Therapeutic truths and illusions

On the causes of the worldwide pandemic of mental illnesses

Mental fragility seems to be rampant worldwide, for decades the number of people diagnosed with mental disorders has been on the rise. At least three factors are responsible: a conglomerate of scientists and therapists has chosen neurobiology as its sole explanatory model, the pharmaceutical industry has been printing new drugs on the market with enormous power for decades, and in the process has encountered a society that is as fragile as it is enthusiastic about substances. These three factors will be the subject of the following.

A few numbers to get in the mood. In the U.S., the number of people enrolled in the welfare system with mental illness increased two and a half times between 1987 and 2007. Where once there was one mentally ill person for every 184 US burgers, today there is one under treatment among 67 burgers. In Germany, mental illnesses have become a frequent reason for sick leave since the 1990s. In the statistics of most health insurance companies, they now rank among the four most frequent causes of incapacity to work. If one also takes into account the fact that, according to experts, only every second depression is recognized, a pandemic of mental insanity seems to be rampant. But the numbers are not as clear as they sound.

On the one hand, there are hardly any representative long-term epidemiological studies that track the development of the mental health of the population. On the other hand, the statistics depend considerably on the survey instrument used; questionnaires, for example, resulted in higher rates than diagnostic interviews. The OECD points out that suicide rates have been declining in almost all member countries since the 1980s. A meta-analysis by the University of Munster has shown that the number of people affected by mental disorders and diseases has hardly increased over the last 50 years.

Why do more and more people nevertheless leave the doctor’s office with the diagnosis? "psychic disturbance"? Probably also because the stigma of "Mack" slowly subsides, today people are more willing to admit a crack. But even more important is the diagnostic prere that weighs on the doctors. The psychiatric-psychological branch has so far buried any increase in diagnosis rates as a sign of reducing under-treatment. This paves the way for chemical intervention in the current system. Because not only in the USA treatment almost always means the prescription of psychotropic drugs. Psychiatrists now like to refer their patients to psychotherapists if they think they need another treatment besides pharmacotherapy. This focus on drugs has historical reasons.

therapeutic truths and illusions

In the USA and Europe, Freudian psychoanalysis was the standard of therapy until the 1950s – with more or less rough success. When the first psychotropic drugs came on the market in the early 1950s, the professional world pounced enthusiastically on the new drugs. At last, relief, even healing, seemed possible at the push of a button. Thus a paradigm developed that is still valid today: mental illnesses are based on a chemical imbalance in the brain. And this disturbed balance can be healed by medicaments.

In just four years, four drugs came onto the global market that were to change the view of mental human states forever:

  1. The active ingredient reserpine was isolated in 1952 from Rauvolfia serpentina, which had been known in India for centuries, and its use for schizophrenia began in 1954. Due to the severe side effects it is no longer used today.
  2. Also in 1954, the tranquilizer Thorazine (active ingredient: chlorpromazine) was introduced. Initially, it was primarily used to sedate severely psychotic patients, later it was also used to cure "senile agitation" advertised. Chlorpromazine is considered the cornerstone of modern psycho-pharmacotherapy.
  3. In 1955 Miltown (active ingredient: meprobamate) made it into the praxes. It was soon considered the remedy of choice against fearful convictions.
  4. In 1957, Marsilide (active ingredient: iproniazid) was finally introduced as a mood enhancer to help with depression. The term "Antidepressant" was introduced by Max Lurie in 1952.

Within a short time, these four drugs completely turned therapy upside down: Suddenly schizophrenics were responsive again, phobics calmed and depressives re-energized. All these substances were not developed for psychotherapy, nobody knew at first how they work. All the more joyful was the fact that they did not sedate the patients as much as the tranquilizers used until then. Only later research could show that they influence the neurotransmitter balance in one way or another. The conclusion was obvious to declare chemical imbalance the cause of all mental illnesses.

Happiness for the souls

Spatestens with the incredible success of the antidepressant "Prozac" (active ingredient: fluoxetine) the paradigm of imbalance prevailed not only among physicians, but also in the media and thus in the public sphere. Introduced in 1987, Prozac and the other SSRIs (serotonin reuptake inhibitors) were considered a miracle cure. In the interplay of actual and created needs, a huge market developed for this group of substances, which primarily interferes with the production and processing of the neurotransmitter serotonin. The melancholic, gloomy, depressed, hopeless people of the western industrial societies had found their new remedy.

It must also be attributed to SSRIs that the number of people diagnosed with depression in the U.S. nearly tripled between 1987 and 1997. Today, about 10% of all Americans take antidepressants.

In Germany, the prescription frequency of early antidepressants has never been studied in detail; only since the 1980s have there been consistent statistics. No other group of psychotropic drugs has had as long a career as the antidepressants. If one believes the figures of the annually published drug prescription report, the prescriptions have increased by 3.5 times since 1994, the sales – despite generics – by 3.7 times. The number of daily doses (DDD) has recently increased again by about 15%, sales by about 12. About 40% of all psychotropic drugs are prescribed by neurologists, the rest by general practitioners or internists.

