Most of my blog posts get titled after completion. Only rarely do I start with the caption and build an essay out of it. This morning the two words above best express what’s going on in my little world. In truth, I could stop there. It probably isn’t necessary to write anything more, but I’m going to anyway. Don’t expect too much from the text that follows, since my creativity feels dulled, and my energy is flagging.

The past eight days have been among the most trying of my adult life. First came the abdominal pain, internal hemorrhage, and hospitalization. My confinement taught me a lot about modern inpatient care, little of which was comforting. After discharge I tried for three days to get by without analgesics until the pain became so overwhelming that thought nearly evaporated, leaving nothing but raw suffering. So on the advice of my doctor I finally gave in and started taking a Percocet twice a day. This enabled me to start functioning again, but now I’m stuck on narcotics (exactly what I was trying to avoid). Since getting off them the last time was such an ordeal, I’m very worried about this necessity for pain relief.

A close friend of mine visited me the day after I returned home. He confronted me with some very upsetting opinions about our interactions on a day when I felt highly vulnerable. This makes me feel wounded and sad.

I’m worried about dying. Looking around I see how my life, as humble as it is, has so much precious beauty. It contains far more of value than I ordinarily acknowledge. For all my years of suicidal thinking, I don’t want this show to end right now.

A cousin of mine and I have been carrying on an email conversation that has expanded my understanding of our families and my own past. This feels quite useful to my growth, but it adds to my sense that everything that seemed solid in my life is dissolving.

The doctors still have no idea what went wrong inside me. Although they tell me not to worry about malignancy, my own medical training tells me that it remains distinctly possible. I realize that many people battle cancer, and that many survive. I’ll fight the good fight if necessary. But at this point there isn’t any disease to battle, only uncertainty.

The weather here was gloomy until yesterday: chilly, damp, and gray. Before this week the winter climate had little effect on my mood, but now I’m feeling oppressed by it.

The discomfort continues, even with the pills. In addition to pain I feel fatigue, malaise and nausea.

In short, there is a great deal going right now, I’m a bit overwhelmed. It feels like living does when it gets challenging. I am feeling life.

Too many of us grew up in families wracked with pain. Emotional wounds accumulate in settings of neglect, abuse, bereavement, molestation, violence, and misery. As adults, these ancient injuries undermine our happiness. We often choose poorly in relationships, careers, and pastimes. Even if we don’t make gross mistakes, we lack the confidence to endorse our own choices. We feel uneasy in good times and overwhelmed in bad. This is the legacy of childhood trauma.

At times we shut down emotionally, closing ourselves off from the affection we crave. Other times we act out and hurt the ones we love or destroy our own reputations.

Still, healing can happen after even the worst of upbringings. It takes time, and backslides are unavoidable, but eventually we stabilize in greater maturity and emotional openness than we ever imagined.

In the last post we highlighted the body’s gentle wisdom and how often we ignore it. As I move further along the path to peace of mind, the importance of befriending physical nature becomes ever more obvious. The injuries of the past are stored in our biology, where they affect every aspect of our lives.

For instance, upon remembering painful events from our past, our minds recoil in shame, anger, or sorrow. In equal measure, our bodies respond with corresponding feelings of hollowness, tension, or exhaustion. Just as emotional surges reflect the state of mind that accompanied past trauma, somatic symptoms recreate the physical feelings recorded at the time of the original hardship. Often, such emotional and somatic reactions arise without any conscious memory of the childhood injury that caused them. For example, when a spouse criticizes us, we may feel ashamed and small, or furious and explosive, without overtly connecting these responses to the parental harshness that first established the pattern.

Before we learn healthier strategies, our habitual response to distressing sensations is avoidance. We turn our mental spotlight away from our body’s messages. We may lose ourselves in thought and analysis, ignoring the cramp in our gut, the ache in our shoulders, or the shallowness of our breath. We may evade direct, felt experience by focusing on the actions and misdeeds of others. We may use the distraction of intoxicants, food, sex, or television as shields against painful emotional and sensual turmoil. We become skilled escape artists.

