Our Psychiatric Future

Nikolas Rose

• Publisher: Polity
• Year: 2018
• ISBN:
  9780745689159
• Edition: 1
• Topic: Social Sciences
• Subtopic: Sociology
• Index: Social Sciences

Our everyday lives are increasingly intertwined with psychiatry and discussions of mental health. Yet the dominant medical discipline of psychiatry remains surrounded by controversy. Is mental distress really an illness like any other, treatable by drugs? Can psychiatrists differentiate between mental disorders normal eccentricities, anxieties or even sadness? Should the power of psychiatrists be challenged by the knowledge of those with lived experience of mental ill health? In this penetrating analysis, Nikolas Rose critiques the powerful part that psychiatry has come to play in the lives of so many across the world. A series of chapters, each tackling an area of dispute head on, opens wide the terrain of debate addressing issues such as advances in brain science, the politics of Western psychiatry's spread across the globe, and recent evidence of social adversity's role in producing mental ill health. The answers we find to these pressing questions will shape the psychiatric futures that are being brought into existence. Ultimately, this book proposes a radically different future, no less evidence-based or rigorous, and indeed far more attuned to the realities of mental health, and argues that, as a branch of social medicine, another psychiatry is possible.

1
What Is Psychiatry?

This is a book about psychiatry, the part that it has come to play in the lives of so many of us across the world, and the challenging questions the pervasiveness of psychiatry raises about mental distress, about the promises and powers of psychiatrists, and about normality itself. Why focus on psychiatry and not mental health or mental illness? In fact, of course, the two are inextricable: the very idea of madness, mania, melancholy and more as illnesses is, in large part, a function of the history and reality of psychiatry, because it has shaped how we have come to know these conditions, how we speak of them and how we try to intervene upon them. To think of mental illness or even, to use the phrase becoming common, ‘mental health issues’ thus inescapably places us in relation with psychiatry. It is that relationship, our relationship to psychiatry, that is the focus of this book.¹

But what is psychiatry? This seems a simple question – the dictionary tells us that, psychiatry is the branch of medicine concerned with the causes, diagnosis, treatment and prevention of mental illness.² Yet a moment’s thought tells us that psychiatry, even in this simple sense, is a rather special ‘branch of medicine’ not least because it seems to have become a part of the lives of almost all of those who live in advanced liberal democracies and increasingly for some of those in the developing world.³ So let us begin by exploring the ‘territory’ of psychiatry today.

Our psychiatric lives

This sense that our everyday lives are increasingly intertwined with psychiatry becomes even stronger if we accept the description of the scope of psychiatry which is now used by the World Health Organization (WHO) and many other organizations. For these bodies, notably when they compile their estimates of the prevalence of mental disorders, the territory of psychiatry does not merely include familiar conditions such as depression and schizophrenia; it also covers neurodegenerative disorders such as Alzheimer’s disease, includes complaints such as anxiety and panic, extends to relatively recent diagnoses such as dyslexia as well as to conditions such as addiction, substance abuse and obesity, which some might not think of as mental disorders at all. Taken together, estimates put the prevalence of such a wide array of conditions at over 25 per cent of the adult population in the European Union in any one year, and 50 per cent over a lifetime – these are broadly the same for the United States.⁴ Indeed, perhaps the most often quoted recent figure for Europe estimates that over a third of the European population each year is afflicted with a potentially diagnosable ‘disorder of the brain’, even though many of these people never consult a psychiatrist or receive treatment (Wittchen et al., 2011: 843). If psychiatry is the name we give to those diverse experts and practices which deal with these conditions, it is clear that it is no longer a matter of concern to a few unfortunate souls: over our lifetime, almost all of us are potentially suitable cases for treatment.

