Talk to me or give me the Drugs (EN)

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In this post I would like to address the issue psychopharmacology vs. therapy.

There is a common misconception that if someone is depressed it is because there is something wrong with their brain chemistry and they need to take medicine to “cure” it.

A few years ago, I visited a friend of mine in the States and I was taken aback by the amount of advertising on TV dedicated to prescription drugs, especially antidepressants. The number of people who take this type of medicine in the western world is much higher than in the rest of the world. Is it because people get less depressed in other parts of the world or is it because they do not have access to those medicines?

Depression is a 'sickness' of modern living. Statistical data shows us that depression rates are twice as high in urban areas as in the countryside. Also, in places where daily survival is the rule, there is no such a thing as depression. People who live in hostile environments, where they need to walk a certain amount of time just to get water, do not get depressed like we do in the first world.

However, we, creatures of the modern world with mobiles phones, high-tech devices and plenty of water and food at our disposal, do get depressed, stressed and anxious. Some people blame the existence of these feelings to our brain chemistry.

Is our brain chemistry wrong?

Have you ever thought that maybe 'our crazy lifestyle' might have something to do with our feeling depressed?

In a country where the legal yearly vacation is just one week, where everything happens so fast and people must do so many things in a day, people take many more prescription drugs than in any other part of the world.

Some people may find difficult to stop their flow of activity, which will lead them to fail meeting their deadlines and doing all the things that they believe they 'should' do? So, if someone is feeling down and cannot go on with their daily duties they will get a pill that will allow them to keep on going with the belief that there was something wrong with their brain chemistry and that is why they were feeling that way.

But we can ask ourselves another question. Is our brain chemistry really 'wrong' or not strong enough to achieve everything we think we are supposed to?

People who take antidepressants might have noticed that since they have been taking the medicine they feel much better. Probably their mood has improved and they feel more stable.

The truth is drugs do work. If I dance nine hours a day for seven days a week and I complain about my body aching. My trainer might give me some nice steroids (and maybe a bit of cocaine, too) and I will be able to go training beyond my possibilities for a while. I will be able to achieve results: maybe win a dance competition, improve my muscle growth, whatever those results are.

Body chemistry

Imagine someone running for their lives. They are being chased by a bad person who wants to kill them. If you could take chemical samples of that person at that moment, you would find a high amount of adrenaline together with 'alert enhancing' neurotransmitters that help the person escape. In the laboratory this is done with a rat and a cat (yes, psychologists do those things to investigate).

But, we could find the same amount of adrenaline on a person sitting on a chair in a very safe environment, a person watching a very scary movie, for example. The person is not in a life threatening situation, however that makes no difference to their brain.

We could cause the same physiological effect by injecting the person with the right amount of adrenaline and other chemicals into their body. They would experience the same reactions which the person could interpret as a 'panic attack' or the feeling of being scared or anxious, among others.

Whether it is through a mental image (a movie) or an injected drug, you can get the same experience. The reaction of your brain to the movie or to the injected drug works through the same mechanisms within the body.

Brain chemistry

Psychoactive drugs work by altering the neurochemicals in your brain, for example, increasing the number of neurotransmitters, which are substances that your neurons use to communicate with each other. They are produced generally in the body of the neuron and released at the level of the synapse. A synapse is the junction between two neurons where generally one neuron passes chemical signals to another neuron.

If this does not make much sense to you, just imagine a person giving out a piece of paper to another person. The paper would be the neurotransmitters and the people would be the neurons. If the paper for example has the word “jump and pass it along” written on it, the second person would get the paper, read it, jump and then pass the paper to the next person in line and so on.

I know I am oversimplifying things a bit, but for the purpose of this explanation the image of a line of people giving out written instructions to each other will do. Of course the brain is build out of many lines of neurons working together. So, to imagine the brain in a simple way, picture a lot of those lines of people together passing written information to each other.

Fluoxetine (commercially known as Prozac) works by altering the amount of some neurotransmitters available. Imagine you give out more papers with the word jump on it, then more people would start jumping. And for the sake of this example, I will end up saying that a brain with more neurons jumping would be a happier brain.

What about therapy?

