[Rebound]

Ya know, this is something that only was thrown in my direction recently, but when I thought about it, it really made me think: when it comes to physical ailments, medicine of all kinds has been worked on and improved for many hundreds of years, but serious effort to treat mental illness in a scientific way has only been going on for a relatively short time. I have frequently found myself bemoaning the lack of ability to accurately diagnose and treat us but when you think about it, a lot more progress has been made in the last 100 years than may seem immediately obvious.

I only wish to point out that there's reason to hope for us all.

[wickedwings]

i agree, rebound. same here for the u.s.

> when it comes to physical ailments, medicine of all kinds has been worked on and improved for many hundreds of years, but serious effort to treat mental illness in a scientific way has only been going on for a relatively short time.

Um... I'm not sure that that is correct... Hippocrates coined the term 'hysteria' and wrote on 'melencholia' as well... Edward Shorter (a historian) places the birth of psychiatry near the end of the 1700's which is around the time that medical specialisation became all the rage. Prior to then there weren't many specialities (aside from surgery).

Shorter also talks about two different 'biological revolutions' in Psychiatry. We are in the middle of the second biological revolution right now.

There is much more controversy in psychiatry than there is in any other medical specialisation (I'm sure it is fair to say that). While most medical conditions are fairly well understood (in the sense that we know where to look for the relevant mechanisms) we still haven't sorted that one out for a single psychiatric conditions. For example, any given mental disorder could be:

1) Genetic
2) Neurological
3) Cognitive
4) Phenomenological
5) Behavioural
6) Environmental (I'll put sociological in here too)

And there are competing accounts of the nature and much controversy over which of the above are essential to mental disorder.

Part of the problem is that we don't have a good understanding of how these levels of explanation relate to each other. It is one thing to say 'they ALL are relevant' and quite another to show precisely how each level relates to each other level.

There is also much controversy over where we should look (with respect to the above levels) in order to intervene or treat mental disorders. One popular notion (that is simply false) is that whichever level is right for nature is right for treatment and / or vice versa. So if, for example, we find some medication works to treat depression then it follows that depression is neurological and it also follows that the best treatment for it is going to be neurological. That doesn't follow at all, however.

If you want to teach someone to cook then you have to change their neurology. There is no other way they can learn something new. I'll still put my money on the best 'intervention' being teaching them how (so environmental or social) rather than neurological (medication or psychosurgery), however.

Psychiatry is held up by extra-scientific concerns (where politics and issues of treatment reimbursement and the financial investment of drug companies is more of a driving force than the scientific concerns). Psychiatry is also held up by conceptual confusions (such as the couple that I've outlined above).

There are a proliferation of theories... Many of them are not obviously consistent with each other and you have geneticists, neurologists, neuroscientists, cognitive theorists, cognitive neuropsychologists, behaviour theorists, sociologists, anthropologists, phenomenologists, not to mention: psychologists, psychiatrists, councellors, who all have an investment in the verdict. and that is to say nothing of the drug companies, the different brands of therapy, the people making money off the self help books, and so on and so forth. then you have the suffering masses who are prepared to pay...

and its a big monster it surely surely is.

> I have frequently found myself bemoaning the lack of ability to accurately diagnose and treat us...

Accurate diagnosis is thrown off considerably by the fact that the current diagnostic manual is constructed around extra-scientific concerns (that are political) rather than scientific concerns of carving nature at its joints.

Treatments are similarly driven by the extra-scientific concerns. Funds for drug companies and health insurance reimbursement for addicts and the like...

i think there is hope but i guess i don't think that hope will ever come in the form of a pill. it will help sedate you for a bit of a break... but i don't expect that the best way to alter the neurology is (or ever will be) in the form of a medication.

[nothemama8]

good to see ya back Rebound

[SeptemberMorn]

I agree with you, Rebound. There is hope, though! There's always hope, especially nowadays.

