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Making Sense of Psychiatric Drugs

Written by Steven Coles on . Posted in Clinical Psychology Bite-Size

Making Sense of Psychiatric Drugs

Issue 41 – September 2014

Authors: Steven Coles and Joanna Moncrieff (steven.coles@nottshc.nhs.uk)

Key points

  • Service users’ experiences of taking psychiatric drugs are varied, but often ignored
  • Evidence for the chemical imbalance theory of psychiatric drug action is weak
  • An alternative ‘drug model’ views psychiatric medications as working in a similar manner to other non-prescription drugs such as alcohol, and highlights the subjective experience of taking medication

Implications for practice

  • Explore in detail service users experiences of taking psychiatric drugs
  • Support service users to weigh up the costs and benefits of taking them
  • Critically reflect on our assumptions about the nature of psychiatric drugs
The use of psychiatric drugs in mental health services is extremely common – with the majority of people prescribed some form of medication. Service users often report a range of experiences resulting from taking medication, from: positive “So far this has kept my mood balanced “; negative “I lost my ability to feel emotions”; and perhaps most commonly a combination “Although I felt very well, I felt as if I had absolutely nothing to talk about” 1. Academics and professionals continue to debate how we understand the effects of psychiatric drugs and their effectiveness2, though the idea of a chemical balance is often promoted3. How psychiatric drugs are discussed with service users will affect how they understand their distress. A model of psychiatric drugs which emphasises disease or biological processes, such as the chemical imbalance idea, may mean staff minimise the lived experience of taking medication. Do drugs correct a chemical imbalance? What are the alternatives? What are service users’ experiences?

Chemical Cure: The Disease Model

A disease model of psychiatric drug action suggests that that medication works by correcting underlying abnormalities in the brain (often viewed as a chemical imbalance). Even the names of the psychiatric drugs “anti-depressant”, “anti-psychotic” etc tend to suggest that they target a particular abnormal process4. For example a common idea is the ‘dopamine hypothesis of schizophrenia’, which argues, in its simplest form, that people who have experiences labelled as psychosis have excessive dopamine activity, and that antipsychotics work by correcting this abnormality. Similarly, it is suggested that depression is caused by a deficiency of serotonin, and that modern antidepressants work by increasing serotonin levels. However, neither of these chemical imbalance theories have been substantiated 4, 5. Instead of correcting underlying abnormalities, antipsychotics have been shown to cause brain abnormalities, such as brain shrinkage 6, 7. So, why do such ideas persist? The dominance of simplistic biochemical theories appears to be significantly influenced by the interests and activities of pharmaceutical industry and other interest groups, rather than the pursuit of science and evidence8, 9.  

An Alternative: The Drug Model

An alternative way to understand psychiatric drugs is the drug model, which sees psychiatric medications as working in the same way as other non-prescription drugs, such as alcohol 4, 10. Rather than correcting an imbalance, medications are seen as creating a new and altered brain state which will have its own positive and negative effects. A useful example is the effect of drinking alcohol on someone who is shy – after drinking alcohol at a social event a shy person may temporarily become more sociable and talkative. In this case, we would not say that the cause of the person’s shyness was an alcohol (or other chemical) deficiency, nor that the alcohol worked by correcting that deficiency. Instead we would say that the experience of drinking alcohol makes someone less inhibited and perhaps more relaxed, which temporarily overcomes their fear of speaking to people. Alongside these positives, using alcohol in this way will have well known short and long term negative effects and would not be a lasting solution, particularly as the risks increase over time. Psychiatric drugs can also be seen as working in a similar way. Antipsychotics, for example, cause a state of generalised neurological suppression, which can be useful in reducing psychotic symptoms. Historically this is how such drugs were viewed.   The drug model of psychiatric drugs urges staff to explore in detail what someone’s experience of taking psychiatric drugs is like. Unfortunately research has not paid much attention to such experiences, arguably due to the over focus on chemical imbalances and cures. Some of the research that has been conducted shows that, on top of the well-known range of physical side effects of psychiatric drugs (e.g. sexual impairment, weight gain, hormonal effect etc), there are a wide range of subjective / psychological alterations, such as: sedation, flattened emotions, a lack of thoughts, loss of interest (depending on the drug involved)1.  

A Patient’s Dilemma

Weighing up the costs and benefits of psychiatric drugs depends on the specific experience of the person taking them and the nature of the original problems. 1. The experience might be complex, with some positive effects, but also drawbacks. For example many psychiatric drugs make people feel sedated, or apathetic and indifferent. In the short term these effects might be considered positive if someone is less distressed or less disturbed by voices or difficult beliefs. However, feeling sedated or apathetic is likely to have a detrimental effect on building a meaningful life – getting a job, having hobbies, maintaining friendships and so on. A drug that flattens emotions might be beneficial in terms of suppressing painful feelings and memories of abuse, but it may also prevent people from dealing with such trauma in a more lasting manner, and may mean positive feelings of love, care and warmth are also lost.   The drug model highlights that we need to pay close attention to people’s lived experience of taking psychiatric drugs. This lived experience is crucial when staff support someone to weigh up the specific pros and cons of taking, altering and coming off a specific drug. People need to consider, in the short and long term, the physical health effects of the drugs, a person’s experience of it and its wider impact on their life. Some people may not have capacity at a particular time to make these judgements; however, the drug model also urges staff to take a more questioning approach to assumptions around how we understand the causes of distress and role of medication in alleviating suffering.  

REFERENCES

  1. Moncrieff, J., Cohen, D. & Mason, J. (2013). The Patient’s Dilemma: An analysis of users’ experiences of taking neuroleptic drugs. In S. Coles, S. Keenan & B. Diamond (Eds.), Madness Contested: Power and Practice. Ross-on-Wye: PCCS Books.
  2. Bracken, P. et al. (2012). Psychiatry beyond the current paradigm. The British Journal of Psychiatry, 201, 430–434.
  3. Kendler, K. F. & Schaffner, K.S. (2011). The Dopamine Hypothesis of Schizophrenia: An Historical and Philosophical Analysis. Philosophy, Psychiatry, & Psychology, 18, 41-63.
  4. Moncrieff, J. (2008). The Myth of the Chemical Cure. Hampshire: Palgrave MacMillan
  5. Bentall, R. P. (2003). Madness Explained. London: Allen Lane.
  6. Dorph – Petersen, K.A et al. (2005) The influence of chronic exposure to antipsychotic medications on brain size before and after tissue fixation: A comparison of haloperidol and olanzepine in macaque monkeys. Neuropsychopharmacology, 30, 1649 – 1661.
  7. Ho, B.C. et al. (2011). Long-term antipsychotic treatment and brain volumes: A longitudinal study of first-episode schizophrenia. Archives of General Psychiatry, 68, 128 – 137.
  8. Busfield, J. (2013). The pharmaceutical industry and mental disorder. In S. Coles, S. Keenan & B. Diamond (Eds.), Madness Contested: Power and Practice. Ross-on-Wye: PCCS Books.
  9. Mosher, L., Gosden, R. & Beder, S. (2013). Drug companies and schizophrenia: Unbridled capitalism meets madness. In J. Read & J. Dillon (Eds.) Models of Madness (2nd ed.).Hove. Routledge
  10. Moncrieff, J. (2013). The Bitterest Pills. Hampshire Palgrave MacMillan
 

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