Saturday, December 17, 2005

The Mainstream Media is Waking Up

http://www.theage.com.au/news/in-depth/tangled-up-in-blues/2005/11/26/ 1132966001051.html

Printed in the Age Newspaper, Melbourne, Australia
November 27, 2005

Tangled up in blues

The dominant treatment for mental illness focuses more on brain chemistry than on human behaviour or personal distress. Peter Ellingsen wonders what we are covering up with drugs.

Stand outside any psychiatric ward and you will find the markers of madness. They lie in no particular order, and convey no message, except a kind of covering up. Fag ends for forgetting. Maybe the drugs dispensed inside spur nicotine craving or maybe cigarettes are the only solace when society turns away. Whatever, butts are the carpet the mentally ill stand upon. They build up in unlovely piles with a smell that suggests despair.

It is not the same with physical illness. Pleurisy and kidney infections can be confronting, but they usually pass. And even when you are bedridden, life is more than a disassociated smokescreen. Cancer can kill you, but it does not impel you to kill yourself, as happens with severe mental illness. Rating these things is problematic, but according to those who sift through suffering, schizophrenia is twice as bad as being blind.

Which is saying something. My greatest fear as a child was going blind, not because of the usual warning parents issue to young boys, but because I had a lazy eye, had to wear a pink eye-patch, and worried that the darkness on one side of my face would never go. It did, but that does not happen with a lot of mental illness. More often than not, it hangs on, even - or especially - when your eyes are open. "Darkness visible" the writer William Styron called it, and it can draw a curtain over the most serene day and sanguine prospects.

This much is clear, if not conceded by governments who, as the recent Human Rights and Equal Opportunity Commission report - Not for Service - demonstrates, under-fund mental health and treat the mentally ill with disdain. What is less clear is what we mean when we talk of mental illness, and how it is that the one in five Australians said to suffer from it remain opaque. If mental
illness is akin to a treatable physical illness, is it not just a matter of finding a specific treatment? Beyondblue boss Jeff Kennett insists depression is a disease, just like diabetes, and can be treated, simply by visiting a GP
who will invariably dispense antidepressants.

But is mental illness - depression being the most visible - just a chemical imbalance in the brain, remedied, like a virus, by another chemical? Drug companies claim as much, yet they have failed to come up with an "insulin" to treat depression, let alone a specific chemical for the more severe psychotic conditions, such as schizophrenia. Instead, last year we had 12 million prescriptions (up from five million in 1990), for antidepressants, drugs that can have side-effects so bad some are driven to suicide. The most popular, Selective Serotonin Reuptake Inhibitors such as Prozac, are supposed to banish depression by boosting serotonin, a brain chemical associated with feeling better. In fact, there is nothing selective about them, nor is there any evidence that any drug acts specifically to reduce depression.

While they can lessen some symptoms, antidepressants don't tackle the underlying issue. Nor is the dominant mental health model interested in finding out what is behind the distress. This has come about because the biological explanation that now rules mental health is obsessed with brain chemistry, not human behaviour.

Being abandoned, poor, or, as fourth century poet Menander realised, gutted just because life means loss, is sidelined, which is a curious state of affairs. If something goes wrong in the body we find out what it is and try, usually successfully, to address it. But something goes wrong in the mind and we cover it up with drugs that are unspecific to the ailment. The brain-blame camp argue that they treat mental disease, not unhappiness - "clinical" depression, not blue moods - but these are all
arbitrary definitions depending on culture, not science.

As Douglas Coupland, inventor of generation X, notes, the spin on Prozac is not that it faces your frailties; rather it "creates a parallel brain". This fantasy notion lies in place of an interest in aetiology (the study of the causes of disease) and has arisen only since psychiatry ditched psychoanalysis, and the idea, however woolly, of a model of the mind linked to the emotions - what Freud thought of as the unconscious. Now mind means brain. Mental health is brain sleuthing; yet no researcher has come up with the cerebral substratum of human passions and discontent.

And they won't. Even though the 1963 book Three Hundred Years of Psychiatry argues that progress in understanding mental illness is "inevitable and irrevocable from psychology to neurology, from mind to brain", the biological bias is quaking. Experts, notably Auckland University's Dr John Read, and Manchester University psychology professor Richard Bentall, are pointing to the emperor's state of undress. Read thinks schizophrenia is caused by child abuse while Bentall, in his prize-winning book, Madness Explained, shows that, not only are psychiatry's categories illusory, its approach has more in common with astrology than science.

