accepted and prescribed to millions within a few months after its introduction in December 1987 (7). Some patients have shown such a dramatic response to this antidepressant that, as author and psychiatrist Dr Peter D. Kramer (6) notes in his national bestseller Listening to Prozac, they “are not so much cured of illness as transformed.” Indeed, the drug, which became both the media’s darling and its victim during the early 1990s, often relieves lifelong depression, leading to improvements in self-image, confidence, self-esteem, sensitivity to conflict, and awareness of the needs of others (6). Tales of transformation raise fascinating questions about the potential for this family of drugs. Fears or hopes that the SSRIs might be able to change personalities through “cosmetic psychopharmacology (6)” have not been fulfilled. But the dramatic responses that some patients have to the SSRIs raise that possibility for future generations of drugs. Will we be able to provide a “psychological makeover” to a patient’s personality of choice? Who will address the ethical issues?

Until solid answers to the many difficult questions are available, physicians are making decisions about whether and when to prescribe psychotropic drugs on the basis of current knowledge and their own clinical experience. In The Chemistry of Conscious States, Dr Hobson (5) describes his personal exploration of the fascinating relationship between mind and brain chemistry and comes to a measured, conservative conclusion: “Drugs are a powerful aid to changing the brain-mind states of the mentally ill, but we must use them with appropriate caution.” Citing concerns about our still-infant state of knowledge about drug interaction with brain chemistry, as well as side effects and the potential for abuse and overuse, Hobson calls himself a reluctant prescriber. Today, tomorrow, and beyond Things are changing rapidly in the field of psychopharmacology. In last month’s issue of Postgraduate Medicine, for example, Dr Leslie Citrome (8) discussed the latest developments in antipsychotic medications. He noted that two new agents introduced within just the last few years—risperidone (Risperdal) and olanzapine (Zyprexa)--promise to be as effective as clozapine for positive symptoms and more effective for negative symptoms of schizophrenia. Sertindole (Serlect), quetiapine (Seroquel), and ziprasidone are “on deck” in the testing and approval process. Research is also under way to develop and evaluate new SSRIs, monoamine oxidase inhibitors, and other drugs for treating depression and other mental disorders.* The US Food and Drug Administration is in the process of approving expanded roles for existing drugs too. For example, in January 1997, it approved the SSRI sertraline hydrochloride (Zoloft) for treatment of obsessive-compulsive disorder and approved fluoxetine for treatment of bulimia.* Advances on other psychopharmacologic fronts are on the horizon.Researchers are exploring new methods of drug administration, such as small pumps that can inject drugs directly into the brain and electrical devices that stimulate discrete brain regions. Another intriguing possibility is dose sequencing, in which special, intermittent dosing may prove more effective than daily regimens in treatment of some psychiatric disorders (7).*Developments in drug therapies will also be accompanied by advances in adjunct therapies. For instance, light therapy has proved effective treatment for seasonal affective disorder; perhaps it will prove useful in treating other depressive disorders too. And continued study of the biologic causes of mental illness on the genetic level may one day yield genetic diagnoses and treatment.

