Is Psychology Broken?
Why aren’t we making progress against mental illness?
Posted Jun 15, 2020
Here’s a quick quiz:
- What is "depression"?
- What causes depression?
- What is the best depression treatment?
My guess is that your answer looks something like this: depression is a form of mental illness, caused by a chemical imbalance in the brain, and treated well with antidepressant medication. If that’s the case, then consider yourself wrong, wrong, and wrong.
This, in essence, is what the anthropologists Kristen Syme and Edward Hagen of Washington State University argue in a thought-provoking recent article.
Psychology, they assert, is currently facing a fundamental problem: put simply, the dominant models by which we view, classify, and treat psychological problems have failed to produce any measurable progress in reducing rates of psychological suffering.
Compare, for example, psychology to biology. While the advance of germ theory of disease has led to a dramatic increase in life expectancy, psychological theories have had virtually no effect on the prevalence of mental disorders. Moreover, unlike other sciences (such as biology), where careful classification efforts have led to the discovery of causal mechanisms (i.e., evolution), our classification efforts have failed to produce such results. The nature and origins of mental disorders remain as opaque as ever.
The authors point out that the field’s great hope in recent decades—hitched to our improved capacity to probe the brain and its processes—has failed to materialize. While it is no longer controversial that mental health phenomena have biological bases, “the track record of biological psychiatry… a field that investigates the neurophysiological and genetic bases of mental disorders, is poor… So far, there are no diagnostic tests, and treatments have limited efficacy.”
A big part of the problem concerns how we think about mental illness. Specifically, the authors point to the decades-long effort to reframe mental problems as diseases, caused by “chemical imbalances” in the brain to be fixed with medication. This well‐intentioned effort, energized by improved technology and aimed in part at combatting stigma, was largely hijacked by drug companies, who used the “chemical imbalance” model to sell their wares to great profit.
Selling a solution to a problem for profit is fine, assuming that the problem exists and the solution works. Alas, psychotropic medications fail on both counts. Consider, for example, the history of depression treatment: Antidepressants supposedly work to correct a chemical imbalance in the brain by increasing the availability of serotonin. Two problems here: First, the fact that drugs that increase serotonin also reduce depressive symptoms does not mean that depression is caused by a serotonin deficiency. In other words, “Aspirin reduces headache symptoms but headaches are not caused by an aspirin deficiency.”
Upon closer inspection, the chemical imbalance theory falters badly. To wit: serotonin increases are immediate yet the medication’s therapeutic effects are delayed; many drugs that increase serotonin are wholly ineffective in treating depression; and serotonin depletion does not induce depression in non‐depressed individuals. In sum, “there is no evidence that depression is caused by a simple imbalance of serotonin… or any other neurotransmitter.”
Second, psychotropic medications possess only limited efficacy. “Analyzing both published and unpublished reports of antidepressant trials obtained from the U.S. Food and Drug Administration” researchers have found, “strong biases in the published data in favor of positive treatment effects. After adjusting for unreported studies, they found… a modest advantage of treatment over placebo.”
In sum, “most psychopharmaceuticals are not very effective, their effects have been exaggerated by biased scientific publishing and advertising campaigns, they often have numerous harmful side effects, and the genuine effects that they do have do not provide compelling evidence for any specific etiology of any mental disorder.”
According to the authors, our failure to treat mental health problems well may also be traced to a failure of classification, embodied by the long-standing reliance on the DSM—the field’s diagnostic "bible." The current DSM is a-theoretical and descriptive; in essence, it labels clusters of co-occurring symptoms and sorts them into various "disorder" categories. Alas, there is no evidence that the existing DSM categories “correspond to distinct biological realities.” This amounts to a paradoxical state of affairs by which our field labors mightily to find the biological bases of "disorders" the very definition of which disregards biology. Thus, rather than "carving nature at the joints," DSM categories muddy the diagnostic waters and in fact hamper rather than facilitate our understanding.
