Psychoactive drugs have become widespread for treatment of mental disorders.
Mental Illness, Psychosomatic Illness
Psychoactive drugs have become widespread for treatment of mental disorders.
Mental hospitals have been replaced by psychoactive drugs. Some mental illnesses derive from malfunctions in the brain, but George Brown and Tirril Harris found that the most common kind of mental illness, depression, usually starts with something going wrong not in a person’s brain, but in a person’s life. Higher rates of mental illness in different countries, and in different regions within the same country, relate to the amount of inequality between people’s incomes in that country or region. Different kinds of psychological therapy have been found helpful. Psychosomatic illnesses can be brought on by certain kinds of stress and these, too, have been shown to be influenced by psychological therapy.
Can We Be Right in the Head?
The nervous system employs many chemicals, and in the brain they are distributed unevenly. Most drugs that affect the mind do so by influencing the metabolism of transmitter substances, hormones, or other chemicals in certain systems of the brain. One drug might make people alert, another can diminish pain, another changes mood. Such drugs, of the kind shown in the photo at the opening of this chapter, have become familiar. Although some psychoactive drugs, such as alcohol, have been known for thousands of years, the supply of prescription drugs intended to affect psychological functions didn’t really get going until the 1950s; now it’s widespread.
In the 1950s and 1960s in Europe and North America, psychiatry was transformed. You can read about this in Andrew Scull’s Madness in Civilization. Although one reason for the change was the coming of the new drugs, another was the anti-psychiatry movement in which doubts were expressed about the ways in which people with mental illnesses were kept, sometimes involuntarily, for long periods in mental hospitals, not all of which were well staffed or well maintained. At that time, people who suffered hallucinations or delusions, or who were manic or depressed, were kept “under observation” in hospital. In the 1950s, says Scull, “in England and Wales 150,000 patients were to be found locked up in mental hospitals on any given day … in the United States the figure was nearly four times that many.”1 In this way, “In New York State in 1951,” writes Scull, “one third of the amount spent on state operations went to underwrite the costs of its mental hospitals, compared with a national average of 8 percent. ”2 Despite this, at that time, there was no standard system of psychiatric diagnosis, and agreement on specific diagnoses and recommendations for specific treatments was about 65 percent.3
Leaders in the anti-psychiatry movement were Thomas Szasz in the United States and R. D. Laing in Britain. Both had trained in psychoanalysis, which at that time was the principal approach to psychological therapy. Also at that time there was a biological approach to psychiatric treatment: Electro-Convulsive Therapy (ECT). Popular sentiment became involved as concern grew with how people were treated in mental hospitals. This may be seen in Milos Forman’s film One Flew over the Cuckoo’s Nest, in which Randle McMurphy is involuntarily hospitalized and tormented by the authoritarian Nurse Ratched. When he disobeys the rules he is given ECT as punishment. In the end Ratched succeeds in having him undergo surgery with a frontal lobotomy.
The target of the anti-psychiatry movement was psychiatric practice. Long-term hospitalization came to be seen as inappropriate and, at the same time, local authorities became alarmed at the expense of mental hospitals. These changes combined seamlessly with the coming of drugs such as the anti-psychotic Thorazine.4 The result was that mentally ill people were to be cared for, as the phrase stated, “in the community.” Huge mental hospitals that were built in the nineteenth century still stand on the borders of cities, some decrepit, some repurposed to other uses. And, in turn, people who previously would have been in-patients at these facilities are now among those who sit on upturned milk crates outside grocery stores, asking for change. If a person is admitted to the hospital with a mental illness in the current environment, there is pressure to put the patient on a drug regime, and discharge her or him within a few days.
One way in which psychoactive drugs work is by keeping a transmitter substance in synapses for longer or shorter periods. Lengthening this time can occur by preventing re-absorption. Drugs called selective serotonin reuptake inhibitors (SSRIs) are thought to reduce reabsorption of the transmitter substance serotonin, so it remains in synapses and continues to activate the next neurons in the chains of connection. The best-known selective serotonin reuptake inhibitor drug is Prozac, which began to be marketed as an antidepressant in 1987.
