The Role of Pills in Mental Health

A standard strategy, when we are physically unwell, is to head to the doctor, take a pill and then expect, in a short while, to feel a lot better. This recourse is so established, so practical and generally so successful, it is only natural if we were to try to replicate it in the mental field. Here too, when we are feeling ill, we may want to visit a doctor, take a pill and wait for our symptoms to disperse.

For most of the history of humanity, there was – aside from obviously fraudulent concoctions – nothing at all one could swallow when one was mentally afflicted. The full force of one’s sickness had to run unchecked; there would be uncontained sobbing, violence and despondency. It was said that the screams of the inmates of London’s Bethlem Royal Hospital, more popularly known as Bedlam, had the power to curdle the blood of listeners a mile away. There seemed little to do with mental sufferers other than place them in cells, tie them in chains and do one’s best to forget they existed.

Then, in 1950, Paul Charpentier, a French chemist working at Laboratoires Rhône-Poulenc, succeeded in synthesising a drug called 4560RP, later renamed chlorpromazine. When rats were injected with it, placed in a crowded cage and convulsed with electric shocks, they showed none of the expected alarm and frenzy, settling instead into a serene and indifferent mood. When given to humans, the drug had a similarly calming effect: American soldiers in the Korean war were able to walk into the battlefield with a fearlessness close to apathy. In hospitals, psychotic patients who were placed on the drug became sociable, unaggressive and ready to rejoin ordinary life. The world’s first antipsychotic drug was born. It would over the coming decades be followed by dozens more seemingly miraculous medicines, all of them playing – in ways that their creators did not and still do not entirely understand – with the brain’s receptors for dopamine, the hormone held to be responsible for excessive excitement and fear. Alongside these antipsychotics, there emerged a family of antidepressants, in particular those known as SSRIs, that could increase the brain’s levels of serotonin, the neurotransmitter and hormone associated with uplift, motivation and positive moods. The drugs were baptised with names that put language to ever more daunting uses: fluoxetine, citalopram, paroxetine, escitalopram, risperidone, quetiapine, aripiprazole. Whatever the particularities of each example, modern psychiatry ended up operating with two essential instruments: pills that could calm us down (reducing terror, paranoia, mania, disinhibition, insomnia and aggression) and pills that could lift us up (alleviating despair, moroseness and loss of meaning).

Thanks to these medicines, occupancy rates of psychiatric hospitals plummeted, decreasing by an estimated 80% in developed countries between 1955 and 1990. Illnesses that had been a near-death sentence a generation before could now be managed by swallowing one or two pills a day. It looked as if our unruly minds had finally been brought under control.

But these medicines did not meet with universal approval. All of them turned out to have serious physical side effects (being intermittently responsible for dramatic weight gain, diabetes, kidney malfunction and blood clots). However, the charge against them at a psychological level was more fundamental: that they did not and could never – on the basis of their approach – get to grips with the true causes of mental illness. At best, they could control certain appalling symptoms yet they were unable to grapple with what had led to them in the first place.

To be fair to psychiatry, even if this were true, it is no mean feat to be able to offer a person even a measure of control over their mental symptoms, given the horrors these tend to entail. Those of us who have known mental illness from close up would – at the height of our suffering – generally choose to be physically tortured rather than endure yet more of the abominations our minds can inflict on us. There are varieties of mental unwellness in which we are taken over by anxiety and foreboding – and paralysed by a sense that every minute is carrying us closer to an immense and unnameable catastrophe. We can no longer eat or speak, we may just have to lie in a ball crying, scratching ourselves and waiting for the axe to fall. There are states in which we wake up every morning with a conviction that we need to take an overdose in order to put to an end to the turmoil in our minds. There can be voices inside us that do not for one moment cease telling us that we are guilty, shameful and abhorrent beings. We may live in terror that we are about lose control or might already have done so. Our imaginations can be haunted by images of stabbing a child or tearing off our own finger nails. It can feel as if there is a monster inside us urging us to do appalling deeds and filling our consciousness with lacerating persecutory thoughts. We may feel our inner coherence dissolving and giving way to a maelstrom of aggression and paranoia. We may be so mysteriously sad that no pleasantry or act of kindness can distract us and all we wish to do is stare mutely out of the window and hope to be gone soon.

With the right pills to hand however, some of these nightmares can end. We may know our anxiety is still there but we are granted some distance from it, able to stare at it as if it were an enraged tiger in a zoo on the other side of a thick pane of glass. We may not lose sight of our despair and self-loathing but we can acquire an attitude of detachment in relation to it; it doesn’t matter quite so much that we are entirely awful and should be put down. We can park the idea for a morning in order to do some work or clean the house. We can put off thoughts of suicide until tomorrow. We don’t need to have a complete reckoning with our sadistic ideas at every moment. The crushing sadness can partially lift and we might have the energy for a conversation with a friend or a walk in the park. Only someone who hadn’t endured vicious mental suffering would dare to casually dismiss such psychiatric interventions as a mere plaster over a wound.

Nevertheless, most mental illness has a psychological history – and its hold on us will for the most part only properly weaken the more episodes of this painful history we can start to feel and make sense of. Pills may be able to change the background atmosphere of our minds, but our thoughts about ourselves need to be challenged and adjusted with conscious instruments if we are to get truly well. The genuine resolution of mental disturbance lies in our ability to think – think especially of our early childhoods and the key figures and events within it.

The unfortunate paradox is that illnesses of the mind generally effect precisely the instrument that we require in order to interpret our lives. It is our conscious reason that is both sick and desperately needed to do battle with despair and fear; it is reason that we need to locate persuasive grounds to keep living. This is where pills may usefully join up with psychotherapy to deliver a coherent solution. We might say that the supreme role of pills is to hold back panic and sadness just long enough that we can start to identify why we might want to continue living; they aren’t in themselves the cure, but they are at points the essential tools that can make therapy, and through it authentic healing, possible. They promise our minds the rest and safety they require to harness their own strengths.