The Epidemic of Mental Illness: Why?

~ Jason Schwartz

CNN.com summarizes a NYT Book Review review of three recent books that challenge conventional wisdom about mental illness.

All of the authors of the new books agree on two thought-provoking viewpoints:

1. Our understanding of categories of mental illness and their treatments has been influenced by drug companies, through both legal and illegal marketing.
2. Mental illness is not caused by chemical imbalances in the brain.

You can view a talk from the author of Anatomy of an Epidemic here. He does not appear to be the gadfly one might expect. He appears pretty dispassionate and grounded in (ignored) research.

My impression is that it might be unfair to say that he argues  “mental illness is not caused by chemical imbalances in the brain”. This would give the impression that he believes mental illness is entirely exogenous. Rather, he seems to argue three points:

  1. That we have been barking up the wrong trees focusing on dopamine and serotonin regulation for psychiatric symptoms;
  2. that we overestimate the helpfulness of psychiatric drugs and underestimate the long term harms; and
  3. that the assumption that psychiatric symptoms indicate a chronic brain imbalance is wrong and that many people experiencing psychiatric symptoms might be better off if they are not placed on psychotropics on a long-term basis.
He suggests a different path for treatment that does include use of medications:
This does not mean that antipsychotics don’t have a place in psychiatry’s toolbox. But it does mean that psychiatry’s use of these drugs needs to be rethought, and fortunately, a model of care pioneered by a Finnish group in western Lapland provides us with an example of the benefit that can come from doing so. Twenty years ago, they began using antipsychotics in a selective, cautious manner, and today the long-term outcomes of their first-episode psychotic patients are astonishingly good. At the end of five years, 85% of their patients are either working or back in school, and only 20% are taking antipsychotics.
I also just noticed this unrelated paper finding high rates of recovery from borderline personality disorder. This conflicts with the conventional wisdom and raises the question of whether “personality disorder” is the proper way to characterize what’s going on with these patients.

Published by Jason Schwartz

I have been an addiction professional and social worker since 1994. I started blogging in 2005 as the Clinical Director at Dawn Farm. I no longer work at Dawn Farm and am now the Director of Behavioral Medicine at a community hospital, and a lecturer at Eastern Michigan University’s School of Social Work. Views expressed here are my own. Keep in mind that the field, the contexts in which the field operates, and my views have changed over time.

19 thoughts on “The Epidemic of Mental Illness: Why?”

  1. I’m concerned by this in the UK too. The defensive (and dismissive) reactions from those with a vested interest in this when challenged are also of concern.

  2. We see so many clients who were diagnosed with bipolar disorder in and emergency department at the end of a crack binge or major depression after their alcoholism has led to the loss of their marriage, job and estrangement of their children.

    So, I always worry about a rush to diagnosis and that we’ll mistake the effects of addiction for mental illness.

    But, even in those who are impaired by psychiatric symptoms, I worry about them getting into mental health services. Why? Because the automatic, universal assumption is that they have a chronic illness that will require mental health services for the rest of their lives. And, too many clients start integrating this diagnosis into their identity.

    We have our own similar history, but I hope we’re doing a better job of distinguishing between chronic and acute substance use problems.

  3. I really enjoyed Dawn Farm’s position paper on mental illness and psychotropic drugs found here: http://scr.bi/jftDdZ I do think that mental illness is over diagnosed especially in America, there significantly less rates of depression and bipolar in different countries. The problem I have with this issue is the stigma there is against Mental Illness in the 12 Step community. There are people who get sponsors, take the steps, go to meeting, and find a God of their understanding and still don’t feel right. Then they don’t get the help they need because of shame and stigma.

    I think Dawn Farm has a tremendous influence in the Ann Arbor AA community and contributes to the stigma against mental illness in our 12 step community. While I understand that Dawn Farm has a nuanced view on mental illness and medication management for opiates that nuance does not come across on this blog or in the community as a whole. The only thing that comes across is that these things are bad. Dawn Farm does many things to lessen its environmental impact as far as being “green” it should also look at the footprint that it has in the AA community.

    Here is AA’s opinion on Medication

    Click to access AA_brochure.pdf

    Here is Dawn Farm’s Again
    http://scr.bi/jftDdZ

  4. @BigEasy Thanks for the comment. I sometimes worry that, in commenting on what’s in the news, this blog is sometimes reactive and misses the mark in terms of emphasis.

