On Tuesday, I went to see a discussion chaired by the philosopher Julian Baggini (JB) which touched on various difficult issues regarding our attitude to mental health and pharmaceutical interventions. The key contributors were: Oliver James (author of Affluenza), Richard Bentall (author of Madness Explained), and Kathryn Ecclestone (a professor of education at the University of Birmingham) Further details can be found in the blurb for the talk at the Chelt Lit Fest website here
I am not an expert in psychology or in the scientific research which was discussed, but have read quite a lot about this kind of thing, and wanted to hear some different points of view. I have previously taken a course on 'Philosophy and Psychiatry' when I was at university which opened up many of these questions to me in such a way that I have remained somewhat uncomfortable about some of the ways we talk about mental illness and deal with unhappiness and depression in our society today. I also felt this was a particularly interesting issue having had some personal experience of the kinds of treatments, consultations and referrals you may be offered, and having worked in education and met many young people who in some way or other are struggling with life and seem to need some form of help.
By and large I felt the discussion was a success: fascinating and enlightening. Nevertheless, I would like to start with a criticism: there was too much agreement and too little debate. There were some minor differences in opinion, but on the whole I feel the discussion could have done with some dissenting voices or counterarguments. Although, if JB had invited a representative of Eli Lilly or equivalent, I doubt if the talk would have flowed so smoothly!
I will attempt to report the viewpoints of all participants in the debate as accurately as I can based on notes I made during the talk. If I misrepresent anyone slightly, I apologise (please do feel free to get in touch and clarify your position). This is not intended to be a fully academic paper, but an observer's blog, and so, whilst I have included some links, I don't intend for this to be a fully referenced article at this stage. I may add further references/links as addenda as I come across them, as and when it seems appropriate.
I have tried to identify what I saw as the 6 key claims that were made as part of the discussion. The first key point made in the discussion was by Richard Bentall (RB), a man who I have held in high esteem particularly for his work on schizophrenia:
1. The biomedical approach to understanding mental health has not really led to any better outcomes.
This claim is about the outcomes. In terms of measurable statistics, he claims, there really hasn't been any improvement as a result of our increased knowledge of genetics, pharmacology or neurology. The claim can presumably be supported with reference to statistics on incidence of depression, suicide, psychosis, etc. over the last 50 years. Without further clarification of what exactly is meant by 'outcomes', this might seem to be an empty point. But taken in its most basic sense it still seems a striking thing to say.
If true, it is quite astounding. To think that all the understanding we have gained about how our mental states correlate with brain states, about the chemicals and electrical signals involved in feeling pleasure, pain, hope, fear has not brought about a real improvement in the way we treat people seems remarkable. All this expense, all this research...and we aren't any happier.
Why might this be? One answer suggested by RB's further talk was that mental illness is essentially rational. One quote I remember from studying R. D. Laing at university was the famous one that insanity is a 'perfectly rational adjustment to an insane world'. He didn't quite say this as such, but I felt his position was that mental illness is ultimately explicable, in the sense that it is as he put it "a reaction to unpleasant aspects of life". The conclusion that could then be inferred is that it is quite difficult to attempt to make the reactions go away, and it would be better to try to minimise the causes.
Much talk then naturally went towards the causes or 'social determinants of mental health'. For example, the following were listed:
*Living in an urban environment
*The death of a parent
*Being an ethnic minority
*Being homosexual
It was argued that these are much more useful in predicting the incidence of mental health problems than genetic factors. The most interesting aspect was that this all tends to suggest certain politically controversial conclusions. To be clear, I mean that it seemed to me that a kind of 'lefty' understanding of society was being supported here (i.e. a Guardian-reading kind of thinker would be inclined to agree with this argument). RB stressed throughout the talk the importance of relative poverty, and he claimed that inequality was in itself a (the?) primary cause of the mental health 'crisis' we face today. He described the epidemiology of most mental illnesses as being the result of a "chronic experience of social defeat". At the end of the talk, they returned to this topic in responding to a question about 'what should we actually do about the situation'? And so I will finish this blog on that question...