A book in which the regulation of society is assisted by psychoactive drugs is Aldous Huxley’s Brave New World, in which the genetics of intelligence are regulated by having people born in special breeding units to be alpha, beta, gamma, delta, or epsilon, with alpha being the more intelligent, and epsilon the grade of those to whom menial jobs will be assigned. Conditioning helps fit people without complaint to their societal roles, and the drug soma is universally used to promote happiness.
Prozac is not soma, but this is from a blurb of Peter Kramer’s 1993 best-selling book, Listening to Prozac. According to the blurb, the book
announces a revolution in the science of the self. Tess takes Prozac because she’s always been depressed; Julia takes it because she doesn’t know who she is; when Sam takes the drug it makes him feel “better than well.” Four and a half million Americans have taken this anti-depressant since it has been introduced, and many have become more confident, popular, mentally nimble, and emotionally resilient.
In a 2008 article Marcia Angell argues that drug companies now control most research on psychoactive drugs and, she says: “there is mounting evidence that they often skew the research they sponsor to make their drugs look better and safer.”5 Three years later, in the New York Review of Books, she reviewed books that questioned the efficacy of Prozac and other such drugs. In her review, Angell reproduces an advertisement for Prozac from a 1995 issue of the American Journal of Psychiatry. It includes a color photograph of a lively looking woman, smiling happily. The heading of the advertisement says: “For your patients with depression: The Prozac Promise.” Below that, the advertisement lays out the promise: “It delivers the therapeutic triad: Confidence, Convenience, Compliance.” What this means is that if you are a psychiatrist, you can have Confidence that your patient will like your prescription, that despite all the problems of depression this solution will be best for your Convenience, and that you can expect the patient to show Compliance with your treatment regime. Depression is the most prevalent mental illness in the Western world.
The marketing of Prozac and other selective serotonin reuptake inhibitors is based on the drug companies’ idea that depression is an imbalance of serotonin in the brain’s synapses. By correcting such imbalances, these companies say, drugs of this kind will solve the problem. Angell reports that that in 2011, 10 percent of people over the age of six in America were taking antidepressants, and many said the drugs were helpful. One problem with the drug companies’ theory of depression is that it is not to be found in the scientific literature. In The Emperor’s New Drugs: Exploding the Myth of Anti-depressants, Irving Kirsh writes: “It now seems beyond question that the … account of depression as a chemical imbalance in the brain is simply wrong.”6 This account is equivalent to the aspirin theory of pain: the theory that pain is a deficiency of aspirin in the blood.
In his book, Kirsch explains that obtaining approval of a drug by the Food and Drug Administration requires a far lower standard than showing that the drug actually works better than alternatives. Kirsch has found that in analyses of properly conducted trials in which people have been randomly allocated either to take a placebo or drug, then in comparison with placebos, specific selective serotonin reuptake inhibitors had either no effect, or a tiny effect. Placebos are inert substances, given as pills, that patients believe in. Kirsch says placebos have been found in such trials to be more effective than no treatment and 82 percent as effective as antidepressants.
Approaching the issue by way of brain chemicals assumes that depression is simply something wrong in the brain. Although brain processes are no doubt involved, the evidence is that people start to become depressed when something goes seriously wrong not in their brains but in their lives.
Life Events and Vulnerability
Our understandings of physical illness have been established in two stages. In the first, known as epidemiology, surveys have been conducted to find who has a particular illness, and what their life circumstances are. Then, in a second stage, hypotheses derived from this first stage have been explored to find particular mechanisms and to work on remedies. The first definitive epidemiological discovery was by John Snow in 1854. Among other findings, he traced an outbreak of cholera in the Soho area of London and showed that people had acquired the infection by getting water from a particular pump. He inferred that the disease was spread by germs. A hundred years later, Richard Doll and Bradford Hill found in a survey of doctors that smoking was associated with lung cancer. It wasn’t until ten years after that that the epidemiology of mental illnesses began with a study of children who lived on the Isle of Wight, in the south of England. The most important psychiatric epidemiological study in adults was made ten years after the study of children. It was on the topic of depression. It was made by George Brown and Tirril Harris, on women who lived in the south of London. Women were chosen as participants because whereas addiction is more common in men, depression is more common in women.
