FIVE
Psychiatric Prescription Drugs
Tired Soldiers
A Drug-Induced Epidemic of Disabling Mental Illness
Our society believes that psychiatric medications have led to a “revolutionary” advance in the treatment of mental disorders, and yet these pages tell of a drug-induced epidemic of disabling mental illness.
ROBERT WHITAKER, ANATOMY OF AN EPIDEMIC: MAGIC BULLETS, PSYCHIATRIC DRUGS, AND THE ASTONISHING RISE OF MENTAL ILLNESS IN AMERICA
I’ve been practicing psychology for almost fifty years, and this quote echoes what I have witnessed and observed during this period. Namely, that there is a drug-induced epidemic of disabling mental illness. This epidemic is not caused by illicit street drugs like cocaine, heroin, methamphetamine, and marijuana, but rather by prescription medicine given to patients all over the country.
This topic of pharmaceutical company–induced sickness is near and dear to my heart. When I took my first job as a psychologist back in 1961 at the Laconia State School for the Mentally Retarded and Emotionally Disturbed, I witnessed patients being wrapped in sail cloth from sailboats—heavy canvas—and sprayed with ice-cold water. Then they were rolled around on the ground and then sprayed again with ice-cold water. I witnessed patients being hit with what they called sock tranquilizers—where they would put pieces of soap in a woman’s stocking and swing it and hit the patients. I witnessed electroconvulsive shock therapy given to patients in the cells that they lived in. It was shocking (pun intended). I was in my early twenties, and witnessing these physically abusive “treatments” was what I imagined a medieval torture chamber to look like. But I was not in a medieval torture chamber. I was in a hospital in New Hampshire and the year was 1961.
Today’s interview may be the most important you have ever experienced if you or a family member or friend are suffering from some form of emotional, psychological, or intellectual challenges. If you’re taking some form of psychoactive medicine, or if you are considering taking some form of psychoactive medicine, you will want to consider extremely carefully the following interview with award-winning journalist Robert Whitaker.
Whitaker was the director of publications at Harvard Medical School until 1994, when he cofounded the publishing company CenterWatch, which covered the pharmaceutical clinical-trials industry. He has spent a major part of his career investigating the pharmaceutical industry and their products.
Although the topic of his book, Anatomy of an Epidemic, is selective serotonin reuptake inhibitors, SSRIs, which are not technically considered psychedelics, they are psychoactive and thus have a profound influence on emotional and cognitive functioning. Whitaker’s findings are so important that I felt compelled to include them.
Questioning the Psychiatric Paradigm
Robert Whitaker
December 6, 2011, and November 4, 2014
ROBERT WHITAKER is author of Mad in America: Bad Science, Bad Medicine, and the Enduring Mistreatment of the Mentally Ill. His book Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America won the 2010 Investigative Reporters and Editors Book Award for best investigative journalism. He has won numerous awards as a journalist covering medicine and science, including the George Polk Award for Medical Reporting and the National Association of Science Writers Award for best magazine article. In 1998, Robert cowrote a series on psychiatric research for the Boston Globe that was a finalist for the Pulitzer Prize for Public Service.
RLM: Robert, you wrote an article in the Boston Globe in 1998 about the mentally ill being given chemical agents that heightened their psychosis, is that correct?
Robert Whitaker (RW): That’s true.
RLM: Talk a bit about your Boston Globe series and how schizophrenia has worsened over twenty years, and then please tell us about how poor countries are having better outcomes with schizophrenia than the richer ones.
RW: Initially, in that series, we were writing about abuses of patients in psychiatric research settings. One of the abuses we wrote about were studies in which people came into emergency rooms experiencing psychotic symptoms, and the psychiatrists, rather than treat them in a way designed to help diminish those symptoms and agitation, instead gave them agents that they expected would make them worse—amphetamines and ketamine, that sort of thing. The idea was that if they gave them different agents expected to make them worse, this would lead to some understanding of the possible chemical problems that were going on with the person at the time of their psychosis.
Imagine you’re suffering, or you’re struggling with your mind. Or maybe it’s one of your brothers or sisters or your son or daughter, and you take them to an emergency room where you expect they are to be helped, and instead they are put in an experiment where they are given chemical agents designed to heighten their symptoms. The informed consent forms for those experiments misleadingly stated that they were being given an experimental drug that may or may not help, but that was not so at all. You wouldn’t do this to people coming in suffering from heart pains. You wouldn’t give them some agent to make their pain worse. So that was my introduction into this very odd world of how we treat those said to be mentally ill.
In the Globe series, we also wrote about studies in which researchers had withdrawn antipsychotic medications from patients diagnosed with schizophrenia. At that time, I had a completely conventional understanding of psychiatric drugs. I thought that antipsychotic drugs fixed a chemical imbalance in the brain and acted like insulin for diabetes. I thought they were absolutely essential. So I asked myself, “Why would you ever run studies in which you had withdrawn a drug that was seen as so essential?” Later, as we’ll see, I came to rethink this understanding based on some information I began to uncover while doing the research for that Boston Globe series.
The Schizophrenia Conundrum
Better Results with Fewer Meds
RLM: What happened with that Boston Globe series?
RW: Well, first of all, I came upon two studies done by the World Health Organization that compared outcomes in three poor countries—specifically India, Nigeria, and Colombia—with longer-term outcomes in the United States and five other “developed countries.” Each time, they found that the outcomes were much better in the poor countries—specifically India and Nigeria. They even concluded that living in a developed country—a rich country like the United States—is “a strong predictor” that if you’re diagnosed with schizophrenia, you won’t have a good outcome.
So I’m wondering, “Why would that be?” I looked further into the studies, and after the first such study, the researchers hypothesized that maybe the reason for the better outcomes in the poor countries was that they were more medication compliant—they took their antipsychotics more regularly. That makes sense as a hypothesis, if you believe the drugs are so essential. They measured medication usage in the second study and found, much to their surprise, that the opposite was true. In the poor countries, they used the drugs acutely, for a short period of time, but they did not keep their patients on the drugs long-term. In the poor countries, only 16 percent of schizophrenia patients were continually maintained on antipsychotics, whereas in the United States and other developed countries, that was the standard of care for all patients.
All of a sudden I was presented with this finding that went against what I had just written for the Boston Globe, which was that the drugs were essential. Yet here in this cross-cultural study, you found better outcomes where they were using the drugs much more sparingly.
The second thing was that when I was doing that series with the Boston Globe, I had a completely conventional understanding of psychiatry’s history. I believed that we were coming to understand that the biology of major mental disorders like schizophrenia was caused by chemical imbalances and that we had drugs to fix those chemical imbalances. We had a new generation of antipsychotics, which were better than the first generation. That’s a story of medical progress.
