Will Self reviews a recently published book on psychiatry and has some interesting observations on the relationships between addicts, mutual aid groups and psychiatry:
Interestingly there is one large sector of the “mentally ill” that Burns believes are manifestly unsuitable for treatment – drug addicts and alcoholics. He points to the ineffectiveness of almost all treatment regimens, possibly because the cosmic solecism of treating those addicted to psychoactive drugs with more psychoactive drugs hits home despite his well-padded professional armour. Elsewhere in Our Necessary Shadow he seems to embrace the idea that self-help groups of one kind or another could help to alleviate a great deal of mental illness, and it struck me as strange that he couldn’t join the dots: after all, the one treatment that does have long-term efficacy for addictive illness is precisely this one.
Psychiatrists are notoriously unwilling to endorse the 12-step programmes, and argue that statistically the results are not convincing. There may be some truth in this – but there’s also the inconvenient fact that there’s no place for psychiatrists, or indeed any of the psy professionals, in autonomously organised self-help groups. Burns agrees with Davies that our reliance on psychiatry, and by extension, psycho-pharmacology, may well be related to our increasingly alienated state of mind in mass societies with weakened family ties, and often non-existent community ones. Surely self-help groups can play a large role in facilitating the rebirth of these nurturing and supportive networks? But Burns seems to feel that just as we will always need a professional to come and mend the septic tank, so we will always need a pro to sweep out the Augean psychic stables. I’m not so sure; psychiatry has been bedevilled over the last two centuries by “treatments” and “cures” that have subsequently been revealed to be significantly harmful. From mesmerism, to lobotomy, to electroconvulsive therapy, to Valium and other benzodiazepines – the list of these nostrums is long and ignoble, and I’ve no doubt that the SSRIs will soon be added to their number.
Sooner or later we will all have to wake up, smell the snake oil, and realise that while medical science may bring incalculable benefit to us, medical pseudo-science remains just as capable of advance. After all, one of the drugs that Irving Kirsch’s meta‑analysis of antidepressant trials revealed as being just as efficacious as the SSRIs was … heroin.
Allen Frances, Chair of the DSM-IV Task Force lets loose on the DSM-5. He acknowledges the noxious effects of professional interests on research and practice in a way that is rarely seen from leaders of his stature. [emphasis mine]
This is the saddest moment in my 45 year career of studying, practicing, and teaching psychiatry. The Board of Trustees of the American Psychiatric Association has given its final approval to a deeply flawed DSM 5 containing many changes that seem clearly unsafe and scientifically unsound. My best advice to clinicians, to the press, and to the general public – be skeptical and don’t follow DSM 5 blindly down a road likely to lead to massive over-diagnosis and harmful over-medication. Just ignore the ten changes that make no sense.
…
The motives of the people working on DSM 5 have often been questioned. They have been accused of having a financial conflict of interest because some have (minimal) drug company ties and also because so many of the DSM 5 changes will enhance Pharma profits by adding to our already existing societal overdose of carelessly prescribed psychiatric medicine. But I know the people working on DSM 5 and know this charge to be both unfair and untrue. Indeed, they have made some very bad decisions, but they did so with pure hearts and not because they wanted to help the drug companies. Their’s is an intellectual, not financial, conflict of interest that results from the natural tendency of highly specialized experts to over value their pet ideas, to want to expand their own areas of research interest, and to be oblivious to the distortions that occur in translating DSM 5 to real life clinical practice(particularly in primary care where 80% of psychiatric drugs are prescribed).
The article opens by reflecting on where we stand with our attempts to understand the causes:
…the outcome of two decades of serious psychiatric science is that schizophrenia now appears to be a complex outcome of many unrelated causes—the genes you inherit, but also whether your mother fell ill during her pregnancy, whether you got beaten up as a child or were stressed as an adolescent, even how much sun your skin has seen. It’s not just about the brain. It’s not just about genes. In fact, schizophrenia looks more and more like diabetes. A messy array of risk factors predisposes someone to develop diabetes: smoking, being overweight, collecting fat around the middle rather than on the hips, high blood pressure, and yes, family history. These risk factors are not intrinsically linked. Some of them have something to do with genes, but most do not. They hang together so loosely that physicians now speak of a metabolic “syndrome,” something far looser and vaguer than an “illness,” let alone a “disease.” Psychiatric researchers increasingly think about schizophrenia in similar terms.
The author reports disenchantment with a simple biomedical model and offer three reasons.