[eskielover]

In agreement also....it seems like the major treatment advancements have been in a big way in just the last 20 years. Even in the hospitalization treatment has changed so much. We are actually lucky to be living now.....so the future can only be better.

Debbie

[Rebound]

Alexandra, I appreciate your contribution and you make several good points, however, you contradict yourself also, and in parts, seem to support my premise despite beginning your post with, "I'm not sure that that is correct." In particular, "While most medical conditions are fairly well understood (in the sense that we know where to look for the relevant mechanisms) we still haven't sorted that one out for a single psychiatric conditions(sic)."

I agree entirely with this statement. Eskielover captured very well the point I was trying to make.

p.s. Thx Momma. Nice to see you too. Here's hoping all's as well as can be.

Hey. I appreciate your contribution too. I'm always happy when people post their thoughts on this kind of stuff because it gets me thinking :-) I'm not sure where I contradict myself... Though it is of course possible that I do :-)

I found Roy Porter's 'The Greatest Benefit to Mankind: A Medical History of Humanity From Antiquity to The Present' at a book stall the other day:

http://www.amazon.com/Greatest-Benef.../dp/0393319806

Part of the reason why I was inspired to get it was because of your post :-) I also made a blog entry on the theme:

http://analysis.psychcentral.net/2007/08/

Someone asked me this question several months ago: 'How is it that doctors got involved with mental disorders anyway?'

I didn't know what to say in response to that. I've read Edward Shorter's 'A History of Psychiatry: From the Era of the Asylum to the Age of Prozac':

http://www.amazon.com/History-Psychi.../dp/0471245313

But the answer to the question was still unclear to me. Porter offers many examples of how what are now commonly regarded as psychiatric symptoms (e.g., hysteria, melencholia (depression) etc) have always been part of the subject of medical understanding. While it might be wrong to consider there to be 'doctors' in the time of ancient greece etc the people who were interested in helping people with broken legs, battle wounds, fever etc were also interested in helping people with delusions, hysteria, melencholia etc. So... mental (or psychiatric) symptoms have been of interest to medical people for as long as non-mental (or more paradigmatically medical) symptoms have been of interest to medical people.

Porter tells a story where there didn't use to be a divide between 'mental' and 'physical' in the sense that supernatural causes and physical causes were intermingled in understanding and treatment. Remidies included prayers, aumulets, herbs, etc. Materialism (as we know it today) is a fairly recent invention and I'm not really up to that part of the book yet (still in the enlightenment).

I guess a fairly major advance was appreciating that the brain is the physical organ responsible for functions like emotion and perception and reason etc. Hard to understand the physical basis of mental disorder without knowing that. That being said medicine used to be a whole heap more holistic than it is at present. A very old idea indeed is the idea that one should practice 'moderation' with respect to food, drink, sleep, exercise etc. That a moderate person was a healthy person (in the physical/mental sense). There was more focus on (and appreciation of) environmental or situational causes of physical/mental disorder than there is at present. Nowdays people seem very focused on proximate mechanisms (e.g., the brain) rather than less proximate mechanisms (e.g., how the environment causes the brain to be in its proximate state).

I guess... I'm not much convinced that there have been major treatment advances (for mental disorders) in the last 20 years. It is true that more medications have been developed and it is true that therapies have been subjected to empirical investigation and it is true that we have developed better neuroimaging techniques. I'm not sure how much this has led to 'advances' in treatment, however. We don't seem to understand the mechanisms of mental disorder any better than we did. When something seems to work (to provide some relief) we don't really have any idea how or why it works.

Ideas of 'humane (or 'moral') treatment for people with psychiatric conditions are very old indeed (from Pinel, I think). Ideas of 'moderate' living are also very old indeed (prescribed in ancient greece and in egypt and in the middle east and china etc). Ideas of sedating people so that they are more manageable in institutions... Not sure how much that constitutes an advance...