Then I came upon a study by Harvard researchers that looked at longer-term outcomes over the past century, and they came up with two conclusions. First, modern outcomes today were no better than they had been in the first third of the twentieth century, long before the drugs came on the market. And second, outcomes had actually worsened in the previous fifteen years. So again, this belied the story of progress that I thought to be true. It was those studies that made me curious and made me want to investigate further about treatments for the mentally ill—those labeled mad, schizophrenic, and so forth—and why we are getting such bad outcomes today. That is what led me on this long journalistic enterprise.
The Early History of Psychiatric Treatment
1751: Patients Treated as Animals in the “Age of Reason”
RLM: So here we have an investigative reporter who discovers that people going into emergency rooms are being given chemical agents that heighten their psychosis and mental illness rather than reduce it. He finds out that outcome studies for schizophrenia in the United States indicate that results are worse over the past fifteen years than they were in the early part of the century. And furthermore, he finds out that countries like India and Nigeria have had better outcomes than countries like the United States while prescribing fewer drugs.
Take us back to 1751, when Benjamin Franklin petitions the assembly in Pennsylvania for a mental hospital. What kind of attitudes did people have back then about people suffering from mental illness? We’re going to look at the history of this and how it informs how we’re treating the mentally ill today.
RW: Once I began investigating this, it became clear to me that we need to use history to understand how we treat and think about the mentally ill today. So I decided to trace the treatment of the seriously mentally ill in the book Mad in America, from colonial times until today. While Pennsylvania was still a colony of England, Benjamin Franklin and others opened the first hospital in the colonies. They said they would have a section that would take care of the mad. In the basement of the hospital, they basically built a number of cells and furnished them with straw as if they were stalls for animals. Once they opened the hospital, the mad would be put in those basement cells. There was a window just a little bit above the ground, and during the weekend or on Sunday, people from Philadelphia could come in and actually pay a few cents to look at the crazy people in the cells, almost as if they were going to a zoo.
RLM: Now what’s going on at this time?
RW: In medical textbooks, the thought at this time—the “age of reason”—was that the mad, by virtue of having lost their reason, have descended to a lower level of being and are a sort of animal. So the way to treat the mad is to instill fear in them and treat them harshly. They thought the mad were insensitive to heat and cold and didn’t need clothes in those cells. Documents from the hospital talk about how the person who oversaw the mad was like a keeper of the animals—he had whips and shackles and that sort of thing. So at this very early moment in the treatment of the seriously mentally ill, we have a conception of them as less than human—as having descended to a lower level of being and that they needed to be treated harshly in order to be kept in line.
RLM: They were called brutes, weren’t they?
RW: Absolutely, and that’s a reflection of how they were conceived.
RLM: Didn’t Benjamin Rush put some kind of paste on them to make their skin blister?
RW: Yes, absolutely. Benjamin Rush is remembered today as the father of American psychiatry. He brought back the teachings from Europe, and the idea was that you needed to use medical therapies that in some ways weakened the patient.
If you could give them something to make them vomit over and over again or make them have diarrhea over and over again, you would deplete them and make them weaker. In that weakened state they would no longer be able to be so agitated, or so difficult, or so angry with their keepers.
So you see in the medical texts that Rush adopted in the 1700s, there were a number of therapies that were in fact designed to weaken them—in fact make them sick or make them dizzy. To do that, they would spin them around and around and around.
RLM: Benjamin Rush invented a chair—I read in your book—to make them spin and make them weak.
RW: There were actually two different things. There was a spinning device that Rush used—but that one was actually invented in Europe. You would just put people on a spinning disk and run them around until they would throw up, and then they would crawl back to their cells and wouldn’t bother anybody for a while. Rush invented something called the tranquilizer chair. He believed that madness was due to a blood imbalance and that madness was caused by too much blood rushing to the head. So he bled his people profusely. They would be bound into this chair, kept there from anywhere from four hours to several days, and be bled while having ice dumped on their head, all of which drained blood from the overheated brain.
Now imagine that you’re wrapped in this chair for three or four days, with ice being poured on your head. You’re going to be pretty weak at the end of that time, and you’re going to be quieter, because you’re going to be so exhausted; and that’s what Rush talks about—he says after a certain length of time people become composed, quieter, and more tranquil. He talked about how satisfied he was. This chair, which you can still see in some museums, was then exported to Europe and it became the first psychiatric medical therapy, so to speak, developed in the United States and then exported to Europe.
RLM: So you strap a person in a chair, you pour ice water on their head, you spin them in the chair, you purge them, and you take blood out of their system. You force them to vomit and you blister their skin, and then you say, “Lo and behold—this is a nice, docile person we have here.”
RW: Exactly, and if we did a clinical trial of Rush’s chair today, we’d probably see, as an effect, a more manageable person who would be expressing fewer psychotic symptoms. We laugh about these therapies from long ago, but if the goal is to make people more manageable and quieter, those early therapies indeed did that.
RLM: Very unfortunate, because Benjamin Rush, who was also one of the signers of the Declaration of Independence and the foremost physician in the United States, went from being a Quaker humanitarian to using these almost barbaric techniques. I know he ruined his reputation eventually in the United States because he purged too many people of blood and too many of them died from it.
1812: The Temporary Sanity of “Moral Treatment”
RLM: Take us forward now to about 1812, to the beginning of what’s called “moral treatment.”
RW: We forget this part of history. In conventional histories of psychiatry there is a sense that the mentally ill were always mistreated in the past, but if you really look in the history you find this era when “moral therapy” held sway. It was a reform movement that came out of York, England, ushered in by Quakers there, who looked at how one of their own people had been mistreated in mental hospitals in England and said, “We don’t know what causes madness, but we do know they are brethren. As brethren we’re going to develop a form of care that treats them as fellow human beings.” There is this reconception—they are not animals. The York Quakers built a retreat out in the countryside because they thought that nature could be healing. There, the people were treated as ordinarily as possible. They were dressed in normal clothes. They had ordinary bedrooms. They would have entertainment in the evening. There were walks in the country and gardening, because they thought that exercise was good. The Quakers would feed them four meals a day, and they believed in a little bit of sherry in the afternoon. So what happened?
The Quakers found a couple things: the resistance of patients and the propensity for violence pretty much disappears, because they’re not being treated so aggressively. They found that many people with this kind treatment got well after just twelve months.
RW: After some time in the country, many people never needed to come back to the asylum. After the Quakers in York, England, pioneered this in the very last years of the 1700s, it gets imported into the United States by Quakers here, and we started getting these moral therapy asylums dotting major East Coast cities.
There was one in Philadelphia, one in Boston, and one in Hartford. Researchers today have gone back and looked at their records and have concluded that there has probably never been a more effective form of care in the United States.
They found that more than 50 percent of the newly admitted would be discharged within twelve months. The best long-term study we have, which went for about thirty years, found that something like 50 percent of first-episode patients, who were then discharged, never returned to the asylum.
RLM: And these were places that were called asylums—they were actually small homelike facilities, weren’t they?
RW: Yes, exactly. I mean, we’re using the word “asylum” in the old sense of the word—as a refuge, not as a mental hospital but a time-out place from the rigors of daily life. They were meant to be comfortable, small, and architecturally pleasing. People wanted pleasing grounds where they could walk and such. So in terms of a humanistic ethical form of care, we can look back to these early retreats from 1812 to 1850, more or less, and rediscover a form of care that would be great if we could duplicate it today.
