On January 18, Thomas Insel, MD, published an article on The World Economic Forum Blog. The article is titled 4 things leaders need to know about mental health. Dr. Insel is the Director of the National Institute of Mental Health. The World Economic Forum “is an International Institution committed to improving the state of the world through public-private cooperation.”
Dr. Insel’s paper makes a number of assertions, some of which are misleading. Here are some quotes, interspersed with my comments.
“Too many people dismiss mental illnesses as problems of character or lack of will, rather than recognizing these disorders as serious, often fatal, medical disorders.”
This is a fairly standard psychiatric assertion. Note particularly how Dr. Insel has couched the issue as a choice between two alternatives: “mental illnesses” are either:
– problems of character or lack of will
or
– serious, often fatal, medical disorders
In reality, the many problems of thinking, feeling, and/or behaving that psychiatrists list as mental illnesses can be conceptualized in a great many other ways. It is inconceivable that a person of Dr. Insel’s stature and prestige isn’t aware of this, and so the question needs to be asked: why would he present such an important and controversial question in such a misleadingly simplistic way?
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“For anyone who has not experienced depression, the most common mental illness, it is important to distinguish the disorder of depression from the sadness, disappointment, or frustration we all experience in our lives.”
This is another piece of standard psychiatric orthodoxy: depression (the “mental illness”) is not at all the same kind of entity as depression (the “sadness, disappointment, or frustration we all experience in our lives”). And although this is repeated frequently by psychiatric practitioners and leaders alike, no one, to my knowledge, has ever provided proof of this assertion. Indeed, the APA itself provides fairly convincing indications to the contrary. The first item in their list of criteria for major depressive disorder is:
“Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful). (Note: In children and adolescents can be irritable mood.)” (DSM-5, p 160)
I suggest that feeling “sad, empty, hopeless” or appearing “tearful” to others, or irritability are pretty much the hallmark of depression (the “sadness, disappointment, or frustration” that we all experience from time to time). The remaining DSM criterion items reflect the severity or depth of the depression, but there is nothing in the list to suggest that depression (the “mental-illness”) is something that needs to be distinguished in any dichotomous sense from less severe depression. Nor, it needs to be stressed, does Dr. Insel provide us any evidence to support this assertion.
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“In extreme forms, depression can be so disabling that the thought of getting out of bed or making a phone call becomes overwhelming.”
The word “disabling” is ambiguous. It can mean that a person is literally incapable of performing the act in question (for instance, a paraplegic’s inability to walk), or it can mean that a person finds the act difficult. An example of the latter would be a person who had the flu, describing his plight as “disabling” – in the sense that it made it difficult to go about his ordinary activities. The term “overwhelming” has similar ambiguity.
But Dr. Insel’s statement occurs in the section of his paper titled “When you can’t get up or make a call” [Emphasis added]. So I think it’s clear that he’s using the term “disabling” in the former sense. In other words, he’s asserting that a severely depressed individual might be as incapable of getting out of bed or making a phone call or presumably engaging in other ordinary activities, as a paraplegic is of walking around the block.
There are two observations that need to be made. Firstly, there is no way that psychiatrists – or anyone else, for that matter – can know what a depressed person is not capable of doing. We can know what a person is capable of doing by observing what he/she actually does. If an individual does something, then clearly he can perform this act. But the fact that a person does not engage in a certain activity provides no logical grounds for assuming that he can’t This is not particularly abstruse. It is Logic 101. Secondly, to tell depressed people that they are incapable of getting out of bed or engaging in other normal activities is a fundamentally disempowering act, and is a grave disservice to the individuals in question. It also, incidentally, serves to trivialize and devalue the plight of people who really can’t do these things.
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“In the United States, approximately 7% of people suffer an episode of depression and about one in five people experience some form of mental illness each year. With prevalence rates so high, the human and economic case for leaders to take mental health more seriously is clearly compelling. What do they need to know?”
