Fierce territory – psychology v psychiatry

 

…­Prozac and its imitations and derivatives, he argues, are based on a questionable ­theory — that lack of the neurotransmitter serotonin in the brain is a cause of depression. The apparent effectiveness of these ­compounds, he suggests, is due to the fact that they have become powerful placebos.

I saw a news report on channel four yesterday, which brought up the subject of the failure of psychiatric drug treatments and our over-reliance on prescribing drugs for mental health issues, when such drugs are, it is claimed, often no better than “a sugar pill” in alleviating symptoms and distress.

This issue has been brought up a lot lately in the media and it poses some real dilemmas for those of us taking drugs that some are now saying don’t work at all.  More and more frequently it is alleged that the basis on which we accept psychiatric drugs as successful treatments, is not valid.  Specifically, drug companies have been accused of manipulating the evidence for the efficacy of their drugs, for instance by binning the trials that showed negative results and publishing only the positive trials.  Bit alarming, huh?

In this particular news report the psychiatric detractor was Richard Bentall, who has a book out, called Doctoring the Mind, in which he puts forth his views on how psychiatry is failing its clients.  The Sunday Times has an article about his book you can have a look at if you want to know more.  The writer of that article is also the source of the quote at the top of this post.

The rather interesting statistic from which Bentall kicks off his discussion (on the news report) is that you are more likely to recover from mental illness in the developing world than you are in the developed world (I think this may have been with particular reference to psychotic illness)

As is usually the case, for each of Bentall’s attacking points, there was someone from the psychiatric profession to profer a rebuttal.  I didn’t catch his name.  Anyway he didn’t seem to do a great job of defending psychiatry in the way he responded – there was a lot of “I don’t think it’s particularly helpful to take this position” and “it is divisive to make this assertion” type of remarks.  These are statements that may well be true but they in no way offer a cogent counter-argument to what is being claimed by Bentall.  Do these drugs work less well than we have been led to believe?  If so, are they literally no better than placebo?  Is there a distinction between classes of drugs e.g. are SSRIs all pointless, whilst others may be effective?  It’s a minefield, to me anyway.

I’m not going to turn this into a long essay (edit: turns out I did turn it into a longish post, sorry ’bout that) because there are enough presentations of cases for, against and somewhere in the middle, in reference to the psychiatric drug debate.  I’m not sufficiently equipped with the evidence for and against psychiatric drugs to have a strong opinion either way.  There are a few things that are relevant for me, though, that I wanted to make a point of saying -

I take an SSRI and have done for the majority of nine years.  I have always taken the drug, soberly judging that “it might be stopping me from going under”, rather than the more joyful “it makes me feel much less depressed” or the affirmative ”it has really helped me get out of my depression”.  I never really felt a huge improvement in my depression whilst on Prozac (the drug of choice for me, due to my utterly lethargic depression when I was first diagnosed).  The most I could tell the psychiatrist and G.P. was that I didn’t really know if it was helping, I still felt like crap. 

However, the lovely medical professionals appeared to take rather an interest in just what kind of crap was I feeling?  Better or worse crap than the last time I saw you?  The opinion of the psychiatrist and my doctor was that it was doing something.  Nobody suggested  a fanfare procession down the street, with me perched atop an open-air bus, a giant inflatable replica of a Prozac capsule by my side, waving and smiling at the crowds below.  That might have been going too far.  But they did think that I was responding somewhat. 

My answers told them that my sleep was improving slightly, that is, I was falling asleep more quickly and staying asleep for longer.  I was getting up and dressed more frequently and had more energy.  I think that the early days of being on Prozac did produce an energy spurt of sorts, but it felt more like being wired and I suspect it was an initial side effect that abated somewhat once my body was used to this strange new chemical.  I did improve whilst on P, but while the doctor could attribute that to the drug having an effect, I felt that the plodding, agonisingly slow nature of the improvement could be either the drug having an effect or the depression getting better with time, which most depressions naturally do anyway.

I take my anti-depressant still, because if there’s the chance that it is keeping something altogether more horrific from happening, then that is good enough for me.  Of course, if it were proven that the pills were ineffective I would come off them.