1859: From Darwinian Evolution to Galtonian Eugenics
RLM: So after this “moral treatment,” what came next?
RW: The next big swing in our conceptions of the mentally ill happens post-Darwin. Darwin writes his Origin of Species in the mid-1800s, and although he doesn’t really talk about humans, it’s obvious that humans evolved. Then his cousin Sir Francis Galton picks up on this. He says that if a human society wants to prosper, it needs to take those with good germ plasm and encourage them to breed and have kids as well as identify those with bad germ plasm to prevent them from breeding.
Galton is from England, but it’s in the United States that leaders really embrace this idea. So the eugenics policy that then gets enacted into law first happens in the United States before anywhere else. Once you accept this idea—in order to prosper, a society has to prevent those with bad germ plasm from breeding—you can see what society needs to do. It needs to begin distinguishing between people it calls fit and those it deems unfit.
As America adopts eugenic attitudes, democracy becomes a ridiculous idea because not all men are in fact created equal. Now once you start trying to identify the unfit, who comes at the top of that list? Of course, it’s the mentally ill.
1896: Imprisonment and Sterilization
RW: Beginning in 1896, eugenicists in the United States began passing policies designed to prevent “the mad” from breeding. First, they pass laws saying it’s illegal for the insane to marry. Next, they start locking people up and keeping them in hospitals for long periods of time—at least until they pass their breeding years. Once these ideas really take hold—around 1900—people stop being discharged from the mental hospitals, and we had huge growth in the number of institutionalized people. Once you were declared insane or mentally ill, it became very hard to get out.
RLM: Definitely. Remember when I said earlier in the program that my first job was at a mental hospital in 1961? I remember distinctly interviewing a man there who just talked to me as a peer, and I said to him, “I can tell that you’re just talking to me ‘regular.’ Why are you here?” He said, “Because they’ll never let me out.”
RW: Yeah. You see this in the records—it’s just tragic. People coming in when they’re eighteen to twenty-five who often had a lot of difficulties that preceded their time in the hospital and then they never get out.
RLM: Yes, I also met people, at the time, who were in the hospital for twenty or twenty-five years because their families wanted to get rid of them.
RW: You have that as well, of course. Then we began sterilizing the mentally ill too, and that was deemed constitutional by the U.S. Supreme Court in 1927.
RLM: We were the first country that had sterilization. In fact, I think I read in your book that 80 percent of the sterilizations in the United States happened right here in California where I’m broadcasting from.
RW: I don’t remember the percentage, but California was certainly a leader in this whole initiative, so much so that when Hitler wanted to start a sterilization program in Germany he actually sent some of his scientists to California.
RLM: Wow.
1918: Insanity as Genetically Determined
RLM: Moving into the twentieth century, this germ-plasm theory is the foundation for our current notion of schizophrenia. We’re thinking it’s something in the genes—that is passed on from generation to generation—that must be stopped in some way.
RW: The eugenicists wanted to say that people were genetically determined. The whole point was to identify people with bad germ plasm. The science of eugenics was really promoted with the pursuit of scholarly activity at some of the best universities in United States—I mean, Ivy League universities. This wasn’t some sort of fringe endeavor—this was done at the heart of American academics. By around 1918, there were texts that said insanity is a single-gene recessive disorder, like blue eyes. So if you get the normalcy gene from say, your father, and the insane gene from your mother, you will be a carrier but you will be normal. But if you get an insane gene from father and an insane gene from mother, then you’re going to be insane.
RLM: So they’re saying that insanity is a recessive gene.
RW: Yes. There was never any good science behind this, but state and county fairs in the 1920s had exhibits by the American Eugenics Society that said: “Every eight minutes another insane person is born.” They would call this a burden on society. Around this time we begin to see the stigmatization of the mentally ill in history, as they were being seen or conceived of as a real burden on society. We were spending a lot of money on these people. Now and then you would see a book asking whether we should just be killing these people instead of housing them.
1930s: Coma and Convulsive Therapies—Old Methodology, New Technology
RLM: So, we’re going from 1751, where the mentally ill are considered animals in cells lying on straw, to the twentieth century, where people are talking about doing away with them—there’s sterilization going on—and then along comes World War II, which brings us into hydrotherapy, shock therapy, and convulsive therapy.
RW: In the 1930s you see the number of therapies increase dramatically. You have something called insulin coma therapy, where you’d give someone a shot of insulin—so much that they would go into shock—and then you’d administer sugar to bring them back. You would do this repetitively. But it just made people quieter. They became childlike because they felt grateful to the therapist for reviving them. With insulin coma therapy, you could actually see repetitive signs of brain damage in an autopsy. But again, it made people more manageable and childlike.
We also got something called metrazol convulsive therapy. Metrazol was a poison that caused convulsions so severe that people would break their teeth or possibly fracture bones in their back. As that is introduced, you also see people changing after you had this poison administered. But people were so afraid of it in the asylums, you could just threaten them with metrazol convulsive therapy and they would often get in line and become quieter.
After this we get electroshock therapy. Electroshock is initially ushered into mental hospitals for the same reason that metrazol convulsive therapy was. The idea was that these seizures were good for people, and electricity became an easier way to induce these seizures. But again, the initial reports were all about how it makes them quieter—they don’t even remember who they are after they come out, and they’re more childlike.
RLM: We know Ernest Hemingway received a series of electroshock therapies prior to his suicide.
RW: That’s the thing—to the public this therapy is being presented as a miracle cure, but in the case studies it was recognized that these were brain-damaging therapies. Some theorists posited that perhaps some people, that is, the mad, do better with less brain function, and of course, ultimately, this leads to prefrontal lobotomy.
1940: The Prefrontal Lobotomy
RW: A Portuguese neurologist, Edgar Moniz, claimed that if you destroy the frontal lobe, people are quieted and the madness goes away. This gets imported into the United States, and in 1940 it is treated as a miracle.
RLM: The prefrontal lobotomy was considered a miracle?
RW: Yeah. Walter Freeman was the big promoter of it in the United States. He would go around from hospital to hospital and destroy thirty to forty people’s frontal lobes in one day. There was even talk that maybe the frontal lobes are like the appendix and that we don’t really need them.
RLM: We go from almost waterboarding to spinning, to puking, to purging, taking out the blood, to wet wraps, on to insulin shock, and then electroshock, and now finally Dr. Freeman comes up with the ultimate way to make the mentally ill docile, which is to cut out a major piece of their brain.
RW: Right, and it’s not just any piece of the brain. It’s the prefrontal lobes. This is the part that makes us human. If you look at a chimpanzee brain and a human brain, the difference is that you see in the human brain the pronounced frontal lobes. This is the part of the brain thought to be the seat of consciousness. This is the part that worries about the future and monitors our actions. The mentally ill were somehow seen as not in need of this part of their brain. But again, while the press was treating it as a miracle brain surgery—Edgar Moniz even wins the Nobel Prize in Medicine for inventing it—you then read the actual case descriptions. They talk about people no longer caring about the world or themselves.