But right away we have hit controversy! Should we accept these estimates? Who made them and how? There seems to be a lot of slippage here – mental illness, mental disorder, brain disorder – don’t we need much more precision? Can these conditions really affect one in four – or even one in three – of us each year? And what is implied by lumping all these conditions together – surely anxiety and Alzheimer’s are rather different species of things? And in what sense are these ‘brain disorders’? Apart from the banal fact that all mental activity has neural correlates, is it really the case that these diverse troubles share common mechanisms in the brain? Indeed, are some of these things ‘disorders’ at all? Surely obesity, which has increased greatly in many countries over the past 50 years, is a matter of lifestyle, not a disorder, let alone a disorder of the brain. Can’t the same be said for all those mental health issues that almost everyone seems to suffer from at some time or another – mild depression and anxiety – or even more severe conditions such as post-traumatic stress disorder and self-harm, which are on the increase, especially among women? Are these not best understood as fundamentally social problems, exacerbated by the stresses and strains of everyday life in our 24/7 society with its constant barrage of social media and so forth?⁵ And so on. Let us hold these thoughts for a moment, for we will revisit all of them in later chapters.

For now, we have established one important thing – that whatever psychiatry deals with, or wants to deal with, is no marginal matter.⁶ If you or I are not directly among the number directly affected, it is very likely that a family member is – a spouse, a child, a relative. Indeed, when it comes to children, we are seeing a worldwide increase in the numbers diagnosed with problems of behaviour, or attention or ability that are deemed to be psychiatric, or at least thought likely to benefit from the attention of a psychiatrist or a related mental health professional. Numbers vary greatly from country to country, but a recent estimate in the UK is that one child or young person in every ten will suffer from a diagnosable mental health condition, with increasing numbers of young people being diagnosed with depression or self-harming, leading to the introduction of mental health programmes in schools involving mindfulness and ‘happiness lessons’.⁷ And this does not include those who are diagnosed with attention deficit hyperactivity disorder, whose numbers in countries such as the United States have been the subject of much controversy. And given our demographic changes, in which so many of us are living longer, at the other end of life there are the dementias that are now no longer ‘in the shadows’, but are widely discussed, and that we now think are likely to afflict so many of us, our relatives and friends, as we age.⁸

It was once possible to think of psychiatry as a rather esoteric activity, conducted by doctors and nurses, who were almost as weird as those whom they treated, dealing largely with people locked away in mental asylums, and extending outside the walls of the mental hospital only to a few self-obsessed individuals receiving some kind of psychotherapy. That is the image portrayed in the movies from the 1940s to the 1970s, from Spellbound and The Snake Pit to One Flew Over the Cuckoo’s Nest or Morgan – A Suitable Case for Treatment. But psychiatry now seems to be part of almost everyone’s life, in many cases quite literally. That is to say, psychiatry is shaping the very experience of living as its languages and diagnoses pervade the ways we understand and respond to our problems and think of those of our children, our relatives and our own life course.

Everyone’s little helpers

Another crucial dimension of this psychiatric reshaping of our life itself is the global reach of the most common psychiatric intervention – psychopharmaceuticals. While figures vary from country to country, as a rough estimate about one person in ten in the countries that are part of the Organisation for Economic Co-operation and Development is taking a prescription pharmaceutical for depression, anxiety or some other mental health problem at any one time; for women, the figure is closer to one in six.⁹ Once more, though, we immediately enter controversial territory. How can we account for the rise of the use of these drugs – not just the tranquillizers that were once such an object of cultural attention – ‘mother’s little helpers’¹⁰ – but now the antidepressants, of which Prozac became the most famous.¹¹ In most of the countries where we have data, use of these antidepressant drugs doubled in the decade from 2000, with the greatest use in Iceland, Australia, Canada, Denmark and Sweden.¹² And these drugs, initially celebrated because of their specificity for depression, are now prescribed for a multitude of disorders, including panic disorders, anxiety disorders, shyness and social phobia. No country has seen a reduction in their use. Why has there been such a worldwide rise? Why are there such huge variations between countries? Surely not because the conditions themselves show such huge variations in prevalence. Have psychiatrists become so attached to the prescription of these drugs because their use seems to give them real treatments, and hence demonstrate the scientificity of their professional expertise, and ally them with the rest of medicine?¹³ Do the drugs work, or are they just ‘placebos’? Are we not just medicalizing normal problems of living, with psychiatrists in some countries more keen to do this than in others? And why do these drugs appeal to so many people? For while it is still the case that some people, not just those in psychiatric hospital but also some living in the community, are compelled or obliged to take such drugs, most do not do so under compulsion, but because they believe that they will, in some way, help. Once more, hold onto these thoughts, for we shall certainly come back to them in later chapters.

