Mental Health and Outcome Paradoxes

 In 2010, Robert Whitaker published Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America.  As the title suggests, he viewed the rapid rise of long-term mental illness as an epidemic, one caused by the massive use of psychotropic drugs as remedies for mental illness.  He produced compelling arguments indicting the pharmaceutical industry for promoting and selling vast amounts of drugs that were of little value and would often lead to long-term medical issues and dependence for the users.  His warning went unheeded.  It seemed that the general public was unable to believe that the treatment of mental illness could be such an incredible mess.  Since that publication the rise in numbers of people captured by a perceived need for chemical support has continued to grow.  Recently, Rachel Aviv produced an overview of mental health issues that provides a different perspective on possible treatments and produces a potential explanation for why the “epidemic” has continued.  Aviv’s ground-breaking book was titled Strangers to Ourselves: Unsettled Minds and the Stories That Make Us.  This work was previously reviewed in Mental Illness: The Stories We Tell Ourselves and the Stories Psychiatrists Tell Us.  Aviv probably had no intention of supporting Whitaker’s contention, but, in effect, she does.

Whitaker suggested two interpretations of the available data that Aviv had trouble accepting.  The first involves data accumulated on the outcomes of peoples suffering from schizophrenia in various countries.  Researchers were particularly interested in whether the presumed superior healthcare available in developed countries would produce better health outcomes relative to the results obtained in less-wealthy developing nations.  The first surveys began in the late 1960s by the World Health Organization (WHO).  The developed world was startled to discover that the poorer countries experienced better outcomes than the wealthy countries with their readily available drugs and experts.  Healthcare professionals have been resurveying populations over the years hoping that the results will change.  But they haven’t.  The following quotes detail the results from a typical survey. It is from an article that appeared in Nature: Developing countries: The outcomes paradox (2014).

“The pattern for most diseases is clear: the richer and more developed the country, the better the patient outcome. Schizophrenia appears to be different.”

“The study found that developing countries had higher rates of complete recovery: an average of 37% compared with 15.5% in developed countries. The rates of chronic illness, however, were similar: 11.1% in developing and 17.4% in developed countries. Patients in developing countries experienced longer periods of unimpaired social functioning, even though far fewer of them were on continuous antipsychotic medication.”

The conclusion that both Whitaker and I would draw from such data is that schizophrenia patients who are regularly medicated with antipsychotic drugs are not receiving the best care available.  It is of course true that that all dealings with human health are subject to errors in interpretation.  On the other hand, this interpretation has withstood fifty years of attempts to negate it. 

Whitaker would likely take this a step further and suggest the medications are inhibiting any natural patient recovery and converting a periodic condition into one that is chronic.  Here it will be proposed that the mere notion that mental illness is caused by a brain malfunction that can be fixed by medications is sufficient to dramatically increase the incidence of diagnosed illnesses.  The tale of how this might occur leads is to another outcome paradox.

Whitaker’s second take from the data available to him was that the dramatic increase in diagnosed incidences of mental illnesses, and the increased number of disabilities due to claims of mental illness is likely due to the effects of the drugs being used on patients.  Consider data from the CDC: About Mental Health.

“Mental illnesses are among the most common health conditions in the United States.

More than 50% will be diagnosed with a mental illness or disorder at some point in their lifetime.

1 in 5 Americans will experience a mental illness in a given year.

1 in 5 children, either currently or at some point during their life, have had a seriously debilitating mental illness.

1 in 25 Americans lives with a serious mental illness, such as schizophrenia, bipolar disorder, or major depression.”

Those of us with long lives can remember a time when mental illness was rare.  A time when childhood involved encountering a wide range of personalities in playgrounds, none of which were considered in need of chemicals to alter their behaviors.  And our experience recalls few if any who needed chemical assistance later in life.  What has happened?  Whitaker’s concerns must be answered. 

Aviv states over and over that what is referred to as mental illness is highly complex and too unwieldy to be addressed by simple classifications and remedies. 

