Don’t dismiss science behind drugs and treatment of mental illness

Heather Baldwin responds to our article on mental illness from last issue

The article “Mental illness and the sickness of capitalism”, published in the September issue, is problematic at best, and irresponsible at worst. I’m disappointed to see that Chris doesn’t appear to have taken onboard any of the criticisms provided by the audience during the presentation of it at the Keep Left conference in August. As was pointed out by several people then, the argument that capitalism is the cause of mental illness, and resistance is the best way to tackle it, is reductive, and frankly dangerous. The line of reasoning is superficial, displays misconceptions about the genetics of disease susceptibility, and presents cherry-picked evidence to support a predetermined conclusion. The logic of the piece is informed purely by ideology.

I’m not saying that society is not sick; it is. And I’m not saying societal factors can’t trigger, exacerbate or increase lifetime risk of developing a mental illness or disorder. But societal factors can also increase risk of developing heart disease and cancer—that doesn’t mean that they don’t exist or shouldn’t be treated.

The term “mental illness” encompasses a wide range of illnesses and disorders, from psychotic disorders like schizophrenia to mood disorders like anxiety, depression and bi-polar disorder. Treating them as if they are all the same makes as much sense as claiming that brain tumours and Alzheimer’s disease are both “physical illnesses” of the brain, and using this to inform sweeping statements about causes and treatments. Mental illness may have an additional layer of complexity compared with physical illness (though I’m not sure a fundamental distinction between the two is justified), but this complexity is all the more reason why it is folly to lump them all together and treat them as if they are homogenous.

It’s wrong to imply that questions about effectiveness of SSRIs (the class of drugs that includes Prozac) in treating depression can be used to dismiss all pharmacological treatments for all mental illnesses. Not treating serious conditions like schizophrenia and bi-polar disorder can be fatal. Drugs can save lives.

Social support and non-pharmacological treatments are likely important for many conditions, perhaps more so than pharmacological treatments. There is evidence that cognitive behavioural therapy is at least as effective as SSRIs for treating anxiety.1 But such findings cannot be generalized. The evidence must be evaluated independently for each condition and potential treatment.

The idea that the only contribution of genetics is that “some people to dealing better or worse with particular situations” hints, to my mind, at attributing blame. Are mentally ill people just of weaker constitution, those less able to cope with the constructs of capitalism than those who are well? There is a great deal of evidence for a genetic role in predisposing people to conditions from bi-polar to schizophrenia.2-5 Of course there are other risk factors—environment (which encompasses societal, socio-economic and other external factors) likely plays a very strong role, and no geneticist worth their weight would claim that genes are the only factor, or even the most important factor for many conditions, and there is still a lot that is unknown about the genetic role in many diseases. But the fact that because there are many people with a gene variant associated with a disease (genotype) who don’t have the condition (phenotype), does not disprove genetic predisposition. The disease phenotype likely arises from complex interactions with multiple susceptibility genes as well as environmental factors, including those mentioned in the article. It is relatively rare that known genetic risk factors constitute single genes whereby a person with that genotype always develops the disease, be it a mental or physical illness.6-7

Certainly there are important points raised in Chris’ article. Capitalism is the root of a great many problems in our society, and those problems—deep inequality, social isolation, the nuclear family, the 40 hour work week, urban living and separation from nature—contribute to poorer physical and mental health.8 It’s clear that rising rates of mental illness are not caused by an increase in prevalence of genetic susceptibility traits, and genetic susceptibility is obviously not the reason for the disturbingly high rates of mental illness among the refugees and asylum seekers on Nauru and Manus Island. It’s also fair to question over-medicalisation of natural variability in personality or behavioural traits.

Addressing modifiable causes and contributors, such as social determinants, would undoubtedly contribute to a better, more equal and healthy society. However, over-simplification and sweeping statements are irresponsible. Mental illness is very real, as are its consequences for the individual, families and broader society. Socio-political analysis is important, but evaluation of causes and treatments need to be based on evidence from rigorous, peer-reviewed science, not on ideology.

Notes

1. DeRubeis RJ, Siegle GJ, Hollon SD. Cognitive therapy versus medication for depression: treatment outcomes and neural mechanisms. Nature Reviews Neuroscience www.ncbi.nlm.nih.gov/pmc/articles/PMC2748674/#

2. Voracek M, Loibl LM. Genetics of suicide: a systematic review of twin studies. Wiener Klinische Wochenschrift http://link.springer.com/article/10.1007/s00508-007-0823-2

3. Bramon E, Sham PC. The common genetic liability between schizophrenia and bipolar disorder: a review. Current Psychiatry Reports http://link.springer.com/article/10.1007/s11920-001-0030-1

4. Levinson DF. The genetics of depression: a review. Biological Psychiatry www.sciencedirect.com/science/article/pii/S0006322305010139

5. Sullivan PF, Neale MC, Kendler KS. Genetic epidemiology of major depression: review and meta-analysis. American Journal of Psychiatry http://ajp.psychiatryonline.org/doi/abs/10.1176/appi.ajp.157.10.1552

6. World Health Organisation. Genes and noncommunicable disease. In: Genes and human disease. www.who.int/genomics/public/geneticdiseases/en/index3.html.

7. Institute of Medicine (US) Committee on Assessing Interactions Among Social, Behavioral, and Genetic Factors in Health. “3, Genetics and Health”. In: Hernandez LM, Blazer DG (eds.) Genes, behavior, and the social environment: Moving beyond the nature/nurture debate. www.ncbi.nlm.nih.gov/books/NBK19932/

8. Wilkinson RG, Marmot MG. Social determinants of health: the solid facts World Health Organization; 2003. www.euro.who.int/__data/assets/pdf_file/0005/98438/e81384.pdf

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