However, the points raised were not all conducive to a typical 'guardianista' worldview. Oliver James (OJ) agreed that the environment is crucial, and stated emphatically that mental health is *not* in your genes. He also emphasised the plasticity of the brain, and argued that this was something we can see as encouraging, as improvement can be made even once our mental health has been damaged. For example, the evidence he mentioned suggests that sexual abuse of children can cause problems in neural development, leading to someone having a 5% smaller hippocampus, but that this may be recoverable (I'm afraid I'm not sure exactly how). However, he strongly emphasised the importance of parenting - a message that might appeal more to those political tropes about the importance of the family unit.
Although he did not specifically put down alternative family structures, I wondered if he felt that divorce and 'broken families' were a major cause of mental health problems. For example, he said: "consistency of parenting over the first 6 years of a child's life sets the electrochemical thermostat". A single parent could provide this consistency better than a household with an unhappy, violent or miserable marriage at its heart, of course. But one of his suggestions at the end of the discussion seemed to promote a more traditional model for family life...
My thought is that whilst glad that these social issues were emphasised, I am not inclined to give up hope on better understanding of the biomedical aspects of happiness. For example, our grasp on Alzheimer's and schizophrenia seems better in the context of this kind of research. e.g this site. Greater scientific understanding of our genetics, pharmacology and neurology can't be a bad thing in itself. However, we should certainly be wary of how reliable the knowledge is, how it is used, and most certainly by whom...
2. There is very little evidence that antidepressants work better than a placebo (and a lot showing that they work about the same as a placebo).
This part of my blog should largely be full of data. Data that I should go and seek online. I should go and read it all for myself...
But I haven't. Yet.
Have you?
I presume Richard Bentall has. He has access to this kind of information, and the time and technical expertise to understand it and analyse it. And I doubt he has an irrational vendetta against pharmaceutical companies. It's possible that he is biased against them for some ideological reason, but I think it's more likely that he's right.
The problem with this conclusion is that it doesn't tally very well with the personal experience of people who feel that the drug has worked for them. They are fairly sure that it was more than placebo. For example, a friend of mine says they had a 'definite chemical imbalance' and that 'without a shadow of a doubt' antidepressants 'saved his life'. My own personal experience is less conclusive, and so I'll leave it to one side.
If they don't work, why on earth are they so prevalent? One possibility is discussed below as point 3. Another possibility is that people who are suffering want to be validated in this way by having a clear response from the doctor. The 'label' or endorsement that such treatment provides somehow seems more satisfactory, perhaps? The doctors, in turn, don't want to feel unable to help, they want to have a clear response that makes their patients go away satisfied. In discussing the tripling of antidepressant prescriptions (I didn't note down over what period, sorry) RB comments that "the main function of such prescriptions is to get someone out of a GP surgery".
[This space is for good links to data... (pharma companies / opponents please feel free to send me a link!)]
3. Pharmaceutical companies are engaged in a massive and profitable deception of the masses.
Oliver James (OJ) agreed with RB. Whilst he admits to not being part of the academic community as RB is, he is clearly well read on the issue. He says the drug companies are essentially guilty of a "deliberate conspiracy". Simply put, they are lying about the efficacy of these drugs.
Why? That part is easy. The conspiracy theorist here doesn't have much work to do... Because they make lots of money out of it. Big pharma companies are not popular. They make billions of dollars. And they don't seem keen enough to get involved in providing cheaper more affordable drugs in the developing world. It's easy to see them as enemies.
But this relies on the belief that a number of people are conspiring. In the modern era, it's easy to imagine CEOs as wicked people. Some of the tax-avoiding, selfish, greedy stereotypes we might already have had have been recently amply fuelled by Mitt Romney's kind of men: Cooperman and co. They argue that they have been unfairly demonised by Obama's rhetoric and the Occupy movement for example. They don't do themselves any favours, but one wonders whether they really care what we think of them as long as they don't get taxed too much. But I digress... maybe they have been demonised too much? Would they actually engage in such a massive deception? Are they that bad? I like to think the best of people, but I'm sad to say that I fear they may be. But they would have to be putting pressure on their employees and scientists to go along with this and manage to avoid whistleblowers. Furthermore, they would have to avoid major resistance from groups of concerned doctors, academics, etc. This kind of conspiracy is certainly possible, given the common tendency of many people towards silence or apathy. After all, people who need a job and/or want a quiet life can be pressured in various ways, not necessarily overtly. But, despite all these concerns, it still seems hard for me to believe there has been such a deliberate deception of the sort implied. I'm not generally a fan of conspiracy theories...
