Two papers published in the last month should be required reading for anybody dealing in mental health. The first is a collaboration of fourteen academic authors, mainly in the UK but with a few in North America, studying "social determinants" of mental disorder [1]. The abstract begins: "People exposed to more unfavourable social circumstances are more vulnerable to poor mental health over their life course in ways that ... generate and perpetuate intergenerational cycles of disadvantage and poor health."
We could summarise this as "Bad stuff messes heads, and messed heads produce little messed heads." Readers who have recovered from the festive season will recognise that, in psychiatry, this is radical. Very radical indeed. In fact, so radical that I expect mainstream psychiatrists and researchers will be lying back in their chairs, fanning themselves at the cataclysmic consequences of anybody daring to say in public: "It's not all biology." OMG. The audacity, the sheer, wanton recklessness of these people, where will it end? Good question, but let's look briefly at the other paper.
This is by a Prof. Edwin Fuller Torrey, who is now 86 but doesn't see any reason to keep quiet. I first heard of him in 1978 when he was pushing the hardest of biological lines on schizophrenia. He is a prolific and dramatic writer who is enormously influential behind the scenes and, it seems, an inveterate self-publicist. He has been closely associated with a range of "grassroots" organisations, which are essentially kept afloat by donations from drug companies, and with his own groups. One, the Stanley Medical Research Institute, has spent over half a billion dollars on biological research on psychosis, with next to nothing to show for it. The other, the Treatment Advocacy Center, lobbies politicians to make it easier to detain people for involuntary treatment.
Torrey's paper [2] summarises the results of perhaps $30billion spent over the past thirty years to find "the genetic basis for mental disorder." Results? Essentially nothing, which clearly amuses Torrey as he has long pushed the line that schizophrenia is a biological disease involving (these days) inflammatory processes, probably activated by an infection called toxoplasmosis, which mostly comes from cats. His paper is interesting because it gives a clear account of all the backroom dealing that goes on to get major projects funded, apparently without any awareness that this may not be the best way to conduct science. Torrey concludes: "... NIMH’s genetics investment has yielded almost nothing clinically useful for individuals currently affected. It is time to review NIMH`s schizophrenia research portfolio." Once again, Wow! A blow below the belt to all the psychiatrists making their careers out of studying genetics, including a sizeable group here in Brisbane.
The sociology paper reviews evidence that there are individual effects and community effects contributing to mental disorder, both in childhood and in adults. These include being poor, which leads to mothers with poor nutrition and little maternal care; childhood adversity, meaning all the different types of abuse, separately or together; migration; racial and other discrimination, including gender-based; and loneliness and social isolation. Lonely people die younger than people with busy social lives, that has been known forever. Other factors include growing up in a crappy environment with industrial pollution and high levels of crime, drugs and alcohol, and general community disintegration.
Needless to say, when it comes to prevention, these are the sorts of factors that don't interest governments. Governments like quick results that they can hold up at the next election and brag, not something that works over 15-20 years. That's why prescribing drugs for children and teenagers gets unlimited money, whereas behaviour-modification programs in schools rarely get a mention, even though the results are better in the long run. That's the point: everybody wants the quick cure, so New York city is toying with Torrey’s idea of forcing homeless people into mental institutions for "treatment," rather than dealing with the deep-seated problems that lead to homelessness in the first place.
Anyway, it's a worthy (and free) paper but I noticed there were 464 references, which is a lot even for eleven authors. They must have spent heaps of time on this, how much did it cost? Searching their grants suggests this was not their day jobs. Most of them appeared to be supported by other projects, but they were worth a lot of money: £2.9million (nearly six million AUD), £1million, and so on. Was it money well-spent? Well, you'd have to look at that in the context of total spending on mental health research. Speaking at a conference on biological psychiatry in Baltimore in 1970, psychiatrist Nathan Kline said:
Medicine and science will be just that much different because we have lived.... Treatment and understanding of (mental) illenss will forever be altered.... and in our way, we will persist for all time in that small contribution we have made toward the Human Venture.
