It is one of the fundamental beliefs of modern psychiatry that the mentally-disturbed must have drugs to prevent their disorders deteriorating. Drugs are now given in the very long term, generally meaning for life, even though almost none of the drugs has ever been tested in anything like the longer term: most drug trials last only a few weeks or maybe a couple of months. A problem soon arises because the side-effects take a while to appear and become troublesome. For example, many modern psychiatric drugs cause massive weight gain but this is normally not seen under about four months or more. So it is only when people are home and trying to get back to normal life that they realise, “Hey, this stuff isn’t good for my figure/ my sex life/ my ability to think or learn/ my skin/ getting a job/ staying awake to talk to people, etc.” They may raise the matter at one of their monthly appointments at the mental health service only to be told, “Don’t worry, that’s not a problem, just keep taking your drugs, you’ve got a chemical imbalance of the brain.”
As a result, a lot of them stop taking the drugs, which throws the service into a panic because they are firmly convinced that to stop taking the drugs is to court disaster – and, coincidentally, takes away their reason for existing. This is despite the clear and accumulating evidence that psychiatric drugs aren’t as effective and are much more toxic than people claim, and are probably contributing to the “epidemic” of mental disorders (eg David Healy’s Pharmageddon 2012). In orthodox psychiatric circles, it is firmly believed that if people stop their drugs, they will end up in hospital again. Non-compliance, it is believed, causes the “revolving door” syndrome, where people go in and out of hospital with monotonous regularity.
For some reason, going to hospital is seen as A Bad Thing but that’s another matter. For the administrators, if people come in and out because they have stopped their drugs, then the obvious solution is – stop them from stopping their drugs. Hence community treatment orders. A CTO is a form of civil custody, where a person living at home can be ordered to accept whatever treatment the hospital deems necessary. There are usually lots of other restrictions so the final order is often much more restrictive than a parole order imposed on somebody released from prison after a major crime. However, the larger society is prepared to put up with some of its members suffering severe losses of civil rights if it is For Their Benefit, and the way to measure benefit is to look at the number of admissions to hospital.
CTOs are in use in many countries of the world, including Australasia, the UK, many states of the US and provinces of Canada, and some European countries. It is of interest that they are seen as terribly modern, but we had exactly the same system in Western Australia in the 1960s and 70s, when it was known as After Care. Anybody who had been admitted as an involuntary patient could either be discharged Outright, meaning he was completely free of the Mental Health Act, or to After Care, a sort of legal half-way house in which he was still technically a patient even though he was living independently. He got out earlier and had to take his drugs and try to behave himself but the trade-off was that, if he did anything wrong, he more or less had a ready-made mental defence. So After Care status was kept under strict control, it wasn’t handed out for fun. It had no effect, of course, the admission rate in WA was exactly the same as in states that didn’t have it but it probably cut down on administrative time and paper work so it wasn’t all bad. All it took was answering a few questions about the patient and one signature, and off he went.
What once involved a quick talk with the patient is now a frankly adversarial matter. Getting a CTO is A Big Deal, with a cast of thousands. The patient must appear before a mental health tribunal (three very highly paid people), usually with a lawyer of his own from legal aid and one or two nurses as escorts. On the other side, there will be a psychiatrist, usually a registrar (resident in US), a medical officer or intern, a social worker, quite often a psychologist, a clerk and one or more people from security. The hearing is quasi-judicial. It will normally last an hour or more and may be adjourned to get more reports or ask witnesses to attend, so the patient has to stay in hospital. However, despite the forbidding setting, they are really quite chummy affairs as everybody knows in advance what the outcome will be: whatever the hospital asks for will be granted, if not more. These things cost a heap of money, something like $2000 an hour while the circus is in session. This is all put down to Helping The Mentally-Ill, when it doesn’t help them one bit. It helps all the people getting paid to hang around while somebody dithers over the meaning of a word in the Act.
Conditions can be onerous. One man I have seen was placed on an order eight years ago after he accepted bad advice from a lawyer and pleaded not guilty by reason of insanity to a matter that would have involved a six month bond, or perhaps a short period of probation. Instead, he got eight years of torture, with more to come. He must stay in his own home, so he cannot stay overnight at his mother’s place about two hours away. He cannot buy or sell any property or anything of value (such as buy a car). He is not allowed to drink or go to a place where alcohol is served. He cannot leave the town nor move interstate (as he wants to do). He has to keep his house to a standard the nurses think reasonable. Nurses can come into his house at any time of day and order him to hospital for no stated reason. He must accept any medication prescribed by the psychiatrist in any form for any psychiatric reason. All this is in place for a man in whom I could not find a significant psychiatric symptom (he hasn’t had any for about 7.5yrs) and for whom the hospital could not provide a diagnosis. When asked why he was considered a danger, there was no evidence at all. In fact, the act does not require any evidence, only the “perception.” Oh, and it costs a lot of money to keep him trussed up legally.
