© Borgis - Postępy Nauk Medycznych 1/2013, s. 10-21
*W. Joseph Wyatt
Model biomedycznego podejścia do depresji, zaburzeń lękowych, schizofrenii, ADHD, dziecięcego zaburzenia dwubiegunowego i ataków złości: przełom naukowy czy iluzja?
Medicalization of Depression, Anxiety, Schizophrenia, ADHD, Childhood Bipolar Disorder and Tantrums: Scientific Breakthrough, or Broad-Based Delusion?
Department of Psychology, Marshall University, USA
Head of Department: Steven P. Mewaldt, PhD
Wiadomo, że niektóre nieprawidłowości rozwojowe mają podłoże biologiczne. Do nich należą, między innymi, autyzm, Zespół Downa, zaburzenia związane z zatruciem toksynami, choroby metaboliczne i endokrynne. Nie ma jednak mocnych przesłanek naukowych, aby stwierdzać biologiczne przyczyny wielu zaburzeń psychologicznych, takich jak depresja, stany lękowe, schizofrenia, zaburzenia zachowania u dzieci, zespół nadpobudliwości ruchowej (ang. attention deficit hyperactivity disorder – ADHD), dziecięce zaburzenie dwubiegunowe, czy zachowania opozycyjno-buntownicze. W świetle obecnej wiedzy odwoływanie się do modelu medycznego (“medykalizacja”) jako przyczyny powstania ww. zaburzeń jest nadmierne. Powodami, dla których w USA najbardziej popularnym podejściem do problemów psychiatrycznych i psychologicznych jest model biomedyczny są: 1) dążenie psychiatrii do utrzymania silnej pozycji, jako dyscypliny monopolizującej leczenie oraz 2) działanie firm farmaceutycznych w celu zwiększenia zysku finansowego ze sprzedaży leków. Biorąc pod uwagę, że psychiatria i przemysł farmaceutyczny są przedsięwzięciami ogólnoświatowymi, fenomen medykalizacji może szybko rozprzestrzenić się poza Stany Zjednoczone. Takie podejście do zdrowia psychicznego prawdopodobnie będzie prowadziło do: poczucia pacjenta, że poprawa jest mało prawdopodobna i stygmatyzacji związanej z umieszczeniem zaburzenia „w osobie”. Innym niekorzystnym zjawiskiem jest wykorzystywanie leczenia farmakologicznego jako głównego sposobu oddziaływania, a w przypadku zaburzeń behawioralnych poświęcanie zbyt małej uwagi oddziaływaniom psychologicznym, których efektywność jest potwierdzona naukowo. W obecnym artykule omówione są wyniki badań nad biologicznymi przyczynami niektórych zaburzeń. Przedstawiono również rekomendacje dotyczące zmniejszenia koncentracji na działaniach opartych na modelu medycznym w przypadku wielu zaburzeń psychologicznych.
Clearly, a number of psychological and behavioral disorders arise within our biology. These include autism, Down’s syndrome, those due to toxin exposure, metabolic and endocrine difficulties, and several others. In contrast, there is minimal research evidence to support biological origins of the vast number of common disorders such as depression, anxiety disorders, schizophrenia or child problems such as conduct disorders, attention deficit hyperactivity disorder (ADHD), childhood bipolar disorder, oppositional behaviors or tantrums. These disorders have been medicalized when, in the absence of supportive research evidence, they are said to be caused by genetic defects, chemical imbalances or other biological phenomena. The roots of contemporary medicalization in the U.S. are traced to two primary factors – psychiatry’s efforts to re-gain lost status, and profit motive in the pharmaceutical industry. Given that both psychiatry and the drug industry are global enterprises, medicalization threatens to escape the boundaries of the U.S. and spread to other nations. There are a number of unfortunate by-products of medicalization including patients’ feelings that there is less hope for improvement and increased community prejudice, when disorders are thought to be rooted in biology. Another by-product is that validated behavioral treatments may be overlooked, as drugs with unfortunate side effects become the treatment of choice. Research in support of biological causation is discussed and found to be relatively weak. Efforts at pushback against medicalization are discussed.