How?
The key point here, is that they don't have to falsify any data. They simply withhold information. Ben Goldacre has raised the issue before about the suppression of clinical trial data that does not promote the drug. This obviously leaves the public short of the full facts and distorts the evidence in their favour. A brief google search of 'suppression of clinical trial data' yields thousands of hits. According to one particularly thorough analysis of the problem, ‘the ideal solution to publication bias is the prospective, universal registration of all studies at their inception’. I think transparency of such data is a moral and legal imperative, and would urge you to support Ben's campaign. In a recent article, he writes:
"It's a cultural blind spot that comes about, I think, because the misconduct arises from a slightly diffused network of failure. So in some cases there will be obsessive, evil people at the centre, with full panoramic knowledge of everything that's happening, stage managing it. In other cases, you'll have individuals in organisations, maybe quite junior, they've got a trial with a negative result, nobody's enthusiastic about putting it out there, and to that one researcher, not publishing a paper intuitively doesn't feel the same as deleting some data points in a study, even if the end product is the same, in terms of the impact on doctors' and patients' knowledge of the risks and benefits.
That's why I think it's really disappointing that nobody, not the Royal Colleges, the Academy of Medical Sciences, the British Pharmacology Society, the British Medical Association, none of these organisations have stood up and said: selective non-publication of unflattering trial data is research misconduct, and if you do it you will be booted out. And I think they really urgently should."
(Update: 12/10/12: Ben Goldacre gives some reason for optimism in the case of one big pharma company GlaxoSmithKline, who seem to be cleaning up their act, but warns that there has not been a good history of compliance, despite similar promises from the industry in the past.)
Regardless of whether point 2 is actually correct, we all deserve a society where science is used for the benefit of all, and not abused for profit. There is a major issue of trust here. We rely on scientists' conclusions when we board a plane, ingest a pill or teach children about biology. The damage done to our society is hard to calculate. This is a bigger issue than simple deception and fraudulent profit making. Particularly because these drugs are not harmless. By their own admission, they cause some minor negative side effects, such as increased acne. But that is at the very very least. Which leads on to the next point...
4. Many medications provided for mental health problems have severe side effects that may be much worse than the problem they aim to treat, and even the minor side effects may be enough to worsen the problem more than any benefit they provide.
There isn't actually a lot to say here. Simply put, when a drug that is marketed to treat depression has been associated with causing suicidal feelings, something isn't right. Hallucinations, panic attacks... if you were depressed before, this is the opposite of progress. Also, things such as higher cholesterol or potential serious liver damage are not going to lessen your worries. And as OJ emphasised, impotence must surely be one of the most crushing things for a young man to deal with in such a situation.
So, the drugs are not harmless. But does the benefit outweigh the downsides? That's hard to judge. It's important not to overstate the case, as doing so is liable to minimise the seriousness of the problems that led the patient to seek help. A patient who is suffering from sufficiently severe mental problems is likely to say they'd much rather have high cholesterol. But of course, if the problems are vaguer, and the improvements that these drugs statistically offer is negligible, it seems likely that a reviewer would come to the conclusion that we should stop their usage.
But it isn't that simple. People who are using these treatments may well fear that if they stop they will go backwards. And whilst dismissing drugs that are allegedly 'no better than placebo' seems wise as first, it tends to forget how very powerful a placebo can be! (I am tempted here to make an analogy- though I'm not sure how good it is- with religious believers who think that they couldn't survive without their faith. They are liable to claim they would spiral into wild crimes and total despair. Mostly, I doubt it, but what if they're right?!)
In the open questions, one of the audience members asked about patients for whom drugs seem clearly to be working, and gave the example of major delusions. RB responded, being one of his specialist fields, pointing out that the statistics for anti-psychotics are different from antidepressants. He argued that in 25% of cases, anti-psychotics show a clear and marked benefit, so they shouldn't be stopped. (Though, to me, this 25% doesn't actually sound very good! It's obviously not a total failure - every one person that is helped is worthwhile - but 3/4 of patients are by this logic getting no clinical benefit from anti-psychotics.) The further issue here, though, is whether the "grey unrewarding world" described by the 25% 'successful' users of such drugs is better than the 'pharmaceutically untreated' alternative.
