Biology, Antidepressants, and Psychotherapy

The history of psychiatric and psychological problems and disorders stretches far back into the past. Since ancient times, people who felt helpless in the face of mental health problems sought relief from sorcerers and shamans, attributing illnesses to supernatural forces. Indeed, even today, people may turn to supernatural forces whenever they feel helpless, inadequate, or out of control. Viewed in light of the knowledge available at the time, it may seem understandable that “mental illnesses,” a genuine mystery frequently encountered in everyday life, were approached using such strategies [1]. With the Enlightenment and subsequent scientific advances, the principle that decisions concerning mental health should be made by physicians rather than religious authorities gained acceptance in the 17th century. By the 19th century, descriptions of disorders began to resemble those used today. Even then, mental disorders were thought to result from degeneration in the brain. Subsequently, the great scientist Krepalin brought order to the complexity of psychiatric disorders by distinguishing two categories: psychosis and psychoneurosis. He described the condition we now call schizophrenia as “dementia praecox,” or early dementia. He also described the symptoms of what we now know as bipolar disorder. Then, in the 20th century, Charcot brought hypnosis to prominence in the treatment of mental disorders, while Freud introduced psychoanalysis and psychodynamic psychotherapies [1]. Psychotherapies now promised a fascinating new reality. Various problems, previously thought to belong to the soul and later to the brain, and attributed to disturbances in hormones and bodily secretions, could be resolved through talking! The discovery that an illness could improve through talking, and the application of this discovery with the support of scientific knowledge, marked a major development in human history.

After Freud, the work of behavioral and cognitive therapy practitioners, supported by well-designed experimental research, gave rise to Cognitive Behavioral Therapy (CBT), now the most extensively studied form of psychotherapy. We can pause this historical account here, as you can read about the development of CBT in detail elsewhere in this issue. We now know well that many psychiatric disorders, including depression, panic disorder, generalized anxiety disorder, phobias, obsessive-compulsive disorder, and similar conditions, can improve through “talking.” Talking therapies delivered by mental health professionals—physicians and psychologists—on the basis of scientific knowledge are an efficacious, effective, safe, and first-line option for many psychiatric disorders.

Today, both psychiatry and philosophy continue to investigate the origins of mental disorders. We know that various illnesses involve structural abnormalities and biological changes in the brain. Dementia, for example, is a condition associated with brain atrophy [2]. We also know that disorders such as schizophrenia and bipolar disorder are associated, at the cellular and intercellular levels, with various structural abnormalities involving substances collectively known as neurotransmitters, such as dopamine, noradrenaline, and serotonin, and the “gateways” that allow them to communicate with cells [3]. In addition, we know well that various mental disorders arise in connection with interpersonal communication and sociological factors. For example, a sudden, terrifying event that threatens a person's bodily integrity or involves a sexual threat can lead to a disorder characterized by sleep disturbances, loss of appetite, flashbacks (sudden, unwanted images), an exaggerated startle response, and negative thoughts [4]. What initiates this is not so much the brain's neurotransmitters or cellular gateways as the brain that directly experiences and interprets events, and our capacity to understand and interpret—the qualities that make us human [5]. Research has, of course, shown that people who experience prolonged post-traumatic stress disorder following trauma may also develop changes in brain structures and in the substances we call neurotransmitters [6]. In other words, the picture is somewhat more complicated than it appears. There is yet another issue that adds to this complexity. Research into other medical conditions has shown that treatment-resistant depression can also occur in association with, for example, anemia [7], various vitamin deficiencies [8], or thyroid disorders [9]. For “secondary” psychiatric symptoms caused by such “other medical conditions,” the solution is not primarily “psychotherapy” or “medication” from the psychiatric and psychological toolkit, but rather addressing the “other medical condition” first [1]. Unless the other medical condition is addressed, treatments from the psychiatric toolkit will encounter resistance. Another complication is that disorders such as schizophrenia and bipolar disorder often begin at a younger age. For example, the age of onset of schizophrenia is between 15 and 25 in men and between 25 and 35 in women [1]. We rarely see schizophrenia beginning for the first time at age 50 or 60. When schizophrenia-like symptoms appear at these ages, we need to consider other causes, such as a brain tumor or substance use, first. The treatment for a brain tumor, for example, is entirely different, and psychotherapy will not cure it. Of course, in younger people too, conditions that can directly alter the brain's structure, such as active substance use or a brain tumor, can cause schizophrenia-like symptoms such as hallucinations or delusions. In such cases, treatment may be compromised if the other cause is overlooked. All these considerations demonstrate how comprehensive an assessment is required to identify and treat psychiatric illnesses and disorders, and how important thoroughness is. If we overlook these considerations and begin psychotherapy or medication as soon as we encounter depression, without any assessment or diagnostic interview, we may miss the primary treatment target and lose valuable time. Psychiatric assessment is therefore crucial. For psychiatric disorders in which we know there is no “other medical condition” causing the presenting symptoms, there are currently two main treatment options. One is pharmacotherapy, or treatment with medication. The other is the great discovery of treatment through talking: psychotherapy… There are, of course, many other treatments that modern psychiatry actively and effectively uses for psychiatric disorders, although they are needed less frequently, including electroconvulsive therapy, transcranial magnetic stimulation, light therapy, and similar approaches. All these treatments have emerged from many years of experience and scientific research throughout the history of psychiatry outlined above.

