Talk Elections

Diagnoses are psychiatry's star signs. Let's listen more and drug people less



Surveying the history of psychiatry, the medical historian Edward Shorter remarked: "If there is one central intellectual reality at the end of the 20th century, it is that the biological approach to psychiatry – treating mental illness as a genetically influenced disorder of the brain chemistry – has been a smashing success."

Far from being a success, there is compelling evidence that the biological approach has been a lamentable failure. Whereas last century saw dramatic improvements in the survival rates of patients suffering from heart diseases and cancer, so far as we can tell, outcomes for patients suffering from the severest forms of psychiatric disorder – the psychoses (disorders in which the patient experiences hallucinations or delusions, usually resulting in a diagnosis of schizophrenia or bipolar disorder) – have hardly changed since the Victorian period. Poor countries without well-resourced psychiatric services seem to do at least as well as the developed world. Therefore, although the perception is often different, there is little evidence that modern psychiatric services have had a global, positive impact on mental health.

At the beginning of the 21st century a new picture of severe mental illness is emerging, which shows that the genetically determined brain disease paradigm is not only ineffective but scientifically flawed. First, it seems that diagnoses such as schizophrenia and bipolar disorder do not identify discrete conditions analogous to, say, appendicitis or tuberculosis. Patients with a mixture of bipolar and schizophrenia symptoms are at least as common as patients who fit one or other diagnosis. The concept of schizophrenia is so broad that two patients can share the diagnosis while having no symptoms in common.

In the case of both types of symptoms, there appear to be many people whose experiences place them on the borderline between health and illness, so that we can think of a spectrum running from ordinariness, through eccentricity and creative thinking, to full-blown psychiatric disorder. Research has also shown that psychiatric diagnoses are poor predictors of response to treatment, giving little indication of which patients will respond to which drugs. They are therefore hardly more meaningful than star signs – another diagnostic system that is supposed to tell us something about ourselves and what will happen in the future, and which is widely embraced despite no evidence of its usefulness.

When new methods of molecular genetics have been used to study psychiatric patients, no genes of major effect have been found. The latest evidence suggests that many genes – possibly thousands – each make a tiny contribution to vulnerability to psychiatric disorder, and that these effects are highly non-specific (the same genes are implicated in patients with different diagnoses).

Some findings that were announced with enormous fanfare have not been replicated in subsequent studies. Much, for instance, has been made of the discovery of a variant of the 5-HTTLPR gene, which appears to make people liable to depression if they are exposed to unpleasant life events. A recently published analysis of the data available on this gene found no evidence that it directly causes depression, or that it makes people vulnerable to depression. However, it was found that negative life events had a direct impact on mood: as our mothers could have told us, bad things tend to make us miserable.

This last observation is consistent with other evidence that life experiences shape even the most severe forms of mental illness. Migrants have at least a four times greater risk of psychosis than other groups, and this effect is most pronounced if they live in areas in which they are in a minority. Early separation from parents has also been shown to increase the risk of psychosis, as have growing up in an urban environment and chronic bullying.

Many studies have also reported an association between trauma in early life and psychosis. These effects are large: one recent study estimated that individuals who had been sexually abused in childhood were 12 times more likely than others to suffer from serious mental illness, and another calculated that the population-attributable risk of a diagnosis of schizophrenia associated with an inner-city childhood was 15% (that is, there would be 15% fewer cases if we all grew up in the countryside). The risk associated with having a parent with the diagnosis is 7% (ie, there would be 7% fewer cases if patients stopped having children).

These effects are understandable in the light of psychological research. For example, early trauma seems to disrupt the process by which we distinguish between our own thoughts and our perceptions, leading to a specific risk of hallucinations. Disruption of early relationships with caregivers, coupled with victimisation, create a tendency to mistrust others and to anticipate threats, leading to paranoid delusions.

The cruel and ineffective treatments that characterised psychiatry in the mid-20th century – for instance, prefrontal leucotomy and insulin coma therapy – would not have been accepted had psychiatrists not been in thrall to the idea that mental illnesses are genetically determined brain diseases. Today, although mental health professionals are usually much more compassionate than in those dark times, psychiatric services continue to see their primary objective as ensuring that patients take their medication.

Legislation has been introduced allowing doctors to coerce patients to take their drugs with threats of a return to hospital if they do not comply. Patients often find that their own understandings of their troubles are ignored. A study of psychiatrists in London found that, when patients asked questions about the meaning of their experiences, the doctors typically changed the subject.

