Following the issue of the Surgeon Generals report
on mental health (December, 99), press headlines echoed Dr. David Satcher in
declaring a new era of enlightened understanding. Headlines and media sound bites
proclaimed sciences demonstration that emotional disorders and behavioral problems
were truly legitimate physical illnesses, some would say brain disorders, rooted in
genetics and biochemistry.
Imagine how surprised the writers of such headlines might be to discover these research
summaries in the professional literature:
- "Few lesions or physiologic abnormalities define the mental disorders, and for the
most part their causes remain unknown."
- "[N]o single gene has been found to be responsible for any specific mental
- "[T]here is no definitive lesion, laboratory test, or abnormality in brain tissue
that can identify
- "It is not always easy to establish a threshold for a mental disorder, particularly
in light of how common symptoms of mental distress are and the lack of objective, physical
Surprise: these are QUOTES from within the Surgeon Generals report, just some of
the many similar summaries of decades of research.
Why are headlines trumpeting that our emotional problems are best defined as medical
illnesses, when physicians such as the SG can find no biological lesions or markers that
define them? And why is the press simply parroting the SGs summaries, when such
headlines mislead the public, evidenced by details within the report?
Is it possible that this report, and the oft-repeated truisms that emotional problems
are at root medical diseases, also reflect the influence of business interests, and not
strictly academic science? Sound too paranoid? Whats next, would we suspect business
interests of trying to influence government? Suspect the pharmaceutical industry of trying
to influence the Food and Drug Administration and organized medicine? Could the press
unwittingly be coopted by uncritically accepting the pronouncements of people in
authoritative white lab coats?
We all know that emotional turmoil and human suffering exists -- but is it disease?
Were so used to hearing that "mental illnesses" are "chemical
imbalances" that we miss the point: Decades of research have failed to confirm this
hypothesis. There are no "chemical imbalances" which validly and reliably define
peoples troubles. That is why there are no lab tests or other assays of physical
disease which confirm the "diagnosis" before youre offered Prozac or your
child is given Ritalin.
If your Aunt Doris is sad, demoralized or in a longstanding unhappy rut in her life,
should we call her "dysthymic," a psychiatric label with no demonstrable basis
in biochemistry? If your 9 year old neighbor Andys parents inconsistently instill
discipline in him, and he now misbehaves in school, do we affix the label "ADHD"
[attention deficit hyperactivity disorder], a category for which there is no physical
marker or disease entity? Yes, we can give Andy a medical-sounding label, and supply
stimulant pills. We can give pills which have a sedative or stimulant effect on anyone;
this does nothing to confirm the presence of a physical disease.
Misled by this medical paradigm, we frequently miss a key opportunity to understand the
underlying personal reasons that someone is distressed.
A substantial literature now demonstrates that many psychiatric medications show only
modest efficacy versus placebo, if studied scrupulously (and in research not funded or
squelched by drug companies). [note: Some of this research has been published by Dr.
Irving Kirsch right here at the University of Connecticut.] Interestingly, this
perspective was briefly acknowledged, but minimized in the SG report.
The Wall Street Journal describes "an era of creeping commercialization in
science," citing an analysis of "210 influential journals, mostly in the
bio-medical field" in which researchers publishing studies rarely disclose their
financial ties to drug manufacturers. Such conflicts of interest have been covered in
major medical journals and newspapers in the last year, even eliciting an apology from the
New England Journal of Medicine recently, but this
issue is not to be found in the SG report.
Surveys published in Psychiatric journals show that medical students are rejecting
psychiatry as a specialty, often "citing a lack of scientific foundation," with
trends suggesting that psychiatry is viewed as "outside the mainstream of medical
practice." Psychiatric residents publish satires depicting their education as funded
and shepherded by pharmaceutical companies, with little attention given to the subtleties
of understanding the personal turmoils and hidden dilemmas of another human being. Loren
Mosher, M.D., formerly a prominent researcher with the National
Institute of Mental Health, published his resignation letter from the American
Psychiatric Association in Psychology Today
(Sept./Oct. 99), documenting how the organization is "unduly influenced by
pharmaceutical dollars;" over-relying on drugs, underemphasizing their shortcomings,
side-effects, and toxicities, and virtually ignoring psychotherapy.
