Today, I have the honor of publishing a piece by Professor Edward Shorter, PhD, FRSC.

Is Lithium the Drug of Choice for Bipolar Disorder?

It is encouraging to see this excellent Psychology Today piece on the safety and efficacy of lithium in the treatment of bipolar disorder.  Indeed, lithium might be considered the drug of choice in all mood disorders, because they all seem to be part of the same package — a package that German psychiatrist Emil Kraepelin labeled “manic-depressive insanity.”  And if lithium works for one piece of the package, there is no reason to think it might not be effective for other pieces, as well.

Good News and Bad News About Lithium

So, that is the good news: lithium is probably the most effective drug that psychiatry has on offer.

The bad news is that psychiatry, in failing to acknowledge the superiority of past agents over current widely prescribed remedies, has not yet realized its full scientific potential.  The reality is that psychiatrists often act more as sales reps for the pharmaceutical industry than as independent scientists with well-weighed judgment backed by incontrovertible evidence.

Psychiatrists all have MDs.  They have, in theory, been trained to abide by scientific rather than commercial guidelines.  Yet time and again we find them backing away from the agent of choice in order to prescribe the agent that industry has flogged most vigorously.

Clinicians often back away from lithium, in particular, with much pseudo-deliberative brow-wrinkling about “side effects.”  Good thing that Prozac and Paxil have no side effects (joke).  Doctor, just try to get your patient off Paxil.  One side effect is that it’s close to being addictive for those who abuse it.

Misunderstanding Electroconvulsive Therapy (ECT)

In electroconvulsive therapy (ECT), we see very clearly this backing away from science. Introduced in 1938,  ECT is probably the best studied treatment in psychiatry.  A ton of evidence confirms its relative safety and high effectiveness.  Yet many clinicians fail to recommend patients with serious depression, mania, and catatonia for ECT on the grounds, you know, of supposed “side effects.”

Much pseudo-deliberative brow-wrinkling,  “You’re a teacher.  Can’t take any chances with your memory.”  The patient then commits suicide because a combination of Prozac and an antipsychotic has failed to break up his deep melancholia.  Some while ago, this happened to one of my colleagues.  I remember sitting down and drinking coffee with him.

“ECT?”

“No, I can’t take any chances with my memory.”

Three weeks later, he was dead.

How Ignorance Hurts Patients

Often, psychiatrists may tentatively propose ECT, then back away from it as patients, having seen “One Flew Over the Cuckoo’s Nest,” turn it down in ignorance.  Doctor, your job is to educate and guide your patients, not to give them options on a checklist.

The bottom line is this. Psychiatry is still struggling to clamber over the threshold of science.  And all this chatter about neurotransmitters is unhelpful, really just a fig leaf for ignorance about how drugs work.  There is nothing wrong with ignorance.  It is present in every field of medicine. It includes stuff we don’t yet know that we are trying to find out.

But to tell patients that their depression is caused by a shortage of serotonin is not science.  It is carnival-barking.

 

About the Author, Dr. Edward Shorter

A Harvard-trained social historian, Dr. Edward Shorter has held the Hannah Professorship in the History of Medicine at the University of Toronto’s Faculty of Medicine since 1991.  In 1996, he was cross-appointed as Professor of Psychiatry in recognition of his rising profile as a historian of psychiatry.  He is the author of numerous books on the evolution of the discipline, including A History of Psychiatry (1997);  Before Prozac (2009); How Everyone Became Depressed (2013); and What Psychiatry Left Out of the DSM-5 (2015). He is also the author of Stormy’s World: Inside Porn (2019). You can visit him on online at www.edwardshorterauthor.com or on Twitter: @DrEdwardShorter.