A mother wrote and asked about her adult daughter and whether certain drugs can damage the brain?

She wrote: My daughter had been stable and working part time for the past 5 years after 20 years of illness (a serious mental illness with psychotic episodes and co-occurring substance abuse problems). She had been taking 15 mg of Abilify (an antipsychotic medication) and was doing pretty well, functioning at a relatively high level. She relapsed into drugs last October and began using cocaine even while on 70 mg of methadone. She never completely stopped the Abilify although she took much lower doses.  She was voluntarily hospitalized in a psychiatric facility for 4 weeks in January.  She is now back living in the community and attending a day program where she is tested for drugs 3x a week.  She went back on the Abilify but she has not really stabilized.  Her doctor at the hospital said that her brain was very sensitive to using cocaine and methadone at the same time.  He suggested further damage to her brain. 

She asked: Is that possible?  Have you heard of someone not returning to a previous state of functioning due to the use of cocaine and methadone simultaneously?  Are we not waiting long enough?

My reply: Two troubling ways in which a person’s brain can be badly affected by using street drugs are from 1) the drug and what it is mixed with and 2) from untreated mental illness.

1)   Abuse of cocaine, in its pure form, leaves the brain depleted of dopamine, a neurotransmitter that affects many parts of the brain’s function. Repeated use of cocaine also appears to have an effect on the blood vessels in the brain. The more cocaine used, the longer it takes the brain to recover from this depletion or vessel damage. On top of that, when someone takes cocaine there is no knowing what they are taking. Street drugs are cut with all kinds of additives and impurities. Some are just filler but others are meant to give the drug more kick since it has been diluted before it is sold. So, using cocaine, or any other street drug, means using more than what a person intended. The additives themselves may cause damage. Since we cannot know what else was in the white powder, we cannot say what else might be doing harm to the brain – but the risk is there.

2)   Psychotic illness has been called “neurotoxic”. This means that the illness itself, untreated and unchecked, can cause damage to the brain. Serious mental illnesses, like schizophrenia and schizoaffective disorder, are characterized by psychotic symptoms – or loss of reality and the presence of hallucinations and delusions. Individuals who have repeated episodes of psychosis and refrain from getting effective treatment are at risk to do more poorly in their lives over time. Hypertension is an example of a progressive disease that produces mounting damage if untreated (to blood vessels, and ultimately to the heart). The brain, like our blood vessels, needs to be protected from disease. While debate exists as to how cocaine causes problems in the brain, whether directly to the nerve cells or the way they connect to one another, the consequences can be grave.

Treatment can and does work, but far too often those who can benefit do not get the care they need. As I say on my home page, less than 20% of people with a serious mental disorder get properly diagnosed and effectively treated. Understanding mental illnesses and what treatments work are essential in rebuilding a life (as it is for families to know how help your loved one). It is never too late to start.

For more information on cocaine and other street drugs, go to The National Institute on Drug Abuse website at http://www.drugabuse.gov/

For more information on untreated psychosis, a major psychiatric journal reported on important findings that pertain especially to people early in the course of their illness. The journal citation is: Perkins, DO, Gu, H, Boteva, K, Lieberman, JA: Relationship between duration of untreated psychosis and outcome in first-episode schizophrenia; American Journal of Psychiatry, 2005;162:1785-1804

Well this is a charming explanation, like saying the sun is a big ball of flames. Indeed, the sun looks like a ball of flames, and you don’t want to get too close, but there is a lot more going on than that. As for what is going on in the brain in people with severe depression, and how antidepressants (ADs) work, no one really knows.  Maybe ADs work by producing greater concentrations of mood altering neurotransmitters, like serotonin and epinephrine, at specific sites in the brain thought to effect mood? Maybe these neurotransmitters permit nerve cells to protect against other cells and transmitters, like glutamate, believed to produce anxious and depressed mood states? Maybe neither of these. In twenty years we will be saying how little we knew twenty years ago.