The solution can be found in the body. In fact, we cannot fully transcend our pain until we face its somatic legacy. At first, this feels excruciating. When we begin to tune into our bodily responses, we become aware of a sensory universe populated by knots, soreness, burning, blockage, agitation, and numbness. These discomforts are the physical counterpart to the emotional uproar that also arises. We discover how underneath our superficial and obsessional thought, our core system buzzes with anxiety, grief, anger, and fear. It all seems so noisy and confusing that we may find ourselves pouring a bowl of cereal with little memory of rising from meditation and heading to the kitchen.

The good news is that as we reacquaint ourselves with our bodies, the sensations become less intense. We relax into nonjudgmental awareness, which lessens the stimulation of tension and pain. It can seem like our systems shout less loudly when they have our attention.

Furthermore, we can learn to enter even the most unpleasant symptoms with an attitude of openness, acceptance, and love. In my own case, I experience deep, burning pain in my neck and upper back that worsens during times of stress. It is easy to hate this discomfort and resist it, but doing so only increases the misery. A better strategy is to move toward the soreness with focused attention and gentle affection. I apologize to my neck for all the times my activities harmed it. I feel compassion for its burden of muscle spasm, arthritis, poor posture, and neglect. I honor the hard work it performs in service of supporting my head every day.

By treating my body with the same care I would treat any beloved animal, I send a message of acceptance and affection to my entire being. The self-compassion resonates on the somatic, psychological, and spiritual levels. It feels profoundly healing. Often, the pain seems to abate with this practice, but the goal isn’t to alter my experience in any way. I seek only to honor my body and whatever it communicates.

All painful experiences can be approached in similar fashion. Crushing sorrow, vertiginous loneliness, shattering fear, and even livid rage can all be embraced with this attitude of loving, wise embrace. One finds that life is full of pain, but that this does not mean it is going badly. For as we open to our discomfort and terror, as we accept uncertainty and loss, we automatically increase our ability to feel joy, love, and spacious bliss.

The body will teach us the inexhaustible majesty of life when we surrender to both its wounds and its strengths.

Two posts ago I announced a moment of victory in my long battle with insomnia. Without meaning to, I had settled my body into sleep despite continuing mental activity. Upon recognizing this unusual state of being, I took the next step and endeavored to start dreaming. Reconstructing a remembered dream from another time, I rebuilt the landscape and evoked the emotional tone of the reverie. This succeeded in sending my mind into a deeper stage of sleep: I dreamt.

Although this development excited me, I did not for a moment believe my problem solved. I welcomed the new insight, the improved control of consciousness, but expected no permanent end to insomnia.

And yet…

Two nights have passed since the one described in the earlier essay. The first went by per usual: I could only manage about two hours asleep. Happily, last night went better. Although I did not experience the sleeping body/waking mind state, I employed the earlier night’s trick of deliberately formulating a dreamscape in my mind’s eye. Combined with the deep relaxation of a meditative ‘body scan’ this sufficed to put me to sleep and stimulate dreaming.

For the second time in a week, I enjoyed five hours of fairly solid slumber. This teaches me that my ability to induce sleep is greater than suspected. Through intentional relaxation and dreamlike visualization, I can choose to synchronize my brain waves and relax into normal sleep.

This development fills me with hope, but not just because I anticipate sleeping better. It demonstrates conclusively the power of mind. If through fairly simple mental tricks I can resolve such stubborn insomnia, then it must be possible to overcome almost any mental affliction with motivation and the right kind of effort. Not only that, but this strategy incurs neither side effects, addiction, nor expense. So much healthier than the pharmaceutical bandaids that cost money, cause harm, and help only briefly.

