Psychotherapy is one way to treat psychological disorders. The other is biomedical therapy. Biomedical treatments can change the brain’s chemistry with drugs; affect the brain’s circuitry with electrical stimulation, magnetic impulses, or psychosurgery; or influence the brain’s responses with lifestyle changes.

Are you surprised to see lifestyle changes in this list? We find it convenient to talk of separate psychological and biological influences, but everything psychological is also biological. When psychotherapy relieves behaviors associated with obsessive-compulsive disorder or schizophrenia, PET scans reveal a calmer brain (Habel et al., 2010; Schwartz et al., 1996). How about our day-to-day lifestyle—the food we eat, the activities and environments we engage, the social fabric we maintain? Can these choices also be therapeutic? (See Thinking Critically About: Therapeutic Lifestyle Change.)

The influence is two-way. Every thought and feeling depends on the functioning brain. Every creative idea, every moment of joy or anger, every period of depression emerges from the electrochemical activity of the living brain.

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By far, the most widely used biomedical treatments today are the drug therapies. Most drugs for anxiety and depression are prescribed by primary care providers, followed by psychiatrists and, in some states, psychologists. Since the 1950s, drug researchers have written a new chapter in the treatment of people with severe disorders. Thanks to drug therapies and support from community mental health programs, today’s resident population of U.S. state and county mental hospitals has dropped to a small fraction of what it was a half-century ago. In one decade alone (1996 to 2005), the number of Americans prescribed antidepressant drugs doubled, from 13 million to 27 million (Olfson & Marcus, 2009).

Almost any new treatment, including drug therapy, is greeted by an initial wave of enthusiasm as many people apparently improve. But that enthusiasm often diminishes on closer examination. To judge the effectiveness of a new treatment, we also need to know:

To control for these influences when testing a new drug, researchers give half the patients the drug, and the other half a similar-appearing placebo. Because neither the staff nor the patients know who gets which, this is called a double-blind technique. The good news: In double-blind studies, several types of drugs effectively treat psychological disorders.

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The four most common drug treatments for psychological disorders are antipsychotic drugs, antianxiety drugs, antidepressant drugs, and mood-stabilizing medications. Let’s consider each of these in more detail.

Antipsychotic Drugs

Accidents sometimes launch revolutions. In this instance, an accidental discovery launched a treatment revolution for people with psychoses. The discovery was that some drugs used for other medical purposes calmed the hallucinations or delusions that are part of these patients’ split from reality. First-generation antipsychotic drugs, such as chlorpromazine (sold as Thorazine), reduce patients’ overreactions to irrelevant stimuli. Thus, they provide the most help to schizophrenia patients experiencing symptoms such as auditory hallucinations and paranoia (Lehman et al., 1998; Lenzenweger et al., 1989). (Antipsychotic drugs are not equally effective in changing the schizophrenia symptoms of apathy and withdrawal.)

How do antipsychotic drugs work? They mimic certain neurotransmitters. Some block the activity of dopamine by occupying its receptor sites. This finding reinforces the idea that an overactive dopamine system contributes to schizophrenia. Further support for this idea comes from a side effect of another drug. L-dopa is a drug sometimes given to people with Parkinson’s disease to boost their production of dopamine, which is too low. L-dopa raises dopamine levels, but can you guess its occasional side effect? If you guessed hallucinations, you’re right.

Do antipsychotic drugs also have side effects? Yes, and some are powerful. They may produce sluggishness, tremors, and twitches similar to those of Parkinson’s disease (Kaplan & Saddock, 1989). Long-term use of antipsychotics can also produce tardive dyskinesia, with involuntary movements of the facial muscles (such as grimacing), tongue, and limbs. Although not more effective in controlling schizophrenia symptoms, many of the newer-generation antipsychotics (such as risperidone and olanzapine) work best for those with severe symptoms and have fewer side effects (Furukawa et al., 2015). These drugs may, however, increase the risk of obesity and diabetes (Buchanan et al., 2010; Tiihonen et al., 2009).

Despite their drawbacks, antipsychotics, combined with life-skills programs and family support, have given new hope to many people with schizophrenia (Guo et al., 2010). Hundreds of thousands of patients have left the wards of mental hospitals and returned to work and to near-normal lives (Leucht et al., 2003). Elyn Saks, a University of Southern California law professor, knows what it means to live with schizophrenia. Thanks to her treatment, which combines an antipsychotic drug and psychotherapy, “Now I’m mostly well. I’m mostly thinking clearly. I do have episodes, but it’s not like I’m struggling all of the time to stay on the right side of the line” (Sachs, 2007).

Antianxiety Drugs

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Like alcohol, antianxiety drugs, such as Xanax or Ativan, depress central nervous system activity (and so should not be used in combination with alcohol). These drugs are often successfully used in combination with psychological therapy to treat anxiety disorders, obsessive-compulsive disorder, and posttraumatic stress disorder. They calm anxiety as the person learns to cope with frightening situations and fear-triggering stimuli.