But for the moment, let me return to that simple dictionary definition answer to the question ‘what is psychiatry?’ The dictionary definition is deceptive for many reasons – indeed, the very question itself is misleading. Let me list four sets of reasons why, unfortunately, we need to make things more complicated.

Many psychiatries

First, of course, there is no one ‘psychiatry’ – psychiatry is heterogeneous with many different and sometimes incompatible conceptions of mental disorder, and many different treatment practices. While it is true, today, that biological psychiatry is dominant, at least in the field of Euro-American research, and that biological treatments, notably drugs, have the widest coverage of all psychiatric interventions, most practising psychiatrists in clinics and hospitals, even though they consider drugs essential to their practice, are not simply ‘biological’ in their ways of understanding, diagnosing and treating disorders.

We will spend some time in this book considering the argument made by some neurobiological researchers, and also part of the rationale for the heavily funded ‘brain projects’ that have been established in Europe, the United States, China, Japan and many other countries, that mental disorders should be considered as diseases of the brain.¹⁴ But we also need to recognize that many psychiatrists, even if they accept the premise that the troubles they are dealing with have their roots in the brain, focus their diagnostic and therapeutic attention on matters that are normally thought of as mental rather than cerebral – that is to say, on disordered or repetitive thought patterns which may or may not have a biological basis, but which they hope can be ameliorated by cognitive therapies of various sorts. Indeed, many now recommend ‘mindfulness’, which has morphed rapidly from something associated with esoteric practices of Buddhists to a rather banal practice that aims to change the way we feel about stressful experiences,¹⁵ and which has become an option in the toolbox of psychiatrists, psychologists, social workers – and indeed anyone who has access to the internet or a smartphone. Those responsible for setting out policy guidelines, such as the National Institute for Health and Care Excellence (NICE) in the UK, often advocate nonmedical activities for mild and first episode conditions, such as lifestyle changes, followed, if this is not effective, by psychosocial interventions – though in many countries, drugs remain a first, not a last, resort.

Of course, diagnostic and treatment guidelines for medical and psychiatric professionals – where they exist – vary from country to country and change over time, and not everyone follows such guidelines. Indeed – and this is something that should always be borne in mind – the diagnosis and treatment of mild mental health issues often never reach psychiatrists at all. Most experiences of mental distress are managed by families, friends and lay persons outside the mental health system; indeed, what professionals term ‘primary care’ is actually secondary care. Further, when such distress does come to the attention of a medical professional – a process much studied by sociologists (for a classic study, see Smith, 1978) – it is often managed in the general practitioner’s clinic, where those reporting troubling moods or feelings are usually given prescriptions for psychoactive drugs, because these are the most readily available options, and because waiting lists for specialist consultations and psychological interventions are long even in the countries where they exist at all...

Table of contents

• Cover
• Dedication
• Copyright
• Acknowledgements
• 1 What Is Psychiatry?
• 2 Is There Really an ‘Epidemic’ of Mental Disorder?
• 3 Is It All the Fault of Neoliberal Capitalism?
• 4 If Mental Disorders Exist, How Shall We Know Them?
• 5 Are Mental Disorders ‘Brain Disorders’?
• 6 Does Psychopharmacology Have a Future?
• 7 Who Needs Global Mental Health?
• 8 Experts By Experience?
• 9 Is Another Psychiatry Possible?
• References
• Index
• End User License Agreement