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Unmasking Mental Illness

Mark Dombeck, Ph.D.

Recently, Tom Cruise, an internationally famous movie star, had the following odd interchange with host Matt Lauer while on the Today Show to promote his new movie, "War of the Worlds". To put the quote in context, Mr. Cruise had made headlines earlier in the month by suggesting that actress Brooke Shields was wrong to take antidepressant medications after she suffered a postpartum depression.

Lauer: Aren't there examples, and might not Brooke Shields be an example, of someone who benefited from one of those drugs?
Cruise: All it does is mask the problem, Matt. And if you understand the history of it, it masks the problem. That's what it does. That's all it does. You're not getting to the reason why. There is no such thing as a chemical imbalance.

The interchange is odd because Mr. Cruise's statement flys in the face of today's popular wisdom. Not a day goes by where there we aren't exposed to one or more messages or advertisements that suggests that chemical imbalances cause things like depression and that depression can be remediated with psychiatric medication. Certainly if you are visiting this website and viewing the advertisements that may accompany this article, you may be seeing such messages now. Literally millions of people have been prescribed such drugs, and many have had the experience of benefiting from them (although to be fair, there are also many who have felt that the drugs have not helped, and some who believe that drugs have harmed them). How can it be possible that Mr. Cruise could know something that the rest of us don't know? Whats up with him?

Cruise is a self-identified member of the Church of Scientology, which has a long and well publicized history of being very critical of Psychiatry for reasons known only to them. It is a reasonable assumption to make, then, that in making his assertion that psychiatric medicines only serve to cover over mental illness problems, that Mr. Cruise is speaking on behalf of his church.

Psychiatric Stereotypes

If you go on to read the full transcript of the Today Show interview (available at http://www.msnbc.msn.com/id/8343367/), you see that a particular and rather prejudiced image of psychiatrists emerges. In this image, psychiatrists are accused of promoting: 1) drug addiction and over-medication (in the case of ADHD and the stimulant medicine Ritalin that is often prescribed for this condition), 2) Lobotomy (the surgical destruction of the frontal lobe), and 3) Electroshock therapy. Psychiatrists are accused of holding patients against their will and subjecting them against their will to both lobotomy and electroshock therapies. This is a pretty negative picture.

The thing about this picture is that, while there are substantial elements of truth in it, it is a quite exaggerated and unrealistic picture of how modern psychiatrists function.

To start with, lobotomy is a historical procedure developed prior to the availability of modern psychiatric medication. It is no longer in use. It was never universally embraced as a "best practice", and when it was used, it was used to quiet otherwise very difficult to manage psychotic patients. This doesn't excuse the procedure, but it does help explain how it came to be.

Electroshock therapy (electro convulsive therapy, or ECT) is still in use today. However, modern ECT bears little resemblance to the techniques crudely depicted in "One Flew Over The Cuckoo's Nest" many years ago. The technology driving modern ECT has improved vastly from the old days; The current profile has been smoothed, and anesthesia now used to prevent body convulsions. The reason the technique is still in use is because it often produces good results in cases of otherwise-treatment-resistant depression and psychosis. Patients whose severe depressions did not otherwise respond to medication or other therapeutic techniques and who would otherwise remain in severe mental pain and at a high probability of suicide have been helped by ECT. The procedure is associated with some memory loss, but otherwise can clear up or reset moods. Exactly why it works is not entirely known, but it does work. It is never used against a patient's will.

There is a real and distinct possibility that too many of today's children are diagnosed with ADHD. However, that this may be true does not subtract from ADHD (attention deficit hyperactivity disorder, sometimes otherwise notated ADD when hyperactivity is not present). ADHD is a very real brain condition, and some subset of the children who receive the diagnosis do have it. One of the better treatments for this condition happens to involve the use of a psychostimulant drug, Ritalin, which is highly similar to drugs of abuse such as amphetamine. At the right dose, Ritalin has a 'paradoxical' effect on the ADHD brain. It focuses it instead of making it high. Correspondingly, ADHD children prescribed Ritalin are better able to focus in school and elsewhere. Ritalin is certainly an addictive medicine, and one that some children have abused. However, that this is so is only regrettable. It doesn't mean that the medication should be withdrawn from use. These substances are available by prescription only precisely because they have abuse potential. Many helpful medications have this abuse potential. Should we never prescribe pain patients Morphine or anxiety patients Valium for fear that we would corrupt those patients utterly through such practice? Such a solution seems to my mind a way of throwing the 'baby out with the bathwater'.

But is is possible that the drugs really don't work? What if they are only dangerous, and have no real therapeutic potential as claimed? That seems to be the position Mr. Cruise has taken. To read his testimonial, it is hard to doubt his sincerity and belief that psychiatric medications have no upside. How can we go about understanding the deeper question here of whether psychiatric drugs simply mask mental illness (as claimed) or whether they can help fix that illness. The answer to this question can only be made in the context of the theory one has with regard to how mental illnesses are caused.

