Mental illness discussions
May. 23rd, 2013 07:18 pm![[personal profile]](https://www.dreamwidth.org/img/silk/identity/user.png){kind=small}
livI am not sure I should really wade into this, because this kind of topic can really easily turn into non-mentally-ill people pontificating about how people with actual mental illnesses should live their lives while obliviously forgetting that they are likely to be talking to people who have actual personal experience. At the same time I think there is a big problem with prejudice against people with mental illnesses (as well as lack of access to treatment, which in some ways is connected to prejudice) and that's something I want to challenge.
A while backsonia linked to this article arguing that anti-depressant medications don't really work by increasing brain serotonin. I don't know whether this claim is really true; I don't have enough of a neuropharmacology background to know whether it's a crackpot theory or simply a minority but evidence-based view. The article appears on a site which is explicitly taking an anti-medication stance, and there's a lot of "evil pharmaceutical companies" business in it. OTOH there's peer-reviewed citations a couple of links deep. Since I hadn't come across this view before at all, I thought it was worth passing on as a possible hypothesis at least.
I also find it basically credible that drugs developed (and, yes, marketed) as "selective serotonin reuptake inhibitors" don't in fact exert their effects by increasing levels of serotonin in the brain. Most drugs don't turn out to operate by the mechanism originally proposed when the drugs were being developed, once they're in general clinical use and people start testing the original hypothesis to failure. SSRIs might very well be like that too. And it may be true, as some of the sources linked from Cassani's article claim, that depression in turn has a more complex aetiology than simply a deficiency of brain serotonin. Depression may well be several different diseases with an overlapping set of symptoms; for a start, bipolar depression isn't the same as depression.
The question I find interesting is, what's the moral consequence of this? You could conclude, as some of the Beyond Meds circle seem to, that SSRIs actually don't work at all, they're just expensive placebos sold to gullible and desperate people (who may not even actually be ill, just perhaps naturally unhappy at living in a fractured society) by evil pharmaceutical companies. I don't think this at all follows from the idea that SSRIs may not work the way their acronym claims, though. It seems to me equally likely that SSRIs are effective for some people with depression and related mental illnesses – though most certainly not for all – but we simply don't understand exactly how they work yet. That's scientifically interesting, of course, but a far more vital question than how SSRIs work on a molecular level, is whether they work, whether they actually do more good through improving mood disorders, than harm through side effects. That is still very much an open question, and can really only be solved empirically.
The problem with this line of argument is that there's an often unstated assumption that depression is only a "real" illness if it can be cured by taking a drug that has a known molecular target to explain its mechanism of action. If that's not the case, then some people are going to argue that depression is purely "imaginary," a moral failing, not an illness. And some more sympathetic people are going to argue that depression is essentially a social construct, a symptom of oppression, not a "medical" condition. There's some discussion in the linked articles from the Beyond Meds piece of psychiatrists, who themselves believe that the evidence is against the classical model of how SSRIs work, telling their patients that they do work by increasing serotonin levels, because being told that white lie helps to overcome the stigma of having a mental illness. But that makes no actual sense; why should it be somehow more respectable to have an illness caused by a chemical imbalance in your brain, than to have an illness whose origin is, so to speak "purely" psychological?
That connects to a discussion I've seen the edges of floating around social media. I haven't traced the outrage to its origin but as far as I can gather someone with a prominent platform declared that exercise is better for depression than medication. I imagine this may well be connected to the rather insensitive recent Mental Health Awareness Week campaign which was very big on the benefits exercise but didn't really make any allowances for the fact that not all depressed people have equal access or ability to do physical exercise (H/T tokaberett for thoroughly shredding the fail there.)
The thing is, it is literally true that exercise is "better" for depression than pharmaceutical antidepressants, in the sense that in well-designed, large-scale trials, exercise has better outcomes than medication. But that's an anti-helpful statement to be trumpeting completely out of context, because what well-designed trials also show is that the only really effective way to treat depression is a combination of exercise, drugs and psychological therapy (people argue about CBT versus talk therapies, but some kind of expert support is clearly important). Now, some people can't take drugs because they can't tolerate them, and some people can't do exercise because of physical limitations; the last thing I want to do is to blame depressed people who are in those unfortunate situations. But the fact is that therapy alone helps a small proportion of people a little bit, drugs alone help a small proportion of people a little bit, assuming you get the right match between drug and individual, which usually takes substantial trial and error. And increased physical activity helps slightly more people a little bit, but really you need all three and even then lots of depressed people never get completely better. So it's not meaningfully correct to say that "exercise is better than medication".