Some critics fear that antianxiety drugs may reduce symptoms without resolving underlying problems, especially when used as an ongoing treatment. “Popping a Xanax” at the first sign of tension can provide immediate relief, which may reinforce a person’s tendency to take drugs when anxious. Anxiety drugs can also be addictive. Regular users who stop taking these drugs may experience increased anxiety, insomnia, and other withdrawal symptoms.

Antidepressant Drugs

The antidepressant drugs were named for their ability to lift people up from a state of depression. These drugs are now also used to treat anxiety disorders, obsessive-compulsive disorder, and posttraumatic stress disorder (Wetherell et al., 2013). Many of these drugs work by increasing the availability of norepinephrine or serotonin. These neurotransmitters elevate arousal and mood and are scarce when a person experiences feelings of depression or anxiety.

The most commonly prescribed drugs in this group, including Prozac and its cousins Zoloft and Paxil, lift spirits by prolonging the time serotonin molecules remain in the brain’s synapses. They do this by partially blocking the normal reuptake process (see FIGURE 2.4 in Chapter 2). These drugs are called selective serotonin reuptake inhibitors (SSRIs) because they slow (inhibit) the synaptic vacuuming up (reuptake) of serotonin.

Some professionals prefer the SSRIs over other antidepressants (Jakubovski et al., 2015; Kramer, 2011). SSRIs begin to influence neurotransmission within hours. But their full psychological effect may take four weeks, possibly because these drugs promote the birth of new brain cells (Becker & Wojtowicz, 2007; Jacobs, 2004). Researchers are also exploring the possibility of quicker-acting antidepressants (Grimm & Scheidegger, 2013; McGirr et al., 2015; Naughton et al., 2014).

Drugs are not the only way to lift our mood. Aerobic exercise can calm people who feel anxious, energize those who feel depressed, and offer other positive side effects. Cognitive therapy, which helps people reverse their habits of thinking negatively, can boost the drug-aided relief from depression and reduce posttreatment relapses (Hollon et al., 2002; Keller et al., 2000; Vittengl et al., 2007). The best approach seems to be attacking depression (and anxiety) from both above and below (Cuijpers et al., 2010; Hollon et al., 2014; Kennard et al., 2014; Walkup et al., 2008). Cognitive-behavioral therapy works from the top down to change thought processes. Antidepressant drugs work from the bottom up to affect the emotion-forming limbic system.

People with depression often improve after a month on antidepressant drugs. But after allowing for natural recovery and the placebo effect, how big is the drug effect? Not big, report some researchers (Kirsch, 2010; Kirsch et al., 2002, 2014; Kirsch & Sapirstein, 1998). In double-blind clinical trials, placebos produced improvement comparable with about 75 percent of the active drug’s effect. In a follow-up review that included unpublished clinical trials, the antidepressant effect was again modest (Kirsch et al., 2008). The placebo effect was less for those with severe depression, which made the added benefit of the drug somewhat greater for them (Fournier et al., 2010; Kirsch et al., 2008; Olfson & Marcus, 2009). “Given these results, there seems little reason to prescribe antidepressant medication to any but the most severely depressed patients, unless alternative treatments have failed,” concluded one researcher (BBC, 2008).

Mood-Stabilizing Medications

In addition to antipsychotic, antianxiety, and antidepressant drugs, psychiatrists have mood-stabilizing drugs in their arsenal. One of them, Depakote, was originally used to treat epilepsy. It was also found effective in controlling the manic episodes associated with bipolar disorder. Another, the simple salt lithium, effectively levels the emotional highs and lows of this disorder. Australian physician John Cade discovered this in the 1940s when he administered lithium to a patient with severe mania and the patient became perfectly well in less than a week (Snyder, 1986). Although we do not understand why, lithium works. About 7 in 10 people with bipolar disorder benefit from a long-term daily dose of this cheap salt (Solomon et al., 1995). Their risk of suicide is but one-sixth that of people with bipolar disorder who are not taking lithium (Oquendo et al., 2011). Kay Redfield Jamison (1995, pp. 88–89) described the effect:

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Lithium prevents my seductive but disastrous highs, diminishes my depressions, clears out the wool and webbing from my disordered thinking, slows me down, gentles me out, keeps me from ruining my career and relationships, keeps me out of a hospital, alive, and makes psychotherapy possible.

Electroconvulsive Therapy

Another biomedical treatment, electro-convulsive therapy (ECT), manipulates the brain by shocking it. When ECT was first introduced in 1938, the wide-awake patient was strapped to a table and jolted with roughly 100 volts of electricity to the brain. The procedure, which produced racking convulsions and brief unconsciousness, gained a barbaric image. Although that image lingers, today’s ECT is much kinder and gentler. The patient receives a general anesthetic and a muscle relaxant to prevent convulsions. A psychiatrist then delivers to the patient’s brain 30 to 60 seconds of electric current, in briefer pulses (FIGURE 14.5). Within 30 minutes, the patient awakens and remembers nothing of the treatment or of the preceding hours.