Brown and Harris used a standardized method of diagnosis, by means of a semi-structured interview. They found that those who had a diagnosis of depression were likely to have had a serious life event or difficulty that had adverse consequences for them. Among 458 women interviewed, 37 had an onset of depression during the year before the interview. Of these 37 women, 33 had experienced a severe life event or a severe difficulty before the onset of their depression, a far higher rate of adversity than that for women who were not depressed. A severe event was something such as a loved one dying, or being fired from a job with no prospect of reemployment. A difficulty was a longer term problem, something such as serious illness, or a child being in trouble with the police. When such an adversity occurred to women who also had what was called a vulnerability factor—such as having no one in their lives to whom they were close and with whom they could share their emotional lives—then they were likely to become depressed. The support one gets from interaction of friends and intimates, called “social support,” is now recognized as a major factor in preventing depression when adversity strikes. A common case of someone likely to become depressed is a woman who has two small children, no job, few friends, and a very small income, who suffers the adversity of her marriage breaking down.
Since Brown and Harris’s work, it has been found that having one episode of depression makes further episodes more likely, even without further adversity. At this point changes do seem to occur in the brain to increase the probability of becoming depressed.
An important piece of early work on these issues was carried out in 1930 by Marie Jahoda, Paul Lazarsfeld, and colleagues on effects of unemployment in the village of Marienthal, near Vienna, where the main source of work was a textile mill, which closed down.7 The research was interdisciplinary and innovative. Methods included observations, interviews, and asking inhabitants to keep diaries. The research team also introduced the idea of unobtrusive measures, which included numbers of books borrowed from the local library; these numbers declined, although people had more time on their hands. Poverty became severe. More severe were demoralization, apathy, and depersonalization: depression. Although income is, of course, important, Jahoda and colleagues concluded that the most important benefits of work are social and personal.
In the twenty-first century, an important study of depression is that by Avshalom Caspi, Terrie Moffitt, and their collaborators. They showed that serotonin does seem to be involved in depression, although not as a chemical imbalance of the kind implied by how drug companies say selective serotonin reuptake inhibitors like Prozac are supposed to work.
In 2003, Caspi and his colleagues published a study of 1,032 people (52% male, 48% female) in Dunedin, New Zealand, whom they had followed up from age three to age twenty-six. Participants were tested for the 5-HTT transporter gene, the function of which is to promote the transmitter substance serotonin. The gene comes in two forms, long and short. The long form is more efficient at promoting serotonin. Since everyone has paired chromosomes, one set from their father and one set from their mother, everyone has two of these 5-HTT transporter genes. So these pairs can be long-long, long-short, short-long, or short-short. In the cohort, 31 percent of people had two longs, 51 percent had a long and a short, and 17 percent had two shorts. The participants also had an assessment of how many severe life events they had experienced between their twenty-first and twenty-sixth birthdays.
The results were that people who suffered a severe life event and who had at least one short form of the gene were more likely to become depressed than those with two long forms of the gene. The greatest risk was for those who suffered a severe life event and had two short forms of the gene. Those with one or two short forms of the gene but no adverse life event did not become depressed. The long form of the gene protected people from depression even when severe life events occurred. Many follow-ups have been done. In one meta-analysis, Katja Karg and colleagues found both a role of adversity in the causation of depression, and the moderation of this effect by the 5-HTT transporter gene. In another meta-analysis, Neil Risch and colleagues found evidence for adversities in the causation of depression, but not for the role of the 5-HTT transporter gene in this relationship.8 In the most modern studies, for example by Saskia Selzam and colleagues, it is now recognized that it’s not single genes, but large groups of genes, which have substantial psychological effects.