Psychiatry’s so-called prevalence figures have to be seen against a context in which they can inflate the numbers at will, by the simple expedient of widening the criteria items or by inventing new “illnesses”. Examples of this in DSM-5 are: the removal of the bereavement exclusion in major depression; the removal of the inexplicability requirement in somatization disorder; the invention of disruptive mood dysregulation disorder, and attenuated psychosis disorder; etc., etc…. The paradigm example from DSM-IV was the removal of the need for a manic episode for a “diagnosis” of bipolar disorder.
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But setting all that aside, let’s take a look at the five items that Dr. Insel believes leaders “need to know”.
“First, mental disorders are brain disorders. The brain is a bodily organ just like any other. We should no more blame ourselves or others for a malfunctioning brain than for a malfunctioning pancreas, liver, or heart. People with brain disorders deserve exactly the same level and quality of medical care as they expect for disorders of any other part of the body.”
The reality is that apart from those “mental disorders” clearly identified as being “due to a general medical condition”, or to “the effects of a substance”, there is no published evidence to support the notion that the various problems of thinking, feeling, and/or behaving catalogued in DSM-5 are brain disorders. Dr. Insel must be aware that his assertions in this regard are controversial, and if he has evidence to support his contentions, there is, I suggest, an onus on him to cite it.
Note also how Dr. Insel has injected the same spurious dichotomy mentioned earlier into this first item that leaders “need to know”. The suggestion is that one must either accept his contention that “mental disorders” are brain disorders, or one is blaming the individuals concerned. In reality, there are multiple other perspectives.
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“Second, mental illnesses are tied inextricably to physical illness beyond the brain. Brain disorders like depression and schizophrenia greatly increase the risk of developing chronic diseases such as cardiovascular and respiratory diseases. People with mental illnesses and substance abuse are at increased risk of certain infectious diseases such as HIV/AIDS.”
In real medicine it is widely recognized that some illnesses are frequently associated causally with other illnesses. Chronic hypertension, for instance, is a leading cause of kidney failure, as is diabetes. Head colds sometimes progress to pneumonia, etc… In most of these situations, the causal sequence is well understood. High blood pressure, for instance, can damage the vessels in the kidney, and in extreme cases can cause kidney failure.
There is in Dr. Insel’s second item a suggestion that something similar is at work with regards to “mental illnesses.” The assertion that “…brain disorders like depression and schizophrenia greatly increase the risk of developing chronic diseases such as cardio-vascular and respiratory disease” implies a causal link. But the implication is spurious. Psychiatry defines major depression by the presence of five or more problems of thinking, feeling, and/or behaving from a checklist of nine. One of these items is weight gain of more than 5% of body weight. Another item is diminished interest in activities. It is known that weight gain leads to cardiovascular problems. So the notion that major depression causes cardiovascular illness is simply an artifact of the APA’s definition.
Similarly with regards to inactivity, the World Heart Federation writes:
“…if you do not keep active, the risk to your cardiovascular health is similar to that from hypertension, abnormal blood lipids and obesity.”
So by making reduced activity a criterion for major depression, psychiatrists are in effect selecting into this diagnostic category people at increased risk for cardiovascular disease. Then, like Dr. Insel, they announce that depression “increases the risk” of cardiovascular disease. What a surprise!
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“Third, mental illnesses can be as fatal as physical ones. Suicide causes more deaths than homicide.”
Here again, we have the implication that the psychiatric “illness” called major depression is causing people to kill themselves, when in fact suicidal thoughts/activity are one of the defining features of this condition. What Dr. Insel is saying, in effect, is that people who think a lot about suicide, and/or make suicide attempts, have a high incidence of suicide. This is not very profound.
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“Fourth, effective treatment can be low-cost and low-intensity. Not everybody with a mental illness needs expensive drugs, hospital care, or even direct access to highly trained psychiatrists. In low resource environments, locals or family members can be trained to provide brief, effective psychotherapies that treat moderate forms of depression or anxiety. Even phone- or internet-based therapy can be used to help recovery. While we don’t have the equivalent of a vaccine for measles or the bed net for malaria, there are low-cost, highly effective interventions for most people either at risk for, or already suffering from, a mental illness.”
