Jan 16 2018

More Mental Illness Denial

I was recently pointed to this article by Johann Hari in The Guardian that takes a critical look at depression and the treatment for depression. Unfortunately, it turned out to be nothing more than the usual mental-illness denial talking points, misdirection, and obfuscation.

As you will see if you follow the link above, this is a well-worn topic here. The basics are this – there are those, for various reasons, who are engaged in what I think qualifies as mental-illness denial. They include scientologists, because they push their cult/religion as an alternative to psychiatry. There are also those who follow Szasz who saw psychiatry as a mechanism for political oppression. I also find denial at times among rival professions who want to take psychiatry down a peg or two (often they just confuse their experimental expertise for clinical expertise – always a problem).

They all tend to have in common the core claim that “mental illness” is a fiction. How can thoughts be diseased? This is ultimately a straw man that confuses different types of illness. Some illness is based in biological pathology – cells are damaged, deteriorating, poisoned, genetically flawed, or essentially not functioning within healthy parameters for some reason. You can often see the pathology in a biopsy or measure it with some physiological parameter.

But not all illness is pathological disease. There are also disorders in which some biological function is outside of healthy parameters without clear pathology. The brain in particular is prone to this type of illness, and that is because brain function depends on much more than just the health of its cells (neurons and glia). Even healthy brain cells can be organized in such a way that their neurological function is compromised.

Let’s say, for example, that the anxiety circuitry in the brain is hyperactive creating spontaneous, unfocused, and debilitating anxiety. Now of course, anxiety itself is part of our natural neurological function. It serves a purpose. But excessive and spontaneous anxiety no longer serves a functional purpose, it just inhibits the ability to function. It is a mental disorder, in the absence of biological pathology.

Mental health deniers, however, twist themselves into logical knots trying to deny that there could possibly be anything about excessive anxiety that we can properly call an illness or disorder.

Like all campaigns of denial, there is also a range of approaches to denying the existence and implications of mental illness. At the extreme end you will find pseudoscience and conspiracy theories. At the milder end you will find softer denial, and denial that they are deniers. At this end there is the attempt to sound reasonable, and to conceal that at the end of the day they are engaging in motivated reasoning to deny the topic they oppose for ideological or other reasons. They give themselves away, however, by using the tactics of denial, and always flirting with the more extreme arguments.

For example, climate change deniers trying to sound reasonable will often acknowledge that the Earth is warming, we just can’t be sure that humans are causing it. But if you back them into a corner with evidence, they will acknowledge this but just deny that we can do anything about it. There is evidence that this behavior is rooted in “solution aversion” – in the end they oppose proposed solutions to climate change, and will deny the science only as much as they need to in order to oppose those solutions.

With mental illness denial, sometimes the motivation is psychiatry denial – opposition to the psychiatric profession. Of course you can do this by denying mental illness, but for those trying to seem reasonable you can also say you accept that there is such a thing, but then deny that we understand it well enough to treat it. Or you can simply deny the approach to mental illness of the psychiatric profession.

At this point I want to be clear – there are legitimate criticisms of psychiatric science and practice. Just as there are legitimate criticisms of medicine in general, and any applied science, including climate science. There is also no sharp demarcation between fair and legitimate criticism and motivated denial. You need some knowledge and judgement to see the difference at the fuzzy border. That is why I tend to characterize denialism as a process, try to define and understand the process as best as possible, and then be vigilant about the intrusion of denalism strategies at any level.

So let’s get back to Johann Hari’s article and see where I think he veers into denialism. Hari is writing about the difference between a depression disorder and normal grief. He is commenting on the DSM (the manual psychiatrists use to make diagnoses – a popular target among deniers):

The authors conferred, and they decided that there would be a special clause added to the list of symptoms of depression. None of this applies, they said, if you have lost somebody you love in the past year. In that situation, all these symptoms are natural, and not a disorder. It was called “the grief exception”, and it seemed to resolve the problem.

So, in order to avoid confusing normal grief with a depressive disorder the DSM included a grief exception. This is common in defining mental illness. The brain interacts with the environment, so if we want to decide if a certain pattern of mood, thought, and behavior is due to a brain disorder we have to rule out that it is just responding to environmental triggers. Like with the anxiety example above – anxiety is normal if you have something to be anxious about, but a disorder if it is spontaneous or clearly out of proportion to the stimulus.

