David Healy: The Shipwreck of the Singular

David Healy’s reply to Hector Warnes’ comment

I thank Hector Warnes for his comments. There is nothing here that I disagree with but there is something else that I am trying to introduce that falls outside the points Hector makes. Hector focuses on the constitution of the disorders that present clinically. I am looking at the dilemmas facing a doctor who might treat the patient or the patient himself.

The initial impetus to this article came from puzzlement as to why the market in healthcare - not just mental healthcare - isn't working. I expect markets to work. In this case, insurance companies, whether as payers for drugs or as those who have to pay out on claims, would seem to be market players who would want pharmaceutical companies and doctors to go by the best possible evidence. It should not be in the interests of an insurer to let companies sequester the data from clinical trials. Why are these companies, whom I broadly categorize under the rubric of Big Risk, not acting as a counter-vailing market force to Big Pharma. If they were filling their generally accepted market role, we would get cheaper and better drugs.

As I have delved more into the history of this, it has seemed to me that this is not an anomaly but is in fact the norm. The system we have, systematically produces outcomes like this and as a result, healthcare, in general, is in crisis.

We have a bizarre inversion of the 1960’s. Then, critics of psychiatry claimed our labels were in fact the illness that needed treatment but now we live in a world where people use labels from ADHD to neurodiverse to transgender as badges of identity and we are being forced to treat labels we often do not recognize as diseases.

Then there was a push for de-institutionalization; now in the UK, we are detaining three times more people under the Mental Health Act than we did in the 1960’s and there is a growing profusion of community treatment orders and non-statutory arrangements that mean an increasing number of patients who are old or have learning disabilities or adverse reactions to psychotropic drugs that are often detained in hospitals unable to get out with little recognition of this encroachment on our liberties.

This raises questions about what is going on. Can we pinpoint the forces involved and offer some dates that mark when they came into play.

Clearly the journal Biological Psychiatry was present from the late 1960’s and thus antedates Sam Guze's position on these issues. My sense, however, is that biological psychiatry was not an ideological position in the 1960’s. It was one aspect of the field that those interested in both brains and minds pursued without thinking this branded them as the term biological psychiatry now does.

Do you agree?

David Healy

June 2, 2012