Map of life expectancy at birth from Global Education Project.

Sunday, August 21, 2005

Are you nuts?

The incidence and prevalence of psychiatric disorders -- mental illness -- has risen steadily in recent decades. Estimates are that 20% of Americans are currently mentally ill, and that 50% will be mentally ill at some time in their lives. These rates are far higher than 50 or 100 years ago.

Are we all going crazy, because of something in the water, or because modern life is so stressful, or because of television? Maybe so, but the incidence and prevalence of mental illnesses is really driven by the availability of diagnostic labels that fit more and more people, and the opportunity of psychiatrists and psychologists to apply them. As I pointed out in another context, Robert Kennedy Jr.'s assertion that autism did not exist prior to 1943, when Dr. Leo Kanner described it and gave it a name, confuses classification with existence. But while most people will agree that autism is a real entity whether we have a name for it or not, the ontological status of the majority of the constantly growing catalogue of psychiatric illnesses is far more questionable.

Psychiatric diagnoses are based on behaviors. Once a specific biological basis for abnormal behavior is known, the disease is usually classified as neurological rather than psychiatric (viz. tertiary syphyllis, Huntington's Disease, Mad Cow Disease, etc.) Whether a complex of behaviors is pathological is a judgment strongly influenced by cultural norms. Indeed, changing cultural norms inspired the American Psychiatric Association to stop classifying homosexuality as a disease. However, the trend has been for there to be more and more psychiatric diseases over time.

You've undoubtedly seen the ads on TV for drugs intended to treat diseases like Social Phobia. This is a new disease -- but is shyness new? Schoolchildren are expected to sit quietly in rows, concentrate on boring tasks, and speak only when authorized. Children do not like to do this, and many, most often boys, have traditionally refused to cooperate. But now they have a disease, Attention Deficit Hyperactivity Disorder. Those who engage in the modern equivalent of dipping little Suzy's pigtail in the inkwell have Conduct Disorder. Those who sass the Principal when sent to the office have Oppositional Defiant Disorder, and so on. I exaggerate slightly -- people need to display these symptoms consistently over a period of at least a few weeks, in order to be deemed mentally ill. Nevertheless, while these behaviors have always existed, we have not previously called them diseases.

Many of these diseases are commonly treated with drugs. A provocative, iconoclastic and disturbing take on psychiatry and psychiatric drugs in particular is offered by Robert Whitaker, a former health care reporter who blames the current "epidemic" of mental illness in large part on psychiatric drugs. I would criticize some of his arguments. For example, he points to a steady rise in people who are disabled due to mental illness, but these statistics reflect people who have become eligible for Social Security Disability Income or Supplemental Security Income, and are influenced powerfully by factors other than people's underlying ability to hold some form of remunerative employment. In particular, people are better off being on disability than taking low wage work, because if you are officially disabled, you will have comprehensive health insurance, paid for by the state, whereas if you work, you will have none. Whether more people really are disabled in some (hard to define) "objective" sense by psychiatric illness is not really known.

He is correct that antipsychotic medications have severe, often irreversible side effects including neurological damage. On the other hand schizophrenia is a terrible, disabling illness that people clearly have before they start taking these drugs. Many people would choose to take their chances in the hope of having at least some of the most disturbing symptoms of schizophrenia suppressed -- but it is also true that doctors usually do not fully disclose the dangerous side effects of these drugs to patients.

But I believe Whitaker is completely correct about Selective Serotonin Reuptake Inhibitors, the massively promoted "miracle cure" for depression -- and now for all sorts of other diseases including Social Phobia. I've written about SSRIs earlier, here, and now my beliefs have become even more definite. Even the trials showing some efficacy -- which even in the best cases can only be interpreted as a small effect in 10-15% of people diagnosed with depression -- are cancelled by other trials showing no efficacy at all. And such efficacy as there may be is short term. In the long term, all of the available evidence, as Whitaker says, is that people who take SSRIs do worse than people who do not -- and by worse, I mean they are more prone to depression.

There is a strong response to placebo in depression. SSRIs can produce various physical symptoms and feelings of agitation, perhaps they really do elevate some people's mood although that is far from proven. People sense that "something" is happening, and since they want to get better, this conviction may help some people actually feel better, more so than an entirely inert substance would. For others, it may help them to follow through on suicidal or antisocial impulses, or intensify their preoccupations with thoughts about such things. But in the long run, as with any drug that affects brain chemistry, the brain adapts -- hence the addictive process with cocaine, heroin, etc. These changes in the case of SSRIs have not been carefully studied, and we do not really understand anything about them. If Mr. Whitaker wants to say they are damaging, no-one has any evidence to contradict him.

(Thanks to my friend Dr. Y for the link.)

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