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Psychiatry-Bashing

Psychiatry is arguably the least science-based of the medical specialties. Because of that, it comes in for a lot of criticism. Much of the criticism is justified, but some critics make the mistake of dismissing even the possibility that psychiatry could be scientific. They throw the baby out with the bathwater. I agree that psychiatry has a lot of very dirty bathwater, but there is also a very healthy baby in there that should be kept, cherished, nourished, and helped to grow – scientifically.

Common criticisms in the media

  • We are over-medicating our children, producing a generation of drugged zombies.
  • We are using medication indiscriminately for people who don’t fit the diagnosis (i.e. antidepressants for people who only have normal mood fluctuations and life problems).
  • Antidepressants lead to violence and suicide.
  • Psychotropic medications all have terrible side effects.
  • Antidepressants are no better than placebo.
  • Psychotherapies are no better than talking to a friend.
  • Electroconvulsive therapy (ECT) is a barbaric, damaging assault with no redeeming value.
  • And we all remember how Tom Cruise attacked Brooke Shields on the issue of postpartum depression.

Thomas Szasz: Mental Illness is a Myth

Thomas Szasz goes even further: he rejects the whole concept of mental illness and considers it a plot to interfere with people’s human rights. He says:

  • Psychiatric diagnoses are not valid because they are based on symptoms rather than on objective tests. (Steve Novella has pointed out that there are other well-established diagnoses like migraine that cannot be verified by any objective tests.)
  • Mental illness is a myth: unusual behavior does not constitute a disease.
  • Psychiatric diagnoses are an arbitrary construct of society to facilitate control of individuals whose behavior does not conform.
  • Involuntary commitment is never justified even for the protection of the patient: patients always have the right to refuse treatment even if that means they will die.

The CCHR

Szasz and Scientology (a marriage made in heaven?) joined forces to create the Citizens Commission on Human Rights. They have a slick website with a home page that proclaims its bias with a picture of a door labeled “Psychiatry: An Industry of Death.” They claim to be supporting human rights, but they appear to be engaged in a vendetta against psychiatry and psychotropic medicines. They do have some good points, but they go way overboard. And they systematically ignore any evidence showing that psychiatric care benefits patients.

A Recent Study

A recent study published in the New England Journal of Medicine helps bring several controversial psychiatric issues into focus. It was a randomized trial of 488 children age 7-17 with “substantial impairment” from anxiety disorders. It compared an SSRI drug (sertraline), a psychotherapy (cognitive behavioral therapy), a placebo medication, and a combination of sertraline and CBT. 23.7% of subjects improved with placebo, 59.7% improved with cognitive behavior therapy alone, 54.9% improved with sertraline alone, and 80.7% improved with combination therapy. Adverse events, including suicidal and homicidal ideation, were no more frequent in the sertraline group than in the placebo group; no child in the study attempted suicide. As would be expected, there were fewer side effects (insomnia, fatigue, sedation and restlessness) in the CBT group than in the sertraline group. An accompanying editorial suggested that many children are not being identified and treated appropriately, and that early treatment could reduce subsequent problems. Instead of “we are overmedicating our children” it suggests that “we are failing to treat all those who would benefit from treatment.”

This study is not perfect and can’t stand by itself, but it confirms previous studies showing that psychotherapy and SSRIs are both effective and the combination is even more effective.

SSRIs and Suicide

In 2004 warnings inundated the media: studies had indicated an increase in suicidal ideation (from 2% to 4%) in children taking SSRIs for depression. The studies were flawed, and there was no increase in actual suicide rates, only in reported ideation. There were other clear data showing that SSRIs reduced suicide rates in depressed children. Nevertheless, the scare caused prescription rates to fall by 18-20%. And suicide rates promptly increased by 18%. The misguided attempt to prevent suicide instead led to an increase in suicides.

DSM

The Diagnostic and Statistical Manual of Mental Disorders or DSM is problematic. Diagnoses like homosexuality come and go depending on societal pressures. It is not very scientific. Neither was Freud, whose ideas have been largely discounted and whose diagnosis of “neurosis” is no longer used. DSM is seriously flawed, but it’s better than any previous diagnostic system. It’s a noble effort, and the best we have at the moment. The real problem is when people misuse it and over-diagnose. Instead of discarding it, we can work to make it more reliable.

Mental Illness Does Exist

It’s rejecting reality to think that mental illness doesn’t exist. Something is clearly wrong with an individual who is too depressed to get out of bed or eat, who is afraid to leave the house, or who believes he is Jesus Christ. These symptoms interfere with life and are usually distressing to the patient. One of my uncles developed paranoid schizophrenia: he lost contact with reality and was a danger to himself. In a previous century he might have spent the rest of his life warehoused in a locked ward. Medications allowed him to function: he married, had children and grandchildren, was loved, and led a relatively normal life in society. He had some side effects from the medications, but he and his loved ones felt that was a small price to pay.

Patients who clearly have mental illness can be appropriately diagnosed and treated. Admittedly, a lot of not-so-clear cases end up with diagnoses and treatments they should not have. But that’s not a problem with psychiatry per se, but with the misapplication of psychiatry. We need to do better and we can do better. With science.

