I’d like to propose a way to classify different types of psychiatric drugs. There’s a chance that this classification already exists but if it doesn’t it is at least helpful for me conceptually→Draw a line between drugs that operate by continually affecting existing endogenous systems in the brain and drugs that operate by forcefully “rewiring” endogenous systems in infrequent but intense treatments.
The first category contains all of our typical self-prescribed and medically-prescribed drugs: caffeine, alcohol, nicotine, marijuana, SSRIs, SNRIs, Adderall, etc. These drugs operate by continually augmenting existing endogenous systems that are supposedly not functioning in ways that are conducive to healthy living. SSRI’s (supposedly) artificially impact our serotonergic system. They are supposed to continually improve the efficacy of serotonin, and, in turn, allow the depressed to feel happiness more consistently. On the self-prescribed side, caffeine is used to continually antagonize adenosine receptors that are used to typically inhibit the release of neurotransmitters. In turn, this artificial augmentation of the adenosine system leads to more stimulated neural release of many different transmitters.
The important point of this first category is that it only works by continually impacting already existing systems in the brain and body. It’s continuous use in many situations decreases our endogenous abilities to regulate and produce many of the things that the drugs augment. Unsurprisingly, if you smoke weed all of the time, you will impact your body’s ability to produce and use it’s natural cannabinoids. If you take SSRI’s you will impact your body’s ability to produce and use serotonin. If you take testosterone (now an infrequently prescribed antidepressant for men) you will limit your body’s ability to produce testosterone. In a way, this replacement and augmentation of endogenous functions makes the drugs almost part of your body. Your “normal” function relies on it and will continue to rely on it till you wean yourself off.
The second category is a little harder to pin down because many of these drugs are self prescribed and more frequently part of non-western medicine. These drugs can include LSD, Ayahuasca, Psilocybin, Ketamine, MDMA, and Ibogaine. These drugs are not well socialized in polite western scientific culture. They are associated with shamans and reckless young people. They are considered to be anti-medicine and alternative and low. This association has made these drugs an uncomfortable topic for decent people. Despite their efficacy in some situations, they are still not often taken seriously. But as we speak, the FDA and other “serious” scientific bodies are conducting extensive trials on using these drugs to treat PTSD, end of life anxiety, depression, and addiction. MDMA and ketamine, in particular, will soon be used in clinical settings in many places within the US.
Second category drugs don’t work like first category drugs. First category drugs work through continuous augmentation of otherwise natural processes. Second category drugs work like surgery. Just as an orthopedic surgeon repairs a broken leg only once, these drugs almost operate like mental surgeries that happen at infrequent intervals (sometimes once in a lifetime with drugs like Ibogaine, sometimes once every month with drugs like MDMA). Second category drugs operate by making massive impacts on existing neural organization and structure in very infrequent but intense sessions. Though they have long term impacts on the function of endogenous systems, the endogenous systems undergo singular, massive transformations and then continue under the new restructuring. The patient doesn’t continually rely on the drug in most situations. In a way, these drugs are built in ways that necessitate the infrequency. Their efficacy goes down considerably after a session. For instance, if you take a strong serotonergic hallucinogen like psilocybin, it will take weeks or even months before the drug is effective again at the same dosage as the original treatment.
This is all not to say that one category is in any way safer or healthier than the other. Just as massive surgeries have huge risks — you will always take a brain surgery or hip surgery seriously — second category treatments can have huge negative impacts on patients. Things can go wrong in surgery and they often do. People can have psychotic episodes that can have impacts on their ties to reality for the rest of their lives. None of this should be taken lightly and I don’t ever intend for this to be seen as anything other than wild and reckless speculation (a.k.a. not medical advice).
The important thing is mostly to realize that this categorization will become increasingly important as second category drugs are normalized within polite scientific and medical communities. It will play a larger role in psychiatry as treatments become more available. We will have to become more aware of the downside of both techniques: becoming physically reliant on the continual use of certain drugs one one hand, and dealing with the massive risks of mental surgery on the other hand.
It will be especially interesting to see how people change their minds about the order in which they take drugs from these two categories depending on the severity of their issues. For instance, ketamine is widely available in many states as a controlled and efficacious treatment for depression. But it is a last ditch effort treatment that is looked at as an option on par with ECT, only used once all of the first category drugs have been exhausted. That may reverse, but, for now, the preferences of the medical community and patients seem to be more aligned with first category drug-use as the proper first therapy.