A psychological disorder or behavioral disorder is “medicalized,” when the patient is given a pseudo-explanation based in the patient’s biology. That is, in the absence of supportive evidence, the patient is told that the disorder was caused by processes within his or her brain chemistry or genes or another biological process. For example, a patient’s depression is medicalized when he is told that the cause is a chemical imbalance in his brain. There is no medical test for such an imbalance in a living person.
For at least forty years in the U.S., psychological and behavioral disorders have been increasingly medicalized by the drug industry, organized psychiatry, and patient advocate groups that are heavily funded by the drug industry such as the National Alliance on Mental Illness (NAMI) which received nearly $12 million from the drug industry in only a four-year period in the late 1990s (1). Today, such unscientific explanations of psychological and behavioral disorders are so frequently spoken and written that they are routinely accepted as factual, although they are not based in research evidence.
In contrast, a number of developmental disorders and other disorders are biologically caused. These include autism, Down’s syndrome and other genetic forms of retardation, as well as disorders that are related to traumatic brain injury, exposure to toxins, nutritional deficiencies, endocrine and metabolic factors, and several others.
However, it has not been proven that the majority of other common behavioral and psychological disorders are biologically caused. Nevertheless, in the U.S. there exists wide-spread belief that our biology causes the majority of cases of depression, schizophrenia, anxiety disorders and children’s disorders such as non-compliance, tantrums, attention deficit hyperactivity disorder (ADHD), bipolar disorder, tantrums and others.
Medicalization is so widely accepted in the U.S. that to call it a delusion may be appropriate. There is little doubt that Americans are capable of widespread false beliefs. Recent polls show that about one-quarter of Americans are either convinced or suspicious that President Barack Obama was born outside the U.S. even though his birth certificate has been made public, and newspapers in Hawaii published announcements of his birth within a week of its occurrence. Moreover, the Governor of Hawaii, who knew the Obama family at that time, has publicly stated that he remembers seeing Barack Obama soon after the future president was born (2). A similar false belief involves global climate change. Only 53% of members of the U.S. Republican Party believe in global warming, despite an overwhelming scientific consensus that global warming is real (3). Thus, it is no surprise that medicalization has flourished, given that sources with credibility, such as the American Psychiatric Association, promote it to the public.
There is another concern. Although psychiatry and the pharmaceutical industry have rendered medicalization quite strong in the U.S., it could go global, given that both psychiatry and the pharmaceutical industry are global.
In the past forty years, medicalization has increasingly substituted for science-based explanations of many disorders of both adults and children. This is true for the disabled and non-disabled (1, 4, 5). It is these common disorders that are the focus of this article. For additional discussion of this topic see a special issue of Behavior and Social Issues (6).
UNANTICIPATED CULTURAL SIDE EFFECTS OF MEDICALIZATION
Medicalization of behavioral and psychological disorders has become more pervasive in the past forty years, and seems to be accelerating. This has occurred within both the professional and public communities. Regarding the latter, from the mid-1990s to the mid-2000’s the percentage of the U.S. public who believe that our biology causes most mental disorders rose from 38% to nearly 75% (7).
There are dangers in the widespread turn to biological causation. For example, research shows that patients feel that there is less hope for improvement, even with proper treatment, when they are convinced that their disorders are bio-determined (8). Belief in biological causation also is related to public increased prejudice against and fear of mentally disabled people, as well as a strong desire to maintain distance from them (9, 10). Medicalization has increased the use of psychotropic drugs as the treatment of choice, and the medicines produce many bad side effects, including some that are potentially fatal. Psychotropic medication errors result in more than six thousand deaths per year in the U.S. (11). These side effects may disrupt the functioning of nearly every organ system in the human body. Also, while medications may provide temporary relief, they do not alter the environmental variables that maintain many problem behaviors. When the medication is stopped, at times the difficult behavior may return at greater intensity than prior to the course of medication, a phenomenon termed behavioral rebound (1).
