In Part I of Elusive cures: Why it’s time for new thinking on brain diseases, Sarah Catherall spoke with US neuroscientist Nicole Rust about the need for a new approach to find the causes of brain disease. Here, we share an extract from Rust’s book Elusive Cures where she argues for the middle ground in the treatment of mental illness.
There exists a continuum of positions on how research on mental disorders should proceed. At one extreme, some believe that the regular ups and downs of living have been overmedicalised. They point to the financial interests of pharmaceutical companies as the driving force. We are medicating our most energetic children to make them compliant, to sit unnaturally for hours and learn. We are creating societies that make people miserable and then providing happiness pills to the most sensitive among us to take the misery away.
Advocates of this position argue that we need to focus our research efforts on psychological and social interventions to alleviate the misery, not brain-based ones.
At the other extreme is the position that all mental disorders should be thought of as brain disorders. The motivation behind it circles back to the notion that no force in the universe gives rise to the mind other than the brain, and so all mental illness must ultimately be reflected in the brain.
Advocates of this position argue that the goal is not to medicate away misery but rather to treat mental illness in the same way we treat other medical disorders, like diabetes. Of course, environmental factors play a role – clean air, healthy food, exercise, and freedom from both trauma and extreme stress are important, but the same is true for individuals with diabetes as well; in this view, diabetes is conceptually no different from depression.
Advocates of this position acknowledge that, yes, of course, we should research the psychological and social factors that exacerbate these conditions (as we do for diabetes research). However, the bulk of our research efforts and dollars should focus on the biological phenomenon that is the bottleneck for disease (in the case of diabetes, the pancreas and insulin; in the case of mental disorders, the brain).
As a brain researcher and professor embedded in a psychology department (with a clinical psychology programme), I know researchers who hold positions at many points along this continuum. However, I do not know anyone who adopts the position of either extreme.
Some of my colleagues are vocal opponents of the overmedicalisation of mental illness, and they argue we should be investing more extensively in psychological and social prevention and treatments. Most also acknowledge, however, that brain-based interventions are required and effective for at least some individuals, and that brain research to treat mental disorders is worth investing in, going forward.
Conversely, I don’t know of any brain researchers who think brain-based interventions like antidepressants should be the only (or even the first) treatment for depression or anxiety, or that brain-based interventions will ever be the singular approach. Disputes within the community amount to questions over how to direct resources (in terms of effort and research dollars) for brain/mind research – should it be 10/90, 50/50, 90/10? And to what degree can and should we remove financial interests (for instance, of pharmaceutical companies) from the equation?
My own take lies squarely in the middle of these two extremes. I am concerned and alarmed by the rise of misery, and I do not think we should try to medicate our way out of it; we need to do more to alleviate it through social restructuring. I am also extremely alarmed by the degree to which medication is prematurely and needlessly pushed on us by our doctors without first trying other options, like behavioural therapies.
Mind and brain
But it is clear to me (and probably everyone else) that psychological and social interventions will not be the route to good treatments for neurological disorders like Alzheimer’s and Huntington’s disease. My take is that they also won’t be the exclusive path to treating psychiatric disorders, in part because some of those interventions will target the brain. Even for ones that do not, my strong intuition is that an impactful understanding of the mind will require understanding the brain, as Kendler says, “to expand the domain of the understandable.” Consequently, I believe we need a distributed portfolio for mental health research that focuses on both brain and mind research.
I’m also moved by the notion that there are two different and complementary ways to “know” minds. The idea was popularised by the psychiatrist Karl Jaspers in a psychopathology textbook first published in 1913. The first way of knowing minds resides in the natural sciences and focuses on objectively understanding them, with questions like: How do minds work? Under what conditions do minds thrive? What causes mind dysfunction?
I am extremely alarmed by the degree to which medication is prematurely and needlessly pushed on us.
The other way we understand minds is through the empathetic ways we come to know an individual’s mind. What is their story? When they are depressed or anxious, what caused it? With a focus on storytelling, the latter better captures the beauty, tragedy and complexity of the human condition, and it overlaps with the domain of the humanities. Certainly, something profound can get lost when we focus exclusively on minds objectively. Psychiatrists have to navigate both ways of knowing when treating their patients.
In comparison, researchers focused on understanding how minds work must be objective. Finding ways to incorporate the diversity of causes for mental disorders is part of that agenda. But with so much at stake in brain and mind research, they must focus on developing rigorous, verifiable knowledge that will ultimately lead to good options that psychiatrists can use to treat their patients.
The quest of a brain and mind researcher might be intensely motivated by empathy for individuals with dysfunction; for many, that is what gets them out of bed in the morning and into the lab. But once there, the first way of knowing needs to kick in for them to contribute rigorously to science.