Science-Based Psychiatry

The mental health professions have made some stunning errors in recent decades, including the recovered memory craze, Satanic abuse confabulations, facilitated communication, multiple personality disorder with up to a hundred or more alters including animals, and Harvard psychiatrist John Mack’s gullible speculations about alien abductions. The good news is that science and reason have worked to identify these as errors and they have been largely avoided in mainstream practice.

Science is harder to apply to psychiatry than to other medical disciplines. Mental illness can’t be studied like pneumonia. We have no good animal models for most mental illnesses because animals don’t mentate the way humans do. We can’t do a blood test for depression like we do for diabetes. But we certainly can identify patients who are impaired by a recognizable constellation of symptoms, and we can test various treatments to see what relieves those constellations of symptoms. We can also look for underlying causes and ways to prevent illness.

Modern psychiatry, with its psychotropic medications and psychotherapies, is not as scientific or as effective as we would like, but it has undeniably saved lives and improved the quality of life of countless sufferers. Instead of bashing psychiatry for its faults, we should build on psychiatry’s successes and make it ever more science-based. Let’s put an end to psychiatry-bashing and stick to bashing specific practices that are not science-based and to bashing psychiatric malpractice like over-diagnosis and inappropriate prescribing. There is an excellent journal that tries to do exactly that: The Scientific Review of Mental Health Practice It is far more credible than anything Szasz and Scientology have written.

Posted in: Neuroscience/Mental Health, Science and Medicine, Science and the Media

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45 thoughts on “Psychiatry-Bashing

  1. Ted says:

    “It’s rejecting reality to think that mental illness doesn’t exist. Something is clearly wrong with an individual who is too depressed to get out of bed or eat, who is afraid to leave the house, or who believes he is Jesus Christ.”

    Where does Szasz say there is nothing wrong with such people? If there is something clearly wrong, does that entail a medical illness? 100 years and $billions later, there is no evidence for that assertion.

    “It is far more credible than anything Szasz and Scientology have written.”

    I am not familiar with Scientology, but your understanding of Szasz does not fit with my reading of him. Szasz does not oppose psychiatry per se, but only the coercive aspects of it.

    Ted.

  2. Michelle B says:

    Excellent article. You addressed many points that I needed clarified especially what aspects of modern Psychiatry that does need to be ‘bashed.’

  3. Harriet – nice post. I have been engaged in long debates with psychiatry bashers. Here is a five-part entry I wrote on Neurologica about mental-illness denial for those who are interested.

    http://www.theness.com/neurologicablog/?p=168
    http://www.theness.com/neurologicablog/?p=169
    http://www.theness.com/neurologicablog/?p=170
    http://www.theness.com/neurologicablog/?p=171
    http://www.theness.com/neurologicablog/?p=172

  4. DevoutCatalyst says:

    I’m troubled by some of the advertising for psychotropic meds. That widespread Cymbalta ad tugs at people in a weird way. If I ran an animal shelter I’d hire that voice-over artist to find homes for my puppies. Manipulating people to ask for this drug by brand name seems odd to me, it’s almost as if the ad is making the diagnosis, deciding the course of treatment, then sending the patient to the dispensing professional to pick up the goods. To the extent that the ad motivates people to seek treatment I remove my objection.

    The internal advertising directed to psychiatrists is sometimes strange, too. A lifestyle magazine that was put out by the makers of a very popular atypical anti-psychotic drug appeared to me as a collection of some of the corniest techniques of industrial psychology, but possibly it was effective advertising. However, to what end? I’m not mentioning the drug, but do wonder if it wasn’t pushed into overuse by marketing hype. After the bacchanalia phase, the atypicals turned out to be useful meds, but with some problematical side-effects of their own.

    Psychotropic drugs save lives. What is more, they can in many cases dramatically reduce HUMAN TORMENT. Mental illness can produce sensations the equivalent of depraved torture. Denying the existence of mental illness is hitlerian in scope, and deserves severe condemnation.

    The bathwater of psychiatry needs changing because too much is at stake.

  5. A number of corrections to make here (sigh).

    1. Antidepressants don’t increase completed suicides but they do increase suicidal thinking. ALL studies show doubling of suicidal ideation. May not seem like a big deal, but if it happens to your family member it will be. Completed suicides are rare so it is not possible to do a ‘study’ of that. Please don’t make comments that studies are ‘flawed’ without giving specifics.

    2. Study of zoloft and childhood anxiety results were not that incredible, as the media has said. Continuous outcome of anxiety on the Pediatric Anxiety Scale was not statistically significant. As a psychiatrist I do not recommend screening kids for anxiety and putting them on Zoloft.

    3. Is Thomas Szasz still alive? I remember reading him in my residency.

    4. Recovered memory is not an ‘error’ of psychiatry. Many abuse patients have amnesia for abuse events that comes and goes. Memory can also be malleable. Pedophiles have trumped the media coverage of this story however. Time magazine reporter covering this issue quit because of stalking and refusal of magazine to cover liability.

    5. DSM is problematic. Good psychiatrists treat their patients, not their disorders.

    6. Multiple personality disorder [an error]. See #5. However the diagnosis is actually Dissociative Identity Disorder (DID) which is associated with significant brain changes. As a colleague working in the area once said, it isnt possible to have more than one personality, the problem is that people perceive that they do.

