I find my self slightly unsettled to watch the slow infiltration of anti-psychiatry into the various skeptical movements. This is probably facilitated by political ideology. Some left-leaning liberals have a suspicion of psychiatric medication because they are provided by large multinational corporations. Some libertarians are susceptible to anti-psychiatry because the government helps to finance psychiatric care. This is the kind of situation that made me have careful qualifications about new aspiring social movements in my post Crossing the Chasm. Even though there is a broad agreement on social values, there can be a strong disagreement on what empirical methods are best used to fulfill these values. I am carefully optimistic about Atheism+ and I support many of its values, but I first want to see where the movement is going in practice.
Recently, a thread appeared on the Atheism+ forum discussing mental health issues. Right now, it is just one thread and we should not overestimate the size of the problem. We should also not approach the ideas of a few as if they were a majority position. I am not saying that any particular forum poster is necessarily anti-psychiatry and I am also not saying that Atheism+ has been corrupted by anti-psychiatry. After all, anti-psychiatry proponents can probably be found in every movement. I am also not telling marginalized people to stop telling their stories. With those qualifiers out of the way, I do note that arguments commonly put forward by anti-psychiatry proponents has started to appear on the Atheism+ forum. I do not want to make accusations against any individual poster, but I feel it is important and worthwhile to address the claims being put forward. I could have done it the forum thread itself, but as anti-psychiatry is a topic that this blog covers, I thought I might as well make a blog post about it.
The thread is called Mental Illness Support. It starts out completely reasonable where the opening poster is inviting others for discussing things like how mental conditions affect group participating in the atheist movements and what can be done to help those coping with mental conditions become more involved in the movements. I think these questions are highly relevant. In passing, the opening poster apfergus mentioned that a new medication had been beneficial for him or her. For those of you experienced with debating anti-psychiatry proponents, you know what happens next.
Medications and therapy together is the best treatment for most mental conditions
When assigning treatments to an individual with any given mental condition, what factors should determine what treatment is given? One such factor is evidence. It seems reasonable that people should get treatment that has been shown to be effective in scientific studies. In other words, people should get treatments that works. As it turns out, combining different treatments that are effective on their own usually produce better outcomes than any of the treatments alone. If we take depression as an example, three treatments that work on their own are antidepressants, cognitive behavioral therapy and moderate physical exercise. Treatment protocols that combine some of these elements work better than any of them in isolation. It is not necessarily a strictly additive situation, but there is some interaction going on. So, on the balance of evidence, a combined treatment should be the first resort, if possible. This is not to say that the individual components are not effective on their own, because they are. For a example study on this interactive effect that has been referenced before on this blog, se Walkup et. al. (2008).
With this in mind, let us look at a comment made by the forum user rriverstone made the following claim: “I see dependence on an dysfunctional medical model where prescribing medications is the FIRST resort, rather than farther down in the treatment regime, because it’s convenient to medical personnel and because Big PhRMA has had a devastating impact on the medical industrial complex.” This argument is confused, because the best treatments available should be given to patients as a first resort (although there are other factors to take into account). In other words, medication is an effective treatment, so it should be used. Preferably, every individual who needs it should get medication and therapy, but there may be issues with insurance etc.
Note that the argument asserts that modern psychiatry uses a “dysfunctional medical model”, yet no evidence for this is presented. Also note the implicit appeal to Big Pharma conspiracy theories. The user rriverstone then goes on to make claims about level of prescriptions and suicidality.
Medications are not over-prescribed as most individuals with mental conditions are never discovered
A fairly standard textbook in psychology (Passer et. al. 2009) delivers the following statistics on depression: 1 in 33 young people suffers with depression, yet only 1 in 3 of these are detected and treated. So how can e. g. antidepressants be over-prescribed if the majority of individuals with depression never get them?
