To my surprise and delight, I received a response today to the questions I emailed about two weeks ago to Dr. Douglas Romero, an expert in psychiatry and psychopharmacology from the Centro de Mejoramiento Personal (Center for Personal Improvement) in San Juan, Puerto Rico. I was about to give up on hearing back from him, but it turns out the reason he took so long to respond was because he apparently took the time necessary to write an extremely thorough, thoughtful response to each of my questions. (This is a man who, like most doctors, has very little free time, and yet he generously gave up a lot of his to help me and all of you understand how psych meds work.) Because he did such an excellent job, I’m not going to summarize what he had to say; instead, here is his insight in his own words.
Dr. Romero responded to questions I had that were provoked by this article from the New Yorker, which makes the claim that science does not yet know exactly how or why psychiatric medications work in terms of what goes on in the brain. Dr. Romero’s answers shed light on this issue, and this article from the MIT Technology Review gave me hope that science is headed in the right direction.
Me: Is it true that scientists still don’t know exactly why or how psychiatric medications work?
Dr. Romero: It is true that the neurosciences and psychiatry have yet a lot to understand about the brain, both in its normal and diseased states. However, in the last few decades neuroscientists have mapped the major anatomical and functional areas of the brain. Every decade brings better understanding of the human body and its brain.
Take for example the dopamine theory of schizophrenia. The theory was developed on the observation that hallucinogens increase dopamine and cause hallucinations. Medicines that increase dopamine in the brain, like those for Parkinson’s disease, can cause hallucinations and paranoia. So we know that can be a factor. That knowledge is the basis for anti-psychotic medications, which block dopamine in the brain, and can be very effective for the treatment of paranoia and hallucinations in people with schizophrenia.
As we become more sophisticated on our knowledge of the brain we will continue to develop better pharmacologic therapies. But no sane person in the field of psychiatry or neurosciences would claim that we completely understand the brain, the most complex system known to science.
Me: What progress is being made towards discovering this information?
Dr. Romero: Our biggest challenges lies in understanding better how the brain works, even in a normal state. We know the basics, and in some cases we have pretty solid information a=on how the brain processes information (the visual cortex has been mapped extensively). But having a good understanding of something is not equal to understanding it completely.
Understanding the brain is compounded by the fact that psychiatry intersects with what has been called the Hard Problem, the how and why we have experiences. So psychiatry attempts to understand the brain, the mind, genetics, and how we might be able to help people when they go wrong.
Diverse academic institutions continue mapping the brain through technologies such as functional MRI, SPECT, and PET scanning. Those are expensive machines that are limited resources not available to the average clinician. That’s the reason a psychiatrist doesn’t order those tests on a regular basis. Our ability to map brain function on a live brain is something very recent.
The National Institute of Health continues to do basic research on how that knowledge correlates with people with brain disorders like depression. From that research, new medicines will hopefully emerge that work better than the ones before them.
Me: What are the current prevailing theories on how psychiatric medications work?
Dr. Romero: The prevailing theory of the brain is that it is a neural network of interconnected areas, frequently specialized, which configuration allows a person to experience the world and change the environment. Various biochemical process must align in a coherent pattern for the functional brain to work. Over the years, several biochemicals and brain areas have been identified that appear to correlate with diseased states of the brain.
The serotonin-dopamine-norepinephrine theory of mood disorders do a good job of explaining our current understanding of what goes wrong in the brain when someone is depressed. Recent research is exploring the role of inflammation and other neurotransmitters in brain dysfunction. Theories of dopamine in the brain provide reasonable explanation for the salient aspects of schizophrenia and manic episodes. Part of the reason the field of psychiatry has such a hard time explaining to the public how the brain is affected in psychiatric illnesses is that these are very complex systems that are difficult to understand, even with advanced knowledge of human anatomy and physiology. Just ask any first year medical student if neuroanatomy is easy and you will get very emotive responses.
Yet clinicians every day, including primary care physicians who don’t specialize in the brain, have to treat people who are severely mentally ill and offer them a cursory explanation of what is going wrong in their bodies.
Me: Can you explain in layman’s terms how you understand psychiatric medications to work?
Dr. Romero: The explanation I give my patients is that medications for depression, say Prozac, get into the brain and regulate certain areas that are affected by increasing the level of serotonin in the brain. It is a limited explanation but true at a basic level.
Each medication has its peculiarities, and even though we know a lot about them, there is still a lot more we would like to know. For example, we don’t know exactly how lithium curbs manic episodes. We how it affects how neurons communicate and affect the transport of sodium into neurons, which affect the electric conduction of brain cells. But there is still much we need to know. Yet, lithium is the gold standard for the treatment of bipolar disorder.
Medicine is a practical field. I tend to think of medicine as art guided by science. We tend to use what works. And every generation tends to chuckle at what we did a hundred years ago, but at that time that was what we knew. It is always useful to remember that medicine used aspirin for almost a hundred years before we knew how it worked. But worked it did. Every year we know more than the year before.
Every good scientist, physicians included, should question the established theories and paradigm of their field. Psychiatry is no different. That is the way knowledge advances.
Me: What advice would you give someone who is “on the fence” about taking psychiatric medication that has been prescribed for them?
Dr. Romero: I would recommend the person have a discussion with his or her physician about the use of medication, explore alternatives to medication, and get a second opinion if in doubt. For some patients a course of psychotherapy can be a good idea, and the need for medication can be reassessed depending on how well that works for them. Having a supportive health care provider who is willing to address your concerns and is sensitive to your needs is always of great importance. Usually someone who is “on the fence” has valid concerns which the clinician must address in order for that person to understand the potential benefits and risks of taking medication and make an informed decision.