Presentation at the Eighth Annual International Centre for Study of Psychology and Psychiatry (ICSPP) conference (http://www.icspp.org/conference/confprogandreg2004.htm)
Biomedical bias of institutional psychiatry: a critique of the American Psychiatric Association statement on the diagnosis and treatment of mental disorders.
D B DOUBLE
Coming from Britain, I suppose I should not criticise America. After all, politically Britain is currently said to be America's greatest ally. I actually think we are allies on the subject of my talk, which is "The biomedical bias of institutional psychiatry". In my view, institutional psychiatry has similar problems in both countries. This is why ICSPP is an international centre and we are partaking in this international conference, to which I am very grateful to have received this invitation. The title of the conference "Critiquing disease models of psychosocial distress and implementing psychosocial theories and interventions" applies all over the world.
Despite what I see as the universal problems of institutional psychiatry, in this presentation I am specifically criticising the American Psychiatric Association. What I do not want you to think, though, is that this means that I am more supportive of my own professional organisation, which is the Royal College of Psychiatrists in the United Kingdom and Republic of Ireland. Both the American Psychiatric Association and the Royal College of Psychiatrists should represent a broad spectrum of opinion in psychiatry, because of the many different approaches amongst its individual members. Statements that these professional organisations make, if they are to be representative, are likely to be bland and non-partisan. However, the American Psychiatric Association (APA) last year made what seems to me to be a biased, ideological statement.
The APA statement was precipitated by a hunger strike that began on the 16 August 2003 by six "psychiatric survivors". At least one of them, David Oaks, is at this conference. The aim of the protest was to press for human rights and choices in psychiatry. Details are available on the Fast for Freedom in Mental Health webpages on the MindFreedom Online website (http://www.mindfreedom.org/mindfreedom/hungerstrike.shtml).
The specific challenge of the hunger strikers was that the US Surgeon General, the National Alliance for the Mentally Ill (NAMI) and the American Psychiatric Association should produce evidence to support common claims that major mental illnesses are "proven biological diseases of the brain" and that emotional distress results from "chemical imbalances" in the brain.
No response was received from the Surgeon General. This was despite a follow up letter to the President, George Bush.
NAMI did reply, although it did not really engage with the issues. Its executive director, Rick Birkel, said that he thought the protest would accomplish nothing of value. He merely offered a counter-challenge to work with NAMI to achieve better conditions for people with mental illnesses and better access to treatments and supports.
Tom Lane, NAMI's Director of the Office of Consumer Affairs, did go a little further in his comments. Although he did not reply directly to the hunger strikers, he indicated in a response to a relative that he was angry because, as far as he was concerned, the hunger strike was a diversion from the true work of mental health advocacy. He was clear that the aetiology of mental illness involves both biological processes and environmental factors. He implied that everyone already knows this fact and that a reductionist approach to mental illness is misguided, so there is no point in debating it further. Although Tom Lane later apologised for impugning the motives of the hunger strikers, the argument he makes about everyone not agreeing with reductionism does require further comment. It was never really taken up by the hunger strikers. It is, though, a very common way of deflecting the critique of the biomedical model. I think this is an important issue and will return to it at the end of my presentation.
The American Psychiatric Association did engage somewhat better with the hunger strikers. James Scully, its medical director, responded to the original statement. He advised that answers to the questions raised were widely available in the literature. In his view, there had been substantial progress in understanding the neuroscientific basis of many mental illnesses. He gave some very general references to the literature.
The hunger strikers asked their scientific panel of 14 academics and clinicians, who are associated with ICSPP, to respond to Scully's letter. In the reply, the panel pointed out that the references made by Dr Scully were all in fact, contrary to his view, explicit about the lack of specific pathophysiology in mental illness. The letter gave quotations from the references to support this perspective. It concluded that there is not a single study that provides valid and reliable evidence for the so-called "biological basis of mental illness."
On day 11 of the hunger strike, there was a surprise breakthrough when a delegation of the hunger strikers held a face to face meeting with Dr Marcia Kraft Goin, President elect, at the time, of the American Psychiatric Association (APA), inside her Los Angeles office. Dr. Goin indicated that an in-depth reply from the APA would require further consideration.
Also present at the meeting was Dr. Bruce Spring, a member of the APA and active in California APA leadership. When pressed for evidence about the biological basis of mental illness, Dr Spring proposed the "Danish twin study". This seemed to be the best he could do at the time. He in fact probably meant the Danish-American schizophrenia adoption study rather than any twin study as such. As we will see later, it is not unusual to believe that the genetic case for schizophrenia has been proven.
At one point in the meeting, Dr. Goin noted that she had a psychoanalytic background, and she shared an interest in having talk therapy more available to clients. She also said she supported the President's New Freedom Commission's call for inclusion of mental health consumers and psychiatric survivors in decision-making. Despite coming from this position in psychiatry, she seemed to find it difficult to openly accept criticism of the biomedical model on behalf of the APA in her role as president elect.
