Shirah Vollmer MD

The Musings of Dr. Vollmer

Talkin’ Drugs

Posted by Dr. Vollmer on June 29, 2015

Mechanism of action (MOA) is the holy grail of psychopharmacology. How exactly do these drugs work? This is not the same question as which neurotransmitters are altered by the administration of this drug. How do we know that altering neurochemicals produces symptom relief? We do not. We practice “black box” medicine, meaning that a medicine is administered and for reasons which are unclear, the patient reports a change, either good or bad, in symptoms. Placebos can also alter neurochemicals, at least conceptually, they can. So, perhaps it is the anticipation of relief which creates new neurochemistry, and hence improvement. Nora Volkow MD,, the head of NIDA (National Institute of Drug and Alcohol Abuse) has pioneered the new theory that addicts remain addicts, not because of the drug’s influence of the brain, but because of the anticipation of the drug’s influence on the brain. Love, and hate, and stress, can all, theoretically change brain chemistry. Perhaps the doctor/patient relationship, the aspect of medicine I am most in fear of losing, is in fact, the agent of change for neurotransmitters, resulting in better self-care and more enjoyment. Transcranial Magnetic Stimulation,, a novel way of altering brain chemistry, is yet another attempt to change the electrophysiology and thereby change the patient’s approach and outlook towards his life.

Am I taking the curtain off of psychiatric medicine, or psychopharmacology, that word I have come to despise because it has not particular meaning other than that psychiatrists, physicians, prescribe medications which change brain chemistry? Psychiatrists have been doing this for years before we re-packaged ourselves as “psychopharmacologists.” Maybe that veil needs to be lifted. Medications, like cooking, or any art for that matter, is a skill honed with years of experience, but at the end of the day, the choice of medication is an educated guess. There, I have said it. So, does a patient pick a psychiatrist because they guess well? I would hope not. I would hope that a patient picks a psychiatrist who understands the speculative nature of the work, and as such, is willing to be prepared for any eventuality, knowing that each medication, interacting with each patient, is a unique experience which therefore requires close monitoring and careful attention. That is the key to a good “psychopharmacologist.” It is not picking the drug off the shelf; it is what happens after that.

2 Responses to “Talkin’ Drugs”

  1. Shelly said

    Placebos work because we believe they can. You are right in that our emotions theoretically can change brain chemistry the same way placebos do; however real medications chemically alter our bodies in addition to providing trophic effects. We choose our physicians not only because they are good clinicians but because we have faith in them and we have good relationships with them. If not, we drop them like hot potatoes. There is no reason to stay in a bad relationship (even the doctor-patient relationship) if it makes one feel badly. If a physician feels that he or she can’t help the patient or the patient feels a lack of faith in the clinician, then why stay?

    • People stay with doctors they do not like for all sorts of reasons including, mixed feelings, convenience, insurance, or pressure from a therapist or family member. Cultivating a relationship with a patient is becoming the lost art in medicine, and so patients are coming to expect a physician to be like their mechanic, in that they just want the job done, and then for more emotional issues they are looking elsewhere. This bifurcating of treating disease and developing relationships is so very hard for me, as you know, because although that might be a more cost effective way of delivering care, it changes the profession drastically. Thanks.

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