Psychiatry's failed paradigm

The solution to mental illness has seemed to lie in application of drugs. If a serious psychiatric disorder arises, the reasoning goes, it must be centered in the brain - and, the reasoning further assumes, the most successful treatment is a biological one. Or is it? In his book, "Doctoring the Mind: Is Our Current Treatment of Mental Illness Really Any Good?" Richard P. Bentall challenges psychiatry's presumption that drugs are best for tackling mental illnesses. Bentall, a professor of clinical psychology at the University of Bangor in Wales, argues for treatment that focuses on the patient as much as on the brain in a setting that stresses a strong relationship between patient and doctor.

GUEST BLOGGER: Richard P. Bentall

Recent decades have seen dramatic improvements in the survival rates of patients suffering from heart diseases and cancer. But the same cannot be said of psychiatric disorders.

So far as we can tell, outcomes for patients suffering from the most severe forms of psychiatric disorders -- the psychoses -- have hardly changed since the Victorian period. Poor countries without well-resourced psychiatric services seem to do about as well or even better than the developed world. There is therefore little evidence that modern psychiatric services have had a global, positive impact on mental health, but the perception is often different.



The medical historian Edward Shorter has remarked that, "If there is one central intellectual reality at the end of the twentieth century, it is that the biological approach to psychiatry -- treating mental illness as a genetically influenced disorder of the brain chemistry -- has been a smashing success."

In fact, the contrary seems to be the case. Attempts to find a genetic basis for schizophrenia or bipolar disorder have led to the identification of a number of candidate genes, for example COMT, NRG1 and DTNBP1, each announced with enormous fanfare. Similarly, huge attention has been given to the discovery of an allele (variant) of one gene, 5-HTTLPR, which appears to make people liable to depression if they are exposed to negative life events.

But, without exception, later studies have failed to replicate these findings. In one of the largest psychiatric genetic studies ever published, which appeared in the American Journal of Psychiatry last year, no association was found between any candidate gene and schizophrenia. A recent analysis of the evidence on 5-HTTLPR found no evidence that the gene directly causes depression, or that it makes people liable to become depressed if something unpleasant happens. However, the study observed a direct relationship between depression and adversity. As our mothers could have told us, bad experiences make us miserable.

This last "discovery" is consistent with other evidence that life experiences shape even the most severe forms of mental illness. Research has consistently shown that migrants have at least a four times increased risk of psychosis compared to other groups, and the effect is most pronounced if they live in areas in which they are in a minority.

Early separation from parents has also been shown to increase the risk of psychosis, as has growing up in an urban environment and chronic bullying. An association between trauma in early life and psychosis has been well-replicated: one recent study estimated that individuals who had been sexually abused in childhood had a twelve times increased risk of serious mental illness. As one of the researchers who carried out this study told me, "Any geneticist who had found such a strong association would have already booked his steamer ticket to Stockholm."

Psychiatrists often downplay these findings with a variety of argument. I have heard it reasoned that findings of this kind are offensive to families, that patients' genes might cause them to seek out experiences that are abusive, or that environmental effects are weak in comparison to those of genes. (However, one study calculated that the population attributable risk of schizophrenia associated with an inner city childhood is 15 percent -- there would be 15 percent fewer cases if we all grew up in the countryside -- whereas the population attributable risk of having a parent with the diagnosis is only 7 percent.)

Some dismiss patients' accounts of their childhoods as untrustworthy (although, when attempts have been made to corroborate them, they are usually proven accurate). It is also said that environmental effects are non-specific, and that early trauma causes a wide range of problems (neglecting the fact that the same is true of genes -- on the most optimistic estimate NG1 is found in about 15 percent of schizophrenia patients and 7 percent of healthy people but, as there are approximately 100 healthy people for every schizophrenia patient, this means that there are about 70 people with NG1 for every patient). Some simply dismiss the evidence with the cry of, "I don't believe it."

Why does all this matter? First, research efforts to understand the causes of mental illness have become hopelessly unbalanced. Only about 5 percent of studies on schizophrenia focus on patients' subjective experiences and research projects on the biological causes of psychosis outnumber those on environmental factors by at least 5 to 1; funding differences are no doubt greater, as much of the research on psychosocial factors is done on a shoestring.

