1.1. Etiology—Problems in Living
The first thing that needs addressing is the question of the etiology of mental disorders (if we, for a moment, agree to call specific configurations of manifestations of suffering “disorders”), as this understanding projects onto all other domains. There is now a wealth of research highlighting the role of social, economic and other factors, such as adverse life events, on the probability of being diagnosed with a mental health problem, even psychosis. They have been shown to be causally associated [
50]. Some of them have much higher relevance than any known biological or genetic correlates [
51]. To mention just a few examples, financial and social status [
52,
53], belonging to an ethnic minority [
54], or being a victim of child abuse and other adversities [
55] have been shown to influence the frequency of particular diagnoses and prescription of psychiatric drugs. A longitudinal study revealed that financial problems of British students precede depression and alcohol abuse [
56], and difficulty paying back debts precede common mental disorders in the adult population in the Netherlands [
57], pointing to economic factors as causal. This clearly shows that cultural and social determinants must not be ignored or even that they should be given priority, and psychiatric disorders could be seen as consequences of frustrated human needs [
58]. As Longden [
59] puts it: “an important question in psychiatry shouldn’t be what’s wrong with you but rather what’s happened to you.”
Still, the prevailing narrative is one of the biological mechanisms or abnormalities that should be corrected with drugs (as biological illnesses need biological treatments), and this narrative, among many other issues, shapes the way mental health care systems and mental health awareness campaigns are designed and financed. One particularly worrying consequence of this, in the context of individual suffering, is the fact that some people with psychiatric diagnoses may even lose the ability to understand their mental states as something that is directly connected to the lives they live, e.g., the suffering of somebody who was abandoned in a romantic relationship could be explained by themselves (and mental health professionals) as a “relapse of depression”—one caused by “chemical imbalances”—without realizing at all and disregarding the impact of the psychological or social situation [
60]. The use of medication can also have a detrimental effect on identity [
61].
Understanding psychiatric disorders as primarily consequences of various life circumstances and their meanings for individuals would require a radical reshaping of mental health care, but this could lead to improvements in terms of outcomes (to use medical language) or quality of life and life satisfaction in general (to use a more neutral one) for those suffering and societies as a whole. Improvements that biological psychiatry has largely failed to deliver, as current treatment outcomes for depression and schizophrenia are probably worse, especially long-term, than in the first half of the 20th century, before the era of pharmacotherapy [
62,
63]. It could also be argued that if the mental distress people experience is seen as problems in living instead of specific disorders, speaking of etiology or pathomechanisms becomes self-contradictory. However, individual psychological factors definitely play a role, which may explain why some people are affected more by adverse circumstances, and so it is not necessary to posit inherited (or inherent) biological differences to account for this. Even if they exist, they are not necessarily the primary cause, as they may well be a consequence of psychological and social situations—after all, brains are shaped by and adapt to the environment. Appropriate actions would have to follow this kind of understanding of mental distress, and perhaps the most important thing that should be addressed and changed is the way drugs are used and their action conceptualized in mainstream psychiatry.
1.2. Understanding and Using Medications
The prevailing narrative concerning psychiatric drugs is that they are “magic bullets” targeting disorder-specific biological abnormalities. This discourse is so strong that a refusal to use psychiatric drugs is often equaled to a lack of insight, even when a patient seems quite rational in all other aspects, while consent for drug use is equaled with better insight, even when patients express otherwise bizarre claims about themselves and their condition [
64]. The dominating approach is what Moncrieff [
5] calls a Disease-Centered Model of Drug Action, while advocating instead for a Drug-Centered Model of Action. In the latter, psychiatric medications are understood not as agents that correct some kind of pathology or cures for disorders but rather as something that actually creates abnormal bodily states. Their potential usefulness in alleviating suffering comes precisely from this quality, which allows them to suppress, blunt, alter or enhance subjective experiences. This means that psychiatric medications could be understood essentially as psychoactive agents, not that different from alcohol or illicit drugs and with similar potentially harmful consequences regarding both biological and psychological levels. If we look at psychiatric disorders as primarily meaningful reactions to life events, our goal is then not to cure a disease but to help in overcoming life difficulties. Psychoactive effects of drugs may be helpful in that.
Conceptualizing medications this way has many consequences for the way they should be used in clinical practice and how their action should be studied. Research could rely more on qualitative methods in order to understand what is really the subjective experience of taking psychiatric drugs (and what is really the experience labeled as a disorder requiring drugs). Currently used instruments focus on predefined outcome measures related to the symptoms that diagnostic categories consist of, and these may not really correspond to the actual psychoactive effects the drugs exert. Moreover, a predefined set of criteria/symptoms streamlines both the researcher and the patient into a presupposed mode of understanding and forces distortion and deformation of actual phenomena in order to fit them into ready-made check-boxes. If there is no box for something, it gets overlooked, as if it was not there.
Thinking of drugs as acting on symptoms can be misleading also because of other factors, e.g., in the case of antihistamine drugs, the same effect—sedation—can be regarded as a side-effect (in the case of treatment of allergies) or as a desired therapeutic effect (in the case of reducing the expression of symptoms of psychosis). For drugs used in psychiatry, the important question, in this case, should be how much the “symptom reduction” in fact depends on the psychoactive effect of sedation, how does the sedation make the patient feel and if the effect is perceived as beneficial and desirable or if the opposite is the case: as harmful and unwanted, especially with regards to social and interpersonal functioning. The subjective psychoactive effect of a drug should be at the center of our attention. The same applies to “energetic,” “numbing-down” or other properties of antidepressants and different classes of psychiatric drugs. In general, the focus should move away from research about symptoms towards questions about how the drugs actually make people feel.
