Psychiatry Unlimited

The war on normality

Just over 500 years ago, an irascible young Augustinian monk called Martin Luther declared war on the mighty Church of Rome. The priesthood had become corrupt and self-serving, he shouted to all who would listen, while the message of Christianity, so clearly set out in the Gospels, had been sidelined by infallible doctrine written by the same corrupt priests. In particular, he excoriated the practice of selling indulgences, a sort of “get out of jail” card for sinners. On paying a fee to the local priests or bishop, sinners were given a certificate that would let them out of purgatory early. Some were sold to people who paid a weekly fee then went back to their usual sins, but it seems most were sold to grieving relatives trying to make the after-life a little more bearable for the dear departed. And, as Luther rightly but impolitely pointed out, the whole thing was nothing but a racket.

This was more or less the first shot in the Protestant Reformation, which soon became real shots in the unspeakable savagery of the religious and political wars that ravaged Europe for nearly two hundred years. Luther won his battle but didn’t see it. The Church finally stopped selling indulgences 20 years after he died in 1546. I thought of this after a job advertisement came my way, offering $350-500 an hour for a psychiatrist to sit on a phone and write scripts (the median salary for Australian workers is $6,500 a month). It’s for a Canadian company called Fastreat who are setting up shop in Sydney. Their website in Canada tells all: “Get your ADHD diagnosis in days, not months.” Note that: Your diagnosis. Essentially, it’s a case of “Send us the money and we’ll post your indulgence.” Excuse me, I should say we’ll send the diagnosis you feel you deserve and a script for your life-saving tablets. Even the wording is a give-away, it’s like the nuisance adverts: “Click here to reserve your seat at our amazing sales seminar” or “Call today for your free sample.”

First, it asks about 8 dopey questions on concentration and so on, which leave no doubt as to the answers you’re supposed to choose. If you want “your diagnosis,” then you have to give personal details, which I didn’t so I’ll have to get by without a diagnosis. Perhaps I can do better on another website, “Elite Focus Adult ADHD Clinic.” This mob are in Australia and offer: “All-in-one service for ADHD diagnosis, treatment and prescriptions. NO REFERRAL NEEDED.” On second thoughts, their fees are a little off-putting: $1400 but no Medicare rebate, because the patients are unreferred and thus unscreened. They simply pause their computer games or call from their bedrooms because they feel the need for some amphetamines in life (note how the unlikely-looking staff on their site all have stethoscopes draped around their necks, no doubt to listen to all the racing thoughts squealing around the cerebral corners).

Meantime, the Faculty of Adult Psychiatry of the RANZCP has just released the program for their annual conference, to be held in late June in the Barossa Valley, South Australia’s premier wine-growing region. The punters will need their thermal undies because it will be bitterly cold, or perhaps the theme of “Adult ADHD” will prove hot enough to keep them awake. The three days are a cooperative effort of the Private Practice section and something called the ADHD Network. The opening talk is by a Prof. David Coghill, whom we have met before (Substack Oct 18^th 2024) so we don’t need to risk frostbite by going to their conference, we already know what he’s going to say: “Everything mental is ADHD, ADHD is the cause of everything bad, everybody should be on ADHD drugs unless they have a compelling alibi.” This jamboree, I should point out, is in honour of a condition that didn’t exist a dozen years ago.

Also a dozen years ago, I wrote a couple of chapters arguing that mainstream psychiatry is engaged in a massive program of re-diagnosing everybody with any hint of personality trouble with bipolar disorder, and putting them on drugs for life [1]. If they weren’t mentally disordered before they started the drugs, they soon would be. That followed a fine tradition, probably in started in 2007 by sociologists Allan Horwitz and Jerome Wakefield with The Loss of Sadness: how psychiatry transformed normal sorrow into Depressive Disorder [2]. Two years later, Bob Whitaker argued a similar case in Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs and the Astonishing Rise of Mental Illness in America [3]. These were warnings: there’s something very strange going on with psychiatry. Far from sitting out of sight in their mental hospital fortresses or hidden high in luxury towers on the edge of cities, it was clear that psychiatrists were extending their franchise. Armed with their new, all-encompassing DSMs, they had set their sights on people who were previously considered just a bit glum or slightly over the top. Previously, everybody had understood that normality is a huge range, an untidy smear across a graph and not a sharp line. Psychiatry’s new message was blunt: If you’re not 100% normal, you’re mentally ill so come up and see us some time. They had declared war on normality.

