Amazing psychiatric breakthrough: talking works.

A paper by twelve authors from Belgrade [1] was published earlier this year in the Journal of Affective Disorders Reports on managing depression without using drugs. This journal is sponsored by the International Society for Affective Disorders (ISAD) which “…exists to promote research into the mood (affective) disorders through all relevant scientific disciplines, including genetics, neuroscience and the social and behavioural sciences.” As that suggests, they take a hard biological line on mental disorder. Researchers pay from AUD3,500 – 5,000 to publish their scribblings in these journals (it comes from their research grants; in case you didn’t know, scientific publishers are fabulously profitable, thanks to their amazing business model).

The project used what they called Watchful Waiting (WW) to see whether people referred for treatment of depression could get better without psychopharmacotherapy (it means drugs). This is not the same as “no treatment” as they spoke to their patients with the goal of constructive change based in “ depathologisation, psychosocial advice and shared decision making.” Depathologisation means letting people know that not all sadness or misery is depression; it can be a perfectly normal response to life events, and should be treated as such. The classic example is grief. The symptoms of grief and depression are the same but their management is different. Psychosocial advice meant help with various things while they didn’t explain quite what “shared decision-making” means.

Patients were seen at normal government clinics and had to be depressed, healthy and not suicidal. They were followed for three months, with most getting between 2 and 4 appointments after the original assessment. There were 83 patients at first; seven insisted on getting drugs so they were excluded. Another seven were prescribed drugs at some stage but stayed in the study. Patients had an initial assessment of 30-40 minutes followed by 2-4 appointments of 15 mins each. After three months, two thirds of them were better without medication or formal psychotherapy. The authors pointed out that the initial severity of the depression didn’t affect the outcome but people who wanted drugs (because they believed they had a biological illness) didn’t do as well as those who weren’t keen. They concluded WW is a legitimate form of treatment and should be more widely used.

Wow. Who could have expected that? People actually get better from a serious biological disease just by talking? What next? But perhaps the most interesting line in the whole paper was right at the end:

… if presented with a hypothetical scenario where they themselves had depression, most psychiatrist would choose Watchful Waiting as the first-line treatment, while if put in a position to suggest treatment to a patient asking for recommendation, they would choose ADs as the first-line.

A case of “Don’t do as I do, do as I say.”

It’s a bit surprising that this normally hard-nosed journal published the paper as it’s not very well organised and the statisticians who call themselves psychiatrists will be able to pick holes in it. However, it’s nice to see it in print: Most people with ordinary depressive states shouldn’t be prescribed drugs. With a bit of support and consideration and the passage of time, they’ll get over it. But not to be outdone, I’ll also pick holes in it, and the first (which mainstream psychiatrists won’t detect) is the idea that you can assess a person’s mental state in 30-40 minutes. That’s ridiculous. That will not give anything like a reliable picture of the person.

The first appointment is designed to answer: “Who is this person? What state is s/he in and how did s/he come to this point in life?” That takes a minimum of one hour of tightly structured questioning directed at the person’s (a) current mental state, (b) current status in life, (c) personal background (family history, education, work, etc) and (d) personality. A proper psychiatric history puts the person’s life in an ordered perspective and this is itself a therapeutic intervention. Time and time again people said to me: “I’ve never looked at it that way,” or “So you don’t think I’m making too much of this?” or “What a bloody mess my family are, compared with them, I’m OK,” etc. That’s important, especially as modern psychiatrists are not trained in the idea of seeing a person as the outcome of a life of experiences. They’re looking for biological signs and by George, they’ll find them.

The other thing about skimpy histories is that if you don’t have a context to put things in, it’s very easy to get them out of context. An inadequate history makes it easier to say “None of this makes sense, it just has to be biological, what else could it be?” The goal of the psychiatric history is to understand exactly how this person got to be in this state. Not taking a history increases the likelihood that the person will be seen as incomprehensible, and therefore mentally ill rather than a sensible person who doesn’t know how to get out of the trap.

