One of the most shameful episodes in the history of psychology is the use of frontal lobotomies. Despite very scant evidence of their effectiveness – and in spite of much evidence of serious negative after-effects – lobotomies were standard procedure through the US and Europe for around two decades, until the mid-1950s. In the US, around 40,000 people underwent a procedure that involved cutting away connections between the prefrontal cortex and the frontal lobes of the brain. Initially lobotomies were performed by drilling holes into the skull, until the American physician Walter Freeman discovered that he could reach the frontal lobes through the eye sockets, by hammering a long metal pick into the bone and then into the brain.
The procedure was extremely dangerous – some patients died, others became brain-damaged or committed suicide. A “successful” outcome meant that a patient who had previously been mentally unstable was now docile and emotionally numb, less responsive and less self-aware.Even if there appeared to be some improvement in their mental “disorder”, this was often outweighed by cognitive and emotional impairments.
From a modern perspective, the use of frontal lobotomies seems incredibly brutal and primitive. However, we are nowhere near as far removed from such barbarism as we might like to believe. There are strong parallels between lobotomies and the modern use of psychotropic drugs. In fact, the blanket treatment of psychological conditions as if they are medical problems, and the consequent massive overprescription of psychotropic medication, has had a much more harmful effect than lobotomies, because it is so much more widespread.
According to some estimates, around 1 in 10 Americans take anti-depressants. Similarly, an estimated 9-10% of US children between the ages of 5 and 17 have been diagnosed with ADHD, most of whom take prescribed medication.
This might not be an issue if it was clear that these treatments worked. But it isn’t. One obvious parallel with lobotomies here is that antidepressants have become widespread without any convincing evidence of their effectiveness. Research has found that the best known “selective serotonin-reuptake inhibitors” (SSRIs) do not alleviate the symptoms of depression for 60-70% of patients (which suggests they are less effective than placebos). Some clinical trails suggest that anti-depressants can be effective in cases of severe depression, but they are most often prescribed for mild depression, where they are mostly ineffective, and have serious side-effects.
The assumption that depression is associated with lower levels of serotonin in the brain is taken for granted by many people, but actually has very little foundation. Writing in the British Medical Journal in 2015, the psychiatrist David Healy described how the myth of a connection between depression and serotonin was propagated during the 1990s by drugs companies and their marketing representatives, not long after tranquillisers started to be abandoned due to concerns about their addictiveness. In fact, as Healy states, earlier research in the 1960s had already rejected a connection between depression and serotonin, and shown that SSRIs were ineffective against the condition. However, propelled by the marketing millions of the pharmaceutical industry, the myth of a depression as a “chemical imbalance” that could be restored by medication quickly caught on. It was appealing because of its simplistic portrayal of depression as a medical condition which could be “fixed” in the same way as a physical injury or illness (1).
Another parallel with frontal lobotomies is that psychotropic drugs continue to be so widely used despite massive evidence of their harmful side-effects and after-effects. Although the American Psychological Association states that anti-depressants are “not habit-forming”, a 2012 survey by the Royal College of Psychiatrists in the UK showed that 63% of people who came off antidepressants reported withdrawal symptoms, with anxiety the most common. One problem here is that withdrawal symptoms are often interpreted as a “relapse” and used as a justification for continuing treatment, which continues indefinitely. The most unfortunate aspect of this is that research has shown that most cases of depression fade away naturally within a few months, without treatment. For example, a 2012 study in the British Medical Journal found that the mean natural duration of “major depressive episodes” without treatment was just three months (2). This means that, absurdly and tragically, millions of people are being treated for a condition which wouldn’t exist if they weren’t taking treatment for it. (In line with this, a 2015 study in the Journal of Clinical Psychiatry found that 69% of US citizens on anti-depressants had never met the criteria for depression and should never have been prescribed them )
Other common side effects of SSRIs are fatigue, emotional flatness and detachment, and an overall loss of personality. They are also strongly associated with sexual impotence and “movement disorders” such as akathisia – although again, psychiatrists often treat akathisia as an underlying problem which needs to be treated with drugs, rather than an effect of the drugs themselves.
The most fundamental parallel between lobotomisation and psychotropic drugs is that they are both based on a flawed assumption: that psychological problems are brain conditions, and that they can be “fixed” by neurological interventions. The “medical model” of depression de-contextualises the condition, treating as a discrete problem which can be treated in the same way as a broken toe or skin rash. But this is dangerously simplistic.
