Wednesday, March 20, 2019

Psychiatry and Its Discontents

Gary Greenberg is not a psychiatrist. He has no degrees in biochemistry or psychopharmacology and does not write prescriptions for psychiatric medication. Anne Harrington is not a psychiatrist. She has no degrees in biochemistry or psychopharmacology and does not write prescriptions for psychiatric medication. Whereas Greenberg is a practicing psychologist, Harrington is a Harvard professor, one whose expertise lies in the history of science. We are interested to read Greenberg’s review of Harrington’s new book, being a systematic take-down of psychiatry’s pretensions, but we note, from the top that one thing is missing.

Speaking as a non-psychiatrist with no degrees in biochemistry or psychopharmacology, I would point out that Harrington's book-- and Greenberg's review-- seems to ignore the fact that today’s psychiatric medication is a vast improvement over yesterday’s. While psychiatric drugs have consistently been oversold and while their proponents have trafficked in outlandish promises, the truth is that a schizophrenic today has far better treatment options than did one  a century ago. The same applies to depression. People who worked in psychiatric clinics before the advent of neuroleptics and tricyclic anti-depressants will tell you that these medications were life saving.

Today, many psychoses are considered brain diseases, while conditions involving most depressions and anxiety disorders are not. That the psychiatric profession has worked long and hard to pretend that the latter are of the same class as the former, being conditions of the brain and not the mind, does it no honor.

On the other hand Harrington is certainly correct to see that psychiatry is a lost soul trying to latch on to the prestige we grant to medical practice. Psychiatrists want to be considered to be scientists. They want us to recognize their diagnoses and nostrums as medical treatments, on the same level as infections and antibiotics.

And yet, every time psychiatry discovers a new treatment, whether neuroleptic drugs, lithium, SSRIs… it suddenly imagines that every psychiatric patient suffers from the conditions that these pills treat. Overprescription of psychiatric medication is not just a problem. It indicts the profession and makes it look like less than science.

Greenberg summarizes Harrington’s thesis:

From ice baths to Prozac, each development Harrington describes was touted by its originators and adherents as the next great thing—and not without reason. Some people really did emerge from an insulin coma without their delusions; some people really are roused from profound and disabling depressions by a round of electroconvulsive therapy or by antidepressant drugs. But in every case, the treatment came first, often by accident, and the explanation never came at all. The pathological basis of almost all mental disorders remains as unknown today as it was in 1886—unsurprising, given that the brain turns out to be one of the most complex objects in the universe. Even as psychiatrists prescribe a widening variety of treatments, none of them can say exactly why any of these biological therapies work.

Of course, if the treatments were really effective, we would not be worrying about why they work. The problem lies in the failure to distinguish between mental illness, a contradiction in terms, and physiological illness. It has led to promiscuous over-prescribing of each new medication:

It follows that psychiatrists also cannot precisely predict for whom and under what conditions their treatments will work. That is why antipsychotic drugs are routinely prescribed to depressed people, for example, and antidepressants to people with anxiety disorders. Psychiatry remains an empirical discipline, its practitioners as dependent on their (and their colleagues’) experience to figure out what will be effective as Pliny Earle and his colleagues were. Little wonder that the history of such a field—reliant on the authority of scientific medicine even in the absence of scientific findings—is a record not only of promise and setback, but of hubris.

Once upon a time, and it was not very long ago, psychiatrists discovered the mental imbalance theory of depression. People glommed on to this theory because it was a counterargument to the notion that depression had a moral basis and that people who were depressed were suffering from the sin of sloth. To be clear, there are many different kinds of depression. The depression suffered by someone with bipolar disorder differs from the depression suffered from someone who feels discouraged, downcast and beaten. To the best of my knowledge good medical treatments exist for bipolar disorder. And, SSRIs, while certainly not the panacea that their proponents pretended them to be, have produced some good clinical outcomes for some patients. That does not mean that these pills can or should be prescribed for everyone who complains.

As for the biology of mental illness, we should also note that physical exercise has been shown to be one of the best treatments for mental illness. Thinking that we can easily separate mind from body seems to be questionable.

Greenberg explains Harrington’s view:

The need to dispel widespread public doubt haunts another debacle that Harrington chronicles: the rise of the “chemical imbalance” theory of mental illness, especially depression. The idea was first advanced in the early 1950s, after scientists demonstrated the principles of chemical neurotransmission; it was supported by the discovery that consciousness-altering drugs such as LSD targeted serotonin and other neurotransmitters. The idea exploded into public view in the 1990s with the advent of direct-to-consumer advertising of prescription drugs, antidepressants in particular. Harrington documents ad campaigns for Prozac and Zoloft that assured wary customers the new medications were not simply treating patients’ symptoms by altering their consciousness, as recreational drugs might. Instead, the medications were billed as repairing an underlying biological problem.