Consider this case: Mrs Susan K, 36yo school teacher and mother of three aged six to ten; supportive marriage, husband a technician with government; no financial problems; good work atmosphere, says: “My friends all say I should be on antidepressants.” On questioning, she has a full book of depressive symptoms: sad, feels hopeless and guilty, no interest, no energy, disturbed sleep, loss of appetite and sexual interest, irritable with children and at work, often thinks everybody would be better off without her, occasional suicidal ideas, worse if she has anything to drink. Has felt this way since her mother died of breast cancer a year before, aged fifty-three. With a 30 minute history, the questioning doesn’t pause at this point (if it got that far) but moves on quickly, but the proper response is:

“She was only 53? So how old was she when you were born?”

“I’m not sure, she was very young.”

“Well, she would have been 18 or even 17. Did that matter?”

(hesitates) “I… don’t know, I never think about it.”

“Have you ever talked about it?”

(long silence, eyes fill with tears). “I think you need to. What was she like as a person?”

(weepy) “Everybody said she was a saint. I don’t want to speak bad of her.”

“We’re only concerned with facts here. Objectively, what was she like as a person?”

“She was two people. There was mum as everybody else saw her and mum as I copped it at home.”

“So what did everybody else see?”

“Oh, she was so helpful, nothing was too much for her. She helped at school and with the sports clubs and couldn’t do too much for my children and all the neighbourhood kids. If anybody was sick, she’d take care of their kids while they went to the doctor, all that.”

“And at home?”

(covers face) “I… I can’t. She’s gone. Nobody saw that side of her, not my younger brothers, not even my father. It was the guilt. It wasn’t deliberate but she had wanted to study. Actually she wanted to study medicine and apparently she could have done it but she got pregnant with me so that killed it. They married, my father was only 18 but he’s a good man, my brothers are doing well but she never let a day pass without reminding me that if it hadn’t been for me, she could have studied and life would be different. It was like she was just telling me because she had to tell somebody, she didn’t want to be just another housewife. I felt so guilty, as long as I can remember. But then she’d laugh and say ‘Oh but look what I got instead, a little bundle of joy,’ and then I’d feel worse. It got to the point where I couldn’t go near her without freezing inside. And when she was sick, she was a wonderful patient, they loved her at the radiotherapy unit, she was so cheerful and lifted everybody’s spirits. But all I could feel was guilt, I even started to think I’d caused her cancer but my husband said it’s not true. And now I see on TV and everywhere that I have a biological disease of the brain, maybe I’ve given it to my children…”   

Getting this sort of information takes time. You cannot get that in 30 minutes and it cannot be managed with only monthly appointments of 15 minutes. In 30 minutes, all you will get will be the bare facts: “Sad, feels hopeless and guilty, no interest, no energy, disturbed sleep, loss of appetite and sexual interest, irritable with children and at work, often thinks everybody would be better off without her, occasional suicidal ideas.” After their usual brief assessment, 98% of psychiatrists and 99% of general practitioners would say she should be on antidepressants, if not admitted to hospital for ECT. What you won’t get from a 30 minute assessment, because it takes time and effort, is why she feels that way, and it is the Why that decides what should be done. If she had simply been put on drugs with no attempt to deal with the psychological factors, she would never have recovered. The antidepressants would have dulled the worst of her emotions but the problem would remain, untouched and festering away in the darkness, and she would never get off the drugs.  

Guilt is the gift that keeps on giving. It never fails.

The problem, as the authors of the paper noted, is that people now expect, and quite often ask for, drugs. This is partly due to the relentless campaign by drug companies and their academic shills to indoctrinate the medical world with the narrative “All mental disorder is brain disorder.” The other part is the effect on the general population who are fed “destigmatisation programs.” These don’t actually say “Your brain is sick and needs our drugs.” Instead, they spread the jolly message “Depression is very common but don’t be ashamed, it needs treatment like any other disease.” Overtly, it says “Don’t be ashamed” but covertly, it says “… because it’s all biological.” What is sold as reducing the stigma of mental disorder conceals frank biological propaganda.

