DOCTORING THE MIND: IS OUR CURRENT TREATMENT OF MENTAL ILLNESS REALLY ANY GOOD?
By Richard P. Bentall
NYU Press, 364 pages. $29.95
"Conventional psychiatry, which reached its zenith with the neo-Kraepelinian movement, has not only failed to deliver tangible benefits for patients (antipsychotics...were an accidental discovery) but has also failed to deliver a credible explanation of psychosis. It is not that there is a lack of biological evidence; rather, the evidence has been misinterpreted and shoehorned into a biomedical framework that fits it poorly. A radical new approach to understanding severe mental illness, which brings together the evidence on the social, psychological and biological causes of psychosis, is urgently required."
In the 1960s, a movement called "antipsychiatry" (prompted in Britain by R. D. Laing and in the U.S. by Thomas Szazs) questioned the basic assumptions about mental illness and its treatment. Not only psychiatry, but methods popular earlier in the twentieth century, such as the prefrontal leucotomy, electroconvulsive therapy (ECT), and insulin coma therapy, lay thoroughly discredited. The anti-psychiatrists encouraged treating the patient as a whole person, putting his "madness" in the social and environmental context. Unfortunately, with the passage of the counterculture the medical establishment returned with a vengeance to explaining mental illness strictly as a manifestation of physical disorders of the brain and treating it with particular medications.
Dr. Richard P. Bentall, professor and practitioner of clinical psychology in Britain, who earlier wrote Madness Explained: Psychosis and Human Nature (2003), exposes the highly dubious nature of reigning presumptions about the causes and treatment of mental illness. He favors the "recovery-oriented, autonomy-promoting" model, particularly cognitive behavioral therapy, over the "paternalistic-medical" model, which favors reductionist diagnosis, genetic causation, and reliance on drugs to correct so-called "chemical imbalances." Bentall explores why the biomedical approach has become dominant, instead of a social approach to madness, which was gaining traction in the 1960s. There is little evidence to show that psychiatric drugs are effective in the long run; by making spurious connections between damaged brains and drugs alleged to overcome such disfigurement, the medical profession ignores better treatment options.
In his important book The Rise and Fall of Modern Medicine (1999), James Le Fanu identifies twelve definitive moments in the history of medicine, one of which is the discovery of the drug chlorpromazine in the early 1950s. Over the long run, however, the medical profession has been manifestly unable to improve recovery outcomes for patients suffering from mental illness. A striking finding is that patients in developing countries, with much less health care expenditure per capita, recover better from schizophrenia than patients in developed countries. The accidental discovery of chlorpromazine by a French doctor must be viewed in the context of the state of psychiatric treatment, a shambles before the excitement caused by the new drugs. As Le Fanu concludes, "Why should a compound that blocks histamine in the tissues of the body also interfere with an entirely different chemical--dopamine--in the brain in a way that alleviates the symptoms of schizophrenia? What is schizophrenia? What is its cause? The map of mental illness, like that of Africa before the arrival of the Victorian explorers, remains a blank." Medical discoveries have sharply fallen off since their post-World War II peak; both "The New Genetics" and "The Social Theory" (attributing disease to lifestyle choices) have failed to halt the rise of illness, particularly psychiatric illness.
Emil Kraepelin (1856-1926) is the key figure in the classification of psychiatric disorders, making a distinction between dementia praecox (senility of the young, later relabeled schizophrenia) and manic depression. The growth of mental asylums, particularly in the U.S., didn't abate until the middle of the twentieth century. Also in parallel, extreme remedies including electroconvulsive therapy, prefrontal leucotomy, and insulin coma therapy became popular. Walter Freeman, the American evangelist for prefrontal leucotomy, used "a hammer to tap an ice-pick-like instrument placed above the eyeball and against the orbital bone behind," after which "he would move...[the instrument] from side to side in order to produce the desired lesion." Rosemary Kennedy, sister of President John F. Kennedy, was a famous victim of Freeman: "a woman who had perhaps suffered from mild intellectual impairment, but who could read and write...was left incontinent and able to utter only a few words." In insulin coma therapy, patients' "brains were starved of glucose," and they would slip into a coma. Brain-cell death, and the desired catatonic state, resulted.
Contesting behavior modification programs, articulated by pioneers B. F. Skinner (author of Walden Two) and Carl Rogers, varied in their approaches to control versus autonomy, but the impact of innovation remained limited in the asylums and clinics. David Rosenhan published a famous paper in Science in 1972, called "On being sane in insane places," throwing doubt on the supposed empirical nature of psychiatric diagnoses. With seven other "pseudo-patients," Rosenhan showed up at psychiatric clinics pretending to have symptoms of schizophrenia. Staff at the hospitals were unable to change their diagnostic presuppositions to match the pseudo-patients' perfectly normal behavior once admitted: "A pseudo-patient waiting outside a cafeteria half an hour before it opened (there was nothing else to do) was described by one psychiatrist as having an 'oral acquisitive syndrome.' When observed making notes, another was said to exhibit 'obsessive writing behavior.'" Interestingly, the patients picked up that the pseudo-patients were journalists or professors.
