03/7/17

Between a Rock and a Hard Place

© albund | stockfresh.com

Terry Lynch is an Irish physician and psychotherapist who challenged the commonly held view that psychiatric disorders are legitimate brain disorders. He did so in a brief video that had an interesting take on the issue. He showed where two of the organizations affiliated with the U.S. National Institute of Health (NIH) apparently have different opinions about whether several psychiatric disorders should be considered to be brain disorders.

In his video, “It’s official: Psychiatric diagnoses are NOT known brain disorders,” Lynch gave a screen capture from the “Brain Basics” educational resources page of the National Institute of Mental Health (NIMH). He highlighted the opening statement there, which says: “Welcome. Brain Basics provides information on how the brain works, how mental illnesses are disorders of the brain, and ongoing research that helps us better understand and treat disorders.”  Further down the page is the following: “Through research, we know that mental disorders are brain disorders.” These disorders were said to include depression, anxiety disorders, bipolar disorder, attention deficit hyperactivity disorder (ADHD) and many others.

He also called attention to a second NIH Institute, the National Institute of Neurological Disorders and Stroke (NINDS). The official mission statement of NINDS is “to seek fundamental knowledge about the brain and nervous system and to use that knowledge to reduce the burden of neurological disease.” On the NINDS homepage is search engine where you can search by disorder. Lynch proceeded to show that depression, bipolar and schizophrenia were not listed in the NINDS database as neurological disorders. ADHD does appear in the NINDS, database but was not mentioned by Lynch in his video. You can replicate what I’ve said here be searching the “Brain Basics” page on NIMH and the NINDS database here.

One response to the differences Lynch found would be to say that NINDS attends to neurological disease, while NIMH addresses a different kind of brain dysfunction, namely mental or psychiatric disorders. But that response doesn’t resolve the dilemma. Because the next question becomes what is the difference between neurological disease and mental/psychiatric disorder? Attempting to articulate the difference may have placed psychiatry in a sort of catch-22 situation.

Lynch addressed this dilemma in an essay he wrote, “Psychiatry: Between a Rock and a Hard Place.” His opening statement there was that contrary to their repeated claims of doing so, “psychiatrists do not treat known organic illnesses.” They do not treat known organic brain disorders, which are under the care of neurology and neurosurgery. He said emotional and psychological distress typically comes under the care of counseling or psychology. So where, then, does psychiatry fit in?

Psychiatry is caught between a rock and a hard place—somewhere between the medical specialties treating known brain diseases (neurology and neurosurgery) and the talk therapies of counseling and psychology. Psychiatrists, according to Lynch, invented terms such as “mental illness” or “mental disorder,” and made themselves the experts who would diagnose and treat said illness/disorder. “They have fed the public with unsubstantiated ideas about neurotransmitters, chemical imbalances and brain disorders, ideas which the public have generally believed wholeheartedly.”

The challenge for psychiatry has been to carve out its own distinct identity. Claims that depression and other psychiatric diagnoses are biological illnesses are crucial to psychiatry’s identity and its unmerited position at the top of the mental health pyramid. These assertions separate psychiatry from the talk therapies and ensure that psychiatry has first claim to these “diseases” and the people they diagnose as having them.

He said psychiatry wants to be more closely aligned with the respected medical standing of neurology than to psychology or counseling. But it has to be seen as distinct from neurology to maintain a separate identity. “Specializing in ‘mental illnesses’ and ‘mental disorders’ provides the needed distinction.” Towards that end, Lynch said psychiatry has convinced the general public (and perhaps themselves) that psychiatric disorders are biological illnesses. In the process, they have side stepped “the fact that there is no reliable corroborative scientific evidence for this.”

For over a century, psychiatry has reassured the public that both the necessary understanding and more effective solutions lie just around the corner. “Bear with us, we are almost there,” psychiatry’s catchphrase for the past 100 years and more, buys them more time, every time.

Lynch thought psychiatry would confront a nightmare of their own making if it ever connected brain abnormalities to psychiatric diagnoses. If structural or functional brain abnormalities were ever found to be associated with psychiatric diagnoses, care of those individuals would likely be transferred away from psychiatry to neurology—“a specialty that deals with known brain abnormalities.” He said precedent within medicine would dictate that responsibility for those patients would be transferred to neurology or some other relevant specialty.

Given this, Lynch thinks the best position for psychiatry is to stay exactly where it is. As long as there are no reliable biological abnormalities identified, there is no threat to their position. By claiming that mental disorders are rooted in biology, psychiatry has set itself apart from talk therapies. “As long as no biological abnormalities are reliably identified, there is no threat that their bread and butter will be removed from them to other medical specialties.” Maintaining the myth that biological solutions are imminent, satisfies the public and preserves it’s position.

“If biology isn’t seen as central to the experiences and behaviours that have become repackaged as so-called “mental illnesses,” what special expertise can mainstream psychiatrists claim to possess?” So when psychiatrists defend their pronouncements on depression or any other psychiatric label, they are not just defending a diagnosis. “They are defending themselves, their ideology, their modus operandi and ultimately, their status and role in society as the perceived prime experts in mental health.”