Modern Drugs for Modern Times
Antipsychotics, Benzodiazepines, and SSRIs
1955: Antipsychotics—Lobotomy in a Pill
RLM: Take us from lobotomies to the modern era, beginning with Thorazine [chlorpromazine], the first antipsychotic.
RW: Thorazine arrived in mental hospitals in 1954, kicking off what is remembered today as a great psychopharmacological revolution—a “Great Leap Forward” in care. Remember, they’re called antipsychotics today, as if they’re antidotes to psychosis; but, when they were first introduced, they were actually lauded as causing a change in being similar to that of a surgical lobotomy. The people touting the drugs even say, “It’s as if the drug causes a chemical lobotomy.” But that is not seen as a bad thing in 1954; that’s seen as a good thing, because Edgar Moniz had just won the Nobel Prize in Medicine for his discovery of the therapeutic value of lobotomy. This change from an agitated person—someone with wild thoughts—into a quieter person—someone who shuffles along and doesn’t care, who’s disinterested in the world—was seen as a good thing. Well, it might be a good thing for the people managing the asylum, but is it a good thing for the person himself or herself?
This is so important. Our common understanding is that drugs represent a break from these problems of the past. Yet you go back to the 1950s and they’re seen as a continuation of what we’ve been doing rather than a break. It’s important to note that early on they’re seen as “tranquilizers,” called neuroleptics [taking hold of the nerves], but then they get reconceptualized in the public mind as “antipsychotics,” as if they’re antibiotics. They’re seen as an antidote to psychosis.
Moving forward, we see a new story emerge—that all of these drugs fix chemical imbalances in the brain like insulin does with diabetes. And if that metaphor is true, that is a story of great advance. It means you’ve identified the pathology of a disorder and now you have a treatment that is specific to it.
But now you look into the science, and once again you find that’s not true. You find that we still don’t know the pathology of depression or of psychosis. They never found that people with a certain diagnosis had a characteristic chemical imbalance. Also, you find that you can’t say that the drugs correct a chemical imbalance. Moreover, you see a subjective value in the ratings of these drugs. If someone is quieter, moves around less, and is less aggressive, then this is seen as evidence that the drug works in a medical way. But we could take the old view and say that these antipsychotics are causing a change in being that makes them more acceptable to others.
RLM: Yes—they’re becoming zombielike. We can’t get away from your original findings, which showed developed countries are doing worse than people from undeveloped countries who take fewer of the medicines, in countries such as Nigeria and India.
RW: In the aggregate, that’s absolutely true. In terms of doing worse, there are several elements of this. People on medication long-term actually are more likely to still be psychotic at ten and fifteen years later, whereas, on the whole, those who go off the medications see a diminishment of psychotic symptoms starting around year two, such that over the long-term they are much less likely to still be psychotic. That is what we see in a long-term study by Martin Harrow.
People in these poorer countries, once off the medication long-term, are much more likely to be employed. They’re much more likely to be in school. They’re much more likely to have some sort of decent social life, and they are, frankly, much, much less likely to be psychotic long-term than those who stay on antipsychotics continuously. What you see in those who stay on antipsychotics continuously—and there’s a minority who do well on them—the majority live quiet lives of desperation or often end up physically ill and unemployed . . . not the sort of life anyone would wish for their son or daughter.
RLM: Mental illness is on a continuum, and the schizophrenics are at the edge of the continuum. Let’s talk about the regular people; in this country, millions are suffering from depression and anxiety and are taking various forms of these psychoactive medications. Give us a little history about how benzodiazepines came about.
RW: Benzodiazepines grew out of post–World War II research where people were looking for a magic bullet for Gram-negative bacteria. Penicillin works on what’s called Gram-positive bacteria, a different type of bacteria, and researchers were looking for a magic bullet for this other type of bacteria. They found that one of the chemicals they came up with in initial animal testing had an odd effect—it basically caused muscle paralysis in rats, which was reversible. The researchers noted the rats were not distressed by this sudden paralysis. The researchers said, “Aha, this agent has a tranquilizing effect. It blocks the ability of the body to mount an emotional response.” This line of research eventually leads to the first benzodiazepines—drugs like Librium [chlordiazepoxide] and Valium [diazepam].
They were brought to market in the early ‘60s [we hear about “Mother’s Little Helper” and that sort of thing] as nonaddictive drugs. But it becomes clear pretty fast that while they’re very effective in knocking down anxiety over the short term, that effect begins to wear off after four to six weeks; and then, when people try to come off, they have extreme withdrawal symptoms and get what’s called rebound anxiety, where they are now worse than they were when they went on the pill. Because of that, by the end of the 1970s the governments of the United States and the United Kingdom both said, “Wow! These drugs are addictive. We need to limit them to short-term use.” In fact, it was Betty Ford’s physician who said in the late ‘70s that benzodiazepines were one of the biggest drug problems we had in this country at that time.
RLM: The First Lady was on Valium?
RW: Yes, but what’s so remarkable is that you still see physicians prescribing benzodiazepines in spite of this understanding of the drugs—that while they are very effective for about a week or two weeks, they lose that effectiveness and then you’re into this situation where you can have a problematic withdrawal period when you come off. If you stay on, the research is quite clear that you get physical and emotional decline, increased anxiety, and often agoraphobia—where people can’t go out of the house. You see increasing disability. All of that’s really solid in the research literature.
In modern times, they’re becoming part of a usual drug cocktail, which is really astonishing because no one is even claiming that benzodiazepines are good for you long term and yet that’s how they’re being used—incorporated into prescribing patterns.
RLM: Yes. It’s very important that we tell our listeners the actual names of the medicines that are in this family of benzodiazepines. Of course, the older generation was Miltown [meprobamate], and then we had Librium. Remember the old slogan, “Give me Librium or give me meth?” We now have Ativan [lorazepam] and Xanax [alprazolam]—which is very popular all over the United States—and we have Klonopin [clonazepam]. What have I missed?
RW: Those are the big three right now. The market for benzodiazepines was declining in the 1970s with the understanding that Librium and Valium could be so addictive. And sure enough, Xanax was then promoted as a nonaddictive drug when it was brought to market. But when you look at the research in which they tested Xanax, you found that it was very effective for about four weeks. By the end of six weeks, it was not really much more effective than placebo. Then they did a withdrawal study, and by the end of that withdrawal study, the Xanax patients were so much worse than the placebo patients. You see rebound anxiety and you see all sorts of other adverse effects.
But unfortunately, the people being paid by the makers of Xanax to do that trial—academic psychiatrists at academic medical centers—didn’t focus on the withdrawal problem. They didn’t focus on how rebound anxiety got so much worse. They didn’t even focus on the six-week results. When they published their results, they focused on this shorter, four-week period of time when Xanax is supposedly very effective. There was even talk about how it was nonaddictive. It’s just nonsense. I get emails every day from people who are in despair—locked into a benzodiazepine addiction, just can’t get off—and it has ruined their lives.