This has been echoed hundreds of times since by the most influential psychiatrists, the people who wrote the DSM manuals or who direct research institutes and so on. In about 1989, Samuel Guze, who more or less kicked psychiatry into its current, biological line, said: "There cannot be a psychiatry which is too biological." David Kupfer, chairman of the DSM5 Committee, stated emphatically: "Psychiatric disorders are brain disorders ... Psychiatric disorders are medical disorders." Thomas Insel, the longest serving director of NIMH, said:
The good news is that we now have the tools to enable a new science of mental disorders... this science will revolutionize the diagnosis and treatment of mental illness and... transform psychiatry, ultimately realigning it with neurology and potentially creating a new discipline of clinical neuroscience... (2009) (Our model) conceptualises mental illnesses as brain disorders… Second, (it) assumes that the dysfunction in neural circuits can be identified with the tools of (standard laboratory) neuroscience... … the biological model (of mental disorder) is sufficiently entrenched to ignore criticism and commit psychiatry to a new reductionist program ... (2010).
These are very bold positions to occupy. The bad news, as Torrey cheerfully points out, is that it hasn't worked. Steven Hyman, NIMH director before Insel who pushed hard for the Human Genome Project, said:
I made one enormous error. I thought that family and genetic studies, advances in neuroscience, and the newly emerging discipline of molecular biology would soon elucidate pathogenesis and result in improved therapeutics. How wrong I turned out to be.
After he retired from NIMH, Thomas Insel agreed:
I spent 13yrs at NIMH really pushing on the neuroscience and genetics of mental disorders, and when I look back on that, I realise that while I think I succeeded at getting lots of really cool papers published by cool scientists at fairly large costs - I think $20billion - I don't think we moved the needle in reducing suicide, reducing hospitalisations, improving recovery for the tens of millions of people who have mental illness.
Social research would therefore appear to be very good value. To my simple mind, the reason for this hugely expensive failure (in lives, not just money) was that the field of mental health was taken over by ideologues. These people were (and still are) absolutely committed to the idea that all mental disorder is biological in nature. This position was never argued, it was adopted as a matter of belief [3]. Anybody who argued was pushed to the sidelines, or even turfed out of the training programs. There's a reason why this happened, we can talk about it another day. What it says is that there are very serious cracks in the foundations of the modern mental health industry, cracks that have been present since the beginning but were ignored in the mad rush to find a biological mental disorder.
Everybody wanted to be first in line for the Nobel Prize; drug companies were hypnotised by the money; and governments wanted a quick cure so they didn't have to listen to all those mental people bleating and bumping themselves off. So confident were they that they even said "We're real scientists, we don't have to listen to critics," which is the exact antithesis of science. They had the trappings of science, but not the substance. Time for a change, to start giving serious thought to how adverse life experiences cause mental disorder: back to the future, you could say. All this was to lead into an editorial by the new editor of the Aust.NZ. Journal of Psychiatry, which is a superb example of pseudoscience, but I've run out of space so it will wait a week. By then, I'll know whether they've accepted my critique or whether they still believe their "biological model of mental disorder is sufficiently entrenched to ignore criticism." We'll see.
In an interesting article just to hand, Mad in America's Peter Simons analyses Torrey's paper in a lot more detail.
****
References:
1: Kirkbride JB et al (2024). The social determinants of mental health and disorder: evidence, prevention and recommendations. World Psychiatry 2024;23:58–90. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10786006/
2: Torrey EF (2023). Did the human genome project affect research on Schizophrenia? Psychiatry Research, 333 (2024) 115691. https://doi.org/10.1016/j.psychres.2023.115691
3: McLaren N (2013). Psychiatry as Ideology. Ethical Human Psychology and Psychiatry 15: 7-18. 10.1891/1559-4343.15.1.7
****
This material is copyright but can be copied or quoted on condition the author is acknowledged.
****
Abbreviations:
OPCAT: Optional Protocol to the UN Convention Against Torture
NIMH: National Institute for Mental Health, Bethesda, Maryland, USA.
RANZCP: Royal Australian and New Zealand College of Psychiatrists
RCPsych: Royal College of Psychiatry (UK).
UNCAG: UN Convention on the Prevention and Punishment of the Crime of Genocide.
UNCAT: UN Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment.
UNCRPD, or just CRPD: UN Convention on the Rights of Persons with Disabilities.
WHO: World Health Organisation.