The general concept expressed here is non-contentious, but the vast majority of psychiatrists routinely prescribe drugs (some of which are very expensive indeed) to virtually everyone who comes through the door.
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“Finally, this is an area where policy makers need to do more than ‘build it and they will come.’ It is not enough simply to make treatment available. People with psychotic disorders may deny they are ill and those with depression may be too consumed by self-loathing to feel worthy of help. Even in the developed world, it is estimated that only about half of all people with depression are diagnosed and treated. In the developing world, WHO estimates that 85% of people with a mental illness are untreated. We need sensitive ways to identify those at risk and to help those who are most disabled receive treatment.”
So only half the people “with depression” in the developed world are “diagnosed and treated”. This is another standard psychiatric assertion. The much more interesting statistic, of course, would be: which of these groups does better – those who receive psychiatric treatment or those who don’t. Psychiatry’s widespread promotions of their treatments, including Dr. Insel’s article, imply that those who receive psychiatric treatment do better, but here are three references and quotes that suggest otherwise:
“Contrary to the hypothesized relationship, the study found that after introducing mental health initiatives (with the exception of substance abuse policies), countries’ suicide rates rose.”
“The main findings were: (i) there was no relationship between suicide rates in both genders and different measures of mental health policy, except they were increased in countries with mental health legislation; (ii) there was a significant positive correlation between suicide rates in both genders and the percentage of the total health budget spent on mental health; and (iii) suicide rates in both genders were higher in countries with greater provision of mental health services, including the number of psychiatric beds, psychiatrists and psychiatric nurses, and the availability of training in mental health for primary care professionals.”
National suicide rates and mental health system indicators: an ecological study of 191 countries.
“Significant positive correlations between suicide rates and mental health system indicators (p<0.001) were documented. After adjusting for the effects of major macroeconomic indices using multivariate analyses, numbers of psychiatrists (p=0.006) and mental health beds (p<0.001) were significantly positively associated with population suicide rates.”
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The notion of people denying that they “are ill”, or feeling that they are not “worthy of help”, as well as the asserted need to find “sensitive ways” to help those who are “most disabled” reads very much like coerced “treatment”.
There is certainly a great push at present among many psychiatrists and their supporters to persuade political leaders that coercive “treatment” needs to be expanded and made more accessible. It appears that Dr. Insel is supporting this drive, but his words aren’t entirely clear, and I may be misinterpreting.
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Then Dr. Insel appears to reverse his general stance.
“…it should be acknowledged that treatments for mental illness remain far from infallible. Of those who get treated, only about half get the right treatment, and only about half of those remit.”
So – of the people that do get drawn into psychiatry’s web, only half get the “right treatment”, and only half of those “remit”. Which leaves me wondering: what happened to the half who got the wrong treatment? And, is wrong treatment the same as malpractice? And if so, then what is organized psychiatry doing about this? If half the people who receive psychiatric treatment are getting the “wrong treatment”, shouldn’t this be a cause for major concern within the APA? Shouldn’t the APA be holding press conferences to alert the public to such a scandalous state of affairs? Shouldn’t there be Congressional inquiries? Shouldn’t we be seeing full-page cautionary ads in newspapers and online?
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” But for many people, today’s treatments are not good enough.”
And who could argue with that?
Tragically, Dr. Insel’s recipe for remediation is to go on with more of the same:
“Biomedical research gives us hope for cures, for brain disorders as much as any other part of the body. With better policies for providing existing evidence-based treatments in the near-term and research for developing better treatments in the long-term, we can aspire eventually to consign mental illness to the history books.” [Emphasis added]
So we’ll all have our brains corrected. No more depression; no more defiant or inattentive children; no more crazy people disturbing the peace; no more delinquency; no more anxiety; no more temper tantrums; no more obsessiveness; no more substance abuse; . . . . There will be a drug to cure every human problem of thinking, feeling, and/or behaving.
Oh Happy Day!