This leads to the problem they mention briefly, that of pathologisation of the normal range of human emotion, specifically the blurring of the “…distinction between depression as a disorder and sadness as a normal human feeling …” Because mainstream psychiatry doesn’t have a theory of mind or a model of mental disorder, it can’t say when normal sadness stops and depression starts. As a result, they have moved the boundary of mental disorder closer and closer to normality until now they touch. If you’re not 100% happy, you’re depressed and you need drugs. That would be fine except the drugs have a huge list of unpleasant and potentially dangerous side effects, including addiction. And they cost money, and they don’t work (Peter Gotzsche calls them ‘depression pills,’ not antidepressants, and he’s right).

People suffering a bout of normal unhappiness are not mentally ill, there is absolutely nothing wrong with their brains. If they’re given antidepressants, they will quickly develop a “chemical imbalance of the brain” so that if they try to stop the drugs, they will get more or less severe withdrawal symptoms and be forced to resume them. This is a major part of why 15% or more of the adult population are now taking antidepressants. It’s not because they’re depressed, it’s because they can’t stop. Anyway, now it’s official. A mainstream journal has published a paper which says two thirds of people can get over the miseries with just a bit of support and empathy. Talk about reinventing the wheel, but if you’ve been told for decades that any hint of unhappiness is a brain disease, then that must come as quite a shock.

Reference:

1.      Kostic M et al (2024).  Watchful waiting for depression using depathologization, advice and shared decision making. J Affective Disorders Reports. https://doi.org/10.1016/j.jadr.2024.100753

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Last week, while talking of the eugenics movement in Western countries in the 1920s and 30s, I said ideas of racial superiority and inferiority were deeply entrenched, especially in the upper classes (who were also very largely the educated classes). Even though everybody would like to forget it, the German belief in the Aryan Superman was absolutely normal for that era: “This was not a fringe movement of cranks, it was very much a product of mainstream, self-consciously scientific thought.” In Mein Kampf, Hitler frequently referred to the German race as being the source of everything worthwhile in human history, but in grave danger from racial contamination, e.g.:

In short, the results of miscegenation are always the following: (a) The level of the superior race becomes lowered; (b) physical and mental degeneration sets in, thus leading slowly but steadily towards a progressive drying up of the vital sap … All the great civilizations of the past became decadent because the originally creative race died out, as a result of contamination of the blood (pp 180-182 in the Murphy translation, 1939) … (Trump says things like this when he talks about immigrants bringing in “bad blood”).

This belief was very widespread and fitted perfectly with psychiatry’s obsession with the biological causation of mental disorder. It led directly to the T4 Program, to exterminate mentally-impaired people, then to the Holocaust and to the equally horrendous slaughter of Slavic peoples. None of it was uniquely German, so I was interested to come across a quote from 1937. At the time, Britain held the League of Nations Mandate over the territory of Palestine and was actively facilitating Jewish immigration, consistent with the notorious Balfour Declaration of 1917. The local Palestinian population became enraged, riots broke out and became an uprising which went on for several years. As a result, the UK Parliament held an enquiry under Lord Peel. Its report of July 1937 recommended partition of the territory, setting up an exclusive Jewish state within traditional Palestinian lands. Naturally enough, having lived there for thousands of years, the Arab population didn’t see why they should be booted out to make room for foreigners. Their refusal to leave quietly did not go down well with His Majesty’s Secretary of State for Colonies, who said:

I do not agree that the dog in a manger has the final right to the manger even though he may have lain there for a very long time. I do not admit that right. I do not admit for instance, that a great wrong has been done to the Red Indians of America or the black people of Australia. I do not admit that a wrong has been done to these people (Palestinians) by the fact that a stronger race, a higher-grade race, a more worldly-wise race to put it that way (European Jews), has come in and taken their place.

While to us such attitudes are reprehensible, in expressing them, the Honourable Gentleman, born as he was in a palace, the son of a peer and grandson of a duke, was entirely in step with his class and his time. Nobody blinked at Winston Churchill’s tirade as he said nothing that day that he and his ilk didn’t believe in every fibre of their beings. Surprisingly, a few years later when the Germans decided they should have control of the British Isles, the indigenous population resisted fiercely. You would have thought they’d step aside and let the higher-grade race in. But hypocrisy is part and parcel of politics – and of upper class life.

I will be reactivating the Narcisso-Fascism thread before long, in order to examine world politics through the lens of the biocognitive theory of mind. As politics, it may not appeal to everybody but I hope readers will find it interesting and different.