We need to nudge the mental health system toward more emphasis on skills and less reliance on pills. This isn’t a new realization. After all, therapists have focused on reshaping mental activity since the dawn of cognitive behavioral therapy. The difference is that in addition to teaching healthier thoughts, we need to teach the healthfulness of less thought. Imagine how those who now haunt mental health clinics, with little hope of decisive change, could benefit from intensive meditation.

Progressive clinics offer introductory mindfulness meditation instruction, which is a good first step. However, my recent experiences convince me we could go much further. We could train ordinary sufferers to master their minds. There is no need to fly to India or study under a renowned guru; the skills come automatically with sufficient practice. If we publicize its transformative power, those who feel fully sick of their problems will be motivated to learn deep meditation.

I’m not suggesting meditative practice as a cure-all. There will still be need for insight about childhood trauma, relationships, and personal values. But these should be natural add-ons to a meditative practice, and not the central goals. Eastern traditions have long spoken of the power of well-trained minds. Thought, desire, and action can be mastered. Those who are willing to devote the time and effort can harness their own psychic reserves to resolve longstanding neuroses.

Does brain science help us? In times past, I never doubted it. Then, last week, I attended an all-day seminar about the neuroscience and clinical management of destructive habits. Afterwards, I found myself wondering how much our massive research into the brain’s activities is really benefitting human life.

The neurophysiology of addiction has been studied in depth, and the lecturer talked a lot about it. Dopamine secreting neurons in the ventral tegmental area (VTA) send messages to the nucleus accumbens apprising it of opportunities in the environment. The accumbens integrates all of its inputs and either releases the basal ganglia (e.g., the striatum and substantia nigra) to indulge in a habitual action, or restrains them to abstain. Drugs of abuse, especially those that act directly on dopaminergic neurons (e.g., cocaine) are acutely habit forming because they trick the brain into thinking a tremendous payoff will result from their ingestion.

This brief sketch belies an enormous amount of investigative work. Countless scientists now study addiction, mental illness, and brain science in general. Pharmaceutical marketing and popular media have celebrated how this huge and costly investigative effort has yielded many advances for treating psychiatric disease, substance abuse, and neurologic problems. But has the clinical payoff really been that high?

At the seminar, when the presenter started speaking about the treatment of addiction, rather than the science of it, there was a shift in emphasis. Medium spiny neurons and dopamine physiology dropped out of the discussion. Instead, we heard how changing social groups is important, so addicts can find support for abstinence rather than peer pressure for addiction. We learned how alcoholics should clear their homes of booze. The speaker extolled healthy activities like exercise and yoga. She strongly endorsed mindfulness meditation to improve tolerance of uncomfortable emotional states.

Sure, there was a section on drugs that treat addiction, like naltrexone for alcoholism, buprenorphine for opiate dependence, and mecamylamine for nicotine cravings. But in each case we heard how the medications won’t work in isolation, and instead need to be part of larger programs of behavioral management. In other words, they aren’t miracle cures.

What are we to think when the brain science sounds so sophisticated, but the best treatments remain based on common sense (e.g., change social networks), or come from ancient wisdom traditions (e.g., meditate)? Can we conclude that brain science has resolved much mental distress? To me, it would seem premature to assert that neurophysiology has greatly helped us in day-to-day life.

I say this as someone who underwent cutting-edge psychiatric treatment for many years. A prominent Bay Area psychiatrist managed my mood issues with as many as six medications at a time. I seldom questioned her advice when she added another drug, or increased the dose of one that clearly wasn’t working. Only as side effects overwhelmed me and my productivity plummeted did I finally begin to question her strategy.

Unfortunately, it took a long time for me to realize that I’d be better off with meditation than medication. Now that I no longer use pharmaceutical support, I see that although drugs help in crisis situations, they often serve poorly as long term treatments. Don’t take my word for it. Robert Whitaker’s book, Anatomy of an Epidemic, shows clearly the many shortcomings of psychopharmaceuticals. Whether we speak of addiction management, or treatment of depression, or assisting schizophrenics, the sparkling promise of brain science remains largely unfulfilled in clinical terms.