    7. Mental illnesses are not like pneumonia. Some of us psychiatrist physician scientists are perfectally happy living with the ambiguity of working in an area where things are not black and white. There are animal models for mental disorders (e.g. stress), the question is how applicable they are to disorders like PTSD. You might consider that those who want to say that they can provide a chemical description for the woes of mankind are coming from pharma marketing departments.

  6. David Gorski says:

    They claim to be supporting human rights, but they appear to be engaged in a vendetta against psychiatry and psychotropic medicines. They do have some good points, but they go way overboard. And they systematically ignore any evidence showing that psychiatric care benefits patients.

    “Way overboard”? That’s an understatement. The exhibit on psychiatry blames psychiatry for pretty much all of the horrors of the Holocaust. It’s a cheesy exhibit with what looks like a gas chamber door at the entrance, all sorts of horror movie sound effects of people being tortured, and horrible pictures from the Holocaust.

  7. Fifi says:

    Dr Gorski – Well it’s not really surprising that L. Ron was anti-psychiatry since he was a sociopath or that there’s a whole pseudomedical aspect to Scientology since it started out as a self-help/healing scam before becoming a religion to dodge taxes. To make things even weirder, L. Ron got the idea of starting a religion after hanging out with the American head of the Church of the Golden Dawn (Alistair Crowley’s Magikal church – this is where using “k” instead of “c” comes from in fact – which was run by a rich American) – which was pretty much just the usual cult excuse to get high and have sex while dressed up in costumes (kind of the old school version of Dungeons & Dragons but with total belief it’s real and one is supernaturally powerful and in control). After having an affair with the head’s wife, L. Ron set out on his own to get rich. I believe it was his second wife who, in the process of divorce, was trying to prove he was insane and this helped create his intense hatred for psychiatry. (Though he was partial to prescription drugs despite ordering his followers not to use them.)

  8. Harriet Hall says:

    Ted.

    Szasz rejects far more than the coercive aspects of psychiatry. He says mental illness is a myth. When you remove the concept of mental illness from psychiatry, there isn’t much left. The fact that psychotropic medications can relieve depression and psychosis seems to me clear evidence that these are real biological illnesses. I don’t know of any myths that respond to medications.

  9. Harriet Hall says:

    jamesdouglasbremner,

    I didn’t say recovered memory was an error, I said the recovered memory craze was an error. The craze that included the belief that practically every symptom could be attributed to childhood sexual abuse and that if you couldn’t remember being abused, your inability to remember constituted proof that you had been abused.

    The flaws of the study that I called flawed are discussed in the link I provided under SSRIs and suicide: http://www.aacap.org/cs/root/developmentor/suicide_and_ssri_medications_in_children_and_adolescents_an_update

    As far as I know, Szasz is still alive. He was born in 1920.

  10. ::crawls under a rock at the mention of the Golden Dawn::

  11. Jules says:

    I think the main problem is that psychiatry is far more culturally dependent than people want to admit to. Anorexia, for instance, is now recognized as having a biological basis, but it’s speculated that the “starving saints” of ages past might have suffered the same thing, except that they had the (mis?)fortune of having their illness cast in a holy light. Of course we’ll never know what those saints really died of, or even if they were truly anorexic, but the point is that culture plays an enormous role in determining what is acceptable and what is not.

    If psychiatry is to come into its own as a science, the way oncology or cardiology are, then it must come up with ways of getting around cultural barriers. A person with ADHD, in a corporate office, would be sh!t out of luck, but in a jungle, where every twitch of any leaf could be the difference between eating and being eaten? ADHD would be a good thing to have–except in that situation, it wouldn’t be a disorder.

    I can understand why people whinge about overmedication. Science is all about standards, having a solid stick to measure the world by. But the brain, as we’re finding out, is far from measurable. I think it was Peter Kramer, writing for Slate (I could have the author mixed up), who detailed the paranoia of parents when their two-year-old still doesn’t speak. Is the child merely slow to develop speech? Or is there something seriously wrong? (keeping in mind, too, that Einstein didn’t speak until he was four) We’re learning that the frontal cortices don’t fully mature until the twenties–what’s that mean for the “overly hormonal” teenager? Not everything that is abnormal is wrong, but science can make it seem that way.

    I think future studies are going to find that there’s much more variability in normal human brain function than we’ve previously thought. After all, if the fusiform facial recognition center can be hijacked for chess configurations–oh hell, the mere existence of synesthesia–means that the brain is extremely pliable.

  12. Prometheus says:

    It’s rejecting reality to think that mental illness doesn’t exist.

    Too true by half!

    Let us consider the “alternative” that one group of mental illness “denialists” proposes – that what we call “mental illness” is really the result of possession by the souls of aliens murdered on our planet millions of years ago.

    If that’s not rejecting reality, I don’t know what to call it. They are not only rejecting reality, they are substituting their own UNreality in its place.

    Prometheus

  13. Fifi says:

    Sorry Perky Skeptic! I find the history of ideas and how strange cults came into being very interesting (though I’ve pretty much concluded that it’s often just an excuse to pretend a bohemian lifestyle, and drugs and sex, are somehow “spiritual” and not just good old fashioned physical fun!) I’m already dreading 2012 myself (note to self, plan NOT to be in South America ;-) )

  14. SD says:

    “Let us consider the “alternative” that one group of mental illness “denialists” proposes – that what we call “mental illness” is really the result of possession by the souls of aliens murdered on our planet millions of years ago.