“…mental illness is caused by an interplay between biological, genetic, psychological, and environmental factors…”

Psychoanalysts led the way in addressing mental illness by focusing on psychological and environmental factors.  Their success was quite limited, and they were mostly superseded by psychiatrists who focused on biological and genetic factors and attempted to treat patients with medications.  Their success has, by many measures, been quite limited as well.  The fact that neither caregiver can deal with the full range of issues suggests that caregiving has a serious problem.  Psychanalysis is expensive, time consuming, difficult, and has a low record of success.  Treating mental illness as a physical problem that can be addressed with drugs is simple, enormously profitable, and can produce growing ranks of patients.  It is this last feature that contributes to Whitaker’s “epidemic.”

What is revealed in Aviv’s case studies, including her own experiences, is the power that individuals have over their own thought processes.  As in Aviv’s title, the stories we tell ourselves can make us who we are.  We can concoct these stories on our own or we can assimilate stories told by other individuals or by the supposed “experts.” 

“There are stories that save us, and stories that trap us, and in the midst of an illness it can be very hard to know which is which.”

As a young child Aviv told herself a story that nearly proved tragic.  When she was age six, she suddenly stopped eating.  She doesn’t recall much about her reasoning at the time but suggests she may have been influenced by the Jewish Yom Kippur tradition which calls for people to reject food and liquids for a full day as a means of cleansing body and spirit.  She recalls feeling proud of her ability to turn away from food and remembers thinking it was important to her to feel like she had become a better person.  She also remembers being pleased by the reaction of her parents and the attention she received. She ended up in a hospital where she and other girls were treated as sufferers of anorexia.  Rachel was the youngest girl anyone could recall suffering from this condition.  During this period the malady was not well understood, and her doctors tried to apply psychanalytic techniques to discover the sources of her problem.

Her story would be enhanced by the older girls whose practices she would imitate, thinking of them as mentors.  She was taught that in addition to limiting eating, one could lose weight by exercising.  She would try to keep up with the exercises done by the older girls and followed their lead by standing and moving around all day, only stopping at bedtime.  Aviv was lucky to drift into this mode of behavior at such a young age.  It did not manage to capture her because she did not fully possess the consciousness and experiences of the older girls.  She was not allowed to see her parents while confined unless she ate a certain amount of food.  This provided enough motivation to get her eating again and she was soon released.  However, she continued to be affected by the experience.  The need to remain standing all day long followed her as she resumed school.  It would be around a month before she felt comfortable sitting down like the other children. 

As a staff writer for The New Yorker, Aviv would encounter examples of behaviors that could be categorized as mental illness.  She tells of a particularly startling case that illustrates the power of a story that satisfies a need and is also supported by the beliefs of others.

“A few years ago, I went to Sweden to report a story about a condition known as ‘resignation syndrome.’  Hundreds of children from former Soviet and Yugoslav states who had been denied asylum in Sweden had taken to their beds.  They refused food.  They stopped talking.  Eventually, they seemed to lose the ability to move.  Many had to be given feeding tubes.  Some gradually slipped into states resembling comas.”

This only happened in Sweden, not in any other Nordic countries where similar refugees were attempting to settle.  It seemed that in Sweden one child chose the anorexic-like response, probably as an act of protest, and others imitated the behavior.  But a response, initially voluntary, can become intrinsic and compulsive.  This seems to be the path by which anorexia captures its victims.

“Something about the mute, fasting children in Sweden felt familiar to me.  For a child, solipsistic by nature, there are limits to the ways that despair can be communicated.  Culture shapes the scripts that expressions of distress will follow.  In both anorexia and resignation syndrome, children embody anger and a sense of powerlessness by refusing food, one of the few methods of protest available to them.  Experts tell these children that they are behaving in a recognizable way that has a label.  The children then make adjustments, conscious and unconscious, to the way they’ve been classified.  Over time, a willed pattern of behavior becomes increasingly involuntary and ingrained.”