Understand that I studied synaptic signal processing as a biophysics graduate student. In medical school I took most of my elective classes in neurology and neurosurgery. I’ve educated myself about the nervous system ever since. I’m well aware that neuroscientists have collected impressive quantities of information about the brain and its component parts. As an intellectual enterprise I continue to support this research. But we need to recognize that genuinely safe and effective treatments have not so far been forthcoming.

It frustrates me that despite this limitation, it has become difficult to say anything about human behavior without invoking the findings of neuroscience. Although meditation clearly helps people cope, and has done so for millennia, its benefits now need the imprimatur of functional MR scanning in order to be accepted. Although building positive activities into one’s lifestyle can assist with battling addiction, we apparently need to hear this common sense advice framed as neuroscience before we’ll take it seriously.

If it were just a question of objective science validating ancient wisdom, I’d have no complaint. But because of the neuroscience perspective, human behavior is now viewed as a product of computations carried out in brain tissue. Different aspects of our experience get ascribed to named nuclei in the brain. Thus, the amygdala is our ‘fear center,’ the hippocampus is a ‘memory module,’ and so on.

These descriptions are not only highly reductionistic, and therefore a bit suspect, they are also gross simplifications of exceedingly intricate and redundant neural processes. By describing people in these stark terms, we strip them of their native complexity. Perhaps this wouldn’t be a problem if something valuable were gained, but as I noted above, the best clinical treatments come from experience with people, not experiments with brains. The largest effect of neuroscience has been to persuade us to think of ourselves as computers made of flesh. Is this really an improvement over the view that humans are sacred beings of mysterious origin? Is it an accurate belief? Could it not be the case that there is more to humanity than synaptic activity?

Personally, I’d recommend a grandmother’s advice about how to achieve happiness over a neuroscientist’s. I’d embrace a yogi’s opinion about how to manage anxiety over a psychiatrist’s. And I’d endorse a saint’s ideas about the meaning of human life over a reductionist’s. Sure, let’s continue to study the brain. But until the research proves itself in the behavioral realm, let’s not grant it so much influence over how we view ourselves and our struggles.

On this coming Saturday, the 27th of February, I am slated to give my first presentation about mental health. The talk will only last fifteen minutes, so it’s not a big deal, but the location and timing are unusual. The venue will be a hospital about an hour’s drive from my home, and it happens to also be the institution that confined me when I suffered a manic psychosis almost exactly a decade ago. In fact, my last full day at the medical center where I performed oculoplastic surgery was the 27th of February 2000. (It was the loss of my career—due to severe arthritis in my neck—that led to my psychiatric breakdown.) I wonder if there is a bit of serendipity in the fact that this first chance to speak publicly about my new domain of interest falls on the ten-year anniversary of my prior career’s collapse.

Off and on throughout my life synchronicity has seemed to play a role in the major turning points. In my more open-minded states I wonder if there exist complicated cause and effect relationships that result in such remarkably timed opportunities; some events seem to ‘fit’ too perfectly to be explained by happenstance completely unconnected to my trajectory through life. At this moment, I’m uncertain and feel more inclined to dismiss the possibility of ‘cosmic’ meaning. Maybe it’s because my luck has been dismal for so long that this oddly timed opening doesn’t stimulate a feeling of: “Wow! How perfect!” Instead, my thoughts are more along the lines of: “It’s about time something went right!”

Either way, my task now is to clarify my message. Visitors to this blog have seen my philosophy evolve over many months. At one time I started to argue the thesis that neither science nor logic rule out the possibility of a Universal Consciousness permeating the cosmos. (I had planned to cite the frequent occurrence of serendipitous events as one support for this assertion.) The several posts I wrote on that topic primed me for a profound ‘breakthrough’ experience in January, which made completing the argument unnecessary. The ‘awakening’ also had the effect of sharply reducing my psychological distress; worry and depression faded to a mere fraction of their former intensity. So one point I want to make in this upcoming talk is that there exists a state of consciousness that greatly reduces psychic suffering.

