Facing the Facts about Mental Illness

T. M. Luhrmann is an anthropologist at Stanford University.  One of her interests has been mental illness with a focus on schizophrenia.  She has been writing about the need to consider what we label as mental illness as a psychological condition as well as a biological condition.  She has been interested in reminding the world that there are means of treating—if treatment is necessary—behaviors that do not fit within society’s definition of what is normal without resorting to dangerous medications.

Just as people are born with a range of intelligence, they are born with a range of responses to sorrow-inducing or threatening circumstances.  If the magnitude of the response is deemed excessive, we have decided to describe those people as suffering from depression or anxiety.  The range of such responses is continuous across individuals so the point at which one becomes “mentally ill” is absolutely arbitrary.  In addition, people have a considerable degree of control over their responses.  They can learn to deal better with sorrow and threats more effectively over time.  That is why Luhrmann and many others suggest drug therapy as more of a last resort than the treatment of choice.

As an example of learning to cope, consider a fascinating article Luhrmann produced for The American Scholar: Living with Voices.  She describes the discovery that people who are troubled by hearing voices, a certain path to a schizophrenia diagnosis, often find relief from confronting the voices and negotiating with them rather than fearing them or trying to make them go away.  Forming a relationship with the voice seems to change the character of the voice, transforming it from a threat to something that can occasionally even provide encouragement.  A movement has been formed promoting this approach.  Many participants had previously been subjected to intolerable brain-altering medications aimed at making the voices disappear.  They like to refer to themselves as “survivors of psychiatric care.”  More on the topic can be found here.

Luhrmann produced an article for the New York Times titled Redefining Mental Illness.  She was encouraged by recent developments that seemed to indicate a greater acceptance for more flexible treatment of mental issues—and not treating all issues as illnesses.

“TWO months ago, the British Psychological Society released a remarkable document entitled ‘Understanding Psychosis and Schizophrenia.’ Its authors say that hearing voices and feeling paranoid are common experiences, and are often a reaction to trauma, abuse or deprivation: ‘Calling them symptoms of mental illness, psychosis or schizophrenia is only one way of thinking about them, with advantages and disadvantages’.”

“The report says that there is no strict dividing line between psychosis and normal experience: ‘Some people find it useful to think of themselves as having an illness. Others prefer to think of their problems as, for example, an aspect of their personality which sometimes gets them into trouble but which they would not want to be without’.”

It was particularly encouraging to find the report recommending that psychological approaches be made available as well as medicinal.

“The report adds that antipsychotic medications are sometimes helpful, but that “there is no evidence that it corrects an underlying biological abnormality.” It then warns about the risk of taking these drugs for years.”

“And the report says that it is ‘vital’ that those who suffer with distressing symptoms be given an opportunity to ‘talk in detail about their experiences and to make sense of what has happened to them’ — and points out that mental health services rarely make such opportunities available.”

Luhrmann is also encouraged by new research funding guidelines announced by the National Institute of Mental Health (NIMH).  Mental illness diagnoses have long been made by correlating a patient’s symptoms with a list of symptoms collected in cookbook form by the American Psychiatric Association.  This approach was not associated with any physical response or condition, and a given set of symptoms did not have a unique diagnosis.   It was defining mental illness to be whatever a conclave of psychiatrists decided they wanted it to be.

NIMH’s director, Thomas Insel, was sufficiently embarrassed by this state of affairs that he decided the time had come to demand a better approach.

“In 2013, the institute’s director, Thomas R. Insel, announced that psychiatric science had failed to find unique biological mechanisms associated with specific diagnoses. What genetic underpinnings or neural circuits they had identified were mostly common across diagnostic groups. Diagnoses were neither particularly useful nor accurate for understanding the brain, and would no longer be used to guide research.”

“Under a program called Research Domain Criteria, all research must begin from a matrix of neuroscientific structures (genes, cells, circuits) that cut across behavioral, cognitive and social domains (acute fear, loss, arousal). To use an example from the program’s website, psychiatric researchers will no longer study people with anxiety; they will study fear circuitry.”

Luhrmann is correct in identifying the new NIMH funding criteria as progress.  However, if your main concern is seeing better balance between psychological treatment and medicinal treatment it is not clear how great the progress might be.  Insel’s funding focus still seems to be on determining physical mechanisms for brain malfunctions that are the causes for mental illness.  The fundamental thrust is unchanged.

And while the recommendations of the British Psychological Association seem spot on, the paper on psychosis and schizophrenia that came out recently is a partner publication to one that was issued in 2010 on bipolar disorder that basically came to the same conclusions and made the same recommendations.  And that publication was an elaboration on a similar document prepared in 2000.  The words are good, but where is the progress?

The problem with good intentions in the healthcare arena is that they must be coupled with the means by which current stakeholders can continue to make money.  Following the money with respect to mental illness can leave the sanest of us in a state of severe depression. 

The drug companies have an obvious interest in defining mental illness as broadly as possible and selling their products to as many people as possible and for as long a period as possible.  They are in the business of providing treatments not cures.  Any publication, such as Luhrmann’s, can be swamped by any number of clinical studies, scientific publications, and television commercials promoting the benefits of their drugs.  Their propaganda does not even have to be accurate; as long as they have someone who pretends to be a doctor endorsing their products they seem to acquire automatic credibility.  A single “good” patient on a lifetime drug regimen can provide hundreds of thousands of dollars in revenue

Many people with mental concerns go to their normal physician for care.  These physicians are not trained in psychological therapy.  The simplest thing for them to do is believe the drug company advertising.  Psychological therapy is likely to be more expensive, seem more risky, and less likely to be covered by medical insurance.

Psychiatrists in the United States have totally bought into treatment by medication.  That is what they are taught in their professional education.  It is also obvious that they can make a lot more money prescribing medications than spending a lot of time discussing issues with patients.  Talk therapy requires devoting an hour to each patient with an unknown number of sessions required.  Medicinal therapy allows them to see three or four patients per hour, and they are more likely to be fully reimbursed for their services by insurance companies.

Medical insurance companies seem happier with drug therapy because it gives them a better method of estimating costs, and the endorsement of the psychiatrists and drug companies provides them cover for their actions. 

This alignment of economic interests has taken our country from a situation where disability from mental issues was rare and usually episodic to one in which disabling mental issues are common and chronic.  The World Health Organization (WHO) and others have performed studies examining mental health outcomes in developing countries like India, where treatment is rudimentary at best, with outcomes in countries like the US and concluded that one’s chances of recovering from an episode of mental illness is better in the developing countries. 

Something is terribly wrong here.

Kudos to Luhrmann for continuing to fight the good fight!