Surgeon General’s Report Is Laudable but Misleading

Some weeks ago, I was a guest on public radio and a caller described a study in which children were sent from out of state to the Colorado Rockies to observe the effects of high elevation on their asthma. The children improved, some quite significantly. However, when their families arrived for a visit, the children’s asthma took a turn for the worse, suggesting that an important determinant was psychosocial stress.

The caller asked whether I had heard of similar psychosocial influences regarding childhood hyperactivity. I answered that such cases have been regularly reported, although most are anecdotal. One study, however, from the Journal of Pediatrics, reported differences in the levels of the biochemical serotonin in hyperactive versus nonhyperactive children. When the two most hyperactive children in the study were kept at the hospital, away from home and school, both the hyperactivity and serotonin changed to levels observed in the nonhyperactive children. However, when measured one month after the two children went home, the serotonin and hyperactivity had reverted to earlier levels.

The lesson here is an important one, and one that is not well heeded by the report on mental health issued this month by U.S. Surgeon General David Satcher. A centerpiece of the report is the effort to make mental disorders a legitimate health issue by redefining them in terms of illness and disease. This logic is decades old and assumes that if the public comes to view problems such as depression and schizophrenia in biological terms, a more open atmosphere will emerge, thus reducing the stigma of mental health problems and encouraging individuals to pursue treatment.

As can be seen in the case of alcoholism, where the disease model is accepted by the public, this approach appears to have some merit. At the same time, viewing all mental disorders and addiction as biological diseases--and then treating them as medical problems--will not help stem the tide of psychological despair rolling across the nation. To wit, several of the children involved in school shootings had been prescribed the latest psychiatric drugs. Whatever good the medical model and psychiatric medications did them, it certainly was not enough.

I do not believe these drugs caused these outbreaks of violence. I do believe, however, that the shift toward biologizing and medicalizing psychological distress has begun to blind us to the social roots of many of these problems. This includes the rising challenges of finding meaning in modern life, and the stresses it imposes on individuals and families.

The surgeon general’s report rightly stresses the importance of tearing down the stigma associated with mental problems. But if increasing people’s awareness of mental-health issues comes at the price of turning man into a biological machine, the cost is surely too high.

In a television interview, the surgeon general stressed that “there is no longer a justification for distinguishing between mental and physical illnesses.” This sentiment, which pervades the report is both true and false. The experience of emotional distress is as real as any experience of physical illness, and often more disabling. However, to say the biological underpinnings of mental problems are just as real as for physical illness is false and dangerously misleading.

First, the notion of physical illness implies an inner, biological cause, and independent tests exist for most physical illnesses. In the case of mental disorders, there is not a single biological test. Second, much research in neuroscience and psychiatry shows a basic methodological blunder by failing to distinguish between causation and mere correlation. It is true that psychological states correlate with physiological ones. But these underlying states may represent nothing more than the impact of present and past psychological experiences. The public thus falls into the trap of believing that psychological problems are biological and out of their control.

A decade of focusing on the brain (and forgetting the human context that shapes the mind) has left the public both dazed and confused about the sources of the self. Mending mind and brain should mean a fuller understanding of how nature and nurture combine to create psychopathology; it should not mean turning all that is mental and psychological into something medical and biological. As this happens, people may well be inclined to ask their physician for a quick fix to soothe their (or their children’s) psychological woes, but they are much less inclined to do the hard work of taking responsibility for their and their children’s futures. All the evidence in the world tells us that real human transformation is possible, or at least it should.