For medical reporters, the annual conference of the American Psychiatric Association is the gift that keeps on giving. With some 600 presentations and an audience of many thousands, the scribblers can scurry around finding all sorts of exciting and/or frightening stories to run. So it was a bit surprising to see that for its main piece this week, the on-line, drug company- sponsored newsletter, Psychiatric Times, could only manage a rerun of an interview from May. This was a 5 minute commentary by Dr John Miller, its newish "editor in chief," reporting on "Evolution of Pharmacological Treatments at the 2023 APA Annual Meeting" (if you can't access it, don't worry, it's just another puff piece for drugs).
Reporting from a luxury hotel in San Francisco, the good Dr Miller gave an "overview of exciting treatments" discussed at the meeting. One of these related to the neuroreceptor After some sixty years of telling everybody that depression is caused by disturbances of certain neurotransmitters (monoamines such as 5-HT and noradrenaline, etc), we now have the amazing breakthrough of drugs coming from basic brain research that actually have nothing to do with these chemicals. This should be exciting but firstly, he was only talking about esketamine and the psychotomimetics, MDMA (ecstasy) and psilocybin (magic mushrooms). More to the point, these had nothing to do with "basic brain research." Any research on their mode of action came long after they had been found to have all sorts of strange mental effects. A recent report from Harvard says "It's not entirely clear how ketamine works." That's medical jargon for "We don't have a clue." After a brief paragraph, it concludes: "Most likely, ketamine works in several ways at the same time, many of which are being studied." After it has been approved, mind you.
Also this week, another edition of the professionally-produced Depression Research Review, including an article from China on yet another psychotomimetic, scopolamine, a drug long-used for nausea in sea sickness and after surgery. The reviewer struggled with the article:
Reading this abstract challenged my own cognitive limits. Is it just me, or is it truly just incomprehensible? In desperation, I read the full article on the open-access website in an attempt to attain enlightenment. I finished the task none the wiser ... What does (it) even mean? I give up. If anyone can enlighten me as to the scientific implications of this study, please email me ... I’ll buy you a drink.
The article is indeed garbled, probably by machine translation, so I'll email him because I'd like to know why he included it. What was he trying to prove? Watch this space.
Two articles from the Netherlands were of interest. The first studied the genotypes of people given old-fashioned tricyclic antidepressants and found no difference in outcome. Gosh, who could have expected that? The second was a fairly large survey covering trends in diagnosis of mental disorder for 15 years from 2007. Rates of mental disorder are rising, particularly among young adults, but ... this had nothing to do with the pandemic. Oh dear, clearly they hadn't been listening to Australia's very own expert on all things mental, Prof. McGorry. In the earliest stages of Covid, he was in a state of near melt-down over predicting psychiatric disaster for the country, for which the government of the day found some spare cash. Nothing happened, of course, people coped, as people tend to do, and that is exactly what the Dutch researchers found.
What is the point of these papers? There is a point, but it's covert. To see it, we can look at the model I love to hate, the so-called biopsychosocial (BPS) model, attributed to the late George Engel. Decades after it was pronounced dead on arrival, this zombie model refuses to lie down, kept upright by bands of determined supporters. One of the most determined is Professor Derek Bolton, whose full title is Emeritus Professor of Philosophy and Psychopathology at the Department of Psychology; Institute of Psychiatry, Psychology and Neuroscience; King’s College London (he trained in philosophy and psychology). In a lecture delivered to the Royal College of Psychiatrists, Prof. Bolton revealed he is "Looking forward to a decade of the biopsychosocial model" [1]. He began by acknowledging certain doubts about its status as a model:
The problem that we don’t know exactly what the model is naturally gives rise to the worry that it isn’t anything, and a decade or so ago this worry was being voiced loudly and clearly by experts in medicine generally and psychiatry in particular ... a theorised biopsychosocial model would include core concepts and principles/models of the biological, psychological and social sciences relevant to health and disease [1, p1-2].