1980s: SSRIs and the Epidemic of Mental Illness
RLM: Let’s now talk about your research into the selective serotonin reuptake inhibitors, SSRIs.
RW: Part of the conventional narrative of progress is that in 1987, Prozac [fluoxetine] arrives on the market. This is the first SSRI and the first of the second-generation psychiatric drugs—this next step up this ladder of progress. Generally in medicine, when you see progress—when you see new therapies arrive—the burden that disorder takes in terms of disability and so forth lessens in society. It makes sense that the burden that disorder takes on your society should, at the very least, stay the same or improve since you have an effective new treatment for a disorder.
RLM: For example, Jonas Salk comes up with a vaccine, and polio is decreased.
RW: Exactly. Instead, our disability rates due to mental disorders have steadily risen during this era of the psychopharmacological revolution—the number of people unable to function well in society and in need of government care. In absolute numbers, it’s basically risen from around 360,000 adults in 1955 to more than 4.7 million adults today. In the past twenty years we’ve really embraced this paradigm of care, and what has happened to disability rates? In 1987, 1.25 million adults were on disability, receiving a government payment because of mental illness. Today, there are around 4.7 million people receiving such payments. During this time of increased use of second-generation psychiatric drugs, we have had a fourfold increase in the number of adults on disability.
And, of course, we’re now medicating kids. We didn’t used to do that. In 1987, there were 16,200 children whose families received a disability payment because they were “severely mentally ill.” Today we’re well over 600,000 kids—so during the past twenty-five years we’ve had a thirty-five-fold increase in severely disabled children due to mental disorders. If you follow those kids who go on disability as children, when they hit age eighteen, about two-thirds are going right onto adult disability, and they basically now have a life as a mental patient laid out before them. Those numbers do not tell of a form of care that is lessening the burden of psychiatric distress in our society. Instead they tell us exactly the opposite.
RLM: Is there any substantial evidence that people who are depressed have different brain chemistry than the rest of us?
RW: The idea is that people who are depressed have low amounts of the neurotransmitter serotonin. This arose not from investigations into people who are depressed but by understanding how drugs and antidepressants acted on the brain. Just to simplify this: Prozac and the other SSRIs block the reuptake of serotonin from the synaptic cleft between neurons, therefore theoretically increasing serotonergic activity. People have hypothesized that maybe depression is due to low serotonin, but they found that prior to going on medication, depressed people had nothing abnormal with their serotonergic system. The psychiatric community failed to communicate that finding, which goes back to the early 1980s, to the American public. Is there evidence that people with depression suffer from an abnormal serotonergic system? Not before they go on the drug. After the drug, we see that may be the case.
RLM: To visualize the synaptic clefts that Bob is talking about, picture some wiring in your house running along the baseboard, and every once in a while there’s a little junction box, and from the junction box wires go out to various other areas of the house. We’re made the same way—we’ve got electrical wiring, and it goes into these little boxes where all this neurochemistry takes place, and then it goes out to other places. When we close the exit doors in the junction box, the neurotransmitting chemicals, which are inside the box, are trapped and thus they increase in concentration. That’s what a reuptake inhibitor does. It closes off some little doors in that box, so the chemicals can’t go out, and the chemicals build up inside the box.
Long-Term Consequences of Antidepressants
How the Brain Maintains Homeostasis
RLM: The medical profession decided it was their genetics that made psychiatric patients “different” from the rest of us. Bob is telling us that those who are depressed do not have a different brain chemistry. An important question thus arises, what happens if you take people who have the same brain chemistry as the rest of us and then give them something to change their brain chemistry?
RW: The irony is that once we understood how drugs act on the brain, researchers hypothesized that depression was due to low serotonergic activity. So now you go on an SSRI, which upsurges serotonergic activity in the brain. The brain, being this extraordinarily neuroplastic organ, now tries to compensate for the presence of that drug. So what does it do? Since the drug is upping serotonergic activity, the brain actually down-regulates or decreases its own serotonergic activity. So the neuron—that wire that’s coming up to the gap [synapse]—starts releasing less serotonin than normal. And then the receiving postsynaptic neuron actually decreases the density of its receptors for serotonin. You can see why this is: researchers say the brain is trying to maintain homeostatic equilibrium, its normal functioning. They found that prior to going on an antidepressant, you don’t have this problem. But once you are on the drug for a longer period of time, you do. So the drug actually induces the very abnormality hypothesized to cause depression in the first place.
Antidepressants may be the most commonly prescribed drugs in America. In terms of their short-term efficacy, they beat placebo, but only for those with severe symptoms. That’s where you see a clear benefit over placebo in the short term—in the severely ill—but not for those with mild or moderate depression. But when you start looking at long-term outcomes, you find time and time again that while medicated people may initially get better a little quicker, they seem to relapse back into depression more frequently than before they were using antidepressants. As early as the 1970s you see some psychiatrists saying, “I think these drugs are causing a chronification of the disease. People aren’t staying well as long as they used to after recovering from an episode.”
2012: The Exercise Study
RLM: Correct me if I’m off here, but I thought the Duke University study comparing an SSRI with exercise indicated that the SSRI actually made people worse.
RW: The Duke study is quite clear. There were three groups: One, drug; two, drug plus exercise; and three, exercise alone. The hypothesis was that the drug plus exercise would do the best at the end of ten months. At the end of about sixteen weeks, the drug-treated patients were doing a little bit better than the exercise-alone group. But then between sixteen weeks and roughly forty-four weeks, the exercise-alone patients continued to get better, whereas those on the drug alone or drug plus exercise had many relapses. Only 30 percent of the exercise-alone group was still depressed at the end of ten months, whereas around 55 percent of the drug-plus-exercise group were now depressed. In that study, the drugs can be seen as acting as an anchor, weighing down or subtracting from the exercise group, rather than being an added benefit.
RLM: And Duke University replicated that study about four or five years after the original one and found the same thing.
RW: That’s pretty compelling, but there are a number of studies like this. One of the underappreciated studies was called the STAR*D study—the largest antidepressant trial ever conducted—of 4,041 patients. This trial was funded by the National Institute of Mental Health [NIMH] and was supposed to guide future care. Here were the bottom-line results: Of the 4,041 patients at the end of one year, there were only 108 patients who remitted*33 and then never relapsed and stayed in the trial for the year. All the others never remitted, relapsed, or dropped out of the trial. So that’s a documented stay-well rate of 3 percent, which is the worst outcome I’ve ever seen in a longer-term antidepressant study.
RLM: This is right from the National Institutes of Health website: “The most common side effects associated with SSRIs include headache, nausea, sleeplessness or drowsiness, agitation, sexual problems . . .” and they go on to say they’re popular because they do not cause many side effects. So, I take this drug because I’m depressed, and then I get sexual problems. I get anxiety. I can’t sleep well. I’ve got a headache, but I’m reading here “not many side effects,” and I start to think, what’s going on with me? Am I different from everybody else? Getting these negative effects and thinking I should not be getting negative effects almost assuredly will make me feel much worse.