The common mistake is to believe that psychoactive drugs work in a different way than therapy does. Since the use of neuroimaging, the brain can be scanned to investigate the neurochemical changes that take place after taking a psychoactive drug or attending to a therapy session.

It has been proven that psychoactive drugs and therapy work through the same basic principles of brain chemistry. Just to give an example, using positron emission tomography (PET) (a nuclear medicine imaging technique) in patients with obsessive compulsive disorder, they could see that those who took fluoxetine and improved their disorder had the same biochemical changes in their brain as those who improved by being treated with psychotherapy. Patients who did not improve (either by taking fluoxetine or through therapy) did not have those changes.

Drugs or therapy?

The question is not either/or. Both work and many times drugs are necessary. Especially with patients that do not have the psychological or economical resources to attend therapy. It might not be such a good idea to treat only with therapy a person who is very depressed and wants to kill themselves.

A point of caution when speaking about antidepressants and other psychoactive drugs: the biological effects of these drugs on neurons happen very quickly. If I have some neurons in a cell culture and I administer one of these drugs, I can almost immediately measure changes (increased neurotransmitters levels, for example). But, many times in therapy the effect of that drug and the condition that is being treated does not become apparent until weeks down the road.

Why will neurons isolated in a lab react immediately to the administered drug, while their effects on the person’s mood take weeks to start working? That remains the big question. We pretend that we understand that fluoxetine treats the effects of depression, but if that were the case you would expect the treatment to have immediate effect, since those drugs work on the neurons immediately. It is not like when you take an aspirin and your headache is gone in 20 minutes or so. Instead what is a more accurate description is that affecting the neurotransmitters initiates a sequence of events in the brain that ultimately results in reduction of symptoms and that may involve many other unknown neurotransmitters. So, it is the adaptation of the brain to the drug that causes the reduction of the depression.

However, this adaptation might be achieved faster through therapy. This is still being researched, but just to give you an example how therapy can work, imagine you are sad because you got fired from your work and you spend part of the day moaning about it and then in the evening you find out that you’ve just won the lottery, the big prize! Your sadness is suddenly gone and you have this rush of energy and bliss in your body. In just one second!

Many performers say that going up on stage gives them a rush that cannot be compared to any drug. Those are also neurotransmitters working as a reaction to the situation and not as a reaction to a drug.

Imagine a day in your life when you are feeling dull and you do not feel like doing anything. You were just lazing around all day and do not want to leave the house. Then imagine a person that you like very much calls you and wants to go on a date with you, you immediately cheer up, and become active again. You go take a shower, dress up, and out of a sudden you feel like going out and being more energetic. Again, your mood changed and no external drugs were involved in the process.

More about drugs

Another issue about drugs - and a lot of people are not aware of this - is that once a drug has been approved by the Food and Drug Administration for treatment for a certain disorder, physicians can prescribe that drug for anything they want. So, even though Prozac was initially researched for depression in adults it is now prescribed for obsessive compulsive disorder and eating disorder and it’s prescribed for children, as the approval essentially opens it up.

Also remember that drugs always have side effects. They influence other parts of the body as well. They tend to have a more general effect in the body physiology, while therapy is more specific to a problem.

If you have a phobia to spiders and another person has a phobia to dogs, and another one to flying by airplane, the pharmacological treatment for these phobias might be the same (it might be an anxiolytic that will block the person’s ability to feel fear and anxious.) Meanwhile therapy will treat each phobia specifically (the treatment for getting over the fear of spiders might have no effect on the fear of dogs, or flying) while also working on the ability of the person to confront their fears.

The need to go on 'non-stop'

In the past if one was hungry, one would eat, and if one was tired, one would stop working for a while and take a nap and so on. Now we live in a world where we eat at certain times, we must work at certain times and sleep at certain times. Even some people are only allowed to pee at certain times! This improves overall performance and production in a capitalistic society, but it comes with a cost.

Depression and anxiety are really illnesses of our time and culture. This does not mean that they did not exist before, but rather that we provide the right conditions for them to happen, then treat them with psychoactive drugs and tell ourselves that it was all a malfunction of our brains.

I will go deeper into some of the modern theories about depression on a future post. I leave you with a very interesting video about the placebo effect.