Scientific Panel replies to APA statement
15 December 2003
MindFreedom Support Coalition International
454 Willamette, Suite 216
PO Box 11284
Eugene, OR 97440 USA
James H. Scully, Jr., M.D.,
Medical Director American Psychiatric Association
1000 Wilson Boulevard, Suite 1825
Arlington, VA 22209-3901 USA
Re: American Psychiatric Association Statement on Diagnosis and Treatment of Mental Disorders, 25 September 2003, Release 03-39.
Dear Dr. Scully:
We believe that the above-mentioned APA Statement was released in response to the questions posed last summer to the American Psychiatric Association, the National Alliance for the Mentally Ill, and the Surgeon General of the United States by the Fast for Freedom in Mental Health based in Pasadena, California.
The scientific panel convened by the hunger strikers has written the present letter to respond to this APA Statement. We have paired the contents of the 11-paragraph APA Statement to the strikers' original questions and also added our own comments about some issues the APA Statement raises.
The Fast for Freedom in Mental Health wrote on 28 July 2003:
"WE ASK THAT YOU PRODUCE scientifically-valid evidence for the following, or that you publicly admit to media, government officials and the general public that you are unable to do so:
"1. EVIDENCE THAT CLEARLY ESTABLISHES the validity of 'schizophrenia,' 'depression' or other 'major mental illnesses' as biologically-based brain diseases.
"2. EVIDENCE FOR A PHYSICAL DIAGNOSTIC EXAM -- such as a scan or test of the brain, blood, urine, genes, etc. -- that can reliably distinguish individuals with these diagnoses (prior to treatment with psychiatric drugs), from individuals without these diagnoses."
The APA Statement's fourth paragraph states:
"Research has shown that neurobiological disorders like schizophrenia reveal reproducible abnormalities of brain structure..." Without any citations, these statements cannot be supported, qualified, or rejected.
However, in the fifth, sixth, and eighth paragraphs, the APA Statement admits to the absence of "discernible pathological lesions or genetic abnormalities" in mental disorders. This admission contradicts the previous assertion of "reproducible abnormalities."
Without evidence of brain pathology no basis exists to call emotional distress, disturbing behavior, or unusual thoughts or perceptions "neurobiological disorders." This and similar terms negate the sufferer's distress as reaction, protest, or adaptation to his/her position in the personally relevant social context. A person is understood in terms of personal history and social circumstances. A neurobiological disorder is understood differently. The choice of labels is of great consequence.
Moreover, finding reliable biological markers would be only a first step toward concluding that mental disorders are essentially neurobiological. For example, blushing, an obviously physical reaction, is not biologically caused. Its effective cause is acute embarrassment. Biological processes make blushing possible but they do not cause blushing.
Even total congruence between biological processes and psychological events does not show that the former cause the latter. Psychiatric research is far from showing any reliable connections between mental disorders and biological measurements, much less revealing anything definitive about the nature of mental disorders.
Aware of this shortcoming, the APA cites migraine headache and hypertension to illustrate that the lack of biological markers (and thus of physical diagnostic tests) is not unique to mental and behavioral disorders. It is true that medicine has yet to find the biological cause for these two disorders, though it has developed a very reliable physical measurement for blood pressure.
However, in other branches of medicine such disorders are exceptions. In psychiatry theyare the norm. Psychiatry is the sole medical specialty that treats only disorders with no biological markers.
Moreover, hypertension is regarded as a symptom of physical disease because hypertension can degenerate into frank physical disease, even death. No such parallel exists in psychiatry. For example, people diagnosed with schizophrenia or major depressive disorder often are physically healthy: unless their social circumstances and neglect interfere negatively, they may live long lives and die of the same physical causes as other people.
The APA confirms in paragraph six that, in the absence of biological markers, mental disorders are defined by "a variety of concepts": "distress experienced and reported," "level of disability," "patterns of behavior," and "statistical deviation from population-based norms." Precisely. The APA should therefore explain how such sociological concepts -- which easily define conditions such as poverty, discrimination, or war -- substantiate the existence of "neurobiological disorders."
