Hey.

Thanks for the interesting discussion :-)

Yeah. New therapies are devised all the time. I didn't mean to imply (though I might well have implied - in which case I take it back!) that there haven't been advances in treatment. Though... I do worry a little sometimes about precisely what constitutes an 'advance'.

I'm reminded of Marsha Linehan who developed this form of therapy for Borderline Personality Disorder that is known as DBT. They did clinical trials and found that DBT outperformed brief psychodynamic, cognitive behavioural, and control (no treatment). One might be tempted to say that the development of DBT constitutes an advance in the treatment of Borderline Personality Disorder.

How is it that DBT outperforms rival treatments? Nobody knows. Marsha Linehan had this to say (paraphrase): Nobody knows precisely why or how this treatment is outperforming alternative treatments. One thing that it might be doing... Is giving hope to and energising therapists and that is what is beneficial to clients.

With respect to new treatments... I often wonder if the main mechanism behind them is... Hope. Prayer provides hope for some. Bloodletting (practiced in the majority of early medicines) provided hope for some. Strategic application of magnets provided hope for some. EMDR provides hope for some. Talking to pastors provides hope for some. Wearing crystals provides hope for some. Light therapy provides hope for some. Prozac provides hope for some. And so on and so forth... Because we don't know (because nobody knows) the mechanisms of how new treatments work it might be the case that the main mechanism is... Hope.

I'm not sure what I think about the electrical stimulation for depression. I haven't read the studies... I do think that many 'fad' treatments rise to popularity... Then fade over time. I think the history of psychiatry is characterised more by those advances than by any 'breakthroughs' in treatment. The one thing that might constitute a 'breakthrough' for psychiatry was the realisation that a sub-set of people with (what was thought to be) schizophrenia were curable with antibiotics. They called that 'syphilis' and handed that condition over to general medicine, however. Some sceptics say that the difference between psychiatry and neurology is that we understand (relatively) the neurophysiological basis of neurological conditions whereas we have no idea of the neurophysiological basis (or other causal factors) involved in psychiatric disorders. As our understanding advances (sceptics say) that psychiatry will become subsumed under neurology. I don't think this will happen, but I guess it is a seperate issue.

Pinel was the main person behind 'moral treatment' which basically consists in humane treatment for people with mental illness. Before Pinel many mentally ill people were kept in appalling conditions. Bethel hospital... I'm pretty sure charges were laid there once it became publicly known what went on. There are pictures in psychiatry / psychology text books of Pinel letting the chains off mentally ill people. He thought they shouldn't be kept in isolation, they needed air and exercise, and activities and stuff.

It is about there that Shorter places the birth of psychiatry as a distinct field. He says that it wasn't the rise of the psychiatric institution that marks the start of psychiatry as mentally ill people had been confined in institutions in the middle ages and by their families well before then. He marks the rise of psychiatry with the increasing prevalence of the idea that confinement itself could be theraputic or beneficial to the mentally ill person. Giving people a little break from the stresses of their lives and giving them a little moral support and care could be curative. The idea was that it took a physician with special qualities to run an institution in a curative fashion and hence psychiatry as a specialist field within medicine was born.

So... That is to say that humane treatment for mentally ill people was right there at the birth of psychiatry in the end of the 1700's. Fairly recently there has been a massive 'deinstitutionalisation movement' which is very controversial...

I, too have been very frustrated with the difficulty of obtaining an accurate diagnosis. Part of the problem there is that the classification system for psychiatry is hopeless. Driven more by extra-scientific concerns (issues of reimbursement for health care and the like) than scientific concerns. The present system is in very bad shape indeed. Psychiatry is similar to alchemy with respect to where it is at scientifically. I mean to say that psychiatric disorders are classified on the basis of superficial (behavioural) similarity. Alchemists similarly classified metals etc on the basis of superficial similarity (e.g., gold things, hard things). Chemistry progressed considerably with the development of the atomic theory of matter and the periodic table of the elements. That classification is on the basis of underlying structure rather than superficial properties, however. Psychiatry is in the unfortunate situation that since we don't know the underlying structure/causes of any mental illness... We are unable to have such a classification system. Hempel thought that the present system (DSM) that focused on observable features (behaviours) would be an advance on the rival systems that were developed by rival psychoanalytic theorists. He was correct that the DSM has been universally accepted by psychaitrists. But... It is not a classification system that 'carves nature at its joints'. Not by a long shot. (I have a blog entry on this too strangely enough).

Treatments aren't diagnosis specific for the most part, though it is true that sometimes the development of a treatment results in a new kind of disorder in the DSM. I think... panic attacks became a disorder in their own right once it was discovered that a subset of people with anxiety (those with panic attacks) seemed to respond well to... xanax(?) (I think i have the condition and the treatment right). Aside from that... people without mood swings seem to benefit from mood stabilisers and people without psychosis seem to benefit from anti psychotics etc etc.

Things could be a lot worse...

I also hope that things will get better. I'm not terribly sure how optimistic I am... I think... That the state of society has a considerable role to play with respect to mental illness. I like to think that we are evolving as societies into societies that will take better care of its citizens (like to think that the abolition of slavery etc count as genuine advances towards a more co-operative society) but sometimes it seems like we make steps forwards (abolition of slavery) and then a few steps backwards (e.g., harmful practices that society condones as 'interrogation'). i don't know...

caring. i really do think... caring societies.

i'm reminded of something that wittgenstein said to one of his students:

student: for all our faults i'd rather be living the way we do now than the way cavemen used to
wittgenstein: of course you would. but would the caveman?

progress... a tricky notion... by whose standard?????

in the same way that epidemic diseases (measles, smallpox, plague, maleria etc) were extremely rare when we hung out in groups of 20-30, and wandered around... i would bet mental illness was similarly rare.

but then along comes agriculture (typically considered an advance) and before you know it people are living in bigger social groups (with less social supports) in their own filth (contaminated water) and in their animals filth (contaminated water and food) and nutrient poor diets (some of the grains that were grown). and then you have malnutrition, parasites, diseases that evolved from animals (influenza, measles, smallpox, etc).

and then you have the industrial revolution (typically considered an advance). even more people. even less social support. even more filth. even more disease. plagues wiping out a quarter of the population. people in cities dying faster than the birth rate relying on rural dwellers to go to the city to replace the population.

advances on the one hand... steps backwards on the other... maybe our view of 'social progress' is backwards... we have the technology but we seem pretty sucky at using it for good. (think nuclear weapons and nuclear technology used in medical treatment).