Mental Illness, Societal Conditions, Therapy
Depression is the most common single diagnosis in psychiatry. It occurs as a pervasive sadness, or low mood, often together with loss of interest in activities that had been enjoyable, along with five other symptoms such as inability to concentrate, disturbances of sleeping, loss of weight, being slowed in one’s movements, feelings of worthlessness, thoughts of suicide.
Longer-term adversities that increase the risk of depression include having been neglected in childhood, being socially isolated, being unemployed, being in an abusive marriage. Although modern industrial society has many benefits, disparities of income increase adversity and so are a major risk to the many people who live in poverty, surrounded by advertisements, television coverage, and physical evidence of what they do not have. To become depressed is to become despairing about life, and about what could ever be done to make it better.
The degree of income inequality in a nation contributes to risk of psychological disorders such as depression in that nation. Figure 16 shows the percentages of people in the populations of four countries who suffer from some form of mental illness. Beneath the column for each country is a number that represents income inequality: the ratio of income of the top 20 percent of incomes in that country to the bottom 20 percent. In Japan, that ratio is 3.4. In the United States, which is among the most unequal societies in the industrialized world, the top 20 percent of the population have incomes 8.4 times those of the bottom 20 percent. You will see, too, that the higher the income inequality, the more people suffer from a mental illness. In the United States, the percentage of the population with a diagnosis of mental illness is 26 percent. Most frequent is depression but mental illness in this study included anxiety disorders and addictions. Richard Wilkinson and Kate Pickett show that negative effects of income inequality apply similarly to physical illness, longevity, obesity, and many other outcomes. They show, too, that the patterns seen across countries are replicated across the different states of America. Although culture and customs across the United States are broadly similar, states with greater inequality of income have higher rates of mental and physical illnesses.
Figure 16. Percentages of people with mental illness in countries that have different levels of income inequality, as found by Kate Pickett, Oliver James, and Richard Wilkinson. Data source: Pickett, K. E., James, O. W., & Wilkinson, R. G. (2006). Income inequality and the prevalence of mental illness: A preliminary international analysis. Journal of Epidemiology and Community Health, 60, 646–647. Drawn by Keith Oatley.
Neglect and abuse of children have been shown to be exacerbated by poverty, and they have been shown to set up vulnerabilities and risks, in adulthood, for states that include depression. These vulnerabilities have been shown to be ameliorated when parental incomes are improved, because the parents become less worried about how to live and can provide better care for their children.
Depression is hopelessness, giving up. It can occur for people whose problems in life have become overwhelming. In this state, people become less able to solve their problems, and so although we don’t yet have a good theory of the brain processes of depression, drugs that enable people to feel less depressed can be helpful to people in coping with their lives. But there is some distance to go before drugs enable people to feel less hopeless, or less anxious about the slings and arrows of fortune. Drugs don’t solve problems such as those induced by inequalities in society, by adverse life events and difficulties, and by childhood neglect and abuse. And, importantly, they should not distract us from the seriousness and pervasiveness of these problems. At the same time, they can sometimes enable people to cope better with their problems and with dispositions that arise from genetics and early childhood experience.
Disorders of depression and anxiety are helped by psychological therapies—talk therapies—for which Freud was an early proponent. Psychoanalytic therapy has been evaluated by Rolf Sandell and colleagues, who found substantial improvements after three years in 156 patients who had severe symptoms.9 After their analyses, these patients continued to improve so that their mental health became indistinguishable from that of the ordinary population.
Psychoanalytic therapy takes a long time and it’s expensive. Another problem is that it’s very difficult to do well. Even Freud said he wasn’t very good at it, or Dora would not have left before her therapy was finished. In her book, Janet Malcolm called psychoanalysis The Impossible Profession. There are now hundreds of psychological therapies, many of which aim to make therapy quicker and easier to conduct. Almost all follow Freud in being based on a therapist listening carefully and striving to understand psychologically what the patient (or client) says.
