Is Popping Pills Healing or Harming Psychiatric Patients?

It is relatively easy to get lost in our mental world. However, finding our way back to a life in which we feel comfortable in our skin is no sinecure. Along the journey, wishful thinking aside, we have no airtight guarantee that we will arrive at the final destination we have in mind.

And if at one particular moment we believe that we have ran aground, we may come to the assessment that we are broken. Am I off the ‘normal’ track of life? Is there something wrong with me?

If we decide or are obliged to call upon professional help — assuming that we have access to it — there is a chance that we get diagnosed with one or more specific mental disorders. Not only that, we could be confronted with the dilemma whether to walk through the proverbial door into the realm of psychiatric medication.

But, by crossing that chemical threshold, do we irreversibly launch ourselves deep down a rabbit hole?

Thinking in Boxes

Once we can map comprehensively all the characteristics of the prevailing mental illnesses, the reasoning goes, we should then be better equipped to treat them appropriately.

According to Hannah Ritchie and Max Roser of Our World in Data, more than one in ten people on Earth are walking around with a mental health issue. And the World Health Organization (WHO) insists that “One in four people in the world will be affected by mental or neurological disorders at some point in their lives.”

To get a handle on our prolific mental unruliness, a slew of experts goes through a painstaking effort to classify all the different psychiatric conditions. It turns out that there is a whole plethora of them.

The North America’s leading guide, i.e. the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), comes up with an encyclopaedic variety of no less than 152 psychiatric maladies. Admittingly, that number might be higher still. The WHO has crafted their own catalogue. Chapter V of their International Statistical Classification of Diseases and Related Health Problems, Tenth Edition (ICD-10), produces a staggering figure of over 300 mental and behavioural ailments. The latest version, i.e. ICD-11, will come into force in 2022. Besides these two landmark handbooks, there are also other taxonomic systems in place, e.g. the Chinese Classification of Mental Disorders and the Psychodynamic Diagnostic Manual.

Fig. 1. The International Statistical Classification of Diseases and Related Health Problems, Eleventh Edition (ICD-11), The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), the Chinese Classification of Mental Disorders and the Psychodynamic Diagnostic Manual. (Source: American Psychiatric Association, eatingdisordersreview.com, tspsy.com and guilford.com).

In an attempt to see the forest for the trees in this maze of mental lawlessness, DSM-5 installs 20 categories based on the distinctive features of various psychiatric disorders, whereas Chapter V of ICD-10 distinguishes 11 of them. The chapter on mental, behavioural and neurodevelopmental disorders of version ICD-11 has been modified to match DSM-5, in that it equally contains 20 main categories.

It is not my purpose to list and discuss all the present classes and types. Yet, what I do wish to mention is that globally the most prevalent conditions include anxiety (284 million people as of 2017), depression (264 million), bipolarity (46 million), schizophrenia (20 million) and eating disorders (16 million).

Let us as an example put schizophrenia under our investigative microscope to understand in greater detail how psychiatric medication actually works.

Unscrambling Confusing Signals

In popular terms, schizophrenia is often wrongly described as having multiple personalities, which is rather an identifying mark of the dissociative identity disorder.

Schizophrenia, however, is a severe and chronic mental health condition, frequently defined as a form of psychosis, of which both hallucinations and delusions are idiosyncratic traits. The former symptom refers to the event in which we see, hear or feel things that are supposedly not real. The latter delineates an attitude whereby we rigidly cling to a particular viewpoint despite existing proof that suggests otherwise. Together with disorganized behaviour and dysfunctional thinking, these four symptoms are generally denoted as positive symptoms, as their presence is what typifies this psychiatric malady.

Additional typical characteristics that can crop up are feeling disconnected from self, lack of joy or motivation, irregular sleep pattern, self-neglect, social withdrawal and dissonance between body language and experienced emotion. These behavioural impairments are commonly called negative symptoms, since they represent a lack of certain kinds of behaviour.

A troubling consequence of this illness is an impoverished life expectancy. Thomas Laursen et al. proclaim that affected people lose approximately twenty years of their lives relative to the general population. The underlying reasons, they argue, extend to poor physical health and health care, secondary effects of antipsychotic medicines, lifestyle qualities, suicide and accelerated aging.

