Just Say No

Cases of violence involving unmedicated people with psychotic diagnoses get a lot of media attention. In 2003, Elli Perkins of Buffalo was murdered by her son, who doctors later deemed schizophrenic. Perkins and her husband were Scientologists, opposed to psychiatric drugs and psychiatry in general. Last September, Virginia psychiatrist Wayne Fenton was killed by a young patient who was off medication after being diagnosed bipolar.

Dr. Josh Israel is very concerned on a daily basis about the possibility of these kinds of incidents. His office at the San Francisco VA Medical Center is adjacent to the locked psychiatric intensive care unit he directs. Veterans come in hallucinating or paranoid; they may have just assaulted a police officer, or been found wandering naked at the airport. He tries to get them on or back on medication. Usually they agree; sometimes it takes a court order. Electro-convulsive therapy is a voluntary treatment he offers the more severe sufferers, and many try it.

There are a lot of thick psychiatry books on his office shelves, and Israel wistfully gestures toward them when acknowledging how little we still know about how the brain works. "Looking at those, you'd think we'd know a lot more than we really do," he says. How psychosis affects the brain long-term, and even how treatments like medication, ECT, therapy, or alternative medicine ultimately alter brain structure for better or worse — these realms are still quite mysterious. The short-term is easier to understand, Israel says.

Dr. Israel has seen people who've done destructive things to themselves. "They've cut off digits, or testicles. There are people who have literally burned down their own homes. Things like that are not the inevitable result of not taking psychiatric medications, but no one — well, maybe not no one, but I would say it would be extremely rare to do those kinds of things on medication."

UCSF psychiatrist Sophia Vinogradov also works at the VA campus. She sees severely disturbed individuals unable to get help from other doctors. About 85 percent of her patients use prescribed medication in combination with behavioral therapy.

"With a very severe psychiatric illness, it's like having a cancer in your brain," Vinogradov says. "So sometimes you have to think about the medications a little bit like chemotherapy. They're crappy to take, but at least they're going to stop things from getting worse."

To those who study and work with the brain in mainstream psychiatry, it's not that Morrissey's diagram is far-fetched or nonsensical. It's just that more of the conventionally accepted science shows that meds are a better bet for alleviating psychosis than therapies alone.

Psychiatric drugs contain molecules that fix onto specific receptors in the brain and either block or enhance the actions of certain brain chemicals, thereby modifying how affected neuronal pathways work. For many, this reduces symptoms like hallucination and delusion. Vinogradov says non-medication-based approaches — psychotherapy, exercise, spending time with friends and family, meditation, learning new skills — can all alter brain pathways as well. But far less is known about how this occurs, she says, other than that it is somehow related to the brain's plasticity — its ability to constantly remodel itself as it collects new information and experience.

Vinogradov notes that psychiatrists who work on an insurance reimbursement basis often only get paid for 15 minutes with a patient, and must relieve their symptoms in the span of something like 12 such appointments or risk not getting paid for additional visits. She says this incentivizes treatment by quick-fix prescription rather than costly psychotherapy or other alternative approaches.

She has her own questions about the long-term viability of psychiatric medications, especially as a stand-alone treatment, and is researching behavioral methods for alleviating symptoms of schizophrenia. But with a lack of sufficient resources for mental health, Vinogradov says medications are still a very important part of treatment.