The Epidemic of Mental Illness: Why?

By Marcia Angell
The New York Review of Books, June 23, 2011

Edited by Andy Ross

It seems that Americans are in the midst of a raging epidemic of mental illness. A large survey of randomly selected adults, sponsored by the National Institute of Mental Health and conducted between 2001 and 2003, found that 46 percent met criteria established by the American Psychiatric Association for having had at least one mental illness within four broad categories at some time in their lives.

Most psychiatrists treat only with drugs. The shift to psychoactive drugs as the dominant mode of treatment coincides with the emergence over the past four decades of the theory that mental illness is caused primarily by chemical imbalances in the brain that can be corrected by specific drugs. Drugs to treat psychosis are the top-selling class of drugs in the United States.

Is the prevalence of mental illness really that high?

Irving Kirsch is a psychologist at the University of Hull in the UK. He asks whether antidepressants work. When he began, his main interest was in the effects of placebos. Placebos were three times as effective as no treatment. Antidepressants were only marginally better than placebos. He analyzed data from 42 trials of six drugs. Overall, placebos were 82 percent as effective as the drugs. The average difference between drug and placebo was clinically meaningless. The results were unimpressive for all six drugs. In trials using an active placebo, there was no difference between the antidepressant and the active placebo.

Robert Whitaker a journalist and previously the author of a history of the treatment of mental illness. He considers that most psychoactive drugs are not only ineffective but harmful. Even as drug treatment for mental illness has skyrocketed, so has the prevalence of the conditions treated. Psychoactive drugs disturb neurotransmitter function, even if that was not the cause of the illness in the first place. With long-term use, the brainís compensatory efforts begin to fail. Whitaker sees an epidemic of brain dysfunction caused by the widespread use of antipsychotics with serious side effects.

The theory that mental illness is caused by a chemical imbalance in the brain had its genesis shortly after psychoactive drugs were introduced in the 1950s. The drugs treated psychosis, anxiety, and depression. They were derived from drugs for treating infections, and were found only serendipitously to alter the mental state. Over the next decade, researchers found that the new drugs affected the levels of certain chemicals in the brain. The theory arose that the cause of mental illness is an abnormality in the brainís concentration of these chemicals that is specifically countered by the appropriate drug. That was a great leap in logic.

But if psychoactive drugs are useless, why are they so widely prescribed by psychiatrists?
 

AR  Because the psychiatrists are following the paradigm expressed by Joseph LeDoux in the 2002 NYAS conference that I reported
here and here.
 

The Illusions of Psychiatry

By Marcia Angell
The New York Review of Books, July 14, 2011

Edited by Andy Ross

The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM), often referred to as the bible of psychiatry, is now heading for its fifth edition.

Leon Eisenberg wrote that American psychiatry in the late twentieth century moved from brainlessness to mindlessness. Before psychoactive drugs were introduced, the profession had little interest in the physical brain. But with their introduction the focus shifted. Psychiatrists began to refer to themselves as psychopharmacologists. By embracing the biological model of mental illness and the use of psychoactive drugs to treat it, psychiatry was able to identify itself as a scientific discipline along with the rest of the medical profession.

The APA was then working on the third edition of the DSM, which provides diagnostic criteria for all mental disorders. When the
DSM-III was published in 1980, it contained 265 diagnoses (up from 182 in the previous edition), and it came into nearly universal use. Its main goal was to bring consistency to psychiatric diagnosis. Each diagnosis was defined by a list of symptoms, with numerical thresholds.

Not only did the DSM become the bible of psychiatry, but like the real Bible, it depended a lot on something akin to revelation. There are no citations of scientific studies to support its decisions. The current version, the DSM-IV-TR (text revised), dates from 2000 and contains 365 diagnoses. The DSM-IV sold over a million copies.

The pharmaceutical industry was quick to see the advantages of forming an alliance with the psychiatric profession. About a fifth of APA funding now comes from drug companies, who are eager to win over key opinion leaders (KOLs) in the profession. Of the 170 contributors to the DSM-IV-TR, almost all of whom would be described as KOLs, 95 had financial ties to drug companies.

The fifth revision of the DSM is scheduled to be published in 2013.

Americans should be concerned about the astonishing rise in the diagnosis and treatment of mental illness in children. These children are often treated with drugs that have serious side effects. We need to stop thinking of psychoactive drugs as the best treatment for mental illness or emotional distress. Both psychotherapy and exercise have been shown to be as effective as drugs for depression. We need to rethink the care of troubled children. Here the problem is often troubled families in troubled circumstances. We need to do better. Above all, we should do no harm.
 

Psychiatry

By Andrew Scull
LA Review of Books, August 2012

All We Have to Fear: Psychiatry's Transformation of Natural Anxieties into Mental Disorders
By Allan V. Horwitz and Jerome C. Wakefield

In 1980, the American Psychiatric Association published the third edition of the Diagnostic and Statistical Manual of the American Psychiatric Association, DSM 3. DSM 5 is due for release in 2013. DSM categories were assembled through votes and compromise. The effect over the decades has been to enlarge the numbers of ordinary people labeled mentally unstable.

Psychiatrists use simplistic diagnoses and loose criteria to transform normal problems into diseases. Thirty years ago they said less than 1 in 20 of Americans had an anxiety disorder, now they say 1 in 2 do. They call depression the common cold of psychiatry and diagnose hugely more cases of ADHD, juvenile bipolar disorder, autism, social phobia, PTSD, SAD, and a variety of other disorders. Psychiatry has lost its way.
 