Ethically, it seems dubious. Again, the politics involved are suspect. We are talking here about the sedation of people who society deems to be different in some way of thinking. And it can hardly claim to be an objective judgment, as traditionally, religious people (if they are of the right flavour) tend to avoid this stigmatization, despite often believing all sorts of unusual (and sometimes, frankly, psychotic) things. These people, nevertheless, may be the most creative, the most insightful or the most sensitive in our society. They may enrich our community. We may find some of their beliefs frightening, offensive, wacky, etc, but unless they pose a clear and present risk to a community, why are they effectively being silenced? One thinks of Aldous Huxley's 'soma' and other dystopic visions.
There was a lot more discussed. I haven't begun to mention any of the points raised by Kathryn Ecclestone (KE), but I will leave these further points for a separate posting. In particular, I would like to comment on the claims I have numbered as points 5 & 6 below:
5. The medicalised language used about everyday problems (e.g. describing a tendency to misbehave as a 'conduct disorder') builds a panic that does not help society as a whole or the individuals suffering.
6. So-called 'positive psychology' is largely a load of cabbage, stemming from a simplistic notion of happiness.
Conclusions: What should we actually do about the situation?
So, what did the panel have to say about what policies might be put in place?
One audience member wanted to make her point about the importance of good nutrition. No one had much to say about that, although JB agreed that physical health and decent food would help.
RB focused on social inequality. A discussion developed about balancing social mobility with realistic ambitions about what people can achieve. The emphasis was on expectations and the relativity of subjective wellbeing. OJ felt that, to take one controversial example, Obama was not a realistic role model for most African Americans, (given his unusual and privileged upbringing). Until the opportunities for ordinary black people are improved, it could be harmful to see him do so well, if it makes people think they should be doing much better than they are. That is, conspicuous success might blind people to the obstacles that they actually face. (I thought myself of things such as the national lottery and X-factor, which hold the 'american dream' out apparently tantalisingly closer than ever before). Meanwhile, the gap between rich and poor has widened, and social mobility has arguably decreased since the 60s. No one wants to lower aspirations, but OJ argued that ultimately it is our expectations that largely determine our subjective wellbeing.
KE focused on education. The other participants enthusiastically endorsed its importance, and the crowd seemed to nod more vigorously at this point than at any other in the discussion. But whilst every political party wants to improve education, how to actually improve it is another matter. (I would suggest that taking money out of education provision isn't a good idea for a start, but then again I'm a teacher, so I would say that, right?) Let's just all agree it is crucial, OK?
Perhaps the most specific and most interesting suggestion made was by OJ. He argued that governments should pay for one parent to stay at home for a much longer period. (I think he referenced Austria at this point). I would like to have asked more about this suggestion - (what evidence? how long for? does this only apply to two-parent families?) and so on. His most important overall claim seems to be that the most crucial element in mental health is love, particularly stable and consistent parental love.
So, what do you all think about all that?
Thursday 11 October 2012
Wednesday 10 October 2012
Meeting an old friend at the Cheltenham Literature Festival
Decided to resurrect this rarely-used blog to write a little about stuff this year at the Cheltenham literature festival.that really makes me think. Firstly, on a personal note, it was great to catch up with an old friend who I haven't seen since primary school. (For those of you who don't know me: that's over 20 years ago!) It was a real pleasure to chat to him, and I found the experience quite inspiring (for a start: I'm here writing properly again for the first time in a while).
A reflection on this experience: I really had little idea what Alex was going to be like anymore, for several reasons: 1) We haven't been in touch until very recently (through a social network) 2) at the age of 11, how much can we know about one another? I think I was less cluttered by stereotypes and preconceptions, but in that admirable state of innocence, are we also less able to make the kinds of judgements about someone's character, background etc. that we find so natural to make as adults? 3) A lot of our adult identity is worked out gradually through our teenage years, and much of it is shaped by our pubescence- not just our physique and sexuality. 4) my memory of those years is pretty poor (Alex, by contrast, was able to recall some scenes from 'back then' with astonishing vividness).
In short, Alex could have become in the interim years a Marxist, a lawyer, a convict, a 6 foot rugby player, a rapper, or a ballet dancer. He could have left school at 16 or be about to take a second PhD.
As it happens, he turned out to be highly intelligent, interested in philosophy, and an accomplished artist and talented illustrator who is actually responsible for the Cheltenham festival artwork!
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