I was sent a paper last week by, of all professions, a political scientist in South Dakota. Alex Roberts works on the phenomenon of "medicalisation of normal," the process by which normal variants of behaviour and mental life are labelled as "deviant/sick" by psychiatrists and turned into new medical "illnesses." What this means, of course, is that they get whole new populations to "treat," meaning medicate, but most important, these new patients will never get better, they have to keep coming back.
The classic example is "depressive illness," the diagnosis that allowed psychiatrists to take over what had previously been seen as normal sadness and turn it into a life-threatening, genetic (and therefore lifelong) disease. This was exposed in a book published in 2007 by two sociologists, Allan Horwitz and Jerome Wakefield, titled The Loss of Sadness: how psychiatry transformed normal sorrow into depressive disorder [1]. The problem began to get out of control in 1980 with the publication of the American Psychiatric Association's Diagnostic and Statistical Manual III, always known as DSM-III. This broadened the criteria, which meant that more people could be put on drugs, which meant that when they wanted to stop, they couldn't because the drugs are addictive and people go into withdrawal states which aren't recognised as withdrawal states but are seen as "your depression coming back."
Before DSM-III, two sorts of depression were recognised, endogenous depression and reactive or neurotic depression. These were not the same in any way. What was called endogenous depression was a serious condition which came on for no obvious reason and seemed to have a lot of physical effects, such as lack of energy, loss of weight, loss of libido and so on. It lasted 6-12 months and was believed to have a high suicide rate, so there was pressure to treat it, but it could recur years later, again for no obvious reason, which was why it was called endogenous, "coming from within."
On the other hand, there was a type of depression, much more common in younger people, which came on following upsets, losses and so on. They were dramatic and often took overdoses or cut their wrists but mostly their intent to do serious damage was very low. The more you looked into it, the more you found a pattern of lifelong instability and over-reaction to minor upsets. The patients were often demanding, dependent, manipulative and given to drugs and alcohol. They lurched from one crisis to the next but, in between, they were bright and cheerful, life of the party.
The two types were similar in name only, and thus their management was totally different. In mainstream psychiatry, endogenous depression was seen as biological, so it got the biological treatment: drugs and ECT. Reactive depression, as in feeling low after some upset, needed only time and support, perhaps some time off work and something to help sleep. Neurotic depression was really depression in a neurotic personality disorder, so if they could be talked into committing themselves, they would get some sort of psychotherapy to deal with their personality "issues" (in those days, that word still meant "going forth," as in "last week's issue of the Women's Weekly").
DSM-III obliterated all those differences by lumping all depression into the single category of "Major Depressive Disorder." That meant that, regardless of the cause, everybody got drugs. Heaps of drugs. For years. And, as the figures clearly show, everybody got worse. It also meant, especially in the US, that any doctor who heard a patient say "I feel low and miserable" who didn't then lunge for the prescription pad would be in serious trouble if anything went wrong. And, because it meant that a whole lot of people who were inclined to react impulsively and take overdoses after any upset were suddenly handed scripts for toxic drugs that weren't tested on personality problems, things often did go wrong.
And that's the state of play today. 17% of adults in the UK regularly take antidepressants. Bearing in mind that psychiatry claims to be an "evidence-based" profession, there is no evidence that the population are any better off than they were before the drugs arrived (especially now that the euphoria of the Coronation has worn off). And this is what Alex Roberts studies: how a normal human emotion can, on no convincing evidence whatsoever, overnight be converted into a genetic "chemical imbalance of the brain."
Bob Whitaker's very readable Anatomy of an Epidemic [2], from 2009, gives detailed figures for how this has affected the US across the board. I've put a case to say that the modern epidemic of so-called "bipolar disorder" is largely the result of people with personality problems being rediagnosed as suffering a genetic disease of the brain. Thus labelled, they are put on toxic drugs that cause severe and largely unknown chemical imbalances in the brain, resulting in constant mental instability [3]. It also means they are never offered the sort of psychotherapy that may offer an improvement, with the fringe benefit to the psychiatrists that they can't be sued for mismanagement: "We followed the DSM and gave the recommended drugs but the patient didn't respond and jumped under a train. Terribly sad but obviously it was a very severe case. We know that because of the outcome."
We've mentioned before how the ever-expanding categories of "mental illness" mean that ever-growing numbers of people are given a label, such as "ADHD," and put on drugs. Two weeks ago, the RANZCP had one of their online education sessions devoted to the idea that more and more children (and hence adults) are living without a psychiatric diagnosis and it is psychiatry's duty to rectify their deprived state. This month's hot diagnosis is "autism." This is definitely the diagnosis that keeps on giving because, in the words of the speaker, nobody actually knows what it is, whether it can be treated or, remarkably, whether it ought to be treated. Nonetheless, they're sure that early screening of all children will allow lots more to be diagnosed, often as early as 18 months old and, wonder of wonders, even by six months.
