Unlocking the mysteries of mental illness

Published on Monday 24 August 2009 21:54

LAST year, the global market in drugs to fight mental illness reached £9 billion, fuelled by a long-held medical consensus that diseases such as depression and schizophrenia are caused by imbalances in the chemistry of the brain.

This consensus grew from post-war discoveries of the apparent effectiveness of drug treatments, as well as advances in genetic research that suggested mental illness could be inherited as part of a genetic malfunction.

Though the treatments were a positive departure from the lobotomies and electric shocks used previously, they heralded an age in which pharmaceutical treatment often became the first, and only, option offered to patients.

According to clinical psychologist Dr Richard Bentall, this view has caused a general misdirection in treatment in psychiatry, a fact seemingly laid bare by an unmistakable lack of progress in the field.

"Is there any evidence that psychiatric services are having a global, positive impact on public health?" asks Dr Bentall. "There is good evidence cancer services and heart services are having a global positive impact. There is good evidence it is much better to have a heart attack at the beginning of the 21st century than the beginning of the 20th.

"There is also evidence it is better to have these problems in the industrialised west. In the case of severe mental illness, if anything, the opposite is the case. There is some evidence to suggest that if you are going to go mad, it is better to go mad in rural Africa than the west."

An evidence-based clinical researcher, Dr Bentall has ruffled feathers in psychiatric circles with persuasive books on the ineffectiveness of current thinking. In Madness Explained he began a thesis that held that mental illness was not simply a product of a "broken brain" but caused by a much more complicated set of factors, fundamental to which was societal input.

He contends that it is unhelpful to think of any mental illness as one disease that causes a set group of symptoms. Instead, he believes, symptoms such as hallucinations or hearing voices, should be examined in isolation and understood as an extreme extension of normal behaviour, sometimes triggered by catastrophic events in a person's life. So, according to Dr Bentall, the chemical imbalances in a patient's brain could be the result of a major life event, rather than purely inherited.

"It occurred to me that hearing voices might happen when people were trying to think in words but didn't realise that they were doing the thinking," he explains. "So, instead of asking why somebody is schizophrenic, it is about asking why do they hear voices or why do they become paranoid?"

More brutally, he questions the usefulness of the term "schizophrenia" to understand the group of symptoms conventional psychiatry recognises as signifying the disease. "There has been a growing sense that the concept of schizophrenia doesn't make any sense," he says. "If you look at the research into the disease, you find that any variable, at one time, has been singled out as the cause. The most extraordinary things have been singled out – such as getting a virus from your cat. You get progressively more desperate attempts to find the cause of schizophrenia. But of course, if there is no schizophrenia, you won't find the cause of it."

His thesis is taken further in his latest book, Doctoring the Mind, which examines the state of clinical treatment for mental illness. It is a subject muddied, Dr Bentall says, by a skewed research dominated by pharmaceutical company studies.

"In the west, psychiatric services have been built around the idea that these disorders are genetically caused brain diseases," he says. "This has a number of implications. One is, that tinkering with people's biochemistry is a good idea, because you are going to fix whatever is wrong in the brain. In fact, the evidence for the effectiveness of psychiatric drugs is pretty limited.

"That has been hidden from general view until recently, largely by the efforts of the pharmaceutical industry. The evidence is now pretty clear – antidepressants aren't particularly antidepressant. You might as well take a sugar pill."

This drug company domination, he claims, means doctors focus simply on making patients take the drugs. "Services have become quite coercive" he says, pointing to community treatment orders that compel people to take medication on threat of being returned to hospital," he says.

"I have a huge fear about this. It seems to me that the people who will be compelled to take the drugs will be the very ones who don't find them very useful. The ones who find them useful will take them anyway and what we will find is an ever increasing number of people on mega-doses of drugs, to which they are not responding, and suffering very severe side effects. When they object, those complaints are seen as evidence that they have a mental illness."

To counter this, Dr Bentall says services should recognise that no current treatments are very effective and emphasise the quality of the relationship between doctor and patient. "Psychiatry, bizarrely, out of all the medical disciplines plays less attention to the quality of therapeutic relationships," he says.

"Services need to focus on how to build relationships with the patients, because the quality of relationship is a good predictor of outcome."

&#149 Doctoring the Mind is out now from Penguin Books. www.penguin.co.uk

&#149 Richard Bentall will appear at the Book Festival on Friday at 3pm www.edbookfest.co.uk