Would you agree to ECT for yourself or a loved one? The decision might be difficult, but the treatment works. Surprising as it may seem, study after study confirms that ECT can effectively treat severe depression in patients who have not responded to drug therapy (Bailine et al., 2010; Fink, 2009; Lima et al., 2013; Medda et al., 2015). After three such sessions each week for two to four weeks, 70 percent or more of those receiving ECT improve markedly. They show some memory loss for the treatment period but no apparent brain damage (Bergsholm et al., 1989; Coffey, 1993). Modern ECT causes less memory disruption than earlier versions did (HMHL, 2007). ECT also reduces suicidal thoughts and is credited with saving many from suicide (Kellner et al., 2005). The Journal of the American Medical Association’s conclusion: “The results of ECT in treating severe depression are among the most positive treatment effects in all of medicine” (Glass, 2001).

How does ECT relieve severe depression? After more than 75 years, no one knows for sure. One patient compared ECT to the smallpox vaccine, which was saving lives before we knew how it worked. Perhaps the brief electric current calms neural centers where overactivity produces depression. Some research indicates that ECT works by weakening connections in a “hyperconnected” neural hub in the left frontal lobe (Perrin et al., 2012).

No matter how impressive the results, the idea of electrically shocking a person’s brain still strikes many as barbaric, especially given our ignorance about why ECT works. Moreover, the mood boost may not last long. About 4 in 10 ECT-treated patients have relapsed into depression within six months, with or without follow-up drug therapy (Kellner et al., 2006; Tew et al., 2007).

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Nevertheless, in the minds of many psychiatrists and patients, ECT is a lesser evil than severe depression’s misery, anguish, and risk of suicide. As one psychologist reported after ECT relieved his deep depression, “A miracle had happened in two weeks” (Endler, 1982).

Alternative Neurostimulation Therapies

Two other neural stimulation techniques—magnetic stimulation and deep brain stimulation—also treat the depressed brain.

MAGNETIC STIMULATION Depressed moods sometimes improve when repeated pulses surge through a magnetic coil held close to a person’s skull (FIGURE 14.6). The painless procedure—called repetitive transcranial magnetic stimulation (rTMS)—is performed on wide-awake patients over several weeks. Unlike ECT, the rTMS procedure produces no memory loss or other serious side effects, aside from possible headaches.

Initial studies have found a small antidepressant benefit of rTMS (Lepping et al., 2014). How it works is unclear. One possible explanation is that the stimulation energizes the brain’s left frontal lobe, which is relatively inactive during depression (Helmuth, 2001). Repeated stimulation may cause nerve cells to form new functioning circuits through the process of long-term potentiation. (For more on long-term potentiation, see Chapter 7.) Not all researchers agree that rTMS reduces depressive symptoms (De Raedt et al., 2015). More research will shed light on how rTMS works and whether it’s reliable.

DEEP BRAIN STIMULATION Other patients whose depression has resisted both drugs and ECT have benefited from an experimental treatment pinpointing a brain depression center. Deep brain stimulation manipulates the depressed brain by means of a pacemaker that activates implanted electrodes in brain areas that feed negative emotions and thoughts (Lozano et al., 2008; Mayberg et al., 2005). The stimulation inhibits activity in those brain areas. With deep brain stimulation, some patients have found their depression lifting. Others have become more responsive to drugs or psychotherapy.

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Deep brain stimulation may also show promise in other treatment areas. Researchers are exploring whether this technique can relieve obsessive-compulsive disorder and drug and alcohol addictions (Corse et al., 2013; Kisely et al., 2014; Luigjes et al., 2012).

Psychosurgery is surgery that removes or destroys brain tissue in an attempt to change thoughts and behaviors. Because its effects are irreversible, it is the least-used biomedical therapy.

In the 1930s, Portuguese physician Egas Moniz developed what would become the best-known psychosurgical operation: the lobotomy. He (and, later, other neurosurgeons) used it to calm uncontrollably emotional and violent patients. This crude but easy and inexpensive procedure took only about 10 minutes:

Tens of thousands of severely disturbed people received lobotomies between 1936 and 1954. By that time, some 35,000 people had been lobotomized in the United States alone.

For his work, Moniz received a Nobel Prize (Valenstein, 1986). But today, lobotomies are history. Their intention was simply to disconnect emotion from thought, and indeed, they did usually decrease misery or tension. But their effect was often more drastic, leaving people permanently listless, immature, and uncreative. During the 1950s, when calming drugs became available, psychosurgery became scorned—as in the saying sometimes attributed to comedian W. C. Fields that “I’d rather have a bottle in front of me than a frontal lobotomy.”

Today, more precise micropsychosurgery is sometimes used in extreme cases. For example, if a patient has uncontrollable seizures, surgeons can destroy the specific nerve clusters that cause or transmit the convulsions. MRI-guided precision surgery is also occasionally done to cut the circuits involved in severe obsessive-compulsive disorder (Carey, 2009, 2011; Sachdev & Sachdev, 1997). Because these procedures cannot be reversed, neurosurgeons perform them only as a last resort.

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TABLE 14.3 summarizes the therapies discussed in this chapter.