Hari continues his narrative:

Then, as the years and decades passed, doctors on the frontline started to come back with another question. All over the world, they were being encouraged to tell patients that depression is, in fact, just the result of a spontaneous chemical imbalance in your brain – it is produced by low serotonin, or a natural lack of some other chemical. It’s not caused by your life – it’s caused by your broken brain.

This is an oversimplification to the point of being wrong. See above – depression is caused by life, and when it is, that is not a disorder. But if an evaluation rules out reasonable life causes of depression, then we are left with the possibility that there is something about brain function that may be causing depression. Also keep in mind that the depression, in order to be considered a disorder, has to interfere with one’s life. It has to cause “demonstrable harm.”

And now here is where Hari goes entirely off the rails:

The grief exception seemed to have blasted a hole in the claim that the causes of depression are sealed away in your skull. It suggested that there are causes out here, in the world, and they needed to be investigated and solved there. This was a debate that mainstream psychiatry (with some exceptions) did not want to have. So, they responded in a simple way – by whittling away the grief exception. With each new edition of the manual they reduced the period of grief that you were allowed before being labelled mentally ill – down to a few months and then, finally, to nothing at all. Now, if your baby dies at 10am, your doctor can diagnose you with a mental illness at 10.01am and start drugging you straight away.

Is he really claiming that a competent psychiatrist practicing within the standard of care would diagnose a client with mental illness and prescribe medication one minute after their child dies? You might be tempted to say he was using an extreme example to illustrate a point – but that misses my point. Making such a diagnosis is all about context.

Hari creates a neat little narrative here that serves his purpose of mental illness denial. In his narrative, psychiatrists removed the grief exception from the DSM because it was inconvenient. However, here is a passage from the DSM V that Hari neglects to mention:

Note: Responses to a significant loss (e.g., bereavement, financial ruin, losses from a natural disaster, a serious medical illness or disability) may include the feelings of intense sadness, rumination about the loss, insomnia, poor appetite, and weight loss noted in Criterion A, which may resemble a depressive episode. Although such symptoms may be understandable or considered appropriate to the loss, the presence of a major depressive episode in addition to the normal response to a significant loss should also be carefully considered. This decision inevitably requires the exercise of clinical judgment based on the individual’s history and the cultural norms for the expression of distress in the contest of loss.

So what they really did was remove it from the list of criteria, which required putting a time limit on grief, and instead moved it to a note that was more open-ended and encouraged “clinical judgment.” Any fair and reasonable discussion of the psychiatric approach to mental illness and the evolution of the DSM should have contained this passage. But I guess it didn’t fit Hari’s neat little narrative.

After recounting his startling discovery that people are psychological beings with emotional needs (shocker), he finishes with this false dichotomy:

If you are depressed and anxious, you are not a machine with malfunctioning parts. You are a human being with unmet needs. The only real way out of our epidemic of despair is for all of us, together, to begin to meet those human needs – for deep connection, to the things that really matter in life.

This is a hopelessly simplistic approach to mental health, ironically as simplistic as the straw man “malfunctioning parts” approach he is criticizing. Rather, our mood, thoughts, and behavior are the net effect of a complex interaction between brain and environment. There are always a complex mix of psychological and psychiatric and sometimes neurological factors involved (rarely, it is a brain tumor). It takes care and clinical judgement to tease apart when someone just needs some counseling, or to make some practical changes to their life, or just time to process grief or other life events – and when they have a disorder that also needs to be treated in order to make it even possible for them to engage in therapy.

The DSM psychiatric approach to patients who have mental complaints, signs, or symptoms is to take a multi-tiered approach. First, rule out any underlying medical condition (make sure their anxiety isn’t due to hyperthyroidism, for example). Then assess their signs and symptoms in the context of their history to determine how much of it is likely to be due to life events. How much is personality. And how much, if any, may be due to some misfiring circuit in the brain.

This is really hard, and we have limited knowledge, but we have accumulated enough to take a practical approach to many patients and to help them improve their lives. This should include the full range of options available, including medication and counseling. To deny the role of medication can do great harm to those who may need it.

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