What do we know about mental illness?
Science is a work in progress.
Depression is one of the most commonly diagnosed mental health conditions, but there is no clear-cut explanation for why it happens.
The most prevalent belief is that depression is caused by low levels of serotonin in the brain, which means the brain’s chemicals are out of balance.
But the serotonin theory arrived by accident when a drug that boosted serotonin was found to be effective at treating depression. The theory was retrofitted to explain why the drug worked.
A recent meta-analysis of serotonin studies found that the serotonin-deficit theory of depression is not grounded in scientific evidence. Depressed people don’t have less serotonin in their brains than non-depressed people, and if we artificially reduce the serotonin in non-depressed brains, these brains do not become depressed.
This doesn’t mean that serotonin-boosting drugs don’t work. Scientists just don’t know exactly why they work. Some antidepressant drugs boost serotonin, others don’t.
What’s true for mood disorders like depression is also true for thought disorders like schizophrenia: There are drugs to treat psychosis, but there is no concrete explanation for why they work. A common theory holds that psychosis is a result of overactive dopamine production in the brain, but this theory is muddled when it comes to the evidence. As with antidepressants, there are different antipsychotic drugs that operate differently on the brain’s chemistry.
The lack of scientific certainty about mental health problems is underscored by the ongoing experimentation in the field of psychiatric treatments.
Here in Arizona, a bipartisan group of state lawmakers want psychedelic mushrooms to be studied and used in clinical treatment. Last year’s budget included a $5 million grant to fund the initial phases of human trials with natural psilocybin. Gov. Hobbs vetoed a bill earlier this week that would have established the legal infrastructure for psychedelic treatment. In her veto letter, Hobbs cited a lack of scientific evidence for the treatment, but she reiterated her support for the research. Psilocybin research dollars were protected in this year’s budget.
The hope for psychedelic treatments — which is examined in Michael Pollan’s 2018 book How to Change Your Mind — is that they will offer a mind-bending cleanse that will alleviate persistent problems with depression, anxiety, or PTSD.
The experimentation with psychedelics is just the latest twist in the winding history of mental health treatment
Last summer, I read a book by Anne Harrington called Mind Fixers. Harrington is a professor of the history of science at Harvard University.
The book “tells the history of psychiatry’s quest to understand the biological basis of mental illness and asks where we go from here.”
The scientific history is presented as a seesaw between biological and social explanations of mental illness.
Here’s a very brief overview of the stages of knowledge described in Harrington’s book:
In the late 1800s, patients were kept in asylums until they died. After they died, their brains were studied by scientists to see if there were common physical attributes in the afflicted.
Emil Kraeplin in 1891 began a process of description and prognosis. He set about in a scientific manner to observe mental illnesses, describe what was happening, and track their development over time. In doing so, he created a category for schizophrenia and a category for manic depression.
Then along came Sigmund Freud with his psychoanalysis. Freud focused on the mental aspects of behavioral ailments. Everything was caused by subconscious conflict or repressed development. Everything was a neurosis. Freud’s conclusions were non-verifiable by scientific research.
Then there was a phase when everyone started searching for biological infectious diseases as the causes for mental problems; then came a genetic frenzy where mentally ill patients were forced to be sterilized; then came a “maladjustment” trend where everyone started to blame “bad parents” and focus on “mental hygiene” and psychoanalysis.
In the 1950s, the first major psychotropic drugs were developed, the most famous being Thorazine. In the 1960s, a new federal law pushed patients out of state mental health hospitals, but the planned community mental health centers were never built. Between 1955 and 1994, the number of people in a state mental health hospital dropped from 560,000 to 70,000, even as the general population grew significantly during the same time. Meaning that 90% of the patients who would have been in a state hospital in 1950s were no longer there by the 1990s.
The 1990s launched the era of Big Pharma, heralded by the 1987 introduction of the antidepressant drug Prozac. Also in 1987, the third iteration of the Diagnostic and Statistical Manual of Mental Disorders (DSM) was revised to remove Freudian explanations of ailments and focus on Kraepelin-like descriptions of symptoms — in the belief that biological identifiers would soon be discovered.
Harrington’s conclusion is that the field of psychiatry would do well to focus on the most severe mental health conditions and “give away some of its powers” to therapists, counselors, and social service providers.
One of the more contentious public policy questions today is whether to force treatment on people who don’t have the cognitive capacity to seek it for themselves.
Progressive thinking on this issue is that it would be inhumane or insensitive to force someone into treatment against their will — even if the person was visibly descending into schizophrenic madness on the streets. Conservatives will express concerns about violating someone’s personal freedom.
Freddie DeBoer, a leftist who has written openly about his own experience with mental illness, strongly supports involuntary treatments. His argument is that it is more humane to force someone into treatment than to let them spiral into self-destruction.
From an article he wrote for the Daily Beast:
It is, of course, a very serious step, to force someone into treatment against their stated desires, and it should never be done lightly. But for those barely holding on, such action can very well be the difference between life and death.
In the same article, Freddie provides a history of mental health public policy in the United States.
The overarching problem today, he argues, is wrapped up in deeper problems with the American healthcare system:
One of the fundamental problems with American mental health care lies in the bifurcated inpatient-outpatient system. While the wealthy can always get discreet treatment in upscale hospitals that feature all the amenities of a resort, ordinary people have to confront equally unappealing alternatives.
The choice is often between immediate and uncomfortable inpatient care in facilities that deprive patients of autonomy and freedom, and which (contrary to many people’s assumptions) can leave you with huge medical debts. That route also often involves hunting for a doctor who will refer you and a facility with an open bed, which can be very daunting when in a psychiatric crisis. The other option is seeking outpatient care, which entails all of the difficulty of getting health insurance to pay for anything (if indeed you have insurance), with the additional problem that there’s a serious shortage of psychiatrists in this country, again while you’re suffering through a crisis. Contrary to what many people seem to think, every city does not have a hospital on the edge of town where you can just turn up and get help.
DeBoer has written about his own experience of bipolar disorder. He believes his life has been saved by psychiatric medication, and he wants others to get the psychiatric help they need.
In a different piece for UnHerd, Freddie attacks the trendy progressive ethos that views mental illness almost favorably as another type of “identity”:
Today’s activists never seem to consider that there is something between terrible stigma and witless celebration, that we are not in fact bound to either ignore mental illness or treat it as an identity.
Were we wiser and more serious, we might be able to see psychiatric disorders as both natural and lamentable, as beyond the control of the individual but still within their responsibility. We would have sympathy for those who suffer from them, but recognise that sympathy only accrues to those whose conditions are unfortunate, unhealthy. We might be honest and say that, yes, it’s bad to be afflicted with psychiatric disorders.
Along with being uncertain about the causes of mental illness, we are still experimenting with our public policies and social understandings of mental illness.
The most honest explanation for the causes of mental illness is unsatisfying: mental illness is caused by some unknown combination of nature and nurture.
Maybe the “solution” will be found with magic mushroom research, but more probably, the innovative psychedelic therapies will fall within the same patterns of the old medical solutions: they will work for some people, but we won’t know exactly why.
This field of science is still young. Looking at it optimistically, we have already made decent scientific progress over the last century. We have ruled out a lot of bad ideas, and we have stumbled upon some things that seem to work sometimes.
In terms of the “nurture” aspect, we are stuck in a rut. Modern civilization isn’t always conducive to mental health and happiness, especially now that our technological lifestyles are causing us to be more physically isolated from each other.
The best we can hope for is to continue improving our treatment mechanisms while finding a social balance between self-efficacy and mutual support.