What worries me slightly about this kind of debate is that people like Bentall are putting doubt in people’s minds about the efficacy of one treatment whilst alternative treatments are hard to come by.  If a variety of talking therapies were routinely available and easily accessible for all mental disorders, on the NHS, then Bentall’s claims of the uselessness of psychiatric remedies would not be such a big deal.  Perhaps there is no other way to go about raising awareness of the issue.  I absolutely agree that these allegations of bias in drug trials should be spoken about and investigated thoroughly.  I’m just not sure that a short sharp news report is the place for their airing.  There is the danger that people on these meds who watch this news report will be left rather confused as to what they should do.  I know I am.

Another point, and this is mentioned in the article I’ve linked to, is that there is a war between those who would view the brain as an organ, just like any other, and those who view it as the seat of something more spiritually actuated.  This second group are more likely to refer to the brain as the mind, something more socially/environmentally influenced than genetically predisposed. 

I know a lot of people take a more even, middle ground and one would think that there has to be a solution somewhere in the middle.  On the one hand it’s easy to see that groups of people with significant social stressors, for example, migrant workers and refugees, have higher rates of mental health problems.  1-point goes to the mental illness-is-a-social-problem group.  On the other hand we are still in the early stages of using neuroscience to study the workings of the brain.  The fact that we can now ’see’ the brain at work with scanning technology looks promising for future discoveries of specific faults at play in a mentally ill brain.  That’s 1-point to the mental illness-is-a-biological-event group. 

Psychiatry’s opponents have said that our hopes of finding a specific gene involved in the development of a mental disorder have not been successful; this proves that they are barking up the wrong tree, so to speak.  I’m no scientist so I’ve no idea if that is a fair accusation to level at the geneticists and neuroscientists at this stage of their research.  I have a personal feeling that neither approach is completely right.

I am glad that these issues about the reliability of the evidence backing psychiatric drugs is being brought out into the open.  This will hopefully result in useful research and re-testing.  I also think that psychologists like Bentall do have a major role to play in helping people with mental health problems – I just wish they would acknowledge that, actually, none of our current treatments for mental illnesses are wholly successful (I don’t know the intricacies of Bentall’s views, so I’m speaking broadly).  The relapse rate is pretty high for a lot of people.  I fantasise a time when mental illness is treated with the same specificity as laser eye surgery – a fine-tuned treatment that gets to the crux of the illness and resolves it.  I’ve no idea whether our current therapies, drug-based or talk-based, will even feature in this ‘cure’.  We might find our current approaches are altogether wrongly constructed.  On the opposite side of the rainbow, it could even be the case that we re-package mental illness, deciding that our conception of that distress as illness was indeed just plain wrong.  Who knows?

Until the laser eye surgery equivalent for mental illness/distress becomes available and known we have to pick the best treatments of the bunch we have.  Excuse me for battering this analogy to within an inch of its life, but let’s say the current types of treatment are the equivalent of wearing glasses – if you get a personalised prescription, your bad eyesight can be alleviated, but only whilst you are wearing your specs.  Furthermore, when your mate gives you their glasses and says “try these, they really help me see clearly”, and when you try their glasses and find the world looks blurred round the edges, that probably means you need something different.  Even if your eye doctor likes giving everyone the same pair of glasses because they’ve seen a few of their patients get benefit from them.  Sorry if that’s overly cynical, it’s just in my experience doctors tend to stick to one or two drugs (or therapies) they have prescribed the most, and in fact my own doctor said that this was the case.

A final point I wanted to dangle in the air is this idea of psychiatric meds being a strong placebo, as mentioned in the quote at the top of this post.  I can imagine that this could be the case.  However, I’m uncomfortable with the ramifications of that.  A placebo, strong or otherwise, is better than nothing.  Of course we can’t continue to let people think pills are doing something more than they really are, but until someone has done the bloody research that shows it one way or another, definitively, I don’t want people pissing on my placebo effect, as I stated in a previous post on the topic.  I don’t want one set of treatments casually rubbished without corresponding research of something more hopeful in another direction.  Am I asking too much?  Maybe.