Meanwhile, unable to rise to the challenge posed by Thomas Szazs's groundbreaking The Myth of Mental Illness (1960), psychiatrists doubled down on the idea that there is something "wrong with the brains of mentally ill patients." Thus came about the "chemical-imbalance explanation for mental illness, an idea that was to prove more potent in the minds of ordinary people than anything dreamed up by the antipsychiatrists." In other words, even as Freudian assumptions about the unconscious, the role of sexuality, and repressed fantasies were being discredited, the science of biological psychiatry emerged to put forth the idea that "too much dopamine at the [brain synapses]...causes schizophrenia," and that "an imbalance in the neurotransmitter serotonin" causes depression. Note that these two ideas are at the basis of every psychiatric drug peddled since the 1960s, and if they can be thrown into doubt, so can the efficacy of all the drugs currently on the market. Certainly, the drug companies' interests (as Marcia Angell, above all, has pointed out in her work) are well-served, but can we say the same for patients? Even the president of the American Psychiatric Association lamented in 2005: "As a profession, we have allowed the biopsychosocial model [of mental illness] to become the bio-bio-bio model."
The new biological researchers styled themselves neo-Kraepelinians, and the American Psychiatric Association's landmark Diagnostic and Statistical Manual-III (DSM), issued in 1980 and since then further revised, is a monument to Kraepelin in sharply distinguishing between the normal and the sick, in separating discrete categories of mental illnesses, and in focusing on the biological approach to mental illness. If each of these dubious propositions can be shown to be weak or even false, then the entire edifice of current psychiatric practice also collapses. Neuroscience, not any sort of talking therapy, was to be the panacea; "manipulating neurotransmitters, not...understanding and interpreting the patients' thoughts and feelings," was what young psychiatrists should learn. Has the DSM led to more accurate diagnoses than was the case before? Lauren Slater, in Opening Skinner's Box: Great Psychological Experiments of the Twentieth Century (2004), describes replicating Rosenhan's experiment by presenting herself as a patient at psychiatric emergency rooms.
Now to the dismantling of each of the three key propositions upon which present psychiatric practice rests. First, are psychiatric diagnoses meaningful? The concepts of both dementia praecox (schizophrenia) and manic depression, first proposed by Kraepelin, have undergone repeated transformations over the last century, with allied growth in various neuroses (anxiety disorders), subdivided into many classes. The DSM sought to achieve consistency in psychiatric diagnoses, but precision remains spurious. A significant obstacle to precision, according to Bentall, is comorbidity; often patients suffering one psychiatric illness seem to suffer from others as well, which keep shifting in intensity over time. As Bentall concludes damningly, "If the same drugs work for everyone, the diagnosis given to the patient has virtually no implications at all."
Second, as to the boundary between the "sick" and the "normal," many people have psychotic symptoms without requiring treatment. Schizophrenia is best perceived on a continuum, rather than as the dark side of a clear dividing line between normality and a lifetime of helplessness. In recent years, psychiatrists have desperately sought to preserve the structure of diagnostic precision by resorting to increasing "fractionation," for example of the "bipolar spectrum into bipolar 3 disorder, bipolar 4 disorder, and so on." Schizophrenia and bipolar disorder, instead of being thought of as 'real conditions," might be better seen as 'scientific delusions."
The third fundamental error of psychiatry follows from the "neo-Kraepelinian... assumption that psychiatric disorders are genetically determined diseases that are little influenced by the trials of life." The most that can be argued is that "genes play some role at some point in increasing the risk of mental illness, but nothing else." Bentall explains that "the only findings that have proved to be even marginally replicable concern genes that confer only a very small risk of psychosis and which are absent in the majority of patients" and that "if there were any genes with more direct and marked effects, they would have certainly been discovered by now." It is important to consider that "not a single...[patient] has ever benefited from genetic research into mental illness."
Yet current psychiatric practice prefers unchanging genetic influence over environmental factors--particular stresses and traumas in life--in aggravating mental illness. As Bentall argues, "Insecure attachment and victimization appear to contribute to paranoia, sudden trauma appears to cause hallucinations, and parental communication deviance has been implicated in thought disorder." Yet the psychiatrist's job these days is focused on getting the patient to agree to a discrete diagnosis, followed by quick agreement to take the prescribed medication. At the research level, psychiatric geneticists are busy trying to identify specific genes involved in schizophrenia, bipolar disorder, and other conditions--a fool's errand, if ever there was one, since the venture is premised on ignoring environmental influences.
The neo-Kraepelinians, i.e., the majority of the psychiatric profession today, have been obsessed with reliance on CT scans, and more recently MRI's, to locate the exact sites of brain disease. Yet even if dopamine neurones are involved in paranoia, it stands to reason that "the nervous system of an animal living the life of repeated victimization will become highly attuned to the detection of further threatening events." So it is reasonable to think that "the dopamine system becomes sensitized as a consequence of adverse experiences that predate the onset of illness," rather than being the cause.