    This particular post included discussion of a an alternative approach to psychiatric treatment that included medication. I included this to make it clear that we’re not kneejerk about meds or anti-psychiatry.

    What do you wish I would have added or omitted?

  5. @BigEasy I’m also interested in hearing more about how you see the stigma manifesting itself. I don’t doubt that there’s truth to what you say, but my experience is that a very large portion of the recovering community is on a psychotropic or has been on one. They are pretty open about it and it’s not a big deal. Do you see certain meds, certain diagnoses, etc getting stigmatized?

    That being said, I know that there are a few tribes within the recovering community that discourage the use of meds, but I’ve always seen those positions as being on the margins rather than the norm.

  6. I am also part of the 12 step community in A2. I have been around for a few years and I have not observed the stigma referred to above. I agree that there are many people on psych meds in the community here, including me at various times in my recovery, and its been all right. I sponsor guys in the community who take meds like lithium, celexa, and gabapentin and I have never heard any of them complain of stigma. Now if you are talking about suboxone, thats a different story.

  7. I have seen the stigma against mental health while working with clients who have “worked a good program” but are still suffering form depression and wont seek help. This could be there own personal bias and I can be wrongly attributing it to the community as a whole. I have definitely seen stigma against suboxone, where clients were being told how bad that stuff was.
    I was really trying to make a broader statement where I believe that Dawn Farm’s policies affect the A2 recovering community because so many people come from the Dawn Farm family of programs. When I read this blog it seems to have an anti-psychotropic, anti-suboxone bent and I think that affects the community as a whole.
    If I am not mistaken clients involved in the Dawn Farm transitional housing cannot be on psychotropics or suboxone and I have heard of people hiding that fact.
    I don’t know if I am being helpful by repeating things I don’t know to 100% true.
    I really did want to make the point that Dawn Farm has a huge impact on the community as a whole and that it should be aware of that fact.
    There are meetings that have sprouted up that are distinctly anti-Dawn Farm or anti ***** (Edited to remove a name that identified an AA member) meetings. I think its unfair to name those meetings pejoratively ***** (Edited to remove a name that identified an AA member) or Dawn Farm meetings. But the fact is they exist. If Dawn Farm were to change it’s approved meeting list or the meetings that it takes Detox to it would change the Dynamics of all the meetings involved.
    The problem sometimes is that it is hard for people who are not in the Dawn Farm Eco System to break in to A2 AA.
    Some my point is really that everything Dawn Farm does has an impact on our AA community and they should be aware of that.
    Personally I love the farm, being able to volunteer at detox and give ride outs to farmers has saved my life, but I do want to hold the mirror up for the farm the best I can.

  8. “If I am not mistaken clients involved in the Dawn Farm transitional housing cannot be on psychotropics”

    Not true, never has been. We have a hands-off approach to medications other than benzos, opiates, stimulants and a few other mood-altering meds like DXM. Also, a pretty large minority of our residential clients are on psychotropics.

    “If I am not mistaken clients involved in the Dawn Farm transitional housing cannot be on … suboxone”

    True. We think suboxone is a great detox tool, but we’re very concerned about suboxone maintenance. Incidentally, we’ve had increasing contact with prescribing programs and physicians that have become concerned about the effects of their own maintenance prescribing practices.

    “If Dawn Farm were to change it’s approved meeting list or the meetings that it takes Detox to it would change the Dynamics of all the meetings involved.”

    Our approach to our meeting selection is here. (We’re also starting to pay more attention to avoiding meetings in which smoking is part of the culture. We’re trying to make it easier for people who are trying to quit.)

    We’re open to adding meetings that have the characteristics we describe.

    I’d like to know more about how changing the Spera meeting list might change the dynamics of meetings.

    “The problem sometimes is that it is hard for people who are not in the Dawn Farm Eco System to break in to A2 AA.”

    I don’t understand this. Talk to me like I’m stupid and explain it to me.

    Thanks again for the comments.

  9. Thanks for clarifying some of my misconceptions. There is a Dawn Farm clique in A2 recovery. If you come from the Dawn Farm program you are more likely to get a Dawn Farm sponsor and be invited into one of the cliques and have an automatic support system because of the fact you are in the Dawn Farm ecosystem. This is not inherently a bad thing in fact it is a good thing to have a built in support system. This clique phenomenon is most prominent with young caucasian people who are a part of the ecosystem.
    People who are not young and caucausian seem to be forced into the outgroup and it is harder for them to find support within the meetings that are dominated by Dawn Farm.

