Our Psychiatric Future

Source: Polity Press

*This post is strictly the opinion of the author, Christopher Lane, Ph.D.

“What greater indictment of a system could there be than an epidemic of mental illness?”

The question was asked by Guardian newspaper columnist George Monbiot in 2016. “The latest, catastrophic figures for children’s mental health in England reflect a global crisis,” he continued, citing reports that “one quarter of a million children [were] receiving mental health care” across the nation. “Plagues of anxiety, stress, depression, social phobia, eating disorders, self-harm and loneliness now strike people down all over the world.”

Doubtless, “plagues” wasn’t the best metaphor for the occasion, conjuring microbes to flee and confinement for the “stricken.” But Monbiot wanted to remind us that there are powerful social determinants of ill health—consequences, as well, to treating mental illness as primarily biological in nature and cause. For one thing, the emphasis tends to default to biological remedies as the favored solution, even when nonbiological alternatives may be preferable—more effective or less expensive, with no medical side effects.

As if bearing out his point, a different section of the Guardian reported earlier this year that scientists were working on a pill for loneliness. “If there are medications for social pains like depression and anxiety,” the article asked, “why not loneliness?” The effort appeared to miss the point or, worse, to confirm it in spades: loneliness (with its serious medical consequences) was at risk of being recast entirely as a medical condition, for which medicine would then be needed. With such a worldview, continued loneliness might in turn be rendered as a failure of pharmacology: the wrong pills, in effect, not the wrong social policies.

The episode and discussion opens the third chapter of Our Psychiatric Future, Nikolas Rose’s incisive new book on “the politics of mental health,” which throughout asks cogently, “Is another psychiatry possible?” Each of his nine chapters examines a major controversy in the field: whether mental disorders are best defined as brain disorders. Whether biomarkers are a viable and necessary research emphasis. What is the true scale of psychiatric diagnosis and medication across OECD countries? How should treatment proceed and for how long? And what is the future of psychopharmacology when its own data spotlight a disturbingly poor track record, one summed up by a specialist in a 2012 edition of Schizophrenia Bulletin: “Psychopharmacology is in crisis. The data are in, and it is clear that a massive experiment has failed: despite decades of research and billions of dollars invested, not a single mechanistically novel drug has reached the psychiatric market in more than 30 years.”

In his willingness to tackle these controversies head-on, Rose—one of Britain’s leading thinkers on their history, who deserves a still-larger profile in the U.S. for such trenchant, field-altering works as The Politics of Life Itself (Princeton, 2006) and, with Joelle M. Abi-Rached, Neuro: The New Brain Sciences and the Management of the Mind (Princeton, 2013)—is succinct and on-point: “Who will be accountable,” he asks, “for the many millions of individuals throughout the world taking medicines of dubious value for conditions of dubious diagnostic validity, while key figures who determine funding and shape research in psychiatric neuroscience still cling to the dream of molecular explanations and molecular interventions? When is it time to say ‘enough,’ to admit that this pathway of thinking about, and intervening upon, mental ill health has run into the sand?”

These are questions doubtless haunting some of the leading minds in the field—those aware of the many billions of dollars sunk into the ambitious bid to identify psychiatric biomarkers, despite yielding few actionable results. “When is it time to say ‘enough,’” Rose wonders, when the investments are such that it becomes awkward but vitally necessary to concede the need for a different tack. That alternative would guide deprescribing for overdiagnosed conditions, while acknowledging the full experience of those prescribed medication, who live with its secondary effects even when they wish to end treatment. “Unfortunately,” he notes, the current “‘brain-first’ view does shape a funding regime and a system of professional status that directs the efforts of the most able researchers toward neurobiology rather than to the explorations of the causal webs that start from the sociopolitical environment.” This is, he contends, psychiatry’s “style of thought”—its dominant orthodoxy and scarcely acknowledged ideology.

Revisiting these controversies has become urgent, Rose explains, and this reviewer would agree, because “psychiatry and psychiatric classification systems play a significant role in shaping our understanding of normality itself.” The urgency arises as well because the conditions themselves are so frequently misdiagnosed: “Over our lifetime,” he explains of the current low bar for diagnosis, “almost all of us are potentially suitable cases for treatment.”