Following the Money
Bad Incentives in Psychiatry and the Rise of Big Pharma
RLM: Let’s follow the money—what’s going on here from a monetary point of view?
RW: You can see that it is a commercial enterprise. We were spending about $800 million in psychiatric drugs in the United States as a whole when Prozac came to market in 1987. We’re now spending about $40 billion a year, a fifty-fold increase. So from a business point of view, that’s an extraordinary success.
The other problem we’ve had is that the pharmaceutical companies gave a lot of money to the American Psychiatric Association for various things, starting in 1980. At that time, they began hiring psychiatrists at academic medical schools to serve as consultants, speakers, and advisors. Once they do that, those speakers, who have such legitimacy in our society, are not going to be telling us much about adverse effects or worries about long-term chronicity—they’re just going to be celebrating the merits of these drugs. There’s a guild interest behind that as well—of course the American Psychiatric Association [APA] has to defend its product. So we see these various monetary interests corrupting the story told to the public: the interests of the pharmaceutical industry, of money going to psychiatrists and to the APA, and the APA’s own guild interests. That monetary interest corrupts the story they tell to the public.
Their story is that these drugs are a great help and a great necessity. Yet what is happening in our society as we use these drugs more? We’re seeing the burden of mental illness go up, both among adults and as we diagnose more of our kids. We’re seeing all the measures of mental health in kids getting worse. And the number of people on disability due to mental illness is soaring in the United States. So when we look at the big picture, this modern paradigm of care where we use these drugs so commonly—is it helping our society reduce the burden of mental illness? Not at all. It’s going in the exact opposite direction.
Lobotomy Nation
RLM: One thing this trend is accomplishing is making people docile, isn’t it? And that’s what you said was going on originally with the mentally ill. With more people in our country on these various zombie medications, people are becoming docile and easier to control. They don’t agitate. They don’t speak up for themselves. And eventually they don’t get represented. What you’re talking about here, using the mentally ill as an example, is a movement for an entire culture in the direction of docility, which sounds very dangerous.
RW: It’s quite clear that one of the reasons for diagnosing attention-deficit hyperactivity disorder [ADHD] is for prescribing medications that are meant to quiet children and reduce their social interactions. As far as the SSRIs, a lot of people find that they don’t feel depressed—they feel numbed out. They just don’t care as much as they used to.
RLM: That’s what I mean when I say “zombielike.”
RW: You hear many people after they’ve been on these drugs say they don’t care so much about their spouse, their kids, their job—they say they can’t really get interested in a rainbow—that sort of thing. Sexual dysfunction is much more common than people realize with SSRI usage as well.
RLM: Yeah, that’s one of the unspoken aspects of the SSRIs. What I find most painful as a clinician is thinking about what my patients and patients around the country are supposed to do when they hear what you have to say. They’re taking these medicines. They’ve been taking them for a long time. They think they are doing good. They now hear that they may be creating damage. But they also know that if they come off the medicine, the very withdrawal is going to cause them a lot of difficulty—no different than coming off heroin or cocaine; you’re going to have a withdrawal effect. They’re asking me, “Do I stop taking them? Do I continue taking them? They may be doing the damage, but to stop taking them I have to go through the withdrawal.” What a painful position to be in. Well, this is sort of gloomy in a way, folks.
There is one thing that we do know—that’s noninvasive and that has been proven to be effective—and it’s the least expensive thing possible: that is . . . exercise. Everything that we know about exercise indicates that it may not be a cure, but it certainly alleviates depression and it certainly puts people in a better mood. This is a plea for the use of exercise as your form of treatment, even walking. Robert, thank you for the research you’ve done, which is so important for my profession and the country at large.
RW: Thank you.
Living Naturally with Julie Holland
Julie Holland is a psychopharmacologist, psychiatrist, and author who has written books on MDMA, marijuana, and pharmaceuticals. In her New York Times best-selling book Moody Bitches, she reveals the interaction between birth control pills and SSRIs, which cause millions of American women to suffer wide mood swings.
Resisting the “New Normal” of Overmedication
Julie Holland, MD
June 16, 2015
JULIE HOLLAND, MD, is the editor of Ecstasy: The Complete Guide (2001) and The Pot Book (2010). She also wrote a best seller about her experiences at Bellevue Hospital in New York called Weekends at Bellevue: Nine Years on the Night Shift at the Psych ER (2010). Her latest book is Moody Bitches: The Truth About the Drugs You’re Taking, The Sleep You’re Missing, The Sex You’re Not Having, and What’s Really Making You Crazy (2015).
How a Society on Drugs Can Return to Living Naturally
The New Normal
RLM: What led you to write the book Moody Bitches?
Julie Holland, MD (JH): Twenty years ago, I was practicing psychiatry and a woman came to my office who was really sick and didn’t know what was going on. I had to hold her hand and destigmatize the process of taking psychiatric medications, which she really needed. Ten to fifteen years down the road I had people coming to me who didn’t have very significant symptoms and basically just wanted to know which medicine they should be on, because they had seen ads for all of these different antidepressants. Their friends were on one thing, their Pilates instructor was on something else, and they were getting a lot of information and advice about which medicine they should take without really looking at whether they were genuinely sick or whether their environment, and their response to their environment, was sick.
Sometimes it is the way we are living our lives that is making us feel terrible, and the answer is not to sweep the dirt under the carpet and mask the symptoms by taking something that makes you feel good but to change the way that you’re living your life—to take that carpet and beat the heck out of it and sweep your whole floor.
I started seeing this “new normal” where more women were getting on psychiatric medications and antidepressants and antianxiety meds. Then antipsychotics started being used for depression, and I started seeing Big Pharma advertising more to women. They’ve always targeted women, but it seemed like it was getting worse. I felt like I had to say something. I felt like I needed to turn the ship around. It’s a big ship, so it’s not going to go quickly, but I felt like I needed to join the parade or lead the parade against everybody being medicated. Being overly medicated results in people being unaware of themselves and their environment. They become oblivious to how they’re living and how their world is changing.
Natural Movement for Natural Moods
RLM: What’s the biggest take-away for a woman who reads this book?
JH: It’s the idea of natural moods. Women are naturally cyclical and dynamic. If you’re not taking oral contraceptives or antidepressants, it’s natural to have times in the month where you feel great and normal at times in the month to feel lousy. The further away we get from nature, the sicker we’re going to get. The book is really about returning to nature. I mean, literally going outside and getting some sun. Move your body and get in your body. All of us are spending a lot of time sitting. We’re on our phones or computers or in our cars. Just moving your body and being outside with the grass and trees will make you feel better, and you don’t necessarily need to keep taking pills every day and living in a way that’s very unnatural for you.