First, disappointment with medication:
The first reason the tide turned is that the newer, targeted medications did not work very well. It is true that about a third of those who take antipsychotics improve markedly. But the side effects of antipsychotics are not very pleasant. They can make your skin crawl as if ants were scuttling underneath the surface. They can make you feel dull and bloated. While they damp down the horrifying hallucinations that can make someone’s life a misery—harsh voices whispering “You’re stupid” dozens of times a day, so audible that the sufferer turns to see who spoke—it is not as if the drugs restore most people to the way they were before they fell sick. Many who are on antipsychotic medication are so sluggish that they are lucky if they can work menial jobs.
Second, the genetics are much more complicated than was assumed:
The second reason the tide turned against the simple biomedical model is that the search for a genetic explanation fell apart. Genes are clearly involved in schizophrenia.
But:
The effort to narrow the number of genes that may play a role has been daunting. A leading researcher in the field, Ridha Joober, has argued that there are so many genes involved, and the effects of any one gene are so small, that the serious scientist working in the field should devote his or her time solely to identifying genes that can be shown not to be relevant.
Third, global research is revealing that culture and social factors play a much bigger role than previously understood:
The third reason for the pushback against the biomedical approach is that a cadre of psychiatric epidemiologists and anthropologists has made clear that culture really matters. In the early days of the biomedical revolution, when schizophrenia epitomized the pure brain disorder, the illness was said to appear at the same rate around the globe, as if true brain disease respected no social boundaries and was found in all nations, classes, and races in equal measure. … In recent years, epidemiologists have been able to demonstrate that while schizophrenia is rare everywhere, it is much more common in some settings than in others, and in some societies the disorder seems more severe and unyielding.
For example:
Schizophrenia has a more benign course and outcome in the developing world. The best data come from India. In the study that established the difference, researchers looking at people two years after they first showed up at a hospital for care found that they scored significantly better on most outcome measures than a comparable group in the West. They had fewer symptoms, took less medication, and were more likely to be employed and married.
The article closes with a few examples of alternative strategies from other countries. I’m sure it will provoke controversy, but seems increasingly hard to defend the status quo.
This may help explain why addiction treatment guards itself from the encroaching medical model so tenaciously. (Worth noting that mental health system guards its model pretty vigorously too.)
Of course, none of this means that there aren’t lousy treatment providers or that there isn’t room for improvement in addiction treatment. Just that there is something worth protecting there and patients in the mental health system see it.
“Once I became my diagnosis, there was no one left to recover.”
(Photo credit: Robbie Wroblewski)
Yesterday’s Pat Deegan post led me to Dr. Daniel Fisher’s work on mental illness recovery. He promotes an “empowerment” model of recovery that he contrasts with a “rehabilitation” model of recovery.
According to this vision, one is capable of recovering from the mental illness itself, not merely regaining functioning while remaining mentally ill. … We realize that the idea that people can recover from mental illness will create more work on the part of entitlement programs. Instead of a single, once-in-a-lifetime determination of disability, episodic periods of disability will need to be supported.
In this model, treatment is part of self-managed care. The goal of treatment here is assisting people in gaining greater control of their lives and assisting them in regaining valued roles in society. The primary goal of treatment should not be to control the person’s behavior. The use of medication does not itself mean that a person has not recovered from mental illness. It depends upon the degree to which the person and those around them see the medication as constantly needed. Ideally, each person should learn to take medication on an as-needed basis, after having learned to self-monitor. Many people also embrace holistic health as an alternative to medication.
Not surprisingly, many researchers have concluded that medication alone is best for the treatment for mental illness. Despite recent convincing research showing the usefulness of psychotherapy in treating schizophrenia, psychiatric trainees are still told “you can’t talk to a disease.” This is why psychiatrists today spend more time prescribing drugs than getting to know the people taking them.
I, too, used to believe in the biological model of mental illness. Thirty-one years ago, as a Ph.D. biochemist with the National Institute of Mental Health, I researched and wrote papers on neurotransmitters such as serotonin and dopamine. Then I was diagnosed with schizophrenia — and my experience taught me that our feelings and dreams cannot be analyzed under a microscope.
…
Schizophrenia is more often due to a loss of dreams than a loss of dopamine. At the NEC, we try to reach out across the chasm of chaos. I know there are many people who feel they have done all they can, have struggled against mental illness to no avail, and we understand their pain. Yet we believe that recovery is eventually possible for everyone — although it can take a long time to undo the negative messages of past treatments. We can offer hope from first-hand experience.