Today, there are dozens of psychotherapy approaches with proven effectiveness for various disorders. The most extensively researched approaches, for which disorder-specific protocols are being developed, are Cognitive Behavioral Therapies, the subject of this issue. Cognitive Behavioral Therapy is an efficacious and effective approach for many psychiatric disorders and psychological complaints, ranging from depression and panic disorder to eating disorders and tobacco dependence [10]. Antidepressants, meanwhile, contrary to popular belief, are not addictive and are used efficaciously, effectively, and safely, with benefits emerging within a relatively short period, for many psychiatric disorders, including depression, generalized anxiety disorder, panic disorder, obsessive-compulsive disorder, and similar conditions [11]. Although we now know that psychotherapy has more lasting, long-term effects and offers the considerable advantage of helping people recover without medication side effects, antidepressants continue to be widely and safely used in psychiatry. Even though psychotherapy is now a highly developed and effective approach, if antidepressants were discovered for the first time today, this would still be tremendously good news for society. Antidepressants continue to be used safely in psychiatric treatment for people who lack access to therapy, have difficulty arranging or finding time for therapy, or have symptoms so severe that even active participation in therapy is difficult. We also recommend psychotherapy today for disorders such as schizophrenia and bipolar disorder, which, as discussed above, involve various structural abnormalities at the cellular and intercellular levels. Psychotherapies provide significant improvements in the secondary difficulties caused by conditions such as schizophrenia and bipolar disorder, in adjustment while coping with these illnesses, in various symptoms, and in quality of life. Nevertheless, when a psychiatrist recommends antipsychotic or mood-stabilizing medications developed for these disorders, these medications are not alternatives to psychotherapy. Rather, for these conditions, psychotherapy can be effective when used alongside medication.

Today, various self-help books based on the cognitive behavioral therapy approach have been developed for people who cannot find the time or opportunity to access psychotherapy or cannot make the necessary arrangements. These books aim to convey the knowledge of this approach much as it is shared in therapy. Books such as “İyi Hissetmek”, “Hayatı Yeniden Keşfedin”, and “Fark Et Düşün Hisset Yaşa”, which may be recommended to some patients who cannot access psychotherapy, whose symptoms are not severe, and who prefer not to take medication, present the scientific background and knowledge of this field to readers on an evidence-based foundation.

In conclusion, although these questions have not yet been fully resolved, research has provided us with considerable knowledge about the development and treatment of psychiatric disorders and syndromes. Medication and psychotherapy can be highly effective and beneficial for specific disorders. Following a detailed medical and physical assessment by a psychiatrist, the presenting syndrome is identified. Scientifically supported options likely to help with that disorder are usually reviewed together with the person seeking care, and a roadmap is developed for the most suitable treatment. When treatment is planned in this way, guided by science, many psychiatric symptoms can subside readily and within a short time, whether through medication prescribed by a psychiatrist or psychotherapy provided by psychiatrists and psychologists.

• Suggested Further Reading:
• Ruh Sağlığı ve Bozuklukları, Prof. Dr. M. Orhan Öztürk, Prof. Dr. Aylin Uluşahin
• Düşün Hisset Farket Yaşa, Prof Dr Hakan Türkçapar
• İyi Hissetmek, David D. Burns

References

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4. Scurfield RM. Post-trauma stress assessment and treatment: Overview and formulations. Trauma its wake study Treat post-traumatic Stress Disord. 1985;219–56.
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6. Onder G, Penninx BWJH, Cesari M, Bandinelli S, Lauretani F, Bartali B, et al. Anemia is associated with depression in older adults: results from the InCHIANTI study. Journals Gerontol Ser A Biol Sci Med Sci. 2005;60(9):1168–72.
7. Anglin RES, Samaan Z, Walter SD, McDonald SD. Vitamin D deficiency and depression in adults: systematic review and meta-analysis. Br J psychiatry. 2013;202(2):100–7.
8. Dayan CM, Panicker V. Hypothyroidism and depression. Eur Thyroid J. 2013;2(3):168–79.
9. Butler AC, Chapman JE, Forman EM, Beck AT. The empirical status of cognitive-behavioral therapy: a review of meta-analyses. Clin Psychol Rev. 2006;26(1):17–31.
10. Glenmullen J. The Antidepressant Solution: A Step-by-step Guide to Safely Overcoming Antidepressant Withdrawal, Dependence, and" addiction". Simon and Schuster; 2006.

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This article was first published in a 2020 issue of Bilim ve Ütopya.