A Modern Review of Anti-Psychiatry:

Why do people refuse pharmacological treatment for psychiatric conditions?

Most of you are probably familiar with the famous scene from One Flew Over the Cuckoo’s Nest, where McMurphy (Jack Nicholson) pretends to consume and then spits out him medication after nurse Ratched refuses to tell him what it is. It’s just medicine, it’s good for him and he shouldn’t be asking questions.angell_1_071411_jpg_630x497_cr

‘If Mr. McMurphy doesn’t want to take his medication orally, I’m sure we can arrange that he can have it some other way. I don’t think you’d like it.’

The film, made in 1975, was based on the book written by Ken Kesey in 1962, at the hight of the anti-psychiatry movement that was pervading the western world. In this period the theme of patients evading pharmacological care became quite common in literary and cinematic depictions of psych wards and mental health. Other interesting readings on mental health care at the time include Michel Foucault’s ‘Madness and Civilisation: A History of Insanity in the Age of Reason’ (1961), Szasz’s ‘The Myth of Mental Illness’ (1960), ‘Asylums’ by Goffman (1961) and ‘Psychiatry and Anti-Psychiatry’ by Cooper (1967). The Anti-psychiatry movement mainly questioned three things:

(1) the existence of mental illness and the use of psychiatric diagnosis as a power tool to control social deviants; (2) the power of psychiatrists to detain patients against their will and the use of barbaric methods in psych wards and (3) the medicalisation of madness.

When he spat out the pill, McMurphy was defying a system that was oppressive and malfunctioning, as indeed many internment facilities of the time were. Many of the past treatments used to treat patients with mental instability were primitive and often barbaric: to name a few, trepanning, lobotomies, insulin shock therapy, bloodletting and badly administered electroconvulsive therapy. Similarly their pharmacological counterparts where just as invasive and excessive, and patients were often stuffed to the brim with sedatives such as bromides and barbiturate, and primitive anti-psychotics (chlorpromazine was one of the first), which caused severe side effects, drowsiness and physical dependency.

However, things have significantly improved in the past years, and society’s relationship with mental health is consistently changing towards a world of increasing awareness. Pharmacological treatment in psychiatry has also developed much since its origins. Let us look, for example at the first effective medicine for the treatment of mental illness: lithium carbonate, the effectiveness of which as a mood stabiliser was demonstrated in 1948 by Australian psychiatrist John Cade and approved by the US Food and Drug Administration (FDA) for the treatment of acute mania in 1970.

Although the evidence for lithium as an anti-manic agent is incontrovertible, the drug is also known to cause rather serious adverse effects and carries a “black box warning”. It can cause central nervous system (CNS) toxicity, renal toxicity, thyroid toxicity, and teratogenic effects, all of which can be life threatening. It is also associated with non-life threatening but rather bothersome side effects, such as tremor, excessive urination, dry mouth, nausea, sedation, acne, and cognitive dulling. Mild CNS toxicity manifests as restlessness, irritability, and sedation. Severe neurotoxicity can progress to delirium, with ataxia, coarse tremor, seizures, and ultimately coma and death.

Dr. Lembke at Stanford University writes how earlier studies on the dosage of lithium in treating acute mania advocated a concentration of serum lithium levels between 0.9- 1.4 mEq/L. Severe neurotoxicity is associated with lithium serum concentrations exceeding 1.6mEq/L, but can occur at egonschielelower levels in susceptible individuals. Later studies have illustrated that effective mania response can be achieved with doses between 0.5 – 0.72 mEq/kg/day, corresponding to serum lithium levels below 1.0 mEq/L.

With the reduction in the posology of lithium, patients are much less susceptible to the bothersome side effects associated with high levels, which were extremely common in past times. Today, the optimal dosage of lithium ought to be carefully administered by professionals, with attention to factors such as a limited starting dose, rates of titration, serum concentration for efficacy and toxicity, drug-drug interactions, dosing frequency, and rates of discontinuation.