It is especially tempting for those trained as physicians and nurses to be pulled into the vortex of medicalization, because their training has taught them to observe a patient’s symptoms and then diagnosis a medical illness within the patient’s body. This temptation is heightened because there are biological causes of some disorders, such as autism and others mentioned above. But a warning is called for. Researchers have not discovered biological causes of the majority of common behavioral disorders.
In contrast, there are a number of environmental contingencies that likely cause most disorders. While it is not the purpose of this article to review that literature, researchers have provided convincing evidence that ADHD, conduct disorders and temper tantrums may result from either positive reinforcement of the inappropriate behavior, or inadvertent parental attention to children’s misbehavior. We know that many adults with depression have failed to learn adequate stress-coping skills and, thus, they are at high probability to feel depressed when faced with routine levels of stress. We know that other depressed adults may have adequate coping skills but they become depressed because they are faced with extreme stress at a given point in their lives. We know that anxiety disorders tend to result when people have been subjected to unusual levels of aversive stimulation such as extreme punishment during childhood or elevated levels of job stress, economic stress or family/social stress in adulthood. There are numerous sources for more information about any of these findings. For more, see Flora (12), Whitaker (1) or journals such as the Journal of Applied Behavior Analysis, Behavior Modification, Behavior Research and Therapy, The Behavior Therapist, The Behavior Analyst in Practice, The Behavior Analyst Today, and others.
As one example of the way that one’s learning history may create a psychological/behavioral disorder, simple phobias typically originate via classical conditioning and then are maintained by operant conditioning. For example, the child who is highly fearful of dogs typically has been frightened by a vicious dog with the result that his fear initially was established. Later, when near a friendly dog, he begins to feel extreme fear and he dashes into his home. The relief he feels negatively reinforces his escape behavior, which then causes him to escape in the future, when in the presence of a dog. Anti-anxiety medication will cause him to feel more relaxed in the presence of dogs, but does not treat the underlying cause of his phobia. When told by well-intentioned professionals that his problem lies in a chemical imbalance or other biological variable, he is being misled. He and individuals like him, and their treating professionals, have much to gain by reading this article.
THE RISE OF MEDICALIZATION
The past four decades have witnessed an increasing tendency toward medicalization of the majority of psychological/behavioral disorders such as depression, anxiety disorders, substance use disorders and childhood disorders such as attention deficit hyperactivity disorder (ADHD), conduct disorders and childhood bipolar disorder. Medicalization now pervades both the professional and popular cultures (1, 4, 12).
To understand the roots of medicalization it is important to examine a number of factors that have nourished it. A major influence has been the role of the psychiatry profession as it has attempted to protect its turf from other professionals. Prior to World War II, there were no professions in competition with psychiatry for the right to treat mental health patients. However, following World War II a number of other professions emerged to steadily gain both patients and prestige. These include clinical psychology, counseling, clinical social work and behavior analysis. As a result, psychiatry attempted to buttress its position at the top of the mental health pecking order by tightly embracing medicalization.
By the 1980s the rhetoric of leading psychiatrists had become revealing, as they reacted to the burgeoning status of the “intruder” professions. One psychiatrist, writing in Hospital and Community Psychiatry, stated that “medicalization” of disorders was useful “to rally the troops... to thwart the attackers... Economics demands that we be medical... we use the term to rout the enemy within...” (13). Another wrote in the American Journal of Psychiatry that psychiatrists should “...speak with a united voice not only to secure support but to buttress (psychiatry’s) position against the numerous other mental health professionals seeking patients and prestige” (14).
In 1988, Paul Fink, who was president-elect of the American Psychiatric Association, stated that psychologists and others who were not psychiatrists “...don’t have the training to make the initial evaluation and diagnosis... (and) are not trained to understand the nuances of the mind...” (15). Also that year, as psychologists were attempting to gain hospital privileges in New York, Melvin Sabshin, who was Medical Director of the American Psychiatric Association, warned New York State lawmakers about “the grave and inevitable risks to healthcare...of psychologists’ self-serving claimed advantages for their clients...” Sabshin asked, “Do the substantial and inevitable risks to the quality of patient and medical care in hospitals outweigh the dubious, purported benefits associated with hospital privileges for these non-physician practioners?” (15). Unfortunately, psychiatry’s attacks on other professionals have continued into the present century (16).
