Drugs: Yes or No? Rethinking Mental Health Beyond Pills

Catalonia doubled the number of antidepressant prescriptions from 2020 to 2023. In the case of children under fifteen, it tripled. And the use of anti-anxiety drugs is rampant in the country. Has this significant increase in psychotropic drug use translated into Catalans suffering less depression and anxiety? Well, it seems not: more than a third of the population suffered from some mental health problem in 2023, according to data from the Spanish National Health System.

In this context, there is growing awareness, both among those who take these medications and among researchers, that psychotropic drugs are not always effective for everyone or in all contexts.

Part of the problem lies in how these drugs were discovered. "Many were designed under fairly limited disease models, such as chemical imbalance. They've been useful, but disorders aren't explained solely by low serotonin levels. We also need to consider life experiences, trauma, or social and psychological context," says Elisabet Domínguez, a psychologist and doctor of pharmacology at the Hospital de la Hospital de la Hospital de la Hospital de la Hospital.

The popular Prozac

If one drug epitomizes this issue, it's the antidepressant Prozac. Launched in the 1990s with one of the most effective marketing campaigns in history, its antidepressant effect was interpreted as rebalancing a serotonin deficiency, which was assumed to be the cause of depression. In other words, the chicken came before the egg. However, it reduced the side effects of previous antidepressants. From this derives an entire biological hypothesis to explain mental disorders, which has still not been proven, but which has perpetuated the use of psychotropic drugs to adjust supposed chemical imbalances in the brain.

If the cause and brain mechanisms are unclear, the systematic use of medication falters. Jordi Marfà, a psychiatrist with almost fifty years of experience, has experienced this firsthand: "Every psychiatrist has their own way of doing things and their own experience. What works for one may not work for another. We act entirely empirically, and sometimes you find surprising things." For example, antidepressants are already used to treat anxiety, insomnia, anorexia and bulimia, obsessive-compulsive disorder, post-traumatic stress disorder, chronic pain, childhood bedwetting, and even migraines.

Psychedelics as an alternative

"Given this situation, there are two complementary paths: reviewing the role of psychotropic drugs in therapeutic strategies or opening up to other possibilities, such as substances with a long history, like psychedelics," says Domínguez, who advocates for the latter. In fact, he focuses part of his research on studying the therapeutic potential of ayahuasca. The idea is not new: indigenous communities in the Amazon have consumed this beverage, made from a vine and a shrub, for healing and spiritual purposes for centuries.

Current research suggests that ayahuasca can reduce symptoms of depression, anxiety, and post-traumatic stress, decrease emotional arousal, and even help with substance addiction. Domínguez's group has found that it also improves emotional dysregulation and promotes acceptance and self-compassion.

In addition to Amazonian plants, there are other drugs. In Catalonia, the San Juan de Dios Health Park has three clinical trials underway to treat drug-resistant depression with psychedelics such as psilocybin, found in some mushrooms, and 5-MeO-DMT, found in the venom of a Sonoran Desert toad. Similarly, the San Juan Hospital in Reus and the ICEERS Foundation published positive preliminary results in a trial using ibogaine, a psychedelic from an African shrub, to help patients with methadone dependence. Some substances have already crossed the legal barrier.

Esketamine, a drug chemically similar to ketamine, can be used in Europe and the United States to treat drug-resistant depression. Catalan hospitals such as Bellvitge and Parc Taulí have already incorporated it.

"Psychedelics operate episodically and experientially. At specific moments, they facilitate a mental state that can unlock rigid patterns or thoughts and allow access to blocked memories. They work more on the experience than on the chemistry," says Domínguez. These substances seem to promote neurological and cognitive flexibility. Illegal doesn't necessarily mean dangerous: some psychedelics have a reasonably good safety profile in controlled contexts, which is not the case with recreational use.

"They've been demonized for decades for unscientific reasons. In the 1970s, they were classified as drugs with no therapeutic value. In the last fifteen years, we've experienced a scientific renaissance," the researcher adds. "What we're looking for is to expand our tools, especially for those for whom conventional treatments haven't worked."

This interest in updating the catalog of psychotropic drugs from the world of hallucinogens is reflected in entities such as the Spanish Society of Psychedelic Medicine, of which Domínguez is a member, and the European initiative Psychedelicare, with Domínguez as coordinator of the Spanish node.

Rethinking strategies

But Marfà is committed to reducing dependence on current medications. "The minimum indispensable dose, if necessary and if possible. Because sometimes it's not necessary to medicate," he says. He points out the fear many psychiatrists have about reducing medication, especially those from the "old school." In his opinion, younger psychiatrists are already beginning to consider reducing doses or the duration of treatment.

One of the reasons for rethinking psychopharmacological strategies is the chronic use of these drugs, when they were not designed for that purpose. There are no studies on long-term side effects, and they can cause headaches, nervousness, insomnia, drowsiness, memory problems, or tremors.

British psychiatrist Joanna Moncrieff, from University College London, one of the voices critical of psychotropic drugs, argues that it is necessary to put the drug at the center, in the sense that it cannot be used lightly. In this sense, the Ministry of Health has announced a prescription guide to reduce and delay the use of psychotropic drugs, especially among young people, a key stage in neurodevelopment and in which they are most vulnerable to adverse effects.

"I am clear: the best medicine "It's a person. It could be a professional, someone close to them, anyone," says Marfà. And the person is the focus of a revolutionary therapeutic model that seeks to practically eliminate medication and does so with some of the best results in the West in the treatment of psychosis: open dialogue.

This approach brings together a team of professionals with the person and their loved ones. Listening horizontally, without hierarchies. The goal is to generate dialogue so that the person can recontextualize their speech and understand it.

Marfà pioneered the implementation of this model in Catalonia, at the Adult Mental Health Center 2 in Badalona, ​​​​during his time as director, with positive results in all but the most chronic cases, in people with severe mental disorders.

Mental health care must change

Whether it's about reducing medication or expanding the therapeutic catalog, both options share a fundamental change in mental health care: it must be something else. The framework needs to be broadened so that mental health problems are not solely dependent on the healthcare system, but also include aspects such as housing and employment. The goal is to demedicalize distress and remove the psychiatrist from the top of the hierarchy in the care of psychological suffering.

The Mental Health Commissioner, despite reporting to the Ministry of Health, has precisely that objective. "We know there is an epidemic of psychological distress, but we also know that it has its origins in social problems that go beyond the four walls of the Ministry," said Minister Mónica García during the presentation of the new undersecretariat.

This change in perspective also advocates for group and community interventions, such as open dialogue or mutual support groups among peers, where the role of the professional is dissolved. Voice-hearing groups, people who hear voices, are a clear example of this path.