Many Theories

Here is my first important point. There isn't simply one theory of how mental illness is caused. There are many. And more than one of them are scientific at the same time.

We can illustrate these different views by pointing out the difference in world-view between two types of mental health doctors, Psychiatrists and Psychologists. We can start by pointing out the obvious:

Q: "What is the difference between a Psychiatrist and a Psychologist?"
A: "Oh, about $75,000 a year".

Rim shot, anyone?

Despite the fact that the two fields share a common subject matter (mental illness), they have some distinct differences. Psychiatrists are medical doctors who have the MD degree, while Psychologists are doctors of philosophy, education or psychology with the Ph.D., Ed.D., or Psy.D. Degree, respectively. Psychiatrists' primary training occurs under the influence of the medical model which emphasizes a rigorous biological explanation for illness more often than not. In contrast, psychologists training occurs under a different, more "psycho-social" model that emphasizes the ways that people tend to be products of individual differences in personality and social experience. Today, both fields recognize the vital importance of the factors studied by the other, and strive to operate under the "Bio-Psycho-Social" model. However, historical tendencies and inertia persist in biasing each group towards their respective competencies. The long and short of it is that psychiatrists tend to emphasize the biological underpinnings of the illnesses they treat, while psychologists emphasize the psychological and social underpinnings of the illnesses they treat. A psychiatrist might tell you that depression is caused primarily by a "chemical imbalance" and she'd be quite factually correct in making such a statement. At the very same time, a psychologist might tell you that depression is caused primarily by "irrational thinking" and she'd be quite factually right too. Both statements are true because there is more than one way to look at the truth of what causes depression.

Many Causes

If it isn't enough for you that different professionals see the same phenomena thorough different lenses (and therefore come to different conclusions about how they are caused, and how they are best treated), there is another layer to the problem as well. My second important point is that individual mental illnesses can have multiple causes. This diversity of causality is reflected directly in the five-axis diagnostic method used by all doctors and health professionals working in mental health.

Some mental health disorders are more clearly driven by physical determinants than others, but then you have other disorders that seem to require both physical and psychological causes, or which can be caused by psychology alone. Go figure. Schizophrenia for example is known to have a strong genetic and thus biological cause. However, there are a bunch of people out there in the world who have all the genetics for schizophrenia but not the disorder. So there may be a variety of more psychological and environmental things that have to occur to 'release' the disorder into its maturity. For example, drug abuse is one of those things being looked at today. Anxiety disorders seem to occur more easily in populations of people who carry a gene for 'neuroticism' (a tendency to be emotionally reactive). However, not all people who have this biological background go on to develop anxiety disorders. Instead, there is clear evidence that social skills and environmental variables and experiences must be present in the formation of the problems. Ditto for many forms of depression.

What about depression. Do medication treatments for depression simply mask the real causes of depression? What causes depression anyway. The answer to these questions will depend on who you talk to, and also what sort of depression you are talking about. It is not mere semantics to say this. There seem to be distinctly different types of depressions. Some are more clearly physically caused (endogenous or organic) than others.

If there are different causes of depression and some of those causes aren't purely physical, then why is antidepressant medication helpful for so many people? Why should a physical manipulation of body chemistry (which is how drugs achieve their effect) influence a problem if that problem wasn't caused in the first place by physical means? Here is where the problem gets really interesting.

It's All Connected

My third important point is that people are not unconnected collections of physical and mental and spiritual things. Rather, they exist holistically. Every part is connected to every other part. Sure, the leg bone is connected to the hip bone – but the 'body bone' is also connected to the 'mind bone' as well. It's all one thing from the perspective of the person who is suffering a mental illness problem.

All of the parts of the person are implicated in causing mental illness, and they are all connected together. You can manipulate all of a person's parts by by moving any one part. For example:

You can give a depressed person an antidepressant drug (with their permission of course), and thereby influence that person's brain chemistry. This will change the types of thoughts that this person tends to have (from very negative and self-depreciating thoughts to more positive or at least neutral thoughts). This will also influence what the person does; they might stop sleeping all day for instance, and take up a more normal activity schedule, or be more willing to go out with friends.

You can manipulate a depressed persons thoughts (via Cognitive Behavioral Therapy or CBT, with their permission of course). With continued CBT practice, depression tends to remit and activity levels can increase as well. It is very likely that brain chemistry changes occur as well, although they are difficult to measure.

You can manipulate a depressed person's behavior by encouraging them to exercise physically. This activity increase, if sustained, typically will have a positive effect on depressive behavior and mood.

Even when mental illnesses are known to be more physical than environmental in terms of causation, there are still ways to improve functioning through the use of non physical therapies. For example, CBT is currently being studied as an adjunctive therapy for Schizophrenia. No one would suggest that therapy alone would be any use at all, but recent data suggest that proper antipsychotic medication plus a specific kind of therapy helps patients to function better than medication alone.