Furthermore, there is most likely a gender discrepancy in schizophrenia. For instance, Heinz Häfner contends that “the disorder becomes manifest clearly later in women than in men.” Also, he reports that oestrogen has a protective effect concerning the severity of the expressed symptoms. As a result, men would be more severely symptomatic than women at a younger age. Nevertheless, this protective effect diminishes with a progressively stronger genetic liability. And with respect to social behaviour, men would engage with a higher frequency in several detrimental styles of conduct, such as self-neglect and social withdrawal, compared to women.

Up to now, researchers have not yet pinpointed the primary cause of schizophrenia. The disorder is largely believed to stem from a dizzying amalgamation of genetic, biological, psychosocial, cultural, political and other environmental influences. What is more, its emergence is closely connected to stressful life-changing events.

When it comes to the choice of recovery strategy, antipsychotics usually make up the cornerstone of any proposed pathway towards betterment. Indeed, Subin Park et al., for example, claim that “the best available treatments appear to be antipsychotic medications (which is the first-line treatment) along with psychological and psychosocial treatments.”

Nonetheless, it remains fact that many individuals do not have access to either proper health care or the required medicines. The WHO pertinently remarks that lack of access to medical support helps to clarify why 90% of the cases of untreated schizophrenia are flagged in low- and middle-income countries.

Now that we have built up a fuller picture of what schizophrenia entails, let us next delve into the question why medication is more often than not the linchpin of its treatment program.

Yes, Medication Is Necessary

Proponents of antipsychotic drugs say taking them is essential because schizophrenia is primarily a brain disease.

Brainy Scientists

One of them is John Gilmore from the University of North Carolina. He puts forward that “Schizophrenia is increasingly considered a subtle neurodevelopmental disorder of brain connectivity, of how the functional circuits in our brains are wired.” Similarly, researchers Michael Owen et al. affirm that this psychiatric condition “seems to originate from disruption of brain development caused by genetic or environmental factors, or both.”

Vivian Hook et al. at the University of California San Diego made further headway by identifying substantial neurochemical imbalances in schizophrenic people. What this means is that “the neurons derived from schizophrenia patients secreted significantly greater amounts of the catecholamine neurotransmitters dopamine, norepinephrine and epinephrine.”, a related press release explains. To be clear, a neurotransmitter is a molecule discharged by neurons that enables impulses — information — to travel between neurons in our brain.

And some scientists have even submitted the claim that, in relation to schizophrenia, the brain structure itself is markedly different. As a case in point, Elena Antonova et al. from King’s College London assert that “Almost every cortical and sub-cortical brain structure has been found to be abnormal in schizophrenia.” Moreover, recent research by Katja Koelkebeck et al. insinuates that schizophrenic people have a lesser amount of grey matter, which impacts memory, information-processing, muscle control, speech, emotions and self-control.

Let us now descend to the molecular level to see what reaction current medication aims to achieve. As a case study, we will look at one of the most popular drugs to treat schizophrenia, i.e. Seroquel or, by its generic name, quetiapine, which is a second-generation or atypical antipsychotic.

Inside Our Head

Along the membrane of a neuron, we come across chemical structures known as receptor proteins. They interact with numerous incoming signals, e.g. neurotransmitters, hormones, toxins, proteins and pharmaceutical medication, depending on the type of receptor. Antipsychotic drugs are able to do their work, since their molecules attach to the binding site of specific receptors that offset one or more symptoms of the respective mental disorder.

Mind you, in spite of its global popularity, the exact underlying mechanism of action of quetiapine remains, until today, poorly understood (see, for example, Sean Kim et al. (2017), Yusuke Morata et al. (2019) and Amanda Silva de Miranda et al. (2020)).

What we do know is that, with its chemical formula C₂₁H₂₅N₃O₂S, quetiapine blocks several receptors simultaneously: dopamine, serotonin, adrenergic receptors and histamine. Overall, the molecular compound exhibits a calming and sedative effect, but it does not seem to fertilize addictive behaviour.

