Psychopharmacology: the art of treating the synapse

When the guards escorted the young man out of the room you could hear the steel shackles slap against the linoleum tiles like a slinky. Methodically, he shuffled out, trussed up in a heavy leather straight jacket. He hadn’t said a word during the interview, which lasted all of fifteen minutes, at the most twenty.

The psychiatrist scribbled the medication orders on the young man’s chart and handed it to the orderly. Afterwards he carefully slipped the pen into the pocket of his white dress shirt under the lapel of his tweed sport coat, and the four of us exited past the heavy steel door with the small thick mesh-reinforced glass window. We passed through a series of check points and stepped out into the warmth of spring sunshine.

“That’s what I appreciate about you — about your approach to the patient,” the medical director was saying to the psychiatrist. “At least you make an attempt to talk to these kids before deciding to push up their meds. Your predecessor just wrote the orders. He didn’t seem all that interested.”

“You’ve got to document the rationale for making those adjustments,” the psychiatrist said, slipping a hand into the pocket of his trousers. “Still, many times you’re forced to push up the dose until you see some sort of clinical response.”

“As long as we avoid any violent outbursts,” the administrator said. “I like to have a nice clean calm operation around here.”

I tagged along behind them, relieved to be able to take in the fresh uninhibited air.

“So what’s your overall impression so far, young man?” the administrator asked me. “You think you might consider a position in the prison system?”

I coughed a non-committal answer.

“Give him a chance,” the medical director said. “He hasn’t seen the rest of the operation yet.”

I was certain that nothing I might see could induce me to consider taking a job as a physician assistant in this maximum security prison. This was back at the time when folks were complaining bitterly about the recent increase of the price of gasoline — it had just surged to 69 cents a gallon at the pump.

Eventually, I elected to pursue a career in pediatrics. I enjoyed interacting with children, fascinated by their growth and development. I had come to a point where I realized that if I wanted to have some sort of positive impact in the lives of other human beings, I probably needed to intervene in a meaningful way before their first birthday.

The field of child psychiatry has mushroomed over the span of my professional career. Thirty years ago psychopharmacology played a minor role in primary care. Since the turn of the 21st century, psychosocial issues have moved to the forefront in pediatric practice. Nowhere has this become more evident than in the surge of prescriptions written for psychoactive drugs in children. Experts estimate that at present nearly 3.5 million children regularly take some sort of prescription medication for a psychiatric condition.

Such statistics give one pause to reflect on the development of this phenomenon. Why have the last several generations of children born in the U.S. suddenly developed ADHD, anxiety, depression, and bipolar disorder in epidemic proportions? Has there been some sort of random genetic drift at work on the molecular level in this population? Or could it be that we are dealing with a medical paradigm shift — the way in which we consider what constitutes the origin of illness in human beings?

Over the past decade research has demonstrated a relationship between traumatic childhood experiences and the development of chronic illness in adults through behaviors like smoking, heavy drinking and overeating. We now know that early adverse events are capable of altering the chemistry of DNA in the brain. It may be that many chronic illnesses we see in the adult population — lung cancer, liver disease, diabetes, hypertension, heart disease, depression, substance abuse — are the direct result of a sort of generalized post-traumatic stress disorder in childhood.

It is one thing to consider a child from the standpoint of his behavior. Behavior can be shaped through the use of positive and negative reinforcement, something that parents and psychologists have known for decades (if not centuries). But when we view the behavior in the young child as the end result of neurotransmitters stimulating selected synapses in the brain, the treatment changes drastically.

In treating infectious disease, clinicians are taught to match the bug with the drug: isolate the causative organism and prescribe an antimicrobial that targets it. The drug kills the bug, and the patient is cured of the malady.

We have come to the point where behavioral issues in children are regarded as the result of biochemical imbalances in the brain. If the observed behaviors portend a relative deficiency in serotonin, a selective serotonin uptake inhibitor is prescribed. With our modern psychopharmacological armamentarium we can manipulate cerebral neurotransmitters at will — many times with fuzzy results, but we’re making progress. Designer drugs, ones tailored to target specific synapses, are in the pipeline. The day is swiftly approaching where we will be able to shape human action — perhaps even human thought — through psychoactive medications.

Whether that is desirable or not is another question entirely — one which we as a society need to think long and hard about. Over three million human brains in various stages of development have already been subjected to psychopharmacological manipulation, the long-term side effects of which are as yet unknown.