This is in part the reason why, “unlike the natural classifications of plants, animals, infectious diseases, and inorganic substances, which all played key roles in the discovery of underlying causal principles, such as the theory of evolution, the atomic theory of matter, and the germ theory of disease, the various classifications of mental disorders have failed, so far, to uncover their underlying causes.”
To remedy this mess, the authors propose adopting Rutgers University psychologist Jerome Wakefield's model of harmful dysfunction, in which "harmful" signifies “an individual, social, or cultural value judgment,” while "dysfunction" represents, “the failure of a trait to perform its evolved function.” This approach integrates the two fundamental determinants of behavior—nurture and nature—into an evolutionary framework, bringing some conceptual coherence to the enterprise of psychological diagnosis.
For one, it clarifies the definition of mental illness. In this approach, “traits that are biologically dysfunctional but socially benign, or that are biologically functional but socially harmful, are not illnesses.” For example, birthmarks are a dysfunction of skin growth but are not socially harmful. Therefore, they are not illnesses. Conversely, aggression and lying, while socially harmful, are not biological dysfunctions. Thus, they are not illnesses. “Only conditions that are both biological dysfunctions and harmful, like cancer, infectious diseases, and neurodegenerative diseases, are illnesses.”
Based on this proposed model, the authors further call for a revision of the psychiatric classification system as a whole—in effect ditching the DSM altogether. Their proposed system instead sorts psychological problems into four broad categories:
The second category includes problems that result from the “mismatches between modern and ancestral environments.” Such mismatches may cause dysfunction, harm, or both. An example of this category is the diagnosis of ADHD, which might “simply be a harmful (but not dysfunctional) mismatch between highly structured modern environments and less structured ancestral ones.”
The third category is, ”a group of mental disorders that are probably best explained by genetic‐based developmental dysfunctions.” This group, according to the authors, includes “relatively rare disorders, such as autism and schizophrenia… that involve dysfunctions of cognitive adaptations related to sociality and defenses against socioecological threats. These are highly heritable and probably caused, in large part, by genetic variants.”
OCD is one example. According to the authors’ argument, humans have, “an evolved capacity to invent, perform, and transmit rituals, which play crucial roles in key life transitions and social relationships, such as the transition to adulthood (e.g., rites of passage) and mating (e.g., marriage rituals).” OCD rituals, in this telling, are the result of some “dysfunction of the psychological processes that support culturally meaningful rituals.”
The fourth category includes conditions that are, “probably not disorders but instead are aversive and socially undesirable but nevertheless adaptive responses to adversity.” This group includes prevalent and high impact disorders such as anxiety, depression, and PTSD that have in common low heritability and adversity-related onset.
Just as physical pain and fever have evolved as adaptive protections against infections and tissue‐damaging stimuli, so may anxiety and depression symptoms serve as, “aversive yet adaptive responses to adversity”—forms of psychic pain that focus attention on survival or reproductive fitness threats. Aversive social experiences may likewise denote adaptive function rather than dysfunction. As noted by MLK in his brilliant 1967 speech at APA's Annual Convention, a person's maladjustment is not always a sign of personal malady. An individual’s inability to adjust to society may be due to societal rather than individual ills. The refusal to adjust to an unjust system, while aversive, is mentally healthy.
In this view, then, the symptoms of depression, anxiety and PTSD, “largely indicate social problems, not medical ones,” therefore requiring social rather than medical interventions. To the extent that these symptoms are in fact adaptations and responses to adversity, treatments should focus on the adversity, not on “manipulating brain chemistry.”
A rotten tooth represents biological dysfunction, but the pain of it does not. It would, therefore, be unethical—not to mention destructive in the long run—for the dentist to treat the pain and not the tooth. Likewise, “it would be unethical to suppress the psychic pain without addressing the source of adversity.” In other words, treating the symptoms of individuals rather than the injustices and stressors of the social order is both misguided and immoral.
By the proposed model, the correct answer to our opening quiz would be something like this: Depression is not an illness, but a socially aversive yet evolutionarily adaptive response to adversity, best treated by changing adverse social conditions, not by labeling people as sick and medicating them.
(Oh, and if you hear anyone talking about "chemical imbalance," run).
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