A psychiatrist who once "treated" me used to recite this rueful
little mantra: "They say failed doctors become psychiatrists, and that
failed psychiatrists specialise in drugs."
By drugs this psychiatrist meant drugs of addiction – and his
"treatment" of me consisted of prescribing Temgesic, a synthetic opiate,
as a substitute for the heroin I was more strongly inclined to take.
So, he undertook this role: acting, in effect, as a state-licensed drug
dealer; and he also attempted a kind of psychotherapy, talking to me
about my problems and engaging with my own restless critique of – among
many other things – psychiatry itself. Together we conceived of doing
some sort of project on drugs and addiction, and began undertaking
research. On one memorable fact-finding trip to Amsterdam, we ended up
smoking a great deal of marijuana as well as drinking to excess – I also
scored heroin and used it under the very eyes of the medical
practitioner who was, at least nominally, "treating" me.
All of
this happened more than 20 years ago, and I drag it up here not in order
to retrospectively censure the psychiatrist concerned, but rather to
present him and his behaviour as a perversely honest version of the role
played by his profession. For what, in essence, do psychiatrists
specialise in, if not mood-altering drugs? Or, to put it another way,
what do psychiatrists have to offer – over and above the other so-called
"psy professions" – beyond their capacity to legally administer
psychoactive drugs, and in some cases forcibly confine those they deem
to be mentally ill?
Psychiatry is undergoing one of its periodic
convulsions at the moment – one that coincides with the publication by
the American Psychiatric Association of the fifth edition of
their hugely influential "Diagnostic and Statistical Manual of Mental
Disorders" (
DSM–5)
– and I think we should all take the opportunity to join in the
profession's own collective navel-gazing and existential angst. After
all, while the influence of the talking cures is pervasive in our
society
– running all the way up the scale from anodyne advice dispensed on
daytime TV shows, to the wealthy shelling out hundreds of pounds a week
to pet their neuroses in the company of highly qualified black dog
walkers – psychotherapy and psychoanalysis remain essentially
voluntaristic undertakings; only psychiatry deals in mandatory social
care and legal sanction. Besides, only psychiatry partakes of the
peculiar mystique that attaches to medical care. We may dismiss the
opinions of all sorts of counsellors and therapists, secure in the
knowledge that their very multifariousness is indicative of their lack
of overall traction, but psychiatry, dealing, as it claims, with
well-defined maladies – and treating them with drugs and hospitalisation
– exerts an enormous pull on our collective self-image. Just what the
nature of this pull is, and how it has come to condition our
understanding of ourselves and our psychic functioning, is what
I wish to unpick.
Full-blown mental illness is an extremely
frightening phenomenon to observe – let alone experience. And much of
the debate that surrounds the efficacy of contemporary psychiatry is
warped by the knowledge – lurking in the wings of our minds – that we
wish to have as little as possible to do with it. We may understand
rationally that psychosis isn't a contagion, yet still we turn aside
from the street soliloquisers and avoid the tormented gazes of those
being "cared for in the community". Arguably, the response of those who
treated a trip to Bedlam to view the madmen and women as
an entertainment had the virtue of at least being a form of contact. At
their peak, mental hospitals such as Bedlam (and formerly known as
"lunatic asylums") housed over 100,000 inmates, many of whom had been
confined for behaviours that today would be regarded as lifestyle
choices, such as socialism or sexual promiscuity. The hospitals were
also dumping grounds for patients who we now know to have had organic
brain diseases. It's sobering for those on the left to realise that the
first politician to commit to their abolition was Enoch Powell. By the
early 1990s many long-stay inmates had been returned to the outside
world, but their lives were for the most part still grossly
circumscribed: living in sheltered accommodation and visited by
mental health teams, confined not by physical walls but by the chemical straitjackets of neuroleptic drugs.
An engraving of a bedridden patient at the New York City Lunatic
Asylum Hospital in the late 1860s. Photograph: Stock Montage/Getty
Images
Still, if you wish to visit Bedlam you can do so. The locked mental
wards of our hospitals present a terrifying spectacle of seriously
disturbed patients shouting, yelping, gurning and shaking – I know, I've
seen them. And it's the much-repressed knowledge that this is going on
that helps, I would argue, to prevent too much criticism of the
psychiatric profession. Just as we are quietly grateful to prison
officers for banging up criminals, so too we are grateful
for psychiatrists and psychiatric nurses for providing a cordon
sanitaire between us and flamboyant insanity. Yet while the regime under
which those diagnosed with mental pathologies has changed immensely
in the last half-century, the prognosis remains no better. Some say that
it is manifestly worse, and that psychiatry itself is to blame. But the
truth is that hardly anyone – apart from the professionals, whose
livelihoods depend on it – can either be bothered to wade through the
reams of scientific papers concerned with the alternative treatment
regimens, or understand the different methodologies arrived at to assess
competing claims.
