Regarding Nassir Ghaemi's helpful post a few comments are in order

1. Its very useful to be reminded of Jasper's neuromythology concept that was directed at Kraepelin among others.

2. In so far as the class of mood stabilizers now contains the antipsychotics and these give rise to tardive dyskinesia and other neurological syndromes as well as increased risks of stroke they are clearly not neuroprotective.

3. While Nassir has misleadingly used the term post-modernist to describe my position, he is not the first. Its unlikely that anyone versed in postmodernism would see as a fellow-traveler someone who has an extensive background in biological research in nervous disorders, who has co-authored a postive history of ECT and who in this book, as well as Mania, and all other books clearly endorses the reality of mental illness.

More to the point, no-one who has (accidentally) made a career out of arguing for the reality of drug induced changes (albeit injuries) can be seen as postmodernist. Even this posting in this blog makes clear claims for the reality of drug induced diabetes, and suicidality.

There is a simple way to sort out who's the postmodernist in this correspondence or among the readership - anyone who agrees that psychotropic drugs have side effects is not a postmodernist.

But beyond this, there is a common problem Nassir, I and all readers of this blog have. It goes back to Jaspers. How to establish the clinical reality of psychiatric conditions. Jaspers didn't turn to operational criteria. He turned to clinical judgement - only a experienced clinician can do the job.

While this might have been possible in the pre-psychopharmacological era, it is not possible now for clinical judgment to hold the fort against other forces. In the early psychopharmacological era there was great hope that biological markers such as the dexamethasone suppression test might both buttress and extend clinical judgment but both biological research and clinical trials have become marketing copy.

How at present do we move forward from this position? Many hopes rest on biological resarch but its simply being prudent rather than postmodern to note that even this is not incorruptible.

David, as much as I like what you have to say about the mythology around mental illness and the fallacy of drugs...

I'm sorely disappointed and can't even begin to fathom how in the heck you can support ECT when there is so much documentation on how brain damaging it is.

It's severely impaired a number of people I know personally and when I worked as a social worker I was exposed to hundreds of people who took both drugs and used ECT...I see no difference in the degree of inhumanity involved.

it's all about damaging the brain.

Thanks for posting this interview! I for one would love to see a follow-up sometime. My question: exactly what is the evidence that any psychoactive drug (antidepressants included)is "neuroprotective" and what the hell does that mean concretely? It is being used as a very emotionally powerful (almost coercive I think) selling point for long term use of these drugs by a lot of doctors -- especially to parents. It's usually joined to the "kindling theory" in which each new spell of illness left unmedicated supposedly leaves one's brain vulnerable to more frequent and worse attacks. The implication being that if you don't start now to take these drugs for life, it will be too late in 5 or ten years. I have heard Dr. Larry Diller, author of one of the child psych blogs here, express skepticism about "kindling" of psychiatric problems. Any opinions from David Healy, or Nassir Ghaemi?

Kindling is something of a myth. It derives from the epilepsy field but even in the case of confirmed convulsions, the largest controlled trial now shows that those not treated immediately with anticonvulsants do better over a 5 year term than those treated immediately.

Anticonvulsants and other mood stabilizers are brain stressors. They will cause problems. In difficult cases the problems the illness causes may warrant taking judicious risks with treatment induced problems, but they rarely warrant the cocktails prescribed in the United States.

Interestingly there is very little talk of neuroprotection in clinical settings in Europe - this is much more an American phenomenon and I have to say it does sound coercive to me when I hear it.

I really enjoyed this interview and hope to see more on the subject matter.

What if ADHD, Bi-Polar, and Schizophrenia are merely dots on a schizotypy bell curve?

The diagnosis difference lies in degree of dissonance between the "low road" of the amygdala and the "high road" of the hippocampus.

I suspect that these three disorders may be caused by an overstimulated amygdala and an understimulated hippocampus.

I'm sure you enjoy the rich irony of denigrating pharmaceutical companies all the while your interview is surrounded by pharmaceutical company advertisements, of which you receive money for.

If pharmas are so evil, why do you have a blog that makes its money from pharmaceutical company advertising? Seems like hypocrisy at best.

There is evidence that "true" bipolar disorder and schizophrenia have similar genetic vulnerabilities - lots of certain genes and you have a risk of schizophrenia, moderate number and it is more likely schizoaffective, less but still substantial number of these genes and more likely to get manic-depression if you are going to get ill (and environment will play a factor as to when and if).

As far as I know ADHD (which is a bunch of symptoms and behaviours that can have any of a wide number of causes, including as David Healy says boys with neurodevelopmental pathways that were not particularly problematic in past cultures but don't cope with the academic classroom demands of modern life) has no genetic relationship to the psychotic spectrum (manic-depression - schizoaffective - schizophrenia).

Whilst some bipolar-II disorder may be incomplete manifestations of manic-depression/bipolar-I, most of the softer "bipolar disorders" are on this count more likely to lie with the neurotic spectrum of mental disorders - where psychotherapy, family therapy, parenting training, lifestyle changes, mindfulness and relaxation-training etc have more potential and drugs much less.