Although it acknowledges the absence of genetic abnormalities, the APA still claims that "compelling evidence exists for a strong genetic "component" for schizophrenia and other conditions. This statement might mislead people who have not read the research into thinking that physical evidence for a genetic condition has been discovered. In fact, this research only involves counting cases of schizophrenia (diagnosed according to behavioral criteria and clinical judgment) and testing the probability that such cases would occur in certain samples.
The twin and adoption studies of this nature that the APA usually cites are plagued by untenable theoretical assumptions (e.g., that identical and fraternal twins grow up in identical environments) and serious methodological problems (e.g., expanding the diagnosis of schizophrenia to include conditions no one thinks are schizophrenia). Any results that remain after accounting for these manipulations can be fully explained on non- genetic grounds (Joseph, 2003; Lewontin, Rose, and Kamin, 1984; Pam, 1995).
The Fast for Freedom in Mental Health also requested:
"3. EVIDENCE FOR A BASELINE STANDARD of a neurochemically-balanced 'normal' personality, against which a neurochemical 'imbalance' can be measured and corrected by pharmaceutical means.
These issues were not addressed in the APA Statement.
The APA Statement could have replied accurately that neuroscientists have not established any normal baseline quantity for any known neurotransmitter (no measurements even remotely parallel to blood pressure to diagnose hypertension exist), nor have they shown any chemical imbalance to correlate with mental disorders diagnosed in un- medicated individuals (Breggin, 1991; Healy, 1997; Valenstein, 1998).
The Fast for Freedom in Mental Health also requested:
"4. EVIDENCE THAT ANY PSYCHOTROPIC DRUG can correct a 'chemical imbalance' attributed to a psychiatric diagnosis, and is anything more than a non-specific alterer of brain physiology."
The APA Statement merely states what has been known for at least 50 years, that "medications clearly exert influence on specific neurotransmitters..." This response states the obvious: all mind and mood altering drugs have effects on the brain. This includes illegal mind and mood altering drugs, though no one has suggested that they correct chemical imbalances in the brain.
Given the Food and Drug Administration's impotent exercise of its mandate to protect consumers from false advertising, pharmaceutical companies recklessly advertise cartoons showing neurotransmitter "imbalances" corrected by drugs. However, in the absence of scientific proof to substantiate such claims, it is ethically and medically reprehensible for doctors to convey such messages to justify prescribing drugs, and for the APA's own journals to publish such advertisements.
And finally, the Fast for Freedom in Mental Health also requested:
"5. EVIDENCE THAT ANY PSYCHOTROPIC DRUG can reliably decrease the likelihood of violence or suicide."
Not addressed in the APA statement.
"6. EVIDENCE THAT PSYCHOTROPIC DRUGS do not in fact increase the overall likelihood of violence or suicide."
Not addressed in the APA statement.
"7. FINALLY, that you reveal publicly evidence published in mainstream medical journals, but unreported in mainstream media, that links use of some psychiatric drugs to structural brain changes."
Not addressed in the APA statement.
Despite its use of terms such as "compelling evidence" and "research shows," the APA Statement provides no citations to any scientific literature. This was also the case in the first letter that Dr. Scully addressed to the scientific panel on 12 August 2003.
Associations devoted to research and treatment of genuine diseases readily provide consumers with scientific references on the pathological basis of these diseases. The APA is a 35,000-member organization, with an annual budget exceeding $38 million. With a handful of allies, it shapes mental health practice and policy in this country and has convinced taxpayers to spend billions to support its claim that psychiatrists treat "neurobiological disorders."
The APA should be able to provide a one-page list of published scientific studies to support this claim. Yet, the APA only speculates on future findings: "Mental disorders will likely be proven to represent disorders of intercellular communication; or of disrupted neural circuitry." (This sentence is yet another de facto acknowledgement that neuropathology cannot be shown in mental disorders.)