Meanwhile, research on the biology of severe mental illness continues to be prioritised over social and psychological research. Biological investigations into psychosis currently outnumber those on environmental factors by at least five to one, and are much more generously funded by the UK's Medical Research Council. To date, about 30 trials of cognitive therapy for psychosis have been completed; by comparison, in the period 2001-3, nearly 400 drug trials were published in the five leading American psychiatric journals. There is therefore an urgent need to develop a less drug-based, more person-centred approach to understanding and treating mental illness, which builds on the recent scientific findings and which takes the experiences of patients seriously.

When new methods of molecular genetics have been used to study psychiatric patients, no genes of major effect have been found. The latest evidence suggests that many genes – possibly thousands – each make a tiny contribution to vulnerability to psychiatric disorder, and that these effects are highly non-specific (the same genes are implicated in patients with different diagnoses).

When new methods of molecular genetics have been used to study human height, no genes of major effect have been found. The latest evidence suggests that many genes – possibly thousands – each make a tiny contribution to vulnerability to human height, and that these effects are highly non-specific (the same genes are implicated in patients with different heights).

and this effect is most pronounced if they live in areas in which they are in a minority. Early separation from parents has also been shown to increase the risk of psychosis,

as have growing up in an urban environment

and chronic bullying.

Many studies have also reported an association between trauma in early life and psychosis. These effects are large: one recent study estimated that individuals who had been sexually abused in childhood were 12 times more likely than others to suffer from serious mental illness,

and another calculated that the population-attributable risk of a diagnosis of schizophrenia associated with an inner-city childhood was 15% (that is, there would be 15% fewer cases if we all grew up in the countryside).

These effects are understandable in the light of psychological research.

The cruel and ineffective treatments that characterised psychiatry in the mid-20th century – for instance, prefrontal leucotomy and insulin coma therapy – would not have been accepted had psychiatrists not been in thrall to the idea that mental illnesses are genetically determined brain diseases.

Today, although mental health professionals are usually much more compassionate than in those dark times, psychiatric services continue to see their primary objective as ensuring that patients take their medication.

Legislation has been introduced allowing doctors to coerce patients to take their drugs with threats of a return to hospital if they do not comply. Patients often find that their own understandings of their troubles are ignored. A study of psychiatrists in London found that, when patients asked questions about the meaning of their experiences, the doctors typically changed the subject.

Meanwhile, research on the biology of severe mental illness continues to be prioritised over social and psychological research. Biological investigations into psychosis currently outnumber those on environmental factors by at least five to one, and are much more generously funded by the UK's Medical Research Council. To date, about 30 trials of cognitive therapy for psychosis have been completed; by comparison, in the period 2001-3, nearly 400 drug trials were published in the five leading American psychiatric journals. There is therefore an urgent need to develop a less drug-based, more person-centred approach to understanding and treating mental illness, which builds on the recent scientific findings and which takes the experiences of patients seriously.

and you'd be equally true!  Height is significantly heritable; about 55% of the variation in height within a certain population is due to genetics, which incidentally is lower than the heritability of weight.  It even falls in the realm of "clearly physical traits" (like hair and eye color), which most people don't have a problem with saying are the result of genetics.  Yet geneticists have had serious problems identifying specific genes that have anything to do with height.  The gene they've found that explains the most variance accounts for about 0.5% of the variation in human height, which, um, isn't very useful at all.  Yet no one goes on a long rant along the lines of "OMG HUMAN HEIGHT IS NOT HERITABLE OR BIOLOGICAL!!!"

As per usual with such articles the author frequently confuses correlation and causation, and confounding variables abound:

People who migrate are not a random sample of the population, especially if they're forced to migrate.

People who are separated from their parents early are not a random sample of the population, especially if the state took them away from their parents.

Urban dwellers are not a random sample of the population.

Bullies don't pick kids to bully at random.

People whose parents sexually abuse them (or whose parents let people who sexually abuse them interact with them) are not a random sample of the population.

Again, inner-city youths aren't a random sample of all youths.  And even despite this it's not like this proves that mental disorders are not biological or whatever; environmental toxicity can cause detrimental effects on the biology of people.

He seems to be conflating "psychological research" with "common sense and the public perception of psychological research".