So it is of interest that somebody has at last looked at whether these orders do what they are supposed to do, keep people out of hospital. A carefully planned study by a psychiatrist in the UK, Tom Burns, has used the standard of a randomised clinical trial to see whether CTOs are any better than no orders. His team assigned nearly 350 patients to two groups, one placed on an order and one without, and followed them to see whether they were readmitted. The groups were practically identical on all social and psychiatric parameters. So was the outcome. Being on a CTO made absolutely no difference to whether the patient was readmitted during the study period:
“Despite a more than three-fold increase in time under initial supervised community care, the rate of readmission to hospital was not decreased by CTOs. Neither was the time to readmission decreased nor was there any significant difference in the number or duration of hospital admissions. We also recorded no differences in clinical or social outcomes.”
Two previous but smaller studies from the US, from 1999 and 2002, reached the same conclusion:
“The evidence is now strong that the use of CTOs does not confer early patient benefits despite substantial curtailment of individual freedoms… International experience indicates that clinicians rapidly form strong opinions for or against CTOs and clinical equipoise is soon lost.” (I like that expression, it means ‘their prejudices beat balanced judgement’).
There is another aspect to consider, and that is the way the movement to legislate CTOs has spread around the world in the absence of anything that approximates supportive evidence. If we look at the drama surrounding, say, childhood immunisation, cigarettes, compulsory testing for HIV or mammograms, it becomes even more remarkable that people were able to convince legislators to impose major restrictions on civil rights for an essentially defenceless group. We would like to think that if there is no advantage or benefit in CTOs, they will be dropped but I’ll lay any money that won’t happen: there are far too many people making a handsome living out of CTOs for anybody to dare talk about amending mental health acts to get rid of this useless bit of bondage.
On another note: psychologist Bruce E Levine asked the question nobody wanted to hear:
“If a nation murdered and sterilized an estimated 73 percent to 100 percent of its diagnosed schizophrenics, yet a generation later that nation had a higher rate of incidence of new cases of schizophrenia than did surrounding nations, shouldn’t we have questions about the claim by the mental health establishment that schizophrenia is highly heritable?” (Truth-Out, Jan 18th 2013 ).
Drawing on figures from Germany, published in an authoritative report in Schizophrenia Bulletin in 2010, Levine quoted a psychiatrist, Heinz Häfner at the University of Heidelberg:
“Häfner reported that in Mannheim, Germany for each year from 1974 to 1980, new incidents of schizophrenia ranged from 48 to 67 per 100,000, averaging 59 per 100,000. Häfner compared the rate of new incidence of schizophrenia in Mannheim with 11 studies in the Netherlands, Italy, Denmark, Norway, Iceland, the United Kingdom, the United States and Australia. The non-German locations averaged 24 per 100,000, less than half the incidence rate for Mannheim. Another study done in Bavaria, Germany in 1974-1975, reported an annual incidence rate of 48 per 100,000, double the incidence of non-German locations. Today, the World Health Organization reports the prevalence of schizophrenia in Germany is virtually the same as it is for other European and North American nations.”
Oh dear. This puts quite a twist on the oft-repeated argument that schizophrenia is a “genetically-determined chemical imbalance of the brain” or, in the words of the current director of NIMH, a “disorder of neuronal circuits,” whatever that means (I have argued that it actually means nothing; that paper will appear in
Ethical Human Psychology and Psychiatry later this month). If the gene pool for a genetic disorder is wiped out but the disorder just keeps popping up, surely that says something? Levine says we need to question the concept of heritability in this and other mental disorders:
“When we begin to question, we discover that (1) scientifically flawed research has been used to promote ideas around mental illness and its heritability, and (2) instead of focusing on nature vs. nurture causes of mental illness, it’s time to consider whether certain phenomena are really symptoms of pathology, or instead are inextricable aspects of our humanity.”