We should probably return to earlier nosologies and dispense with bipolar disorder and go back to cyclothymia as a personality trait/disturbance that can be more manifest in some people during stress/anxiety/depressive reactions.

True manic-depression does need to be detected and treated early in its course but obviously not at the expense of picking up 100,000s of children and teens with other problems and misdiagnosing and overmedicating them.

We need to get away from the DSM entirely and start ordering real lab tests: metallathionein levels, copper/zinc ratio, lactulose-to-mannitol, heavy metals, C. albicans, H. pylori. Check the lab results! Check the poo! Check out the diet and see whether it is entirely lacking in any nutrients the body can use. The average number of chemicals, pesticides and toxins each of us is carrying around is 700; the cord blood of newborns has been found to already contain at least 250 toxins (out of only 413 tested for by The Human Taxome Project). Dylan Klebold (a Columbine "shooter") was on Depakote, which removes zinc from the body and causes violent behavior, among other side effects. James Huberty, (the McDonald's "shooter") was found to have large amounts of toxic Cadmium (he was a welder). We need to automatically order an established list of lab tests before EVER pulling out a presciption pad for behavior.

As the spouse of someone with bipolar disorder, I am alarmed by the language used to discount, diminish and deny a disease that is just as real as cancer or heart disease. You seem to have no idea of the extremes of pain that bipolar patients and their loved one's face, and you seem completely lacking in compassion. I have seen what mood-stabilizing drugs have done for my loved one, the incredible turnaround they caused in a life that would have ended by now if it weren't for the medication and therapy. Words can't describe the pain and frustration I feel when professionals such as yourself further stigmatize an already stigmatized population by suggesting that their illness is imaginary. All I can say is thank God for the drugs, which is exactly what my spouse, who takes them, says. Yes, they are sold by pharmaceutical companies--just like drugs for diabetes and infections. That's who makes and sells them. A healthy level of skepticism is always appropriate, but to suggest that bipolar disorder doesn't exist, and shouldn't be treated with what obviously works, is completely heartless and irresponsible.

From what I read David Healy is not denying the reality of bipolar disorder/manic-depressive disorder nor of using medication. And it sounds like your spouse to have such a good response to medication does suffer from the illness and it is great they are benefiting.

The debate here is about the overdiagnosis of many others and young children with bipolar disorder when other explanations for their emotional and behavioural problems are more likely. For many the medications because of their side-effects pose an unwarranted health risk if mere sedation of personality and anxiety problems (that may be severe) is all that is provided. The other problem is a wrong diagnosis can deflect attention from root causes.

As a matter of fact we went to a long string of psychiatrists before one finally diagnosed my loved one with bipolar disorder. Once I became aware of the illness I read much about it and was shocked by how obvious it was that my loved one had classic bipolar disorder. I am amazed by how slow the psychiatric community was--it took years of struggle--to venture a diagnosis of bipolar disorder, so I am extremely skeptical about the whole concept of the disorder being over-diagnosed. I have also watched the lives of untreated family members who have the same thing dissolve into utter chaos and unmitigated tragedy. They are too afraid of the stigma of seeing a psychiatrist who will fill their heads with DRUGS to ever seek help, so generation after generation of this family reels from one crisis to the next. Dr. Healy's antimedication bias reinforces the reluctance of the truly needy to seek the help that would save their lives, their marriages, their relationships with their children, their jobs, their credit, and on and on. Bipolar disorder is a devastating illness that MUST be treated with medication plus therapy. But as one who went with my spouse to years and years of talk therapy before he was medicated, we got NOWHERE without the drugs. An unmedicated bipolar patient has absolutely no insight into his psychotic episodes or his destructive behavior except during periods of clarity, when he realizes it all and wants to kill himself. With the right drugs, the psychosis almost never returns, the patient has insight into his behavior, gains greater impulse control and has a life that is worth living. However, if you are mental health professional, you ought to know that a bipolar patient, unmedicated, is not going to walk into your office on his own, say "I have bipolar disorder, and these are the medications I need." Psychiatrists have a responsibility to do for the patient what he can't, in the beginning, do for himself. A psychiatrist who says that medications are unecessary for a disease like this is aiding in the destruction of lives and ought not to be able to practice.

One doesn't have to read too many of David Healy's responses here to know that something is wrong, very wrong, with his knowledge base and, it follows, perhaps even his motive.

I don't know what his goal is, but it's sure looking like another rogue academic out to make a name for himself by opposing the "pack" (that is, the consensus of medical and scientific opinion).

It's really too bad the interviewer here doesn't pick more knowledgeable interviewees. It would be so much more useful to readers.

'Aussie Child Psychiatrist' says it well: Healy is in favor of medicating psychotic symptoms, whether due to schizophrenia, bipolar disorder, or other causes. The problem is that non-psychotic agitation and mood-swings are now routinely swept into the bipolar category as well, where the risk/benefit ratio of antipsychotics and mood stabilizers is very different. I don't hear that as "ignorantly pandering to brain pathology." I hear it as making a useful distinction.

Hi,
Can you delete my comment above please. It's coming up on google now. So sorry to bother you.