Better yet, a psychiatrist named Peter Kramer claimed that Prozac would change your personality, even making you into someone else. It’s clearly a sign of hybris and overreach.

So, Greenberg and Harrington blame the marketplace:

The strategy worked brilliantly in the marketplace. But there was a catch. “Ironically, just as the public was embracing the ‘serotonin imbalance’ theory of depression,” Harrington writes, “researchers were forming a new consensus” about the idea behind that theory: It was “deeply flawed and probably outright wrong.” Stymied, drug companies have for now abandoned attempts to find new treatments for mental illness, continuing to peddle the old ones with the same claims. And the news has yet to reach, or at any rate affect, consumers. At last count, more than 12 percent of Americans ages 12 and older were taking antidepressants. The chemical-imbalance theory, like the revamped DSM, may fail as science, but as rhetoric it has turned out to be a wild success.

Again, this ignores the fact that many people find a benefit in Prozac.

Nevertheless, the pretense involve in treating mental illness as physical illness deserves to be exposed:

But by virtue of its focus on our mental lives, and especially on our subjective experience of the world and ourselves, psychiatry, far more directly than other medical specialties, implicates our conception of who we are and how our lives should be lived. It raises, in short, moral questions. If you convince people that their moods are merely electrochemical noise, you are also telling them what it means to be human, even if you only intend to ease their pain.

If such is the case, and I believe it is, psychiatry has crossed another barrier. Its practitioners hold themselves up as authorities on moral issues, on how to conduct one’s life. Surely, these issues matter. And yet, there is nothing in medical training or in science itself that sets down ethical rules. Science, David Hume famously wrote, is about "is." Ethics, he continues, involves “should.” The two are constantly confused. We would do better if we stopped looking to science for solutions to moral dilemmas.

Harrington is surely correct to suggest that psychiatry should limit itself to brain diseases, which she calls severe mental illnesses. And she wants psychiatry to open up dialogues with other fields, like social sciences and humanities. If psychoses as brain diseases are most apt to receive medical treatment, one has difficulty imagining why or how humanists could contribute:

Harrington ends her book with a plea that psychiatry become “more modest in focus” and train its attention on the severe mental illnesses, such as schizophrenia, that are currently treated largely in prisons and homeless shelters—an enterprise that she thinks would require the field “to overcome its persistent reductionist habits and commit to an ongoing dialogue with … the social sciences and even the humanities.” This is a reasonable proposal, and it suggests avenues other than medication, such as a renewed effort to create humane and effective long-term asylum treatment. But no matter how evenhandedly she frames this laudable proposal, an industry that has refused to reckon with the full implications of its ambitions or the extent of its failures is unlikely to heed it.

The most important problem with severe mental illness today is getting treatment to the afflicted. As we have seen on many occasions, we as a society have rejected the idea of committing such patients involuntarily to psychiatric institutions. The fault does not lie with psychiatrists, but with bright-eyed civil liberties attorneys who believe that people who refuse to accept that they are ill should be allowed to run free in our society. 

If it were up to psychiatrists, many more schizophrenics would be hospitalized and would be in position to be helped by modern medicine. In that case, the problem is the civil liberties lobby and social scientists and humanists, people who have never dealt with psychotics and who ascribe their condition to capitalist oppression.


UbuMaccabee said...

The great Richard Mitchell said this many years ago about "educated" people:

"It is possible, of course, to keep educated people unfree in a state of civilization, but it’s much easier to keep ignorant people unfree in a state of civilization. And it is easiest of all if you can convince the ignorant that they are educated, for you can thus make them collaborators in your disposition of their liberty and property. That is the institutionally assigned task, for all that it may be invisible to those who perform it, of American public education. "

The exact same sentiment applies to the psycho community.

UbuMaccabee said...

"Its practitioners hold themselves up as authorities on moral issues, on how to conduct one’s life. Surely, these issues matter. And yet, there is nothing in medical training or in science itself that sets down ethical rules. Science, David Hume famously wrote, is about "is." Ethics, he continues, involves “should.” The two are constantly confused. We would do better if we stopped looking to science for solutions to moral dilemmas."

Spot on. The fact team has appropriated the value team because the value team has quit the field entirely. But the distinction is not so clear cut as Weber would have it. The very best book I've ever read on this subject is by Leo Strauss, "Natural Right and History." Tough slog, but he gets right to the heart of the problem. Definitely worth the investment.

Sam L. said...

It's always "the marketplace" and "capitalist oppression" all the way down.

Anonymous said...

It's Pudding Time.