On Autism

By Jerome Groopman
The New York Review of Books, June 2013

Edited by Andy Ross

Temple Grandin is a professor of animal science at Colorado State University, a successful businesswoman, and one of our most astute interpreters of autism. The first signs that she was autistic began at six months of age. Observing that she lacked speech and demonstrated violent and obsessive behaviors, her mother took her to a neurologist, then sought out suitable settings and schools for the girl.

Grandin has reached a high level of sophistication about herself and the science of autism. Her observations will assist not only fellow autistics and families with affected members but also researchers and physicians seeking to better understand the condition. As she counsels families whose children behave in trying ways, she is concerned about the affixation of labels and generic advice.

The labels are devised by the expert committees that issue the Diagnostic and Statistical Manual of Mental Disorders (DSM).
In DSM 4, a diagnosis of autism depended on three criteria:

1 Impairment in social interaction
2 Impairment in social communication
3 Restricted, repetitive, and stereotyped patterns of behavior, interests, and activities

In DSM 5 it depends on two:

1 Persistent deficits in social communication and social interaction
2 Restricted, repetitive patterns of behavior, interests, or activities

Previously undiagnosed Aspies or high-functioning autistics who meet only the first of the two new criteria will be diagnosed with social communication disorder. Grandin: "Which is, basically, autism without the repetitive behaviors and fixated interests. Which is, basically, rubbish."

These diagnoses overlook the typical Aspie who lives in an unsympathetic world. Aspies must learn how to respect certain social imperatives, but they need forgiving and flexible environments.
 

Reductio Ad Absurdum

By Ian Hacking
London Review of Books, 8 August 2013

Edited by Andy Ross

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, replaces DSM-IV, which appeared in 1994. Everyone in North America who hopes their health insurance will cover or defray the cost of treatment for their mental illness must first receive a diagnosis that bears a DSM numerical code.

The DSM presents itself as a manual for clinicians. Hence it came as a bombshell when, a week before DSM-5 was published, US National Institute for Mental Health head Thomas Insel announced that the NIMH was going to abandon the DSM because it dealt only with symptoms. He wanted science.

The DSM is a living, organic creature. About a thousand individuals served as work group advisors. Many thousands of students, technicians, secretaries and so on must also have been involved. This enterprise is fully supported by the immense American Psychiatric Association, with its 36,000 members.

The classification of mental illnesses is not at all like the classification of animals, vegetables, or minerals. Perhaps the DSM will be regarded as a reductio ad absurdum of the botanical project in the field of insanity. The DSM does not represent the nature or reality of the varieties of mental illness.
 

Book of Lamentations

By Sam Kriss
The New Inquiry, October 2013

Edited by Andy Ross

A dystopian novel need not be a novel. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) by the American Psychiatric Association is a brilliantly realized satire, at turns luridly absurd, chillingly perceptive, and profoundly disturbing.

Here we have an encyclopedia of madness, containing everything that can possibly be wrong with a human being. The novel begins with a lengthy account of the system of classifications used, with its various strains of madness arranged solely in terms of the behaviors exhibited. This is a recurring theme in the novel, while any consideration of the mind itself is entirely absent. The classifications follow a stately progression, rising from the infernal pit of the body and its weaknesses through our purgatorial interactions with the outside world and finally arriving in the heavens of our libidinal selves. What is being told is a story.

This is a story without any of the elements that are traditionally held to constitute a setting or a plot. A few characters make an appearance, but they are nameless, spectral shapes that wander in and out of view as the story progresses, briefly embodying their various illnesses before vanishing as quickly as they came.

Setting, plot, and characterization are woven into the form with extraordinary subtlety. The setting of the novel is a conceptual landscape. The prolog sets a scene of a profoundly bleak view of human beings; one in which we hobble across an empty field, crippled by blind and mechanical forces whose workings are entirely beyond any understanding.

Who would want to compile an exhaustive list of mental illnesses? This mad project is clearly something that its authors are fixated on to an unreasonable extent. In a retrospectively predictable ironic twist, this precise tendency is outlined in the book itself.

The narrative voice of the book affects a tone of clinical detachment, one in which drinking coffee and paranoid schizophrenia can be discussed with the same flat tone. Under the pretense of dispassion this voice embodies a whole raft of terrifying preconceptions. Just like the neurological disorders that appear at the start of the book, mental illnesses appear like lightning bolts, with all their aura of divine randomness. At no point is there any sense that madness might be socially informed, that the forms it takes might be a reflection of the influences and pressures of the world that surrounds us.

DSM-5 seems to have no definition of happiness other than the absence of suffering. Sections like those on the personality disorders offer a terrifying glimpse of a futuristic system of repression, one in which deviance is pathologized. For much of the novel, what the narrator of this story is describing is its own solitude, but the real horror lies in the world that could produce such a voice.
 

Psychiatry

By Theodore Dalrymple
City Journal, December 2013


The American Psychiatric Association (APA) Diagnostic and Statistical Manual of Mental Disorders is now in its fifth edition (DSM-5). It fails to recognize that a description of behavior is not the same as a medical diagnosis. No objective laboratory markers or correlatives of psychiatric disorder exist. Yet the manual is destined to be taken seriously by psychiatrists, insurers, and lawyers.

The DSM-5 informs us that more than 1 in 7 people have a lifelong personality disorder. Several undesirable characteristics must be present in an individual for such a diagnosis. Either a mass outbreak of human nastiness has occurred or the whole business of diagnosis is dubious or even ridiculous. The DSM authors suffer from psychiatric nosology overvaluation disorder (PNOD).