Readings in Humanistic Psychiatry
For several decades now, whenever colleagues or patients have asked us psychiatrists what really causes mental illness we've typically mumbled something about "chemical imbalances" and hoped that you'd go away. The chemical imbalance model of mental disorders has become such a pervasive part of our profession that it's gone unquestioned for a long time. But there are significant problems with the model. And those problems have had a widespread impact on the lives of our patients and on our society.
Our previous beliefs about the nature of severe mental disorders led to a variety of erroneous assumptions. We assumed that once these people were on the correct medications - or, increasingly, combinations of medications - they'd behave and function just like anyone who didn't suffer from the illnesses. Surely they'd recognize the benefits that resulted from the drugs we gave them and take them faithfully. They'd be able to work in regular jobs and they'd show up in our offices promptly for their scheduled appointments. They'd live in mainstream settings and no special services or supports would be necessary since their neurons were now firing properly.
Things haven’t quite worked out that way.
The reality: Today, we have far more mentally ill people in prisons and homeless shelters on any given day than we do in facilities designed to care for them. Roughly 90% of people with severe mental disorders are unemployed. Substance abuse is rampant among this population. Outpatient medication compliance rates run, by generous estimates, in the 50 % range. Poverty, social isolation, and dull, boring existences have become the rule.
At the same time, depression and the taking of antidepressant drugs have increased dramatically in our culture. The use of psychotropic medications in our children has skyrocketed. The prescription of psychiatric meds has increasingly fallen on busy family practitioners as there aren't enough psychiatrists available to treat the mounting number of people who are now presenting with symptoms of the mental disorders. We spend countless billions on new generations of psychiatric medications that are, with very few exceptions, no more effective than the drugs we had back in the 1980's.
Managed care organization scramble to keep from devoting ever-increasing portions of their resources to the care of the anxious, depressed, and emotionally unstable. The numbers of psychiatric hospital beds have been slashed at a time of unprecedented demand for them. Sometimes the entire situation seems hopeless.
Brain function and the environment
If there is any cause for optimism it comes from basic research in the neurosciences. Our previous understandings of the relationship between brain functioning and environmental variables (many of which are modifiable) have seen a major overhaul since the early 1990’s.
It turns out that humans are far more complex and adaptable creatures than we'd ever imagined. Consider a few examples:
Schizophrenia has emerged as a disorder rooted in neuronal migration and connection problems dating back to the second trimester of pregnancy. A host of factors can converge to produce a "schizophrenic brain”. Mothers who are exposed to emotional trauma, bereavement, or natural disasters during critical periods of pregnancy are at increased risk for having children with schizophrenia. The season that the child is born in, maternal infections, obstetrical complications, Rh incompatibility, and even living in an urban environment can affect the incidence of schizophrenia. We build brains in response to our environments, even in utero.
Depression is now linked to changes in the hippocampus. Exposure to excessive stress hormones, inadequate sleep, unstimulating environments, prolonged substance abuse, or too little exercise can result in reductions in Brain Derived Neurotrophic Factor, a protein that encourages the growth and differentiation of new neurons and synapses. Hippocampi can shrink by as much as twenty percent, with resultant problems in mood, memory, and imagination. The idea that antidepressant medications or electroconvulsive therapy would work by increasing the birth of new neurons in this key brain area would have seemed preposterous just a few years back. Now it’s an accepted premise in our models of depression.
Children who are exposed to sexual abuse or other severe trauma are more likely to develop structural changes in the hippocampus too. Those changes can predispose the individual to long-standing problems with emotional instability, impulsivity, interpersonal problems and self-destructive behaviors such as those seen in Borderline Personality Disorder.
The connection between the number of hours spent watching television during early childhood and increased likelihood of Attention Deficit Disorder later on has been a robust finding. Another environmental factor, dietary deficiency of crucial Omega III fatty acids, also can increase the rates of ADD too, as well as those for depression, bipolar disorder, dementia, and violent behavior.
Our understanding of the role of dopamine, serotonin, and other neurotransmitters in the mental disorders has grown exponentially. There are now five recognized subtypes of dopamine receptors, at least fifteen for serotonin, and each of them can produce different actions when stimulated. Medications can cause agonism, partial agonism, antagonism, or partial antagonism at any given receptor site. They can even produce "inverse agonism"-essentially causing the receptor to function in reverse. Compounding matters is the fact that the receptors can exist in different states depending on environmental input.