A form of psychological therapy that has been shown consistently to be worthwhile is cognitive-behavior therapy. For treatment of depression it has been found more effective than drugs, and it has a lower rate of relapse.10 A new principle is that mindfulness meditation is now often combined with cognitive-behavioral therapy or psychoanalytic therapy.11 Mindfulness derives from Buddhist meditation, in which each day one takes a period of time to be secluded and quiet, and concentrate on something of one’s own choosing such as one’s breathing. In this practice, when anxious and depressive thoughts come into the mind during this quiet time, as one returns to what one is concentrating on, those negative thoughts leave it again.
In Ordinarily Well: The Case for Antidepressants, Peter Kramer draws back from the claim in his previous book that antidepressants can make one “better than well.” He offers an extensive review of evidence, statistical and clinical, and concludes that drugs can be helpful to some people some of the time. He also writes that in his practice as a psychiatrist, he relies heavily on psychotherapy, and postpones prescribing drugs.
Psychologists need to work on improving therapies. Perhaps even more important is prevention. Studies by Vincent Felitti and colleagues, including follow-ups such as that by Van Niel, Felitti, and others, have shown that adverse events in childhood—physical or sexual abuse, violence against the mother, having family members who were substance abusers or mentally ill, or had been in prison—are strongly predictive of poorer physical health, as well as psychological disorders including depression and addiction, in later life. They found that the larger the number of childhood adversities, the greater is the risk.12 As well as improving therapies, therefore, psychologists need to work on reducing such risks, all of which are exacerbated by the long-term difficulty of poverty. We all need to work on reducing such factors as income inequality, which negatively affects mental health, starting in childhood, and is also a risk for conditions as disparate as obesity and the number of homicides in society.
The word “psychosomatic” refers to the connection between mind and body. The central issue here is stress. It’s the same kind of idea as adversity, in the epidemiology of depression, but its use tends to be broader and to include mild as well as severe problems. One can read about stress in the newspapers, and ponder the solutions: exercise, yoga, meditation, lead a less hectic life, make more time for yourself.
When we experience a stress, the body responds in two phases. The first is rapid and involves the nervous system and hormones. Adrenaline increases blood flow and cortisol increases levels of blood glucose. The body switches from a state of equilibrium to a state of emergency, ready, as the phrase has it, for fight or flight. In terms of Darwin and emotions (chapter 3) we could say that the stress response is an expression of fear.
In a second phase of stress that is severe and long-lasting, changes can occur in the body’s immune system, presumably from having been in a state of emergency for a long time. First of all, wounds take longer to heal. Second, the immune system can become less efficient in recognizing and destroying infectious germs. Third, the system can fail to recognize the body’s own tissues, so that autoimmune problems such as rheumatoid arthritis (in which the immune system attacks the body’s joints) can get worse. Fourth, the immune system can fail to detect and destroy cancers. Fifth, cardiovascular disease (heart attacks and stroke) can also become more likely, again perhaps mediated by changes in the immune system.
Among innovative researchers is Janice Kiecolt-Glaser, who proposes that stress is fundamental to the integration of psychology and the health sciences. In a study on wound healing, she and her colleagues made a small, standardized 3.5 mm wound on one side of the mouths of eleven dental students during their summer vacation.13 Some weeks later, three days before the students’ first major examination of the following term, the researchers made the same size wound on the other side of each student’s mouth. The wounds made just before the examination took an average of three days longer (40% longer) to heal than those made during the vacation. This study has been replicated.
In a series of studies of long-term stress, Kiecolt-Glaser and her colleagues compared people who were long-term caregivers for spouses who suffered from dementia with similar people who did not have caring responsibilities.14 They found that in the chronically stressed people a substance called interleukin-6 (which is involved in signaling in the immune system) was raised four times above its levels in the non-stressed group. This substance plays a role in promoting heart disease.