Early in
Our Necessary Shadow,
his lucid, humane and in many ways well-balanced account of the nature
and meaning of psychiatry, Tom Burns, professor of social psychiatry at
Oxford University, makes a supremely telling remark: "I am convinced
psychiatry is a major force for good or I would not have spent my whole
adult life in it." This is a form of the logical fallacy
post hoc ergo propter hoc
("After this, therefore because of this"), and it seems strange that an
academic of such standing should so blithely retail it because, of
course, if we reverse the statement it makes just as much sense: "Having
spent my whole adult life as a psychiatrist I must maintain the
conviction that it is a major force for good." After all, the
alternative – for Burns and for thousands of other psychiatrists – is to
accept that in fact their working lives have constituted something of a
travesty: either locking up or drugging patients whose diseases are
defined not by organic dysfunction but by socially unacceptable
behaviours. Burns has the honesty and integrity to admit that the major
mental pathologies – schizophrenia, bipolar disorder, depression inter
alia – cannot be defined in the same way as physical diseases, and he
cleaves to the currently fashionable view of psychiatry as seeking to
understand mental maladies through the tripartite lens of the social,
the psychological and the biological. He also states that he sees the
role of psychotherapy as central to the practise of psychiatry – and in
this he dissents from the more mainstream "biological" model of
treatment that has been in the ascendancy since the 1970s.
But what Burns cannot quite bring himself to do is give up the
drugs.
In a 333 page book (complete with a glossary, a bibliography and an
index), there are just three references to the most commonly prescribed
psychiatric drugs: the SSRIs, or selective serotonin reuptake inhibitors
(such as Prozac and Seroxat). When he does consider the SSRIs, he notes
that they may indeed be overprescribed (as of 2011 46.7m prescriptions
had been written in the UK for antidepressants), and in particular that
they may be used to "treat" commonplace unhappiness rather than severe
depression. What he doesn't venture near are the systematic critiques of
antidepressants – and neuropharmacology in general – that have emerged
in recent years. The work of
Irving Kirsch,
whose meta-analysis of SSRI double-blind trials revealed that in
clinical terms – for a broad spectrum of depressed patients – SSRIs
acted no better than a placebo, is something Burns doesn't want to look
at. He also doesn't wish to examine too closely the underlying "chemical
imbalance" theory of depression on which the alleged efficacy of the
SSRIs is based, presumably because he knows that it's essentially bunk:
no fixed correlation has been established, despite intensive study,
between levels of serotonin in the brain and depression.
Antidepressant tablets. Photograph: Jonathan Nourok/Getty Images
I've swerved into consideration of antidepressants because I believe
the exponential increase in their use is a function of the problem of
legitimacy that psychiatry currently faces. Psychiatrists, of course,
tell the public that the vast majority of these drugs are prescribed by
general practitioners – not by them. But what has made it possible for
someone recently bereaved or unemployed to have a prescription written
by their doctor to alleviate their "depression", is, I would argue, very
much to do with psychiatry's search for new worlds to conquer, an
expedition that has been financed at every step by
big pharma.
Put bluntly: unable to effect anything like a cure in the severe mental
pathologies, at an entirely unconscious and weirdly collective level
psychiatry turned its attention to less marked psychic distress as a
means of continuing to secure what sociologists term "professional
closure". After all, if chlorpromazine (commonly known as Largactil) and
other neuroleptics don't cure schizophrenia – any more than lithium
"cures" bipolar illness – then why exactly do you need a qualified
medical doctor to dole them out?