Furthermore, nowadays patients have increasing access to communication and information technologies, relationships between patient and physician are more dynamic and interactive, there is increasing awareness and de-stigmatisation of mental disorders, and policies are being put in place to assure the equality of human rights for those suffering from psychiatric disorders and mental health difficulties. It would appear that modern psychiatry has worked consistently towards resolving the accusations of the anti-psychiatry movement in the 60’s, even if there still is much progress and research to be made in the field.

Yet out of the three above mentioned critiques, medicalisation still holds a highly significant following in contemporary society, amongst public figures and patients alike. So what is it, in this day and age, that causes patients to refuse their treatment? My conclusion is that three main factor contribute to this issue: (1) fear of social stigma, (2) fear of physical side effects and (3) fear of loss of control.

Let me explain this further through my own personal experience. A few weeks ago, when my psychiatrist suggested I take a low maintenance dosage of Depakine so as to avoid any fall-backs into manic-depressive episodes, my brain automatically started saying: no, no, no, no. Which has led me, over the past few weeks to a great reflexion in what really hides behind my weariness of this type of drug, regardless of being well-informed about its properties, effects and dosages, and confident in the advancements psychiatry has undergone in recent years.

In this post, I would like to share with you my conclusion, as I believe it is a plausible hypothesis for many patient’s behaviour. While I do believe that fear of side effects and/or social stigma can play an important role in an anti-medication approach, I think there is another, more subtle, yet profoundly existential reason to explain this refusal. When I d94412deca31e98092dcef1b5ff532b4advised my psychiatrist regarding my doubts over starting a new drug, her response was one that I have encountered many a time in similar situations, or articles advocating the importance of medication for mental illness.

‘If you were diagnosed with Diabetes, and not Bipolar Disorder, would you be questioning the use of a drug in its cure?’

Well, to be perfectly honest the answer is no. I’ve never really had a problem with taking painkiller, in moderation, for a headache, I daily take medication for my asthma and have used antibiotics in several occasions. (Note: I understand there is a whole school that criticises western medicine in general, as well as the motivations that drive pharmaceutical companies, but this is not the argument I wish to discuss in this post).

None the less, the idea of constantly taking a small maintenance dose of a mood stabiliser gives me the heebie-jeebies. And I do not think this is entirely related to my skepticism towards labelling, although I do believe that a strict adherence to labels in psychiatry may pose some difficulties when dealing with individual cases of patients (which I will discuss further in future). I do not even think it is entirely the fear of losing the manic part of myself, which I have come, after much time and consideration, to view as a diversion and not as an ‘up’ side of my mood and personality.

I think what causes my weariness, is my desire for control over all aspects of my life. What makes psychiatric medication different from other classes of drugs, is that what is acting upon is not a rachel_elise_painting_4physical resentment, but rather a chemical imbalance that plays an enormous role in what constructs my personality. In some way, I suppose my fear is dictated by the possibility that taking such medication, may in some way alter my essence as a human being and my control over my own life.

Let me explain this better. I have been taking 100mg Sertraline (brand name Zoloft, Lustral) daily for almost a year. It is an anti-depressive drug classed as an SSRI (selective serotonine reuptake inhibitor) which essentially means it plays on the level of the neurotransmitter serotonin in my synapses, which is one of the main chemicals responsible for mood. At around the same time I started this therapy, I also undertook many other steps towards well being, such as a better diet, a reduced consumption of caffeine, alcohol and nicotine, physical activity, meditation, therapy and a considerable dose of self awareness and reflection upon my existence.

As of today, I am doing significantly well in my day to day life and, allowing for some minor fall backs, am leading a content, enthusiastic and motivated existence. My main difficulty remains the terror of losing this controlled balance I have cultivated for my self. I almost feel as if I were a blanket hanging precariously on a clothing line, and if one of the many clips holding me up were removed, I may lose my balance, my control over reality. I have found myself asking myself, many a time: how much of my current well being is due to my actions, and how much is due to my pharmacological treatment? Or better, if I had not started on Zoloft a year ago, would I still be in the same place?

