Brad Delp’s Suicide and the Reality of Mental Illness
Jonathan Rowe on Mar 14th 2007
This is sad. Brad Delp seemed like he was in really good shape for a guy in his mid-50s, so I wondered how he died. Like Richard Jeni, it was suicide.
These two recent suicides bring to mind something that disturbs me about the thesis which some libertarians accept, most notably put forth by Thomas Szasz, that mental illness doesn’t exist. Though, I note he’s done some great work in the profession and I’m with him to some extent. I just can’t accept the entirety of his argument. If I understand the argument, if the brain is not “sick” with a virus or cancer or something along those lines — in other words, if a physiological test reveals a “healthy” brain like a healthy heart and set of lungs, there is no mental illness. And all categorizations have been somewhat arbitrary exercises of power (which thesis was pushed hard by the likes of Foucault).
Perhaps my problem with Szasz is just semantics. Things like schizophrenia and severe depression which causes otherwise healthy people to take their own lives are real things, real problems, regardless of whether we call them “illnesses” or not. If we accept that they are real problems which ought to be recognized as such and treated to the best of our ability, that’s all I care about. Often that treatment involves drugs like antidepressants. And Szasz has done Yeoman’s work as an advocate for drug legalization. So I don’t think he’d have a problem with a shrink recommending a certain amount of an antidepressant. Indeed he’d probably liberalize the requirement for a prescription and allow anyone to avail themselves of these drugs as well as illegal drugs.
Where Foucault, Szasz et al. have a kernel of truth (what I accept in their argument) is that the mental health industry has and continues to try to unjustifiably medicalize social norms or conventional morality. Just as things like masturbation and homosexuality were “illnesses” of the past, things like racism and homophobia, according to some practitioners, are present day “mental illnesses.” Indeed, in the Soviet Union, those who questioned the party line could be institutionalized for mental illness.
My solution which both recognizes mental illness but tries to act as a check against the use of such categorization to enforce social norms is to decouple the notion of mental illnesses and social norms. Having a mental illness, even if it doesn’t involve physiological sickness like being infected with a virus, ought to be understood as analogous to physical sickness. Finding out someone is mentally ill ought to be like finding out they have high cholesterol or diabetes. Such says nothing about a person’s character or social norms.
If anything, because of the unchosen element of mental illnesses and given that they are presumptively covered under disabilities related civil rights laws, if a particular condition qualifies as a real mental illness, such ought to weigh in favor, not of its social stigma, but its socially neutral status.
Of course certain behaviors — stealing, killing, hurting other people, and perhaps hurting oneself — are almost always wrong no matter what the cause. But, if they do in fact result from a mental illness, such behaviors are wrong, not because of but in spite of that fact. And, in criminal law and in social morality, behavior which results from mental illness often acts a “mitigating” factor. Someone who chooses to do a bad act with a clear mind and a cold heart is more immoral and criminally culpable than someone who had an impulse, couldn’t “help” himself and then felt terribly guilty about it afterwards. And if the resultant behavior is not harmful or immoral — like for instance jumping over the cracks of a sidewalk (as people with OCD do), or yelping in class (as someone with tourettes syndrome does — though I can understand how this might distract professors!) then there is nothing socially or morally wrong with either the condition or the behavior of the person and discriminating against or thinking less of a person because of their harmless eccentricities which might result from an underlying neurosis is morally wrong and ought to be frowned upon. (And while professors have no duty to accommodate a yelper without tourettes, if a student yelps because she has tourettes, otherwise inexcusable behavior must be accommodated to the extent that it is “reasonable” to do so).
As I noted before, Madison, Jefferson and Lincoln all likely suffered from moderate to serious mental illnesses of the depression and anxiety variety. Finding this out about them should be like discovering that some founding father had male pattern baldness under his whig. Contrast that with finding out that Lincoln might have been homosexual. Whatever we think of the morality of homosexuality, such ought to have nothing to do with whether homosexuality is a mental illness which would presumptively make that condition more like having high cholesterol, or an even closer analogy — tourettes — and demand its inclusion in various disabilities related civil rights legislation and “reasonable accommodations” for the underyling conduct which results from the illness.
Filed in The Basement, The Biosphere, The Bistro
I used to be a libertarian who didn’t like Szasz either. If I am depressed, I am depressed (dammit!), and it is having real repurcussions in my life. Further
I think the important distinction is that given our rudimentary knowledge of the brain, and especially how it relates to consciousness — including those characterized as “depressed” or “schizophrenic” –
Yay, for hitting the submit button by accident. Must be a Chronic Motor Tic disorder, or something.
