Book Review: The Limits of Drug-Based Psychiatry
About 40 years ago, Daniel Bergner’s younger brother, Bob, then 21 and a college dropout, had a psychotic break. He became delusional; he was convinced that he might be the messiah and that he could cure their grandfather’s Alzheimer’s disease. Worn down by insomnia, Bob was also neglecting his personal hygiene. Out of desperation, the brothers’ parents arranged to have Bob committed to a locked psychiatric unit, where he was soon pumped up on a heavy dose of Haldol, an antipsychotic medication.
Shortly after Bob was hospitalized, their father handed Daniel a popular book by the late Ronald Fieve — first published in 1975— on mood disorders. According to this prominent psychopharmacologist, psychiatry was undergoing “a third revolution,” which was leading to new and highly effective drug cures for major mental disorders, including schizophrenia, bipolar disorder, and major depression. This book, notes Daniel Bergner in “The Mind and the Moon: My Brother’s Story, The Science of Our Brains, and the Search for Our Psyches,” gave his parents hope that his brother’s condition could be treated. “It was as if they had ingested the book’s sentences and elevated its paragraphs to articles of faith,” he writes. “They were immediate converts.”
As Bergner, a contributing writer for The New York Times Magazine, emphasizes in his moving narrative, the chief claim contained in that bestseller of yesteryear — that mental illnesses are diseases for which there exist chemical cures — ended up gaining a lot of traction. But Bergner himself has long harbored reservations about such biological reductionism.
As he reports in this deep dive into the history of psychiatric treatments over the last century — which features interviews with leading neuroscientists and psychiatrists, as well as profiles of people like Bob who have waged long battles with psychiatric problems — the biological revolution in psychiatry has not come close to living up to its grandiose promises.
Medication can indeed reduce emotional suffering. Bergner cites research suggesting that about half of people who take selective serotonin reuptake inhibitors, or SSRIs — a category of popular antidepressants that includes the mega-selling Prozac — do experience some symptom relief “if comparison with placebos is disregarded.” But while the number of Americans taking psychiatric drugs has been steadily increasing over the past 20 years (more than 40 million adults and as many as 40 percent of college students, according to recent estimates), drug treatment, he stresses, often does not work at all and sometimes is harmful due to noxious side effects. For example, SSRIs, can cause both sexual dysfunction and withdrawal symptoms, both of which, Bergner notes, their manufacturers have minimized. And antipsychotics can cause weight gain and increase the risk of diabetes; according to internal records of pharmaceutical company Eli Lilly, 16 percent of patients taking its blockbuster drug Zyprexa gained more than 66 pounds.
The triumph of biological psychiatry, Bergner suggests, has everything to do with the close ties between Big Pharma and academic psychiatry and little to do with compelling scientific evidence. As he notes, an opinion article in The New England Journal of Medicine declared in 2019 that “psychiatric diagnoses and medications proliferate under the banner of scientific medicine, though there is no biologic understanding of either the causes or the treatments of psychiatric disorders.”
Take the chemical imbalance theory — as deeply embedded in the contemporary cultural firmament as Freud’s tripartite theory of the mind was a couple of generations ago — which posits that a serotonin deficiency can cause depression. Psychiatrist Steven Hyman, a former director of the National Institute of Mental Health, who now directs a center for psychiatric research at the Broad Institute of MIT and Harvard, suggests that this idea is just marketing double-talk. As he explains to Bergner, “How people could think that mediocre — important, but mediocre — drugs like the SSRIs could give us any comprehension is beyond me. The logic is like saying, I have pain so I must have an aspirin deficiency.”
Likewise, Eric Nestler, a professor of psychiatry, neuroscience, and pharmacological sciences at the Icahn School of Medicine at Mount Sinai, tells Bergner that it would be easy to argue that psychopharmacology has run into a dead-end, noting that “there hasn’t been a truly new mechanism for the treatment of any psychiatric disorder in over a half a century.”
During his initial hospital stay in 1983, Bob was diagnosed with bipolar disorder and told that he would need to take lithium for the rest of his life. After three or four years, he could no longer stand the side effects — a tremor in his hands and a feeling as if a blanket had been placed over his brain. After another stint in a psychiatric hospital, he was shuttled off to a homeless shelter. But after Bob stopped taking the medication and distanced himself from both his parents, he succeeded in rebuilding his life. He got married to “the love of his life” and now works as a pastor. “I’m just lucky,” Bob says to his brother, “that I’m crazy enough to have refused being crazy.”
Bergner also tells the story of Caroline, who, as a young girl, began hearing a slew of different voices. One warned her that various family members were in danger. Another, which she identified as Miss Kathy, repeatedly castigated her, and told her that her clothes smelled. By the age of 9, Caroline was taking a daily cocktail of antipsychotics to treat her troubling symptoms. But the drugs didn’t help much, and she became obese.
As a teenager, Caroline added to the mix a few recreational drugs such as heroin and ecstasy, which she would later pay for either with sex or by selling her prescription pills on the street. After dropping out of college, she stayed in residential facilities such as a therapeutic farm and a group home. She turned her life around though when she got off all the drugs and became a roller derby star. Caroline found a job with a nonprofit that involved working as a peer counselor with the Hearing Voices Network (HVN), an international movement that offers support by helping people accept their voices rather than try to suppress them. While her own voices have not gone away, Caroline has since become a national leader in the HVN.
Bergner tries to discuss what might be going on in Caroline’s brain with Donald Goff, a schizophrenia expert and professor of psychiatry at New York University. Goff’s immediate reaction is to ask Bergner if she had “been tried on clozapine” — an antipsychotic reserved for severe cases due to its particularly dangerous side effects. Goff’s response shocks Bergner. “It skipped the question of what life might currently be, for Caroline, free of medication,” he writes. “It was spoken with the presumption, the principle, that medication was the correct and best way to go.”
While Bergner’s critique of the disease model of mental illness may sound unduly harsh, it accords with the growing scholarly view that psychiatry’s current assortment of somatic treatments — namely, its numerous drugs for major mental illnesses — have not served patients all that well. This disappointing track record is also emphasized in “Desperate Remedies: Psychiatry’s Turbulent Quest to Cure Mental Illness,” a recently published history of the field by sociologist Andrew Scull. Like Bergner, Scull highlights how much severely distressed people need those who care for them — both their doctors and their loved ones — to do a better job of listening to exactly what is going on inside their hearts and minds. They are not merely diseased brains.
As Bergner argues, just as there are various pathways to mental illness, there are also various pathways to recovery; and while medication can be a useful tool, it is not a sine qua non. Psychiatry, he writes, needs to evolve because at present, “the profession’s reflexive reaction to distress and to divergent realities, to life’s agonies and its precipices, is to provide whatever medication is available, and to urge its long or permanent use, no matter how flawed the drugs, no matter how often futile, and no matter how potentially damaging.”
Sadly, as Bergner shows in his well-crafted narrative, the longstanding belief that there is a pill (or a drug cocktail) for every psychiatric ill is little more than a widely shared delusion, which can sometimes make life even harder for those who turn to psychiatry for relief from their mental anguish.
Joshua C. Kendall is a Boston-based journalist and author. His reporting on psychiatry, neuroscience, and health policy has appeared in numerous publications, including BusinessWeek, The Boston Globe, The New York Times, The Los Angeles Times, The Daily Beast, Scientific American, and Wired.