David Healy: Shipwreck of the singular
Leonardo Tondo’s comment
David Healy’s ideas and fascinating style emerge, as expected, in his The Shipwreck of the singular. Through erudite citations and historical perspectives David invites us to take part to his crusade against social injustice, environmental poisons (lead as the most dangerous), biological psychiatry, greedy industry, international classifications of mental disorders, and, after all, against non-ideal strategies to treat the unfortunate psychiatric patient.
In principle, I could not agree more about the necessity of social changes in direction of less inequality, satisfying jobs for all humanity, and making love and not wars. However, when it comes to public mental health, I believe that we are dealing with issues of monstrous complexity that require an interactive vision between social and individual components. There are many passages in David’s essay that I would like to comment singularly, albeit rhapsodically, in the hope that the reader has read the essay carefully.
Degeneracy. For instance, in the trajectory from biological determinism to degeneracy and to gas chambers one can accept the first leg as a thought of the times but the second seems a too long stretch. It is shameful that in the past some deviant behaviors passed under the name of mental disorders, but it is mainly in the past (at least in the West); moreover, it is not a good exercise to apply our modern theory of mind to those times. After all we come from those times and we have made many changes along the way.
Numbers. I agree that numerical methods are useful for prevention of illnesses but they do little for the individuals, as Michael Shepherd (frequently quoted by Healy) used to say. I would suggest that it should become regular practice to treat the individual patients and, at the same time, collect their information that could be used to generate useful numbers.
Bad bugs. For the dispute between Koch and von Pettenkoffer, I needed to look it up and found that the former considered diseases as the results of infectious bad organisms while the latter manifested in favor of clean water and air. Koch was thinking of treating the sick individual and his colleague, professor of hygiene, of treating water. Why disputing? Let’s do both.
Prevention. Healy does not seem so strongly in favor of vaccinations. In theory I may agree since it would be good that children develop their own immune resistance but parents tend to get attached to them and most of them prefer to see them vaccinated rather than crippled or dead if the immune response is not that effective. Recently, this trend seems to have been inverted by some parents nostalgic of their childless lives. On the same train of thoughts, a good fight against cholesterol initiated when large studies on ten thousands people reported that it is a risk factors for severe cardiovascular diseases. Social Security systems may not like those findings so much with the results of many old people still alive who, on the contrary, seem to enjoy their last, albeit medicated, years spent with their grandchildren at home. Yes, cholesterol can be lowered with a good diet and lifestyle, but many persons cannot afford it for several reasons. Why not treat the certain precursor of several cardiovascular diseases in the hope of avoiding or delaying their appearance?
Big Pharma. When Healy speaks of the industry, I could not agree more that the association between treatment of diseases and financial profit is outrageous but pragmatically only investing billion dollars in a product has brought important results as well as good (and bad) medicines. National Institutes should take over? I would not argue. Are they capable or willing?
Responsibility. When we say that the use of medicines “pushed the locus of responsibility back on the individual” we should also recognize that in absence of such responsibility, the individuals blame the society or the environment (both to no avail) and do very little to modify their personal situations. It is also interesting that the same countries (mostly western) so enthusiastic about medicines are also those in which environmental actions are more effective. I have no doubts that the change in many aspects of our society is mandatory and I would put on top of my personal priority list a major fight against social inequality but mental health professionals have to deal with the individuals in front of them and they need to give them some answers hic et nunc. In addition, while at some point a global effort may decrease levels of inequalities, the efforts should exponentiate to correct the incidence of marriage breakdown which, by the way, are often a consequence of a psychic disorder.
Insurance. The attack to the insurance industry is also justified; in fact, it can be blamed for a conflict of interest but actually their interest is more in defeating illnesses and reimburse less whereas for the individual having a protection would allow for better care. On the same line, campaigns against cigarettes smoking have been beneficial for both the insurances and the individuals (bad for the multinational tobacco industry).
