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The Limits of Psychiatry by Much of the expansion of psychiatry in the past few decades has been based on a biomedical model that encourages drug treatment to be seen as a panacea for multiple problems. Psychiatrist Duncan Double is sceptical of this approach and suggests that psychiatry should temper and complement a biological view with psychological and social understanding, thus recognising the uncertainties of clinical practice The increasing accountability of doctors
following the deaths of children in the Bristol Royal Infirmary's paediatric
cardiac surgical unit has focused attention on the foundations of
medical practice. Ian Kennedy, who chaired the Bristol inquiry,1
provides a direct link with earlier cultural critics of medicine Illich made specific comments about psychiatry in his critique of medicalisation and the limits to medicine.3 He attended the 1977 world federation for mental health conference in Vancouver, Canada, where he debated the issue of whether mental health professionals are necessary.4 He maintained that "do it yourself" care was preferable. The central concern of Illich's work was the legitimacy of professional power, whether in health systems or in other systems, such as education. There is no direct equivalent in general medicine of the "anti-psychiatry" movement, commonly seen as a passing phase in psychiatry and associated with the names of R D Laing and Thomas Szasz.5 Illich came from outside medicine, whereas the proponents of anti-psychiatry came from within psychiatry, even if their influence was subsequently marginalised by mainstream psychiatrists. The cultural role of psychiatry is more obviously open to criticism than is the case in the rest of medicine. This is because of its direct relation to social control through mental health legislation. Although diagnosis of mental illness should not be predicated on social conformity, in practice this criterion may be applied. During the 1970s and 1980s, for example, reports that the authorities in the Soviet Union were incarcerating substantial numbers of dissidents in mental asylums caused widespread concern in the West. Over recent years, the use of psychiatry as a tool of state repression in China seems to be increasing.6 A modern critique of psychiatry needs to move on from the perspective exemplified by Illich and the proponents of anti-psychiatry that psychiatry should not be imposed on anyone, as this view is not consistent with a practice in which compulsory treatment has been integral. It was only after the Mental Health Treatment Act 1930 that voluntary treatment became an option in Britain. None the less, because of the potential for abuse, a critical perspective that scrutinises the role of coercion in psychiatric treatment is still required in the current debate about the reform of the Mental Health Act in the United Kingdom. I outline here the expansion of psychiatry over
the past half century and offer a sceptical view of this development.
Growth in mental health service activity and technology Despite the reduction in psychiatric beds in England over recent years (fig 1), mental health service activity has increased considerably. The annual number of antidepressant prescriptions, for example, has more than doubled over the past seven years (fig 2). Similarly, the number of consultant psychiatrists has more than doubled over the past 22 years (fig 3).
As the number of psychiatric beds has decreased, the number of people in prison with a mental disorder has risen, with a higher proportion of women inmates having mental health problems than men.7 Authors in the United States suggest that prisons are replacing mental hospitals, but the data could be explained either as the "psychiatricisation" of criminality or as the increasing diagnosis of mental illness in prisoners not previously recognised as being mentally ill. As more resources have been provided for mental health services, more resources are perceived to be needed.8 Disillusionment is inevitable in a system of mental health care where an increase in professional staffing cannot completely resolve the perceived unmet need of the population. Demand is unavoidably high as mental health problems are common. The proportion of men and women with a neurotic disorder in a given week was found to be 12.3% and 19.5% respectively in the psychiatric morbidity survey, the largest epidemiological study of the prevalence of psychiatric disorders conducted in the United Kingdom.9 As the expectation of solutions to mental health problems rises through the increasing availability of the mainstay psychiatric treatments (psychotropic drugs and "talking" therapies, such as counselling), the traditional boundaries of psychiatric disorder have broadened. Everyday problems regarded as the province of other social spheres become "medicalised" by psychiatry. Mental health care may function as a panacea for many different personal and social problems. The diagnosis of attention-deficit/hyperactivity disorder in children, for example, has increased dramatically over recent years, paralleled by an increase in the prescription of stimulant drugs in the United States.10 This trend is also apparent in England and is likely to be reinforced by recent guidelines from the National Institute for Clinical Evidence.11 The behaviour of children in whom attention-deficit/hyperactivity disorder is identified overlaps with behaviours commonly displayed by children when they feel frustrated, anxious, bored, abandoned, or in some other way stressed. The obvious critical view is that the social phenomenon of mass drugging of children indicates not a genuine increase in mental disorder but rather a displacement