At present, an SSRI drug called citalopram is being marketed in Germany as a so-called "anti-psychotic" "Lead substance" The drug has established itself in the treatment of depression, and accordingly it tops the prescription and sales charts. The lead substances are determined by the Kassenarztliche Bundesvereinigung (KBV), an association representing the interests of German physicians and psychotherapists.

Without going into the entire history of drug therapy for depression, a pattern can be discerned: first, the various advantages of a new active ingredient are pointed out; later, it is discovered that either the side effects of the substance outweigh the benefits, the initial studies were flawed, or dangerous long-term consequences occur. At Miltown, it was the discovery of the heavy dependency potential. Then it’s time for a wake-up call, a new drug promises better efficacy with fewer side effects. Even with the introduction of modern antidepressants, the many advantages were pointed out. But the effectiveness against the tricyclic antidepressants used until then are more practical, meta-studies have compared the effectiveness of the substances in the treatment of depression, the differences are marginal, if any.

Doctor-patient relationship

In a strange reversal, the drugs available, and thus their manufacturers, determine the definition of what is considered a mental illness. Exaggeratedly it can be formulated that, due to the predominance of the disbalance paradigm, drugs are not developed to cure abnormalities, but abnormalities are found to fit the effects of a drug. There are many indications that the chemical imbalance is only a side effect of a disease. And at least for the antidepressants it slowly crystallizes out that their effect is based to a more or less rough part on the placebo effect. Expectation and doctor-patient relationship are developing in psychopharmacology on this detour again to a central coarse, whose influence has been ignored for far too long. Either way, the chemical imbalance paradigm has led some therapists to look for the causes of psychological problems not so much in life circumstances, but in body functions that have gone out of control.

Psychiatrists and psychologists have long considered it important to handle psychotropic drugs in such a way that therapeutic contact is maintained and, if possible, even improved. "However, this attitude has now largely been forgotten", write the medical historians Rainer Tolle and Heinz Schott in their history of psychotropic drugs and criticize the trend, "attributed all the successes of psychiatric treatment unilaterally to psychotropic drugs."

In the handbooks of mental disorders consulted by medical practitioners, depression and other mental disorders have long been considered situational, a reaction to an external stimulus. The paradigm shift to the neurochemical paradigm has made the word "Reaction" from the manuals, today one reacts afterwards no longer fearfully in rough groups, but has a social phobia. This, in turn, suggests a lifelong illness, and one that is not under one’s control. This puts the classification systems on a line that since the early 1980s have pathologized sadness and trubsal to such an extent that the diagnosis of "Depression" is said today more often than ever.

The power of labeling has been demonstrated most recently in the Asian market, where depression was introduced beginning in the 1990s. Earlier, the clinical picture hit there "Neurasthenia" and, according to medical anthropologist Arthur Kleinman, was widely used under Mao. With the opening to the West, neurasthenia slowly disappeared in the drawers of antiquated terminology. And for the cure of the Chinese depression came the antidepressants, whose sales since then have exceeded. The decades-long enthusiasm for the effects of psychotropic drugs has hardly been followed by a worldwide demystification, and there is no market saturation in sight for most neuropathic drugs.

Influence from the side of the law

With the focus on pharmacotherapy, the closeness of psychiatrists and psychotherapists to the pharmaceutical industry inevitably grew. This endeavored increased around the pill prescribers, one sent out samples, offered consulting contracts, invited on conferences, hotel included. The outgrowths of the system love congresses with wife accompaniment on Hawaii too. Even the recognized journals came under industrial prere. Conflicts of interest were the consequence, a worldwide phenomenon.

Where laws required disclosure of industry payments to doctors, the psychiatric profession showed up at the top of lists. Pharmaceutical companies also provide massive funding to advocacy and self-help groups. In the USA this system is most mature; but also the demands for more transparency. In Germany, disclosure requirements have not yet been established at the legal level. The self-administration of the German medical profession has so far prevented fundamental reforms that could lead to more transparency. There are only guidelines and recommendations on how to deal with conflicts of interest; there is no deep knowledge of which doctors and associations are linked to the pharmaceutical or medical technology industry and at what levels.

Independent-minded groups like Mein Essen zahl ich selbst (I’ll pay for my own food) are only slowly gaining acceptance. The umbrella organization of German psychiatrists, the German Society for Psychiatry, Psychotherapy and Neurology (DGPPN), only this year published recommendations on how to avoid conflicts of interest. These are only for the functionaries, not for the 6 people on the train.000 nationwide members.

What is clear: Industry and medical science are dependent on close cooperation; in the current health care system, the development of new drugs is impossible without industrial funding. This leads on the other side to the neglect of the research of traditional natural remedies, with these can be earned by the lack of patent protection clearly less.