I realise now, that this is a rhetorical ‘what if’ question, to which I will never be able to provide an accurate answer. And losing oneself in the hypothetical possibilities of what could have been, is something I hove long deemed unhealthy and unproductive. I spoke with my psychotherapist regarding my skepticism towards medication and a question she asked me really did strike home.

Even if you are doing all these other things for your own stability, and you could potentially be ok without medication, why is it that you still feel inclined to refuse the extra help it could give you, even if it does out-balance the negative effects?

Why is it that we feel inclined to do everything on our own, without other people, without pills, without help of any sorts? Is it fear of weakness? Is it the same reason why so many people around the world art-of-science-3keep their issues in the closet and the same reason for which I myself, for many years, ignored my own pain and instability?

I realised in that moment how much my own preconceptions and perception of control have played a part in my decisions and how hypocritical my weariness of Depakine and Sertraline is. After all, when I drink a beer, spend time with friends, find comfort in a lover, or seek relief in music, art, sex, travelling, food, etc., am I not in some ways asking the world for a helping hand? I fear losing control when indeed I have no control: my existence depends upon the world around me and all of the silly little things that keep me hanging on the clothes line. How is medication any different to them?

So yes, until I am conscious and wise enough to be a blanket that holds itself up on its own, I am not ready to give all of these things up and, for the time being, I need them. I need my friends, I need my family, I need distractions, I need beauty and, as hard as it is for me to admit, I need my medication. What I also realise is that the purpose of all these things is not to ‘hold me up’, but rather to ‘hold me upright’, like the training wheels on a bike that prepare you to ride by yourself. They construct me and make me grow, and allow me to pursue the activities and reflections that make me who I am. And one day, I am certain, I will no longer need these wheels. I will be able to live my life with self-awareness and conscientiousness and experience all around me with light-heartedness and care and no longer with visceral need and dependence.

Cooper, David (1967). ‘Psychiatry and Anti-Psychiatry’ Routledge, Abingdon, Oxon: 2001

Foucault, Michel (1961) ’Madness and Civilisation: A History of Insanity in the Age of Reason’ Routledge Classics, Abingdon Oxton: 2005

Goffman, Erving (1961) ‘Asylums. Le istituzioni totali: i meccanismi dell’esclusione e della violenza’ Einaudi, 2010

Kesey, Ken (1962) One Flew over the Cuckoo’s nest. The Viking Press Ink.

Lembke, Anna. MD, Clinical Instructor, Stanford University, Optimal Dosing of Lithium, Valproic Acid, and Lamotrigine in the Treatment of Mood Disorders accessed on ‘Primary Psychiatry’ on Nov 12th 2015. URL: http://primarypsychiatry.com/optimal-dosing-of-lithium-valproic-acid-and-lamotrigine-in-the-treatment-of-mood-disorders/

Szasz, Thomas S. ‘The Myth of Mental Illness Foundations of a Theory of Personal Cunduct’ (1960). HarperCollins: 2011

Traduzione in Italiano Post #12 – Primo Appuntamento Psichiatrico

(for English version see below)

O forse dovrei dire, categorizzazione dettagliata del soggetto difettivo. Mi sono sentita sotto scrutinio non appena ho varcato la soglia del suo ufficio. Un giovane medico, riccio e quattr’occhi, uno dei migliori nel settore, mi osservava con sguardo saccente, cercando da subito indizi per inserirmi in una delle sue organizzatissime cartelle di categorie malati. ‘Lei parla sempre così veloce?’; ‘sicura di aver dormito questa notte?’ (grazie, mi fa piacere sapere di avere la faccia sconvolta); ‘lei gesticola e si agita molto, mi sembra nervosa’. Se i pensieri fossero tangibili sono certa che lettere della parola IPOMANIA gli uscirebbero dalle orecchie.

