Mental disorders as normal responses, rethinking medication

Recently I read an article about human behavior called “mental disorders” being normal responses. I won’t only put the contents of the article here like I usually do with other articles. This is because I think it makes a very damaging conclusion, which I will get to later, and that I think the information it presents requires additional clarification or commentary. I want to include and comment on snippets of the article that I think are important to know to help instead of damage people with deemed mental disorders.

For now, I will commit a sin by trusting an article faithfully represents the paper it refers to. Don’t try this at home, kids. Anyway, onto the snippets:

Second, the study authors note that despite widespread and increasing use of antidepressants, rates of anxiety and depression do not seem to be improving. From 1990-2010 the global prevalence of major depressive disorder and anxiety disorders held at 4.4% and 4%. At the same time, evidence has continued to show that antidepressants perform no better than placebo.

I am familiar with the idea of “disorders” being responses of the brain to defend against threats, but in case you are not:

Third, worldwide rates of these disorders remain stable at 1 in 14 people. Yet “in conflict‐affected countries, an estimated one in five people suffers from depression, PTSD, anxiety disorders, and other disorders,” they write.

Taken together, the authors posit that anxiety, depression, and PTSD may be adaptive responses to adversity. “Defense systems are adaptations that reliably activate in fitness‐threatening situations in order to minimize fitness loss,” they write. It’s not hard to see how that could be true for anxiety; worry helps us avoid danger. But how can that be true for depression? They argue that the “psychic pain” of depression helps us “focus attention on adverse events… so as to mitigate the current adversity and avoid future such adversities.”

If that sounds unlikely, then consider that neuroscientists have increasingly mapped these three disorders to branches of the threat detection system (polyvagal theory). Anxiety may be due to chronic activation of the fight or flight system. PTSD may occur when trauma triggers the freeze response which helps animals disconnect from pain before they die, and depression may be a chronic activation of that same freeze response.

Applying findings on pain to mental disorders

The bolded text in the article quote about the idea of depression being a defensive response aligns incredibly well with my learnings in college about how pain works in the body. I previously wrote about pain in another post. However, I now notice I missed something important in that post: I learned from my professor that chronic pain is a response of the body to protect itself against future damage. This explains why, in my post, the more emotional distress is associated with an injury, no matter how slight the actual damage may be (e.g. a mild, fender-bender-related neck injury), the more chronic pain is experienced. For the record, my professor is a doctor of physical therapy who studies closely with doctors of neurology who specialize in pain.

Consdering depression can entail chronic emotional pain, it makes sense that depression can be a defensive response the body induced. With pain, the person may be made more aware of the bad situation that induced it. This awareness may bring more caution and prevent further damage to the person. Additionally, this awareness and caution can prevent damage from future similar events.

Labels

The article also touches on a subject I’m greatly concerned with, which is the weight of labels. I may write a separate post on the damage labeling people for their disorders do in the future, for I feel this article is too vague and explores a different idea about the effect of labels (which is also true). I’ve seen the damage this does firsthand. And it goes much deeper than just “labels hurt people’s feelings.” It goes to how we judge every behavior of someone and tie it to their disorder or blame it on their disorder. More on that another time.

Labels are something we internalize to define who we are and what we are capable of. All too often, labels limit us. And that’s why reconsidering how we label anxiety, depression or ADHD is important. Does someone have depression, a medical disorder of their brain, or are they having a depressed adaptive response to adversity? Adversity is something we can overcome, whereas a mental disorder is something to be managed. The labels imply very different possibilities.

Consider how we label ADHD. A generation ago boys with ADHD were labeled as “bad boys” and were given penalties or detentions. Now we help kids with ADHD understand that they have a “learning difference.” Instead of detention, we try to provide support in a variety of modalities. When we do, the behavior problems often disappear. That label change to learning difference is vital because it gives space for kids with ADHD to be “good kids” and to succeed. Yet ADHD is still “attention deficit and hyperactivity disorder.”

ADHD

In alignment with my studies, physical activity is vital for well-being and even affects mental health. But on another note, the article spells out something crucial I realized before about ADHD, which is also something someone I know diagnosed with ADHD realized a long time ago:

In Finland, where substantial physical activity is part of the school day, rates of ADHD are also very low. Meanwhile, in the U.S. children are asked to sit still for the majority of the day. Elementary school students often get only 15-20 minutes of recess a day, a far cry from the 60-90 minutes their parents had. Coincidentally, ADHD rates in the U.S. have gone up over the last 15 years.