A few things…
A big problem with psychological diagnoses is that they yield no additional explanatory power — they simply re-describe your symptoms. A person describes himself as “depressed” when he is frequently sad. The person who gets poor grades, taps his desk a lot, and can’t concentrate believes he’s found the key to his problems when he receives his “ADHD” diagnosis. (Meanwhile the stimulant he will be prescribed will focus anyone, regardless of whether they have that label affixed them.)
To return to my above point, re: the additional explanatory power of psychological diagnoses, When you go to the doctor’s, you’re supposed to describe symptoms (stomach ache), and receive back a diagnosis that explains your problems (appendicitis). At the shrink you’re symptoms (racing thoughts, tapping feet) are met with a re-description of your symptoms (attention-deficit-hyperactive disorder).
Anyway,
It sounds like you agree with Szasz on all issues of consequence such as the legalization of drugs, freer access to prescription drugs, and eliminating normative aspects to the diagnosis of mental illness.
“It sounds like you agree with Szasz on all issues of consequence such as the legalization of drugs, freer access to prescription drugs, and eliminating normative aspects to the diagnosis of mental illness.”
Yes, I do. That’s why I said I agree with him to a point. But I stop at the notion that “mental illness” doesn’t exist. Things like schizophrenia and severe depression are either mental illnesses or otherwise things that ought to be taken very seriously.
“Things like schizophrenia and severe depression are either mental illnesses or otherwise things that ought to be taken very seriously.”
Whether schizophrenia and severe depression are “mental illnesses” is a matter of definition. Szasz chooses to restrict illnesses to those things which have precise physiological etiologies, which schizophrenia and severe depression do not. What we have, instead, is a description of a set of mental states and behaviors that tend to accompany one another. Whether we ought to define mental illness as so is debatable.
As for whether these — let’s just call them — troubling persistent mental states “ought to be taken seriously,” Szasz would probably make the subtle distinction:
Having self-destructive thoughts and wanting to kill oneself are problems that ought to be taken very seriously.
Szasz is right only insofar as the Cult of Therapy stigmatizes “differences” as aberrational, disordered, or dysfunction. Otherwise, he should be thoroughly ignored.
Conversely, psychiatrists Michael McGuire and Alfonso Troisi indicted their colleages for the practice of metaphysics of mind in their landmark “Darwinian Psychiatry” published by Oxford in 1998. The DSM, they claim, is nothing more than “descriptive metaphysics.” Most “scientific” claims within their field come from patient self-reports, tabulated, and then proffered as “evidence.” Not a single difference can be determined between a religious experience or a “cure,” since anecdotal claims have never been considered “scientific.”
To further assail their colleagues, they claim mental health’s “conceptual pluralism” is an ad hoc divination between sociological, psychoanalytic, biomedical, and behavioral admixtures “set” in the context of one’s preferred prophet (Freud, Jung, Skinner, etc.). At best, the professional can only appeal to “clinical experience” using ad hoc measures based on different metaphysical assumptions and very few empirical ones (Freud’s metaphysics may be grand poetry, but has not a scintilla of concrete phenomena).
Their proposal seems imminently sensible: Eliminate the metaphysics. Abandon the DSM. Based on tests, patient self-reports, global assessments, differential diagnoses, and other measures used in evidence-based medicine, evaluate “dys/functionality” principally, and emotional, cognitive, and disordered thinking subsidiarily. All mental disorders, they insist, should be determined by the degree that symptoms lead an individual to a sub-optimal functioning and adaptation to their patients’ environments. They also insist on the 15% principle, in which many factors contribute to a patient’s inability to functionally adapt to his/her environment.
Since none of the psychotropics has any better than a 65% success (which is only marginally superior to flipping a coin), pragmatism must prevail until more definitive evidence substantiates a theory. Patient’s self-report in their therapy must be conclusive, since no external measures for objective criteria exist (although the profession should seek to find and use such measures, rather than their highly-subjective “clinical experience”).
A significant problem with all diagnoses, but exacerbated in psychiatry, is “fitting” a patient’s condition within the metaphysics of the DSM-IV. For example, a series of symptoms gets diagnosed ADD, until the patient reveals she’s never had ADD until her sixth decade (which excludes the ADD diagnosis by definition). Many patients are never asked if they had ADD as a child, which is a “condition” for ADD’s occurrence as an adult. A false diagnosis based on descriptive metaphysics may not be the best route for “scientists.” But the adding-up of symptoms to “fit” a descriptive metaphysics achieves what? It’s pigeonholing in the worst sense of the term.
