Dear Amy Levey & Hillarie Fogel
The APA in its recent statement on the diagnosis and treatment of mental disorders is clearly concerned about the potential undermining of funding for brain research. The statement does not explain how such research has improved psychiatric treatment over the last five years.
The APA may have misunderstood the nature of the challenge to some of the statements that it endorses, such as that schizophrenia is a serious neurobiological disorder. Of course, mental disorders, including schizophrenia, have their origins in the brain, as does our "normal" behaviour. The critique is not suggesting that mental disorders are incorporeal or "spiritual" in the sense of not having a material basis in the brain. However, the validity of the concept or understanding of mental disorder is not helped by postulating an abnormality at the level of the brain. Nor is the concern of the critique any frustration with the pace of scientific advance, as such. Psychiatry, since its origins in the US with Benjamin Rush's treatise Medical Inquiries and Observations upon Diseases of the Mind (1812), has always argued that all that is needed is more scientific research. Nearly 200 years later we are still in the same position, which may suggest there is something wrong with conceptualising mental illness as brain disease.
I take it that the APA thinks that there is evidence for brain abnormalities in schizophrenia, but only mentions ventricular enlargement. Are there any other evidence? It is misleading, though, not to mention the non-specificity of the finding of ventricular enlargement and the dynamic nature of the abnormality on brain scans. If there has been any advance in neuroscience because of neuroimaging over recent years, I would have thought it was to encourage us to dispense with notions of anatomical fixity. Brain cytoarchitecture itself seems to be fashioned by input from the social environment. The APA may speculate that ventricular enlargement is aetiologically linked with schizophrenia but it may be a concomitant of a confounding variable in such patients.
It is also disingenuous to mention the so-called evidence for genetic factors in schizophrenia, bipolar disorder and autism, without at least mentioning the controversial nature of this evidence. Furthermore, it is misleading to talk about the potential for molecular genetics without noting that the sheer complexity of the genetics of common disorders, like mental disorders, may make accurate prediction impossible.
Moreover, I would have thought that psychopharmacologists have long ago given up the notion that if psychotropic medications work that they work through specific identified neurotransmitters. Is the APA saying it still believes in the monoamine hypothesis of depression because Julius Axelrod was awarded the Nobel prize for the discovery of the reuptake mechanism of noradrenaline? The truth is we do not know the mechanism of antidepressants or even if they are more effective than placebos.
The delivery and provision of mental health services needs to be improved in other countries with other forms of health systems besides the US. The international psychotropic drugs bill is not likely to be reduced by further investment in research of the kind the APA is promoting. The Presidents' New Freedom Commission on Mental Health recommends a fundamental transformation of the Nation's approach to mental health care. The recommendations can only fully be met by a shift away from a biomedical towards an interpretative model of mental illness, which tries to understand the reasons for mental health problems and does not mislead people into thinking that psychiatric practice can be justified by postulating brain pathology as the basis for mental illness
The kind of mental health service and research that we want is affected by the model of mental illness we adopt. This is why the issues raised are important and I hope that the APA will continue to engage with them. We do need to make progress towards a synthesis of these dilemmas. I look forward to your response.
D B Double
Norfolk Mental Health Care NHS Trust, UK
27 September 2003