Sunday, July 29, 2012

Mental Illness: Moving Past Medication

Tanya Marie Luhrmann is described as a "psychological anthropologist." She has participated in a remarkably diverse set of projects, several of which involve mental illness and its treatments. She bears glad tidings in a new article that appeared in The Wilson Quarterly: Beyond the Brain. The title does little to elucidate the topic. This will help.
"....the National Institute of Mental Health designated the 1990s as the "decade of the brain." Psychoanalysis and even psychotherapy were said to be on their way out. Psychiatry would focus on real disease, and psychiatric researchers would pinpoint the biochemical causes of illness and neatly design drugs to target them."

The title is meant to convey that the medication-driven approach to addressing mental illness was a dreadful failure and it is now time to move on to the next attempt.

"It is now clear that the simple biomedical approach to serious psychiatric illnesses has failed....At least, the bold dream that these maladies would be understood as brain disorders with clearly identifiable genetic causes and clear, targeted pharmacological interventions (what some researchers call the bio-bio-bio model, for brain lesion, genetic cause, and pharmacological cure) has faded into the mist."

Luhrmann’s discussion focuses mostly on schizophrenia, but she claims the same general conclusions apply to depression and other mental illnesses.

"To be sure, it would be too strong to say that we should no longer think of schizophrenia as a brain disease. One often has a profound sense, when confronted with a person diagnosed with schizophrenia, that something has gone badly wrong with the brain."

"Yet the outcome of two decades of serious psychiatric science is that schizophrenia now appears to be a complex outcome of many unrelated causes—the genes you inherit, but also whether your mother fell ill during her pregnancy, whether you got beaten up as a child or were stressed as an adolescent, even how much sun your skin has seen. It’s not just about the brain. It’s not just about genes."

The tendency to develop schizophrenia is now attributed to a complex assembly of risk factors. This view is supported by advances in knowledge derived from epigenetics, the study of the means by which genetic function can be altered by environmental factors or experiential events. The world appears a whole lot more complicated than it did in the 1990s.

"In recent years, epidemiologists have been able to demonstrate that while schizophrenia is rare everywhere, it is much more common in some settings than in others, and in some societies the disorder seems more severe and unyielding. Moreover, when you look at the differences, it is hard not to draw the conclusion that there is something deeply social at work behind them."

"Schizophrenia has a more benign course and outcome in the developing world. The best data come from India. In the study that established the difference, researchers looking at people two years after they first showed up at a hospital for care found that they scored significantly better on most outcome measures than a comparable group in the West. They had fewer symptoms, took less medication, and were more likely to be employed and married."

The better results obtained in India seem to derive from the approach of focusing on the patients recovery rather than the seriousness of the illness. They were maintained in their normal social environment to the degree possible.

"As a result, none of the patients thought of themselves as having a career-ending illness, and every one of them expected to get better. And at least compared to patients in the West, they generally did."

Luhrmann tells us that the concept of social activation as being causative has taken root within the psychiatric profession. This has led to acceptance that social factors should be part of the treatment process. It was interesting to note that the much-maligned George W. Bush demonstrated an enlightened understanding of the issues.

"One of the most influential patient-driven initiatives in decades, the Recovery Movement received a federal imprimatur of sorts in 2003, when the Bush administration issued a mandate promoting "recovery-oriented services." Treatment providers paid by Medicare and Medicaid were told that schizophrenia would no longer be understood as an illness with a chronic and debilitating course, a death sentence for the mind. Instead, patients and mental health professionals were instructed to believe that people with schizophrenia could live as effective members of a community, able to work and to be valued. The expectation of permanent impairment was to be replaced with hope."

The Recovery Movement is described as a patient-driven initiative. One of the downsides of depending on medication to treat mental illness is that the medication seems to confer to the patients the notion that they are in fact mentally damaged, something they would resist agreeing with. Instead the Recovery Movement focuses on trying to let the misbehaving brain be brought under control by the brain itself.

"....the Recovery Movement, which explicitly embraces the idea that the very way you imagine an illness will affect the way you experience it—an idea that seems, well, almost psychoanalytic. As the movement’s manifesto defined it, ‘recovery is a process, a way of life, an attitude, and a way of approaching the day’s challenges’."