    1. We haven’t always enjoyed such strong ties to the recovering community. About 12 years ago we started working hard to improve this relationship–by making it as easy as possible to engage in 12 step work, showing respect for the recovering community, creating meeting space for the community, and framing ourselves as an adjunct to the recovering community rather than vice versa. We also work hard to keep alumni involved on a long term basis. I wish there were more cliques (I’d prefer to call them tribes.) to support the needs of particular segments of the community.

      The young recovering community in Ann Arbor is unlike any community I have seen before. It’s a rare thing and a tremendous blessing. It is largely white, though I know a lot of Latino young people within it and Ann Arbor is less than 9% black. (For what it’s worth, problems of black under-representation in AA are long-standing and common in other communities. Seems a little unfair to point to Dawn Farm on this. Public funding’s emphasis on injection drug users has reduced African American representation higher levels of care. This is something we’re working on.)

      Also, from your earlier comment. I do sometimes worry that the blog comes across as anti-med. However, pharmacology’s hegemony doesn’t need my help.

      I don’t believe we have a problem of underprescribing or underpromotion of meds. I do believe we have a problem of too few writers and researchers taking a critical eye to these issues. All you have to do is turn on your TV, pick up a magazine or journal to get a medication promoting message. We’re trying to offer a perspective that we think is important and absent from media coverage and professional discourse.

  10. I am grateful I found solutions in my life and countless others that does not require man made medication! All medication does is numb you out and keep a lead on the pressure cooker. It doesn’t solve anything! I don’t mean to be anti – meds either I know there are cases where it is necessary and appropriate. But I also know there are some heavy handed RX writers. Doctors are overworked and over taxed in paper work by the insurance companies. I wonder what doctors would do if they were free to practice medicine without justifying their treatment to the insurance company and without the pharmaceutical companies compensating them for their loyalty.

    1. I’m with you. I know there are a lot of factors that contribute to the problem, but a few that come to mind are:

        There is so little time for doctors to provide care and writing a prescription makes both parties feel like something was done;

      • If the only tool you have is a hammer, everything looks like a nail;

        • Risk management. Especially in emergency care settings where the patient is being discharged back into high risk situations. The institution and practitioners can feel like they did something if something terribel happens to that patient.

  11. I think Dawn Farm is great I think the amount of young people in Ann Arbor AA is great all I am saying is that there are some unintended consequence to the way Dawn Farm does things.
    I am not attacking Dawn Farm, I am just pointing out the well known perspective from many people in the outgroup.
    I don’t think Dawn Farm is racist, So my goal was not to attack Dawn Farm and have you defend but for you to look at some its “footprint” in the community.
    Here is one more thing to look at and maybe a type of solution too.
    You state that Ann Arbor is only 9% black but you are located in Ypsilanti and Ypsilanti is almost 30% black. It is also safe to say that you serve many clients from outside of Ann Arbor and they end up moving to Ann Arbor.
    The thing is that Dawn Farm sends many Drug Addicts to AA. Now this is not a problem in the liberal A2 community but in other communities they would be shouted down for talking about drugs. Many white addicts go to AA because they say it is less chaotic more spiritual etc. But the fact of the matter is that NA has greatly matured in the Washtenaw County Area. NA however tends to be predominately black in Washtenaw County. So providing equal access to AA and NA meetings while in Spera and in the beginning of Dawn Farm residential could help to form the same recovery cliques/tribes (I like the word tribes too.) seen in AA in NA.
    I understand too that Dawn Farm does allow clients to go to NA meetings and also allows them get ride outs from NA members so the honus is not only on Dawn Farm.

    Like I said I hope you just take a look at my comments objectively and not defensively and just realize I’m trying to point some things out that may not cross yours or Dawn Farm’s mind. Thanks for taking the time respond to my earlier comments.

  12. I appreciated reading these comments from Big Easy. I check this blog regularly because I find stories and links I want to explore further. I’m also familiar with Dawn Farms because I live in the greater Detroit area, and because my son was a hard core, downtown Detroit heroin addict for over a decade. Over the years, I researched every type of treatment available around here, and while my son did not go to Dawn Farm, I always found the concept of the farm interesting.

    I agree totally with Big Easy, as far as the blog having an anti med, anti suboxone slant. I actually thought the residents were not allowed psych meds, based solely on the tone of what I’ve read here. My personal opinion on these matters is not important. I’m an independent layperson..OK, I’m a mom…whose only experience with addiction is my own family. I throwing my 2 cents in because Jason asked.