    If that’s not rejecting reality, I don’t know what to call it. They are not only rejecting reality, they are substituting their own UNreality in its place.”

    Well, yes. But here’s the problem: neither the claim of possession by murdered aliens or the existence of mental illness is falsifiable in any real sense in most instances. Mental illness is sort of like obscenity; we have a pretty fair shot at knowing it when we see it, but defining it in closed form is something that remains elusive, and tying it to any sort of hard, testable phenomenon is at the present time impossible. We have to make do with statistical generalities instead. The problem with those is that in the context of complex systems – specifically, the human body, across all variations observed in the human population – they do not necessarily constitute useful truth or understanding in se, but describe a plausible direction in which that truth or understanding may be found. If you can’t define the problem accurately, then, how the hell can you even detect it, much less treat it? (I see diabetes used as an example of a disease you can treat without understanding the underlying etiology, but the thing about diabetes is that it’s always been unambiguously detectable; a blood or urine test will reveal abnormal blood glucose, or for those with slightly greater fortitude and somewhat lesser capital investment in diagnostic equipment, a taste-test of the patient’s urine provides sufficient evidence of this disorder. At the taste-testing stage of medicine, of course, they didn’t know what caused it, and we’re still not entirely out of the dark, but it is at the very least very clearly a definable and detectable phenomenon. Taste-testing the urine of a psychotic to see if he’s crazy, on the other hand, besides being useless, is a good way to wind up in the straitjacket right next to him. >;->)

    The diagnostic criteria of the DSM highlight this problem. The DSM (DSM IV, the last edition I’ve looked at) defines psychiatric conditions in “cafeteria” terms, where some number M of N total symptoms are sufficient for the diagnosis of a given ailment. While this approach may be a good way to narrow the field of useful diagnoses by culling unlikely candidates – coprophilia is unlikely to share many symptoms with obsessive-compulsive disorder, for example – it falls seriously short of what most people would consider to be a good method for definitively evaluating evidence of illness. Example: Most schizophrenics describe hearing voices. Let’s say that I tell a psychiatrist, without qualification, that I heard a voice in my head telling me to do something this morning. (I believe that one stipulation is that the patient believe without reservation that it is an exogenous voice; there are some nuances in DSM definitions. I’m using this as a sort of caricatured example.) That’s a pretty diagnostic major symptom (“auditory hallucination”). That’s a point against me. Two or three more – throw in a belief that I am being controlled by external agency, say – and I might get to enjoy a nice mellow Thorazine high.

    Now, how about if I add the information that the voice was telling me “Don’t forget to grab your keys off the table, dipshit, you don’t want to lock yourself out again”, or something similarly mundane? Let’s say, arguendo, that I still believe that it came from an outside source (my “guardian angel of key-remembering”, or whatever; hey, wouldn’t one of those be handy?). Does that voice still qualify as a symptom? How does that differ from the same voice saying “KILL! KILL! KILL!” [thematic note, add shower-scene theme from 'Psycho' to background, "Eee! Eee! Eee! Eee!"] How do you define that difference without reference to some other indefinite concept? How do you exclude “corner cases” of this type?

    Much of this problem stems from the fact that we don’t even understand how to define cognition, much less describe how it works, a prerequisite for identifying unambiguously what’s normal and what’s pathological, and what precisely is wrong in pathological states. Pretty much by definition, a detailed understanding of the underlying mechanisms and attributes of cognition is what is typically semi-jokingly referred to as an AI-complete problem, since solution of that problem implies a theoretical and practical framework that is capable of producing strong AI. Surprise: we’re not even close.

    Looked at in that light, Szasz’s assertions don’t appear to be that shocking. The validity of any psychiatric test is questionable if it is based solely on subjective patient complaint or subjective practitioner perception of symptoms which are not buttressed by objective criteria – “objective” in this case meaning “traceable back to indisputably and reproducibly consensus-observable physical phenomena” – and the legitimacy of involuntary commitment is dubious given any reasonable theory of individual rights. I seem to recall a study touching on these topics, measuring institutional bias towards internal reinforcement of established diagnosis regardless of conflicting evidence. The study, if I recall correctly, was undertaken by a group of psychiatrists whose lack of mental illness per standard guidelines was established by examination. Their MO was to present themselves anonymously at various hospitals to be evaluated, confessing to a number of subjective symptoms (e.g. auditory hallucinations) that were sufficient to merit their involuntary retention for evaluation by standard diagnostic criteria. Once detained, they reported remission of the symptoms, which in conjunction with their rational behavior, according to the canon of ethics and the DSM, should have triggered immediate release. I believe that in some astonishing majority of cases – I seem to recall a number >50% – the psychiatrists were retained beyond the evaluation period and had to have their colleagues intercede on their behalf. I believe that some were in fact medicated against their will, a clear violation of professional ethics and in some jurisdictions against the law. I don’t have a cite, sorry; I admit that I may be recalling the particulars incorrectly. (If anyone else’s memory is jogged, I’d like to hear a cite; it sounded like an interesting study.) Scary stuff.