The proliferation of new
psycho-pharmacological compounds has advanced in lock-step with the
proliferation of new mental illnesses for them to "treat". As Ian
Hacking observes in
a review of DSM–5
in the current London Review of Books, the first DSM – published in
1952 – and its successor in 1968, were heavily influenced by the
psychoanalytic theories then dominating psychiatry in the US. In 1980,
with DSM–III there came a step-change. Hacking traces this to the
efficacy of lithium in managing mania: "Now there was something that
worked … clear behavioural criteria were necessary to identify who would
benefit from lithium." James Davies begins his book,
Cracked: Why Psychiatry Is Doing More Harm Than Good,
with an examination of how these behavioural criteria were arrived at
by the compilers of DSM–III and its subsequent incarnations. You may
be thinking that all this is so much arcane knowledge – and wondering
why we in Britain should be preoccupied by a diagnostic manual published
in the US. But in fact the ICD (International Classification of
Diseases) used by British doctors is compiled in the same way as the DSM
– indeed most NHS psychiatrists favour the latter over the former. In
the US it's simple: your insurance won't pay out unless you are
diagnosed with a malady detailed in the DSM, but in Britain we have a
less tangible – but for all that pervasive – form of socio-medical
discrimination: no sick note – and no social benefits – unless what ails
you conforms to the paradigms set out in DSM.
The focus of
Davies's critique is that the criteria for what constitutes ADHD
(attention deficit hyperactivity disorder), or autism, or indeed
depression, are not arrived at by any commonly understood scientific
procedure, but rather by committee: psychiatrists getting together and
pooling their understanding of how patients with these maladies
"present" (in the jargon). Under these circumstances it becomes somewhat
easier to understand how the tail can begin to wag the dog: rather than
arriving at a commonly agreed set of symptoms that constitute a gestalt
– and hence a malady – psychiatrists become influenced by what
psycho-pharmacological compounds alleviate given symptoms, and so, as it
were, "create" diseases to fit the drugs available. This in itself,
Davies might argue, explains why there are more and more new "diseases"
with each edition of the DSM: it isn't a function of scientific acumen
identifying hitherto hidden maladies, but of iatrogenesis:
doctor-created disease. So, while it may well be general practitioners
who do the doling out, psychiatrists are required to legitimate what
they are doing and provide it with the sugar-coating of scientific
authenticity. It's a dirty, well-paid and high-status job – but someone
has to do it, no?
The vast number of "hyperactive" children in the
US prescribed Ritalin is so well attested to that it's become a trope
in popular culture – just like the SSRI-munching depressive. But these
are our version of low-level "care in the community", the sad are
becoming oddly co-morbid (afflicted with the same sorts of diseases)
with the mad. Davies treads a familiar path in his critique of the
influence of the multinational pharmaceutical companies on the structure
and practice of psychiatry. If you aren't familiar with the fact that
almost all drug trials are funded by those who stand to profit from
their success then … well, you jolly well should be. You should also be
familiar with the extent to which university research departments and
learned journals are funded by those who stand to profit – literally –
from their presumed objectivity. The money generated by the SSRIs in
particular is vast, easily enough to warp the dynamics and the ethics
of an entire profession, and indeed I would agree with Davies that it
has in fact done just this. The sections of his book that deal in
particular with the way big pharma has moved into markets outside the
English-speaking world and effected a wholesale cultural change in their
perception of sadness (rebranding it, if you will, as chemically
treatable "depression"), simply in order to flog their dubious little
blue pills, make for chilling reading.
Actually, Burns would agree
with some of this critique as well; and recall, he's a psychiatrist who
fervently believes that his profession has been, and continues to be, a
force for good. Davies is a psychologist, and to the outsider the
fierceness of his attack might be dismissed as part of a turf war among
the psy professions (Irving Kirsch is a clinical psychologist as well).
However, I don't think it helps anyone to see the current imbroglio
as simply a function of late capitalism in its most aggressive aspect.
I'm afraid I have to mouth the old lily-livered liberal shibboleth at
this point and observe that, yes, we are all to blame; and our
responsibility is just as difficult for us to acknowledge because we
are largely unaware of it. We don't consciously collude in the chemical
repression of the psychotic (and Davies produces quite convincing
statistics to support the view that those with psychosis actually
recover better if they aren't medicated at all), any more than we
consciously collude in the fiction of depression as a chemical imbalance
that can be successfully treated with SSRIs.