Using the examples of chronic stress and the perception of pain, he demonstrated how biological, psychological and social factors influence the state of health. Because there is so much evidence on how psychosocial factors influence the illnesses, physical and mental, he felt we should declare a "decade of the biopsychosocial model" along the lines of the "decade of the brain" from twenty years ago. He ended with a call for the rest of medicine, not just psychiatry, to embrace a BPS model.
To be clear, his paper was an opinion on the direction psychiatry (and medicine) should take. It was not original research and he gave few references to the scientific literature. But it illustrates clearly how the illusion of the BPS model is kept alive. In the first place, he referred to "vocal criticisms by experts a decade ago." In fact, the first and most serious critique of George Engel's BPS model was published twenty five years ago [2], namely, that it doesn't exist. Bolton chose to ignore this paper but acknowledged a number of critiques dating from more than ten years later which focussed on the vagueness and lack of form of the BPS model. He forgot to mention that it is vague and lacks form because it doesn't exist. He also didn't refer to the steady stream of papers exploring the possibilities of how Engel could have been so seriously mistaken over his own model [e.g. 3].
Now to my mind, if you're going to advocate a particular model, and somebody has published a long series of papers over a quarter of a century arguing that it doesn't exist, you're duty-bound to deal with the objections. Bolton didn't do this. Instead, having spent many years telling everybody what a wonderful future the BPS model has, everybody who says Engel never wrote it must be airbrushed out of the narrative. And that is just what he has done. He said "Vocal criticisms were voiced by experts." The clear implication is that the BPS model is a reality that simply needs a bit of work to bring it up to scratch; anybody who said it didn't exist was obviously not an expert and should be ignored.
The second point is that, just as Engel did 45 years ago, when Bolton talked about the form of a BPS model, he used the future conditional tense ("... a theorised biopsychosocial model would include core concepts ..." [1, p2]), not the present tense. This is a clear statement that it doesn't exist, but he immediately switched to talking about such models (now plural) as real, articulated entities: " ...major new explanatory theories that integrate biopsychosocial factors across very wide ranges of health conditions have been developed in the past few decades ..." [1, p2]. Everybody knows there is an association between psychosocial factors and disease outcomes, but association is not causation. It is simply false to state that there are explanatory, integrative models of mind and body, so why bother? The answer is the covert point mentioned above, the illusory truth effect [4].
The important point about the papers on depression is what they don't mention. Papers on depression and all other mental disorders keep up a flood of biological stuff that eventually leads to the impression that there isn't anything else. The biology says it all because nothing else is heard. Illusory truth effect says that people are more likely to believe false material if they have heard it before. Simply repeating over and over "All mental disorder is biological" eventually convinces people that it must be true. It is one of the many inbuilt or cognitive biases that all humans show. Other important biases include confirmation bias (people selectively notice and recall information that confirms their pre-existing opinions, regardless of its validity) and argumentum ad verecundiam (people are swayed by opinions coming from authorities, regardless of whether the authority is an expert on the topic, or is even right).
This is why the editor of Depression Research Review would rather include a paper he doesn't understand than one that says there may be more to depression than genes and neurotransmitters, that it may have something to do with life events. It is why Bolton doesn't deal directly with my ancient paper that says "The biopsychosocial model doesn't exist." They leave out all the stuff that doesn't fit their narrative and just keep repeating the same old same old. Eventually, most people end up believing it because questioning it is too tiresome. And this is science?
1. Bolton D (2022). Looking forward to a decade of the biopsychosocial model. British Journal of Psychiatry Bulletin, 46: 228–232, doi:10.1192/bjb.2022.34
2. McLaren N (1998). A critical review of the biopsychosocial model. Australian and New Zealand Journal of Psychiatry. 32; 86-92.
3. McLaren N (2020). The Biopsychosocial Model: the end of a reign of error. Ethical Human Psychology and Psychiatry. 22:71-82.
4. Kahneman D (2011). Thinking fast and slow. New York: Allan Lane