Luhrmann also describes the intriguing "Hearing Voices" movement.

"In Europe, the Hearing Voices network teaches people who hear distressing voices to negotiate with them. They are taught to treat the voices as if they were people—to talk with them, and make deals with them, as if the voices had the ability to act and decide on their own. This runs completely counter to the simple biomedical model of psychiatric illness, which presumes that voices are meaningless symptoms, ephemeral sequelae of lesions in the brain. Standard psychiatric practice has been to discount the voices, or to ignore them, on the grounds that doing so reminds patients that they are not real and that their commands should not be followed. One might think of the standard approach as calling a spade a spade. When voices are imagined as agents, however, they are imagined as having the ability to choose to stop talking. Members of the Hearing Voices movement report that this is what they do. In 2009, at a gathering in the Dutch city of Maastricht, person after person diagnosed with schizophrenia stood up to tell the story of learning to talk with the voices—and how the voices had then agreed to stop."

Absolutely fascinating!

Luhrmann tells an interesting story that indicates that the mentally ill may, perhaps, face a future that need not include a lifetime shortened by powerful mind-altering and brain-damaging drugs. Her description of current methods under development is definitely progress.

A burst of enthusiasm was soon replaced by the more depressing realization that nothing she posited as a new and exciting development was really new. Robert Whitaker wrote a book published in 2010 that reviewed what he was able to learn about the history of mental illness and the results of medication on patients: Anatomy of an Epidemic. Whitaker’s curiosity was aroused by the fact that as each new miracle drug was announced to combat mental illness, the larger the number of the mentally ill became. That is not what one would expect from a miracle drug.

There was a brief period of time when schizophrenics were neither thrown in asylums, nor medicated with antipsychotic drugs. During that period most of those diagnosed stayed within a family setting and the majority learned to deal with their issues and managed to lead a more or less normal life, or at least one that did not require medication or incarceration. Is that terribly different from the "new" results presented by Luhrmann?

The World Health Organization (WHO) tracked schizophrenia outcomes, comparing results in developing countries with results from advanced countries. In 1969 the WHO concluded that schizophrenics were more likely to recover in the developing countries than in the advanced countries. Whitaker tells us that the psychiatric community in the US refused to believe the results. The WHO performed another study in 1978 with more exacting controls; the result was the same.

Luhrmann would look at these results and conclude that the socialization in the developing countries was more conducive to healing than the treatment received in the US. Whitaker concluded that the medications commonly prescribed were not only not helping the patients very much, but that they would also eventually make many patients even sicker; hence the term "Epidemic" in his title. They both seem to be correct.

Luhrmann states that the community is beginning to recognize that medication is not the cure-all it was sold as. The data to demonstrate that statement was always available, but people chose to ignore it. Whitaker dug up this result from 1978.

The best thing that could happen to a schizophrenic in the 1970s was to never receive an antipsychotic drug. The next best thing was to escape from a psychiatrist’s care and stop taking any medications that had been prescribed.

The psychiatric community knew in the 70s that psychoactive drugs had been a failure, but they thought that they owed their patients the right to participate in the best experiments they could perform. They listened to siren call of the drug companies who promised a new generation of miracle drugs. Luhrmann tells us how that turned out.

"....the older antipsychotics—such as Thorazine, mocked in the novel One Flew Over the Cuckoo’s Nest for the fixed, glassy stares it produced in those who took it—worked as well as the new generation, and at a fraction of the cost."

In other words the new generation of drugs couldn’t cut it either. Studies were available in the 1990s that demonstrated that depression was best treated by avoiding psychoactive drugs. And then there were the multiple studies that concluded that antidepressants worked barely better, if at all, than a sugar pill. The drug companies weren’t even embarrassed because they knew it all along. The power of suggestion can be an awesome medication.

So now we are said to be moving from a stage where drug companies and pad scribblers are in charge to one in which anthropologists have concluded that anthropologists should be in charge. Let us cheer on the anthropologists and wish them well.

It is hard to see how they can do much damage.

Seriously, the Recovery Movement and the Hearing Voices approaches indicate that there is hope for a better future for the mentally ill.

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