Friday 18 February 2011

Why are psychiatric drugs dysphoric, demotivating and dumbing?


The antihistamine-derived family of psychiatric drugs all comes from roots in the dye industry (e.g. the dyes Methylene Blue and Summer Blue).

(e.g. E.F. Domino, History of modern psychopharmacology: a personal view with an emphasis on antidepressants, Psychosom Med 61 (1999), pp. 591–598.)


The anti-histamine family include the 'anti-histamines' themselves (chlorpheniramine - Piriton, or diphenhydramine - Benylin sedating version, or promethazine - Phenergan) and more importantly the three major best selling drug classes:

1. Neuroleptics/ Antipsychotics (chlorpromazine/ Thorazine/ Largactil was the first),

2. Tricyclic antidpressants (TCAs; imipramine was the first, amitryptaline/ Elavil the best-known),

3. Selective Serotonin-Reuptake Inhibitors (SSRIs; fluoxetine/ Prozac is the best known).


What strikes me about this anti-histamine family is that they are all broadly 'dysphoric' - that is they make a normal healthy person feel bad - or at least worse.

(Properly used they can, of course, reduce particular symptoms which are overwhelming - so that, for example, the emotion-blunting effect of SSRIs may be helpful for someone incapacitated by mood swings; nonetheless emotional blunting is intrinsically a dysphoric effect. In other words, in particular people, the dysphoric or demotivating effects may be 'a price worth paying' - but there is a price.)  


There is also a sense that the antihistamine group are 'dumb drugs' (probably via their anti-cholinergic action), and demotivating drugs (probably via their direct (antipsychotics) or indirect (SSRIs) effect on partially blocking the dopamine reward system.



(Lithium and the some of the anticonvulsants are broadly of this dysphoric, dumbing and demotivating drug type too, in terms of their effects - though sometimes - especially lithium - coming from different chemical families.)


SO - the most "popular", most widely-prescribed, most profitable family of psychiatric drugs are dysphoric, dumbing and demotivating.

(Although benzodiazepines were the most widely-prescribed and popular drugs for a while in the 1960s and early 1970s. A different era!)


This can be compared with a broadly euphoriant (happiness-inducing), stimulating (energizing, motivating), and 'smart' (in the sense of enhancing some valued psychological functions) group of (chemically diverse) psychoative, psychiatrically-useful drugs such as opiates, psychostimulants, alcohol, minor tranquillizers and nicotine.

Opiates were used to treat melacholic depression and other forms of misery; benzodiazepines to sedate, to reduce anxiety and to calm psychosis; psychostimulants (such as amphetamines) for minor depression (dysthymia) and to relieve psychological pain and exhaustion (e.g. in terminal care).


Alcohol (potentially benzodiazepines) is used to liberate creativity (e.g. among creative artists such as writers) and sociability. (Overall, in many societies, alcohol does vastly more harm than good - but it can do good.)

Nicotine is mostly a stimulant (working indirectly on the dopamine reward system) - like the psychostimulants-proper - providing energy, focus. Caffeine is another self-prescribed stimulant. As such, these drugs may have a significant positive function for individuals, and for society.


The popularity of the anti-histamine family in psychiatry (and the reciprocal neglect/ horror of the euphoriant grouping) is - I strongly suspect - precisely due to their dysphoriant and dumbing quality, which means they are very seldom 'abused'.

Because patients (in general) do not like taking the anti-histamine family of drugs, for the simple reason that they make them feel worse (and they already feel bad), this enables psychiatrists to distance themselves from a 'Doctor Feelgood' image of prescribing potentially-addictive agents.


And, of course, any euphoriant drug that makes you feel good will tend to be abused more often than drugs that make you feel worse.

But surely that is a feature not a bug?


The fact is that the psychiatric profession (influenced by Big Pharma) prefers to make people (en masse) into miserable, dumb zombies rather than risk addiction - even though they 'know' (sometimes - at any rate it is all there in the scientific research literature, for those who take the trouble to look and learn) that the miserable, dumb zombie drugs are just as dependence-producing as the addictive ones.

The anti-histamine group produce dependence - such that the chronic patient cannot stop taking them without suffering serious withdrawal effects (very serious, in the base of anti-psychotics: acute psychotic breakdown, or permanent tardive dyskinesia)


By contrast, top level creative work has been done on opiates, stimulants and alcohol (equivalent to minor tranquillizers, more or less) - so these would count as smart/ creative drugs, or at least potentially facilitators of smartness and creativity.

They are addictive, however, in some people; and the addiction often takes the obvious form of a craving for the euphoriant and stimulating effects.

But, used correctly, in slowly-absorbed and slowly-eliminated and less-potent forms, to treat psychological symptoms; most people do not get addicted.

And if people do become drug dependent on euphoriants, they are at least dependent on a drug which basically makes them feel better.


Because, by contrast, there have been and currently are legions of people (including increasing numbers of children) who are chemically-dependent on prescribed (sometime compulsorily administered) psychiatric drugs which make them miserable, dumb and demotivated - especially those many millions who are dependent on the anti-psychotics/ neuroleptics.

Get that: chemically dependent on prescribed drugs that make them miserable and dysfunctional.


In a rational world, and if patients/ the public were in control of their own treatment - it would be better (I think) to use euphoriant drugs as the basis for psychiatric treatment, rather than the antihistamine group.