At the end of the meeting, David Oaks asked, "Have you found this meeting valuable?" Dr. Goin replied, "I found it interesting." "Yes," said David Oaks, "but was it helpful?" Dr. Goin replied again, "I found it interesting." This defensiveness does require further comment, which I will come to later. Its origin is perhaps made more transparent in the APA statement that was released after the end of the hunger strike.
The hunger strike itself lasted 21 days. It did mobilise a lot of support and its challenge does not seem to have gone away.
I want to look in more detail at the statement on the diagnosis and treatment of mental disorders issued by the APA after the hunger strike on 25 September 2003. I have written a critique, which has been published in the current issue of Ethical Human Psychology and Psychiatry. The rest of this talk mainly summarises that paper (available at http://www.critpsynet.freeuk.com/biomedicalbias.htm).
The APA accused the hunger strikers of saying that the lack of a diagnostic laboratory test for mental disorders constitutes evidence that such disorders are not medically valid conditions. As far as the APA is concerned, it is unfortunate that a small number of people persist in questioning the reality and clinical legitimacy of disorders that affect the mind, brain, and behaviour.
I do think it important that the protagonists understand each other. We are all in agreement that there is no diagnostic laboratory test for the major categories of functional mental illness. It is true that the hunger strikers asked for evidence for such a physical diagnostic exam. The simple answer should have been that there is none. Instead the APA attacked the 'straw man' that because there is no diagnostic test, the implication must be that such disorders are not medically valid conditions. This does not +necessarily follow. The hunger strikers were asking that people should not act as though there are biological markers for mental illness. The APA seems to find it difficult to acknowledge this fact.
To give the APA its due, it does admit that brain science has not advanced to the point where scientists or clinicians can point to discernible pathological lesions or genetic abnormalities that in or of themselves serve as reliable or predictive markers of mental disorder. However, it goes further to speculate that although mental disorders may not be the result of any gross anatomical lesion they will eventually be proven to represent disorders of intercellular communication or disrupted neural circuitry.
Acting without proof as though these speculations are true may be common psychiatric practice. However, this state of affairs may also demonstrate the bias of the APA and be indicative of its poor professional leadership on this issue.
The APA clearly states that schizophrenia and other mental disorders are serious neurobiological disorders. Exactly what it means by this remark may be not be totally clear, but it backs it up with three supporting statements that I want to consider in a little more detail.
Firstly, it says that research has shown reproducible abnormalities of brain structure and function. What it means is that brain scanning research over recent years, of which there are a multitude of studies, has reported abnormalities in shape, size and functions in multiple anatomical regions of the brain. However, these reports are not always very consistent or readily reproducible.
The only definite example of brain abnormality given in the statement is ventricular enlargement in the brains of people diagnosed as schizophrenic. This is the most consistent finding from a very confusing and difficult area of research to interpret
However, the difference of ventricular size between schizophrenic cases and controls is modest and there is a large overlap with the normal population. The result is also non-specific in that it is found in other psychiatric conditions, such as bipolar disorder. It is also likely to be a concomitant of confounding variables, such as nutrition and hydration. These non-specific factors can be affected in psychiatric patients and create ventricular enlargement on brain scans
The abnormality of ventricular enlargement may, therefore, not be an indication of the origins of schizophrenia at all. As with any statistical association, a causal connection is not necessarily implied. If ventricular enlargement is an extraneous variable, to conclude that schizophrenia is a neurobiological disorder is unjustified.
The APA has, therefore, not supported its contention that schizophrenia is a neurobiological disorder because of structural abnormalities in the brain. The challenge of the hunger strikers still stands. It is the APA's responsibility to produce the evidence to support its claim.
Secondly, the APA states that the evidence for a strong genetic component in mental disorders is compelling. The APA does not actually indicate what genetic evidence it finds so compelling. It will be referring to three sets of studies. These are family, twin and adoption studies. The evidence is in fact open to interpretation and has been well critiqued in the literature. It is disingenuous to note the so-called evidence for genetic factors, without at least mentioning the controversial nature of this evidence. Claims for a genetic basis to mental illness should not be accepted uncritically. The problem is that what the APA finds compelling evidence may in fact be its prejudice.
Over recent years, the new techniques of linkage studies, despite what you might read in the press from time to time, have not led to identification of the gene for schizophrenia or bipolar disorder or any other functional mental illness. By way of contrast, the identification and cloning of genes has led to major progress in the molecular biology of some neuropsychiatric disorders, which are genetic, such as Huntington's disease. Here the abnormality of triplet repeat on chromosome four has now been demonstrated. But functional mental illnesses, such as schizophrenia and bipolar disorder, are not genetic as such. Merely because there may be an increased family risk does not necessarily imply that the disorder is genetic.