ADHD is not a disorder, the study authors argue. Rather it is an evolutionary mismatch to the modern learning environment we have constructed.

Edward Hagen, professor of evolutionary anthropology at Washington State University and co-author of the study, pointed out in a press release that “there is little in our evolutionary history that accounts for children sitting at desks quietly while watching a teacher do math equations at a board.”

If ADHD is not a disorder, but a mismatch with a human environment, then suddenly it’s not a medical issue. It’s an issue for educational reform.

The article author clarifies that she understands ADHD, as with most mental disorders, can be influenced by biology/heredity. But she states that because of that, the paper “must be taken with a grain of salt.” I don’t see how that’s necessary: it’s a basic known idea in psychology that mental disorders are often influenced by both the environment and biology/heredity. This is called “nature vs. nurture.” Just because a mental disorder can be linked to biological or hereditary factors doesn’t negate that it can be influenced by the environment as well.

I’ll assume she doesn’t actually mean to be skeptical of the paper, as her use of the saying, “take it with a grain of salt” suggests. I’ll give her the benefit of the doubt and entertain the idea that what she may have meant to convey instead was that environment (“nurture”) shouldn’t be the only thing we blame/fixate on when dealing with mental disorders.

Still, we need to take this study with a grain of salt. There is a large body of research showing other biological factors when it comes to ADHD. For instance, there is evidence that premature birth increases rates of ADHD later.

This next part is the most important takeaway I want the world to know:

Study author Kristen Syme, a recent WSU Ph.D. graduate,

compares treating anxiety, depression, or PTSD with antidepressants to medicating someone for a broken bone without setting the bone itself.

She believes that these problems “look more like sociocultural phenomena,

so the solution is not necessarily fixing a dysfunction in the person’s brain but fixing dysfunctions in the social world.”

The paper also did a great thing in directing future research to alternative treatment methods. I’m not sure why the article author thinks that the paper did otherwise. Adversity and conflict mitigation is a treatment model.

It’s a fair criticism of the way we treat mental illness. But the stated goal of the paper is not to suddenly change treatments, but to explore new ways of studying these problems. “Research on depression, anxiety, and PTSD, should put greater emphasis on mitigating conflict and adversity and less on manipulating brain chemistry.”

The author revisits the “nature vs. nurture” issue and clarifies that she actually is aware that both nature and nurture interplay in mental disorders. It confuses me since she previously stated to take the paper with a grain of salt. This might be an article engagement method I’m not aware of, or something. Building tension, or whatever.

But what about the fact that there is plenty of medical evidence for that brain chemistry? Consider a recent study done in Turku, Finland. Researchers showed that the symptoms associated with depression and anxiety are connected to changes in the brain’s opioid system already in healthy individuals.

Can we reconcile brain studies like this with the biological anthropologists criticism of how we handle mental health? Actually we can. The changes in the brain associated with anxiety and depression are evident, but that doesn’t mean they can’t be understood as responses to adversity.

But the conclusion the article author reaches is incredibly damaging.

Based on this, do we need to make changes in how we treat mental health? Yes and no. When it comes to what labels we use, a change is welcome. Mental health recovery in part, depends on whether patients believe they can get better. Telling our patients that their symptoms may be tied to a healthy response to adversity could be very encouraging.

It’s not news to doctors that mental health is impacted by adversity. In my own medical training, I was taught the biopsychosocial model, implying interconnected causes of these problems. But until social reform actually does remove social causes of suffering, physicians must continue to provide the standard of care to our patients. The history of medicine is a story of healers using the best treatments they had at the time, until better ones arrive.

They effectively state, “Well, the societal problems propagating mental disorders aren’t being solved, so we’ll just change nothing about how we treat it.” We can change plenty about how we treat it. Because the current “best practice” is not actually the best we can do. It was stated in the article itself, “we should focus less on altering brain chemistry.” Still, the current standard of care is to drug the young with developing brains with medication that often entail heavy withdrawal symptoms. The current standard of care incentivices drugging people at the get go instead of focusing on alternative treatment models because doctors are paid to prescribe them.

The current standard of care is to turn to altering brain chemicals first and foremost.

So, no. Physicians must not continue to provide the standard of care to patients.

Also, yes and yes; we do need to make changes in how we treat mental health: both when it comes to the labels we use and with focusing on alternative treatments to outright medication.