Frequency of emergent suicidality is the same in antidepressant and psychotherapy treatments
I explained this in more detail in my post Antidepressants, Psychotherapy and Emergent Suicidality. The general idea is that since the frequency is the same, the effect is probably not directly due to antidepressants. As another forum user (Grimalkin) notes in the topic, the apathy goes away faster than the depressed mood. Seemingly paradoxically, individuals with severe depression may sometimes not have enough motivation or hope to make a suicide attempt. It is also worth noting that self-reports during a week before intake is a stronger predictor of emergent suicidality than interview-rated suicidality. A lot of the studies that claim to have found a link between antidepressants and suicidality did not control for baseline level of suicidality.
I covered this a lot more in a previous blog post on anti-psychiatry called Stefan Molyneux’s Unfortunate Spiraling into Anti-Psychiatry, where I wrote that:
the Mayo Clinic (Mayo Clinic, 2011), most antidepressants are generally safe although, the FDA requires that all antidepressant medications carry black box warnings, which is the strongest warnings that FDA can issue for prescription medications. The warnings note that in some cases (children, adolescents and young adults 18-24 years old) may have an increase in suicidal thoughts and behaviors when taking antidepressants. However, does this state that there is a mere possibility, rather than a documented fact, or is it an uncommon side effect? However, the increase that media reported was just from 2 to 4% and this may have been due to increase in reports (Hall, 2009). Also, after the prescription rate fell by 18-20%, suicides increased by 18% (Hall, 2009). Of course, we have to keep in mind that just because B follows A does not mean that A causes B, but is an important fact to keep in mind. The Olfson et al. (2006) study that appeared to show an increase in suicidal thoughts and behaviors was problematic, since it made the incorrect assumption that the two groups had the same risk for suicide, whereas it was likely that the group treated with antidepressants had more severely depressed patients and thus a higher risk for suicide. Furthermore, Bridge et. al. (2005) showed that suicidal behavior and thoughts in antidepressant tests where similar to psychotherapy trails and Simon et. al. (2006) showed that suicide rates before starting antidepressant treatment where higher and that this declined progressively after starting medication. Cuffe (2007) describes this situation in additional detail.
Are psychiatric labels stigmatizing?
Rriverstone also puts forward the common claim that psychiatric labels are stigmatizing. To a certain extent, this is true, but the story is more complex and nuanced than that. The stigmatization appears to mostly come from the reaction of other people to the thoughts and behaviors of the individual with the specific mental condition e. g. paranoid delusions in some individuals schizophrenia. Also, the residual stigmatizing of diagnostic labels have to be balanced against the benefit of diagnosis. Just as in other areas of medicine, psychiatric diagnosis are important for things like communication, provision of treatment etc. (Lilienfeld, Lynn, Ruscio and Beyerstein, 2010).
Psychiatric medications are not part of a eugenics program
After a little while, the user Alyss enters to conversation and makes the claim that psychiatric medication has eugenics-like properties. I kid you not! The justification for this claim is that these medications reduce sex drive and makes people infertile. No evidence is presented for the claim that psychiatric medication makes people infertile, and I have not been able to find any such information on high-quality medical websites like the NHS or Mayo Clinic.
It is true that some e. g. antidepressants may have side effects that include reduced sex drive, this can be handled by telling your doctor and having the doctor switching your over to a medication with less sexual side effects.
In any case, the psychiatric-medications-have-eugenics-like-properties conspiracy theory does not even make internal sense. Why would the medical establishment and pharmaceutical companies are perpetrating a global eugenics program on individuals with mental conditions? Most mental conditions have some degree of genetic influence, so eugenics would mean that these individuals would not reproduce, and thus there would be much fewer individuals with mental conditions in the next generation, thereby making the profit for these companies much less.
Mainstream psychiatry holds that mental conditions are multifactorial
Alyss beings up another classic anti-psychiatry trope: the notion that modern psychiatry thinks that mental conditions are exclusively caused by “chemical imbalances” and then invents drugs to treat these. In reality, almost all psychiatrists and clinical psychologists understand that mental conditions are multifactorial and results from a complex interplay between biological, psychological and social factors. The “chemical imbalance” idea is really a straw man against psychiatry and was originally a simplified way of explaining the mechanisms of action of certain medications against depression and schizophrenia.