Classification instead of class

The desire and ability of doctors to identify, classify and account for ever new mental problems has led to an advanced differentiation of the world’s disease catalogs. The ICD (International Statistical Classification of Diseases and Related Health Problems) of the World Health Organization WHO and the DSM (Diagnostic and Statistical Manual of Mental Disorders) of the APA (American Psychiatric Association) are decisive.

The DSM, the diagnostic manual used in the USA even before the ICD, has grown over the decades into a conglomerate of clinical pictures with a diameter of only. In 1980, it already contained 265 diagnostic options, while the process version still had 182. In the current version (DSM-IV) there are 365 mental illnesses. By the way, the DSM has become an important source of income for the APA. The latest version sells over a million copies – and one copy costs the equivalent of just under 60 EUR. The DSM-V, which is in the process of being edited, will once again integrate more diseases. It’s getting harder and harder to be normal.

There is hardly any other field in which this has already had such an impact as padiatrics. Attention deficit hyperactivity disorder among children seems to be ubiquitous in Europe and in fully industrialized countries worldwide, and there seems to be no end in sight to the rampant prescriptions of psychotropic drugs in this area. Interestingly, there were signs of change in the stronghold of Ritalin dispensing, the U.S. Here one wants to have recognized that ADHS is in reality a bipolar disorder, earlier it succeeded "manic depression" named, be. For almost a decade, therefore, the diagnosis of "youthful bipolar disorder" increased fortyfold. This opens up completely new possibilities for the pharmaceutical treatment of these children.

In addition, in the ailing U.S. welfare system, many low-income families have their children diagnosed as mentally disturbed in order to receive supplemental welfare benefits. The SSI (Supplemental Security Income) system guarantees not only supplemental premiums, but also access to Medicaid, the U.S. health care program. A new service industry has been established around SSI, which helps the poor to be included in the program. Access to SSI is primarily guaranteed when a minor family member is receiving psychotropic drugs. The hospitals and welfare organizations support this procedure partly, because they also profit. Rutgers University claims to have found in a study that children from financially weak families are four times more likely to receive psychotropic drugs than children from well-off backgrounds.

The U.S. media was abuzz in 2006 with the death of four-year-old Rebecca Riley, who had been prescribed a combination of several psychotropic drugs. In addition to a blood prere-lowering drug (clonidine) and valproic acid, she had been taking the neuroleptic quetiapine to combat her supposed ADHD disorder, a diagnosis she had received when she was two years old.

And the company?

The reality of mental incompetence of the population, constructed by the medical-technical apparatus, is only one aspect of the whole picture. The subjective causes of depression are manifold, the explanatory models legendary: Genetic disposition, early learned helplessness, aggression directed against oneself, to name a few approaches. The environment does its part; if life circumstances are not right, every young sunshine can turn into a gloomy adult. Lack of social contacts and poverty are central factors. This brings us to the question of the role of the social system. For depression and other mental disorders, as for other diseases, there is a socio-economic discrepancy in the distribution of opportunities for good health. To put it another way: Misery makes you sick.

In modern information and service societies, the centrality of paid employment has created an army of people who derive a great deal of their satisfaction, self-image and meaning from their work. Those who fail here often break away from their inner corset. For the others this serves as a cautionary example, they try even harder. If you don’t put the brakes on, the constant stress on your body will attack your body functions. The transitions between burn-out and depression are fugitive.

And to bring the popular catchword of neo-liberalism into play: This has once again shifted responsibility to the individual, who is clearly more responsible than before for his or her own fate and successful life. Work stress is countered with hard-core meditation. If you take this view to the extreme, the fitness and wellness industry, esoteric pacification and satisfaction strategies, and the entire event culture serve to maintain the moods of willing working drone masses. Rave on Saturday, bank on Monday. Posting a mishap Youtube video on Facebook is already considered a creative act. This does not even address the completely de-spiritualized society, which more or less consciously has to cope with the loss of the all-encompassing sphere formerly known as God. Even the good Lord has become just one option among many.

Whether this frightening autonomy of the individual leads, as some believe, to the formation of narcissistic personality disorders and depression, is an open question. Wherever one locates the causes of psychological malaise, it is obvious that, for example, an unrecognized sense of meaning in life cannot be permanently remedied merely by interfering with the serotonin balance.

Where is the saving? On a subjective level, certainly in the alert look at one’s own history, meaningfulness of activity and life – and in case of need, the choice of the right doctor, who is able and has the time to evaluate the whole person sitting in front of him/her. Intersubjectively certainly in a new strengthening of social interaction. Culturally, in a breakup of the internalized consumer mentality, which, truncated by functional thinking, believes that for every mental state there is a chemical means to potentiate or vaporize it. Finally, on the system level, a stronger autonomy of the medical-pharmaceutical science from the manufacturing industry is to be aimed at.

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