Samei Huda, MD, is a consultant psychiatrist with the British National Health Service. He has written a book called The Medical Model in Mental Health, An Explanation and Evaluation. It was published by Oxford University Press earlier this year.
BASIC THEME
In his preface, Dr. Huda tells us that he wrote the book to “explain the medical model and to evaluate its usefulness in mental health.” He also tells us that his inspiration was twofold:
Firstly: “Having read many critical comments about the medical model in mental health, it struck me that many of these criticisms seem based on a lack of knowledge or misunderstanding of the medical model, not just in psychiatry but also in general medicine.” (p v)
Secondly: “…many of the concerns about psychiatric diagnostic constructs and the effectiveness of treatments also occurred in general medicine.” (p v)
The central issue here is that anti-psychiatry writers, including myself, have devoted a good deal of time and energy to highlighting the distinction between general medicine, which I call real medicine, and psychiatry, which I call a hoax.
The basic theme of Dr. Huda’s book is that this distinction is not valid, and that psychiatry’s claim to medical status is as well-founded as any bona fide medical specialty. Dr. Huda pursues this goal, firstly by presenting a distortion of the term “medical model”; secondly, by selectively presenting areas and practices in which psychiatry and general medicine share some superficial similarities; and thirdly, by ignoring or downplaying those areas in which psychiatry and general medicine are essentially different.
The reason that we in the anti-psychiatry; movement draw a sharp distinction between real illnesses and psychiatric “illnesses” is because they are fundamentally different. A real illness entails a biological or anatomical pathology which causes the symptoms, and, which although subject to a measure of individual variation, is essentially similar in all the individuals so afflicted. Psychiatric “illnesses”, in contrast, are nothing more than loose collections of vaguely-defined problems of thinking, feeling, perceiving, or behaving. Individuals who have been assigned a particular psychiatric “diagnosis” will inevitably have some features in common, but these similarities are almost always eclipsed by the degree of variation in both the sources of the problem and its presentation.
In this regard, it needs to be stressed that even in those medical diagnoses where the pathological process or structure is as yet unknown, there is always, at the very least, prima facie evidence that the underlying illness is a real disease: i.e. that the unknown pathology does exist and can be discovered through painstaking research and exploration.
In psychiatric “diagnoses”, this is simply not the case. Not only is there no formal evidence that depression, for instance, is an illness, there is not even a superficial indication of illness. There is nothing about depression that would lead a reasonable person to suspect an underlying, causative biological pathology. Indeed, the opposite is the case: depression is an adaptive mechanism that alerts us to the fact that something is wrong or missing in our lives, and encourages us to take appropriate action.
DR. HUDA’S METHODOLOGY
Dr. Huda pursues his quest by reducing the fundamental issue to a series of twenty questions, formulated to elucidate differences or similarities between psychiatry and real medicine. He then addresses each question in turn, citing numerous experts and references.
Here are some of Dr. Huda’s twenty questions, the full list of which appears on pages 307 and 308:
“What is the reliability of the diagnosis when compared to a relevant reference criterion?”
“Is the condition clearly separated from normality?”
“Is there little co-occurrence of conditions, i.e. conditions are separate clinical entities?”
“Is the condition clearly identified with a causal mechanism (aetiology)?”
“Is the condition clearly associated with a proven and detectable difference in structure or process?”
“Is the condition caused by social difficulties and/or traumatic events?”
Etc.
Note the question concerning causal mechanism and the question concerning proven and detectable difference in structure or process. These are the critical questions, but Dr. Huda has simply placed them in the list, essentially affording them equal status with the other items.
From all of these deliberations, Dr. Huda concludes that there is “some overlap” between psychiatric diagnoses and general medical diagnoses with regards to each question.
“Diagnostic constructs in both general medicine and psychiatry often identify areas of spectrums (e.g. of symptoms) rather than distinctive categorical entities (Chapters 3, 9, and 11) and are not always reliable in clinical practice (Chapter 8) or may have variable clinical pictures (Chapter 10)” (p 308)
And then the critical flaw:
“Biological mechanisms and/or causes are often unknown in psychiatric diagnostic constructs but this can also occur in general medicine’s diagnostic constructs (Chapter 12), and social factors are particularly important causes for both psychiatric and general medicine conditions (Chapter 14).” (p 308)
There are three issues here. Firstly, biological cause is the defining feature of illness. This is the commonly accepted meaning of the word, and is fully endorsed by psychiatry itself in their avid promotion of the fiction that their “disorders” are real illnesses, just like diabetes. In this context, their phrase “just like diabetes” means having a biological cause, and by repeatedly using this phrase, psychiatry is essentially acknowledging that this is the acid test for an illness.
Secondly, some psychiatric “disorders” are indeed real illnesses. These include Alzheimer’s and other dementias; cognitive impairments due to brain injury/infections; etc. So when Dr. Huda compares psychiatric diagnoses with real diagnoses, from the perspective of cause and biomarkers, he will, of course, find “some overlap”. This is not contentious. But he will find no overlap in comparing psychiatry’s functional “diagnoses” with general medical diagnoses, and it is in this area that the contention arises.
Thirdly, the phrase “…social factors are particularly important causes for both psychiatric and general medical conditions…” is misleading. It might be argued, for instance, that both pneumonia and depression are caused by poverty. But in fact, pneumonia is caused by a germ. People who live in chronic poverty may have a higher risk of catching this disease, but drawing a straight comparison between this and the fact that poor people have a higher risk of becoming depressed is facile wordplay. And Dr. Huda is well aware of this:
“There is increased risk caused by social difficulties and/or childhood trauma for developing both general medical and mental health conditions with overlap in similarity of magnitude of some increased risks though intermediary mechanisms may differ.” (p 233) [Emphasis added]
The notion that in the etiology of pneumonia, for instance, the pneumococcal germ is an intermediary mechanism, and that the real cause of the disease is poverty or some other “social difficulty” is quite a stretch.