Lynch is not alone in his views of psychiatry and diagnosis. There are clear echoes of the thought of Thomas Szasz in what he says. Peter Breggin, Joanna Moncrieff, Robert Whitaker, Peter Gøtzsche, David Healey, Sami Timimi and others would agree with parts, if not all, of what he asserts. Here, for example, is a blog article by Chuck Ruby for the International Society for Ethical Psychology & Psychiatry (ISEPP), “Blue Illness.” Reflecting on an article that affirmed depression was a mental illness, Ruby noted that for decades, attempts have been made to demonstrate the brain-pathology basis of depression.

Despite the billions of public dollars invested in this research, no such evidence of brain pathology has been discovered. The only thing this research has shown is that our experiences and behaviors are mirrored by changes in the brain. This is something we already knew. Yet, instead of giving up the search and redirecting those monies to more worthy research of real diseases, the mental health industry repeats the worn out pronouncement that discovery is just around the corner! Ironically, if such a discovery came, wouldn’t depression then fall within the medical specialty of neurology, the real medical specialty that studies real brain illnesses?

In the concluding paragraphs of their book, Psychiatry Under the Influence, Robert Whitaker and Lisa Cosgrove wrote that from a scientific standpoint, psychiatry is facing a legitimacy crisis. “The chemical imbalance theory is collapsing now in the public domain.” The former director of the NIMH, Thomas Insel, has written of how second generation psychiatric drug are no better than the first, “which belies any claim that psychiatry is progressing in its somatic treatment of psychiatric disease.”

The disease model paradigm embraced by psychiatry in 1980 has clearly failed, which presents society with a challenge: what should we do next?

Terry Lynch is right. Psychiatry is between a rock and a hard place. But save your sympathy for the patients who are there with it.

07/2/14

Thor’s Psychiatric Hammer: Antidepressants

60 Minutes broadcast a segment on treating depression in February of 2012 that is still causing ripples of controversy. Two of the individuals interviewed, Irving Kirsch, a Harvard psychologist and Walter Brown, a psychiatrist with Brown University, challenged the two accepted pillars of current depression treatment. Kirsch said: “The difference between the effect of a placebo and the effect of an antidepressant is minimal for most people.” According to Brown, “The causes of depression remain a mystery.”

The chemical imbalance theory, which has guided the pharmaceutical industry in developing new drugs since the 1960s, is “probably incorrect.” Brown added that the experts in the field, the academic people who do research on drugs, now believe that the chemical imbalance theory is “a gross oversimplification.” If the neurotransmitters serotonin, norepinephrine, dopamine have anything to do with depression, “it’s of a minor role and probably sets the stage for depression. But they’re not the cause of depression. I think we know that now.”

Yet the chemical imbalance theory is still widely taught in medical schools. Many psychiatrists and mental health professionals still believe it. “The problem in psychiatry is that we don’t have a lot of tools. And if the only tool you have is a hammer, you treat everything as if it is a nail.”

Irving Kirsh has been doing research into the placebo effect for over 35 years. His original research intent with antidepressants was to evaluate the size of the placebo effect with antidepressants. He was a believer in the efficacy of antidepressants and he used to refer people to get antidepressant prescriptions. “I didn’t change the focus of my work onto looking at the drug effect until I saw the data from our first analysis.”

In a 1998 study, Kirsch found that 75% of the response to antidepressants was duplicated by placebo. He did a follow up study in 2002, where he analyzed the data submitted to the FDA for the six most widely prescribed antidepressants approved between 1989 and 1999: Prozac (fluoxetine), Paxil (paroxetine), Zoloft (sertraline), Effexor (venlafaxine), Serzone (nefazodone), and Celexa (citalopram).  He found a small but significant difference between the antidepressant drugs and inert placebo. “If the drug effect is as small as it appears … then there may be little justification for the clinical use of these medications.”

Leslie Stahl challenged Kirsch, saying that people are getting better by taking antidepressants. He agreed. “People get better when they take the drug. But it’s not the chemical ingredients of the drug that are making them better. It’s largely the placebo effect. . . . The only place where you get a clinically meaningful difference [with an antidepressant] is at these very extreme levels of depression.” The placebo effect is stronger with mild depression.

Both Kirsch and Stahl cautioned that antidepressants should not be stopped cold turkey. Leslie Stahl said that individuals who take antidepressants, and feel better as a result, will likely continue to take them. But she worried about the side effects. For some people there are serious side effects. “And if a sugar pill is just as good, how can we keep prescribing these pills?”

For more information on antidepressants, see: “Antidepressant Withdrawal or Discontinuation Syndrome?” and “Antidepressants: Their Ineffectiveness and Risks” under the Resources: Counseling Issues menu.

Do you think evidence about the placebo effect with antidepressants effectively challenges the chemical imbalance theory of depression?