By the 1980s it seemed clear that psychiatrists had become concerned with protection from psychologists and other professionals whom they considered to be intruders. Medicalization of disorders, with or without sufficient research support, had become a means to “buttress” their status within the mental health profession.
Psychiatrists had an additional concern, beyond their competition from other professionals. Psychiatrists had noticed their profession’s crumbling status within the field of medicine itself. Between 1970 and 1980 the percentage of U.S. medical school graduates who chose psychiatry as a career had dropped from 11% to 5%. There were several reasons for the decline in interest among young physicians, including that many young doctors viewed psychiatry as a “dinosaur,” a discipline mired in unscientific psychoanalytic thinking. In response to the difficulty recruiting young physicians into the field, psychiatrists held strategy conferences. They concluded that if their field was to re-gain its lost status it would have to emphasize the scientific roots of the profession, or what resembled the scientific roots. Psychiatry would have to advocate biological explanations of mental illnesses (17).
Psychiatry reached for greater scientific respectability with the 1980 revision of its diagnostic handbook, The Diagnostic and Statistical Manual of Mental Disorders (18), commonly referred to as the DSM. A new edition, The DSM-III, was developed to aid the profession’s quest for scientific credibility. In 1977 the president of the American Psychiatric Association, Jack Weinberg, eagerly anticipated the coming edition of the DSM-III. Weinberg announced that the DSM-III would “clarify to anyone who may be in doubt that we regard psychiatry as a specialty of medicine” (19, p. 114). Following its publication, the DSM-III was hailed as “...the ascendance of scientific psychiatry... the new psychiatry (based on) fact” (20). The Medical Director of the APA, Melvin Sabshin, termed the DSM-III “...amazing... a brilliant tour de force” (21). Unfortunately, this was the rhetoric of persuasion, rather than of research findings. The DSM-III was based on no new scientific discoveries about the causes of disorders.
Rather, the primary change from DSM-II to DSM-III was improvement in descriptions of the behaviors, thoughts and feelings that must be demonstrated by a patient in order that a diagnosis could be made. The improved diagnostic criteria brought with it greater likelihood that mental health professionals would agree on the diagnosis, a phenomenon termed reliability. But that had nothing to do with new discoveries about the origins of disorders. Regarding causes of disorders, there was no reason to consider the DSM-III a significant scientific achievement because, as Robert Whitaker (1) put it, no scientific discoveries had led to the revision.
Although the DSM-III provided no new scientific evidence in support of biological causation, psychiatrists unleashed a tsunami of public relations activity aimed at marketing the field as scientific. As Whitaker (1) described it, the American Psychiatric Association launched a blitz of publicity that continues to the present. In 1981 the APA established a division of publications and marketing whose purpose was to “deepen the medical identification of psychiatrists.” The APA held media conferences, produced radio programs, gave awards to journalists whose stories it liked and worked to place spokespersons on television programs.
Included in psychiatrists’ marketing efforts was a stream of books designed to further convince the U.S. population that scientists had discovered biological causes for most of the common mental disorders. One such book was The Broken Brain by Nancy Andreasen who would later become editor of the flagship journal of APA, the American Journal of Psychiatry. Andreasen wrote that “The major psychiatric illnesses are diseases. They should be considered medical illnesses just as diabetes, heart disease, and cancer are.” At the same time, Andreason confessed that researchers had not actually found the biological causes of those psychiatric illnesses, although she confidently said that the causes would be found, “even if the process requires a number of years” (22). Andreasen was asking the public to believe in biological causation as a matter of blind faith, like a religion.
Andreasen’s confidence was unwarranted. In 2010 Robert Whitaker reflected on her statement and on psychiatry’s marketing efforts:
Twenty-five years later, that breakthrough moment still lies in the future. The biological underpinnings of schizophrenia, depression, and bipolar disorder remain unknown. But the public has long since been convinced otherwise, and we can see now the marketing process that got this delusion under way (1, p. 275).