Fig. 2. The molecular structure in 3D of quetiapine (Seroquel) with carbon (C; grey), hydrogen (H; white), nitrogen (N; blue), oxygen (O; red) and sulphur (S; yellow) molecules. (Source: Pubchem).

As a neurotransmitter in the brain, dopamine or 3,4-dihydroxyphenethylamine (DA) holds sway over various behavioural processes, among which pleasure, decision-making, our way of thinking, motivation and reward. In schizophrenic brains, an excessive release of dopamine stimulates thoughts and signal networking, thereupon propagating hallucinations and delusions. Quetiapine quenches this overactive electrochemical flow, thereby dampening the positive symptoms.

As a hormone and a neurotransmitter, serotonin or 5-hydroxytryptamine (5-HT) is tasked to help regulate our mood, feelings of happiness, anxiety, states of consciousness, sleep cycles, memory, digestion and sexual desire. It steers the workings both within our central nervous system and gastrointestinal tract. By hindering the serotonin neurotransmitter receptors in schizophrenic patients, quetiapine soothes the serotonergic overdrive in their brain. Subsequently, they feel more motivated to be social and better function in general. In other words, blocking the serotonin receptor alleviates the negative symptoms of schizophrenia.

Adrenergic receptors attract catecholamines, which are a type of neurotransmitter that prepare the body for a fight-or-flight response. These neurotransmitters, including norepinephrine (noradrenaline) and epinephrine (adrenaline), trigger the sympathetic nervous system, which translates, among other things, into an increased heart rate and a higher blood pressure. As we have seen earlier, schizophrenic patients possess a greater number of these catecholamines. Therefore, quetiapine blocks these adrenergic receptors so that it reverses those health hazards.

In the brain, the biochemical compound histamine acts as a neurotransmitter. When binding with histamine receptors, these molecules govern crucial functions — energy balance, homeostatic processes, cognition, control of food intake and arousal. Schizophrenia tends to go hand in hand with elevated histamine levels in the cerebrospinal fluid, which is why quetiapine is designed to obstruct the histamine receptors.

Fig. 3. A schematic overview of how antipsychotic medication — neuroleptics — blocks dopamine at its receptors. (Source: dreamstime.com).

Effectiveness and Side Effects

Many researchers call attention to the beneficial characteristics of quetiapine for the treatment of schizophrenia. Huafang Li et al. (2018) ascertain that the antipsychotic is “generally safe and well tolerated”; Hua-ning Wang et al. (2016) underscore that the drug “ameliorated the schizophrenia-like behaviors” in their research trials; Jianjie Huang et al. (2019) highlight that “Quetiapine may offer an optimal benefit-risk balance when a prolactin-sparing antipsychotic is indicated.”; and Zahiruddin Othman et al. (2016) emphasize that “Quetiapine is an interesting treatment option for patients at high risk for schizophrenia with prominent anxiety and/or depressive symptoms.”

As per the types of symptoms in schizophrenia, research conveys that, on the whole, antipsychotic medication is more successful in reducing positive symptoms than countering negative ones. Gary Remington et al., for one, conclude that “the newer antipsychotics are not superior to their conventional counterparts in the treatment of negative symptoms and [that] the effect in either case is modest.” Peng Li et al. push it further by arguing that these drugs even gravitate towards “worsen[ing] negative symptoms, such as blunted affect and social withdrawal, as well as cognitive function[s].”

With regard to the efficacy of restoring cognitive deficits, e.g. issues with task completion, concentration and memory, Indrani Poddar et al. reminded us in 2019 that, “while more than 20 years have been devoted to the development of new drugs to treat cognitive deficits in schizophrenia, none have been approved to date.” By contrast, Jue He et al. present more promising prospects, which hint that “chronic quetiapine significantly attenuated object recognition memory impairment and hippocampal oxidative stress.”

Yet, in other studies, the administration of antipsychotics bore symptomatically little or no results. Marcos Gómez-Revuelta et al. documented such findings in 2018, whereby they noted that psychiatric patients “were more likely to discontinue treatment due to nonefficacy.” One of the tested drugs involved was quetiapine. Such outcomes fall in line with earlier conclusions drawn by Jari Tijhonen et al. in 2017, inferring that quetiapine is associated with a high risk of rehospitalization.

