The Medication Dilemma – Is Brain Chemistry Always to Blame?

If you've ever gone to a psychiatrist or your primary care physician for symptoms of anxiety or depression, you were probably given a prescription for an SSRI (selective serotonin reuptake inhibitor) such as Zoloft or Paxil. This is because many treatment providers ascribe to the popular theory that your symptoms are caused by an imbalance in your brain chemistry. Boost your serotonin levels with medication, and in two to four weeks, you should start feeling better.

Or not.

The brain chemistry hypothesis of many psychiatric disorders has been around for well over half a century. Pharmaceutical companies have made a fortune manufacturing medications that target various neurotransmitters in the brain. However, a growing number of scientists and mental health professionals are questioning the theory's veracity. Despite all our knowledge to date, we still have much to learn when it comes to the brain - the body's most intricate and complex organ - and the real role these chemicals play in psychiatric disorders.

Blame it on the chemicals

I will never forget one particular day when I was an intern, nearing the end of my studies as a doctoral student in clinical psychology. I was working on one of the psychiatric units at a large hospital. Each day one of the staff therapists and I co-led a therapy group with the patients. During our group session that morning, one of the patients happily declared that the psychiatrist had told her that her depression was caused by a "chemical imbalance". She went on to say that all she needed to do to get better was simply take her medication.

I cringed as I listened to her, but chose to keep my concerns to myself. After all, psych interns are the bottom of the food chain and our opinions weren't always welcomed. However, I distinctly remember how disheartened I felt that her diagnosis had been (at least by her account) reduced to nothing more than a problem with her brain chemistry, and thus easily fixed with pills. If only it was that simple...

Granted, I didn't witness the conversation between the patient and the psychiatrist, so I can't vouch for what he actually said. But her interpretation of the conversation was very clear, and I knew she was far from alone in her belief about the cause of her depression. I also knew from experience that, at least on psychiatric units, medication played a significant role in the treatment of practically every patient admitted.

Now, don't get me wrong. I do believe that neurotransmitters that are believed to help regulate mood, such as serotonin and norepinephrine, may very well play a role in depression and many other psychiatric disorders. However, I'm reluctant to place all or even most of the "blame" on brain chemistry in many, if not most, cases.

Stigma reduction

One of the primary reasons many patients prefer the chemical imbalance theory is that it takes away (or at least significantly reduces) the awful stigma of mental illness. Placing the blame on "brain chemistry" puts psychiatric conditions like depression and bipolar disorder in the same camp as medical conditions like hypertension and type I diabetes. Although lifestyle changes are also often encouraged, the primary treatment for many medical conditions (at least in Western medicine) is medication.

The dilemma of misplaced blame

As I listened to the patient that day in group therapy, the most disturbing part was that she now had very little, if any, motivation to participate in group therapy - or any type of therapy for that matter. After all, she now firmly believed that faithfully taking medication was the key to overcoming her disorder. She no longer had any personal responsibility for her depression; a chemical imbalance implied there were no underlying issues or irrational thought patterns and beliefs - two things that almost always play a very significant role in depression - to be addressed in therapy. Without therapy, however, she would likely never learn more effective coping skills or resolve the deep-seated feelings of guilt and worthlessness she had mentioned in group therapy.

Sadly, a medication-only approach is often a set-up for failure. Not only are antidepressants and other psychiatric medications ineffective for many people, medication alone is very often an ineffective treatment in the long run. Even when it does provide some symptom relief, many people find that their symptoms eventually return once they discontinue the medication. Others become increasingly discouraged and disillusioned - not to mention more depressed or anxious - when multiple trials of medication fail to provide any real benefits.

Another problem with medications is their potential side effects. These can range from mild to severe and must always be considered before starting any medication. I'll never forget one patient who became increasingly distraught - to the point of contemplating suicide - due to her 100-pound weight gain from a neuroleptic medication she'd been taking for a year. A fellow therapist went through a horrific ordeal with a condition known as serotonin withdrawal syndrome after discontinuing an SSRI for his depression. Both situations raised the question of whether or not the benefits had outweighed the side effect "costs" of their medications.

Ease versus effort

Taking a pill for whatever ails you is commonplace in a society that thrives on instant gratification and convenience. Doing so takes no real effort and just a few seconds out of your day. If you have good health coverage, the cost is often minimal. If it works, who wouldn't prefer the ease of taking a pill over almost any other type of treatment?

Going to therapy, on the other hand, is time-consuming and inconvenient. Not to mention, talking about deeply personal and painful feelings to someone they hardly know is very uncomfortable for most people. Progress is sometimes slow and the cost can rack up significantly over time. Therapy isn't always effective either, although this can be due to many different factors including an incompetent therapist or a non-compliant patient.

However, spending sufficient time in therapy with a highly skilled therapist can bring about lasting, positive changes. These changes can significantly impact the quality of your personal and professional relationships, your views about yourself and your environment, and your overall wellbeing.

Making an informed choice

It may seem that this article is pro-therapy and anti-medication. However, that isn't the intent. Rather, it's to shed light on the very real problem that occurs when the cause of any psychiatric disorder is grossly oversimplified (and possibly completely inaccurate) - which happens whenever too much emphasis is placed on brain chemistry.

There's no doubt that many people have benefitted significantly from antidepressants and other types of psychiatric medication for various disorders. Of course, some successes may be due to a placebo effect - but certainly not all of them.

The most important things to realize are 1) all psychiatric disorders are complex and the underlying causes aren't yet fully understood, and 2) each person is different. Just because an SSRI worked for your mother or coworker's depression, it won't necessarily work for yours. If your depression or anxiety was triggered or exacerbated by a significant loss or a traumatic event, for example, medication is likely to have very limited effectiveness in the long run.

If you buy into the belief that your disorder is merely due to a chemical imbalance and a pill is all it takes to fix it, you will likely have a long road ahead. Like my group therapy patient years ago, you'll likely have little motivation to do anything else in terms of getting better - or to even consider other treatment options. Don't ignore pharmaceutical treatment as an option, but be aware that it's not always the best approach and may not even be helpful at all. Don't ignore it as an option, but don't assume.

Posted on December 18th, 2012

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