If forced to choose, and assuming there was also access to electroconvulsive therapy (ECT/ shock therapy; which is the most effective treatment for serious psychosis including cataonia) - I would prefer to have the euphoriant agents available and used for myself and my family; and I would be prepared to forgo the dye-anti-histamine class - especially (as now) if they were grossly over-prescribed, and indeed forced-upon people by propaganda and psychological or physical coercion. 

What does this say about our society?

That we prescribe huge swathes of the population dysphoriant, dumb and demotivating drugs? 

Well, it says a lot about our underlying social motivation - about the kind of people that society wants us to be, is indeed increasingly forcing us to be ...



dearieme said...

You've lost me; what do you mean by "dumbing"? Are you writing for Yanks so that you mean making stupid, or for the rest of us and so meaning making silent?

Bruce Charlton said...

wrt 'dumbing' - I got this expression via Dave Pearce - it contrasts with performance-enhancing 'smart' drugs (the commonest of which is caffeine).

Many of the anti-histamine-derived family of drugs make people feel dull, drowsy and fuzzy-headed; impair memory; reduce concentration; impair perfomance on intellectual tasks - that kind of thing.

(This applies more to the neuroleptics and tricyclics than to SSRIs - but SSRIs probably have anti-cholinergic effects to a variable and milder extent in some people.)

In elderly people they often induce delirium (drowsiness, hallucinations, persecutory delusions etc) - which is probably an extreme version of what many people get from them.

Cholinergic drugs are given to people with Alzheimer's disease and Nicotine somewhat prevents Parkinson's disease (including Lewy Body dementia) - *anti*-cholinergics (such as most of the family of drugs derived from anti-histamines) presumably - in some broad sense - do the opposite.

The Great and Powerful Oz said...

I wish I had known this years ago. I tried a number of drugs when I was fighting depression. Most of them had wildly unexpected side effects and did really bad things to me. Zoloft left me mildly miserable all the time. AFter years of that, I quit and am now mildly angry most of the time. In today's society, anger is far more useful than misery.

The other thing I have learned is that there is no help for someone like me. The only thing I am good for in society is as a funding source.

The Crow said...

I realized some time ago that getting depressed was not a lot of fun to begin with, and wasn't much helped by the way anti-depressants made me feel.
I found an obscure and unlikely solution to this unpleasantness: I decided I would no longer allow myself to get depressed.
This novel approach must have changed my body chemistry, because, now I don't ever get depressed.
That's quite something, don't you think, in our modern age?

Bruce Charlton said...

The Crow

As I discuss in my psychiatry book a fair bot of depression involves interpreting physical symptoms as being 'my fault' - some depressed patients with 'malaise' are suffering essentially the same symptoms as the after affects of influenza, but 'blame themselves' for the lack of motivation, fatigue etc.

It is possible that you may have changed the way that you interpret your body and minds symptoms - so that although you may feel the same, you no longer feel the same about the way you feel...

The Crow said...

Your reply, BGC, did far better than any anti-depressant I have yet experienced: It made me laugh :)
Sorry to see you go.

Assistant Village Idiot said...

This is my field. You have apples, oranges, grapes and peaches in the same basket.

The SSRI's, and most other antidepressants, can indeed have this numbing effect. They can also induce mania, another hazardous side-effect. Being in such a state can be a temporary relief from abject depression, but over time people do often decide, as Oz did, that less feeling equals less humanness and abandon them in favor of the original condition. No problem there.

The original antipsychotics have long since gone out of use. There have been several generations of meds since then, chemically quite different. Even on the newer ones, patients do indeed complain of feeling "like a zombie" and want to go off them and feel more lively. But they also have no memory of how miserable they were, to themselves and others, when psychotic. They are only able to examine one side of the scales, yet think it is the whole.

Certainly, we will enforce the decision that you feel less-than-well and have memory of it over your previous situation of trying to kill people, which will get you locked up in bad places and truly miserable. Or of being in constant furious frustration at a world which will not believe there is a chip implanted in your head by the CIA. Where I work, those are the choices, not "oh, he's a bit eccentric" versus "he's miserable now."

True, there are some who are not miserable at all when psychotic and cause little inconvenience to society. So long as they can preserve life and not be dangerous, we let them.

ECT's are not used for psychotic disorders, but for affective ones. Catatonia, while it can present in psychotic disorders, is more usual in affective ones, which respond quite nicely to ECT's. For suicidal depression, make ECT's your new first choice. Some people find the side-effects intolerable and go elsewhere. But most who use it swear by it as having the least intrusion in their lives. Deep brain and vagus-nerve stimulation look even more promising, and over time, may even completely reset the depression mechanisms. (Once depressed, depression is "kindled" and you have an increased vulnerability.)

The "zombie" feeling is not very different from what cocaine addicts feel off the drug. Their impression of dysphoria is colored by their new normal of only feeling good when high. In minor form, such as you note for nicotine and caffeine, this is little problem. If folks like that better, so what. Not everyone has a Rake's Progress to misery.

But many do, and feelings of pleasure and heightened awareness at extreme levels are not sustainable. If you keep ratcheting up the level at which you subjectively feel okay, there is no end but disaster. Some don't ratchet. Fine. Most do.

I think you need to see the misery and relief at close quarters to really get this one. I have this discussion online or live quite often, and I suspect folks really don't believe how bad it can get. They see manics when they are in their pleasant, fun state, complaining about how those oppressive Others want to destroy their creativity. They don't see the misery for themselves and their families they create when the tipping point is passed.