Another post identifies common factors in these recovery experiences. I’ve summarized them. It’s worth noting that that author reports that people achieving recovery reported that traditional psychiatric treatment was a barrier to achieving these factors.
Factor #1: Hope in the possibility of real recovery. All participants in all three of my research studies expressed that in order to even begin the journey towards real recovery, they first had to believe that such recovery is actually possible.
Factor #2: Arriving at an understanding of their psychosis alternative to the brain disease theory. Every participant went through a process of developing a more hopeful understanding of their psychotic experiences, generally coming to see their psychosis as a natural though very risky and haphazard process initiated by their psyche in an attempt to cope and/or heal from a way of being in the world that was simply no longer sustainable for them.
Factor #3: Finding meaning. All participants expressed how important it was for them to connect with meaningful goals/activities that made their life worth living—that provided them with some motivation to greet each new day with open arms and to channel their energy productively.
Factor #4: Connecting with their aliveness. All participants reported how important it was for them to connect more deeply with themselves—particularly with their feelings, needs, and sense of self agency.
Factor #5: Dealing with their relationships. All participants expressed the importance of healing and/or distancing themselves from unhealthy relationships and cultivating healthy ones.
Rethink Mental Illness (Photo credit: Wikipedia)
It seems that the biggest objection to the disease model is that mental health consumers experience this model as something that puts them in a passive position, waiting for someone or something to come along and hopefully mend their broken brain just enough to allow them to get through life with something less than full personhood.
This article in Friday’s Wall Street Journal gets at the same thing with respect to much less severe mental illness as experienced by young people.
When I first began to take antidepressants, I understood that doing so meant I had a chemical imbalance in my brain. I knew that, arguably, I should find that comforting—it meant that what I was going through wasn’t my fault—but instead it made me feel out of control. I wanted my feelings to mean something. The idea that my deepest emotions were actually random emanations from my malfunctioning brain didn’t uplift me; it just further demoralized me.
In my 20s, I sought out talk therapy, partly to deal with the questions that using antidepressants raised for me and partly because the effects of the drugs, spectacular in the short term, had waned over time, leaving plenty of real-world problems in their wake. Only then did I begin to notice just how nonrandom my feelings were and how predictably they followed some simple rules of cause and effect.
Looking back, it seems remarkable that I had to work so hard to absorb an elementary lesson: Some things make me feel happy, other things make me feel sad. But for a long time antidepressants were giving me the opposite lesson. If I was suffering because of a glitch in my brain, it didn’t make much difference what I did. For me, antidepressants had promoted a kind of emotional illiteracy. They had prevented me from noticing the reasons that I felt bad when I did and from appreciating the effects of my own choices.
What’s so interesting about this is that people with addictions have a completely different experience. Within the context of addiction recovery, discovering that one has the illness of addiction means that one has a lot of work to do and a lot of responsibility for their recovery. This model is not without its limitations, but it’s amazing how many people find an admission of powerlessness to be so empowering.
I have two thoughts.
First, there seems to be a parallel here. People band together in response to the failure of existing institutions and, together, find an alternative path to recovery. The institutions use their size, wealth, connections, research and publications to de-legitimize this path to recovery. It’s probably a very good thing that PhRMA didn’t have a stake in addiction treatment in 1935.
Second, as the Affordable Care Act is implemented and we need to start really grappling with the cost of chronic diseases, this empowerment model of recovery fits very well with a lifestyle medicine approach. Unfortunately, our medical system is not structured (staffing, reimbursement, monitoring, research, etc.) to support this approach.
I think mental health and addiction treatment have a lot to learn from lifestyle medicine, but I also think addiction and mental illness recovery movements have a lot to teach lifestyle medicine about how patients can maintain wellness over decades.
NOTE: Dawn Farm is not anti-medication, though we do have concerns about the way they are used. More information here.
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:
That we have been barking up the wrong trees focusing on dopamine and serotonin regulation for psychiatric symptoms;
that we overestimate the helpfulness of psychiatric drugs and underestimate the long term harms; and
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.
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.
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:
That we have been barking up the wrong trees focusing on dopamine and serotonin regulation for psychiatric symptoms;
that we overestimate the helpfulness of psychiatric drugs and underestimate the long term harms; and
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.
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.
Allen Frances, Chair of the DSM-IV Task Force lets loose on the DSM-5. He acknowledges the noxious effects of professional interests on research and practice in a way that is rarely seen from leaders of his stature. [emphasis mine]
CNN.com summarizes a NYT Book Review review of three recent books that challenge conventional wisdom about mental illness.
Addiction & Recovery News 