Regarding Tory nonsense on mental health

A few months ago, my dad sent me an article from The Times titled 'Mental health industry is cheating the public'. It had been sent to him after a discussion about ADHD (a condition my father and I both have, and which he only had diagnosed in his 60s), and while he instinctively felt there was something wrong with it, he couldn't articulate that feeling and asked for my help in doing so.

The most charitable interpretation I can make of the author of this piece is that he is a severe victim of the Dunning-Kruger effect. Unfortunately, given his CV, I suspect intentional disinformation to be more likely.

To address the author's ground-setting, a few notes.

1) Psychology being a popular degree course is not new; it was the canonical "I don't know what to study" subject a good deal before I entered university 16 years ago. It is not indicative of career prospects in the field (which overwhelmingly require graduate work) and does not even cleanly map to the topic the author is railing about, as it encompasses both clinical and experimental psychology.

2) The DSM, while certainly influential and heavily used in the US, Canada, and Australia, is not an approved diagnostic tool in the NHS, where instead the mental health chapter of the broader WHO-authored ICD-11 is used. Notwithstanding that kind of crucial point, a 4x increase in the number of identified disorders over a 75 year period is really not the "profiteers run amok" gotcha the author is trying to insinuate it is. Medicine has in fact progressed a good deal since the reign of George VI, and both the breadth and specificity of our understanding of the human body and brain have grown commensurately.

The underlying issue for the author here primarily appears to be the supposed abuse of government social benefits, to which end he has decided to try and invalidate both clinical psychology and psychiatry as fields in one fell swoop, while also suggesting they are economically motivated to do so. I do feel it's worth noting that clinical psychology and psychiatry are in fact distinct fields, with distinct training paths, methodologies, and modalities of treatment.

I will readily agree that both the proliferation of "self-diagnosis" sites on the internet is a serious problem and the sometimes lackadaisical diagnosis of mental disorders by overworked GPs just trying to get the patient out the door as quickly as possible is also a real albeit I suspect overstated issue. Where I differ from the author is that I view these things as symptoms of the inadequacy of the mental health system, with people struggling and unable to access appropriate help flailing and landing upon the first thing that feels like support.

As for the supposedly rapid growth of people claiming mental health disorders in claims for welfare benefits, I confess I am not particularly well read on the subject, but I'll note that the article the author cites as evidence for this does not make the claim anywhere within it! It does however discuss at length how experts believe the increased rate of reporting of mental health issues among economically inactive 20-somethings is reflective of a real mental health crisis precipitated by the Covid pandemic.

Regarding the author's initial conflation of mental healthcare and bloodletting, it's hard not to laugh. He aims to suggest that quack pseudosciences appeal to theory by referring to 'theoretical phlebotomy', but there's a slight issue, which is that that's not a thing. Therapeutic phlebotomy is a thing, and while it bears a superficial resemblance to bloodletting, is a term specifically used to delineate the very narrow set of evidence-based treatments in which drawing blood for therapeutic rather than diagnostic purpose is useful. And lest I be accused of nitpicking rather than engaging with the intent (I think fabricating whole terms is a little more than a nit), bloodletting as a practice fell into disuse comfortably before the epistemological framework that undergirds modern medicine was fully developed, and as such was never subject to the sort of scrutiny applied to modern medical and allied scientific fields.

This is a bit of a diversion, but it was the author's choice so take it up with him. The economic argument that follows the bloodletting canard is simultaneously so utterly nonsensical and insufferably pretentious that I can't not address it. Setting aside the pointless-but-to-illustrate-the-author's-grasp-of-the-canon, look-at-my-Oxbridge-education Middlemarch non-sequitur and the unforced error of incorrectly citing Smith (the invisible hand is a specific concept in Smith's theory, and not one that has to do with supply and demand), the market he characterizes is incoherent. If, to accept his premise for the sake of the argument, the state has created consumer demand for psychiatric diagnosis, this is not the market in which university faculties and research funding operate! The author has himself acknowledged above that it is GPs who are providing these diagnoses. If the nature of this demand required a ceaseless supply of novel diagnoses, maybe there would be a supply chain that led back to the university faculties, but we know that there's not, because he's already complained about that too! The disorders so egregiously being spoken aloud in pubs are all the old classics, even if the names have changed a little: autism (1978), clinical depression (1856), ADHD (1968), and bipolar disorder (1911).