DR. HUDA’S CONCLUSIONS
Under the heading “Final Words”, Dr. Huda writes:
“The medical model as described in this book is one based on the practice of most doctors in clinical practice. It is the ethical use of knowledge and skills to benefit patients. The method of learning and applying this knowledge is based on learning about diagnostic constructs with attached useful probabilistic clinical information (e.g. range of likely prognosis and the chances of success with different treatments) and recognizing which diagnostic construct(s) best match the patient’s presenting problems.” (p 317)
Although superficially plausible, this statement is not an accurate description of general medical practice. Psychiatrists do indeed use this cook-book kind of approach to diagnosis and prescribing, but it is a far cry from what goes on in real medicine. The bedrock of real medicine is an understanding of the biological processes underlying normal human functioning, and those deviations from normality which we call illnesses.
It is well known, for instance, that many real illnesses are caused by tiny microorganisms called germs. This is by no means superficially obvious and represents a profound insight into the nature, course, and treatment of the diseases in question.
Real medicine is based on thousands of such insights. For instance, the pancreas responds to sugar in the blood stream by secreting insulin into the blood. The insulin breaks down the sugar, allowing it to be eliminated safely. If the pancreas is damaged, or if the individual is consuming more sugar or carbs than the pancreas can deal with, diabetes results. Again, this is a profound insight, not superficially obvious, and extremely helpful in understanding and treating this illness.
The critical point here is that psychiatry has no such insights to support its long-contended assertion that its functional diagnoses are real illnesses just like diabetes. All they have is their unwarranted assertions, their PR, the ethically dubious financial support of pharma, and, of course, their non-existent chemical imbalances.
Dr. Huda’s assertion that there is “some overlap” between psychiatry and general medicine is on a par with the assertion that airplanes and wheelbarrows have some things in common. Sure they do; they can both carry things from one place to another. But the differences outweigh any such similarities, and there is no evidence to support the notion that psychiatry’s functional diagnoses are caused by any kind of biological pathology.
Psychiatry plays with the medical model in cook-book style, but their endeavors in this regard bear as much resemblance to real medicine as the trundling of a wheelbarrow does to the flying of a jumbo jet.
FINALLY
It needs to be acknowledged that Dr. Huda himself recognizes this distinction.
“There is room for improvement in psychiatry’s often heterogeneous diagnostic constructs based usually on clinical picture not underlying mechanisms or causes; that is, they are often descriptive rather than explanatory. Better understanding of mechanisms and/or causes may lead to improvements in psychiatric treatments which currently often do not seem to affect the mechanisms or causes underlying the clinical picture directly. This better understanding may need to be achieved by research using more complex classification systems such as dimensional systems.” (p 317)
In other words: psychiatric “diagnoses” do not describe real illnesses, but “better understanding” will emerge from “more complex” classification systems such as dimensional systems. So it’s the same old stuff. We psychiatrists will have real diagnoses any decade now once we’ve discovered the real underlying causes of depression, childhood inattention, unconventional thinking, painful memories, etc. Meanwhile, the true causes of these human concerns are hiding in plain sight: loss; inadequate training; traumatic history; painful events; etc. But this is the reality that psychiatry has systematically repressed for the past fifty years or more.
And, incidentally, DSM-IV (1994) considered adopting a dimensional approach to classification but rejected the notion on the grounds that:
“Numerical dimensional descriptions are much less familiar and vivid than are the categorical names for mental disorders.” (p xxii)
Dimensional descriptions also de-entify the problem. “He scored seven out of ten on a battery of depression inventories” doesn’t have the same pathological ring as “He has major depressive disorder”. And pathological ring has been psychiatry’s primary agenda since the drugs began to come on stream in the 50’s and 60’s.
Dr. Huda closes on a conciliatory note:
“The different parties involved in mental healthcare – patients, their carers, and the various mental health professionals – should use whichever classification system (or no classification) that helps them best achieve patients’ treatment objectives and perform their roles and duties. They should also recognize that other parties may use different classification systems for good reasons.” (p 318)
And psychiatry’s “good reasons” for promoting a spurious pathological approach is to legitimize the pushing of dangerous drugs, which, by their own choosing, is their only stock-in-trade. It really is that simple.
AND BY THE WAY
Here are the top nine reasons for admissions to US general hospitals in 2015 (last year for which I could find data), with their causes:
- Septicemia: Infection from elsewhere in the body entering the bloodstream
- Osteoarthritis: Mechanical stress on a joint plus low-grade inflammation
- Congestive heart failure: Impairment of heart’s pumping function, multiple specific causes
- Pneumonia: Germs in the lungs
- Cardiac dysrhythmias: Multiple causes, e.g., coronary artery disease; high blood pressure; valve disorders; electrolyte imbalances especially sodium and potassium, etc.
- Complication of device, implant or graft: Self-explanatory
- Acute myocardial infarction: Lack of blood flow to a part of the heart causing damage to the muscle
- Acute cerebrovascular disease: Multiple causes: e.g. arthrosclerosis, embolism, aneurysm, etc.
- Chronic obstructive pulmonary disease: Long-term smoking, or exposure to air pollution, dust, etc.
And here are the top five reasons for US psychiatric admissions in 2012 (last year for which I could find data):
- Mood disorders: Biological cause unknown
- Schizophrenia and other psychotic disorders: Biological cause unknown
- Anxiety disorders: Biological cause unknown
- Adjustment disorders: Biological cause unknown
- Impulse disorders: Biological cause unknown
Degree of overlap: zero