RLM: There actually is some scientific evidence now indicating that being out in nature is in and of itself healing. And I know that there are people who are now experimenting with actually lying on the ground, right? What is this about?
JH: It is something called “grounding,” and I talk quite a bit about this. This is an evidence-based book. There are about forty pages of notes and hundreds and hundreds of citations. I go into the research behind why exercise is good for you and how being in nature and in sunlight is good for you.
Medicating and Suppressing Natural Moods
JH: Being naturally cyclical, or moody, is really one of women’s biggest assets. We have this intuition, empathy, and emotional expression, and we can read other people’s emotions. If you mute this sensitivity, you miss out on a lot of information.
RLM: You’re implying that there are times of the month when women naturally feel lousy. It’s to be expected. So if you feel lousy at certain times of the month, and you track it with your menstrual cycle, then that’s just how it is?
JH: Yes.
RLM: That’s pretty scary, Julie, because we’ve got women—fortunately, I think we both agree—going into very high levels of government including the possibility of president. Are we to expect that on a monthly basis they’re going to be in a lousy mood, and we’ll have to watch out for that? I mean, I don’t know if we want that . . .
JH: There are some women who don’t have premenstrual syndrome at all, and there are other women who are completely incapacitated by it and require hormones. The majority of other women have some change in their mood over the course of their fertility cycle. That is normal, and there are real advantages to that. But in general, women are quicker to calm themselves and get out of an emotional situation than men are. If you’re worried about people being emotional as politicians, I think that’s already been covered by men.
RLM: No, I’m not worried about them being emotional. My concern is more that they won’t be allowed to be emotional because we live in a culture that wants to somewhat suppress emotion. Remember when George Bach wrote the book Creative Aggression—he was saying that some level of very safe fighting is healthy because, otherwise, you suppress all this stuff, and you end up full of junk inside.
JH: We all know that if you suppress a behavior, it’s going to come out in perverted ways. This idea that you can be celibate or that you can go against your real sexual orientation—it’s going to come out in weird ways. For centuries men have had their natural emotional side suppressed. Little boys are taught not to cry—not to act like girls. Women are now getting the message that it’s not okay to be emotional, and it’s not okay to express or feel your emotions. These are really dangerous, unhelpful, and unhealthful messages. They’re getting it also from Big Pharma. The pharmaceutical industry is targeting women in their advertising in women’s magazines and daytime talk shows, much more than they are in male-oriented shows. Big Pharma, in regard to psych medications, is exploiting women who feel vulnerable about the fact that they do get emotional. I’m not talking about people with major depression who can’t get out of bed and their sleep, appetite, and energy levels are completely distorted. They need a psychiatrist and medication. I’m talking about the sort of cosmetic psychopharmacology where more and more women are on psych meds prescribed by nonpsychiatrists, and then they have trouble getting off these meds. It’s very difficult to get off antidepressants.
The Drug-Dependence Epidemic
The Importance of Controlled Withdrawal
JH: It’s hard to get off antianxiety medicines. It’s hard to get off sleeping pills. It’s hard to get off stimulants. There are millions of Americans who are taking medicine year after year because they can’t stop what they started. They may not need it anymore—their lives may have changed—but they are tolerant and dependent and cannot get off their medicines easily. As soon as they start to pull back on the meds and feel lousy, they become convinced that they have a chemical imbalance and they need to stay on the meds, when really they’re experiencing withdrawal.
RLM: That’s exactly what Robert Whitaker said on this program and in his book Anatomy of an Epidemic—namely, that when people try to get off these medications, then they’re running into neurochemical imbalances and thus think they must have needed the medicine to begin with. They think they had better get back on the “needed” medicines but in fact they are going through withdrawal.
JH: Right. There are some psych meds that are harder to get off than others. I’ve certainly had people say to me, “I’ve been trying to get off this medicine, but I’ve been on it an extra ten or twelve years now because I couldn’t get off.”
I’m good at helping people get off their medicines. It’s a slow process, and you need to put a lot of other things in place before you start to pull off these medicines. Sometimes it’s not just behavioral changes. Sometimes you need other medicines to make it easier to get off certain other ones.
Worse than Heroin Withdrawal
RLM: When I was practicing chemical dependence treatment full-time, back in the ‘80s, I was able to detox people from cocaine and heroin in relatively short periods of time. Both drugs are out of your system within three or four days—people can get over withdrawal fairly easily with proper care. Is that not the case with some of the medicines you’re talking about? Or should we be creating social model detoxification centers, where people can go away for a week and get these prescription meds out of their system?
JH: People need to understand that coming off psych meds takes weeks or months. It is not in any case just three or four days. It is easier to come off of heroin or cocaine than it is to come off of most prescription psychiatric medications.
RLM: To repeat, here is Dr. Julie Holland is saying that it’s easier, in her experience, to come off of cocaine and heroin—which is a lot of my work—than it is to come off the psychiatric medicines that she is encountering. Why is this?
JH: Well, when you take an antidepressant every day, there’s all this rebalancing that has to happen with the receptors. When you stop taking the medicine, your brain has to create new receptors and a new balance, and it takes weeks and months. It’s a long process and it’s very uncomfortable. I often need to use other psychiatric medications to get people off what they’re dependent on.
Leveled Emotions on Combination of Contraceptive and Antidepressant
JH: The other thing to mention is that a lot of women are taking oral contraceptives and antidepressants together. And estrogen and serotonin are really linked—yoked to some degree. So when you have naturally high estrogen levels due to the oral contraceptive and high serotonin levels from the antidepressant, and you put those two together, you get a double whammy. It puts you in this hyper-rational, hyper-accommodating state, where you put up with a lot of crap that you normally wouldn’t. One advantage of a woman having premenstrual syndrome for a couple of days is that she becomes more critical and more irritated by things. It’s a chance to make changes in her environment and potentially in the behavior of people around her.
I had a patient call me from work because she wanted to go up on her antidepressants, because she was crying at work—and you can’t cry at work. But when I talked to her about why she was crying, it was because her boss had betrayed and humiliated her in front of her staff, and if she was medicated she wouldn’t be so upset about this. So the antidepressants are enabling malignant behavior to go on around her. And it’s also not doing her boss any favors or her coworkers any favors.
RLM: I remember when Prozac first came out, Julie. I read an article in the paper by a very astute journalist who said that he was taking Prozac, and it was putting him in a better mood. He was happier. And then he went to his mother’s funeral and realized he had no feelings whatsoever, and he said to himself, “This is the price I’m paying for taking this.” That’s what you’re talking about, isn’t it?
JH: One of the prices you’re paying is that it’s going to be very hard to cry and to really feel emotionally connected with people.
RLM: Well, if it’s hard to cry, how do you orgasm?
JH: It’s nearly impossible for most women on a solid dose of SSRIs to climax. It’s a huge, huge problem. In my patient population, women complain about low libido and inability to orgasm, and it is directly affected by the antidepressants they’re on.
