International events related to emotional health issues continue to shock the world, and call into question the value of the mental health industry. Recently, many people around the globe have felt devastated by the suicide of Robin Williams and shocked by the downing of the plane by Andreas Lubitz. Numerous incidents of violence have been shown to involve the mental health industry with some link to mental disorders or psychiatric medication. The important issue to understand is what do these connections mean.
Clearly mental health services are failing many individuals and society. All research on treatment modalities and outcome show poor results, with chronicity and frequent recurrences the norm. Many practitioners have come to accept this as all one can expect and have stopped truly listening to people’s pain. This leads to poor practice, with superficial diagnoses and multiple medications to control symptoms. Symptom control, whether by medication or simplistic approaches to therapy have become the main interest of mental health services.
This approach seems to suit managed care models, corporate needs, big pharma and the mental health industry in general. Emotional health is being redefined by special interests, in a manner that is actually changing the way people think of themselves. It is a case of the tail wagging the dog. It can be argued that it is precisely this orientation that is leading to catastrophic results.
To be up front, I prescribe psychiatric medication frequently, though usually as an adjunct to psychotherapy. Psychiatric medication can play an important role in relieving some symptoms, that may allow some people to feel better quickly and to work in therapy better. We should not be depriving people of relief from emotional pain by adhering rigidly to any kind of doctrine. What is crucial is that we listen to people carefully and with empathy to be able to figure out what can help them and what may hinder their emotional well-being. We need to understand that DSM Axis I diagnoses are made up and do not generally describe disease processes, and that psychiatric medications do not cure diseases.
What psychiatric medications do is to change the functioning of brain pathways. There is no evidence that they make abnormal pathways normal. There is no evidence that even if there might be a brain abnormality in certain conditions that the medications work at the particular site of the abnormality. All they do is either block or accentuate some pathways somewhere along the route of certain nerve transmissions that in some ways alter the appearance of certain symptoms.
In other words; for the most part, psychiatric medications make normally functioning pathways act abnormally. This may have a beneficial effect, or it may lead to side effects, or it may make things worse.
For example, from a clinical perspective, most antidepressants act as emotion dampeners, though Peter Breggin prefers the name ‘zombifiers.” This effect may be helpful, with some people describing this as having a thicker skin, though for other people this feeling is very uncomfortable. From this point of view, let’s examine the situations of Robin Williams and Andreas Lubitz.
The death of Robin Williams saddened the world. Many of us will never watch one of his movies again with quite the same feeling of joy. There were clearly many aspects to his final decision, including a fear of his physical condition. He is also reported to have had bipolar disorder. While making this diagnosis on many people with emotional ups and downs has become a fad, I do not wish to dispute this possible diagnosis in Robin Williams. It does not appear that this diagnosis was a predominant factor in his death, though it is likely that his being seen and treated as if his main problem was a psychiatric disorder may have contributed to his suicide. The most important issue, involved in significant depressed and hopeless feelings, appears to be Robin’s vulnerability to decreased applause. This narcissistic vulnerability, as it is called in psychiatry, appears to have haunted him throughout his life. This is something that is treatable, but only if one recognizes the depth of the problem and doesn’t revert to just treating symptoms. It is likely then that Robin William’s death is an example of a DSM Axis I diagnosis contributing to a suicide. The issue of whether psychiatric medication may also have played a contributing role is highly uncertain in the case, though anyone who does receive a diagnosis and medication may end up feeling more hopeless when the medication does not take away one’s most painful feelings.
The life of Andreas Lubitz may be more germane to the issue of diagnoses and medication. What we know so far about him is that he deliberately planned to crash the plane, had been exploring ways to commit suicide, had a previous history of depressed moods, had seen numerous doctors over the previous months — including a psychiatrist, was preoccupied with worries about his vision, and was taking mirtazapine, an antidepressant, for insomnia.
We know that laws in Germany may have made it difficult for the doctors who saw him to report their concerns. This aspect rests in the hands of German society. What is clear is that Andreas Lubitz never received appropriate treatment for his emotional problems. We cannot necessarily blame the mental health system in Germany for this, nor the individual doctors. It is very possible that he was not amenable to receiving treatment. This is common in individuals with somatic preoccupations who look for a physical cause of their distress and refuse to accept the need for proper therapy. However, every attempt should have been made to engage him in proper psychotherapy and to work with him so that he would understand that agreeing to take time off work would help ensure his ability to maintain his career.
Ideally, the proper psychiatric approach to help him with his emotional distress should have occurred from his first appearance for depressed feelings. Suicide frequently is not the result of an acute appearance of a depressed mood, but happens after a person has struggled with repeated or chronic feelings of distress for years. Just treating symptoms rarely resolves the underlying emotional issues that lead to the depression in the first place, and often, as is shown in research, leads to frequent recurrences and accompanying hopelessness.
The use of mirtazapine in Lubitz is also concerning. Mirtazapine is a fairly poor antidepressant and as a sleeping aid frequently leads to daytime drowsiness. Any antidepressant can leave someone more detached from their feelings or actions. As one patient recently expressed “when I was on the antidepressant I didn’t think or have feelings about my actions. I just did things with little awareness of what I was doing.” As the dose of mirtazapine Lubitz was on was relatively low, one can’t be sure of whether it had any impact on his actions, though it did not appear to have relieved his insomnia or help his mood. As a sleep disturbance seemed to be a major aspect of Lubitz’s distress, there is the issue of why a more reliable sleep aid with less possible side effects possibly wasn’t used.
The most crucial issue, in these tragic situations and in the general mental health field, is the lack of attention to the complex emotional issues that lead to distress in many individuals. The overuse of DSM Axis I diagnoses and the over-reliance on medication and symptom control leaves many people with chronic distress and hopelessness. Doctors are being trained to not listen to people, but to rely on simplistic tools and symptom checklists to determine treatment.
My niece, who recently graduated medical school described what she learned in psychiatry as “elicit a list of symptoms, pick any diagnosis that seems to fit, and write a prescription for any SSRI.” The industry is defining what it means to be an emotional being and dictating how people should see themselves and their emotions, rather than the other way around. Sometimes when the tail wags the dog, the dog bites. -Norman Hoffman MD, FRCPC