This enlightened condition has been described many times, both by individuals and investigators such as William James. I mentioned the book Quantum Change in my last post; William Miller and Janet C’de Baca demonstrate that people can attain this elevated consciousness swiftly, and sometimes almost instantaneously. Contrary to the western mental health model wherein years of strenuous psychotherapy are intended to promote slow and gradual improvement, Miller and C’de Baca show that change can occur as a more-or-less sudden event. That will be my second point in this upcoming talk: elevated mind-states can develop abruptly.

The third point will revolve around ways we can make such sudden elevations of consciousness more likely to occur. In fact, there is already a well-known mental health treatment system designed to do just that; since the 1930’s Alcoholics Anonymous (AA) has been guiding people to spiritual awakening. The DSM (a manual used by mental health professionals to classify psychiatric conditions) lists substance abuse disorders as mental illnesses, so it is appropriate to consider AA as a mental health program. However, the 12 steps of AA are not directly applicable to pervasive psychiatric issues like depression and anxiety. They have a number of phrasing problems that make them inappropriate for that purpose. In my talk, I hope to point out ways that the 12 step system could be streamlined and modified to make it work for emotional distress.

In coming days I may elaborate on each of the three points just presented. Not only will discussing them here further spread the message (a little), it will help me prepare for my brief talk. This would be a great time for me to receive comments, since I could incorporate suggestions into my upcoming presentation.

My last post wore me out, emotionally and physically, so I’ve needed a break. But here I sit again, ready to write. The prior essay centered on structural changes in synapses, and how those relate to difficulties with changes in either behavior or medications. Loss of serotonin receptors with SSRI antidepressant use (e.g. Prozac), leads to a dependence on the medication. When SSRIs are withdrawn, the brain no longer has the receptor capacity to work with the lowered serotonin level which follows. So we get depressed. I have experienced this repeatedly in my efforts to lower my antidepressant load.

The brain gets used to certain inputs. Many pleasurable activities, and drugs of abuse, increase dopamine. Like serotonin, dopamine is a neurotransmitter used by a minute fraction of the brain’s neurons. When the nucleus accumbens, or ‘pleasure center’, gets flushed with this chemical, one feels deep satisfaction, sensual gratification, or even euphoria. Later, when dopamine levels drop, one may develop a desperate craving to get another burst of it. Hence: addiction. Possibly behaviors that lead to unpleasant moods, like isolating or ruminating on worries and problems, provide short term release of neurotransmitters that our brains ‘like’, even though the end result is depression. This portrayal simplifies the situation, like describing an epic film with one paragraph. But my point is just that on some level much of how we feel, and what we think or do, comes from shifting movements in the symphony of chemical interactions in the brain.

So what does this all say about human nature? Are we ‘nothing’ but conglomerations of proteins, neurotransmitters, and other biological molecules? In the last post I also mentioned Jeffrey Schwartz, MD, and his hypothesis that in addition to neurons and associated brain cells, our minds consist of something non-material, which he calls ‘mental force’. This entity could just as well be called our ‘soul’, since he believes it determines our decisions under the principle of free will.

I don’t accept this proposal. Not because I think free will is an illusion, or because I don’t believe in souls. I have conviction that both exist and are the vital organs of human life. My opinion, however, is that both human ‘spirit’ and ‘will’ arise from the matrix of matter itself. The intricate and finely woven fabric of our brains makes freely determined decisions, and houses our divine spark. Humans look for miracles, yet all the time we seek them we are living in their midst. Not only that, but each one of us is divine in every sense of the word. We don’t need to postulate some ethereal force that exists detached from the trillions of cells, each a tiny universe of activity, which have grown in unison and become the mysteries we call bodies. God does not need to speak outside of matter, because our atoms and molecules already sing God’s song.