Since then, psychiatry has opened two huge new fronts in their self-proclaimed war: ADHD and ASD. Their motto is “Take no prisoners, admit no defeat” but, unfortunately, they’re winning. The problem is the same as always. First, the criteria for each of these conditions are so sloppy that, with a bit of shoving, practically everybody in town meets them to some extent. Second, the diagnoses and criteria were written by people with intense vested interests (read: money and glory) in seeing the “illnesses” accepted into the books. Third, the larger society has been bulldozed into reclassifying different or odd or quirky behaviour as “mental illness” and therefore compensable, although nobody put up much of a fight. Finally, everybody who feels the slightest twinge of inner dissatisfaction is invited to join the growing hordes of liberated souls who have just realised that it’s all their genes, so stop worrying and join the war against all the neurotypicals who have been persecuting them.

In the old days, nobody wanted to be considered “mental” but now it’s almost de rigueur, an essential first step to becoming a celebrity. If we add the nearly 20% of the population who take antidepressant drugs, the 10% who are getting the ADHD label, the 5% or so of so-called bipolars and the 5% who claim ASD, the rapidly growing numbers who claim to be the wrong sex or the swarms of kids with “central auditory/visual/sensory etc processing disorder,” dyslexia, dyscalculia, dysphasia, dyspraxic developmental coordination disorder, blah blah, that’s nearly half the population and growing rapidly. The war on normality is now winning: normals are less than half the population. That’s crazy, so what’s going on?

In a word, it’s biological psychiatry, or the biomedical model, call it what you will. It’s the notion that mental life can only be understood as an expression of biology so that any and all deviations from normal are biological, not personality, and demand biological remedies. Driving this are two seriously powerful urges, money and glory, which have escaped their cages because the locks called common sense fell off years ago.

The money in the goldmine called ADHD is perfectly clear from the pill-mills called Fastreat and Elite Focus. The very names reek of venality but that’s what happens when medicine and the “free market” get comfortable. Anybody earning $500 an hour will pull in close to a million a year, and that sort of money attracts people whose commitment to money is higher than their commitment to service. It also serves to pull psychiatrists out of public practice, so their standards go even further down into the pits (yes, it’s possible). You’d think the government would learn from the US experience where opiate drugs were pushed out in their millions by avaricious doctors and chemists, resulting in hundreds of thousands of deaths, but they don’t. What will happen is that anybody who wants the drugs will memorise the symptoms they find on YouTube, recite them to the uncurious person on the other end of the phone, get the script and immediately get the drugs dirt cheap on the PBS. It’s not the US where patients have to pay through the nose for their drugs, here they’re subsidised for life. Which leads to the other side of the money drive, the drug companies.

The market they had built for stimulant drugs for children was saturated so, entirely predictably, the manufacturers found some eager academic psychiatrists to “prove” that the “disease of ADHD” didn’t miraculously go away at the 18^th birthday. Instead, it hung around and needed a lifetime of drugs. I mean, it’s genetic so why wouldn’t it? So we now have the flourishing adult ADHD industry which, in getting a stranglehold on the psychiatry conference, is only just getting into its stride. And, as mentioned, there’s no new market unless an academic psychiatrist stakes out the territory and calls out “Come and get it.” Why would they bother? Glory. As Napoleon said, “Glory is fleeting but obscurity is forever.” Get your name in lights, even if it’s only as opening speaker at some scrawny ADHD conference far down the globe. And, of course, there’s all the “research” money from the ever-generous drug companies which beats going cap in hand to the grants councils who may not be sympathetic to the idea of psychiatry unlimited.

Alert readers may have detected that I see all this business as a racket, but if it’s a racket, where are the cops? The answer is simple: there are no cops for this sort of thing. That’s not quite right. There are cops but there’s no law. Unlike practically all other fields of human endeavour, there is no line drawn in the sand around psychiatry, no law that says: “Go no further. That’s your small territory over there, the rest of this area belongs to normality and psychiatrists aren’t welcome.” Lacking common sense, a theory of mind or a model of mental disorder, there is nothing to stop the piecemeal encroachment on, or even the wholesale engulfing of, normality by psychiatric adventurers. The people who should have developed the theories and models, the thought police of psychiatry, have been asleep on the job for the past few centuries.

