August 31, 2009

Bentall: Diagnoses are psychiatry's star signs

"Let's listen more and drug people less"

Heading over to the Guardian of UK today to check the comments on my essay on the Jaycee Lee Dugard case, I was excited to stumble across a new essay by Richard Bentall. For those of you who don't know him, in my opinion Bentall is one of the most important voices in the mental health field today. His new book, Doctoring the Mind, is an outstanding, empirically based critique of modern biological psychiatry, and its abysmal failure -- all hype to the contrary -- to improve the human condition. His Guardian essay, excerpted below, briefly summarizes his main arguments:
. . . 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 . . . – have hardly changed since the Victorian period. . . .

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. . . . This . . . 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 [and] 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. . . . 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.
The full essay is online HERE. I highly recommend his book, too.

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