Even with the above proviso, I suspect that my spiritual ideas do not particularly interest those who visit this blog. So I’ll stop here with the philosophy. I only want to convince readers that by taking medications, or changing our behaviors, we are tinkering with the intimate particles of our being. However, the two approaches, drugs and action, differ as coal differs from diamonds. They may be the same thing on some basic level, but they diverge in beauty and endurance. Ingesting a chemical to improve one’s experience is akin to to reshaping an ice sculpture with a blow torch. The tool carries too much power, and acts too crudely to result in anything fine. “If you can’t feel better, drugs at least make you feel different.” At the price of (possibly) lifelong dependence on psychiatric chemicals, one (typically) gains a few months of relief from pain. Then, all too often, the pain returns. Only now depression comes encumbered with an addiction (what else to call it?) to drugs that no longer work. Stopping medications takes one from depression into the pounding heart of hell.

Much better to work on meditating, improving spiritual sensitivity, exercising, and adjusting thought habits. Maybe drugs can help for a little while. If so, doctors should remain ever-vigilant for the first opportunity to start withdrawing them. Let us use finesse to chip and carve the ice that encases our moods. Take our time and work hard, and we can sculpt our depression into tragic but nonetheless beautiful memories.

I guess this is a repeat of my last message. Hopefully, since it is (a little) shorter, it will be more widely read. I further yearn for it to help someone. This kind of thinking comes too late for me. I am already addicted to psychiatric medications, and must struggle my way free. This writing project would fulfill both my spirit and my will if a recently diagnosed reader found it useful, and if it bolstered a non-medicated regimen of mood care. If you are that reader, I pray that the uncountable molecules of your brain begin to dance in harmony. I have faith that you will choreograph a lasting peace.

Today, my decision about topics comes down to two choices, both born of recent posts or replies to comments: 1) Bad Thought and Behavior Habits and how hard it is to change them; or 2) Discontinuing Psychiatric Drugs and how it is made difficult by receptor downregulation. The first has to do with why I often ignore the things that have been taught to me about how to be healthy. The second is about why I get so depressed when I try to stop (e.g.) Cymbalta. Then I realized that the two are related. They both have to do with fixed patterns of response in the brain. So this essay deals with both those issues. It is long (despite my resolution to keep posts under 500 words), and involves some physiology. But I think the connection between habits, drugs, and changes in the brain lies at the heart of many difficult emotional problems.

Of course, science understands drugs better than habits. When a negative behavior becomes habitual, so that we repeatedly cave in to it rather than do the harder thing that will make us feel better in the long run, millions (or billions) of cells across the brain may get involved. Many complicated neural centers of thought and action determine such bad habits. On the other hand, when our brains become habituated to the effects of psychiatric medications, the problem largely can be explained by changes in the levels of one or a few proteins. Since I know little about the psychology behind habits and resistance to change, most of this post will focus on receptors. I will try to draw (hopefully not make up) parallels between the brain’s adjustment to pharmaceuticals and its development of habits.

Many people on psychiatric medications have found that a drug may improve ‘symptoms’ after a few weeks, but then gradually works less and less well. This happens, in part, because the body reduces the number of receptor-proteins that respond to that drug, or to one of the natural chemicals the drug increases.

I started my medication odyssey with Prozac (fluoxetine). This drug blocks the removal (reuptake) of serotonin from the synapses in parts of the brain that use serotonin as a signalling molecule. The synapse is the small area that separates the pre-synaptic cell that sends a signal, in this case one carried by serotonin, from the post-synaptic cell that receives it. Removing the released serotonin from the space between the cells–the synapse–attenuates the message, so that it is time-limited, and doesn’t just go on ‘forever’. Since compared to earlier antidepressants Prozac is relatively selective in blocking reuptake of serotonin–but not other transmitters, it is an example of the SSRI class: Selective Serotonin Reuptake Inhibitors.