Notwithstanding on-going progress, ensuring effective antipsychotics is not an easy endeavour. In a recent meta-analysis conducted by John Lally and James MacCabe, the authors remark that “we still remain a long way from being able to recommend with precision, specific treatments for individual patients, in terms of the clinical response and lack of adverse events.“

And surely enough, quetiapine comes with important side effects. For instance, hampering histamine receptors can prompt somnolence (extreme sleepiness), dizziness or weight gain, while barring adrenergic receptors can lead to orthostatic hypotension (low blood pressure). In addition, disabling dopamine receptors implies an exposure to cultivating the neuroleptic malignant syndrome.

Then again, a literature review by Chanoch Miodownik and Vladimir Lerner informs us that quetiapine is found to be advantageous for the treatment of schizophrenia; that it has a relatively safe side effect profile; and that most of the reported serious events relate to overdose.

Fig. 4. Number of prescriptions for second-generation antipsychotics ordered by psychiatrists between 2005 and 2012 in Canada. (Source: Paper Tamara Pringsheim and David Gardner).

Whatever the final verdict will be, much uncertainty continues to exist today predominantly regarding its long-term repercussions, when all the while the United States Food and Drug Administration (FDA) approved Seroquel in 1997.

As a matter of fact, the FDA openly admits that we are in the dark for what lies ahead: “The efficacy of SEROQUEL in schizophrenia was established in short-term (6-week) controlled trials of schizophrenic inpatients […]. The effectiveness of SEROQUEL in long-term use, that is, for more than 6 weeks, has not been systematically evaluated in controlled trials. Therefore, the physician who elects to use SEROQUEL for extended periods should periodically re-evaluate the long-term usefulness of the drug for the individual patient.”

The ambiguity relative to the pharmacological consequences in the long run surrounds antipsychotics at large. Though Chen Zhang et al. assert that “the effectiveness of different types of antipsychotic drugs is equivalent”, Heidi Taipale et al. stress the importance of the timescale, indicating that “Very little is known about the comparative long-term effectiveness of novel antipsychotics.”

This is a concern for the reason that, “Due to the complexity of schizophrenia, patients need long-term medication treatments”, according to Chen Zhang et al. In an apparent attempt to sound somewhat optimistic, the authors further add that, at least, “the adverse reactions of different types of antipsychotic drugs are clear.”

Although, broadly speaking, psychiatric medication seems to make advancements in its efficacy, more research is certainly called for to provide compelling answers to the question which drugs are most accommodating, if at all.

No, Thank You

Undoubtedly, many people are helped through medication, as these drugs assist them with managing their daily life. There is a segment of this medicating population, however, that is suffering unnecessarily as a result of antipsychotic medicines. In the United States (U.S.), 24% of the population is on antipsychotics, of which roughly 30% is supposedly worse off due to the treatment. In 2015, one study in the United Kingdom (UK) examined people with intellectual disability. Of the 33,016 adults, 28% received antipsychotic medication, and a whopping 71% of that percentage “did not have a record of severe mental illness.”

Critical Thoughts

It speaks for itself that we cannot lump all the psychiatric maladies together and apply a one-size-fits-all mindset of ‘to medicate or not to medicate’. Nor does one or more controversial incidents decide upon the drug’s ineffectiveness — remember Dan Markinson in the case of quetiapine — and should it consequently be withdrawn from the market.

As the total effect of quetiapine externalizes differently in every person, taking such antipsychotics remains thus a very individual decision. But precisely because of that subjective element, I find it worthy to sketch out viewpoints and practices that explore the grounds off the traditional trail.

Before doing so, let us take note of two interrelated, mutually reinforcing observations that could possibly lead us out of — or deeper into — the pharmaceutical labyrinth.

