tomorrow is World Mental Health DayAnd in many ways, it seems the world has made great strides in mental health care.
Only in 2023, the US National Institutes of Health (NIH) $1.25 billion poured in Research on how mental illness manifests in the brain. people are More psychiatric medications are prescribed Now more than ever, talking openly about depression, anxiety and ADHD is not only becoming less stigmatized — at least online, It’s almost quiet.
Despite having more access to medicine in the US than ever before, more 50,000 Americans died by suicide last year – Highest number ever recorded. The US Surgeon General has described mental health as “the defining public health crisis of our time,” but we’re much closer to understanding the neuroscience of mental health than we were 50 years ago.
This story first appeared in the Future Perfect Newsletter.
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Despite the popular framing of fundamentally caused mental illness Electrochemical imbalance in the brain, Accumulating evidence over the decades suggests that the truth is more complex. It’s neuroscience’s biggest open secret — psychiatric drugs often don’t work.
If drugs that alter chemical signals in the brain are able to silence auditory hallucinations and suicidal thoughts, then brain chemistry must explain mental illness, at least in part. But while drugs like antidepressants and antipsychotics make many people feel much better, they feel just the same or worse. (Prescribing the right drugs for the right condition is mostly a guesswork, and the wrong match can accidentally shoot someone into a manic episode, for example.)
The brain is one of the most complex machines in the universe, connected by 86 billion cells 100 trillion synapses. It took neuroscientists over four years to convince you how complicated it is Create a map of the brain of a single fruit flyThat only contains about 0.00003% of the neurons in a human brain – and as scientific an achievement as it was, it doesn’t even come close to fully explaining the behavior of a fly. Try to scale the project to different dimensions and the prospect of fully understanding the chemistry of the human brain seems downright impossible.
It may be that neuroscience has not had enough time to develop truly effective mental health therapies for most conditions. This is a relatively young field, and scientists have been able to get a good look at the activity of the living brain for decades. The need for breakthrough psychiatry may be just around the corner.
But it’s also possible that some of the best mental health care lies outside Western psychiatry entirely.
Maybe two things can be true at once.
Psychiatrists no longer believe that chemical imbalances cause mental illness. Why do we?
For thousands of years, mental illness could only be explained by Supernatural powers or moral deviance. In Enlightenment Europe and its colonies, people with mental illness were largely Confined to shelter — later rebranded as “psychiatric hospital” — up Until the 1950s.
In the early 20th century, Sigmund Freud and his colleagues gained popularity Psychotherapywhich helped (And help continues) people navigate disorders like depression and anxiety. But initially there were doctors in the asylum Reluctant to accept itMental health prefers a “somatic” approach to care that stimulates the body and nervous system to change the mind.
Leading physicians once believed that disorders such as schizophrenia were caused by a Passive “vegetative” nervous systemAn old term for the parts of the brain that control basic life-sustaining functions such as digestion and breathing. Early psychiatric treatments were designed to deliver shocks large enough to the brain — whatever electricity, An intentional malaria infectionor Coma-inducing drugs — to kickstart these supposedly inactive processes. Psychiatrists who invented malaria treatments — using the malaria virus to induce high fever, hopefully killing the neurosyphilis-causing bacteria — and prefrontal lobotomy Both won the Nobel Prize in Medicine When political asylum was common in Europe.
Over time, however, physicians began to recognize that their somatic treatments were not working very well. This, combined with the observation that when mentally ill brains were autopsied there seemed to be nothing visibly wrong with them, began to push physical therapy out of fashion.
Everything changed in 1952, when Paris surgeon Henri Labritt Accidentally discovered that chlorpromazineAn antihistamine that he used to make anesthesia less dangerous for his patients was also a powerful antipsychotic. When chlorpromazine entered the market in 1954, it Altered psychiatry choice Discovery of insulin modified diabetes. Suddenly, people who had been chronically restrained in mental hospitals could have quiet conversations with their psychiatrists. within a year, Public psychiatric hospitals are beginning to close in the United States Policymakers hoped that new drugs would make institutionalization obsolete.