So I am somewhat in sympathy with the outraged people. But some of the outrage was over the fact that if you spread the word that exercise is (somewhat) effective for depression, it will add to stigma against depression and other mental illnesses. Again, this seems to be based on the faulty assumption that illnesses are only "real" if you treat them with drugs! Depression is a real illness, and a very serious illness; it also happens to be somewhat improved by physical exercise for some people. That doesn't mean that depression is caused by people being lazy bums and not going to the gym often enough. It doesn't change the fact that depressed people also need therapy and some may need medication as well and everybody needs to be accepted in society and not blamed or ostracised for their illness. If anything is generally accepted to be a real illness it's a heart attack, and people who have had heart-attacks are also advised to do regular gentle exercise to reduce the chances of a recurrence; that's not to say that heart-attacks are purely made up as an excuse to be lazy!
The other thing that social media is outraged about at the moment is that there was a rather nasty violent crime in London yesterday, and people are valiantly trying to hold back the tide of racists who want to hold all Muslims responsible because these particular attackers happen to be Muslim. The problem is that some of these people are making comments along the lines of, they didn't kill that guy because they're Muslim, they killed him because they're crazy, violent nutters. Which. Doesn't exactly help! It's not right to blame a billion Muslims for the evil actions of two Muslims, and it's also not right to blame a billion people with mental illnesses for the evil actions of two people whose mental health history we know nothing about. Now, some people might say that when they call a violent criminal a lunatic, they're not referring to respectable illnesses like depression, but only to "major" mental illnesses which are somewhat associated with violent behaviour. For one thing this general stigma against "crazy" people affects everybody, and anyway it's not right to stigmatize any mentally ill people at all, even if you restrict the particular conditions you blame.
At the same time, there certainly are some mental illnesses that, untreated, can sometimes lead to violent outbursts. It's dangerous to ignore that, as much to the people who themselves live with major mental illness as to the general public. In the course of the discussion, somebody linked to the following article about a man who actually does suffer from schizophrenia and who is currently in the process of pleading not guilty by reason of insanity to the murder of his father. The article is very much a typical Mother Jones offering, talking about very distressing and emotive things in a quasi-objective tone, and immediately inclined to blame all badness on the government's lack of effective anti-badness measures. The tone felt somewhat othering to me as a reader; there's a little bit of a sense that "we" have to do something about the terrible danger posed by those dangerous crazy people. I mean, to be fair McClelland is coming to terms with the fact that a member of her family brutally murdered another relative, so she's not exactly in the best position to see things from the point of view of mentally ill folk.
I think the most charitable reading of the McClelland piece is not so much as an argument that society should be more willing to resort to forced treatment to restrain mentally ill people from becoming dangerously violent. Rather, she holds that there really needs to be a far better safety net of voluntary treatment available before people get to the point of "danger to self and others" where the only alternatives are to treat and confine them against their consent or to let them go on murdering rampages. The article of course is American, but I can see a trend towards similar problems in this country, because mental health services have been so severely curtailed over the last few decades. I am aware of too many incidences of mentally ill people in Britain not being able to access any sort of help or support until it's really too late.
At the point where someone is actively suicidal and / or violently endangering others, at the point where they are too distressed, paranoid etc to make a rational decision about whether they want to take the offered medication or be confined for their own safety, there really are no good options left. Equally, if your only treatment paradigm is about forcing people to take medication or to be locked up or even institutionalized long-term, that's going to make people extremely reluctant to seek help with any kind of mental illness while they are lucid enough to be able to make the decision. Because in fact it is perfectly rational to refuse treatment if the treatment means completely removing all your autonomy! It's also the case that prejudice and stigma against mentally ill people has huge influence on the sorts of actions that the medical establishment is likely to regard as being for the patient's good, even if you concede that in some circumstances people simply can't make rational decisions for themselves.
What I don't know here is how to use rhetoric responsibly. It does a lot of harm to imply that all mentally ill people, or all people with certain categories of mental illness, are dangerously violent. But it also does harm to pretend that mental illness can easily be handled by just, you know, having a "positive attitude"; decent mental health provision is absolutely necessary, both for people with mental illnesses and for wider society. I suppose I want to argue that people should be able to get help because it's morally right that we take collective responsibility for treating the sick, not necessarily because otherwise they might go on a rampage and murder their carers or some innocent bystander. And I want to argue for this in a way that isn't about making me, as a non-mentally-ill person, feel safer at the expense of others.