Well, he does have somewhat of a point here: more exploration of cognitive therapy would be very, very useful.  But it's also a lot harder to design and implement properly, especially because it's hard to have a good control group.

However, he neglects to mention that the drug trials find that people usually do do a lot better with drugs.  I do not disagree that cognitive therapy is useful, too; the best research consistently finds that a combination of prescription medications and therapy (especially cognitive-behavioral therapy, which is the best Grin) is the best way to go.  I mean, the studies that exist have even found that psychodynamic therapy helps patients with mental disorders improve, and if Freud can help people, well, anyone can.  His complaints at the beginning and end that mental health facilities and treatments are HORRID and DISGUSTING and are exactly as they were a hundred years ago are completely groundless.

Obviously I'm sure DSM-bashing is in fashion as it has been for a while.  And with some truth to it; it's clearly flawed in some ways.  I agree that strict, black-and-white segmentation is kind of silly, and I'd be in favor of moving towards a restricted amount of qualification to diagnoses (so instead of saying yes/no to each symptom, one could rank people on a scale of 0 to 10, or some such).  But to argue that it's useless obscures the rationales behind having it in the first place:

It's used to help patients get the help they need, both psychiatric and psychological.  Insurance companies are wont to completely ignore the complaints of a patient who does not have a diagnosed disorder.  If no central authority exists by which people can say, "Yes, I have a problem according to this weighty tome, help me treat it!", insurance companies will not pay.

It's used to standardize disorder classification.

Before the DSM, it seems like everything was just a "neurosis" and definitions of what constituted a "neurosis" varied wildly from mental health professional to mental health professional.  Now, though, if I say a patient has "frotteurism", Dr. Yamamoto in Honolulu and Dr. McFarthington in Portland, Maine will know exactly what I'm talking about and will know how to proceed in treatment of my patient should he decide to relocate to an exotic location.

Who cares what the disease is based on?

The drugs work

By refusing drug treatment for mental illness, you are advocating a return to the 1930s or earlier, where doctors tried to treat schizophrenia solely with therapy and of course failed at it and mental hospitals were full of patients.

Modern drugs allow at least some of these people to care for themselves and have at least a semi-normal life. You want to sacrifice the well-being and mental sanity of these people to satisfy your philosophical prejudices, and that is nothing short of immoral. I thought better of youç.

You want to sacrifice the well-being and mental sanity of these people to satisfy your philosophical prejudices, and that is nothing short of immoral. I thought better of youç.

Irrelevant. What he is basically saying is that there is no known causation for any available "mental illness" and that this is contrary to any widely perceived view that it is. He is also saying that no evidence has been shown to link genetics with any mental illness and those that say that there is were already going out of their way to find some.

{you wondering what the heck my point is with random sample}

Okay that last bit is certainly true. But don't you remember what you said about Correlation and Causation.

Great! Rating people on a completely arbirtrary numbering system!

Okay this is a problem. But has nothing to do with scientific status of biological psychiatry. And everything to do with the perception of it by insurance firms (which gives lie to the view that the opinions of this author are "common sense").

Yes. Which just shows how "scientific" (read: not at all) these disorders actually are. Apparently there has been a several fold leap in Autism in the past 10-20 years - and new syndromes are being found all the time.

But how many of these Autistics are diagnosed in a matter akin to a medical diagnosis - in cancer there are tumours, in Autism there is ??

Which of course tells us nothing at all about the accuracy of such a diagnosis

Stuff to read (just on schizophrenia for a start):

http://bjp.rcpsych.org/cgi/content/full/186/5/361 (http://bjp.rcpsych.org/cgi/content/full/186/5/361)
http://www.schizophrenia.com/sznews/archives/004467.html (http://www.schizophrenia.com/sznews/archives/004467.html)
http://www.amazon.com/Protest-Psychosis-Schizophrenia-Became-Disease/dp/0807085928 (http://www.amazon.com/Protest-Psychosis-Schizophrenia-Became-Disease/dp/0807085928) (This from a professor who came by my university one day and gave a talk on this very book. Fascinating. Unfortunetly I don't have it to hand.)

Btw I will note that I am not arguing that genetics play no role in serious mental illness, however we define it. Rather I am arguing and so is the author is that we should focus on people's actual subjectivity and conditions of life rather than just giving them drugs and trying to find what is 'wrong' with them and labelling them.