Instead, what both
clinicians and patients experience is quite the reverse: we feel
absolutely bloody miserable, we can't get up in the morning, we are
dirty and unkempt, and we go along to our GP and are prescribed an
antidepressant, and lo and behold we recover. My GP, who has just
retired, and who is a wise and compassionate man who I absolutely
trusted, told me that he prescribed SSRIs because they worked, and
I believed him. That they worked because of the overpoweringly
efficacious curative power we believe doctors and their nostrums to
possess rather than because of any real change in our brain chemistry
was beside the point for him – and I suspect it's beside the point for
the vast majority of patients as well. By the same token, Burns is at
pains to stress, contra-DSM, that the great strength and skill of the
practising psychiatrist lies in being able to intuit diagnoses by
empathising with patients. Diagnosis, for Burns, is an art form – not a
science. By his own account I've little doubt that he's a good and
effective psychiatrist who can make a real difference to the lives of
those plagued by demons that undermine their sense of self. One of my
oldest friends is a consultant psychiatrist who I've actually seen
practising in just this way, with preternatural flair and compassion.
In both their cases, however, I feel about them rather the way I do about the last archbishop of Canterbury: I consider
Rowan Williams
to be a wise and spiritual man mostly despite rather than because of
his Christianity; and I think many psychiatrists are good healers mostly
despite rather than because of the medical ideology of mental illness
to which they subscribe.
Interestingly there is one large sector
of the "mentally ill" that Burns believes are manifestly unsuitable for
treatment – drug addicts and alcoholics. He points
to the ineffectiveness of almost all treatment regimens, possibly
because the cosmic solecism of treating those addicted to psychoactive
drugs with more psychoactive drugs hits home despite his well-padded
professional armour. Elsewhere in
Our Necessary Shadow he seems
to embrace the idea that self-help groups of one kind or another could
help to alleviate a great deal of mental illness, and it struck me as
strange that he couldn't join the dots: after all, the one treatment
that does have long-term efficacy for addictive illness is precisely
this one.
Psychiatrists are notoriously unwilling to endorse the
12-step programmes, and argue that statistically the results are not
convincing. There may be some truth in this – but there's also the
inconvenient fact that there's no place for psychiatrists, or indeed any
of the psy professionals, in autonomously organised self-help groups.
Burns agrees with Davies that our reliance on psychiatry, and by
extension, psycho-pharmacology, may well be related to our increasingly
alienated state of mind in mass societies with weakened family ties, and
often non-existent community ones. Surely self-help groups can play a
large role in facilitating the rebirth of these nurturing and supportive
networks? But Burns seems to feel that just as we will always need a
professional to come and mend the septic tank, so we will always need a
pro to sweep out the Augean psychic stables. I'm not so sure; psychiatry
has been bedevilled over the last two centuries by "treatments" and
"cures" that have subsequently been revealed to be significantly
harmful. From mesmerism, to lobotomy, to electroconvulsive therapy, to
Valium and other benzodiazepines – the list of these nostrums is long
and ignoble, and I've no doubt that the SSRIs will soon be added to
their number.
Sooner or later we will all have to wake up, smell
the snake oil, and realise that while medical science may bring
incalculable benefit to us, medical pseudo-science remains just as
capable of advance. After all, one of the drugs that Irving Kirsch's
meta‑analysis of antidepressant trials revealed as being just as
efficacious as the SSRIs was … heroin.
Posts
This
landmark study, 15 years in the making, was carried out by scientists
at the Scripps Research Institute and published in Nature today [doi:10.1038/nature13314
- "A semi-synthetic organism with an expanded genetic alphabet"]. In
normal DNA, two separate strands are entwined in a double helix. These
strands are connected together via four different bases, adenine (A),
thymine (T), cytosine (C), and guanine (G). A always bonds with T, and C
always bonds with G, creating a fairly simple “language” of base pairs —
ATCGAAATGCC, etc. Combine a few dozen base pairs together in a long
strand of DNA and you then have a gene, which tells the
organism how to produce a certain protein. If you know the sequence of
letters down one strand of the helix, you always know what other letter
is. This “complementarity” is the fundamental reason why a DNA helix can
be split down the middle, and then have the other half perfectly
recreated. There, I just explained in about 150 words two of the most
vital processes to all life that we know of.
Now his target is to find a way of getting the alien DNA to actually do
something, such as producing amino acids (and thus proteins) that
aren’t found in nature. If Romesberg and co. can crack that nut, then it
will suddenly become possible to engineer cells that produce proteins
that target cancer cells, or special amino acids that help with fluorescent microscopy, or new drugs/gene therapies that do weird and wonderful things. (Read: What is transhumanism, or, what does it mean to be human?)
The
human race is really starting to feel the consequences of their
actions. One area we are waking up to is the massive amount of
pesticides we spray (especially in North America) on our food that has
not only been linked to human disease, but a massive die off in the
global bee population within the past few years.