As the APA nears publication of the fifth edition of the DSM in 2013, the delusion remains that there is a broad base of research support of bio-causation. Early reports suggest that the primary change in the new edition of the DSM is that greater numbers of disorders will have been “discovered”. For example, one proposed addition is “childhood temper dysregulation disorder with dysphoria,” a diagnostic term for behaviors that bear a remarkable resemblance to childhood tantrums. Interestingly, this disorder has been created in recognition of the fact that far too many children’s tantrums have been erroneously interpreted as (biologically caused) manic episodes that must be treated with mood-stabilizing drugs (23). Unfortunately, like the disorder it is designed to replace, the new disorder may quickly come to be viewed as a biological phenomenon that lurks within the child and is in need of psychotropic medication. In contrast, it might better be viewed as a behavioral difficulty that would benefit from effective and safe child behavior management training for parents.
SYMBIOSIS: PHARMACEUTICAL INDUSTRY AND PSYCHIATRY
Psychiatrists are not the only group to benefit from medicalization. Drug makers also have reaped benefits because biological causation implies that drugs are the treatment of choice. Study after study shows that, as biological causation theory has flourished, drug sales have skyrocketed (4). Between 1988-1994, there was a 20% increase in the number of U.S. doctor visits at which psychotropic drugs were prescribed. Prescriptions of stimulants tripled and prescription of mood elevators doubled to more than 20 million (24).
In 1995 it became legal to advertise prescription medications directly to the public in the U.S. After years of lobbying the Congress for this change in the law, the drug industry had succeeded. Jobs in the marketing of drugs soared (25). From 1996 to 2005, drug makers tripled their spending on marketing (26). Advertisements to the public soon were found throughout the media, and the advertisements often were wrapped in unwarranted claims of biological causation.
The resultant influence of drug advertisments on both the public and doctors was demonstrated in a study published in the Journal of the American Medical Association (27). In the study, 152 family doctors and internists were visited unannounced 298 times by “patients” – actors who had been trained to demonstrate symptoms of either major depressive disorder or adjustment disorder with depressed mood. At some of the visits the patients mentioned the anti-depressant Paxil, adding that they had seen an advertisement for the drug on television, and they asked the doctor whether the drug might be of help. At other visits the patients told the doctors that they had seen an advertisement for anti-depressant medication, but they mentioned no specific drug. At still other visits the patients made no reference to drugs.
Of the visits at which the patients pretended to have major depressive disorder and Paxil was mentioned, it was prescribed 27.4% of the time. Of the visits at which “medication” was mentioned, Paxil was prescribed only 2% of the time. When the patient made no mention of medication, Paxil was prescribed 4% of the time. Results were similar when patients presented with symptoms of adjustment disorder with depressed mood. It is clear that advertisements for medications may exert powerful influence on doctors’ prescribing processes, a fact well-known to the pharmaceutical industry.
Drug makers’ advertisements to the public often suggest that biological causation has been proven. However, often there are large gaps between what is claimed in the advertisements and what is known within the scientific community. For example, the drug makers’ advertisements often describe a connection between the neurotransmitter serotonin and depression. In contrast to the advertising, the following are findings by respected researchers as reported by Lacasse & Leo (28):
– “A serotonin deficiency for depression has not been found,” said Joseph Glenmullen, clinical instructor of psychiatry at Harvard Medical School, in 2002.
– “I spent the first several years of my career doing full-time research on brain serotonin metabolism, but I never saw any convincing evidence that any psychiatric disorder, including depression, results from a deficiency of brain serotonin,” said David Burns in 2003. Burns is winner of the A.E. Bennett Award given by the Society for Biological Psychiatry for his research on serotonin metabolism.
– In 2004, psychiatrist David Healy described the state of the research. “Indeed, no abnormality of serotonin in depression has ever been demonstrated.” Healy is former Secretary for the British Association for Psychopharmacology.
– Psychiatrist Kenneth Kindler said, in 2005, “We have hunted for big, simple neurochemical solutions for psychiatric disorders and have not found them”. Kindler is a former co-editor-in-chief of Psychological Medicine.