Se mi domandate quale contributo abbia avuto questo incontro nel mio percorso di crescita personale la risposta, molto sinceramente, è nessuno. Ha semplicemente svuotato considerevolmente il portafogli dei miei genitori e rievocato quella macchinosa immagine di me stessa come schiava di questa società capitalista: quell’ immagine da cui cerco così tanto di distaccarmi. Mi continuo a domandare quanta sia l’importanza di parole come ‘stato dissociativo’ e ‘distimia’ nell’aiutare le persone a vivere meglio con se stesse. Il mio nuovo amico dottore so-tutto-io direbbe certamente che sia fondamentale, per poter specificare oggettivamente i malfunzionamenti di chi soffre di instabilità mentale.

Da un punto di vista di paziente e di essere umano socialmente interessato, ho tre parole da dire a riguardo: OGGETTIVAMENTE STO CAZZO. Non esistono caratteristiche interamente oggettive quando si contrastano diverse personalità. Quello che avrei molto voluto domandare a questo psichiatra è: come fa ad esser certo che parlare veloce sia un segno evidente di uno stato di iperattività? Mi ha incontrato per la prima volta dieci minuti fa: è così assurdo pensare che io abbia forse una personalità un po’ vivace? O che forse, dato che abbiamo solo sessanta minuti, anche piuttosto costosi, insieme ed io ho molte cose da dirle, io non sia minimamente inclinata a parlare lentamente solo per evitare i suoi presuntuosi giudizi?

Il suo metodo diagnostico, caro dottore, è così prevedibile che io, che non ho mai studiato medicina o psichiatria, intuisco ciò che sta per dire prima ancora che lei apra quella sua boccuccia insolente. Per non parlare di quanto io trovi insultante il fatto che lei mi venda informazioni del tipo ‘il bipolarismo è una malattia di base genetica’ con la certezza assoluta di uno che ha capito ogni segreto dell’universo. Sono la prima a pensare che i geni contribuiscano in parte alla personalità ma, se non lo sa la scienza con certezza, non lo sa neanche lei. Chi crede di essere per proclamarlo con tale convinzione?

Io comprendo l’importanza di strumenti diagnostici nell’ ambito della psichiatria, e so bene che esiste una significativa ricorrenza di tendenze e comportamenti in chi soffre di simili disturbi psichiatrici. Quello che non comprendo affatto, è la fede più assoluta che vien data alla scrupolosa categorizzazione dei pazienti, che sono, a mio avviso e credo quello di chiunque altro, in primis degli esseri umani. Non lo ritengo solo presuntuoso, ma del tutto illogico e irrazionale. Solo perché a un individuo è stato diagnosticato un disturbo bipolare e in un particolare momento capita che questi stia parlando rapidamente, non implica automaticamente che stia un una fase ipomaniacale.

C’è una linea molto sottile tra l’utilizzo di criteri diagnostici come uno strumento per capire e affrontare negli difficoltà individuale, e l’ utilizzare i suddetti criteri per costruire l’immagine di un individuo tutto nuovo, sul quale si può lavorare facilmente seguendo il proprio manualetto di sapere acquisito. E’ la stessa logica per cui, nonostante si utilizzino modelli microeconomici per semplificare e capire il comportamento del consumatore, non significa necessariamente che se questi vengono applicati al mondo reale, conducano a risultati accurati. La realtà è più complessa dei modelli teorici. Le persone, le interazioni sociali, le attività emotive e le funzioni cerebrali, riguardo le quali anche la Neuroscienza è alle prime armi, sono estremamente più complesse.
Non sono un esperta in campo, nonostante abbia fatto una sostanziosa quantità di ricerca riguardo le cause di disturbi mentali ed il dibattito natura-cultura. Mi ritengo tuttavia una mente critica ad aperta, che è particolarmente suscettibile a generalizzazioni e disinteresse. Proprio come reputo patetici coloro che si aggrappano fanaticamente alle loro credenze, religioni ed ideali di veduta ristretta, così trovo ridicolo ed arrogante che pionieri di una disciplina ancora così incerta ed inesplorate, si ritraggano come profeti di verità assolute.