    While I disagree with the notion of the mythicality of mental illness – look at a bum doing a word-salad ravefest on the street sometime and then tell me that crazy doesn’t exist – I will agree with the statement that unusual behavior does not *constitute* mental disease, with the added stipulation that it may *indicate* mental disease. The problem isn’t necessarily identifying madness, it is doing so definitively and with a clear understanding of the underlying problem, something at which psychiatry has not necessarily excelled. The idea that some aspects of diagnosis are arbitrary constructs used to control individuals whose behavior doesn’t conform, well… that definition is sufficiently imprecise to cover a gamut from zealous dieters to serial killers. It’s one of those “true, but not useful” statements, I think.

    “crazy! but that’s how it goes…”
    -SD

  15. Ted says:

    Harriet Hall,

    You are right — Szasz does reject more than the coercive aspects of psychiatry. But the point I was making (perhaps not clearly enough) in relation to the practice of psychiatry was that there is a difference between voluntary and involuntary psychiatry. He does not think voluntary psychiatry between consenting adults should be outlawed. Now, there is a finer point about what voluntary psychiatry can consist of, but your words did not lead me to think that was your point. Perhaps it was, and if so I might agree with you.

    In any case, arguing that the ingestion of drugs coupled with a subsequent subjective feeling is a criterion for biological illness is a very strong claim, and a departure from what most people consider medicine to be. Whatever the ultimate validity of such correlation, subjective feeling is no certain substitute for objective physical test (especially when the potential for denial of liberty is so high). Those who use migraines etc as examples of illnesses not diagnosed objectively tend to make little if any reference to the political consequences of being diagnosed with these things.

    This in part seems to explain why you wrote that Szasz is rejecting reality by denying the reality of mental illness. You neglected to answer my question asking for evidence that Szasz believes there is nothing wrong with people who are depressed etc. Do you not find it stunning that after so many decades and dollars, there is no evidence of any physical abnormality in any of the people who are said to be mentally ill?

    Ted.

  16. Harriet Hall says:

    No, I don’t find it stunning. Steve Novella has explained why in his 5-part post on Neurologica, linked in his comment above.

    Szasz may not believe there’s “nothing wrong” with those people, but he insists mental illness is a myth. I suppose you could quibble all day about what constitutes the definition of an illness, a disorder, a syndrome, or whatever you want to call it. For that matter, you could define diabetes as one end of the spectrum of behavior of the pancreas.

  17. DevoutCatalyst says:

    “For that matter, you could define diabetes as one end of the spectrum of behavior of the pancreas.”

    That’s precious!

  18. qetzal says:

    Ted wrote:

    In any case, arguing that the ingestion of drugs coupled with a subsequent subjective feeling is a criterion for biological illness is a very strong claim, and a departure from what most people consider medicine to be.

    What you left out, though, is that the ingestion of drugs results in a subjective feeling that (arguably) alleviates a “substantial impairment.” Whether or not you call it an illness, it’s clearly a biological phenomenon, and treating it is most definitely medicine. (Assuming the underlying claims to be true, of course.)

  19. Dr Benway says:

    Ted:

    Those who use migraines etc as examples of illnesses not diagnosed objectively tend to make little if any reference to the political consequences of being diagnosed with these things.

    Not only migraine. Subjective symptoms include vertigo, nausea, hot flashes, urinary urgency, and pain of course, just off the top of my head.

    You don’t get locked away because you have a diagnosis. You must be an imminent danger to self or others, and there must be some reason to think that involuntary hospitalization will help.

  20. Dr Benway says:

    Hi Doug!

    Your name brings back memories of Steve Southwick, Hadar Lubin, Dave Johnson, buncha biker dudes out for a smoke, the worst cafeteria on God’s earth, and Yale.

    I’m travelling incognito so that I might say snarky things about Scientologists and have drunken rants without compromising my future.

  21. Ted says:

    @ Harriet Hall

    I don’t have time to read a 5 part post. Perhaps you could summarise why you are not surprised that brain diseases have not been found in those diagnosed with mental illness.

    “I suppose you could quibble all day about what constitutes the definition of an illness, a disorder, a syndrome, or whatever you want to call it”

    Are you saying there are no meaningful agreed upon definitions in medicine? For if the concept of disease etc is unclear, then by extension so is the concept of mental illness. I am well aware that words can defined and redefined, but the downside to expanding a concept is that it quickly becomes meaningless.

    “For that matter, you could define diabetes as one end of the spectrum of behavior of the pancreas.”

    A pancreas does not behave, but people do. You are obscuring the critical difference between mere things and human actors.

    @qetzal

    “Whether or not you call it an illness, it’s clearly a biological phenomenon, and treating it is most definitely medicine.”

    Feeling better after ingesting drugs is as much a biological phenomenon as anything else. Does that imply that there is an underlying illness? No. This being so, there is nothing necessarily there to be treated. I agree with you that there is definitely a biological situation going on, but you must remember that there are other situations present: moral, political, societal. And given there is nothing necessarily there to be treated, it is strange to call the mere ingestion of a substance “medicine.” We all know that taking a pill to try and relieve a low mood is in some ways like taking medication for a disease, but there are important ways in which it is in stark opposition too.

    @Dr Benway

    “You don’t get locked away because you have a diagnosis. You must be an imminent danger to self or others, and there must be some reason to think that involuntary hospitalization will help.”

    But in psychiatry diagnosis is largely prescriptive rather than descriptive. Without the legal powers that accompany the diagnosis, the diagnosed can thank the doctor and walk away if they wish. The reasons for detention you mention are political problems, not medical ones.

