Interdisciplinary Review of General, Forensic, Prison and Military Psychiatry and Psychology and the related subjects of Behavior and Law with the occasional notes and comments by Michael Novakhov, M.D. (Mike Nova).
TWO months ago, the British Psychological Society released a remarkable document entitled“Understanding Psychosis and Schizophrenia.” Its authors say that hearing voices and feeling paranoid are common experiences, and are often a reaction to trauma, abuse or deprivation: “Calling them symptoms of mental illness, psychosis or schizophrenia is only one way of thinking about them, with advantages and disadvantages.”
The report says that there is no strict dividing line between psychosis and normal experience: “Some people find it useful to think of themselves as having an illness. Others prefer to think of their problems as, for example, an aspect of their personality which sometimes gets them into trouble but which they would not want to be without.”
The report adds that antipsychotic medications are sometimes helpful, but that “there is no evidence that it corrects an underlying biological abnormality.” It then warns about the risk of taking these drugs for years.
And the report says that it is “vital” that those who suffer with distressing symptoms be given an opportunity to “talk in detail about their experiences and to make sense of what has happened to them” — and points out that mental health services rarely make such opportunities available.
This is a radically different vision of severe mental illness from the one held by most Americans, and indeed many American psychiatrists. Americans think of schizophrenia as a brain disorder that can be treated only with medication. Yet there is plenty of scientific evidence for the report’s claims.
Moreover, the perspective is surprisingly consonant — in some ways — with the new approach by our own National Institute of Mental Health, which funds much of the research on mental illness in this country. For decades, American psychiatric science took diagnosis to be fundamental. These categories — depression, schizophrenia, post-traumatic stress disorder — were assumed to represent biologically distinct diseases, and the goal of the research was to figure out the biology of the disease.
That didn’t pan out. In 2013, the institute’s director, Thomas R. Insel, announced that psychiatric science had failed to find unique biological mechanisms associated with specific diagnoses. What genetic underpinnings or neural circuits they had identified were mostly common across diagnostic groups. Diagnoses were neither particularly useful nor accurate for understanding the brain, and would no longer be used to guide research.
And so the institute has begun one of the most interesting and radical experiments in scientific research in years. It jettisoned a decades-long tradition of diagnosis-driven research, in which a scientist became, for example, a schizophrenia researcher. Under a program called Research Domain Criteria, all research must begin from a matrix of neuroscientific structures (genes, cells, circuits) that cut across behavioral, cognitive and social domains (acute fear, loss, arousal). To use an example from the program’s website, psychiatric researchers will no longer study people with anxiety; they will study fear circuitry.
Our current diagnostic system — the main achievement of the biomedical revolution in psychiatry — drew a sharp , clear line between those who were sick and those who were well, and that line was determined by science. The system started with the behavior of persons, and sorted them into types. That approach sank deep roots into our culture, possibly because sorting ourselves into different kinds of people comes naturally to us.
The institute is rejecting this system because it does not lead to useful research. It is starting afresh, with a focus on how the brain and its trillions of synaptic connections work. The British Psychological Society rejects the centrality of diagnosis for seemingly quite different reasons — among them, because defining people by a devastating label may not help them.
Both approaches recognize that mental illnesses are complex individual responses — less like hypothyroidism, in which you fall ill because your body does not secrete enough thyroid hormone, and more like metabolic syndrome, in which a collection of unrelated risk factors (high blood pressure, body fat around the waist) increases your chance of heart disease.
The implications are that social experience plays a significant role in who becomes mentally ill, when they fall ill and how their illness unfolds. We should view illness as caused not only by brain deficits but also by abuse, deprivation and inequality, which alter the way brains behave. Illness thus requires social interventions, not just pharmacological ones.
ONE outcome of this rethinking could be that talk therapy will regain some of the importance it lost when the new diagnostic system was young. And we know how to do talk therapy. That doesn’t rule out medication: while there may be problems with the long-term use of antipsychotics, many people find them useful when their symptoms are severe.
The rethinking comes at a time of disconcerting awareness that mental health problems are far more pervasive than we might have imagined. The World Health Organization estimates that one in four people will have an episode of mental illness in their lifetime. Mental and behavioral problems are the biggest single cause of disability on the planet. But in low- and middle-income countries, about four of five of those disabled by the illnesses do not receive treatment for them.
When the United Nations sets its new Sustainable Development Goals this spring, it should include mental illness, along with diseases like AIDS and malaria, as scourges to be combated. There is much we still do not know about mental illness, and much we can do to improve its care. But we know enough to do something, and to accept that knowing more and doing more should be a fundamental commitment.
Correction: January 25, 2015
An opinion article about mental illness last Sunday incorrectly referred to a group that recently issued a report on schizophrenia. It is the British Psychological Society, not the British Psychological Association.
While many experiences — such as hearing voices — can occur without illness, a psychiatric diagnosis is more than a single symptom. The clustering of many symptoms together when combined with persistent distress and functional impairment is required for any consideration of a mental disorder.
Such approaches have been central to clinical medicine for centuries and are a precursor to the scientific understanding of the causes and mechanisms of disease, not an end in themselves.
Ms. Luhrmann notes approvingly that the National Institute of Mental Health, in beginning a program called Research Domain Criteria, determined that existing psychiatric diagnoses “were neither particularly useful nor accurate for understanding the brain, and would no longer be used to guide research.”
However, she does not mention a joint statement by the institute’s director, Dr. Tom Insel, and the former president of the American Psychiatric Association, Dr. Jeffrey Lieberman, which explained: “All medical disciplines advance through research progress in characterizing diseases and disorders. DSM-5 and RDoC [Research Domain Criteria] represent complementary, not competing, frameworks for this goal.” Precisely.
Psychiatric disorders are among the most common and disabling of medical conditions. Because they affect those functions that are most uniquely human, we owe both the best science and respectful listening to our patients.
Boston, Jan. 21, 2015
The writer is president of the American Psychiatric Association and chairman of the psychiatry department at Tufts University School of Medicine and Tufts Medical Center.