For those few of you who have been following this blog, many of the previous entries have been about anti-psychiatry and antidepressants, such as Why Jerry Coyne is Wrong about Medical Psychiatry and Harriet Hall on Kirsch and Efficacy of Antidepressants. A lot has happened over the last few weeks: Dr. Harriet Hall has commented on Angell’s review and the New York Review of Books has published a few letters to the editor responding to Angell. Thanks to the commentator Mark Erickson for alerting me to this in a comment to a previous post.
In Angell’s Review of Psychiatry, Dr. Harriet Hall makes a number of decisive criticisms of Angell’s review that I feel is worth pointing out:
- It is not entirely clear if the incidence of mental disorders is increasing or if we are better at diagnosing them or if the criteria for mental disorders are so wide that almost anyone can be diagnosed to a significant overlap between e. g. depression, anxiety, ADHD and a normal distribution of human behaviors and emotions. The major factor is probably looser criteria for diagnosis, which can partly be influenced by (1) profit motives, (2) giving the clinician the illusion that he or she helps more and (3) indirect fostering a view of efficacy because normal grief etc. may have a higher rate of spontaneous remission than psychological disorders.
- While it is illegal for pharmaceutical companies to encourage the prescription of a drug for a non-approved reason or age-group etc. Hall suggests that a ban on doctors may be unreasonable because there can be specific instances where published evidence exists prior to formal approval and that bans on doctors may slow down incorporation of new medical knowledge and/or disrupt the autonomy and judgement of the medical doctor.
- The “chemical imbalance” hypothesis is oversimplified and misleading and does not appear to be the mainstream position for factors influencing depression anyways, but few credible scientists in relevant fields doubt that many mental disorders, such as schizophrenia “arises from genetically influenced brain abnormalities present at birth that interact with subsequent brain development and environmental contributors in a manner that increases the risk of undergoing a psychotic transition sometime in adolescence or early adulthood”.
- Hall argues that Whitakers argument that psychoactive drugs causes psychopathology is “not convincingly supported by evidence, but they do suggest directions for research.” I would like to add to this that it seems contradictory to say that mental disorders are not caused by chemical and other neurological factors related to the brain, but then also claim that these medications cause mental disorders.
- DSM has its flaws, but it is more beneficial to try and improve it and make it more scientific than to throw the baby out with the bathwater and go back to the days before DSM.
This was just a short summary, but it is worth reading in full. The New York Times has also published a few letters to the editor by John Oldham, Daniel Carlat, Richard Friedman and Andrew Nierenberg with a reply by Angell, which is also interesting to read. They call her on several errors:
- Angell claims that the advent of psychoactive drugs triggered a raging epidemic of mental disorders, suggesting that this means that people are being over-treated. Oldham points out that this is mistaken since 64% of individuals suffering from mental disorders never receive treatment.
- Carlat points out that Kirsch did in fact find a statistical significance effect above and beyond placebo, just that Kirsch rejected it because it did not fit with his arbitrary level of clinical significance. Carlat is also the author of one of the books that Angell reviewed.
- Nierenberg & Friedman exposes the straw man of “chemical imbalance” and points out that the incidence of mental disorders have, in fact, not increased.
It is ironic that Angell, despite being called on the supposed increase in incidence of mental disorders, continues to use the autism card, despite the fact that this is mostly a result of increased awareness and expanding diagnostic criteria. The “autism epidemic” line of reasoning is also a favorite past time of the anti-vaccination movement and it is shameful that Angell has let herself fall prey to the sophistication effect.
There is also an older, five-part series on mental illness denial by Steve Novella that can be found here that might be relevant for context.