  22. Harriet Hall says:

    A pancreas “behaves” or functions by secreting insulin in response to food; when it doesn’t secrete enough insulin, we define it as a disease. Since we can measure the effects of insulin indirectly by measuring blood sugar, we can arbitrarily designate a blood sugar level at which we say a patient has the disease diabetes. There are borderline levels where people may dispute whether an individual really has the disease or is just at the extreme of normal variation.

    A brain behaves by producing thought and behavior. When a constellation of thought and behavior fit the diagnostic criteria for schizophrenia or major depression, we define it as “something” recognizable – whether you want to call it a disease or a disorder or a syndrome or something else.

    The function of the pancreas is to produce a chemical substance we can measure with a blood test; the function of the brain is to produce thought and behavior. For instance, one of the functions of the brain is to maintain contact with reality. We have no blood test for that, but we can tell when someone has clearly lost contact with reality by their words and their behavior. The brain is so complex it is implausible that any simple blood test or neuroimaging test could be diagnostic. We have found correlations between some mental illnesses and test abnormalities, but they are not enough to use as a diagnostic test.

    In both diabetes and depression, there is a complex of signs and symptoms that resolves with treatment. Mental diagnoses are much less straightforward, and errors are more easily made, but instead of giving up on science, we should find ways to use science more appropriately.

  23. Fifi says:

    Dr Hall – While we don’t currently have tests, it seems highly likely that as we discover more about the neurobiology of specific atypical states that objective/physical testing will be possible. (Not to muddy the waters here but with something like schizophrenia the criteria are still discussed and debated.)

    There are a lot of ethical and practical issues around what is considered neurotypical and why – and what is considered “functional” and/or “healthy” vis a vis our society (and values that are societal but not necessarly actually reflective of compassionate or even rational values, let alone “natural” ones). So, even with science involved there are cultural/contextual issues to be considered (and this isn’t to say that mental illness is a construct and/or not real, it’s just to say that culture is an integral part of mental health and what we consider functional and dysfunctional – it’s similar to how pain is also a culturally learned behavior).

  24. qetzal says:

    Ted:

    Feeling better after ingesting drugs is as much a biological phenomenon as anything else. Does that imply that there is an underlying illness? No. This being so, there is nothing necessarily there to be treated.

    Once again you’ve ignored a key point: patients with these conditions suffer from substantial impairment (or so it is claimed). They can’t function normally. Giving them the appropriate drugs can (perhaps arguably) improve their ability to function. If you dispute that these patients are impaired, or that the drugs can help alleviate that impairment, that’s one thing. But absent that, how can you argue that this isn’t medicine?

  25. drpaulr says:

    To SD: I think you’re remembering “The Rosenhan Experiment” conducted by David Rosenhan in 1972. It was published in the journal Science under the title “On being sane in insane places.”

  26. Kultakutri says:

    Delurking.
    A propos of the idea of overmedicated kids, I fell a victim to that one and lost two years of life to a nasty untreated depression. Just because the people around, including my parents, held the idea that at around 16, everybody is happy for just being sixteen, not having to go to work and… anyways.
    I don’t care whether depression is an illness, a myth or a result of surface activity of the Sun. (I don’t have to, I’m an art historian and I have to be pretty exact about totally different arguments.) It however is one’s own private hell and kids get it too.

    Lately, I’ve been pretty active in a self-help group for folks with eating disorders. Most of the people are girls between 16 and 18 and I think I’m by far the oldest there. I’m not a medical professional but I’m pretty sure that most of ‘my’ girls would benefit from a professional counselling and so would their families. It is saddening to hear how the parents refuse to deal with the problem because they choose to live in denial. Again, I don’t know whether eating disorder is a mental illness or anything else but it exist and ruins people’s lives. A good part of people with eating disorders are teenage girls and I seriously doubt that anyone can deal with it without any help.

    It seems to me that ‘adults’ often underestimate the problems children may have. I wonder whether it is pure psychological trick – the bad stuff is forgotten and people remember only the happy bits of their childhood – or whether it is a denial that their precious children could have a flaw. Or the idea that the kids are trying to attract attention by feigning sickness… or they were in love when they were 16 and everything was wonderful so everyone else must feel wonderful at 16? One way or another, the consequences may be pretty nasty.

  27. Dr Benway says:

    But in psychiatry diagnosis is largely prescriptive rather than descriptive. Without the legal powers that accompany the diagnosis, the diagnosed can thank the doctor and walk away if they wish.

    The diagnosis is a description of some problem. No legal powers accompany a diagnosis.

  28. Dr Benway says:

    Kultakutri, it’s very odd but many adults do not listen when young people are talking. Perhaps it’s the sense of greater responsibility. Adults are supposed to be helpful to kids, so they jump to giving advice before they’ve fully appreciated what the kid wants to say.

    Parents can feel like failures if a child is suffering, and some parents aren’t strong enough for that.

  29. Dacks says:

    Kultakutri,
    Your comments really hit home for me. As a teen, I was slightly messed up, but I hung out with kids who had serious problems; as an adult I have a spouse who relies on daily psych meds; and now I watch my own teenagers come to terms with the darker side of maturity.

    It is unnerving for parents to realize that their children may be battling demons, especially when they know how difficult it can be to climb out from that place. You underline the great necessity for mental illness to come out from the closet and be treated in a value neutral way.