The same is true of treatment studies; to date about 30 trials of cognitive therapy for psychosis have been published; by comparison, in a three-year period nearly 400 drug trials were published in the five leading U.S. psychiatric journals. Despite these efforts, there is little evidence of important advances in psychiatric drug treatment.

Recent studies of antidepressants suggest that they are barely better than placebo, although drug companies have made the data look otherwise by selectively reporting positive results. The second generation antipsychotics, introduced with great fanfare and to the enormous benefit of drug company shareholders, have also proved a disappointment; there is no evidence that these drugs are better than the old medications they have replaced.

Just as important, the obsession with the genetic origins of mental illness has created a climate in which many clinicians do not understand the significance of adverse experiences in the lives of their patients. An observational study of psychiatrists practicing in London found that, when patients asked questions about the meaning of their experiences, the doctors typically changed the subject.

When journalist Lauren Slater faked psychotic symptoms and sought help from U.S. psychiatric services, she found that she was treated with kindness, but was only once asked a question that went beyond the symptoms she was complaining of (the question was about her religion). Patients in these circumstances, often find that they are regarded as (to quote an actual patient) "an imbecile ... just another dribbler."

If we are to improve outcomes for people with severe mental illness, we need to abandon the idea that all the answers lie in genes and biochemisty. We need to develop a less drug-based, more person-centerd approach, which takes the experiences of patients seriously.

By Steven E. Levingston |  January 4, 2010; 5:30 AM ET Health Care
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Comments

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Richard Bentall is ignorant or he is intentionally misleading the readers when it comes to the role that genes play in schizophrenia and other psychiatric disorders. There is now replicated and undisputed evidence that many rare mutation in many different genes play a role in the disease. The fact that there are so many mutations makes it hard to identify them, although some have already been identified with high confidence (such as the 22q11 deletion). This is a technical issue that will be resolved in the next couple of years but not a reason for a wholesale dismissal of the role of genes. I want to warn your readers, especially relatives of patients, to take Richard Bentall's claims with a grain of salt.

Posted by: meteor22 | January 4, 2010 2:32 PM

I agree with with the previous commenter that this article is highly misleading and potentially harmful to patients. The evidence that schizophrenia is inherited has nothing to do with studies of individual genes but from epidemiological studies comparing identical and non-identical twins. These studies are decades old and their results are not under dispute.
Further the medications currently used to treat psychiatric illnesses are not utilized because they are related to any genes that might be involved. Instead they have been chosen through a process of trial and error to identify treatments that improve symptoms. We certainly need better treatments for all psychiatric disorders. These better treatments will likely come from furthering our fundamental understanding of the disorders.

Posted by: concernedmichigandoc | January 4, 2010 3:58 PM

I agree with with the previous commenter that this article is highly misleading and potentially harmful to patients. The evidence that schizophrenia is inherited has nothing to do with studies of individual genes but from epidemiological studies comparing identical and non-identical twins. These studies are decades old and their results are not under dispute.
Further the medications currently used to treat psychiatric illnesses are not utilized because they are related to any genes that might be involved. Instead they have been chosen through a process of trial and error to identify treatments that improve symptoms. We certainly need better treatments for all psychiatric disorders. These better treatments will likely come from furthering our fundamental understanding of the disorders.

Posted by: concernedmichigandoc | January 4, 2010 4:00 PM

It seems bizarre to me to accuse Bentall of being possibly "harmful to patients" by pointing out the role of environment and actual experiences in the development of the problems that get labeled schizophrenia! What about the harm of ignoring people's experience and then trying to convince people that their problems are definitely due to genetics, even though there is precisely zero evidence to date that proves that all people with schizophrenia definitely have it due to some genetic vulnerability? What about the hopelessnes about recovery induced when people are told the illness is "in their genes" even though there is a good chance nothing of the sort is true?