That is music to my ears. I’ve been saying for decades that the concept of inherited mental disorders is far more complicated than orthodox psychiatry makes it out to be. The most reasonable explanation is that the disease of schizophrenia is promoted by the interaction of a large number of genes (ie polymorphic), each of which contributes a very small part of the variance but none of which could cause the condition alone. These are normally distributed in the population and may even be beneficial; unless the person gets a multitude of doses (or several very deleterious ones), he won’t manifest the disease but can pass on the tendency (ie this is a process of summation, think of the broad concept we define as “intelligence” and the many different pathways to “intelligence”). This line of thought fits perfectly with the best genetic evidence we have currently, as can be seen at http://www.szgene.org, a website which Ioannidis (his bibliography) helped develop to create an evolving meta-analytical database of schizophrenia genetics research. A quick look through this site will reveal how limited the contributions are for each gene. I was unable to find any that had an odds ratio (OR) of less than 0.70 or above 1.3! For those not versed in statistics this approximates 30% higher rates of protection or risk (ie not that much compared to associations such as insomnia increasing the subsequent risk of depression by many times over, likely somewhere near 500%). This line of thought dramatically changes the way we conceptualize the genesis of schizophrenia. Instead of just being an on or off phenomenon we now have a continuum, a concept that runs contrary to the yes or no categorical methodology of the DSM. Conceptualizing schizophrenia as a blending of risk provides a much stronger footing for mental and environmental contributions. Notice that above I said promoted, not caused. With this line of thought a person can have one of many substrates for schizophrenia but have not been in a position psychologically to “throw them over the edge.” Obviously, the presence of a continuum means there are varying degrees of severity and therefore the homogenized approach of simply checking boxes and giving medications will not do. This leads to a form of treatment that is tailored to the patient with a limited use of neuroleptics and an absolute need for therapy. When utilized, neuroleptics should facilitate therapy but be minimized or even discontinued once symptom control is established (this statement is not out of line: see the 15 yr follow up of Soteria by Harrow). An example of this method with outstanding outcomes is employed in western Lapland, Finland, and can be found at Seikkula et al 2006. An excellent overview with interviews of Dr. Seikkula is outlined in Robert Whitaker’s Anatomy of an Epidemicpages 336 to 344. For those who still believe the sweeping claims the geneticists are making I would highly recommend reading the critical work of Jay Joseph. Their methodology is not as solid as they’d like you to think.
Joseph J. 2004. The Gene Illusion. New York:Algora Press.
Highlighted Books and Articles
Talking of books, one of the most renowned of American philosophers, Thomas Nagel, has recently published a book with the provocative title, Mind and Cosmos: Why the materialist neo-Darwinian conception of nature is almost certainly false (2012, New York: Oxford University Press). Nagel found fame (or notoriety) in 1974 with a paper called “What is it Like to be a Bat?” This is an extremely widely quoted paper although I must admit I’m not quite sure why, as most people quote it only to ignore it. It’s actually a subtle defence of mind-body dualism by way of putting almost insuperable difficulties in the way of physicalists or reductionists (as biological psychiatry is), but that has done nothing to slow the rush to biology, even among philosophers (such as Dennett, Searle, Thagard and Jackson).
But anyway, back to his book. It has attracted enormous attention, last time I looked, there were over 35 reviews listed on Google, mostly weakly approving or overtly disapproving (I wish I could get 35 reviews, good or bad, for a book of mine). I find this book is a bit of a problem. It’s written in a very personal style (meaning, not very clear) and comes across more as the lament of an old man (75yrs) who feels that his very reasonable message has not been given the attention it deserves. I don’t like most evolutionary theorising in psychology and human affairs, yet even I can’t find much sympathy for his major complaint against Darwinian theory, that it doesn’t seem plausible. He won’t do much to prevent the very rowdy people on the other side of the fence, Dawkins, Dennett and company, from dominating the airwaves with their over-simplified and essentially ideological evolutionary ranting. Why? Because it’s easy to turn your opinions into a Just So story using a dumbed-down version of evolution, much harder to present a subtle and carefully argued case against it.
So will Nagel’s swansong win many converts to mind-body dualism, or even force people to pause and question the concept of biological reductionism? Sadly, no, it won’t. The main reason takes a while to emerge: After a lifetime of philosophising, Thomas Nagel doesn’t have a theory of mind. All he has is the humanist intuition that mind is something more than the brain and he can mostly find holes in the main reductionist arguments but that’s where the matter ends. That’s a pity. We need more people prepared to stand up against the biological onslaught because, until there’s a formal theory of mind, there won’t be a formal theory of mental disorder.