A while back
sonia linked to this article arguing that anti-depressant medications don't really work by increasing brain serotonin. I don't know whether this claim is really true; I don't have enough of a neuropharmacology background to know whether it's a crackpot theory or simply a minority but evidence-based view. The article appears on a site which is explicitly taking an anti-medication stance, and there's a lot of "evil pharmaceutical companies" business in it. OTOH there's peer-reviewed citations a couple of links deep. Since I hadn't come across this view before at all, I thought it was worth passing on as a possible hypothesis at least. I also find it basically credible that drugs developed (and, yes, marketed) as "selective serotonin reuptake inhibitors" don't in fact exert their effects by increasing levels of serotonin in the brain. Most drugs don't turn out to operate by the mechanism originally proposed when the drugs were being developed, once they're in general clinical use and people start testing the original hypothesis to failure. SSRIs might very well be like that too. And it may be true, as some of the sources linked from Cassani's article claim, that depression in turn has a more complex aetiology than simply a deficiency of brain serotonin. Depression may well be several different diseases with an overlapping set of symptoms; for a start, bipolar depression isn't the same as depression.
The question I find interesting is, what's the moral consequence of this? You could conclude, as some of the Beyond Meds circle seem to, that SSRIs actually don't work at all, they're just expensive placebos sold to gullible and desperate people (who may not even actually be ill, just perhaps naturally unhappy at living in a fractured society) by evil pharmaceutical companies. I don't think this at all follows from the idea that SSRIs may not work the way their acronym claims, though. It seems to me equally likely that SSRIs are effective for some people with depression and related mental illnesses – though most certainly not for all – but we simply don't understand exactly how they work yet. That's scientifically interesting, of course, but a far more vital question than how SSRIs work on a molecular level, is whether they work, whether they actually do more good through improving mood disorders, than harm through side effects. That is still very much an open question, and can really only be solved empirically.
The problem with this line of argument is that there's an often unstated assumption that depression is only a "real" illness if it can be cured by taking a drug that has a known molecular target to explain its mechanism of action. If that's not the case, then some people are going to argue that depression is purely "imaginary," a moral failing, not an illness. And some more sympathetic people are going to argue that depression is essentially a social construct, a symptom of oppression, not a "medical" condition. There's some discussion in the linked articles from the Beyond Meds piece of psychiatrists, who themselves believe that the evidence is against the classical model of how SSRIs work, telling their patients that they do work by increasing serotonin levels, because being told that white lie helps to overcome the stigma of having a mental illness. But that makes no actual sense; why should it be somehow more respectable to have an illness caused by a chemical imbalance in your brain, than to have an illness whose origin is, so to speak "purely" psychological?
That connects to a discussion I've seen the edges of floating around social media. I haven't traced the outrage to its origin but as far as I can gather someone with a prominent platform declared that exercise is better for depression than medication. I imagine this may well be connected to the rather insensitive recent Mental Health Awareness Week campaign which was very big on the benefits exercise but didn't really make any allowances for the fact that not all depressed people have equal access or ability to do physical exercise (H/T to
kaberett for thoroughly shredding the fail there.) The thing is, it is literally true that exercise is "better" for depression than pharmaceutical antidepressants, in the sense that in well-designed, large-scale trials, exercise has better outcomes than medication. But that's an anti-helpful statement to be trumpeting completely out of context, because what well-designed trials also show is that the only really effective way to treat depression is a combination of exercise, drugs and psychological therapy (people argue about CBT versus talk therapies, but some kind of expert support is clearly important). Now, some people can't take drugs because they can't tolerate them, and some people can't do exercise because of physical limitations; the last thing I want to do is to blame depressed people who are in those unfortunate situations. But the fact is that therapy alone helps a small proportion of people a little bit, drugs alone help a small proportion of people a little bit, assuming you get the right match between drug and individual, which usually takes substantial trial and error. And increased physical activity helps slightly more people a little bit, but really you need all three and even then lots of depressed people never get completely better. So it's not meaningfully correct to say that "exercise is better than medication".
