ARTICLE IN BRITISH MEDICAL JOURNAL LANCET SUPPORTS THE VIEWS DR. D.L. EDMUNDS HAS EXPRESSED

The Lancet

February 21, 2009 - http://www.thelancet.com - pages 621 to 622 - Vol
373

Perspectives

Book Review

~~~~~~~~~~

The fool on the hill

The spinning chair. Bloodletting (copious). Removal of possibly
infected viscera. Extraction of teeth. Electric shock. Forcible
restraint, for days or weeks. Wrapping in cold blankets. Brain
damage. Repeated coma. Back-breaking convulsions. Slicing through the
brain with an ice pick. Sterilisation. Female genital mutilation.

Since the Enlightenment, all the above have been used to treat the
"mad". Even the most grotesque treatments have often been introduced
as humane alternatives to existing options. In the 1950s, the
chemical lobotomy, or "hibernation therapy" was introduced. Patients
were given a drug that rendered them immobile and semiconscious for
days, on the assumption that they would emerge improved. The drug was
called a "neuroleptic", or brain restrainer. Its name?
Chlorpromazine. Since marketed as an antipsychotic, it is used, at
lower doses, today. So too are a host of related drugs. Many doctors,
and some patients, swear by them (other patients swear at them).

Antipsychotics are, at times, cruel drugs. Some cause shaking,
salivation, restlessness, infertility, stiff ness, agitation, and
frail bones; others cause obesity, somnolence, and increase the risk
of heart attack, diabetes, and stroke. Antidepressants also have side-
effects, although theirs are typically less dramatic: sickness,
sexual dysfunction, a feeling of being numbed, or losing one's
personality, and acutely increased risk of suicide. But side-effects,
when they occur, seem justified, since mental illness is extremely
unpleasant; and evidence indicates that the drugs work.

What if they didn't? In "The Myth of the Chemical Cure: A Critique of
Psychiatric Drug Treatment," psychiatrist Joanna Moncrieff has
amassed copious evidence that perhaps the drugs don't work. What have
we missed, all these years? Selective and misleading outcome
measures; inadequate follow-up; selective attention to evidence;
publication bias; and our ability to define questions whose answers
are predictable, but partial. Robert Whitaker's "Mad in
America" (2001) provided a breathtaking overview; Moncrieff, by
contrast, examines many studies in detail. "The Myth of the Chemical
Cure" is not always easy reading, but I do not think that serious
psychiatrists can afford to ignore Moncrieff's book. It is a mine of
information; a provocation to think creatively and compassionately
about patients; and a momento mori, the equivalent of a mediaeval
scholar's skull staring back from his desk: our works are mortal, and
our paradigms always limited.

Psychiatrists are widely regarded (and not just by other
psychiatrists) as insightful and intelligent people. How can
systematic research errors influence practice? In "Side Effects: a
Prosecutor, a Whistleblower, and a Bestselling Antidepressant on
Trial," Alison Bass illustrates the method. The book lacks a little
in intensity; it could be shorter than it is. However, it manages to
illustrate that drug companies fund and design research; academic
advancement depends on procuring research grants; and, especially
with materialist approaches to the mind requiring expensive tools,
ambitious doctors often have little choice about the paymaster. Bass
indicates, as William Broad and Nicholas Wade did many years ago,
that research fraud is not merely anomalous, but the result of
pressures placed on academics, some of them self-generated. Even in
the absence of research fraud, the mechanisms of research would often
not be conducive to original or patient-centred thinking. Moreover,
acceptance of (in retrospect) bizarre and cruel remedies predates the
growth of the pharmaceutical industry.

This occurs although psychiatry, of all disciplines, ought to be
based on the art of listening. A patient's story is a symphony of
suffering, longing, meaning, understanding, hope, fear, loss, wit,
and wisdom. Not to accompany the person afflicted on his journey is
inhumane. People will always need psychiatrists. But do people always
need psychiatry? Instead of the art of expert companionship,
psychiatry has become the discipline of brain mechanics. Experiences
are matched to labels of descriptive poverty. "Depression" implies a
low level of something, presumably mood, rather than the rich and
complex turmoil felt by the patient. "Schizophrenia" means several
contradictory things, but does not reflect the search for meaning
that is at the heart of the disorder.

Is it a disorder at all? Madness is to sincerely hold beliefs that
society regards as insupportable. But no society's knowledge is
complete. Our ancestors would regard us as mad, or, charitably, as
ill-informed; we observe with relief that we do not share all their
beliefs. Healthy societies have often regarded at least some madness
as serendipitous. If reason follows from incomplete assumptions,
madness, by outflanking reason, can complete the human picture. The
notion was enshrined in the King's Fool: a measurelessly eccentric,
often holy, man who told the state, embodied in the king, what it
otherwise could not hear (the tradition died out in Britain after
Charles I was deposed, not long after his fool was expelled from
court, at the behest of a jealous archbishop). Our assumption that
madness is necessarily a disorder assumes that we are necessarily
sane. I would hate to make that an article of faith.

In focusing on, and stigmatising, people with mental illness, we tend
to ignore the context. In our fervour to understand mental illness,
we have applied grossly oversimplified biochemical models to the
brain, with usually unhelpful results. The search for a
"schizophrenia gene" has been heroic and, so far, labyrinthine; but
to be black, isolated, and urban in the UK increases the risk
manifold. Society, and circumstances, can drive people mad; the
epidemic of depression and anxiety is otherwise inexplicable. To
focus research on the person who has become ill can be a little like
concentrating on a damaged house after a tsunami has hit a village.
The cause may be elsewhere.

Some would argue that even if drugs work, they do not work. The
margin over placebo is not large; the number needed to treat is not
vanishingly small; prognosis may be worse than with the "moral
treatment" (rest, respect, good food, work, prayer) of 200 years ago;
patients' adherence, especially to antipsychotic drugs, is patchy;
drug treatment attends to the symptoms, but not to the human being
who has the symptoms. We would, as a society, achieve a great deal by
listening to patients' demands for good food, companionship, respect,
practical support, and gainful activity. As doctors, being with the
patient is one of the most powerful healing tools we have. It can
sound trite; but the phrase describes receiving the patient's
humanity, and allowing it to come through crisis intact and enriched,
without the loss of dignity and self almost inherent in labelling. We
rarely have the time, or encouragement, to treat patients according
to their story, rather than our diagnosis; outcome measures are too
coarse to consider whether the patient has been allowed to preserve
and fulfill his or her humanity. The work of Moncrieff and Bass is a
warning that the doctor must be intellectually and morally free.

Athar Yawar

The Lancet, London NW1 7BY, UK