EXTRA!

August 27, 2003

A FAST FOR FREEDOM IN MENTAL HEALTH

RETHINKING THE MENTAL ILLNESS INDUSTRY

By Loren R. Mosher M.D. and Mary Boyle Ph.D.

"Depression is a flaw in chemistry, not character"

Eight story sign at Amsterdam Ave and 72nd St., New York City

The American public is constantly being told that various forms of mental and emotional distress and disordered behavior are 'illnesses like any other' - depression is just like diabetes. Yet, does the public know that the American Psychiatric Association's Diagnostic and Statistical Manual now has 374 'mental disorders' versus 112 in 1952 and, even though we now have all these new 'diseases', that not one has given up its biological secrets? The US Surgeon General concluded in 1999 that there is no biochemical, anatomical or functional sign that reliably distinguishes between the brains of mental patients and anyone else.

Who benefits from this proliferation of mental disease? An obvious beneficiary is the drug industry, for if behavior and distress look like physical illnesses, then 'treatment' naturally looks like drugs. In 2000, 23 billion dollars were spent on psychotropic drugs, twice the 1995 cost.

And, although psychiatric drugs don't have specific effects on emotions and behavior (they sedate, tranquilize and stimulate in non-specific ways) they are marketed as if they specifically treated particular mental disorders. The result is a strong symbiotic relationship between the DSM's ever-growing list of disorders and the marketing and sales of drugs. Perhaps the most striking aspect of this has been the dramatic growth in the children's drug market, to the point where an estimated 5-7 million American children now take stimulant drugs for 'attention deficit disorder'.

We would be less concerned about this situation if the outcomes were positive. But, on the contrary, long-term outcomes for people diagnosed as schizophrenic are no better now, and may even be worse, than before the introduction of major tranquilizers (misleadingly called anti-psychotics). Not only that, but the World Health Organization found that outcomes for people with schizophrenia in developing countries, where these drugs are used much less, are actually better. Similarly, research indicates that antidepressants have not significantly reduced the suicide rate, and, as the Journal of Clinical Psychiatry recently reported, that these drugs may "actually increase biochemical vulnerability to depression and worsen long term outcomes". There are also serious concerns about the adverse effects of these drugs. The major tranquilizers can produce incurable movement disorders. The minor tranquilizers are addictive. The newer antidepressants induce suicidal and homicidal behavior in some persons and can be addictive. Given these problems, it's difficult to see that the medicalization of emotion and behavior, and its 'treatment' with drugs, has overall had positive effects.

It is not just the lack of positive outcomes that should concern us. In spite of claims that the medicalization of human distress is based on biomedical science, research paints a quite different picture. The strongest evidence about causes of distress and disordered behavior comes from research on social and environmental factors. For example, if at least 50-60% of those admitted to psychiatric hospitals, regardless of diagnosis, have been physically or sexually abused, is it not reasonable to assume that this may have something to do with the distress they are experiencing? If various types of family dysfunction, poverty, trauma, unemployment and other environmental factors are consistently and strongly related to psychiatric problems, is this not significant? Are we seriously to assume that the best answer to these psychosocial issues is drugs?

What is especially tragic about this situation, apart from the human cost, is the closing down of open and honest debate. Readers who thought that the issue of 'mental illness' has been settled in favor of biological psychiatry may be surprised to learn that many people with impeccable academic and professional credentials continue to produce valid critiques of biological psychiatry's research and practice. There is also grave concern about the methods it uses to hide its lack of scientific respectability. But critics' views rarely receive media attention, while authoritative sounding medical assertions are given immediate credibility and publicity. Frequent pronouncements of genetic or biological "breakthroughs" in our understanding or treatment of 'mental illness' keeps the public in a constant state of positive anticipation. When the breakthrough comes to nothing, as it always has, no trumpets are heard and, in any case, another will be along soon.

As the President's New Freedom Commission report recently concluded, the current model of care has proven to be a failure. Given this context it is surely time to re-think biological psychiatry. The public deserves to be better informed about the scientific and ethical issues so that they can question critically how public money is being spent and about the standards of evidence on which claims about biological causation and treatment are based. More open and honest debate can only be good for the field and especially for users of mental health services.

Loren R. Mosher is Clinical Professor of Psychiatry at the University of California at San Diego and former Chief of the Center for Studies of Schizophrenia at the National Institute of Mental Health and first Editor-in-Chief of the Schizophrenia Bulletin.

Mary Boyle is Professor of Clinical Psychology, Head of the Doctoral Program in Clinical Psychology at the University of East London, UK and author of "Schizophrenia: A Scientific Delusion?"