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https://www.nybooks.com/daily/2018/11/19/the-psychopharmacology-of-everyday-life/

The story of psychopharmacology stretches from the advent of barbiturates at the turn of the century to the discovery in the early 1950s of the first antipsychotic, based on a powerful sedative used for surgical purposes that was described as a “non-permanent pharmacological lobotomy.” This drug, Chlorpromazine, led to the development of most of the drugs used today for psychiatric management. The proliferation of psychiatric medications, ones with supposedly less overt dangers, began in the late 1980s—at the same time, a watershed lawsuit was filed in the UK against the makers of benzodiazepines, a class of drugs used for treating anxiety and other disorders, for knowingly downplaying knowledge of their potential for causing harm. Today, psychopharmacology is a multibillion-dollar industry and an estimated one in six adults in America is on some form of psychiatric medication (a statistic that doesn’t even include the use of sleeping pills, or pain pills, or the off-label use of other medications for psychological purposes).

Until I started researching the history of psychopharmacology, I didn’t know that it was an antipsychotic that had spurred the developments of most of the medications we know so well today, such as Prozac and Xanax. But it was the issue of antipsychotics that first made me think about what we were trading as individuals, and as a society, in relying so widely on psychiatric meds. When I went to work in a psychiatric hospital during my training, nothing seemed more self-evident than the need to sedate a psychotic person. They were the most clearly “out of their mind” and the medications worked quickly to reduce psychotic symptoms, especially the auditory hallucinations that menaced these patients. How could this be wrong?

I see that question very differently today. For one thing, these antipsychotic medications still come, three generations after their arrival, with severe, life-threatening and life-shortening side-effects, from tardive dyskinesia (TD), or involuntary movement disorder, which can become permanent, to type II diabetes, obesity, dementia, cardiac arrhythmia, and even sudden cardiac death. This is to say nothing of a whole host of less severe side-effects, especially the overall blunting of the personality. Working in an inpatient unit, onecomes to know well what we called the “psychotic shuffle,” a characteristic way of walking among patients suffering from the bodily tremors caused by TD and the sedative effects of these medications.

What did we do before these substances? We hospitalized people, long-term, and tried various alternative treatments, which is expensive, especially compared to medications. But a major problem with the drugs is that people with severe psychotic symptoms—like schizophrenia, for example—commonly abandon them because the medications make them feel terrible. So these patients end up becoming acutely psychotic over and over, and have to be hospitalized and rehospitalized. Many of them now end up in nursing homes, which have come to be used as psychiatric holding pens in the absence of long-term psychiatric hospitals—many of which closed in the US as psychopharmacology took hold and became the dominant mode of treatment. Such nursing homes are facilities with little to no therapeutic program, intended to house the elderly and the severely disabled. How much money are we now saving by this system? Are we cutting short the lives of these patients by medicating them for life?

There are alternatives to this system. As Sigmund Freud posited decades ago, a psychotic person who is helped to pass through the most acute phase of their symptoms by being kept safe, and who then receives a continuous form of talk treatment, as well as some means of education or ability to work, can potentially stabilize without excessive medication. A fascinating, rare collective of psychoanalysts in Quebec known as “the 388” have created a clinic that provides psychoanalytic treatment and 24/7 emergency care to individuals suffering from psychotic problems. A study of eighty-two patients treated in their facility for three years or more demonstrated that the program was able to reduce incidences of hospitalization by 78 percent, while 82 percent were living autonomously and 56 percent were able to provide for themselves financially. Proving that such a course of treatment costs far less in the end than the conventional one, the 388 group has recently been asked by the Canadian government to open more facilities and expand its approach.

But that’s Canada. This is practically unimaginable in America. The scarcity of resources and the legal hassle a doctor could face would likely be enough of a deterrent to taking on the risk of treating those with severe mental illness, especially given that most medics graduate with too much loan debt to consider such a precarious experiment. And if one such facility did begin to gain traction, drug company lobbyists would surely work to quash it.

This is the extreme end of the story because schizophrenia has always been the most serious of the mental disorders and a litmus test for how our society views mental illness, how we treat it, revealing what our ethical position is toward those who are suffering psychologically. By that measure, it doesn’t look good: from what I have learned, we are trading more humane treatments for a solution that superficially seems effective, but on closer examination is not helping patients in any long-term way and may actually be killing them.

I am indeed a Freudian psychoanalyst, that strange anachronism maligned by psychiatry for not being as scientific as medication supposedly is, by virtue of the control studies that can be done with drug treatments. Modern psychopharmacology goes hand in hand with a psychiatric diagnostic system that has, over time, been redefined to rely on medicating symptoms away rather than looking at the structure of the mind and its complex permutations in order to work with a patient in a deeply engaged way over the long haul. Modern psychiatry is hailed as a scientific success story, and drug companies have profited from the fact that talking therapies are often thought to take too long, their results frequently dismissed as unverifiable. I question, though, whether we should demand verified results when it comes to our mental life: Do you believe someone who promises you happiness in a pill?

Psychoanalysis still has the power to intrigue people, it seems—so embedded is it in American popular culture. Psychoanalytic language has entered the vernacular and psychoanalytic concepts permeate the way we all understand human relationships, especially sexuality. I have the sense that we need it more than ever to help us with our discontents because there is enduring value in the Freudian understanding of, on the one hand, the unceasing conflictual relationship between civilization and neurosis, and, on the other, what talking, simply talking, can do.

Freud himself was anything but hostile to psychopharmacology. Indeed, he was a notorious experimenter with drugs, especially cocaine, whose anesthetic properties and psychological effects he was one of the first to discover and champion (until, that is, a host of his friends and family to whom he administered the drug became addicted, contributing even to the death of one friend whose morphine abuse escalated after using cocaine in tandem, until he eventually overdosed). Freud himself underwent a course of experimental hormonal therapy with the first neuro-endocrinologist to see if it would improve his mood. Such research became the foundation for sex-change therapies today, along with a number of other medical discoveries that earned that doctor seven nominations for the Nobel Prize.

Freud’s beliefs about the human psyche thus did not exclude his own quite liberal experiments with medication and medical procedures. Importantly, at the end of his life, Freud chose to forgo any pain medication after almost thirty surgeries for oral cancer, so that he could think clearly with patients and continue to write—though he never ceased smoking the cigars he loved that had almost certainly caused his disease. The lesson I take from Freud is that you can choose your poison, which is the reason I wanted to turn to the topic of drugs, using what I’ve learned as a psychoanalyst over the last two decades.

We do have a choice about whether to medicate and how we do so. I think we have forgotten this because of how easy it is to obtain pills, along with the pervasive idea that our problems are simply chemical or genetic. So I want to begin by recalling what the drug panacea is treating at the most basic psychological level: pain, attention, sadness, libido, anxiety, sleep. Freud was surprisingly insightful about these crucial aspects of the psyche, even from his earliest writings before the turn of the century. By elucidating some basic psychoanalytic notions concerning the most common “troubles” of the mind, and by focusing on the different categories of medications prevalently used, I hope to disrupt our blind passion for prescriptions.