  30. Fifi says:

    First I’d like to applaud Dr Hall for having the guts to wade into this highly controversial topic and to, even more bravely, bring up Scientology’s dubious assertions and influence.

    1. Scientology and psychiatry

    a. Scientology is a pseudoscience that aims to REPLACE psychiatry not just demonize it.

    b. psychiatrists are obviously considered enemies by any brain washing cult

    c. it’s quite clear L. Ron Hubbard had a narcissistic personality disorder (not uncommon in people who start cults), a fact that came to light publicly during divorces when his controlling and abusive behavior was outed.

    d. Hubbard himself took enormous amounts of pharmaceutical drugs to self medicate even though he forbid them to his followers

    e. Narcanon – is a major recruiting arm, cults that brainwash love getting their hands on vulnerable and needy people to “mold”. They’ve killed people with their “detox” treatments.
    http://www.whyaretheydead.net/
    http://en.wikipedia.org/wiki/Narconon

    f. They’re involved – through a number of fronts – in pushing supplements and pseudoscience. A great deal of the pseudoscience myths about SCAM seem to come pretty directly from Scientology and Dianetics – Scientology is deeply involved with chiropractice and training in profitable high pressure sales tactics.

    g. They perfected the art of using celebrities to sell not only Scientology directly but also the pseudoscientific ideas of Scientology indirectly (meaning with no mention of Scientology).

    h. Scientologists are stunning in their mania and how far they’ll got to bully and intimidate people who speak out against them. Murder is definitely within their scope but they use their great wealth to bully people using the legal system, as well as more direct intimidation like following people and their families.

    i. Scientologists have for a very long time been seeking political power through all kinds of means. One is recruiting people with political power (such as London’s chief of police) but the other is trying to load municipal boards with Scientologists.

    I will say that I believe it muddies the water quite a bit to mix up very legitimate issues and critiques of and within psychiatry with attacks on psychiatry and Big Pharma by Scientology and other cults/SCAM. It kind of conflates the two in a way that seems unhelpful to me and is overly simplistic about some very complex issues. When talking about psychiatry, it’s also relevant to consider that how psychiatrists treat in the US is often very different to how they do in other Western countries. In the US and elsewhere, the involvement of psychiatrists in torture and mind control experiments – not to mention the repression of enemies of the state – is also an ongoing issue that erodes public trust (as it well should!). It’s also worth noting that it’s often not psychiatrists prescribing many of the drugs like prozac and antidepressants that people get up in arms about, it’s often GPs (sometimes in collaboration with a psychologist, sometimes not).

  31. Harriett Hall

    The article you sight for SSRIs not increasing suicidality and reference to flawed studies is incorrect. First of all, conflicts of interests related to consulting and speaking ties with pharma need to be examined when reading the literature. Second of all, the article notes the increase in suicidality of two fold. It is not possible to measure changes in completed suicide since that is rare. Finally, the so-called increase of 18% in teen suicide statistic after black box warnings changes implying changes in prescribing led to changes in suicide is flawed because: 1) suicide rates have fluctuated up and down over the past two decades; 2) a change from 2.2 to 2.6 per 100,000 represents an absolute change of 0.000004% which can represent change due to random fluctuation; 3) SSRIs don’t work in teenagers anyway, so what difference does it make.

    Doug Bremner

    http://www.beforeyoutakethatpill.com/index.php/2009/01/28/a-dissenting-opinion-from-the-acnp-on-antidepressants-and-suicidality-2/

  32. Fifi says:

    I’d suggest that a discussion of SSRIs really needs its own blog.

    I’d suggest that one of the biggest reasons why psychiatric medications are over-prescribed in the US is health insurance that often leaves psychiatrists and GPs with few viable treatment options other than prescribing medication. Most health insurance won’t cover more than superficial basic talk therapy (which isn’t usually long enough to be useful or effective, it can even effectively punish the patient by starting the process and then cutting it off) but they will pay for ongoing medication of patients.

    The other factor, of course, is direct to public advertising and the fact that drug companies have purposely misled doctors about certain medications (drug companies were aware that certain SSRIs were no more effective than talk therapy, or less effective if one considers long term results).

    There are a lot of philosophical, ethical, cultural (familial, ethnic and larger social context) and even personal issues and biases that come into play vis a vis psychiatry, sanity and normalicy (and/or functionality). There are also a lot of sometimes quite contradictory opinions and theories – not to mention treatments and practices – in psychiatry and psychology. It hardly even makes sense to speak about “psychiatry” in a generalized way, particularly if and when discussing drugs often prescribed by GPs with no psychoanalytic training.

  33. Dr Benway says:

    First of all, conflicts of interests related to consulting and speaking ties with pharma need to be examined when reading the literature.

    Yes. And beware authors pimping books. Their provocative, contrarian comments might be self-serving.

    LOL.

    Hope you make a mint.

    Oh noes! I’m having flashbacks to VA call… There was a hard and musty futon on the floor of a psychologist’s office. Hundreds of giraffes were staring from the shelves. The phone would ring; the voices were lonely and slurred. And in the morning there was Lustman.

    ) SSRIs don’t work in teenagers anyway, so what difference does it make.

    I was with you for points #1 and #2, but I can’t join you for #3. It’s too absolute.

    No matter what you do, kids change. They’re a moving target. This makes it hard to separate treatment effects from background noise.