In reality, there are many potential causes of (or at least contributory factors to) depression: an unsatisfactory social environment, relationship problems, the frustration of basic needs (for self-esteem, belonging, or self-actualisation), a lack of meaning and purpose in life, oppression or unfair treatment, negative or self-critical thinking patterns (related to low self-esteem), a lack of contact with nature, poor diet, and so on. How will attempting to increase the brain’s uptake of serotonin help to deal with these issues? In fact, there is a strong possibility that taking antidepressants will make people less likely to directly address these issues, partly because they may not relate them to their low moods, and partly because their drug-induced apathy and emotional flatness will reduce their ability to take effective action in their lives.
This highlights the fact that in many cases depression is actually a legitimate response to certain circumstances. In the same way that physical pain is a natural response to injury to the body, depression may sometimes be a healthy and natural response to negative life events or circumstances. And like physical pain, depression appears to have a natural duration. If allowed to, it will play itself out, express itself and then naturally fade away – even if this takes several weeks or months.
Or from a slightly different perspective, depression can sometimes be an indication that there is something lacking from our lives, or that certain aspects of our well-being or our life-situations are being neglected. Again, there’s a similarity with physical pain here, which is often a warning that a part of our body is damaged and needs attention. Depression may be an indication or warning that certain aspects of our life need attention – for example, that we need to change our environment or life-situation, improve our relationships, find a more fulfilling career and new hobbies, have more rest and relaxation, or more contact with nature. And again, if we take psychotropic drugs we are less likely to make these changes. In both these scenarios, drugs exacerbate the problem they are supposed to solve: they stop depression playing itself out and fading away naturally, and they make it less likely that we will take restorative action to improve our circumstances.
The Over-Diagnosis of ADHD
There are similar issues with ADHD and the drugs which are commonly prescribed to deal with the “disorder,” such as Ritalin and Adderall. There is a great deal of evidence suggesting that the behavioural problems ascribed to ADHD are not the result of a “brain condition” but of social and environmental factors, such as a lack of concentrative training, a lack of organised, creative play, poor diet and a lack of contact with nature. And to a large extent, ADHD pathologizes completely natural infant behaviour. Many children who are simply intrinsically restless and impulsive – although not to any disruptive degree – are mis-diagnosed with the condition. Children’s natural spontaneity and vitality are suppressed, under the misconception that they were somehow meant to sit quietly and stay indoors. (This is, in fact, very reminiscent of the ancient practice of “swaddling”, when babies and toddlers were wrapped very tightly in blankets, to restrict their movements and make them passive and listless.)
Interestingly, in France diagnoses of ADHD are much less common that in the US and UK. Only around 0.5% of French children are diagnosed and medicated for the condition. This is largely because French child psychiatrists are much more likely to view behavioural problems in a social or situational context, and to look at underlying causes which American psychiatrists generally ignore. They are much more likely to recommend family counseling or psychotherapy rather than medication, and to consider factors such as diet. And as Carolyn Wedge notes in her book, A Disease Called Childhood: Why ADHD Became an American Epidemic, another factor may be different styles of child-rearing. In France, children tend to be brought up in a more disciplined way that in the US, with more structure and more strictly enforced constraints.
Again, to view children’s behavioural problems as the result of a medical condition means that it is less likely that underlying causes will be addressed – that their diet will change, that their parents will change their style of upbringing, or that they will have more contact with nature. And of course, the drugs that these children are prescribed have a similar addictive potential to antidepressants, and similarly dangerous side-effects.
No doubt a small minority of the children diagnosed with ADHD do have a genuine condition and do gain some benefit from medication, just as some severely depressed people may gain benefits from antidepressants. There is no doubt that medications can sometimes be beneficial, particularly if they are used sparingly and temporarily. But it is scandalous that hundreds of millions of human beings around the world are suffering addiction and adverse reactions to powerful psychotropic drugs which give them no benefit. Millions of people are being “numbed down” by medications that, far from bringing any healing, artificially perpetuate the conditions they are supposed to alleviate. Millions of children are being unnecessarily diagnosed with a “condition” whose existence is debatable and forcibly given drugs whose efficacy is also debatable.
My guess is that future generations of psychologists will look back at our over-prescribing of psychotropic drugs with incredulity too, amazed at our blind enthusiasm for largely ineffective and damaging treatments, and at how such barbaric methods could become so widespread.
References:(1) http://2spl8q29vbqd3lm23j2qv8ck.wpengine.netdna-cdn.com/wp-content/uploads/2015/07/2015-Serotonin-and-Depression-bmj.h1771.pdf, (2) http://bjp.rcpsych.org/content/181/3/208.full, (3) http://www.psychiatrist.com/jcp/article/Pages/2015/v76n01/v76n0106.aspx