First off, it is not too unfair to acknowledge that the opposite side of the medical coin lies within overdiagnosis. The mixture of online information ubiquitously available to the patient and the ever more detailed description of various mental illnesses to support the physician results in a higher likelihood to take ordinary hardship, such as grief, for abnormal behaviour when, in fact, it is not. A couple of pills in a bottle after a consultation with a physician is then not too much of a stretch.

Secondly, we must contemplate what being labelled with a psychiatric condition does to us psychologically. It is rather unrealistic to assume that such intimate portrayal of who we are will not leave a mental imprint of some sort. In more straightforward terms, there is a hazard of self-fulfilling prophecy: the diagnosis may lead us to believe that it is the only sensible explanation for our allegedly erratic behaviour and thoughts. Hearing the actual name of the disorder pronounced by a professional psychiatrist affirms our initial suspicion that there is something wrong with us. And it now becomes all the more plausible to accept that medication is the best way forward.

But what if there are other explanations for the inexplicable events, which we have not yet considered?

Let It Loose

The British Psychological Society (BPS), no less, writes in their report ‘Understanding Psychosis and Schizophrenia’ that “Hearing voices or feeling paranoid are common experiences which can often be a reaction to trauma, abuse or deprivation. Calling them symptoms of mental illness, psychosis or schizophrenia is only one way of thinking about them, with advantages and disadvantages.”

Fig. 5. The report ‘Understanding Psychosis and Schizophrenia’ by the British Psychological Society. (Source: communityaccess.org).

In that same report, the BPA goes on to claim that psychiatric medication is merely suppressing the expressive manifestation of the malady. That is, “Many people find that ‘antipsychotic’ medication helps to make the experiences less frequent, intense or distressing. However, there is no evidence that it corrects an underlying biological abnormality. Recent evidence also suggests that it carries significant risks, particularly if taken long term.”

In some parts of the world, hearing voices or seeing (dead) people who are not physically there is interpreted as a herald of visionary personality traits. Hallucinations are envisaged as a golden ticket to a revered career as shamanic healer. What we typically call psychosis is in the shamanistic view a process of re-awakening as human being. The tradition of shamanism is celebrated among diverse cultures, including Mongols, Sakha (Yakut), Tukano, Cape Nguni, Navajo American Indians and Tinguians. The documentary film ‘Crazywise’ — scroll down to the end of the article and insert the password ‘CWDUTCH’ to watch the video — follows two psychiatric patients on their mental journey. One of them retrieves her inner peace, away from the drugs, by embracing shamanism.

Inasmuch as not everyone feels or heeds the call to become a shaman, hearing voices could alternatively be linked to a greater sensitivity to spirituality. For instance, researchers Simon McCarthy-Jones et al. determine that “The categories of psychotic and spiritual voice-hearing appear to be significantly fluid.” And Philippa Richardson fittingly remarks that “Another explanation for individual’s being able to hear voices, is that of clairaudience, a psychic ability.”

This spiritual skill holds an eye-opening, healing potential in that a “Clairaudient ability has a positive connotation upon the ability to hear voices, whereas the diagnosis of Schizophrenia is most commonly treated with pharmaceutical drugs to reduce or eliminate symptoms.”, Richardson continues. Other voices resound such interpretations, like the one of Anna Beyer. She ascertains that “parapsychological explanations, for example understanding ‘voices’ as telepathy or spirit communication, are possible.”

Spirituality in Practice

There is actually a case to make around the inclusion of spirituality within psychiatric treatment. In one research project with psychiatric residents as study subjects, Thomas McGovern et al. observe that “There was a strong agreement (85.7%) among residents that psychiatry should not distance itself from religiousness and spirituality.” Similarly, psychotherapist and university professor Vincent Starnino points out “how people with psychiatric disabilities draw upon spirituality to cope as they strive for recovery.”

Not to mention the book ‘Psychiatric Medication and Spirituality: An Unforeseen Relationship’, in which researcher Lynne Vanderpot addresses the positive and negative aspects of how antipsychotics intertwine with spirituality. Although Vanderpot admits that such unusual connection is hard to swallow “because we have been so conditioned to see states of mental illness and health as fundamentally biological”, she nevertheless hopes that her book “expands the conversation around psychiatric medication to include spirituality.”