– Compare the above statements with pharmaceutical industry advertisements that routinely claim that the serotonin-depression connection is scientific fact, also as reported by Lacasse & Leo, (28).
– “Celexa helps to restore the brain’s chemical imbalance...” (29).
– “LEXAPRO appears to work by increasing the available supply of serotonin... In people with depression and anxiety, there is an imbalance of serotonin...” (30).
– “When you’re clinically depressed...the level of serotonin...may drop...to help bring serotonin levels closer to normal, the medicine doctors now prescribe most often is Prozac.” (31).
– “...depression may be related to an imbalance of natural chemicals... Zoloft works to correct this...” (32).
The financial interests of the drug industry supplement the efforts of psychiatry, as both promote medicalization. The two industries have become symbiotic. Biological causation is the theoretical mortar that cements them together, although there is remarkably little research to support the notion that physical disease processes cause the majority of cases of common disorders such as depression, anxiety disorders, schizophrenia and childhood disorders such as ADHD, childhood bipolar disorder and conduct disorder (4, 5). Given that drug makers and psychiatrists are convinced of medicalization, what is the state of the research? A brief look at lines of studies frequently cited in support of medicalization reveals a research base that is surprisingly weak.
THE RESEARCH IN SUPPORT OF BIOLOGICAL CAUSATION
Two lines of research typically are cited in support of biological causation. First are genetic family studies. These studies examine the connection between family relatedness and the likelihood that two individuals will be diagnosed with the same mental disorder, a phenomenon termed concordance. The second group of studies compares the structure, function and chemistry of the brains of individuals with mental illness to the brains of those with no mental illness.
Genetic family studies. These studies have consistently shown that the more closely related are two members of a family, the greater the likelihood that both will be diagnosed with the same mental illness, a phenomenon called concordance. Family concordance studies have been described in psychology and psychiatry textbooks for decades and have been interpreted to provide powerful evidence of genetic causation of mental disorders. Perhaps the most frequently cited overview of the family studies was done by Gottesman (33) whose interest was schizophrenia. His review of earlier studies shows that an individual who has been diagnosed as schizophrenic has an approximate 12% chance that his first degree relative (child, sibling or parent, who would share half his genetic structure), also will be schizophrenic. That is well above the 1% population base rate for schizophrenia and suggests a genetic component. Gottesman’s review also found a mean schizophrenia concordance rate of 48% for identical twins. That finding has special importance because their genetic structures are identical. Thus, it is easy to conclude that Gottesman’s review provides powerful evidence of a genetic component to the disorder. Today, Gottesman’s findings are repeated in many psychology textbooks, typically with little critical examination (34).
However, in 2006 a careful review of Gottesman’s methods and conclusions was undertaken, with disturbing results (34). It was revealed that Gottesman had presented only European studies, some of which had been conducted as early as the 1920s. Gottesman had ignored U.S. studies with better methodology that were done in the 1980s. Many of the earlier studies that Gottesman had summarized were done by investigators who were devoted to genetic theories. Many of these early researchers had advocated sterilization of schizophrenics. They had possessed a genetic causation bias that likely influenced their methodology and conclusions. Also, most of the early studies had not been conducted using double-blind methodology. That is, in examining a sibling, the researchers were aware of whether his brother or sister had been diagnosed as schizophrenic. Also, they had employed vague, non-standardized diagnostic criteria and it is possible that many of their subjects were not schizophrenic.
In contrast to Gottesman’s finding of 12% concordance for first degree relatives, six U.S. studies, that were conducted with better methodology between 1980 and 1985, found the mean concordance rate to be only 3.3%. Combining those findings with two studies from Switzerland and Greece (also done in the 1980s) resulted in a mean 4.1% concordance rate (34). These more recent studies suggest a much weaker genetic component to schizophrenia than is commonly presented in psychiatry and psychology textbooks.
Additionally, Gottesman’s 48% concordance rate for identical twins is unreliable, for a number of reasons. For example, studies reviewed by Gottesman employed the proband method to calculate concordance rates. The pairwise method of calculation, which is methodologically preferable and more straightforward, reduces Gottesman’s figure to about 30% concordance for identical twins.
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