Friday, April 20, 2018

Book Review: “Blue Dreams: The Science and the Story of the Drugs That Changed Our Minds” by Lauren Slater

Lauren Slater is a practicing psychologist and writer. As a psychologist, she cannot, and does not want, prescribing privileges, but she knows a tremendous amount about the drugs psychiatrists have used and now use in their practices, due to both her research and her personal experience with some of these drugs. She has suffered from severe depression, which at times has resulted in hospitalization, and the drugs she has been prescribed have helped but with a significant toll on her body. When she started taking Prozac, it helped, but over time she had to take increasing amounts to achieve the same effect. She is now on a cocktail of other drugs. She says that the pills she has taken and is currently taking have ruined her physical health, making her overweight and diabetic, but she would not have been able to have a productive life without them. She is hopeful that new approaches, some involving hallucinogenic drugs popular in the counterculture of the 1960s, may prove to be better treatments, but the new approaches will not, she has been told, work for her because of the drugs she is currently taking and dares not quit.
In February, I attended her book talk at a Washington, DC bookstore, Politics and Prose. (The video of this talk can be viewed here.) The talk took the form of an interview by Olga Khazan, a writer for The Atlantic. I found what she had to say interesting and was motivated to read the book, Blue Dreams: The Science and the Story of the Drugs That Changed Our Minds.
Blue Dreams is very well written, and, even though I found myself having to look up more words than I usually do, mostly technical terms, the book is entertaining to read. She weaves her own personal story with the history of various psychiatric drugs, beginning with Thorazine. All the drugs had promise, but they all came with severe side effects. 
One of Slater’s main points is that the medical community does not know how or why these drugs work. For example, the selective serotonin reuptake inhibitors (“SSRIs”, such as Prozac. Paxil, and Zoloft) were promoted to cure low serotonin levels, which was said to lead to depression. However, Slater notes that there is no correlation between serotonin levels and depression. Depressed patients can have lower, average, or higher levels of serotonin than average, as can the non-depressed. To the extent that SSRIs work better than placebos, and this is a subject of debate, something else is going on.
Slater points out that the analogy that doctors give their patients when prescribing antidepressants, that it is similar to taking a medication to cure some physical ailment, is all wrong. There is no blood test or other objective test one can administer to detect depression or to determine what is causing it. Perhaps it is reassuring to some to hear that depression is due to a chemical imbalance rather than something else, particularly because of the stigma depression has had, which in recent years seems to have been diminishing somewhat. The truth is that, when doctors prescribe these drugs, they are guessing, and if the first prescription does not work, they guess again.
Another point Slater makes is that with the heralded introduction of Prozac, depression has been on the increase. Of course, it is not clear whether that is due to more reporting of depression or because of other factors, such as a decline of community institutions and increased loneliness in the U.S. What is clear is that current drug treatments for depression do not work for everybody, their long-term use comes with physical costs that have not been fully studied, and the mechanism by which they help some is not understood. 
While the book is interesting and the author makes valid points, there are some weaknesses. Though much of the book is about depression, the discussion is wide ranging to include other mental ailments, which prevent normal functioning and can necessitate institutionalization. And depression, as the author at times states, is not one disease but a symptom which can arise from different causes. Also, there is dysthymia, or mild depression, making for people who are often unhappy but can function normally, and more severe, or major, depression, which affects the ability to deal with the necessities of daily life. These are not the same thing and probably should not be lumped together, even if some psychiatrists think these symptoms fall on a continuum. The author also discusses some non-drug treatments, such as deep brain stimulation. The wide range of topics is interesting, but it dilutes the focus of the book, making it more difficult to tease out the argument she is making. Nevertheless, the book is well-worth reading for those interested in the subject. The author writes well, conveys a great deal of information in an accessible way, and is very good storyteller. 
One comes away concluding from reading this book that antidepressants are over-prescribed. Dysthymia or general malaise may be a reaction to objective conditions of life, and, while we do not know why some people have much stronger reactions than others to bad situations, drugs are often not the answer, especially after considering their physical costs and potential for addiction,  as well as their possible benefits. The other main message delivered at the end of the book is the author’s optimism about progress in psychiatric research. She sees great potential in psychedelic drugs, whether old ones or newly discovered. I have no way of knowing whether that optimism is justified, but, while these powerful drugs may be useful for certain conditions, I doubt that such treatment will achieve the popularity of SSRIs or benefit many of those taking SSRIs for mild depression. That is perhaps just as well, since powerful drugs and other interventions, such as electroconvulsive therapy, should probably be used sparingly.