Tired Soldiers in the Long Battle with Psychiatric Illness
One in Four Women on Psychiatric Medications
RLM: You’re saying 25 percent of the adult women in the United States are on psychiatric medications. Is that correct?
JH: In certain demographics it’s higher. Now the big thing is anti-psychotics. More and more doctors, and not psychiatrists, are prescribing antipsychotics for this kind of malaise and depression that women are experiencing.
RLM: You mean like Abilify [aripiprazole]?
JH: Like Abilify. Abilify was the biggest moneymaker in 2013.
Offering a Quick Fix with No Questions Asked
RLM: How do you feel as a psychiatrist about general practitioners prescribing psychiatric medicine? I know you don’t want to criticize your professional colleagues, but that’s a fair question.
JH: I don’t want to criticize my colleagues, but the truth is that because of the way medicine is set up in America right now, it’s all about customers, and getting people in and out of the door, and seeing people for six to ten minutes.
A psychiatrist will spend sixty minutes—maybe even ninety minutes—before they figure out what the diagnosis is and what meds they want to start. A general practitioner or family-practice person will spend six to ten minutes maximum before writing the prescriptions. What should happen is that a psychiatrist should look at the psychiatric history of the family and at genetics and what the treatment response will be before making the decision to start meds. And the biggest thing that no one is talking about is that if you start on meds you are going to feel good, but it’s going to be hard to come off.
RLM: What’s the exit strategy? If you start these medications, how are you going to get off them? Julie, I want to ask you: Should we be warning people who are taking the psychiatric medicines—who are not under the care of a psychiatrist—who are just getting them from a general practitioner or an internist who sees them for five or six minutes? Should we be giving them some kind of warning? Should we be telling them that they really ought to get to a psychopharmacologist or a psychiatrist? What’s the proper thing to do here to protect our citizens?
JH: I think it’s always better if you can work with a specialist.
Abilify
RLM: Abilify is an antipsychotic. Zoloft isn’t. And Abilify is a major seller in this country. Talk a little about Zoloft and Abilify please.
JH: Well, first of all, Abilify is a really good medicine. It was originally designed to treat schizophrenia, and if you have schizophrenia, it is one of the best antipsychotics you can take. I think it does really amazing things for schizophrenia, and it has worked wonders in my private practice the few times that I did work with schizophrenics. But schizophrenics are only 1 percent of the world’s population. If you can target half the world’s population, you’re going to make a bit more money. So they started targeting women with depression—women who are on meds who weren’t getting a really good response from their meds were given Abilify as an add-on to treat depression. They got an FDA indication*34 [for Abilify] to be used as an add-on and that’s really when the money started rolling in for them.
Zoloft
RLM: I want to switch over now and hear you talk about Zoloft.
JH: Zoloft [sertraline] is the most popular antidepressant prescribed among nonpsychiatrists. The way Zoloft got its foothold is that Pfizer would send the drug reps out to family-practice doctors and internists and general practitioners as medicine they could use for patients who were complaining that they were anxious or depressed or having trouble sleeping. The SSRI that I prescribe, that I actually like, is Lexapro. That is the one more commonly prescribed by psychiatrists. However, in 2010, Zoloft sold more units off the shelf than Tide detergent. It’s a commonly prescribed and commonly taken drug, but I’m not crazy about it because I believe it has a lot of gastrointestinal side effects. We know it can make people nauseous. It can cause diarrhea—that sort of thing. My big complaint with Zoloft is that it can really make your entire pelvis numb—much less sexually responsive—and make it much more difficult to climax.
Zoloft vs. Exercise
The Duke Study Revisited
RLM: There was a Duke study comparing Zoloft with exercise, and I will give a brief summary of it. There were three groups in this study. One group received Zoloft, one group received exercise, and one group was given Zoloft and exercise. Remember that SSRIs mean that the little receivers inside the junction box that pull in the Zoloft and distribute it get blocked by this medicine so that serotonin builds up. One group got the Zoloft, one exercise, and one group got both. The people on the exercise did the best. The people on just Zoloft did second best, and the Zoloftwith-exercise group did the worst. What they saw was that the Zoloft actually counters the effect of the exercise. They did a follow-up on that three or four years after and found the same thing, and yet we continue to give Zoloft—I guess in part, Julie, because it seems you can’t get some people to exercise. What’s the rationale for continuing in the face of this kind of evidence?
JH: I always joke in my office, “If I could just write a prescription for exercise, and you would actually follow it, I would do that.” I have actually written down on a piece of prescription paper specific cardio: “Monday, Wednesday, Friday” or “Tuesday, Thursday, Saturday—for forty minutes” to make it more official. It’s so much easier to go home and fill prescriptions and take the pills every day than to go outside for a walk, or run, or to get to the gym. I understand it’s challenging, and that’s why I spend time talking about it and enabling them and figuring out how to make it work for them.
A Universal Prescription for Stress
The Benefits of Exercise and Reducing Inflammation
Runners High: Endocannabinoid and Endorphins
JH: I’ll tell patients to get off the subway before their stop so they can walk. I also like my patients doing things like yoga. I went through a long phase of really enjoying running. I think it’s important just to find something you don’t resent. Optimally, it is something you actually enjoy that makes you feel good. I talk quite a bit in Moody Bitches about the cannabinoid system and how cannabis is an anti-inflammatory medicine. I also talk about how the endocannabinoid system floods your brain with cannabinoids when you’re doing moderate exercise. There’s a lot more research to suggest that the runner’s high is not endorphin based but is actually cannabinoid based.
My point is that exercise makes you feel good. It not only has anti-inflammatory properties, but it also helps to grow brain cells. Granted, antidepressants can help to grow brain cells, but you’re better off doing it with exercise. This idea that combining antidepressants and exercise will make you feel even worse than antidepressants alone is hard for me to accept, but it makes me more committed to using exercise as a way to help my patients get off their medicine, which is what I do. There are a few things that reliably make it easier for patients to get off their medicine. One of those things is cardiovascular exercise. If I turn someone into a runner, it’s much easier for them to taper their meds.
RLM: That’s very important. If you’re a runner, or let’s say an exerciser, Julie Holland is saying it’s easier to get off psychiatric medications.
The Two-Way Street of Stress and Inflammation
JH: There are a lot of things that you can do to feel better that don’t involve pills. I focus quite a bit on inflammation. Inflammation is the breeding ground for a lot of medical illnesses like arthritis, heart disease, cancer, diabetes, and Alzheimer’s. All the autoimmune diseases have a basis in inflammation. It turns out that depression, anxiety, and insomnia also have a basis in inflammation. Much of the advice in my book is really about an anti-inflammatory regimen—things that you can do to decrease chronic inflammation that will help your mood.
RLM: What about the reverse? What about the possibility that anxiety in and of itself is an irritant causing inflammation?
JH: That’s a good question, because we know that stress causes inflammation. Yes, it is a two-way street. Anything you can do to decrease stress is going to help to decrease inflammation. And anything you can do to decrease inflammation is going to help you with your mood, with your cognitive functioning, and with your sleep.