A third kind of study was published by Jamie Pennebaker and Sandra Beall, who randomly assigned forty-six psychology students to write for fifteen minutes on four consecutive evenings, either about a trauma in their lives or about incidental issues. Some students who wrote about the trauma were asked to write just about the facts, some about the emotions involved, and some about both the facts and their emotions. Those who wrote about both the facts and emotions of the trauma had higher blood pressure and more negative moods immediately following the writing, but during the next six months they had fewer medical consultations at the university health center than those of the other groups.
Joining with Janice Kiecolt-Glaser and Ronald Glaser, Pennebaker ran a replication of the study described in the previous paragraph with fifty participants who came into the laboratory. They were assigned either to a trauma condition or to a control (no-trauma) condition. Those in the trauma condition were instructed: “During each of the four writing days, I want you to write about the most traumatic and upsetting experiences of your entire life.” Those in the no-trauma condition were given a neutral topic to write on at each session, and asked to write about it without discussing their own thoughts or feelings. On the day before the first session of writing, and again an hour after the final writing session, and then again six weeks later, all participants underwent measures of heart rate, blood pressure and skin conductance, blood tests, and psychological tests. The people assigned to write about traumatic events found the actual writing more subjectively distressing than did the control participants, but they later had more resilient responses to an immunological challenge than did the control subjects. As with the study by Pennebaker and Beall, the participants who wrote about trauma as compared with those who wrote about neutral topics also made fewer visits to their university health center.
Replications of these effects have been made many times by Pennebaker and his group, as well as by several groups of independent researchers. There seems no doubt that therapeutic effects follow from reflecting on traumatic experiences, either in writing or by talking to others. Pennebaker proposes that we are often unable to suppress effects of traumatic experience. It produces a stressfulness that is reduced by confiding to others about the event and its emotions, as well as by reflecting on them by writing.15
Overall, says Kiecolt-Glaser, effects of chronic stress are more severe in women, and in people of both sexes as they get older. One problem in this field, however, is that although some studies, such as the one on stress and wound healing, seem straightforward and conclusive, results on the relation of stress to major categories of illness such as cancer and heart disease are more complex.
In the industrialized world, heart disease kills millions of people each year. The evidence is that it can be precipitated by stress. One major investigative group, led by Kristina Orth-Gomer, has started to make sense of the area in the Stockholm Female Coronary Risk Study. In 2000, Orth-Gomer and her colleagues found that among married women who had suffered a heart attack and were followed up for 4.8 years, those with marital stress were almost three times more likely to have a further heart attack than those without marital stress. In contrast, those who suffered work stress were not more likely to have a further heart attack than those who did not. In another result, in 2009, Orth-Gomer and her colleagues studied 237 consecutive patients hospitalized for acute heart disease (patients with myocardial infarction, coronary bypass, or other kinds of coronary event). They were randomly assigned either to the usual post-hospital care or to a psychosocial intervention program in which groups of four to eight patients met for therapy with a female group leader for twenty sessions of two to two-and-a-half hours over the course of a year. Each group session began with relaxation training, then focused on education about risk factors, cognitive restructuring, coping with stress from family and work, counteracting depression and anxiety, and improving social relations and social support. Leaders made sure that every patient talked at each session. During seven years from the time of randomization, twenty-five women (20%) in the usual care group died, but only eight in the intervention group (7%) died. The intervention, then, provided an almost threefold protective effect.
The first substantial advances in modern medicine came with the epidemiological discoveries of John Snow that cholera was spread by contaminated water and that germs were involved. Then came prevention in the form of provision of uncontaminated water to households, and the removal of sewage and waste. Only after that did antibiotics arrive.
Another advance is in progress, in understanding how psychological illnesses and psychosomatic conditions can be provoked by adversities, such as severe life events, chronic life difficulties, and other major stressors. We have only just started with prevention, on improvements for those whose lives for themselves and their children are difficult, for instance because of poverty, and with psychological therapies that help to enable people to cope, within themselves and in relation to others.