The APA has therefore not supported the implication that disorders, such as schizophrenia, bipolar disorder, and autism are neurobiological disorders because of their genetic aetiology. In fact, even if genetic causation were demonstrated as convincingly as the APA thinks it has been, the notion of mental illness as a neurobiological disorder does not necessarily follow. The argument seems to be that genes affect biological mechanisms and therefore that abnormal biology can be corrected by medication. However, it is illogical to regard a genetic basis as indicating that environmental factors are not important. Environmental factors, such as family and cultural variables, do play a role in aetiology. Genetic influence in mental illness may not be very specific. Genes merely set the boundaries of the possible; it is the environment that actually defines what happens.
Thirdly, the APA states that mechanisms of action of effective medications have been elucidated. The only example of the action of medication given in the statement is the blocking of the reuptake mechanism of norepinephrine by antidepressants. It is true that most antidepressants have this action, but not all. However, it does not necessarily follow that this tells us anything about the mechanism of depression. For many years, the prevailing hypothesis in depression has been that it is caused by an absolute or relative deficiency of monoamines, such as norepinephrine, in the brain. What the APA fails to point out is that the monoamine theory of depression, as it is called, has been found insufficient to explain the aetiology of depression. There are so many inconsistencies in the research evidence that the monoamine theory should be abandoned as the basis for understanding the effect of antidepressants in clinical practice. The same applies to the dopamine theory of schizophrenia.
It is a very commonly thought that depression is due to an imbalance of serotonin. The drug companies exploit this belief. To given the pharmaceutical industry its due, it is generally careful enough to admit that the theory that mental disorders are caused by chemical imbalance is a hypothesis. Rather than making a definitive statement, they suggest that disorders like "depression may be caused by an imbalance of chemical messengers in the brain" and "there may be a problem in depression with the balance of the serotonin system that affects the cell to cell communication" [my emphasis]. It is often the psychiatrists who go further by telling patients that these problems are definitely due to a chemical imbalance.
The truth is that we do not know if psychotropic medication corrects a chemical imbalance, because we do not know that there is a chemical imbalance in mental disorders. Certainly the effect of medication cannot be said to confirm the neurobiological basis of mental illness.
I have looked at the three components of the evidence that the APA thinks lead to the conclusion that mental illness is a neurobiological disorder, and found them all to be wanting. If we look more closely at the APA statement we can see what is motivating its stance. It is clearly concerned about the potential undermining of funding for brain research. The statement says that research has improved psychiatric treatment over the last five years but it does not make any attempt to explain how.
It also mentions The Presidents' New Freedom Commission on Mental Health (http://www.mentalhealthcommission.gov/), implying that this process should not be undermined. I would have thought that the recommendations of this commission can only fully be met by a shift away from a biomedical towards an interpretative model of mental illness. We need to understand the reasons for mental health problems and not mislead people into thinking that psychiatric practice can be justified by postulating brain pathology as the basis for mental illness.
Instead, President Bush announced on 26 July 2004 that his administration has begun implementing the recommendations of the New Freedom Commission on Mental Health. These would "improve mental health services and support for people of all ages with mental illness", by such means as comprehensive screening for "consumers of all ages," including pre-school children. The fear has been raised that this is merely a way of the pharmaceutical industry extending its market to subclinical cases of mental disorder. People who are thought to be at risk of developing mental illness may be started on medication before the illness has even shown itself.
This example shows that the debate about the biomedical bias of psychiatry does matter. I do not want you to misunderstand me. I am not saying that mental disorders have nothing to do with the body or that they are "spiritual" in the sense of not having a material basis in the brain. Of course, mental disorders, including schizophrenia, have their origins in the brain, as does our "normal" behaviour. Rather, the problem with the claim that mental disorders are biological diseases is that it creates the reductionist tendency to treat people as brains that need their lesions or disrupted neural circuitry cured. Psychosocial factors in aetiology tend to be avoided. If biological and genetic factors determine psychopathology, the implication may be that personal and social efforts to improve one's state of mind may be pointless. Treating the biological abnormality and not the person, therefore, has ethical implications.
In conclusion, therefore, I want to return to the argument raised by Tom Lane of NAMI, which I mentioned earlier. He suggested that we all know that psychosocial as well as brain factors are important in the aetiology of mental illness. There should be no need for argument about it, as far as he is concerned. The problem is that the reality of the way mental health services function is different. Psychiatrists do act as though the speculations they make about mental disorders being neurobiological in origin are true. The APA statement proves it. However much we may think that there is an eclectic consensus, when it comes to the APA being compelled to respond to a challenge, such as a hunger strike by survivors, it reiterates its biomedical version of events. We need no longer accept that the APA is adopting a pluralistic position on such matters. It has stated in a transparent way its biases, and these need to be exposed. The hunger strikers are to be commended for doing so.