I wrote a more detailed explanation in Stefan Molyneux’s Unfortunate Spiraling into Anti-Psychiatry:
In most introductory textbooks, any given mental condition is explained as a complex interaction between many different biological, psychological and environmental factors. This means that since there are many different causes, there can be many different treatments, not just psychiatric drugs, but many different forms of therapy depending on the specific condition.
Let us look at two examples, namely major depression and anxiety disorders. These descriptions come from the Passer et. al. textbook from 2009 called Psychology: The Science of Mind and Behavior (p. 27 for depression and p. 796 for anxiety disorders).
genetic predisposition, chemical factors in the brain affected by antidepressants, perhaps an exaggerated form of adaptive withdrawal shaped by evolution etc.
negative thought patterns/distortions, pessimistic personality style, susceptibility to loss and rejection, perhaps linked to early life experiences etc.
previous life experiences of loss and rejection, current decrease in pleasurable experiences, increased life stress, loss of social support, cultural factors etc.
evolutionary preparedness to fear certain stimuli, genetic predisposition, over-reactive autonomic nervous system, low levels of inhibitory transmitter GABA, other possible neurotransmitter dysfunctions, possible sex-linked biological factors etc.
displacement of neurotic anxiety, “catastrophizing” appraisals of threatening events, exaggerated appraisals of anxiety symptoms, classically conditioned fear response, observationally learned fear response, negatively reinforced avoidance responses etc.
previous exposure to aversive unconditioned stimuli, traumatic experiences, avoidable fear-inducing conditioned stimuli, exposure to fearful models or to other individuals traumatic experience, fear-inducing media exposure, cultural learning experience etc.
It is important to understand that these factors interact in complex ways, and that putting forward, say, genetic predisposition as a factor that influences mental conditions is not an attempt at dismissing psychological or environmental factors.
So by erecting the straw man that the scientific mainstream position is all about “chemical imbalances”, Molyneux has loaded the dices in favor of anti-psychiatry from the very start. Mainstream psychology and psychiatry absolutely does accept other important factors influencing mental conditions and absolutely does accept treatments other than drugs.
No hugs? :*(
Grimalkin complains about a no-hug rule at a certain treatment facility. The relationship between a client and a treatment provider is very different from the average friendship because they are complicated by something called treatment boundaries (Westbrook, Kennerley and Kirk, 2011). These exists to protect the patient because there is a large power difference between the provider and patient and the relationship is designed to be overall non-reciprocal. While context should matter, some treatment facilities have strict rules governing the physical contact between providers and patients.
Try finding a friend to hug. Or a large teddy bear.
There are more claims that could use a skeptical analysis, but I think I will end here for now. In some sense, this corroborates a point made by some of masterminds behind Atheism+: being an atheist does not guarantee that you are rational or that you accept scientific evidence.
References and further reading:
For most of the references in the blockquotes, see the reference list in the corresponding blog post.
Lilienfeld, S. O., Lynn, S. J., Ruscio, J., & Beyerstein, B. L. (2011). 50 Great Myths of Popular Psychology: Shattering Widespread Misconceptions about Human Behavior. West Sussex: Wiley-Blackwell.
Passer, M., Smith, R., Holt, N., Bremner, A., Sutherland, E., & Vliek, M. (2009). Psychology: The Science of Mind and Behavior. New York: McGraw-Hill Education.
Walkup, J. T., Albano, A. M., Piacentini, J., Birmaher, B., Compton, S. N., Sherrill, J. T., . . . Kendall, P. C. (2008). Cognitive Behavioral Therapy, Sertraline, or a Combination in Childhood Anxiety. New England Journal of Medicine, 359(26), 2753-2766. doi: doi:10.1056/NEJMoa0804633
Westbrook, D., Kennerley, H., & Kirk, J. (2011). An Introduction to Cognitive Behavior Therapy: Skills and Applications (2nd ed.). London: SAGE Publication.