The APA uses terms like "complex," "emergent properties," and "subtle" when describing people's overwhelming mental and emotional crises. It states: "the human brain is the most complex ... object of study in the history of human science." Yet this language about complexity is completely at odds with the biological model that reduces the human mind to a machine. Since the discovery of the infectious cause of neurosyphilis nearly a century ago, this model has failed to explain the cause of a single mental disorder. Yet this model dominates the mental health system.
Aware of this utter failure to find causes, the APA claims that money spent by the public and private sector "has greatly improved our ability to treat severe, frequently disabling mental and behavioral disorders effectively." However, relevant indicators show the exact opposite.
For schizophrenia, worsened relapse rates and increased numbers of people on disability status characterize outcomes over the last 50 years (Hegarty, Baldessarini, Tohen, Waternaux, and Oepen, 1994; Whitaker, 2002). For depression, increased incidence and prevalence are reported. Indeed, the APA Statement cites that mental disorders "rank second in societal burden, behind only cardiovascular conditions" in modern societies.
Perhaps the treatment is worsening the disorder. At best, the treatment is not helping: researchers now recognize that the most popular psychiatric drugs, the SSRI antidepressants, rate only slightly better than inert placebos (Kirsch, Scoboria, and Moore, 2002; Kirsch, Moore, Scoboria, and Nicholls, 2002). In addition, negative research findings (sponsored by industry) are commonly suppressed, and adverse drug effects are massively under-reported in psychiatric journals and to the Food and Drug Administration. These dubious but tolerated practices create an enormously misleading view of the actual impact of drug treatments.
Rather than acknowledge the lack of progress despite the huge expenditure of public and private funds, the APA dismisses its critics as denying the reality of suffering and impatient with the "pace of science." A genuine science states hypotheses in ways that allow them to be proven true or false. For a century now psychiatry has put forth hypothesis after hypothesis that is not falsifiable.
Today, despite no biological causes, no discernible biological markers or abnormalities, no diagnostic tests, no accurate predictions of treatment response and outcome, the APA still continues to claim that emotional disorders are genuine neurobiological disorders ... with causes too subtle to detect at present! This is hardly an advance over earlier unfalsifiable ideas such as the Oedipal complex.
In sum, the APA's statements reflect less the "pace of science" than the pace of commerce: they blur with the pharmaceutical advertising themes saturating our media. This is because the APA is not an independent organization. One third of its operating budget comes from the drug industry. Drug companies dominate its professional meetings to advertise drugs. In addition, the drug industry funds, directs, and analyzes many drug studies (Healy, 2003), and psychiatric journals publish so-called scientific reports of these drug studies that are ghost-written by industry employees or marketing firms. Psychiatric drug experts with no significant ties to industry can hardly be found. Industry largesse binds many psychiatric practitioners to the industry (Editorial, 2002).
The hunger strikers asked the APA for the "evidence base" that justifies the biomedical model's stranglehold on the mental health system. The APA has not supplied any such evidence, which compels the scientific panel to ask one final question: on what basis does society justify the authority granted psychiatrists, as medical doctors, to force psychoactive drugs or electroconvulsive treatment upon unwilling individuals, or to incarcerate persons who may or may not have committed criminal acts? For, clearly, it is solely on the basis of trust in the claim that their professional acts and advice are founded on medical science that society grants psychiatrists such extraordinary authority.
We urge members of the public, journalists, advocates, and officials reading this exchange to ask for straightforward answers to our questions from the APA. We also ask Congress to investigate the mass deception that the "diagnosis and treatment of mental disorders," as promoted by bodies such as the APA and its powerful allies, represents in America today.
Scientific Panel for the Fast for Freedom in Mental Health: Fred Baughman, MD; Mary Boyle, PhD; Peter Breggin, MD; David Cohen, PhD; Ty Colbert, PhD; Pat Deegan, PhD; Al Galves, PhD; Thomas Greening, PhD; David Jacobs, PhD; Jay Joseph, PsyD; Jonathan Leo, PhD; Bruce Levine, PhD; Loren Mosher, MD; Stuart Shipko, MD
The hunger strikers endorse the scientific panel's statement. The Fast for Freedom in Mental Health is a project of MindFreedom Support Coalition International. www.MindFreedom.org
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