Friday, August 29, 2008

Genius and Madness: The Mental "Illness" Metaphor Has Not Worked: What's Next?

By William Todd Schultz in Genius and Madness

Several decades ago the philosopher Ludwig Wittgenstein said it was time to start comparing mental “illnesses” to something different. That is, to move away from the “illness” metaphor. I could not agree more. Insisting on thinking of people with mental problems as “diseased” has been and still is a strategic and practical failure.

It was at the start of the 20th century that medicine managed to wrest control of the treatment of the insane away from non-medical moral treaters, many of whom were Quakers. There then commenced what my friend the sociological historian Andy Scull has called an “orgy of experimentation” on the mad (see Scull’s wonderful book, Social Order/Mental Disorder, UC Press). Medicine had no clue what to do. The mad were injected with horse’s blood and malarial fever, placed in refrigerated “mummy bags,” given camphor derived seizures, subjected to various “heating” therapies--the list goes on. One theory, proposed by Henry Andrews Cotton, held that all forms of insanity, from juvenile delinquency to schizophrenia, were caused by infected third molars or “wisdom” teeth. His treatment? Tooth extraction. All such approaches were steeped in biological reductionism, and they all boasted astronomically high cure rates of 70, 80, even 100 percent. It was during this time that the “illness” model took firm hold. Soon there would be additional types of seizure models, coma models, and eventually lobotomy. At last antipsychotics arrived, and when they did they were referred to as “chemical lobotomies” because their chief effect was to produce disinterest and apathy (just like today, in my opinion).

The sad fact is that in over 100 years of research into mental “illness” driven by a defect-based disease model, the yield in terms of true understanding has been negligible. That may sound unrealistically unkind, but here is what I mean. Still today, we have no idea what schizophrenia even is, let alone what causes it or how to effectively treat it (to take just one example). As a disorder it is extremely heterogeneous; it looks different in everyone who “has” it. This heterogeneity bedevils research into causality since to find what causes something we have to first know what that “something” is. And speaking of causality: no causal model of schizophrenia has ever panned out. No specific site of brain pathology has been reliably identified. And the biochemical models focusing on dopamine (or D2 receptors) are deeply flawed, as most will readily admit. Lastly, as to treatment, antipsychotics are simply terrible drugs. A recent study (in the New England Journal of Medicine) of the newer agents found a 72% discontinuation rate. Why so high? Because the side-effects are debilitating.

Although it may seem different, the case is much the same for depression. We do not know what causes it—though there are lots of theories—and the antidepressant medicines on average only slightly outperform placebo in clinical trials (one study, for instance, found a 89% placebo duplication rate for Prozac in particular).

I’m no simple-minded Szaszian, but let’s be honest: mental problems do not resemble most illnesses in the least. My daughter had a compound fracture of her wrist. The MD took an X-Ray, and lo and behold, there was the break, for all to see. There was no mystery as to what caused the break, and also no mystery as to how to treat it. With mental problems, diagnosis is sketchy and almost never definitive (no UA or blood draw or brain scan tells me what you “have”), causality is a mystery, and treatment is trial and error (for instance, no one knows with any degree of certainty which antidepressant will work for which individual).

Prima facie, the disease model makes very little sense. And, even more importantly, it hasn’t gotten us anywhere. Psychiatry is in the stone ages.

A new metaphor, one to replace “illness” and “disease,” is called for. The question is: What form should it take?

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