But not knowing is not a reason for not acting. Much of what is done in medicine is done for what we call ‘empirical’ reasons: namely, studies show it works (empirical means not from theory but from observation and experiment). Empirically, we know that ADs work – and they are often safe and well tolerated. Which is why doctors prescribe them and many, many people take them, with benefit.

The question you or your loved one may want to ask is “do I need an antidepressant?” The answer to that question can be determined by asking: Is this a depression, with its characteristic symptoms, not a passing mood, grief, or another condition? If so, has it persisted for weeks, regardless of what I do to try to beat it? Does the depression affect my ability to function as a family member, at work, at school? And what options exist for treatment of my mood problem, including medications but also counseling, exercise, controlling drinking or drugs that affect mood, and support of family and friends?

Above all, don’t give up. Depression itself produces feelings of hopelessness and helplessness. Depression can be deadly, driving people to suicide and worsening serious medical conditions like heart disease, diabetes and asthma. Up to 75% or more of people with depression, including serious depression, can improve. That may take time and trying different treatments until the right one works for you.

Don’t let depression get you, before you get the best of it.

William Styron’s book “Darkness Visible” is a , short, poetic account of depression and suicidal feelings, which he survived.

Finally, for reasons you can’t explain, your loved one agrees to go to the local hospital emergency department (ED) – and you get there as fast as you can, knowing that can change on a dime. You think, finally, a chance to get him into the hospital so treatment can begin and maybe take hold. In the ED your loved one waits for a couple of hours, grows restless but you manage to keep him there. Finally, he is seen by the doctor – after you tried unsuccessfully to get a few words in edgewise with the doctor who has 10 more people in the waiting area, and who knows what other responsibilities in the hospital.

The doctor emerges from the exam room and she signals you for a word. She tells you she is discharging your loved one since while he clearly has a mental illness he does not want admission and there is no evident “danger to self or others”, the term that captures what is legally required to admit someone who does not want to be admitted. She says she will give you the phone number of a clinic to call for an appointment. Your heart sinks. You dread what lies ahead, even if you were not sure what could be accomplished in the hospital. Your loved one pulled himself together with the doctor, however briefly, and promised to get help (a promise you know will not be kept). What awful event has to happen before he will be admitted, or will that even be too late?

What can you do to prevent this outcome? While there are no guarantees you want to convey a message that needs to be heard. To do so, you need to know what the doctor needs to know and deliver that information – short and sweet. Most important is that danger exists: you need to say that the situation is dangerous, and it is getting worse. And that there will be grave consequences to the patient, family and doctor if safety is not immediately achieved, namely by hospitalization.

Here is how one family I know succeeded in preventing the nightmare of leaving an ED without having achieved what they came for. The adult children told the doctor that their mother had left the gas on in the apartment while nailing shut the windows and barricading the door. They made a point of catching her before she went into the examining room with her patient (their mother) and saying that their mother had felt hopeless and spoke about being an increasing burden to her family. She had said that they would be better off without her. Her hopelessness, guilt and distrust meant she would not tell the doctor; in fact, she was apt to provide a cover story that would get her discharged from the ED. The family told the doctor that if their mother went home she would likely try again and die from the gas, or start a fire or an explosion, when she lit a match to smoke. They stressed that neither the family nor the doctor wanted that to happen. Their mother was admitted on an involuntary doctor’s order after she refused an offer of admission.

Involuntary admission is always the least desirable intervention. I know patients who avoid the mental health system and psychiatrists for years after such an event. Early intervention, voluntary treatment, and shared decision making (often helped by an advance psychiatric directive) are what work a lot better. But sometimes, when all fails and danger and fear mount the hospital becomes a necessary, short term and emergency action — if only you can get the mental health system to respond!

You will have a lot of explaining to do to your loved one later on. But given the choice of discharge to a dangerous situation or actively providing the doctor with information that clearly supports involuntary hospitalization, which will you choose? If you chose the latter, make a point of explaining why you did what you did to your loved one – but not until there is a good moment when you can convey your love, your fright, and your determination to help.