For years, no one knew how drugs like chlorpromazine worked, only that they did, albeit unpleasantly. side effects Such as drowsiness, weight gain, and uncontrolled muscle spasms. Neuroscientists later discovered that antipsychotics like chlorpromazine bind to a specific type of dopamine receptor in the brain, identifying the neurochemical dopamine — specifically, too much of it — as the biological root of schizophrenia.
The idea that a chemical imbalance could change someone’s thoughts, feelings, and behavior quickly spread throughout psychiatry. Selective serotonin reuptake inhibitors (SSRIs) such as Prozac, widely used antidepressants Introduced in 1980Blocks neurons from reabsorbing the remaining serotonin after sending a chemical signal. In theory, if a lack of serotonin contributes to depression, then having more serotonin molecules should make people happier.
about Half of people who take SSRIs Feel better after a couple of months. However, antidepressant researcher Dr. Alan Fraser told NPR“I don’t think there’s any convincing data that anyone has ever found that depression is significantly associated with loss of serotonin.”
Pinning schizophrenia solely on dopamine is similarly oversimplified and old-fashioned. Today, researchers believe that many neurotransmitters—on top of other genetic, social, and environmental factors—influence someone’s likelihood of mental illness.
While dopamine- and serotonin-related self-help videos are making the rounds on TikTok, neuroscientists and psychiatrists The voice is skeptical The “chemical imbalance” trope has been around for decades. Electrochemical interactions, to the extent that scientists are able to understand them, cannot fully explain — or more importantly, treat — mental illness.
The future of mental health doesn’t just belong to neuroscience
Thinking of mental illness as something that medication can fix gives people “a way to establish their suffering as real and unmanageable, and it provides an easy account and positive prognosis for their struggle,” the sociology professor said. Joseph Davis wrote for Psyche. If a person claims their mental illness is an out-of-control disease like cancer Others may be more likely to see them as human Deserving of respect and opportunity.
Two weeks ago, the United States Food and Drug Administration A new antipsychotic drug is approved It does not target dopamine receptors – a first since chlorpromazine was first introduced. The new drug, Cobenfy, instead targets acetylcholine, a neurotransmitter that is not significantly dopamine, but can indirectly affect dopamine levels.
Cobenfy was enough to headline the first new option presented in 70 years. But whether it actually works better than existing alternatives remains to be seen: None of the drug’s three clinical trials can say whether Cobenfy will cause the same long-term side effects — dramatic weight gain, repetitive body movements — as its predecessors.
Cobenfy’s introduction to the role of neuroscience in treating mental illness highlights much that is troubling — and what is promising. Of course, a new pharmaceutical treatment can relieve the worst symptoms of schizophrenia with fewer side effects than before. But introducing a new drug may not completely eradicate the condition or fundamentally change how people navigate psychosis.
The next strategy—to radically rethink how communities care for people with even the most severe mental illnesses—is Recommended by the World Health Organization. In many cultures, mental health problems are not considered biomedical problems, so people generally do not seek out things like medication. Community-based mental health care, in which lightly trained laypeople facilitate therapy sessions in their own neighborhoods, can work alongside formal mental care with or without medication in many settings.
Although community-based models are often discussed in the context of non-psychotic mental illnesses such as depression, there may be alternatives outside of psychiatry. Help people with more severe depressiontoo. Anti-carceral care strategist and crisis responder Stephanie Kaufman-Mthimkhulu believes Whether the root cause of psychosis is ultimately an ancestral spirit, childhood trauma, post-viral inflammation or a subtle change in neurochemistry, “it’s important to give people multiple ways to define and understand our experiences.”
Neuroscience can only take us so far. At some point, we have to embrace our desire to find value in emotional states outside of ourselves.