Our knowledge of how different medications affect brain function is far from complete. For example, while we've believed that antidepressant drugs from the Prozac class worked by inhibiting the reuptake of serotonin at receptor sites, an antidepressant available in Europe (Tianeptine) actually stimulates the reuptake of serotonin but is just as clinically effective. We're now looking to the intracellular cascade of second messenger systems that result when receptors are tweaked, and resultant effects on protein manufacture and gene expression, as we try to understand the complex actions of our powerful psychotropic agents.
A recently discovered regulatory protein (DARPP 32) controls the sensitivity of the dorsolateral prefrontal cortex, an area known to go awry in schizophrenia. Inadequate DARPP levels can lead to problems with abstract thinking, as well as a decreased ability to keep unwanted memories out of consciousness. DARPP has also emerged as a common link in the actions of multiple drugs, including amphetamines, nicotine, cocaine, alcohol, hallucinogens, and opiates. Pretty heady stuff for a compound we didn't even know existed just a decade ago.
The intersection of environment and brain function was highlighted in an interesting study by Morgan et al in 2002 ( Nature Neuroscience 5 ( 2002) 169-174 ). The study found that adult monkeys raised in private cages developed pronounced changes in brain dopamine systems when they were transferred to group cages. The social status of the primates greatly determined the types of brain changes that occurred. Lower-ranking monkeys became much more inclined to self-administer intravenous cocaine when it was made available to them. The more dominant ones showed no such increase in craving for cocaine. The implications for the way we house our citizens are considerable.
Creating optimal environments
So what can we conclude from these studies and others of their kind? We're at a very early stage of sorting it all out and, clearly, our models of mental illness have not kept pace with the data that are coming in. But the inescapable conclusion is that brains develop and function according to the environments that they develop and function in. A mental health system that does not take this into account, one that is based entirely on brief visits to prescribe and adjust medications, will never be adequate. We simply must do a better job of translating advances in the neurosciences into improved lives for the people we serve.
Enlightened mental health systems of the future will emphasize the creation of optimal environments for our children to develop in - from the womb right up through adulthood. We'll have to attend to all of the needs of developing nervous systems starting by providing pregnant moms with safe, secure environments to carry their kids in, good nutrition, and excellent obstetrical care, and helping them keep free of preventable stresses.
We can't park our kids in front of flickering screens for hours on end and expect that they'll develop good brains as a result. To develop optimally functioning brains, our children need physical exercise and a wide variety of stimulating mental activities. They have to receive all of the essential building blocks for healthy brains in their diets. They have to be free from abuse and other stresses that their developing nervous systems aren't equipped to handle. And, most of all, they must be raised in the presence of loving, empathic caretakers who spend enough time with them. Empathy and love are every bit as crucial for the development of a stable sense of self as any measurable variable that we can come up with.
When people do have established mental illnesses, for whatever reasons, we need to provide them with environments that will provide a good fit for the quirks of their nervous systems. Medications will always play an important role. Just about any psychiatrist would want their own children on medication if they had an established mental disorder. But giving severely mentally ill people high doses of expensive tranquilizers in order to survive in places that any sane person would be terrified to live in makes no sense from a practical or humanitarian perspective. We need to develop residential programs that provide safety, mental stimulation, exercise, and employment.
Mentally ill people need privacy, opportunities for socialization, and a chance to belong to a greater community. They need consistent relationships with physicians that know them as individuals and care about them as people. Of course, these are not solely the requirements of mentally ill people. They are human needs.
Our models of the mind are always evolving and they can never offer more than a glimpse of something that is infinitely more wondrous and complex than the mind itself can ever comprehend. Someday all of our current treatment efforts will probably look primitive in hindsight. The ways that our society now cares for its brain-disordered individuals will, hopefully, be recognized as misguided and ineffective. Perhaps more that any other single issue in medicine the way that we - as a society and as individuals - understand and care for our mentally ill citizens sheds light on the central question of what it really means to be human. We have a long way to go.