杏吧原创

AT THE bottom of Pandora鈥檚 box was hope 鈥� a thought worth hanging onto when reading about psychiatry. But read we should, since up to a third of us may at some time sport a label from the psychiatrists鈥� bible, the Diagnostic and Statistical Manual of Mental Disorder (DSM). And the World Health Organization reckons that by 2020 will be the second largest contributor to the global burden of disease.

Treatment and its failures are the burden of Irving Kirsch鈥檚 The Emperor鈥檚 New Drugs and Richard Bentall鈥檚 Doctoring the Mind. The books鈥� subtitles signal intent: Kirsch鈥檚 is a ballistic 鈥淓xploding the antidepressant myth鈥�. Bentall鈥檚, interestingly, differs between US and UK editions: 鈥淲hy psychiatric treatments fail鈥� for the UK, and 鈥淚s our current treatment of mental illness really any good?鈥� for the US.

The latter鈥檚 tentative tone may be a wise move since the US psychiatric community seems to be in even more serious meltdown than its British counterpart. Big Pharma faces legal action over the effects of antidepressants, Congress is demanding financial transparency from psychiatrists working on the DSM V due out in 2011, individuals scour the net for help, and activists struggle to find viable alternatives to drugs.

Bentall鈥檚 book is a shorter, more accessible version of his Madness Explained (Penguin, 2004) and is full of stories about his patients. As a therapist, Bentall is a gentle, non-judging voice; as a polemicist, though, he is deeply unimpressed with psychiatry鈥檚 progress. We are, he says, still attached to the 鈥渕yth鈥� of mental illnesses as brain disease, and despite claims of dramatic advances, patients are doing no better than they did 100 years ago.

Shockingly, people in the west are less likely to recover than those in poorer countries. Kindness and empathy are missing from the system. Drugs dominate but they don鈥檛 work well: it鈥檚 time to prescribe them only on a suck-it-and-see basis, Bentall says.

Kirsch is famous (or infamous) for a more uncompromising stand on psychiatric drugs. In 1998, he made headlines with research showing that the benefits of antidepressants could mostly be due to the placebo effect. Ten years later came more headlines when he published a meta-analysis of data presented to the US Food and Drug Administration that found the new generation of selective serotonin reuptake inhibitors (SSRIs) to be no better than placebo in treating all but the most severely depressed patients 鈥� and even that might be down to decreased efficacy of the placebo.

While writing the book, Kirsch stopped believing drugs might benefit even this subset of patients. Now he thinks the belief that antidepressants can cure depression chemically is 鈥渟imply wrong鈥�, and questions the idea that depression is an illness at all. His case that the drugs鈥� benefits are due to placebo and enhanced placebo effect is fascinating, and demands urgent research.

鈥淜irsch questions whether depression is to do with chemical imbalances in the brain, or if it is an illness鈥�

If antidepressants don鈥檛 work, shouldn鈥檛 we be told? Kirsch says he has been urged to adopt a 鈥渄on鈥檛 ask, don鈥檛 tell鈥� attitude: in other words, it is wrong for him to say so in public. But he counters, if placebos work, 鈥渄epression can be ameliorated without reliance on drugs that have potentially serious side effects鈥�.

Clearly, it鈥檚 time for a big rethink of what constitutes mental illness and about how to treat it. For Kirsch, even costly psychotherapy comes out well against years of antidepressants. Then there鈥檚 the UK鈥檚 10-year cognitive behaviour therapy (CBT) plan, which the world will be watching critically. And there are plenty more, as yet under-researched, therapies to explore, such as exercise.

The most encouraging take-home message is from Bentall: 鈥淧erhaps the most important lesson of the past century for mental health professionals of all kinds is that we must set aside our hubris and be humble in the face of madness.鈥� Now that鈥檚 real hope.