    I believe daily tracking of target symptoms is a good way to control for selective recall and confirmation bias, and so improve the signal-to-noise ratio. But it’s a pain in the ass. Nurses are busy. Direct care staff are busy. Without a consensus standard-of-care, my whining about daily tracking can seem like a personal quirk.

    “Psychotropics don’t work in kids” serves the cause of the anti-data crowd (e.g., my boss and above). Why? Because the violent, self-injuring, regressed kids are here. The years are passing and they’re still attacking and not learning. The Scientologists are not coming to get them. We’re stuck with them.

    If we feel there’s a rational basis for a drug trial, we can advocate for good record-keeping regarding target symptoms and side effects to prove effectiveness. But if we’re not serious, if we’re simply throwing a Hail Mary pass, no one’s going to bother with so much work.

  34. Doug Bremner says:

    Dr “Benway”

    Thanks for the memories. Efficacy is pretty weak for SSRIs in kids. And since this site is called ‘science based medicine’ I don’t why pointing to the scientific literature is so ‘contrarian and provocative’, but hey, what do I know?

  35. Doug Bremner says:

    BTW I didn’t think I was blugging my book, but thanks for providing the nifty link.

  36. @Kultakutri–

    I know whereof you speak. It broke my parents’ hearts even to think about how dark my depressions were, plus none of us really knew about bipolar disorder. This no doubt contributed to my long delay in getting the problem diagnosed. Also, in hindsight, I’m pretty sure BPD runs in my dad’s family, so there was probably some element of denial in there, too.

    By the way, NO ONE gets my SSRIs until they pry them from my decidedly alive, un-suicidal fingers! And I WILL use bizarre household cleaning implements as weaponry in defense of my oxcarbazepine!!! Grrr… fierce!!!

  37. Dr Benway says:

    Doug,

    The general warning about BigPharma’s corrupting influence on the medical literature seems contrarian. But maybe that’s just me.

    Lately I’ve felt battered by BigPharma paranoia. People say, “those researchers were bought” without any evidence of dishonesty –or even a plausible guess as to how the researcher managed to cook the books–just to dismiss some finding.

    Don’t we presume that humans are vulnerable to corruption even when BigPharma isn’t involved? Money corrupts. Ideology corrupts. Narcissism corrupts. Fear corrupts. That’s why we rig the science game so cheating is difficult. And we don’t trust anyone’s results until they’ve been replicated by independent parties.

    Replication is a good check against bullshit. If no one can replicate your results, you will look kinda funny.

    I’m all for talking about specific examples of cheating. They can help us figure out ways to tweak the rules to make science better –e.g., making sure negative study results end up in the public record, even if the study isn’t published.

    But I don’t know how to respond to vague accusations like, “BigPharma gave that dude money!”

  38. Delphi Ote says:

    “In any case, arguing that the ingestion of drugs coupled with a subsequent subjective feeling is a criterion for biological illness is a very strong claim, and a departure from what most people consider medicine to be.”

    “I don’t have time to read a 5 part post.”

    This is classic denialism. You asked someone to back up a “very strong” claim. They provided a detailed response. You “don’t have time for it.”

  39. Dr Benway says:

    Efficacy is pretty weak for SSRIs in kids. And since this site is called ’science based medicine’ I don’t why pointing to the scientific literature is so ‘contrarian and provocative’, but hey, what do I know?

    Yeah, my post was an argument from emotion not science. Occasionally I suck.

    I think some kids do respond to SSRIs, but we don’t yet know how to identify the responders from the non-responders up front.

  40. Dr Benway says:

    Speaking of psychiatry bashing, I bumped into a position paper from the National Council on Disability*:

    3. Mental health treatment should be about healing, not punishment. Accordingly, the use of aversive treatments, including physical and chemical restraints, seclusion, and similar techniques that restrict freedom of movement, should be banned. Also, public policy should move toward the elimination of electro-convulsive therapy and psycho surgery as unproven and inherently inhumane procedures. Effective humane alternatives to these techniques exist now and should be promoted.

    WTF?

    *“The NCD is composed of 15 members appointed by the President and confirmed by the U.S. Senate.”

  41. Harriet Hall says:

    Electroconvulsive therapy and sychosurgery? Prefrontal lobotomy was a mistake; but there is considerable evidence that ECT is effective and sometimes the last resort that enables patients to return to a functional life.

    Inherently inhumane? How do you decide that? Some might think it’s inhumane to do any surgery to cut out pieces of the body. Wouldn’t it be inhumane to deny ECT to patients who could be enabled to overcome a severe refractory depression?

  42. Prometheus says:

    Electroconvulsive therapy (ECT) is actually a well-documented and effective treatment for depression. It is not very aesthetic and has the usual risks of anesthesia and convulsion. It is not a first-line therapy nor should it be used on patients without carefully evaluating the risks and other options. It also should be done only by people thoroughly trained in its use and in patient selection.

    However, if properly done, it has been shown to be effective in treating depression that is refractory to medication.

    Which is more “inherently inhumane”: ECT or letting someone sit in untreated severe depression?

    Part of science-based medicine is not allowing the aesthetics of a treatment influence our assessment of its effectiveness.

    This – again – shows the folly of relying on the unfettered opinion of politically-appointed “experts”.

    Prometheus

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