In the case of biological psychiatry, greatly favored since Bush Sr. named the 1990s as “the decade of the brain,” the last two directors of the NIMH have strengthened field dominance by asserting that “mental disorders are biological disorders” (former director Thomas Insel) and that “psychiatric disorders are disorders of the brain” (his successor, current director Joshua Gordon). “To make progress in treating them, we really have to understand the brain,” Gordon continued, underlining once again, from the perspective of this reviewer, the inexhaustible bid of his peers and federal agency to align each of the 350-plus distinct disorders in the DSM with a reliable biomarker.

Regarding the diagnostic manual itself, Rose notes, many clinicians and researchers on both sides of the Atlantic treat it as a “Rough Guide” to the conditions they diagnose (alluding to the popular tourist guides), potentially minimizing the true scope of its influence. “Diagnostic manuals do things,” he reminds. “They don’t just ‘sort things out’; they also link things together. Contemporary manuals, like the DSM, also mark out, shape and configure a territory for psychiatry to occupy.” The same manual will therefore mean quite different things to a physician, patient, and prescriber as to a lawyer, researcher, or school administrator. Above all, with significant implications, psychiatric “diagnosis reframes … troubles into an illness.”

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Perhaps surprisingly, then, given the sheer weight of counter-evidence in his book alone, Rose argues firmly that we are not facing an “epidemic” of overdiagnosis. The surprise is partly because he offers a backdrop to the influential National Comorbidity Survey of Substance Use Disorders and Nonsubstance Psychiatric Disorders, conducted in 1994 and mostly “unaltered since,” which was made a bedrock to a large number of DSM-IV diagnoses, ostensibly confirming their validity. The survey had stemmed from interviews with randomly selected American households that were asked questions such as, “Have you ever had two weeks or longer when you lost the ability to enjoy having good things happen to you?” With such leading, open-ended questions, the problem of validity almost answers itself.

With one estimate of OECD countries putting the number of individuals “taking a prescription pharmaceutical for depression, anxiety or some other mental health problem at any one time” at an eye-popping one-in-ten, clearly it matters that all of those conditions have been thoroughly recast and expanded in each edition of the DSM, including not as “reactions” (their earlier designation) but as potentially lifelong disorders. As their age thresholds also have been lowered across-the-board to include the very young (when previous diagnosis was limited to adults, as with Bipolar Disorder) or to include adults when previously framed entirely as childhood disorders (ADHD), it seems odd and incomplete to downplay the effect of empirically verifiable changes to the DSM as one of several major drivers of diagnosis inflation and overprescribing. Throw in the effort to de-list from the manual some of its most questionable personality disorders, including “borderline” and “antisocial,” and whether we technically suffer from an “epidemic” of mental disorders seems misplaced as a question, instead bringing us closer to what Peter D. Kramer called “diagnostic bracket creep” and its many practical consequences.

A related quibble would be with the publisher’s choice of several chapter titles, which sometimes overegg the problem, tending to simplify problems that the chapters themselves must then resolve—for instance, “Is there really an ‘epidemic’ of mental disorders?” and, chapter 2, “Is it all the fault of neoliberal capitalism?” Especially in that last case, the answer clearly is “no.” As the chapter itself concedes, however, that doesn’t stop the “managerialist” emphasis of neoliberalism (enduringly popular in the UK) from having serious, detrimental effects on the discourse and practice of mental health, turning neoliberalism into an important contributor to mental illness and distress, even if it's not the sole cause.

The emphases are important because, overall, Our Psychiatric Future has such a clear grasp of the real-life consequences of psychiatry’s conceptual emphases and policy decisions. As Rose notes in a moving preface, writing the book brought him “face to face with the challenges [encountered] by dedicated psychiatric professionals, and gave me a clearer sense of the lives of those for whom they tried to care.”

Ultimately, he concludes, “a collaborative approach to [psychiatric] research is necessary to put the brain back into the organism and the organism—the human—back into the interpersonal, cultural and physical milieu for which it has evolved … without which it would be unable to perform the most basic of its functions.” Psychiatry would then be neither “brain-first” nor brainless, but with a resized focus on biology relative to all other determinants of mental health, among them poverty, diet, and “toxic stress.” With his emphasis firmly on the need for social medicine, Rose lays down a challenge to his colleagues, signaling the scale of reforms needed if they're willing to heed his message: “another psychiatry, one that plays a leading role in a different biopolitics, is possible.”

*This post is strictly the opinion of the author, Christopher Lane, Ph.D.​​​​​​​