Oh wow, imagine that. Queues of anxious young parents, panicking that baby didn't smile at grannie last visit or pulled away from the pastor at the christening, rustling through their questionnaires from Dr Google (there are thousands), fearfully awaiting to have their worst fears confirmed by the paediatrician. Paediatrician? Of course, they like making psychiatric diagnoses and putting children on pills. For life. But why shouldn't they? The diagnostic criteria are set out in DSM (now No. 5), they are strictly behavioural with no mention of mental states, and it's a genetic condition so they don't have to listen to all that stuff about traumatic events. And that's all that psychiatrists do anyway. Bear in mind that this is all for a diagnosis that, forty years ago, barely existed.
The history is one of those back-and-forth stories so common in psychiatry, with each whack of the ball (from the psychological court across to the biological) making the ball bigger and bigger, so that it includes more and more people. What started out as a most severe disturbance of mental life in apparently physically normal children, with profound failure of language and often quite bizarre behaviour, has morphed into meaning little more than "a bit of a wierdo." The first case I saw was a 10 yo boy who had been entirely normal until about two, then began regressing and losing skills. At ten, he could hardly speak; couldn't read or write, of course; couldn't care for himself apart from shoving food into his mouth with his fingers; was generally incontinent; had many odd and pointless, repetitious behaviours; and had little interest in humans but liked animals. A person I knew at university had twins but, starting at 15 months, the same thing happened to them. They now require full-time care as they have almost no language, no capacity for self-care and no awareness of danger.
Out of curiosity, I completed the questionnaire above, answering it as I was at school. Yep, definitely a case. Also ADHD (disinterested type), ODD, OCD and a few others. So what does that prove? Well, it proves that a "diagnosis" that ropes in Einstein, George Orwell, that opinionated bilingual chatterbox, Ms Thunberg, and various film stars, athletes and writers, probably isn't much help. All it says is that if you want to achieve at a high level, don't let people distract you with their nonsense. But this is important, and political scientist Alex Roberts put his finger on it: a "discipline" that doesn't have a formal model of its field of study (that's technical language for "doesn't know what it's talking about") is either going to fade out or spread its wings to engulf normality. Which one will come first? Always, a new field will try to gain territory, to convince more governments and funding agencies that it should be given more and more power and responsibility (and money), and it will do this just by frightening people.
As far as professions go, psychiatry is fairly young, nobody took any notice of them until after World War I, and they could have remained beneath the horizon but for two things: the invention of psychotropic drugs, meaning drug companies got in on the act, and the reduction in mortality from ordinary diseases. Since humans love to worry about their health, psychiatrists have quickly moved to fill the void with more and broader diagnoses to keep everybody on edge, especially parents. So perhaps the relentless expansion of psychiatry that we're seeing now is only the precursor to people suddenly waking up to the fact that they're being duped, that psychiatry has no basis in science, and that normality is a broad range, not a point on a scale. Putting people on drugs to "cure" normality is an exercise in stupidity, except for all the people who profit from it, like the medicos, psychologists and social workers and, of course, the drug companies. For them, it's a wonderful business model as it has no end.
But what about the bigger picture? Will the general population wake up to the fact that all this relentless pathologising of normality is simply taking them for an expensive and destructive ride? I think so, but not this week, and don't expect psychiatrists to take it lying down. Their normal response to being challenged, as I know too well, is to attack. So the RANZCP annual conference will be held in Perth, WA, later this month. It has the catchy title, "New horizons, connected futures," and is billed as "A scientific program which will spark your curiosity, challenge your assumptions and feed your imagination about how to achieve a truly connected mental healthcare system." New horizons we understand: it means making further grabs on normality with contrived diagnoses. "Connected futures" probably means linking with other professions (such as paediatricians and gerontologists) to present a united narrative but also to reduce psychiatry's isolation, because in isolation lies weakness. And "challenge assumptions"? My experience of challenging assumptions at these conferences is to be shown the door. What they mean is "Challenge any assumptions you like, but not ours."
Well, we haven't even got to the lecture on autism yet. Another day, but the message is this: when political scientists start nosing around finding fault in your business model, look out. It means what was once seen as "daring" conduct is starting to look scandalous. Your business model is starting to show cracks in the walls you have built. Be warned.
I mentioned recently that the antipsychotic drug, brexpiprazole, was proceeding to be listed as treatment for agitated dementia. It happened last week. No doubt the champagne corks were popping in the drug companies. This was reported in Psychiatric Times, who also said "Any questions, email us." I'll send them the question of why they approved this stuff but not the dirt-cheap, equally effective and less toxic pericyazine.
Thanks for the comments. Any questions or suggestions, please submit below.
References:
1. Horwitz AV, Wakefield JC. The Loss of Sadness: how psychiatry transformed normal sorrow into Depressive Disorder. New York: Oxford University Press, 2007.
2. Whitaker R (2009). Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs and the Astonishing Rise of Mental Illness in America. New York: Random House.
3. McLaren N (2012). Chapters 14-16 in The Mind-Body Problem Explained: The Biocognitive Model for Psychiatry. Ann Arbor, MI: Future Psychiatry Press.