But to the meat of the issue, are these two (again, despite the author's implications, actually quite distinct) fields 'legitimate science'?

Where are the results? How could we employ placebos? How could we devise control groups?

If the author is genuinely unable to find answers to these questions, he should be out of a job. Mental health therapies can and frequently are subjected to empirical analysis in much the same way as those treating physical ailments. Placebos and control groups are used in precisely the same way. Controls are likewise well understood and used for physical ailments too. The term most frequently used in public discourse is "sham surgery", but "inactive procedure" is the more useful one that sounds a little less negative while also encompassing treatments that are both non-surgical and non-pharmaceutical.

In an attempt to suggest these studies and reviews don't exist, the author decides to...reference, without citation, a single study in which an unspecified number of therapists diagnosed a single patient. The audacity of doing this in service of criticizing the scientific rigour of two whole fields would be impressive if it weren't in service of spreading disinformation.

The author then decides to construct a strawman in which evidence is collected just by asking whether the therapy helped, to which they apparently will always be inclined to say "yes" in response. No source is provided for this supposition, which is unsurprising as it would take about 30 seconds of searching on any social media site to falsify the claim. People who seek mental healthcare are in fact often dissatisfied with the outcomes and are very vocal about that dissatisfaction. Even if they were always inclined to say yes, we are fortunately saved by the clever boffins who have, as I mentioned above, figured out how to have proper control groups, and have even figured out more accurate ways of measuring treatment efficacy than "just ask the patient if it helped".

But sure, if patients were always inclined to say yes, and the only way to measure efficacy was asking them, and it was impossible to do proper controls, I agree that this fictitious state of affairs would not reflect good scientific practice.

The section on medication is equally short on facts. To start with, we most certainly have drugs that target particular disorders, many of which do not fall into the abridged list of drug categories the author seems to think is exhaustive (i.e. are not sedative, stimulant, alcohol, or hallucinogen). As for the claim that neuroscience 'has yet to determine whether any part of the brain can be identified as “causing” any mental disorder, or “treated” by chemical means', this is in part true but irrelevant, and otherwise false unless you use very creative definitions.

Regarding a part of the brain being identified as "causing" a mental disorder, this is true, but the very concept of identifying a part of the brain as causing a specific disorder is part of a broader philosophical zeitgeist of reifying functional specialization and localization. It was very in vogue when functional MRI (fMRI) data became easy to produce, but has taken a more appropriate role as one tool in the belt as the gold rush failed to produce results. To turn the author's earlier question upon them, where is the theory of mind that proposes why mental disorder must be localized within the brain, when undisputedly 'real' things like long term memory are not?

As for not yet determining whether a mental disorder can be treated by chemical means, they most certainly have. Increasing serotonin concentrations in the presynaptic cell has a well documented therapeutic effect improving depression. It doesn't cure depression, because neurotransmitter concentrations are a dynamic process and we have not so far developed a treatment that addresses the underlying cause of insufficient serotonin in the presynaptic cell, but to claim that this disqualifies it as treatment is to equally reject the "treatment" status of first-line interventions for a whole host of physical ailments (e.g. basically all auto-immune disorders). 

The rest of the article is just knocking down the strawmen the author built, so there's not much to engage with. Sure, if the demonstrably incorrect things that the author asserts were true, then a bunch of weird and bad things would follow. But y'know, if my gran had wheels she'd be a wheelbarrow.