Who knows? As Dr Kramer (6) speculates, perhaps one day physicians will advocate early detection of depression the way they now advocate early detection of cancer, and treatment of very minor conditions will take on a standard preventive function.*Abraham Myerson, who was honored as a pgm “Man of Medicine” in 1948, once wrote that it puzzled him that both philosophers and some scientists would talk about the mind “as if it were too lofty to have any direct dependence upon the structure of the brain (4).” Today, modern science is affirming Myerson’s 50-year-old conviction that “chemistry and mind and brain have become knit as finely together as any chain of cause and effect in this world of ours.” For example, recent positron-emission tomography studies at the UCLA School of Medicine have revealed that both fluoxetine and cognitive therapy “can actually restore normal function in the obsessive-compulsive brain (9).” The idea that either a drug or a learning experience can change the way nerve cells interact is strong evidence for the close-knit brain-mind connection that should spark exciting new directions for treatment.*As the brain is coaxed to reveal its secrets on the molecular level, emerging information can guide efforts to create new drugs that target particular forms of mental illness. For now, as primary care physicians take an increased role in treating patients with mental illness, physicians and patients alike will continue to evaluate the promise of a better life through chemicals.*At the forefront Daniel G. Blazer, MD, PhDDuring his 20 years of practice, Daniel G. Blazer, MD, PhD, has found psychotropic drugs to be “wonderful tools” in the treatment of mental illness. Dr Blazer, who is the J. P. Gibbons Professor of Psychiatry and Dean of Medical Education at Duke University Medical Center, Durham, North Carolina, has watched the evolution of psychotropic drugs carefully. Like many other physicians, he supports the use of medications together with other forms of therapy.* “The emerging thought is that a combination of cognitive or behavioral therapy with an antidepressant, for instance, is superior to either one alone. Intuitively, psychiatrists have known that for years, but now there is good evidence for it. Using the two concurrently is more effective, especially if you broaden the concept of nonpharmacologic therapy to include relating effectively with the patient and working closely with the patient’s family.”* As more primary care physicians deal with mental illness in their everyday practice, their experiences may raise questions about the effects of psychotropic drugs on the personality and the self. Such questions, Dr Blazer notes, are now being addressed by “neurophilosophers.”*“Individuals like Paul and Patricia Churchland, Jerry Foder, Richard Rorty, Ed Hundert, and Owen Flanagan are philosophers who also have an excellent knowledge of neurophysiology and neurobiology. They have pushed the envelope in bringing together the study of neurobiology and human behavior and in looking at what sciences can inform psychiatry, leading to new approaches in therapy for psychiatric disorders. Their writings will stimulate new types of research.”* Looking to the future, Dr Blazer predicts the development of drugs that give greater control over specific conditions. “They’ll have fewer side effects and be more targeted—for example, we know now that valproic acid is particularly effective for manic episodes in patients who’ve had strokes. We’ll also know more precisely what a drug will do and what its side effects will be. And that will help primary care physicians be better able to manage mental illnesses.”

This is just my MORNING dose.
Night dose twice as large!

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The greatest critic of insane asylums, Dr. R.D. Laing, has written amply on the sick psychiatrist syndrome. His website: offers much to read, and his books are a dollar each at ABEBOOKS . COM

Dr. Peter Breggin agrees with LAING in "TOXIC PSYCHIATRY." KIRKUS REVIEWS SAYS: "He is a psychiatric reformer who takes aim and blasts away with both barrels. Breggin (author of the novels The Crazy from the Sane, 1971, and After the Good War, 1972) launches a full-scale attack on the popular view that neuroses and psychoses are diseases with biochemical and genetic causes best treated by drugs--even by electroshock and incarceration. He advocates not pills but psychotherapy, which ideally provides a ``caring, understanding relationship--made safe by professional ethics and restraint.'' Treating mental disorders as chemical imbalances to be corrected primarily by chemical intervention is, he claims, an outrageous hazard to health, damaging the brains of a high percentage of those subjected to it. Breggin notes that the medical training of today's bio-psychiatrists ill-equips them for any other approach: They are taught to make diagnoses and prescribe medical treatments; their communication skills are undeveloped, and they know little about the art of listening to patients' problems. Their penchant for prescribing drugs, according to Breggin, is encouraged by a too-cozy relationship between the medical profession and the pharmaceutical industry, which generously funds research into the biochemical and genetic basis of mental disorders, and whose claims for its products are insufficiently scrutinized by either the FDA or the medical profession. Breggin also has harsh words for health insurers that reimburse for drugs and psychiatric hospitalization but not for psychotherapy and social rehabilitation; coming under fire as well are schoolteachers who seek chemical solutions to classroom discipline problems, and parents who are unwilling to accept any blame for the psychological problems of their children. Although Breggin's preference for nonmedical intervention is clear, he remains skeptical about much of what's available today, warning that ``the buyer of psychotherapy must be extremely cautious.'' A one-sided but forceful caveat emptor for anyone seeking mental-health services. BREGGINS books are at ABE BOOKS COM for a buck each, used, he has a string of them.

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If you have any first hand information on this, please write anita sands, astrology @ earthlink.net