The battle with coronavirus, fought with social distancing and enforced isolation, is taking a psychological toll on many of us and our country, like the rest of the world, is now confronted with another brewing pandemic of mental sickness. But we need to be aware that we are almost as less equipped to handle any such crisis as we have been with novel coronavirus. Anne Harrington, the pre-eminent historian of neuroscience, opines in her books and essays that the mind and brain medicine has not come as far as we all would like to imagine or wish.
The death of an ambitious, hardworking actor Sushant Singh Rajput in the middle of a pandemic, who was allegedly on medicines for depression, has shook us all asserting the need to work on inner fitness as much as we do for physical wellbeing. We need to be fully aware of preventive and curative aspects of any such disease and work on it accordingly. Renowned psychiatrist Thomas Szasz, in his famous book The Myth of Mental Illness, argued that psychiatric diagnoses were too vague to meet scientific medical standards and that it was a mistake to label people as being ill when they were really, as he termed it, ‘disabled by living’ — dealing with vicissitudes that were a natural part of life.
For over half-century Szasz insisted that illness, in the modern, scientific sense, applies only to bodies, not to minds — except as a metaphor. A body part or an organ, say, the heart, can be diseased, but to be heartsick or homesick, though real enough, is not to be medically, but only metaphorically, ill. Equally metaphorical, said Szasz, were such supposed mental illnesses as hysteria, obsessional neurosis, schizophrenia and depression.
Unlike surgeons and oncologists, psychiatrists don’t have the privilege to peer into a microscope to see the biological cause of their patients’ suffering, which arose, they assumed, from the brain. They are stuck in the pre-modern past, dependent on the apparent mental condition as judged from the outward manifestations to devise diagnoses and treatments. Challenges to the legitimacy of psychiatric diagnosis forced the profession to examine the fundamental question of what did and did not constitute mental illness. Homosexuality, for instance, had been considered a psychiatric disorder until the seventies, but now it’s accepted as a natural phenomenon in humans as in animals.
In the late nineteenth century, researchers explored the brain’s anatomy in an attempt to identify the origins of mental disorders. Such studies ultimately could find no specific anatomical location causing such disease. In 1885, the Boston Medical and Surgical Journal noted a rapid increase in the number of the insane over that decade. Mental asylums built earlier in the century were now overflowing with patients. This pointed to a possible relationship of the stark rise in insanity to an increase in syphilis those days. This, what we now know to be “general paralysis of the insane” is nothing but a late stage of syphilis. Patients were afflicted by dementia and grandiose delusions and developed a wobbly gait. Toward the end of that century, as many as one in five people entering mental asylums had general paralysis of the insane. Proof of this causal relationship between a mental condition and syphilis came in 1897, and this for the first time marked the discovery of a specific biological cause for a common mental illness. But the work on syphilis proved to be something of a dead end.
Researchers in neurosciences of those times analysed autopsies of patients who had suffered from mental illness, but the brain anatomists found that these mental illnesses left no trace in the solid tissue of the brain. Anne Harrington frames this outcome in the Cartesian terms of a mind-body dualism: “Brain anatomists had failed so miserably because they focused on the brain at the expense of the mind.” Sigmond Freud commented on the approach by asserting the fact that there was an intimate connection between the story of the patient’s sufferings, his upbringing and social conditions, the severity of mental trauma undergone and the symptomatic manifestation of his illness. Freud, who stated that the case histories of a psychiatric patient should read like short stories and lack the serious stamp of science.
In 1954, the FDA, for the first time, approved a drug as a treatment for a mental disorder — the antipsychotic chlorpromazine (marketed with the brand name Thorazine). The pharmaceutical industry vigorously promoted it as a biological solution to a chemical problem. One advert claimed that Thorazine reduces or eliminates the need for restraint and seclusion; improves ward morale; speeds release of hospitalized patients; reduces destruction of personal and hospital property. By 1964, some fifty million prescriptions had been filled in the US. The income of its maker — Smith, Kline & French — increased eightfold in a period of fifteen years.