Each person has a unique biology and a unique set of cultural experiences.  Being unique can be lonely and unsatisfactory.  One will be intrigued by stories that resonate with the individual and are also recognizable to a segment of society.  A pattern of behavior recognized as a known illness will be attractive to one who seeks confirmation for their story and perhaps provides a path to comfort and aid.  For a very long time, women in distress would turn to a behavior called “hysteria” to express their story in a manner that society recognized.  That behavior pattern disappeared when it no longer seemed appropriate.  The go-to illness today is depression.  Any symptom associated with distress can be recognized by the social and medical communities as a form of depression.

“The philosopher Ian Hacking uses the term ‘looping effect’ to describe the way that people get caught in self-fulfilling stories about illness.  A new diagnosis can change ‘the space of possibilities for personhood,’ he writes.  ‘We make ourselves in our own scientific image of the kinds of people it is possible to be.’…We find a way to express our distress through imitation until, eventually, we ‘have “learned” or—better—“acquired” a new psychic state’.”

Like the children in Sweden who stopped eating, exhibiting aspects of a mental illness can be purely a cultural or social phenomenon.  There need be no biological issues involved.  In fact, much of what is recognized by psychiatrists as clinical depression has been identified as a psychic state that is self-constructed by an individual’s storytelling, or by imitation, or by both.

There is an academic realm of study referred to as response expectancy theory.  The basis for this line of research is the perfectly reasonable assumption that what people experience in a given situation is influenced by what expectations they have.  Such considerations are very important in clinical tests of medications where comparisons are made between the responses of patients who are provided either the drug under study or an inert substance, a placebo.  Patients are not told which type of pill they receive.  Often, patients receiving a placebo will claim to have benefited from it.  This is referred to as a “placebo effect.”  Another aspect of the placebo effect is that a clinical participant is likely to notice side effects from receiving the medication.  This can increase the probability that this patient will perceive benefits from his/her pill.  These factors complicate the interpretation of clinical trials.

The size of the placebo effect only became clear when pharmaceutical companies were required to provide the results of all clinical trials of their drugs, not just the ones producing favorable results.  Analysis of complete sets of test results indicate that antidepressant medications perform only slightly better than a placebo.  Some argue that the benefits of the drugs are too small to be clinically significant (see Antidepressant Drugs versus Placebos).  In other words, most of the benefits individuals experience from using these drugs arise because they have constructed a new story to tell themselves, not because of some physical change to the function of their brain.

Psychiatrists and pharmaceutical companies have known these facts for decades.  They also know that no association between mental illness and specific physical conditions has ever been identified.  In their view, if the medications they prescribe produce beneficial results for their patients, case closed.  As Aviv puts it.

“For more than fifty years, scientists have searched for the genetic or neurobiological origins of mental illness, spending billions of dollars on research, but they have not been able to locate a specific biological or genetic marker associated with any diagnosis.”

Yet people believe the medications work.  And if a distressed person is told that their condition is caused by a chemical imbalance in their brain that can be fixed with medication, that presents them with the opportunity to stop worrying about their problems and blame everything on a mysterious brain malfunction over which they have no control.  It also tells them that they will likely need to be medicated for the indefinite future. 

A pair of articles in The Economist tried to break through this willful ignorance on the issue of prescribing antidepressants.  These articles were discussed in Psychopharmacology and Depression.  The conclusion was that short-term side effects and addiction finish with long-term health problems that they fear will swamp the struggling British healthcare system.

One can identify several medical outcome paradoxes in this discussion.  Perhaps the greatest—and the most consequential—is the continued application of the chemically imbalanced brain hypothesis to nearly all forms of behavior that can be labeled as a mental illness.  As Whitaker observed (and predicted), the incidence of mental illness has grown.  When experts are asked why this has occurred, one usually gets a response such as provided by this source. 

“The increase is due to the rise in social media, the COVID-19 pandemic, and societal trends that have resulted in smaller family units and less community involvement. The mental health crisis, which is particularly acute for older people and the youngest adults, is compounded because people lack health insurance or access to a healthcare provider depending on where they live.”  

So, the increase is caused mainly by cultural changes—changes which mysteriously cause chemical imbalances in our brains.  That is a leap way too far.

The way mental health is characterized and treated is an incredible mess.