Misleading people that mental illness is brain disease

I’ve reposted a previous post from September 2010 about ‘Misleading children about mental illness’. The link to the NIH curriculum supplement on ‘The science of mental illness’, mentioned in that post, is dead. However, the section on the 2007 published “Information about mental illness and the brain’ from the NIH curriculum supplement series is available (see webpage).

That webpage states:-

As scientists continue to investigate the brains of people who have mental illnesses, they are learning that mental illness is associated with changes in the brain's structure, chemistry, and function and that mental illness does indeed have a biological basis.

This is not true. There is no evidence that functional mental illness is brain disease (see eg. previous post). The implication is that psychiatry needs to abandon its biomedical framework (see previous post). Although psychiatry ignores this critique, the complexity of the relation of biology with interpersonal, social and cultural factors does need to be acknowledged (see another previous post). As in the title of a previous post, psychiatry is too based on speculation rather than fact. For my whole career, I argued that psychiatry needed to incorporate a critical/relational perspective (see previous post). It’s about time that psychiatry became more open and therapeutic.

Misleading children about mental illness

(Originally published Sept 2010)

The NIH curriculum supplement for middle school (grades 6-8), The science of mental illness, aims to introduce students to what it calls the key concept that mental illnesses have a biological basis and are therefore not that different from other illnesses or diseases. It is important to get children to understand that the brain is the origin of thoughts, emotions and behaviour, and they do need to learn to challenge their negative prejudices and not be frightened of mental illness, but the way to do it is not to make the misleading and oversimplistic statement that mental diseases, such as depression, are diseases of the brain.

The curriculum is also keen to convey to students how science can help us make informed decisions. What it does in fact is demonstrate how knowledge is shaped and formed by our modern biomedical beliefs. The propagandist nature of the educational material needs to be made transparent.

Is antipsychotic prescribing justified in children and adolescents?

As I mentioned in my book chapter:-

Joseph Biederman, [was] professor of psychiatry at Harvard Medical School and chief of pediatric psychopharmacology at Harvard's Massachusetts General Hospital, …[and] influenced psychiatric practice to the extent that children as young as two years old … [were] diagnosed with bipolar disorder and treated with a cocktails of drugs, many of which are [still] prescribed ‘off licence’. Through Congressional investigations by Senator Charles Grassley, it … [was] disclosed that Biederman received $1.6 million in consulting and speaking fees between 2000 and 2007.

An obituary regarded him as the ‘father of paediatric psychopharmacology’. Johnson & Johnson gave more than $700,000 to a research center headed by Biederman (see NY Times article), which was involved in research on Risperdal, the company's antipsychotic drug, which is prescribed as a so-called mood stabiliser (see eg. previous post). 

Klau et al (2023) recently examined patterns of paediatric antipsychotic prescribing in Australian primary care services in 2011 and 2017. Antipsychotic prescribing increased in children and adolescents between these dates and most such prescribing was off-label, with an increasing proportion of off-label prescribing. Almost 70% of these patients prescribed antipsychotics were also co-prescribed other psychotropic medication. The most common diagnosis of children and adolescents prescribed antipsychotics was depression/anxiety, although international studies have found ADHD to be one of the most common diagnoses, and the proportion of ADHD diagnoses in this Australian sample doubled from 2011 to 2017. Antipsychotic prescribing for autism increased in those without the additional feature of behavioural problems, which is required for on-label use. Antipsychotic prescribing has also increased for those with eating disorder, even though off label, maybe because the weight gain is seen as potentially beneficial, particularly by olanzapine.

When I first trained in psychiatry, children and adolescents were seen as having emotional and behavioural problems but diagnosis of mental illness, as such, was uncommon. Medication had a very limited role in the context of family and behavioural therapies. As I wrote in my 2003 article:-

Historically, child and family studies … tended to take a more holistic approach to personal and social problems. The speciality of child psychiatry … served as a haven and opportunity for those who wanted to escape the reductionism of their colleagues in adult psychiatry. It … [is] a pity that the discipline has now been so invaded by the biomedical model.

Despite the efforts over the years of psychiatrists, such as Sami Timimi (see eg. previous post), this biomedicalisation has continued. As far as antipsychotics are concerned, there are potential harms such as weight gain. More fundamentally antipsychotics are at least overprescribed in children and adolescents outside licensed indications. Their use at least needs to be reduced and more critical debate is required about any benefit/harm ratio. Overmedicalisation of children’s mental health problems is not helpful (see eg. previous post). Young people need to be given correct information about mental illness (see eg. another previous post). The cultural process of seeking to create panaceas for emotional and other mental health problems of children and adolescents doesn’t always work and may be creating more problems than it is worth. 

The nature of psychiatry

I’ve mentioned Ivana Marková before (see previous post). She has an interesting article in History of Psychiatry in which she draws from Heidegger to explore the question of what psychiatry is. Psychiatry is a form of interpersonal interaction in which there is a specific reaching out of one Being to another. Through recognition of the other’s mental condition there is a corresponding sense that something should be done about it. She uses the word ‘distress’ for the condition being recognised, which is perhaps not ideal, and she may need to supplement her analysis with one about the nature of mental illness (see eg. previous post). 

As she says, meaning is created through interaction of clinician and person. The construction of distinctions and categories in diagnosis cannot be reified, or even necessarily reduced to brain abnormalities, and should not be viewed as always depicting absolute reality. We should not be surprised if we “struggle to fit clinical presentations into the conventional descriptions”. As she says, 

In the face of a psychiatry that is driven ever more by a neurobiological reductionism in research and by a mechanistic and algorithmic approach to the assessment and management of patients, it is increasingly important to rethink a formulation of psychiatry from within [her emphasis].

As she concludes, authentic engagement is required in the practice of psychiatry (see eg. previous post). Trouble is that modern psychiatry too often avoids it, even labelling it as anti-psychiatry (see another previous post).

Foundations of the Critical Psychiatry Network

I’ve mentioned before (eg. see previous post) my article on ‘Twenty years of the Critical Psychiatry Network’ (CPN). Key CPN members have written a chapter in a forthcoming book on ‘The emergence of the UK Critical Psychiatry Network’.

As the chapter says, the issues that brought CPN together still remain. To quote from it, “Psychiatry does not always make decisions in the best interests of patients, yet it presents itself as though it does, therefore avoiding necessary political and democratic scrutiny”.