Dr. James H. Scully, Jr.
Medical Director, American Psychiatric Association
Dear Dr. Scully,
I found your response to Mr. David Oaks, one of the “Fast for Freedom in Mental Health” hunger strikers, to be misleading on the subject of documentation of the biological roots of emotional and behavioral disorders.
One of the sources that you site to him is the Surgeon General’s Report on Mental Health. In fact, the text of the 1999 Report of the Surgeon General on Mental Health belies the idea that emotional and behavioral problems are analogous to bodily diseases. Though the document was published with press releases touting headlines to the contrary, the text of the Surgeon General’s Report itself repeatedly stated that “[F]ew lesions or physiologic abnormalities define the mental disorders, and for the most part their causes remain unknown” among many similar quotes.
I’ve attached an essay I wrote after reading the Surgeon General’s Report, demonstrating how the report itself repeatedly acknowledges that psychiatric diagnoses and the categories we deem to be “psychiatric disorders” have not been documented to be based in biological causes, despite decades of research attempting to verify such roots.
Please consider responding again to Mr. Oaks (and his companion hunger strikers) with specific and relevant documentation of the biological roots of the categories of distress and problematic behavior which are deemed to be psychiatric disorders. I believe that theirs is a serious and responsible request that the APA provide such evidence. The Surgeon General’s Report, which you cite, does not provide the evidence you imply, in my estimation.
Sincerely,
Richard Shulman, Ph.D.
Licensed Psychologist
Director, Volunteers in Psychotherapy, Inc.
The Surgeon General’s New Clothes:
How the press and the SG distort the truth about mental distress
(also available in Perspectives Mental Health Magazine, April-May, 2000)
By Richard Shulman, Ph.D.
Following the issue of the Surgeon General’s report on mental health (December, ’99), press headlines echoed Dr. David Satcher in declaring a new era of enlightened understanding. Headlines and media sound bites proclaimed science’s demonstration that emotional disorders and behavioral problems were truly legitimate physical illnesses, some would say brain disorders, rooted in genetics and biochemistry.
Imagine how surprised the writers of such headlines might be to discover these research summaries in the professional literature:
• “Few lesions or physiologic abnormalities define the mental disorders, and for the most part their causes remain unknown.”
• “[N]o single gene has been found to be responsible for any specific mental disorder…”
• “[T]here is no definitive lesion, laboratory test, or abnormality in brain tissue that can identify …[mental] illness.”
• “It is not always easy to establish a threshold for a mental disorder, particularly in light of how common symptoms of mental distress are and the lack of objective, physical symptoms.”
Surprise: these are QUOTES from within the Surgeon General’s report, just some of the many similar summaries of decades of research:
• “The precise causes (etiology) of most mental disorders are not known.”
• “DSM-IV [the diagnostic manual of the American Psychiatric Association] is descriptive in its listing of symptoms and does not take a position about underlying causation.”
• “The thresholds of mental illness or disorder have, indeed been set by convention…”
• “All too frequently a biological change in the brain (a lesion) is purported to be the ‘cause’ of a mental disorder…[but] The fact is that any simple association - or correlation - cannot and does not, by itself, mean causation.”
• “[N]o single gene or even a combination of genes dictates whether someone will have … [a mental] illness or a particular behavioral trait.”
• “Even with…schizophrenia, the median concordance rate among identical twins is 46 percent…meaning that in over half of the cases, the second twin does not manifest schizophrenia even though he or she has the same genes as the affected twin. This implies that environmental factors exert a significant role in the onset of schizophrenia.”
• “Placebo (an inactive form of treatment)…is more effective than no treatment [for mental disorders]. Therefore, to capitalize on the placebo response, people are encouraged to seek treatment, even if the treatment is not … optimal…”
Why are headlines trumpeting that our emotional problems are best defined as medical illnesses, when physicians such as the SG can find no biological lesions or markers that define them? And why is the press simply parroting the SG’s summaries, when such headlines mislead the public, evidenced by details within the report?
Is it possible that this report, and the oft-repeated truisms that emotional problems are at root medical diseases, also reflect the influence of business interests, and not strictly academic science? Sound too paranoid? What’s next, would we suspect business interests of trying to influence government? Suspect the pharmaceutical industry of trying to influence the Food and Drug Administration and organized medicine? Could the press unwittingly be coopted by uncritically accepting the pronouncements of people in authoritative white lab coats?
We all know that emotional turmoil and human suffering exists -- but is it disease? We’re so used to hearing that “mental illnesses” are “chemical imbalances” that we miss the point: Decades of research have failed to confirm this hypothesis. There are no “chemical imbalances” which validly and reliably define people’s troubles. That is why there are no lab tests or other assays of physical disease which confirm the “diagnosis” before you’re offered Prozac or your child is given Ritalin.
If your Aunt Doris is sad, demoralized or in a longstanding unhappy rut in her life, should we call her “dysthymic,” a psychiatric label with no demonstrable basis in biochemistry? If your 9 year old neighbor Andy’s parents inconsistently instill discipline in him, and he now misbehaves in school, do we affix the label “ADHD” [attention deficit hyperactivity disorder], a category for which there is no physical marker or disease entity? Yes, we can give Andy a medical-sounding label, and supply stimulant pills. We can give pills which have a sedative or stimulant effect on anyone; this does nothing to confirm the presence of a physical disease.