Bentall does not dispute that some people are probably more vulnerable to mental problems such as those labeled schizophrenia due to their genes. What he does question is the thoughtless assumption that this is the only possible cause of those problems, and he focuses attention on the way so much energy goes into looking at genes, while other causal factors are overlooked or denied. I do agree with "concernedmichigandoc" that further progress will come from furthering our fundamental understanding of the problem - an understanding likely to come when we abandon biopsychiatric dogma and focus more research attention on the lived experience of the people who have these problems.

Posted by: RonUngerLCSW | January 5, 2010 12:52 AM

These first comments just make me so angry Just what are you so frightened of ? The evidence for the genetic argument is so horrificaly scanty. I consider myself a victim of the psychiatric system in uk but I also have letters after my name M. Harkness BA hons, ALA, PG Dip AIM. GSSR so does that mean you might listen to me ? I was diagnosed schizophrenic in 1983 after a 5 min interview and medicated for 25 yrs. The fact that i was sexually abused throughout my chilhood was discounted. The idea that I could heal and recover without meds was discounted.Thankfully I have now done my own extensive research and am now coming off meds and doing healing work. But I am angry that its taken me til Im 54 to have the confidence to really stand up to these horrific brain washing and brain numbing arguments that 'genetics' has the answers. Im particularly angry at the psychiatrists who stood on their pedastols and patronised me over the years with their 'faulty brain chemistry' lingo. They almost robbed me of a life. Cheers to Richard Bentall !

Posted by: maureenh1 | January 5, 2010 5:00 AM

The first comments are what are misleading. I urge anyone interested in the flawed and failed 'research' in psychiatric behavioral genetics to read Jay Joseph's book The Gene Illusion... in it he spends the entire book showing conclusively that the twin studies are massively flawed.

The fact of the matter is, psychiatry has failed dismally to come up with a single replicable biomarker... and consequently, psychiatry is simply engaged in slapping pseudomedical, pseudoscientific labels on people who are suffering distress.

Psychiatry's failed paradigm is but one model of human distress, and the fact that governments violently force this paradigm on people with coercive psychiatry is simply a human rights atrocity.

Most of the time, having psychiatry slap a label on someone, when they are in crisis, just sends them into a lifetime of learned helplessness, and robs hope from them, blaming the brain... which we must remember... is a brain the psychiatrist can rightly be said to have no direct, objective, patient specific insight into... given the psychiatrist at no time takes any biological or genetic test of the person they choose to label 'patient'...

Psychiatry like no other branch of medicine, is up to its neck in Big Pharma influence, it's practically bought and paid for...

The toxic diabetogenic guesswork neurotoxic drugs it pumps into people, have resulted in a situation where even controlled for suicide, those labeled mentally ill die 25 years younger than those lucky enough to never have contact with this atrocious, rapacious, and venal profession of quacks.

Many people suicide just because they've been indoctrinated by psychiatry to internalize a message of doomsday songs, disease labels, and hopeless futures of learned helplessness.

And don't forget the millions around the globe who live with psychiatry induced traumatic stress from the violence and torture of forced drugging and forced electroshock.

This disgusting psychiatric ideology needs to be stripped of its powers to coerce, so we can stop living in a psychiatric theocracy.

People should have the right to assess for themselves what is a paradigm of human distress they would like to try should they seek help for any distress or overwhelm they might be experiencing.

The meddling that goes on in peoples lives, identities, and bodies by these medical criminals is an atrocity on the widest scale. And one day, those with blood on their hands will be called to account.


Posted by: Hose1 | January 5, 2010 8:26 AM

The first comments are what are misleading. I urge anyone interested in the flawed and failed 'research' in psychiatric behavioral genetics to read Jay Joseph's book The Gene Illusion... in it he spends the entire book showing conclusively that the twin studies are massively flawed.

The fact of the matter is, psychiatry has failed dismally to come up with a single replicable biomarker... and consequently, psychiatry is simply engaged in slapping pseudomedical, pseudoscientific labels on people who are suffering distress.

Psychiatry's failed paradigm is but one model of human distress, and the fact that governments violently force this paradigm on people with coercive psychiatry is simply a human rights atrocity.