    The point made about Ann Arbor and Ypsi is very relevant. Also, I thought a fair number of residents came from prison/jail, and I would think that would include a higher percentage of blacks (not a racist comment, just a fact that Michigan, and the US, incarcerates more blacks than whites based on population numbers).

    FYI, in the western suburban AlAnon meetings I attend, at least half the shares are about “my addict”, not “my alcoholic”. There is no problem with this at the meetings I have attended. It is accepted most people have a drug of choice, but will switch from drugs to alcohol, and vice versa, if the need arises.

  13. There is an extremely strong perception among many people I know in the local recovering community that Dawn Farm is biased towards some meetings and against others, and is biased against NA. This does not mean that Dawn Farm is not respected and that your work is not appreciated. There is a perception that the Farm thinks there is a Farm way to do AA and a wrong way to do AA. Whether this perception is true or false, fair or unfair, it exists. You have staff members, including at least one highly placed member, who are vocal about their opinion of the “right vs. wrong” way to do recovery. I have on occasion heard Dawn Farm staff be unhelpfully harsh or unhelpfully patronizing towards people who were following a recovery path not endorsed by Dawn Farm or who were struggling, and some of the perceptions in the community may come from people interpreting the opinions your staff espouse as being representative of Dawn Farm’s opinion, but I don’t think it is all and only that. One of your three-quarter house managers once told me that he will not ‘count” a meeting that’s not on “the list” towards the required number of meetings residents have to attend. Have you ever actually added a new meeting that someone suggested to your list? If it’s true that you are “open to adding meetings that have the characteristics we describe” to your meeting list – does it seem odd to you that the meetings on that list don’t include even one NA meeting? Do you really believe there are no NA meetings in the entire county that meet the “characteristics” you say you look for? Really? If you do truly believe that then I have to believe you’re out of touch with the recovering community that exists outside your own personal cliques, or “tribes” if you prefer that term, and not interested in getting in touch. I personally go to AA (never did drugs other than alcohol) and until my recent move one of the meetings on your list was my home group. There is a meeting on your list that I stopped attending because gossip was rampant and confidentiality of what is said at the meeting was severely compromised on a regular basis, and as a result the “characteristics” of that meeting didn’t work for me and when I went to a meeting on that night I went to one that is not on your list. Some people may not relate as strongly to your endorsed meetings or your particular “tribes” as they might to another.

    I’m impressed that you were willing to print the previous comments and that you seem open to feedback. Dawn Farm does great work with many people who need your help. You might be able to be of more help to more people (including, as was previously pointed out, a more representative percentage of African American people) by being open to connecting with a broader sector of the recovering community and by working on the perception (whether true or false) that Dawn Farm tries to be the arbiter of what comprises “good” vs. “bad” AA and “good” vs. “bad” recovery, and the perception that you don’t really want to get to know people who do not fit into your own “tribes”.

    1. Transitional housing residents have to attend a meeting every day and a couple of their days off, though this may be relaxed after they are well established. A certain number of meetings must come from the list (Five, I think.) For the other meetings, they are free to go to whatever meetings they choose.

      We provide meeting space for an NA meeting, our clients attend it frequently.

      We believe that steering our clients to meetings that consistently welcome newcomers, offer opportunities for service, emphasize sponsorship, emphasize solutions and include regular members with long term recovery has been integral to our success. I don’t view it as a matter of good or bad AA/recovery. We view it as a matter of knowing we don’t have unlimited bites at the apple to launch this person in recovery and we’re going to steer them to the meetings that we believe offer the best chance for joining a stable, growth-fostering community of recovery. If you had a buddy moving to town, you’d probably do the same thing. This approach is always going to tick someone off, but the alternative of not steering our clients to groups like I’ve described is not acceptable to us.

      Meetings have been added to the list over the years after suggestions from residents. Maybe it’s time to be reviewed again, some may need to be added and others may need to be dropped. (I honestly don’t know, it’s not in my purview.) If you want to make suggestions, email them to me and I’ll pass them to Charles.

      Your comments will be discussed to be sure that our staff and house managers are on the same page.

      We’re never going to be everyone’s cup of tea, but we’re always trying to improve. We try to take Bill’s advice and make our critics our benefactors even if we wish the criticism was a little more constructive and the assumptions were a little more generous.

      Also, we’ve never pretended to me the only way. If someone has a better way, we’d love to see more transitional housing in the community. Go for it.

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