The psychiatrist Thomas Szasz wrote a popular book in the 1960s, “The Myth of Mental Illness.” Mental illness is not a myth, but it is murky.
People with serious conditions such as bipolar disorder and schizophrenia are most assuredly suffering from an illness. The National Alliance on Mental Illness (NAMI) was formed to support the individuals and families impacted by these illnesses, but we need to evaluate our scientific claims and our messaging for mental illness.
Psychiatrists have embraced a biological model of mental illness for decades and have prescribed a variety of psychotropic medications. However, skeptical researchers have evaluated many studies supporting antidepressants (including those submitted to the FDA) and have found that most of their benefits derive from placebo effect rather than chemical action.1 I remember simpler days of telling patients that their physician was prescribing their medication for a “chemical imbalance.” They would typically nod in acceptance of this simplistic biological hypothesis, which they mistakenly assumed to be well-validated, about what was impacting their lives.
Today, we have various neurotransmitters that are presumably unbalanced in various ways, and they are at the root of different solutions developed by the pharmaceutical industry. The chemical balance explanation now makes little sense, and so we should come to terms with all the specious hypotheses that have been put forward about how medications work. At the same time, let’s not fail to raise the more fundamental question: how well do they actually work?
In this regard I would offer the thoughts of Richard A. Friedman, MD,2 professor of clinical psychiatry at Weill Cornell Medical College.
American psychiatry is facing a quandary: Despite a vast investment in basic neuroscience research and its rich intellectual promise, we have little to show for it on the treatment front. With few exceptions, every major class of current psychotropic drugs—antidepressants, antipsychotics, anti-anxiety medications—basically targets the same receptors and neurotransmitters in the brain as did their precursors, which were developed in the 1950s and 1960s. Sure, the newer drugs are generally safer and more tolerable than the older ones, but they are no more effective.
Physical or mental illness
My question is whether every depressed person has an illness—a mental illness—on par with the cold and flu viruses people experience every year. Who asserts this? Proponents of biological psychiatry are the main standard bearers, be they from the pharmaceutical or psychiatric ranks, and they may simply advocate in a seemingly harmless way that a biological model will be validated at some future time. What are the benefits of assuming that all the disorders of mental health or emotional health are rooted in a mental illness? I would suggest none.
Prescribers often fall back on anecdotal evidence from their patients. Is the sad conclusion from medication research studies that we must admit that depression is a condition we really don’t understand after decades of study?
We can approach this from another angle. We know there are plenty of studies (and anecdotal reports) of people who “recovered” from depression after months of treatment with a clinician providing cognitive behavioral therapy. Was this recovery from an illness? Or was it recovery from a mental state that is not really an illness? Was it recovery from a negative state of mind learned over many years?
Many would argue that DSM diagnoses like addictions and eating disorders are illnesses. We certainly know why this is the case. We know how these conditions typically progress clinically and how they often result in death. Is there a physical progression underlying these conditions? Are they deteriorating mental states without a physical basis? We have theories, and yet we have few facts or conclusions. Again, the bias is to find a biological substrate for presumed mental illnesses along with bio-chemical solutions.
The rubric of illness
We know why there is a desire to place destructive patterns of thoughts, feelings, and behaviors under the rubric of illness. The alternative has often been accepting moral judgments about personal failings, and just as worrisome, accepting limited funding for research and treatment for conditions that fall outside the medical model.
There is also a compelling logic to the model of illness. If we view addiction as being comparable to a chronic medical condition like diabetes, then we are more likely to develop a sensible, long-term treatment plan. Is it a problem that in many ways we understand the biology of diabetes better than the biology of addiction? Not if a curative addiction pill is on the horizon.
My point here is to be provocative—such a pill may be on the horizon for all I know—but I am challenging the assumption that it is wise to put most problems into the category of illness and wait for the new medications to arrive.
I would add one final critical thought, and it is about the dark side of marketing. Are we in the arena of science or marketing when we discuss mental illness?
When science is simply a bias about how we should validate a certain point of view—when marketing of that “science” has a financially-driven goal—when the medical model is more important than any findings—aren’t we are simply in the world of marketing? We are promoting ideas that may or may not have validity, but we are driven to support the dominating ideology, for financial value. This is a corrosive development.
Let’s update our message