So I am somewhat in sympathy with the outraged people. But some of the outrage was over the fact that if you spread the word that exercise is (somewhat) effective for depression, it will add to stigma against depression and other mental illnesses. Again, this seems to be based on the faulty assumption that illnesses are only "real" if you treat them with drugs! Depression is a real illness, and a very serious illness; it also happens to be somewhat improved by physical exercise for some people. That doesn't mean that depression is caused by people being lazy bums and not going to the gym often enough. It doesn't change the fact that depressed people also need therapy and some may need medication as well and everybody needs to be accepted in society and not blamed or ostracised for their illness. If anything is generally accepted to be a real illness it's a heart attack, and people who have had heart-attacks are also advised to do regular gentle exercise to reduce the chances of a recurrence; that's not to say that heart-attacks are purely made up as an excuse to be lazy!
The other thing that social media is outraged about at the moment is that there was a rather nasty violent crime in London yesterday, and people are valiantly trying to hold back the tide of racists who want to hold all Muslims responsible because these particular attackers happen to be Muslim. The problem is that some of these people are making comments along the lines of, they didn't kill that guy because they're Muslim, they killed him because they're crazy, violent nutters. Which. Doesn't exactly help! It's not right to blame a billion Muslims for the evil actions of two Muslims, and it's also not right to blame a billion people with mental illnesses for the evil actions of two people whose mental health history we know nothing about. Now, some people might say that when they call a violent criminal a lunatic, they're not referring to respectable illnesses like depression, but only to "major" mental illnesses which are somewhat associated with violent behaviour. For one thing this general stigma against "crazy" people affects everybody, and anyway it's not right to stigmatize any mentally ill people at all, even if you restrict the particular conditions you blame.
At the same time, there certainly are some mental illnesses that, untreated, can sometimes lead to violent outbursts. It's dangerous to ignore that, as much to the people who themselves live with major mental illness as to the general public. In the course of the discussion, somebody linked to the following article about a man who actually does suffer from schizophrenia and who is currently in the process of pleading not guilty by reason of insanity to the murder of his father. The article is very much a typical Mother Jones offering, talking about very distressing and emotive things in a quasi-objective tone, and immediately inclined to blame all badness on the government's lack of effective anti-badness measures. The tone felt somewhat othering to me as a reader; there's a little bit of a sense that "we" have to do something about the terrible danger posed by those dangerous crazy people. I mean, to be fair McClelland is coming to terms with the fact that a member of her family brutally murdered another relative, so she's not exactly in the best position to see things from the point of view of mentally ill folk.
I think the most charitable reading of the McClelland piece is not so much as an argument that society should be more willing to resort to forced treatment to restrain mentally ill people from becoming dangerously violent. Rather, she holds that there really needs to be a far better safety net of voluntary treatment available before people get to the point of "danger to self and others" where the only alternatives are to treat and confine them against their consent or to let them go on murdering rampages. The article of course is American, but I can see a trend towards similar problems in this country, because mental health services have been so severely curtailed over the last few decades. I am aware of too many incidences of mentally ill people in Britain not being able to access any sort of help or support until it's really too late.
At the point where someone is actively suicidal and / or violently endangering others, at the point where they are too distressed, paranoid etc to make a rational decision about whether they want to take the offered medication or be confined for their own safety, there really are no good options left. Equally, if your only treatment paradigm is about forcing people to take medication or to be locked up or even institutionalized long-term, that's going to make people extremely reluctant to seek help with any kind of mental illness while they are lucid enough to be able to make the decision. Because in fact it is perfectly rational to refuse treatment if the treatment means completely removing all your autonomy! It's also the case that prejudice and stigma against mentally ill people has huge influence on the sorts of actions that the medical establishment is likely to regard as being for the patient's good, even if you concede that in some circumstances people simply can't make rational decisions for themselves.
What I don't know here is how to use rhetoric responsibly. It does a lot of harm to imply that all mentally ill people, or all people with certain categories of mental illness, are dangerously violent. But it also does harm to pretend that mental illness can easily be handled by just, you know, having a "positive attitude"; decent mental health provision is absolutely necessary, both for people with mental illnesses and for wider society. I suppose I want to argue that people should be able to get help because it's morally right that we take collective responsibility for treating the sick, not necessarily because otherwise they might go on a rampage and murder their carers or some innocent bystander. And I want to argue for this in a way that isn't about making me, as a non-mentally-ill person, feel safer at the expense of others.