Misled by this medical paradigm, we frequently miss a key opportunity to understand the underlying personal reasons that someone is distressed.
A substantial literature now demonstrates that many psychiatric medications show only modest efficacy versus placebo, if studied scrupulously (and in research not funded or squelched by drug companies). [note: Some of this research has been published by Dr. Irving Kirsch right here at the University of Connecticut.] Interestingly, this perspective was briefly acknowledged, but minimized in the SG report.
The Wall Street Journal describes “an era of creeping commercialization in science,” citing an analysis of “210 influential journals, mostly in the bio-medical field” in which researchers publishing studies rarely disclose their financial ties to drug manufacturers. Such conflicts of interest have been covered in major medical journals and newspapers in the last year, even eliciting an apology from the New England Journal of Medicine recently, but this issue is not to be found in the SG report.
Surveys published in Psychiatric journals show that medical students are rejecting psychiatry as a specialty, often “citing a lack of scientific foundation,” with trends suggesting that psychiatry is viewed as “outside the mainstream of medical practice.” Psychiatric residents publish satires depicting their education as funded and shepherded by pharmaceutical companies, with little attention given to the subtleties of understanding the personal turmoils and hidden dilemmas of another human being. Loren Mosher, M.D., formerly a prominent researcher with the National Institute of Mental Health, published his resignation letter from the American Psychiatric Association in Psychology Today (Sept./Oct. ’99), documenting how the organization is “unduly influenced by pharmaceutical dollars;” over-relying on drugs, underemphasizing their shortcomings, side-effects, and toxicities, and virtually ignoring psychotherapy.
Even Consumer Reports and JAMA (Journal of the American Medical Association) reveal how drug companies conspire to influence prescribing Physicians and the consuming public.
But pharmaceutical company funds and influence aren’t mentioned by the Surgeon General, nor by uncritical publicists in the popular press. Nor does the report highlight that actual consumers of mental health services can be critical of groups comprised largely of family members of consumers, such as NAMI [National Alliance for the Mentally Ill]. The leadership of these latter “family” groups don’t advertise that they are covertly funded by pharmaceutical companies. Remember the group CHADD, a major proponent of stimulant medication for children, later revealed to be secretly subsidized by drug makers? NAMI advocates for biological treatment, even forced drugging, for what they repeatedly call “brain diseases.” The SG report portrays NAMI positively, minimizes the conflict over forced treatment with consumers themselves, and says nothing of NAMI’s multi-million dollar drug industry funding.
Are behavioral and emotional problems illnesses if decades of research have failed to find physical disease entities which cause them? The headlines surrounding the SG report blind us to this confounding miscategorization. Is this a summary of science, or is it marketing of psychiatric guild interests? Isn’t it in the financial and professional interest of psychiatrists (and drug companies) to insist that all of life’s confusion, unhappiness and conflict is their domain, over which they hold unique medical expertise? Especially when managed care will only pay for services deemed “medically necessary,” and clearly prefers to pay for pills over the expense of psychotherapy.
Without demonstrating any physical abnormalities, we can give disease labels that then grant a child the advantage of an extra hour and a half to take their SAT’s. Or we can fabricate disease labels which allow a criminal to murder, rape or embezzle, and then avoid legal consequences due to “psychiatric illness.” But isn’t this a subversion of logic and responsibility that the profession is purveying? Why is the press so uncritically accepting of this illogic, which spins medical illness labels out of no identifiable physical pathology, while benefiting particular “special interests?”
Here’s how two professors summarize this issue: “…American Psychiatry… has unsuccessfully attempted to medicalize too many human troubles…[A child's] school difficulties, your neighbor's marital problems, your friend's drinking habits, and your anxiety about an upcoming speech may cause great pain and be worthy of help from a psychotherapist, but that pain and that need for assistance require no psychiatric diagnosis to understand and no specific medical therapy to treat.”
The SG does endorse psychotherapy, but emphasizes primarily more simplistic forms of therapy that can be easily researched; those that are short-term, focused on limited problems, and that often have manuals. As H.L. Mencken said “For every complex problem there is an easy answer, and it is wrong.” Most people’s lives and problems are complex , and so is thoughtful therapy and the research which tries to document its helpfulness.
Why do we accept such oversimplified and medicalized truisms about life’s problems? Are we all blinded by the trappings of science? By misleading explanations repeated often? By appeals to political correctness? Do we prefer dreaming of “magic pills” rather than facing complex and upsetting human dilemmas that inevitably are part of life?
Why did the Surgeon General’s “sound bites” in the press misleadingly summarize the report in the first place? And why did the press repeat the SG headlines without 1) reading the report, and 2) thinking critically? There may be different answers to these questions, but none serves the advancement of the public’s knowledge.
___________________________________________
Richard Shulman, Ph.D.
Licensed Psychologist, Director
Volunteers in Psychotherapy, Inc.
7 South Main Street
West Hartford, CT 06107
(860) 233-5115
ctvip@hotmail.com
website: http://www.ctvip.org
Volunteers In Psychotherapy, Inc. provides psychotherapy that is truly private, in exchange for volunteer work clients donate to the charity of their choice: A nonprofit alternative to the loss of client privacy and control experienced under managed care.