Under normal circumstances, the pre-synaptic cell releases serotonin, but then sucks it back out of the synapse using ‘reuptake’ proteins. Without the reuptake mechanism, serotonin would persist in the cleft for much longer times, and at higher concentrations, than normal. In fact, Prozac accomplishes exactly that: it blocks the reuptake protein and so causes an increase in synaptic serotonin.

As an aside, only about one-thousandth of one percent of brain nerve cells use serotonin to send signals. Despite their small numbers, serotonin neurons affect many different parts of the brain. That explains, in part, why they have unwanted side effects: areas of the nervous system we’d rather not mess with (like parts mediating sexual response) are modulated by serotonin, just like the parts that alter moods. Another important point is that to date there is no evidence that depression results from an actual deficiency in serotonin levels, even though increasing serotonin activity does elevate moods.

So why does Prozac often quit working over time? In part, it may be because the cells respond to abnormal increases in serotonin by reducing the number of post-synaptic receptors for that transmitter. It’s kind of like what happens with noise. If you want to hear something really faint, like a soft whisper, you cup your hand behind your ear to increase your ability to make out the words. As the person speaks louder, you remove your hand because it’s not so hard to detect their voice anymore. If they start yelling, you might even plug your ears to tone down the volume. The post-synaptic neuron that detects the serotonin signal no longer has to listen so hard. So it reduces the number of proteins in its cell membrane that ‘hear’ the serotonin molecule. And the drug that increases serotonin, and that once had terrific effectiveness, now has less.

Naturally, there are complicating factors. For instance, Prozac may have an immediate stimulating effect, but much of its antidepressant activity is delayed by several weeks. This is thought to be due to changes in receptor numbers on the pre-synaptic cell. I won’t go into this wrinkle, because it does not change the basic fact that eventually serotonin levels increase, and that soon after the system adjusts to the elevated transmitter levels. Regardless of the details, the end result is that the brain settles back toward its natural state. It adapts to the increase in transmitter by reducing its sensitivity.

What happens when you stop the Prozac? At this point, your neurons are accustomed to increased serotonin levels. What was once abnormally high is now, according to your brain, the right amount. When you take the (reuptake inhibiting) drug away, reuptake goes back up, which (probably along with other changes) reduces synaptic serotonin. Since the brain has adapted to high serotonin, this reduction (back to levels that once were normal) feels like a deficiency. The serotonin system is under-stimulated, and you feel depressed. And because serotonin neurons are so widespread, other withdrawal symptoms are not uncommon. You might even be more depressed than when you first started Prozac. If you can weather the depression without killing yourself, there is a pretty good chance that your neurons will return to their original condition. Or maybe not. There is also a risk that not all of the changes are reversible. One line of evidence that suggests receptor downregulation may sometimes be irreversible comes from the fact that some people have long-term sexual dysfunction that continues after SSRI agents have been discontinued.

Either way, the habituation of your brain to the presence of Prozac (and other SSRIs) makes it a difficult drug to stop. The same thing happens with heroin users: the number of opiate receptors drops, and the addict feels horrible if her or she can’t get enough heroin. (In the brain, ‘opiate’ receptors normally detect peptides called endorphins; heroin and related drugs stimulate those receptors and thereby promote analgesia and euphoria.) Hence they have trouble springing back from ‘receptor downregulation’ just like Prozac users. A common name for this is ‘addiction’. For obvious reasons, drug companies and psychiatrists resist applying this term to the withdrawal symptoms people have when psychiatric drugs like SSRIs are stopped.

Now, back to habits. Could it be that similar adaptations to signal strength, protein levels, and other features in various parts of the brain account for why habits are so hard to break? When we try to alter our behavior away from the established pattern, do we experience a seeming deficit in some chemical important to feelings of well-being? This mechanism must be operative in bad habits involving substance abuse, like cigarette addiction. But would it be extending the analogy too far to suggest it explains my habit of retreating into depression after minor setbacks? Or how I avoid doing the things that I know will gradually lead to less depression (e.g., distraction, exercise, positive self-talk), and instead curl up in a darkened room because it somehow feels better at that moment?

