Christopher Lane's blog provides interesting interviews of contrarian figures in the mental health professions. Most recently, he interviews my colleague David Healy about how bipolar disorder is all a biomythology. Based on his recent history of bipolar disorder, Healy presents one perspective; I believe another deserves to be heard. My full critique of his book, which I find, at root, flawed, can be found elsewhere.
For now, I think some specific rejoinders to the following views expressed in that blog deserve mention:
1. Claim: Much of psychiatry is biomythology. True, the concept of biomyths is useful, but the terminology is old. The term "neuromythology" was used in 1913 by Karl Jaspers for the same purpose.
2. Claim: Mood stabilizers are toxic to the brain, not neuroprotective. False. With lithium, toxicity at toxic blood levels, of course, is the case, but standard or low doses have major neuroprotective effects that have been repeatedly shown in animals (rats, monkeys) and humans (unlike most other psychotropic drugs). There is also reasonable clinical evidence of potential protective benefits for neurodegenerative diseases and dementia.
3. Claim: The term bipolar is different from manic depressive illness, which was more severe. True, but if anything, Kraepelin's concept of MDI was much more broad, and would encompass many more patients than DSM-IV bipolar disorder.
4. Claim: The concept of mood stabilization for bipolar disorder did not exist before Abbott's marketing of depakote. This appears to be true, although the term had been used clinically in the 1950s in non-bipolar settings (for combined amphetamine + antipsychotic use, according to Frank Ayd MD in personal communication to me).
5. Claim: "Donna" is being marketed by companies for bipolar disorder when her symptoms are just the same as depression in the past. False: Her symptoms include "she was talkative, elated, and reported little need for sleep," which is nowhere to be found in anyone's definition of depression.
6. Claim: Half of all depression diagnoses were converted to bipolar in the mid 1990s. False. 30-50% of patients diagnosed with bipolar disorder today are initially diagnosed with depression. In community practice studies, major depressive disorder remains far more frequently diagnosed than bipolar disorder.
7. Claim: The concept of latent bipolarity is the same as the concept of latent homosexuality. Only, presuming we all agree that homosexuality is not an illness, if one thinks that bipolar disorder is not an illness, later denied in the interview.
8. Claim: Antipsychotics are overused in children, and as bad as antidepressants. Probably, although the question of whether bipolar disorder happens in children is different than the question of whether we should use drugs to treat them.
9. Claim: Adult ADHD is a highly socially constructed condition, not an illness. Agreed, but shall one draw no line when it comes to schizophrenia or manic depressive illness? Is everything just socially constructed (see next point)? Cultural reductionism would seem to be the cure being suggested for biological reductionism.
10. Claim: The pharmaceutical industry criticizes its critics as postmodernist, while the pharmaceutical companies are the true postmodernists, specializing in manipulation through marketing. I never heard of anyone levelling the postmodernist criticism at critiques such as the interviewee's book on mania, before I did so. I have never heard a pharmaceutical company make that critique; it would seem above their pay grade; philosophy classes are not part of business schools. One senses a not so subtle game here of tarnishing any critique as necessarily emanating from the dubious pharmaceutical industry. It reminds one of the practices of other postmodernist-manipulators par excellence in the totalitarian past (see below). But perhaps someone can show me the evidence otherwise regarding pharmaceutical companies engaging in philosophical analysis.
I agree that the pharmaceutical industry engages in postmodernist-based work, though: the creation or extension of labels, and marketing of beliefs. However, it seems rather clear that many critics of psychiatry, from Foucault onwards, base their critiques on just that skepticism about any truths. I have written extensively about this on other blog postings (see Cross Talk with Lawrence Diller). Here I will only add that philosophically, this is a weak position; the rare bestselling philosophical book On Bullshit makes the relevant critique. In the book on which Lane's interview is based, the author takes an illness that was described initially 200 years ago, and remains broadly similar since then, an illness that has been little diagnosed (with great empirical support of this fact) for most of the past century, an illness with strong evidence of genetic etiology and the most proven biological treatment of all (lithium) - and all this is equated with more dubious constructs like adult ADHD and the analogy is made to Stalinism in the social construction of the diagnosis: One is left to wonder what kind of evidence would convince such authors about the scientific validity of any mental illness.
History, like psychiatry, is a complex discipline; it has many interpretations, and has been subject to much dogmatism, the postmodern dogma being the most current (and hotly debated by historians, without any pharmaceutical industry prodding). Perhaps Professor Lane should begin interviewing others with much more experience and knowledge about bipolar disorder than any of us. I can give him a host of suggestions for persons who would provide quite different answers to the same questions he posed in his blog; one might be Jules Angst of the University of Zurich, who actually was one of the modern inventors of the current bipolar concept in the 1960s and who has written about the history of bipolar disorder extensively, with a profound background in the original French and German literature. Perhaps readers should have access to interviews with others besides just those whose histories reflect a particular ideology.
