To support its position, the WHO highlights the crude words of Thomas R. Insel, who from 2002 to 2015 was the head of the National Institute of Mental Health, the largest funder of health research. mental health in the world: “I spent 13 years at NIMH really pushing neuroscience and the genetics of mental disorders, and when I look back on that, I realize that even though I think I’ve managed to get a lot really cool papers by cool scientists at pretty high costs – I think $20 billion – I don’t I don’t think we’ve moved the needle in reducing suicide, reducing hospitalizations, improving recovery from tens of millions of people with mental illness.
Better outcomes, the WHO predicts, “will depend on a reassessment of many of the assumptions, norms and practices that currently work, including a different perspective on what ‘expertise’ means when it comes to mental health.” Michelle Funk, a former clinician and researcher who leads the WHO’s work on mental health policy, law and human rights and who is the lead author of the report, told me about the need for a sea change in prevailing clinical assumptions: “Practitioners cannot put their expertise above the expertise and experience of those they are trying to support. Current methods can damage and compromise outcomes not only through mind-altering side effects, and not only through the power imbalances of closed wards and court-ordered outpatient care and even seemingly benign practitioner-patient relationships, but also through a unique focus on symptom reduction, a professional mindset that makes people feel like they are seen as checklists of diagnostic criteria, not human beings. “The widespread belief by many in the healthcare industry that people with a mental health condition have a brain abnormality or brain disorder,” Funk added, “leads so easily to disempowerment overwhelming, loss of identity, loss of hope, self-stigma and isolation”.
By demanding a “fundamental paradigm shift” in the field of mental health, the WHO claims nearly half a century of psychiatric history. In the early 1960s, weeks before his assassination, President John F. Kennedy signed a mental health bill and declared that “under present conditions of scientific achievement, it will be possible for a nation so rich in human and material resources than ours. to make accessible the confines of the mind. American science, he promised, would not only land a man on the moon, but triumph over mental illness.
This confidence stemmed from psychiatry’s first pharmaceutical breakthrough a decade earlier, the discovery of chlorpromazine (marketed in the United States as Thorazine), the original antipsychotic. The drug caused debilitating side effects – shuffling gait, facial rigidity, persistent tics, stupor – but it calmed challenging behaviors and seemed to reduce aberrant beliefs. The Times hailed the drug’s “humanitarian and social significance” and Time magazine compared Thorazine to “germ-killing sulfonamides”, breakthrough drugs developed in the 1930s and 1940s to fight bacterial infections. But patients didn’t seem convinced that the benefits outweighed the harms; they frequently dropped their medication.
Thorazine was followed by Haldol, a stronger antipsychotic whose side effects weren’t any kinder. Yet each drug contributed to a mass release of mental asylum residents, and by the 1970s rudimentary concepts emerged about how these drugs worked. Overactive dopamine systems, a neurotransmitter, were thought to be responsible for psychosis, and antipsychotics inhibited these systems. The problem was that they altered dopamine networks throughout the brain, including in ways that led to movement disorders and torpor.
In the 1980s, however, biological psychiatrists thought they would fix this defect by creating more finely tuned antipsychotics. Joseph Coyle, then a professor of psychiatry and neuroscience at the Johns Hopkins School of Medicine, was quoted in a Pulitzer Prize-winning Baltimore Sun series in 1984 that heralded new brain research and cleverly targeted antipsychotics and other mood-altering drugs. on the horizon: “We have gone from ignorance to almost an excess of knowledge in just 10 years. A Coyle protege, Donald Goff, now a professor of psychiatry at New York University’s Grossman School of Medicine and for decades one of the nation’s foremost psychosis researchers, told me, of the late 1980s: “Those were heady years. “Every day as he approached a Boston clinic he ran, he noticed Haldol marks in some of the people he passed on the sidewalk: bodies, their tremors. Not only was the disease debilitating; the drugs left them physically so miserable. Yet he sensed, he said, “the possibility of unlimited progress.”
What have been called “second-generation antipsychotics” – among them Risperdal, Seroquel and Zyprexa – first came to market in the 1990s. , on other neurotransmitters, and they seemed to have fewer side effects. “There was so much optimism,” Goff recalled. “We were sure to improve people’s lives. But soon concerns arose and eventually Eli Lilly and Johnson & Johnson, makers of Zyprexa and Risperdal, paid out several billion dollars – a fraction of the drug’s profits – in lawsuits over illegal marketing and the drug’s effects on users’ metabolism. . Zyprexa caused a significantly increased risk of diabetes and severe weight gain (Eli Lilly concealed internal data showing that 16% of patients gained more than 66 pounds on Zyprexa). Some boys and young men who have taken Risperdal have been affected by gynecomastia; they developed pendulous breasts. In 2005, the NIMH published a study of 1,460 subjects to determine whether the newer antipsychotics were in fact better, in terms of efficacy or safety, than any of the first-generation drugs. The answer was no. “It was a resounding disappointment,” Goff said, though he advocates long-term and probably lifelong medication as, overall, the best way to guard against psychiatric devastation.