To answer that, one confronts the question of whether all of our decisions result from neuronal activity. Surprisingly (to me) not all scientists agree with that notion, or at least not entirely. Jeffrey Schwartz, MD, published a book in 2002 with reporter Sharon Begley called, The Mind and Brain: Neuroplasticity and the Power of Mental Force. In it, he uses obsessive-compulsive disorder (OCD) as a model for how the mind and brain interact. On the one hand, he reports that PET imaging data imply that OCD results from faulty action patterns in the frontal lobe. he goes on to show how entraining OCD patients (via CBT techniques) with new behaviors changes those circuits, and that the better the patients become, the ‘better’ the circuits look. This supports the idea that bad habits can result from changes in neuronal circuitry (note that OCD behaviors are particularly bad and pernicious; I want to reassure OCD sufferers that I am not saying their condition is something you can just ‘quit’ like cigarette smoking–hard as that is).

(Note: these images taken from the site linked by clicking on them. They were not obtained via CC license. Since they are promotional pictures on an OCD clinic’s website, and this is a mental health blog, I assume the developers would not mind. I do not have any affiliation with that organization, by the way.)

Schwartz also conveys the optimistic message that with training and intention we can change cellular connections. In other words, we can physically alter our brains to improve our lives (which brings up the giant topic of neuroplasticity, a subject for another blog). So Schwartz agrees that structural and functional elements in the brain determine habits, and that changing those elements is the key to improvement.

On the other hand, however, he argues that the intention to change behavior (and hence the brain), originates from something outside the physical structure of the nervous system: a so-called ‘mental force’. He is doing nothing less than postulating a new physical entity to add to the nuclear strong, nuclear weak, electromagnetic and gravitational forces already known by physicists. His argument is well-constructed, though it fails to convince me. (That does not mean I don’t believe in forces outside of matter, only that his reasoning and supporting data are insufficient to establish non-material forces acting in this instance.)

Whether intention originates in neuronal tissue or outside of it, it is nevertheless clear that behavior is grounded in the brain, that we can and often do change our behavior, and that doing so probably involves changing the structure and/or function of neural circuits. My whole reason for this long discussion is to make the point that while drugs quickly and efficiently change synapses and brain circuits, we can do the same thing (more slowly) with willpower, training, and practice. Breaking the habits that promote depression is then not all that different from recovering from long-term use of psychiatric drugs, although it is probably easier. In both instances we need to readjust synaptic activity.

Cognitive research has shown that to some extent persistent depression is about bad habits of thought and action. If we can break those habits, we can reduce depression. It may even be that improving thought and behavior increases brain serotonin activity, just like Prozac. However, unlike using a synthetic drug, in this case the neurotransmitter gets increased in just the right locations, not the whole brain. There is no problem with, for instance, anorgasmia or weight gain. We can accomplish the same thing as drugs, but without the side effects. It just takes the desire to change, and enough motivation to step off the easy and well-worn path. One needs to muster the courage to forge new trails and conquer new horizons. But drugs are not required.

Medications all-too-often only provide temporary relief. In some cases, a period of drug-mediated improvement in depression can give one the solid ground needed to step in a new direction. After that, the ideal decision would be to withdraw the drug in short order. I believe medications can play a useful, even vital role. But pharmaceutical agents can not, and should not be the only compass used to find a new way to live. Lifelong treatment with psychiatric medications is questionable, and despite what we are led to believe, most pharmaceutical agents lack scientific evidence of usefulness over long term treatment. So if drugs are used at all, they should be used in the lowest number, at the lowest doses, and for the shortest time possible. It takes much effort and time to change neural pathways without drugs, but the improvement is longer lasting, without side effects, and far more natural.