The excessive profits of drug companies--"in 2002, the combined profits for the ten [largest] drug companies...[exceeded]...the profits of all the other 490 companies put together"--can be explained by our unreasonable expectations about what medical science can deliver. In The Role of Medicine: Dream, Mirage or Nemesis (1979), Thomas McKeown argues that most of the "health gains achieved during the nineteenth and early twentieth centuries were the consequence, not of advances in medical science, but of improvements in nutrition and sanitation." This concept leads to the recent global movement embracing evidence based medicine, which, Bentall argues, has so far not affected the psychiatric profession. Big Pharma continues to exploit loopholes in the concept of the randomized controlled trial (RCT), to adduce greater effectiveness for drugs than warranted.
In the late 1980s, SSRI's (serotonin re-uptake inhibitors), represented by Prozac, became immensely popular. The drug industry made extravagant claims for their effectiveness. Yet "subsequent metaanalyses have reported that nearly all of the therapeutic response to both the old and new antidepressants can be attributed to the placebo effect." Drug company data, submitted to the FDA in support of licensing applications, is kept secret, but when occasionally it comes to light severe problems of duration, size, and sample become manifest. For example, data from "47 trials of the six most popular new antidepressants...[shows] that the most rigorous of the studies had examined the patients for a mere eight weeks without any attempt to find out what happened to them afterwards, and that drop-out rates were so high that only 4 out of the 47 were able to report what happened to more than 70 percent of the patients." In short, psychotic drug trial data cannot be trusted.
Rather than adhere to the Hippocratic Oath of "first do no harm," psychiatrists are recently pushing for the earliest possible intervention--lifetime prescription of psychotic drugs--based on the manifestation of pre-symptoms, rather than actual illness, and for the inclusion of the widest possible population in such prescreening. Contrary to this drive, studies have shown that "first-episode...patients benefit less from...treatment than patients who have been ill for some time." Big Pharma and psychiatrists also claim that so-called second-generation drugs have fewer side effects, but many studies show that this is clearly not true. Of even more concern is the fact that long-term administration of psychotic drugs may worsen symptoms because of "the proliferation of the number of D2 receptors in the brain"--in other words, "the brain responds to having its dopamine receptors blocked by making more of them."
If drugs have been oversold, what is to be done then? Cognitive behavior therapy (CBT), which seeks to alter negative thought patterns, is one approach. It may or may not be more effective than other forms of psychotherapy, but at least it shows more respect for the patient than condemning him to a lifetime of medication, and making him feel useless because of irremediable genetic dysfunction in the brain. Many patients can manage the symptoms of schizophrenia without having to be condemned or committed. The aim should be to help patients improve their quality of life, rather than relying on bright-line distinctions between normality and illness. In the "paternalistic-medical" model, patients' preferences about treatment are ignored because their judgment is not trusted; in the "autonomy-promoting" model Bentall advocates, patients are actively involved in deciding the course of treatment. Bentall offers a neat schematic splitting the two models along the axes of principal advocates, beliefs about mental illness, attitude toward diagnosis, goals of treatment, attitude towards patients' judgments, attitude towards treatment, attitude towards the therapeutic alliance, attitude towards risk and coercion, and attitude towards medical skills that sharply distinguishes the polarities between the two approaches.
At stake in this debate is the utilitarian (Benthamite) versus deontological (Kantian) ethic. Both moral philosophies emphasize individual rights, the Kantians in particular arguing that individuals should always be treated as ends in themselves, rather than as means to ends. Present psychiatric practice, heading as it is toward condemning large swaths of the population to a perpetual sentence of mental deviance, doesn't even match the less rigorous scales of utilitarianism when it comes to individual autonomy. The present model is based on coercion, and coercion is wrong on several counts as an approach to mental illness.
Joanna Moncrieff, in The Myth of the Chemical Cure: A Critique of Psychiatric Drug Treatment (2008), has pointed out that we should free ourselves of the delusion that there can be specific drugs for discrete mental illnesses. She demonstrates that "a majority of the published trials show that antidepressants are a bit better than placebo, but despite the many possible biases which make positive results more likely, many studies found that antidepressants were no better than placebo and some found that they were worse." She also shows how "decades of research have failed to produce clear and independent evidence of a dopamine abnormality in people with psychosis or schizophrenia that cannot be attributed to some other cause" and that "there is little evidence to suggest that there is a characteristic abnormality in [the serotonin and noradrenalin]...systems that is associated with depression." Instead, Moncrieff argues that "the early marketing campaigns for antidepressants had to establish the idea of depression as a common, medically treatable condition"--the more common, the better, from the drug companies' point of view.
In addition to recognizing the limitations of drugs, more emphasis needs to be placed on the sociological roots of depression (as Bentall points out, the majority of mentally ill patients tend to be unemployed, and employment tends to assist in recovery). Psychiatry, since the early 1950s, has stalled; the revolutionary impetus of the 1960s is gone; the profession needs to reboot, and start treating people again as people, not as "plants." The motivation behind the new drugs remains the same as it was for the radical remedies of electroconvulsive therapy, prefrontal leucotomy, and insulin coma therapy.