Bentall's case centres on a claim that the basis of psychiatry, forged by German psychiatrist Emil Kraepelin in the late 19th century, but still influential, is fatally flawed. Kraepelin, born in 1856, the same year as Freud, set up three sorts of madness: dementia praecox (schizophrenia), manic depression (bipolar) and paranoia. The big two, bipolar and schizophrenia, are supposed to be discreet disorders, but as Bentall demonstrates, the boundary can be so blurred that what one psychiatrist calls schizophrenia another calls bipolar. "We have been labouring under serious misunderstandings about the nature of madness for more than a century," he says.

Bentall provides lots of examples, but the one I like best is not in his book, but in The New York Times. In an article comparing Disney's cute Donald Duck with Warner Bros' irascible Daffy Duck, a psychiatrist says of Daffy, "he started as a simple manic-depressive but evolved over the years into a fully-fledged paranoid schizophrenic". Diagnosing cartoon ducks is not easy, but you would think there could be more reliability in the definitions. Bentall, however, says there is little reliability, mainly because modern psychiatry baulks at the idea that the symptoms we suffer have anything to do with the people we are. This is a madness of its own.

In its frantic attempt to become "scientific", psychiatry has not only thrown out what one writer calls the "junk pile of unexamined assumptions descended from Freud", but Plato's advice that an unexamined life is not worth living. We no longer have to search our mind, motivation or memory: it is all down to nerve endings.

So, now when we are mentally distressed, we either get a script from a GP who invariably knows little of mental illness, or, if we are a threat to ourselves or someone else, we get, as the Austin Hospital's professor of psychiatry, Anne Buist, says, patched up and pushed out. It is an appalling result that has come about not because the organic explanation for mental illness is scientifically rigorous, but because it is able to give the impression of success in random trials. This, though, is a sleight of hand. It is not just that placebos rate as high as drugs for depression, or, as University of NSW psychiatry
professor Gordon Parker points out, that "the barons of the new order of psychiatry" have joined the drug firms to "promote depression as a medical disorder". We have broken the historic link between cause and effect in the mental dilemmas we endure.

This was not the case in the days before psychiatry saw mental illness as a heart attack in the brain. Then, as thinkers as far back as Ovid knew, human beings had reasons other than their neurotransmitters to be distressed. I have read some learned papers on minds running off the rails, but none have corralled the black dog as eloquently as the writer Andrew Solomon. Depression, he says in his book Noonday Demon, is the flaw in love. Echoing Ovid, the Roman poet who advised "welcome this pain for you will learn from it", Solomon believes that to be creatures who love we must be able to despair at what we lose. "Depression is the mechanism of that despair," he writes. "It degrades one's self and ultimately eclipses the capacity to give or receive affection. It is the aloneness within us made manifest . . ."

This does not sound very scientific, but then neither does the biological explanation when you unpack it. And for those who protest that poetry has no role in recognising scientific truth, consider Nobel laureate James Watson's account of the biggest discovery of our time. Watson says that when Rosalind Franklin stood before the final model of the DNA molecule, she "accepted the fact that the structure was too pretty not be true".

There is nothing pretty about mental illness, though it may have more to do with poetry, or at least, language, than we realise. It is language - not lab tests - that designate mental distress and, by some accounts, alleviate it. This is partly because there is no medical measure for most mental illness. (Nearly all the one million Australians said to suffer depression are diagnosed by questionnaire.) And it is partly because words have the power to heal. Long before Freud implied the unconscious is structured like a language, and therefore can be deciphered, Shakespeare gave us a picture of the human personality that is deeper and more complex than the biological account pretends. As British psychoanalyst Adam Phillips explains, Polonius, Hamlet's sidekick, sees sanity and madness as two ways of "being pregnant with words". More recently, Czech president and poet Vaclav Havel argued that we become mentally ill when we say what we do not believe.

This is the core of the talking cure, psychotherapies which are rated as effective for depression as drugs, but which, for cultural reasons, are on the outer. If you suppose culture has no impact on madness, think again. Up to 1974, homosexuality was a mental disorder. It was re-thought, not because of science, but because gays lobbied the American Psychiatric Association for change in their clinical bible, the Diagnostic and Statistical Manual of Mental Disorders (DSM). Until the Soviet Union crumbled, signs of schizophrenia included dissatisfaction with the system, "conflicts with parental and other authorities" and "philosophical concerns". As Bentall puts it: "The boundaries of madness are culturally
determined."