Even Consumer Reports and JAMA (Journal of the
American Medical Association) reveal how drug companies conspire to influence prescribing
Physicians and the consuming public.
But pharmaceutical company funds and influence arent mentioned by the Surgeon
General, nor by uncritical publicists in the popular press. Nor does the report highlight
that actual consumers of mental health services can be critical of groups comprised
largely of family members of consumers, such as NAMI [National
Alliance for the Mentally Ill]. The leadership of these latter "family" groups
dont advertise that they are covertly funded by pharmaceutical companies. Remember
the group CHADD, a major proponent of stimulant medication for children, later revealed to
be secretly subsidized by drug makers? NAMI advocates for biological treatment, even
forced drugging, for what they repeatedly call "brain diseases." The SG report
portrays NAMI positively, minimizes the conflict over forced treatment with consumers
themselves, and says nothing of NAMIs multi-million dollar drug industry funding.
Are behavioral and emotional problems illnesses if decades of research have failed to
find physical disease entities which cause them? The headlines surrounding the SG report
blind us to this confounding miscategorization. Is this a summary of science, or is it
marketing of psychiatric guild interests? Isnt it in the financial and professional
interest of psychiatrists (and drug companies) to insist that all of lifes
confusion, unhappiness and conflict is their domain, over which they hold unique medical
expertise? Especially when managed care will only pay for services deemed "medically
necessary," and clearly prefers to pay for pills over the expense of psychotherapy.
Without demonstrating any physical abnormalities, we can give disease labels that then
grant a child the advantage of an extra hour and a half to take their SATs. Or we
can fabricate disease labels which allow a criminal to murder, rape or embezzle, and then
avoid legal consequences due to "psychiatric illness." But isnt this a
subversion of logic and responsibility that the profession is purveying? Why is the press
so uncritically accepting of this illogic, which spins medical illness labels out of no
identifiable physical pathology, while benefiting particular "special
Heres how two professors summarize this issue: "
has unsuccessfully attempted to medicalize too many human
[A child's] school difficulties, your neighbor's marital problems, your
friend's drinking habits, and your anxiety about an upcoming speech may cause great pain
and be worthy of help from a psychotherapist, but that pain and that need for assistance
require no psychiatric diagnosis to understand and no specific medical therapy to
The SG does endorse psychotherapy, but emphasizes primarily more simplistic forms of
therapy that can be easily researched; those that are short-term, focused on limited
problems, and that often have manuals. As H.L. Mencken said "For every complex
problem there is an easy answer, and it is wrong." Most peoples lives and
problems are complex , and so is thoughtful therapy and the research which tries to
document its helpfulness.
Why do we accept such oversimplified and medicalized truisms about lifes
problems? Are we all blinded by the trappings of science? By misleading explanations
repeated often? By appeals to political correctness? Do we prefer dreaming of "magic
pills" rather than facing complex and upsetting human dilemmas that inevitably are
part of life?
Why did the Surgeon Generals "sound bites" in the press misleadingly
summarize the report in the first place? And why did the press repeat the SG headlines
without 1) reading the report, and 2) thinking critically? There may be different answers
to these questions, but none serves the advancement of the publics knowledge.
Dr. Shulman, a Licensed Psychologist, is the Director of Volunteers in
Psychotherapy, Inc. VIP provides psychotherapy in exchange for volunteer work clients
donate to the charity of their choice: A nonprofit alternative to the loss of client
privacy and control experienced under managed care. More information at (860) 233-5115 or
on the web at www.CTVIP.org