It is interesting to me that the WHO conducted 3 studies where it was found that 3/4 of people dx'd with schizophrenia in developing nations recovered completely whereas only 1/3 of people dx'd with schizophrenia in developed western nations recovered completely. Why on earth should this be the case? People in developing nations have less access to psychiatrists, to psychiatric medications, and more access to social supports and suffer from less social stigma. One might wonder how much western medicine has advanced our understanding and treatment of mental disorders after all...

[Fuzzybear]

Good thread .... only just saw this, thanks!

[pachyderm]

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alexandra_k said:I guess... I'm not much convinced that there have been major treatment advances (for mental disorders) in the last 20 years. It is true that more medications have been developed and it is true that therapies have been subjected to empirical investigation and it is true that we have developed better neuroimaging techniques. I'm not sure how much this has led to 'advances' in treatment, however. We don't seem to understand the mechanisms of mental disorder any better than we did. When something seems to work (to provide some relief) we don't really have any idea how or why it works.

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Speak for yourself, Alexandra.

i don't think that researchers do have very good models of ANY mental disorder (and / or the mechanisms that cause it).

it was noted that epileptics seemed calmer and a bit happier after their seizures so some doc thought that ECT might produce calmness and happiness in psych patients.

we still don't know why ECT seems to work. one theory is that the memory loss CAUSES the effect. another theory is that the memory loss is an UNWANTED SIDE EFFECT, however.

all of the major classes of medications were developed for different purposes and 'accidentally' found to benefit sufferers of mental illness. we don't have any idea why they work.

one line of reasoning (that pushed by the drug companies) goes like this:

drug x seems to alleviate behavioural symptom y
drug x seems to raise / lower amounts of neurotransmitter z
___________________________________________________________
therefore too high / low amounts of neurotransmitter z cause behavioural symptom y

but answer me this:

when the medication takes hours to pass through the blood brain barrier and disperse around the brain...

how come the medication takes weeks for its full effect?

any idea?

don't know anybody who knows...

[Rebound]

I did not intend to imply that by treatment I meant only drugs. New therapies are being devised all the time.

Recently, it has been shown that by direct electrical stimulation in certain parts of the brain, sufferers of intractable years-long deep depression, previously treated completely unsuccessfully by any other means, found almost instant and long lasting relief. That's just one example.

I think, however, the main point of my post has been lost in the details of this discussion but perhaps I didn't make it clearly. It's not all that long ago that places like Bedlam were full, their residents condemned to spend the rest of their lives in miserable conditions, untreated, and in some cases, uncared for. I admit that even then individuals were committed to trying to find the causes of, and treatments for mental illness. But for the most part, it was seen as perhaps the result of a sinful life, an act, or in any number of other unhelpful ways. Things have gotten a lot better and we're the beneficiaries. Sure, there's still a lot we don't know. That was part of what I was trying to get at. It all takes time. But progress is being made and our understanding can only improve as time passes.

My post was from a purely personal point of view. I was just trying to say that I have been very frustrated with the difficulty of obtaining an accurate diagnosis and effective treatment, hampered by the subjective nature of the situation, but was pleased to take heart from the idea that things could be a lot worse and are destined to only get better.

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).

[(JD)]

Good post (((rebound))) Good to see you posting!

[pachyderm]

alexandra_k:

> 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.

WE don't know? NOBODY knows? YOU might know more than you think.

My word of wisdom for the day...

[pachyderm]

</font><blockquote><div id="quote"><font class="small">Quote:</font>
pachyderm said:
alexandra_k:

> 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.

WE don't know? NOBODY knows? YOU might know more than you think.

My word of wisdom for the day...

</div></font></blockquote><font class="post">

I have been admonished by a person for posting a negative message. I want to apologize if that's how it was received. I guess I feel like a "bad teacher" who is saying: Alexandra! I think you can do better than that! Don't talk about "we" and "nobody" (please). I am impressed by you. You are a good thinker.

Tell me about your ideas. I think you have good ones. Let us hear more of your ideas. Please.

oh. i'm sorry you were admonished.
if i received your message negatively... i would have said something to allow you to clarify your intention.