Next came sedatives. Approved in 1955, Meprobamate was hailed as a “peace pill” and an “emotional aspirin.” Within a year, it was the best-selling drug in America, and by the close of the fifties, one in every three prescriptions written in the United States was for Meprobamate. An alternative, Valium, introduced in 1963, became the most commonly prescribed drug in the country the next year and remained so until 1982.
One of the first drugs to target depression was Elavil, introduced in 1961, which boosted available levels of norepinephrine, a neurotransmitter related to adrenaline. Then the focus shifted from norepinephrine to the neurotransmitter serotonin, and, in 1988, Prozac appeared, soon followed by other selective Serotonin Reuptake Inhibitors (SSRIs). Promotional material from GlaxoSmithKline couched the benefits of its SSRI Paxil in cosy terms: “Just as a cake recipe requires you to use flour, sugar, and baking powder in the right amounts, your brain needs a fine chemical balance.”
In America, the final decade of the twentieth century was declared the ‘Decade of the Brain’. But, in 2010, the National Institute of Mental Health reflected that the initiative hadn’t produced any marked increase in rates of recovery from mental illness. To it, Anne Harrington calls for an end to triumphalist claims on treatment of mental illnesses and urges a willingness to acknowledge what we don’t know about the mind.
Although psychiatry has yet to find the pathogenesis of most mental illnesses, it’s important to remember that medical treatment is often beneficial even when pathogenesis remains unknown. This is very comparable to the case of peptic ulcers where we now know that stress doesn’t cause ulcers but it can exacerbate the symptoms and hence controlling stress can help a patient with ulcers. There are other instances where the discovery of pathogenesis has produced medical successes, it has often worked in tandem with other factors. Without the discovery of HIV, we would not have antiretroviral drugs, and yet the halt in the spread of the disease owes much to simple innovations, such as safe sex education and the distribution of free needles and condoms.
Cancer specialists are found to reflect that their field bore similarity to the field of psychiatry (despite a growing knowledge of the pathogenesis of cancer), one could not precisely predict whether a patient would benefit from a treatment or suffer pointlessly from its side effects. This catapults the gravity of side effects of medications of psychiatric drugs which is comparable to toxicity of cancer therapies. Weighing and balancing the benefits and losses of a drug regimen of a psychiatric problem needs the same preciseness of clinical judgment as in cancer treatment.
The search for pathogenesis in psychiatry continues. Genetic analysis may one day shed light on the causes of schizophrenia, although, even if current hypotheses are borne out, it would likely take years for therapies to be developed. Recent interest in the body’s microbiome has renewed scrutiny of gut bacteria; it’s possible that bacterial imbalance alters the body’s metabolism of dopamine and other molecules that may contribute to depression. More importantly, we’d do better not to set so much store by the idea of a single key solution to mental sickness. It’s more useful to think in terms of cumulative advances in the field by being more knowledgeable about the range of treatments available and lifestyle recommended.
In addition to medication, there have been other approaches, such as cognitive-behavioural therapy, which was propounded in the seventies by the psychiatrist Aaron Beck. He posited that depressed individuals habitually felt unworthy and helpless, and that their beliefs could be “unlearned” with training. An experiment in 1977 showed that cognitive-behavioural therapy outperformed one of the leading antidepressants of the time. Neurosciences today can demonstrate that cognitive-behavioural therapy causes neuronal changes in the brain (This also happens while learning a new language or a musical instrument.) The more we discover about the brain the easier it will be to disregard the apparent divide between mind and body. Words are another powerful tool in healing of the mind as words can also alter, for better or worse, the chemical transmitters and circuits of our brain, just as drugs or electroconvulsive therapy can. We still don’t fully understand how this occurs. But we do know that all these treatments are given with a common purpose based on hope, a feeling that surely has its own therapeutic biology.
The writer is a medical doctor (pathologist) and her love for creative writing had her accomplish an MA in creative writing from the University of London.