Military. Wars are certainly unhealthy environments for their victims and for the survivors who would live the rest of their lives with different degrees of PTSD. Yes, the point is clear, we all know that the answer should be ‘Make love, not war’ but since many politicians with intimacy issues prefer war in order to show still high levels of testosterone, at least the community has to take care of the disgraced subjects who decided to follow them. If mental health professionals (us) can do something, let them do it.
Refrigerator mothers. Double-bound mothers are also bad environment but they are always considered such after they had their schizophrenic children. I would really like to see a study on low-temperature mothers before their children were ill and follow them up to check how many of these become schizophrenic. This brings back the issue of the failure of identifying unskilled parenting. Unfortunately all parents have little – or too much –parental skills. Fortunately enough, human beings are provided with their own cognitive and emotional ways to grow nice and happy despite terrible parents, and viceversa.
Autism. That psychic diseases are apparently more present in the West, would not depend that their diagnosis in the East is less likely? The oppression of the mad is certainly more pronounced in less western countries and paradoxically is so in poor countries and less educated areas of all countries. This is probably what happens with autism that years ago was limited to severe cases and now it is recognized in all its nuances. But the same with catatonia and post-partum psychoses that have relatively disappeared mainly because of better recognition and treatment before they can even express themselves fully. And that these patients were less hospitalized before may not be associated that in less metropolitan areas it was more accepted or more easily handled by families and communities?
General practitioners. Doctors in primary care keep seeing many psychiatric patients and they need to be more instructed to take care of them. Is it better than being seeing by a specialist? Shepherd used to agree. Current knowledge of psychiatric illnesses may not make the idea practical and primary care professional may not easily accept the burden of psychiatric patients.
Trips. As for alternative treatments, the studies on LSD, albeit interesting, have not brought significant results if not in the hands of users or supporters. In addition, it is a matter of discussion whether cathartic methods are healthy or pejorative for an individual prone to psychic conditions.
Shrinking. Psychoanalysis was almost defeated in the US in the early ‘50s because its results were rather discouraging and psychiatric hospitals were full of patients. The DSM, with all its flaws, came as a natural consequence of that failure.
Neuromodulators. We know little about the relationship between serotonin and its modulation, and origins of depressions but this does not mean that most of the medicines affecting that neurotrasmitter are not effective. It is right that degraded lives of some people can lead to psychic conditions – the inverse is also true, but if we psychiatrist at our individual level cannot fight the degrade, can we at least try to help the persons feel a bit better. I know that this goes against the alternative idea that if they feel better they may not recognize the actual origin of their problem and may not be good revolutionaries, but is that what they and we really want?
Poisons. Lead leading to the origin of low intelligence, hyperactivity, and schizophrenia and other countless diseases seems rather reductionist. I can’t say much about African-Americans but I have one word or two about young and adults patients with ADHD. These patients come to me from good unleaded environments and it is always clear that the disorder has been familiar as much as that stimulants do wonders in them. On the same note, when I see people with ADHD and their life pretty much impaired by the condition and that in a week they feel way much better I can see all the appeal of a fashion week. When one knows that people with Bipolar 2 disorder kill themselves more than in any other condition one may see it fashionable but still rather disquieting. What is actually fashionable now in research is the enormous amount of investments in dollars, euros, and pounds for research in genetics, molecular biology or neuroimaging of psychic disorders. Results? Almost zero. On the other hand the task is probably way more complicated that one could have imagined and in the meantime we know more and more about how the brain works hoping to see some results in the future.
Psychotherapy. Healy speaks in favor of cognitive behavioral therapy (CBT) and one cannot agree more but since we know that it works even better when taking medicines why not use them together? And this without saying that medicines work in shorter times and at a much lower cost.
Conclusion. I have a difficult time to accept the dichotomy between society and biology. Psychic illnesses come in different flavors not only as syndromes but also within them. Their intensity may be subjective; the same life event may be disruptive for one person and easily accepted by another; social, relational, educational, and occupational functioning may be more or less impaired. Moreover, some disorders are certainly more biologic and involve genetic transmission, whereas others are strongly associated with environment. Let’s learn how to deal with all these subtleties.
Leonardo Tondo
May 26, 2016