When this is pointed out to them, psychiatrists get quite irate and start spluttering: “It’s ridiculous to claim there is no biomedical model, there are lots. OK, maybe they’re all wrong but they’re still models.” Others start with a bold claim and then go quiet. The worthy current president of the college boldly asserted: “... the biopsychosocial model (is) ...the predominant theoretical framework underpinning contemporary psychiatry ... a relevant and useful component of training and practice ... " (Moore, E. correspondence, Nov. 20th 2023). When asked to provide details of the model and their training program, she did not reply, not to the first request, nor to the second, nor the third. As she finishes the job soon, I think I’ll send another request for specific details (reading lists, authors, lectures, conferences etc). I won’t get them as the whole show is a lie (here’s another bald-faced lie from a president of the college; I have others).

What it amounts to is the field is wide open to adventurers who know no constraints. In order to get ahead, academic psychiatrists need to come up with new “diseases” because that’s where the kudos and the pelf is found. There’s no joy in saying to them “You’ve got it wrong.” There was a nice example this week when US psychologist Roger McFillin interviewed Prof. Jon Jureidini of the Centre for Critical and Ethical Mental Health Research at Adelaide University (unfortunately pay wall). Jureidini has an enviable reputation for painstaking research into the claims made by drug companies regarding their wares, e.g. [4]. He argues that studies used by drug companies to gain authorisation for antidepressants in young people were seriously deficient. On the evidence, it was impossible for this to happen by chance and for the drug companies not to be aware of this failing: “None of the papers honestly reported the adverse events that occurred.” In his own practice as a child and adolescent psychiatrist, Jureidini hardly ever prescribes antidepressants, as he described:

Just about every problem I see is interpersonal. It doesn't live in the person's brain. It lives in their relationships with other people. So going looking in their brain and putting chemicals into their brain is just really the wrong place to be doing the work.

This finding will be ignored by the mainstream and certainly by the drug companies and their carnival barkers in academia. I think his decision (stop prescribing antidepressants) is correct but the cause is a bit more nuanced than just “relationships.” For young children, that’s where depression starts, with poor parenting, social adversity, losses, illness or injuries, etc. but by 8 or 10, it’s changed. As the child grows, the problem becomes one of self-esteem. It’s not the case that the teenager (or anybody) has poor self-esteem because he’s depressed, and it will improve with drugs; the problem is that he is depressed because he has poor self-esteem and can’t get on properly with people around him. He is too frightened of failing to perform well in school; he fumbles the ball at sport as he is too concerned how people are looking at him; he’s too shy to ask that nice girl to the school ball in case she says No, so he sits at home, alone and miserable, playing some dumbshit computer game while all the other kids are having a great time. One day, he wakes up and thinks There’s no point, it’s not going to get better, may as well end it now.

Depression comes from poor self-esteem, a negative belief system about self, so where does poor self-esteem come from? It comes from unhappy life experiences in early childhood and latency and adolescence and early adulthood. It does NOT come with the DNA, it is not inherited. Genes code for proteins, not beliefs, but it’s impossible to convince the genetics cowboys of that simple truth (“Geneticists always find what they screen for”).

That’s all very depressing but I don’t think things are going to get better until the Key Opinion Leaders of psychiatry realise they’re barking up the wrong tree. The reason they can’t find a genetic cause of depression or a biological cause for schizophrenia is because they don’t exist. Minds exist, but understanding them takes a lot more work than giving ECT. Intellectually, psychiatry is drifting down to the lowest common denominator, the least demanding point on which they can all agree. Maybe a Martin Luther will arrive and kick down their doors but the fury of the Church will be as nothing compared with the fury of the psychiatric establishment when they’re told: “This is all a racket.”

References:

1. McLaren N (2012). Chapters 14-16 in The Mind-Body Problem Explained: The Biocognitive Model for Psychiatry. Ann Arbor, MI: Future Psychiatry Press.

2. Horwitz AV, Wakefield JC (2007). The Loss of Sadness: how psychiatry transformed normal sorrow into Depressive Disorder. New York: Oxford University Press.

3. Whitaker R (2009). Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs and the Astonishing Rise of Mental Illness in America. New York: Random House.

4. Le Noury J et al (2015) Restoring Study 329: efficacy and harms of paroxetine and imipramine in treatment of major depression in adolescence. BMJ 2015; At: https://www.bmj.com/content/351/bmj.h4320

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