The arbiters in all this are the panel of psychiatrists who forge scientific truth by horse-trading over what the DSM will brand a mental illness, and the drug companies who pay for most mental health trials. Yet the DSM is just one particular culture's attempt to make sense of behavioural breakdown. Developing nations deal with mental illness differently, and, as the latest research shows, get better results. Even though it has a more prosaic approach, the developing world has less schizophrenia than the Western world, possibly because sufferers are more likely to recover. Revealing how hollow the claim of universal patterns of psychosis is, Professor John McGrath of the Queensland Centre for Mental Health Research says: "If you get schizophrenia in a place like
India you tend to have a type of illness that recovers." McGrath has just done the most comprehensive
schizophrenia prevalence study ever undertaken.

Gordon Parker points out that depression is not, as the DSM says, a simple disease. Rather it is a spectrum of conditions. But because psychiatry wanted to boost its standing by creating the illusion of medical certainty, it listed depression as a single disorder. This produced structured criteria that looked rigorous, but tossed the baby out with the bathwater by ignoring any consideration of cause. Such pseudo-categorisation also happened with other mental disorders. The result was a manufactured market of misery.

In the 1950s, when the first antidepressant, imipramine, was discovered, makers Ciba-Geigy did not want to produce it because they felt there were not enough depressed people in the world to return a profit. Then, the condition was thought to affect about 1 in 1000 people; now it is something like one in five. Which makes you wonder: how can an organic "disease" suddenly explode? Could it be that depression is a symptom not a disease?

Nineteenth century neuroscientist George Gray certainly thought so. Depression, he said, was a gradual "unlearning of optimism". Earlier thinkers said it was "soul loss", while a giant of Western thought, Spinoza, explained it as a retreat from desire. Interestingly, Freud's French interpreter, Jacques Lacan, believed the real anti-depressive is desire, not drugs. He explained how capitalism forecloses desire by filling up the space of longing with gadgets which claim, like Coke or Prozac, to "be it", yet never are. But acknowledging, let alone, tolerating the truth of our incompleteness is confronting and, as Nick Cave says, gets a bad rap in a culture of shiny, happy McPeople.

Bentall, who like Solomon and Cave, has his bouts with the blues, examines the brain-blame theories - notably the hypothesis that schizophrenia is associated with an excess of dopamine - and finds them wanting.

Pointing out that many psychiatrists have argued for a crude form of biological reductionism, he ticks off the array of brain chemical alibis and concludes they have either been ambiguous, or unable to be replicated.

Which is not to say mental illness does not exist or is not devastating. Disorders of the mind are a painful fact - one that can kill. But in trying to kill off the stigma of madness, we have murdered the meaning of the mind, and created a certainty about mental disorders that does not exist. The result is an Alice in Wonderland take on treatment. As Dr Robert King from Queensland University's department of psychiatry says, the best predictor of outcome for depression is not the scientific status of the method, or even whether the patient is taking a drug orpsychotherapy. The best predictor is the "therapeutic alliance" that is the belief in the healer.

King dubs this the Dodo Effect after a story in the fairytale where the Dodo bird tells Alice after a race that all contestants have won and all must have a prize. So, as all treatments have equivalent impact, all must get recognition. Some clinicians, of course, don't just focus on chemicals, and do look to the importance of the body, mind and society in mental illness. But they are being pressed by the mainstream which, as Bentall says, still embraces the Kraepelinian paradigm. It is "almost unchallenged within mental health professions" and that means psychiatric services are misguided and need new ideas even more than new resources, he says.

Maybe we should blame Rene Descartes, the "I think therefore I am" guy, whose theory of dualism held that mind and brain were different kinds of substances. That led to the idea that the brain could be separate and within an individual's conscious control. Freud, who was pilloried for pointing out that the unconscious meant the ego was not master in its own house, disagreed. And so does research which shows biology inextricably linked to biography. The brain is "plastic", susceptible to re-shaping by environment well into childhood, leading researchers say. This means nurture is hard-wired into the brain as much as genetics, making upbringing and attitude critical.

But, as long as psychiatry tries to pretend there is a strict dividing line between madness and sanity, those suffering mental disorders will be seen as somehow falling short of the "normalcy" we imagine we possess. The most disturbed among them will continue to fill their mouths with smoke, rather than speak about sadness.

1 Comments:

Anonymous Anonymous said...

Dear Phillip,
Understanding mental health and mental health research takes a lot of time, training and effort. Whenever you place anything in the public sphere whether it is a blog or a newspaper article ,it takes on a life of its own. This cal;ls for responsibility in publishing whatever it is that you do publish. I have seen your profile and you seem to be a mature man. Kindly spend some time and effort in understanding the research and research methodologies and educating yourself on this field. I will look forward to a more informed posting which is fuelled as much by knowledge as passion.

10:53 PM  

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