strategy for the difficult task of improving family and school life. It is indeed likely that recourse to drug treatment discourages self responsibility and thereby exacerbates the underlying difficulties that it is supposed to remedy. Attention-deficit/hyperactivity disorder has also become established over the past 10 years as an adult disorder, and it is now regarded by some as the most common chronic undiagnosed psychiatric disorder in adults.12 The expansion of psychiatry is also reflected in the marketing of selective serotonin reuptake inhibitors for neurotic conditions other than depression. Paroxetine, the drug with the greatest net ingredient cost to the NHS in England in 2000, is now approved in the United states for use in multiple disorders: depression, generalised anxiety disorder, social anxiety disorder, panic disorder, obsessive-compulsive disorder, and post-traumatic stress disorder. Selective serotonin reuptake inhibitors have even been promoted and used as lifestyle drugs.13 Two disorders illustrate further the process of medicalisation. Firstly, social anxiety disorder could be seen as the process of medicalising shyness. The disorder is characterised by a marked and persistent fear of social or performance situations in which embarrassment may occur. It is said to be the third most common psychiatric disorder in the United States, after major depression and alcohol dependence. Lifetime prevalence has been estimated at 13.3%.14 Some claim that the condition is not just ordinary shyness and that it is a common public health problem.15 None the less, although definitions of the syndromes of shyness and social phobia may differ, the distinction is difficult to make empirically. Furthermore, we should be sceptical about the potency and benefits of drugs for this condition. Secondly, the diagnosis of post-traumatic
stress disorder was officially recognised after an essentially political
struggle to acknowledge the suffering of the Vietnam war veterans.
Subsequently, the diagnosis has become increasingly associated with
less extreme experiences, encouraged by compensation claims for
psychological damage. However, medicalisation of traumatic human
suffering runs the risk of reducing it to a technical problem.
Providing debriefing and counselling, for example, may not be the
most appropriate focus of humanitarian relief operations in wars and
other disasters.16
Diagnoses are not diseases The number of diagnostic categories has increased in the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association from 106 in DSM-I in 1952 to 357 in DSM-IV in 1994.17 This increase has occurred in the context of attempts to make psychiatric diagnosis more reliable by the introduction in 1980 of DSM-III. DSM-III encouraged the reification of psychological conditions. Social phobia and post-traumatic stress disorder, for example, were first included in international classifications in DSM-III.
Confidence in psychiatric classification
was dampened by the classic study of Rosenhan.18
In this, "pseudo-patients," who were accomplices of the
experimenter, gained admission to different hospitals, each
presenting with a single complaint
This attempt to make psychiatric diagnosis more reliable was associated with a return to a biomedical model of mental illness. The approach has been called neo-Kraepelinian, as it promotes many of the ideas associated with the views of Emil Kraepelin, regarded as the founder of modern psychiatry (box 1).19 Diagnosis does not need to be exclusively in
terms of a biomedical model. It can be about creating an understanding of the
reasons for a patient's presentation. Indeed, focusing on the somatic
nature of a hypothetical underlying disorder tends to deny the
patient as a person and objectifies patients so that they become
merely bodies needing treatment. Although biological explanations are
important An adverse consequence of the biomedical model
is that it encourages a tendency to believe that people are powerless to do
anything about their condition. Such an implication may be obvious, for
example, in the case of alcoholism,20 but the same
principle also applies to other mental health problems, even
psychosis, despite such symptoms and behaviour being more difficult
to understand.
The somatic model has always tended to dominate psychiatric thinking, but psychological and psychodynamic explanations were more widely accepted over 50 years ago. Adolf Meyer, the foremost American psychiatrist in the first half of the 20th century, insisted on regarding his philosophical approach to psychiatry, with its emphasis on the understanding of the person, as an advance over the mechanistic philosophy of the 19th century.21 His work is now largely neglected in the modern biological consensus in psychiatry. He warned against going beyond statements about the person to wishful "neurologising tautology" about the brain (box 2 summarises the assumptions of his biopsychological view22). Psychiatry needs to return to a
biopsychological view to limit its excesses The Critical Psychiatry Network has recently
been formed to provide a network to develop a critique of the current
psychiatric system. Its aim is to avoid the polarisation of
psychiatry and anti-psychiatry. Anti-psychiatry may have failed
because its main proponents were ultimately more interested in
personal and spiritual growth. Moreover, its message became diluted
and confused by combining conflicting viewpoints. The Critical
Psychiatry Network is dedicated to establishing a constructive
framework for renewing mental health practice (www.criticalpsychiatry.co.uk). Footnotes Competing interests: None declared.
Reprinted with permission. Originally published in the BMJ 2002 |
such
as Ivan Illich