Post 12 – Psychiatric Appointment #1

Or should I say, detailed evaluation and categorisation of defective subject. I was under severe scrutiny the moment I walked in the door. A young doctor, bespectacled and curly haired, a know-it-all expression and one of the best in his field, stood before me. I could feel his wiseass eyes on me, searching for clues to pin me down into his neat little tables. Do you always talk this fast?’; ‘did you sleep much this night?’; ‘you are fidgeting and gesticulating a lot’; ‘you seem nervous’. If thoughts were concrete, I’m pretty sure letters of the word HYPOMANIC would be spilling out of his ears.

‘Just like I find it pathetic when people fanatically hold on to their close-minded beliefs, religions and ideals, I find it ridiculous and arrogant when pioneers of a discipline that is still widely uncertain and unexplored, ostensibly portray themselves as prophets of absolute truths.’

If you ask me what purpose this meeting has had in my quest to self-understanding, the answer is, quite frankly, none. All it did was render my parents’ wallet significantly lighter and re-evoke the image of the drone-like, capitalist society slave me: you know, the one I’m trying so hard to be rid off. How important, I ask myself again and again, are diagnostic words such as ‘dissociative state’ and ‘dysthymic’ in helping people get better? Very much so, my smarty pants new doctor friend would say. Fundamental, even, in objectively mapping out what is malfunctioning within people who are mentally unstable.

From a patient and socially interested human being’s perspective, I have three words to say to this: OBJECTIVE MY ASS. There is no such thing as an exclusively objective trait when contrasting individual personalities. What I would have very much liked to ask the doctor today is: how exactly do you know that talking fast is such an evident symptom of mania? You met me for the first time ten minutes ago: is it absurd to think that it may just be part of my personality? Perhaps, seen as we have only one, rather expensive hour together and I have much to say, I would rather not talk slowly for the sole purpose of avoiding your presumptuous judgements.

The evaluative methods you used on me today were so predictable that I, who have never been to medical school or studied psychiatry, knew what the next question was going to be before you even opened your mouth. Not to mention how insulting I found it that you felt entitled to feed me information such as ‘bipolar disorder is a disease which has biological roots’ with such absolute certainty, as if you had the key to understanding all the mysteries of the universe. I myself believe that genetics plays a part in many psychiatric conditions, but if science hasn’t been able to prove it with certainty, who are you to proclaim it with such conviction?

I understand the importance of diagnostic tools in psychiatry, and I am well aware that there is a significant recurrence of particular traits in psychiatric conditions. What I do not understand is the absolute faith that is given to categorisation when dealing with patients, or more generally, with people. It is not just presumptuous, it is downright illogical. Just because someone is diagnosed bipolar and happens to be talking fast, does not directly imply that they are in a hypomanic phase.

There is a fine line between using diagnostic criteria to better understand and deal with individual difficulties, and using said criteria to create a whole new individual on which you can work according to your booklet of conserved knowledge. It is the same reasoning for which, although microeconomic models are used to simplify and understand consumer behaviour, it doesn’t necessarily mean that when applied real life, they lead to accurate results. Reality is more complex than theoretical models. People, social interactions, emotional activity and brain function, which even neuroscience is at its early steps in understanding, are especially more complex.

I am not an expert in the field, although I have done significant personal research regarding the causes of mental illness and the nature-nurture argument. I am however a critical mind who is particularly susceptible when it comes to generalisations and carelessness. And just like I find it pathetic when people fanatically hold on to their close-minded beliefs, religions and ideals, I find it ridiculous and arrogant when pioneers of a discipline that is still widely uncertain and unexplored, ostensibly portray themselves as prophets of absolute truths.