This idea that all the parts of a person are connected together is not limited to mental health. Rather, it very much applies to physical health as well. Consider the following chain of events:

1.A lack of exercise (a behavior) helps causes heart disease (a physical problem) in a susceptible man.

2.The news of heart disease is depressing, and the man becomes depressed (a biopsychosocial problem).

3.Both the heart disease and the depression can be addressed medically (via pills and surgeries), behaviorally (via exercise programs and social support), psychologically (via psychotherapy that promotes behavior and thinking-style changes) and spiritually (via prayer).

Thought some of these therapies for depression and for heart disease will work better for people than others, there is no reason to suggest that any particular avenue of therapy is somehow 'wrong' or shouldn't be used. They all can have some benefit. Each approach can be compared to a lever useful for helping to move the total person back towards the healthy place he or she should be.

Conclusion

We're in a position to answer the main question now, "Does medicine mask mental illness?". The answer would have to be "No", but there is a qualification as well. Medicine (both as a world-view, and as a physical intervention) is a perfectly legitimate (and indeed very important) way of thinking about and treating mental illness. While medicine does not mask mental illness, neither does it address all aspects of mental illness. Mental illnesses do have non-physical aspects, and can be caused by non-physical causes. They can also be helped along through the use of non-physical treatments.

Even in some particularly physically-caused problems like schizophrenia, medicine is more successful in treating some symptoms than others. Hallucinations fall away in the face of good antipsychotic medicines. However, delusions are far harder to get to go away. This is perhaps because delusions are a function of memory and learning, while hallucinations are entirely dependent on distorted sensory inputs. Antipsychotic medicines can change brain chemistry, and thereby lower the level of distortion on sensory inputs, granting temporary relief from hallucinations. However, because they don't directly impact memory, they are less effective on delusions, no matter how 'irrational' those delusions might be.

Both medical and psychotherapeutic treatments for depression (specifically Cognitive Behavioral Therapy for Depression, or CBT) produce a reasonable antidepressant effect when depression is mild. When depression is severe, drugs may reach the patient before psychotherapy, or the patient might not be capable of participating in therapy. However, assuming that all other things are equal, where medical and psychotherapeutic treatments for depression differ tends to be in how long lasting they are once treatment has stopped. The antidepressant effects due solely to CBT for depression supposedly lasts longer than the effects due solely to medication. Consider why this might be so: Medications effect how the brain operates in the moment, while CBT teaches a set of coping skills and strategies that gets fixed into memory. When medicine is withdrawn, whatever forces existed prior to treatment that moved that person into depression are free to start at work again. However, when CBT has been taught, new and permanent skills now exist that help the at-risk person fend off new instances of depression. The antidepressant effect one can have from drugs can be extended simply by not stopping them in the first place, but the point remains the same.

Psychiatrists know all this, of course. No charges of conspiracy need be raised to suggest why some psychiatrists continue to practice exclusively via a medical mindset. Much simpler explanations are available. First, they may be dealing with a kind of inertia created as a result of a primarily biological education. Second, they may perceive that there is a resource issue involved in treating non-medically (and they've be right: (psychotherapy is harder to get reimbursed by health insurance than medicine). Third, they might perceive that their customers are less interested in non-medical treatments (and they might be right there too). Non-medical treatments are not advertised on television and on the web, so patients might not know to ask for them. Also people just tend to chose treatments that appear easier and less demanding when given a choice of possibilities. For a variety of reasons, more people are open to taking a pill to fix their ills than they are to committing to rigorously retraining the way they think and act via multiple hours of psychotherapy.

It isn't clear that Mr. Cruise acknowledges the influence of medical and psychological causes of mental illness. Scientologists appear to have their own theory of mind, and in my reading, that theory of mind appears to be incompatible with a scientific world view based on empirical studies in the life sciences. If, according to Scientology, Brooke Shields developed her postpartum depression because there was something wrong with her spirit (or "thetan" as the Scientologists call it), and not because of brain chemicals and hormones that had gone out of balance after pregnancy (e.g., the medical model), or because of the stress of the transition of being a new mother, and the physical strain of keeping up with an infant (the psychological and psychosocial model), or the combination of these two explanations (the biopsychosocial model), then of course it would appear to a believer that psychiatric medications would only be masking the 'true' problem. It appears to me that this is the case and the explanation for Mr. Cruise's odd remarks.

So the answer to the question "Do drugs mask mental illness" (or any illness really) comes down to how you believe that illness is caused. If you believe in the brain, and in hormones and neurotransmitters, in early learning and social influences on behavior, in the power of social support, and in general, in the explanatory power of rational and empirical scientific explanations of illness, then you have to answer the question by saying something along the lines of "No, drugs do not mask mental illness, but neither do they address all aspects of mental illness". If you believe that religious explanations of mental illness (e.g., demon possession, body thetan parasites, or other soul problems) are more true than scientific ones, well, then, you may end up agreeing with Mr. Cruise.

What do you think?