The emphasis of “functionality” and “adaptiveness” rather than on the clustering symptoms makes supremely more sense. But the “vested interests” already persuaded by their particular prophet’s metaphysics seem difficult to overcome. For those who have benefited from treatment, it’s almost always ad hoc. But if the psychiatrist misinterprets any of the clusters in the differential, an affective mood disorder may be misdiagnosed as a psychosis, and instead of an antidepressant receive an antipsychotic, which is the wrong treatment! Not to mention that Freud’s psychoanalysis has done far more damage than good and costs a hell of a lot of money for worse than nothing.
The Cult of Therapy seems to be substantially more popular in the U.S. than anywhere else. But Cults have always thrived in this country. It’s time for the mental health professionals to choose between evidence-based functional assessment or remain oracles of mental metaphysics. Apparently, the latter has continued to prevail, to the detriment of all.
“Szasz chooses to restrict illnesses to those things which have precise physiological etiologies”
Fine by me. We’re reaching a point in medicine that diagnosis can occur on a molecular level. From the standpoint of molecular neurophysiology, there is a precise etiology in the case of schizophrenia, and even depression.
Chuck wrote:
“We’re reaching a point in medicine that diagnosis can occur on a molecular level. From the standpoint of molecular neurophysiology, there is a precise etiology in the case of schizophrenia, and even depression.”
Two questions, Chuck:
1) Would a psychiatrist or researcher be able to distinguish depressed people from normals without talking to them, but exclusively through the use of fMRI/cerebrospinal-fluid-tests/whatever-else-they-want-to-use? (Answer: No.)
2) But assume a psychiatrists really could reliably nail depression with such tests. If an fMRI revealed you were schizophrenic, but you personally heard no voices/felt normal, would you consider yourself schizophrenic?
It is extremely likely that there is a physiological corrolary to every mental state, but we are nowhere near understanding this correspondence. Further, a description of one’s mental state + observation of one’s behaviors is far more instructive then any molecular analysis is at this point in characterizing a “disorder.”
You raise excellent poiints, Zachary, and in practice of course we have not reached that point. However, it is not far off, and I find it somewhat scientifically illiterate to argue that mental illness does not exist simply because there is no gross physiological correlate (other than behavior) - unless you want to argue that illness does not exist at all (and it is, of course, all relative given the enormous variation in biological organisms).
As I understand it, many folks with depression and anxiety have, on average, lower levels of seratonin in the brain. Right now, it seems not feasible to do a test for brain chemistry; but once it is, these conditions/predispositions will be demonstrated to have a biological basis.
I believe that music is a path to the soul of the listener/performer, and I learn from that all the time. Mr. Delp’s first Boston song was “More Than A Feeling.”
Jonanthan, if the serotonin-hypothesis were true (indicating a SSRI), why do 35% of SSRI antidepressants not work? Why does Wellbutrin work, which does not target serotonin at all? The tricyclic class targets norepinephrine (some also target serotonin and/or dopamine in addition). The MAOI class targets monoamine oxidase, a fourth neurotransmitter (also the most successful therapeutic agent, albeit with many substantial “costs”).
If no single class of antidepressant (other than MAOIs) yields higher than 65% success, the “serotonin-” or any other neurotransmitter-hypothesis remains speculative. Fortunately, all of the various classes has a very high rate of success, even if their individual classes are only marginally superior to a coin-toss.
“Jonanthan, if the serotonin-hypothesis were true (indicating a SSRI), why do 35% of SSRI antidepressants not work?”
It could be because some folks have extremely serious problems which SSRIs are not strong effective enough to combat. I know that Abbie Hoffman committed suicide on prozac and one person I know who had serious depression told me that prozac changed the way he felt — gave him more energy — the energy to do something bad like follow through with a suicide attempt.
I’ve heard other testimonials — too many folks — who say that prozac, paxil, and/or other SSRI’s have worked wonders.
Believe me, SSRIs do work, but only for some people. Wellbutrin works, but only for some people, but it does not target serotonin! Etcetera. It’s the “serotonin-cause of depression hypotheis” that is subsumed that does not always work that is also called into question. If depression is “serotonin-caused,” as many claim, shouldn’t we ask the obvious: What justifies the claim? Because some SSRIs work in some cases only slightly higher than a coin-toss? Why do MAOIs work even better?
I don’t think low seratonin causes depression, probably that it predisposes people to depression and anxiety. There is a reason why those folks who struggle with or are predisposed to alcohol shouldn’t drink; it’s because that lowers seratonin levels (as a depressant, alcohol does the very opposite of what SSRIs do). But for most folks who aren’t so predisposed, they can handle what booze does to their emotions.