On a more practical note, Narendra Kumar Singh et al. list a range of spiritual-minded group activities that can be embedded into psychiatric practice: “spiritual autobiography, discussion of key existential issues, silent prayer and meditation, guided imagery, practice in religious rituals, use of selected readings, and attendance at religious services.” In their academic paper, Alexander Moreira-Almeida et al. equally bring forward concrete “guidelines for spiritual assessment and integration thereof into mental health treatment.”

Adding a more political flavour, Christopher Cook outlines some policy initiatives and developments that underline the role of spirituality in psychiatry. Not unimportantly, a framework for recuperation from illness that incorporates spirituality generally entails “better mental wellbeing, lower psychiatric morbidity and improved outcomes following treatment”, Cook argues.

Alternative Therapies in Demand

In recent decades, a number of research experiments have been conducted to investigate treatments without any or with a reduced amount of psychiatric medication.

In the context of the Soteria Project, John Bola and Loren Mosher put forward, leaning on their research findings, that “a relationally focused therapeutic milieu with minimal use of antipsychotic drugs, rather than drug treatment in the hospital, should be a preferred treatment for persons newly diagnosed with schizophrenia spectrum disorder.”

To date, Soteria facilities exist worldwide and are treating psychiatric illnesses in this limited-medicinal fashion. Their community houses are currently active in several countries, among which Germany, Israel, The Netherlands, the U.S., Finland, the UK, Switzerland and Hungary.

Another such study by Jaakko Seikkula et al. scrutinizes the open-dialogue approach in Finland, during which patients participate in a “psychotherapeutic treatment […] within their own personal support systems.” Apart from a lower hospitalization incidence, the results indicate that only 29% of the subjects used antipsychotics; just 14% lived on disability allowance; and no less than 86% returned to an active social life after five years of treatment.

Clinical psychologist Rufus May and therapist Will Hall are two of many experts who stand for adopting a more constructive and assertive approach on hearing voices. One such approach, according to May and Hall in an interview with All In The Mind, involves participating in a therapeutic method called voice dialogue. With this technique the person learns to understand how to interact confidently with the voices. Another recommended idea is openly engaging with both other people and their own voices through various Facebook groups (see, for example, here, here or here).

If you are drawn to neither shamanism, spirituality nor any kind of psychosocial therapy, but you do feel strongly for a natural way of living, you could resort to natural medicines.

Drug Me Naturally

To start off on a cautionary note, R. Hajiaghaee and S. Akhondzadeh remark that “using herbal medicine as monotherapy for psychiatric disorders may not be effective, but if used [as] adjuvant therapy with first or second generation of antipsychotic drugs, they may be useful.”

Nonetheless, Rogier Hoenders et al. demonstrate in their research that, without any antipsychotics, omega-3 fatty acids, ayurvedic herbs, and ginkgo as well as vitamin B6 are potentially supportive in preventing schizophrenia, mitigating its symptoms and reducing medicinal side effects, respectively.

Fig. 6. Leaves of the Ginkgo Biloba. (Source: newhealthadvisor.org).

In addition, John Holloway suggests that certain herbs show a beneficial impact: curcumin would attenuate the secondary effect of orofacial dyskinesia; B12 might ward off psychiatric symptoms, including psychosis, dementia and severe depression; and Bacopa Monniera is said to counteract positive symptoms in schizophrenia due to its ability to cut back the dopamine concentration.

Do All Roads Lead to Rome?

Psychiatric medication is not going to disappear in the near future. And maybe, nor should it. As said previously, it is helping many people to get through their day. At the same time, there is also no harm in not being too quick to rule out some of the more unconventional explanations or treatments options, even though they appear absurd or far-fetched at first.

Whether pills are healing or harming psychiatric patients may be beside the point, precisely because life is so different for each one of us. Perhaps the more appropriate question is: What is our individual truth in our life’s journey? Regardless of the kind of rabbit hole that we are in, one thought seems reassuring: the more we dare to open up to our own mind, the greater the chances to find a way to live that is aligned with our human peculiarities.

Is this our magic pill?

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