Perhaps unsurprisingly, I endorse every word of George Makari’s New York Times op-ed, written in response to reporting on a trial of integrated care for first-episode psychosis. Integrated care included personalized medication management, family education; resilience-focused individual therapy (I am not 100% sure what “resilience-focused” means specifically), and support for vocational rehabilitation. The study found substantial benefits to the integrated care program over community care that were visible not just to clinicians, but to patients and families, especially for patients with shorter duration of untreated psychosis before they entered the study. Its primary outcome was a measure of overall quality of life, and it also included a symptom severity measure as a secondary outcome; both measures showed strong effects.
This finding attracted a degree of popular attention that read as surprise, presumably because for schizophrenia, and perhaps for no mental illness more than schizophrenia, in the popular imagination its causes are genetic and immutable, or amenable to change only by a compulsory medication regimen. The only part of that it is necessarily true is that its causes are partly genetic. But these ideas about cause, course, and treatment reflect decades of efforts by psychiatry, and increasingly, psychology, to call mental illness a “brain disease.” As Makari says:
After the emergence of Prozac and the newer antipsychotic drugs like Risperidone some two decades ago, there was a sustained effort by academic research leaders in American psychiatry to promote these successes, and to fight the stigmatization of the mentally ill by forgoing the complexities of the biopsychosocial model for a simpler, more authoritative claim: Mental illness is a brain disease.
Inherent to this proposition is the implication that psychological and social events somehow are not also brain events. Acknowledgment of any nonexplicitly neural factors is seen as opening the door to those who dismiss mental illness as metaphysical, fake or the result of a moral failing. By these lights, meaningful interventions for those struggling with mental illness must be biochemical or anatomical.
If I were to quibble with any part of the op-ed, I might say that much as I shared his chagrin at the directive that every study that received NIMH funding must include a biological measure of some sort, I’m not sure that it would in practice prevent a large-scale study from occurring, it would just force the grant-seekers to cobble together some BS biomarker. A fully sequenced genome isn’t even that expensive at this point, and someone out there would probably take that data of their hands and analyze it. It was still a wasteful and wrongheaded message from NIMH, and that message isn’t even good for biologically-based research. For instance, there is plenty of brain imaging research that would benefit from clearer understanding of how people behave, what psychology and neuroscience experiments are actually measuring, and how our words and categories map on to people’s behavior and experience. The ambiguity between motivation and capacity to perform a task is just one example of the many circumstances in which an observed behavior might not mean what it seems to at first glance, and behavioral neuroscientists need psychologists to do programmatic work to put their house in order in this and many other ways. It is unfortunate that NIMH decided to tell psychologists it wasn’t interested in that work.
Regarding the idea that mental illness is “a brain disease,” no lens on mental illness is objective. They are all human ways of conceptualizing human variation, and this variation can only be understood as illness because it is violating social norms. For that reason every lens should be evaluated for its utility (I first wrote “for people who suffer from mental illness,” but I dislike the construction of categories in which “the mentally ill” are a separate group from anyone else). The “brain disease” lens has been powerful and helpful in many ways, not least by providing psychotropic drugs to those who need them, but it also fails at some of the things it’s supposed to offer. First of all, as Makari notes, it can suck resources and attention from researching an integrated approach to care (or trying to understand how further upstream, weaknesses in family or community lead to illness). Part of its promise was that it might reduce stigma, but in fact, there’s reason to believe the opposite is true — that people see a “brain disease” as more permanent than a condition arising from psychological and social causes.
A framing in which a mental illness is a relationship between a person and their environment, a contortion in the adaptation process that can be as much about the environment as the person, allows for the possibility of the world and the person moving into more harmonious agreement. Because it’s a little easier to change a person than everything around them, that will usually mean the person changing, but it also helps to maintain in our language the idea that the world could change, and we could ask it to. Much of the reporting on the Kane et al. study has emphasized therapy, but another way to look at integrative care is as a fusion of medical care and community support. It is creating a functioning community around a vulnerable individual (whose illness may have been in part due to weaknesses in the community in the first place; stress increases the risk for developing psychosis). Our way of thinking about mental illness has the possibility to teach us that the person is more likely to get and stay well when their network is well, and we all share responsibility as a part of that network. Or it has the possibility to teach us that mental illness is just an individual’s disease, enclosed within a skull, or maybe generously inside a sack of skin. I know which one I choose.