Most of the time, having psychiatry slap a label on someone, when they are in crisis, just sends them into a lifetime of learned helplessness, and robs hope from them, blaming the brain... which we must remember... is a brain the psychiatrist can rightly be said to have no direct, objective, patient specific insight into... given the psychiatrist at no time takes any biological or genetic test of the person they choose to label 'patient'...

Psychiatry like no other branch of medicine, is up to its neck in Big Pharma influence, it's practically bought and paid for...

The toxic diabetogenic guesswork neurotoxic drugs it pumps into people, have resulted in a situation where even controlled for suicide, those labeled mentally ill die 25 years younger than those lucky enough to never have contact with this atrocious, rapacious, and venal profession of quacks.

Many people suicide just because they've been indoctrinated by psychiatry to internalize a message of doomsday songs, disease labels, and hopeless futures of learned helplessness.

And don't forget the millions around the globe who live with psychiatry induced traumatic stress from the violence and torture of forced drugging and forced electroshock.

This disgusting psychiatric ideology needs to be stripped of its powers to coerce, so we can stop living in a psychiatric theocracy.

People should have the right to assess for themselves what is a paradigm of human distress they would like to try should they seek help for any distress or overwhelm they might be experiencing.

The meddling that goes on in peoples lives, identities, and bodies by these medical criminals is an atrocity on the widest scale. And one day, those with blood on their hands will be called to account.


Posted by: Hose1 | January 5, 2010 8:58 AM

Can I just say to the comment approvers... thanks or approving my comment and I didn't mean to double post.. there was an error... I kept receiving the message 'dialog publish error' on white screen... so please feel free to remove the DUPLICATE post... not both of them I hope so very much you leave my original one.

Posted by: Hose1 | January 5, 2010 11:14 AM

I appreciate the above arguments, but can only speak as an expert to my experiences living with PTSD and bi-polar disorder for over ten years. I'm not sure which disorder has been most damaging to my mental and overall medical health and my ability to maintain interpersonal relationships and pursue a more demanding career. I am fairly confident at this point that I can intellectually recognize the symptoms and triggers of each, and it's crystal clear to me that one aggravates the other. I've gone from rapid cycling mood swings (bi-polar) to PTSD nightmares overnight. My salvation has been having a psychiatrist who recognizes the importance of BOTH an individualized drug regimen and cognitive behavioral therapy. Now these illnesses don't control me, and I'm free to control my life. We should commend scientists and therapists alike, and focus our energies on strategies to have them to do the same. I am proof that their collaboration offers the least potential harm to patients, after years of ineffective treatment that only addressed one or the other.

Posted by: YAMH | January 6, 2010 3:00 PM

Increasingly, I feel that the truest one-size-fits-all statement is that one size never fits all. I do react with trepidation to Dr. Bentall's statements. The reason is that so many people see the world in black and white, that I worry his column will be taken to support the idea that meds are *never* appropriate. I would feel equally distressed by a column that could be taken to mean that talk therapy is never appropriate. Studies are statistical. The question asked is always about the response of a population of people to a particular treatment. Individuals vary hugely. I believe that patients and practitioners both need to pay close attention to what actually works, not to what someone tells them *should* work.

Posted by: GraceIsMe | January 6, 2010 6:21 PM

The potential benefit to millions of psychiatric patients of what Bentall is doing is incalculable. As the panicked comments above demonstrate, the benefits to people with professional, economic, and psychological investments in the scrip-first treatment paradigm is not so clear.
This week the obscure Journal of the American Medical Association published a review of data on the efficacy of antidepressants which concluded that there is NO benefit to ANY patient diagnosed with mild or moderate depression from taking SSRIs or tricyclics. The damage control now going on in mainstream journalism, by pharmaceutical manufacturers, and by the "helping professions" is what one would expect in response to this new study. Some day at the Smithsonian the Prozac display case will be right next to the lobotomy display case in the Great Moments in Medical History hall. Meanwhile, the psychopharmacologists will go their merry way, prescribing medications that cause unknown long-term effects on an indescribably complex and vulnerable organ (the brain) and which DON'T WORK.

Posted by: miglefitz | January 7, 2010 9:39 AM

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