These differences in perspectives are well pictured in the following quotes of psychiatric survivors:
“I did not manifest any of my internal distress, because I did not show any evidence of internal life at all. This is not the same as the absence of madness. Yet it was the gauge by which the success of treatment was measured.”
“I found the medication made me feel empty and soulless, I could not think past considering my basic needs. The psychiatric drugs made me physically weaker and affected my hormones so I became during this time impotent. I was concerned about this. However, to the outside world because of the mind-numbing effects of the drugs I was less focused on my spy and spiritual beliefs. The doctors pronounced that I was responding well to the medication.”
Standard clinical instruments would probably show an improvement, perhaps even a remission, while, obviously, the patient, the subject, could, in fact, be even more miserable. The same applies to the study of treatment outcomes in general, often failing to include patients’ perspectives on what constitutes an improvement and using imposed and often prejudiced criteria of what counts as a therapeutic success [
67]. A striking example of this fact is that in the Hamilton Depression Rating Scale, attributing depression to social causes is understood as poor insight and worsening of depression [
68]. It seems that in other branches of medicine, patients’ opinions are given more importance than in psychiatry in terms of assessing patients’ condition and treatment outcomes, even though psychiatry lacks objective measures (e.g., glucose levels, X-ray pictures, etc.) that are available elsewhere. Paradoxically, while the dominant model in psychiatry deals mainly with the brain and private phenomena, it relies almost exclusively on a subjective third-person perspective (of physicians, family members, society in general) for assessment, especially in short-term clinical trials.
However, from the utility point of view of clinicians and patients, particular nerological and biological mechanisms are secondary, even though they may be also important, especially for understanding the effects of long-term exposure to drugs and withdrawal [
69]. In practice, clinicians often try to match “symptoms” with the supposed psychoactive effect of drugs, anyway, by relying on their pharmacological profile and assumed relation between the mechanism of action and subjective effects they may produce [
70]. This kind of research agenda would, then, fit the actual practice better and allow for better utilization of drugs.
1.2.1. Drugs as Short-Term Help
Certainly, in some circumstances, pharmacologically induced sleep, for example, is better than no sleep at all, but that does not necessarily mean that prolonged use of hypnotics, sedatives or neuroleptics is indispensable or beneficial. Drugs could be then primarily used as short-term solutions helping to overcome specific temporary difficulties, in a somewhat similar way as one can drink a cup of coffee to fight fatigue or have an alcoholic drink to relax. Research on the psychoactive properties of psychiatric drugs could provide important information on when and how these drugs could be used this way. An important fact to consider is that promoting drugs as correcting biological abnormalities may promote life-long use and hinder discontinuation of treatment even when it is no longer necessary [
73] while thinking of medications as psychoactive substances could have the opposite effect and promote shorter use. Regardless of the way drugs are actually used and studied, more research addressing the question of the methods of safe discontinuation of psychiatric medications is urgently needed, as withdrawing from psychiatric medication is poorly understood and confounds the results of maintenance trials [
74]. This, as well as the study of iatrogenic effects of psychiatric drugs, may be the area of biological studies that would be particularly useful.
1.2.2. Drugs as Facilitators of Psychotherapy
Another way of looking at psychiatric drugs would be to think of them as substances that may facilitate psychotherapy and/or as agents inducing lasting changes thanks to the subjective psychological states they produce. Examples of such an approach would be the current studies on the use of 3,4-methylenedioxymethamphetamine (MDMA) for the treatment of Posttraumatic Stress Disorder, where the psychoactive effects of MDMA are thought to allow for a specific therapeutic relationship to be established [
75,
76]. Other examples would be the use of psilocybin [
77], LSD [
78], ketamine [
79,
80] or ayahuasca and other substances for various disorders. It is important that the effects of such interventions are not reduced to the neurobiological level only. This seems to be already the case with the, patented in the form of a nasal spray, enantiomer of ketamine, which was recently approved for the treatment of treatment-resistant depression, despite poor evidence of effectiveness [
81]. As one of the authors of a recent trial [
82] comparing psilocybin and escitalopram commented: “if psilocybin becomes just another drug, it will be as uninspiring and ultimately disappointing as SSRIs have been for many” [
83].
The relation between the neurobiological and psychological or subjective is another complicated philosophical problem, but the insistence on interpreting the action of psychedelic substances on the physiological level, which leads to the goal of avoiding altered states of consciousness in therapy, could explain the poor results of ketamine nasal spray. In fact, it is precisely these states that may carry the therapeutic potential or effect [
84,
85]. It is important that in the process of implementation of this kind of therapies the traditions from which some of these substances and practices were appropriated are not erased and indigenous knowledges treated as equal contributors, especially as they can provide a much wider social and cultural context for the interpretation and the consequences of the experience [
86]. However, it may also seem that the particular psychological and cultural frameworks of interpretation are secondary, i.e., similar insights could be successfully articulated within Western discourse.
Generally, our thinking about using psychiatric drugs could follow the principles of harm reduction, as in the case of illicit drug use, not only in the cases of withdrawing [
87] but as a guiding principle. Drugs should be used voluntarily (as all other services—otherwise speaking of “service users” is merely a linguistic distraction; someone who is treated against their will is neither a “user” nor a “consumer” [
88]) and rely on an actual informed consent.
1.3. Diagnosis
Kinderman [
89], a former President of the British Psychological Society, goes as far as describing the current diagnostic systems as “invalid and inhumane and even bizarre,” and he is not alone in this opinion. Critique of current diagnostic systems from many different perspectives and backgrounds is abundant [
90,
91]. A recent study concludes that DSM-5 diagnoses are so heterogenous it makes them practically useless [
92]. It is important to remember that the same complaint (e.g., anxiety) can be associated with different causes, as well as that the same cause (e.g., death of a loved one) can lead to completely different complaints or involve different psychological mechanisms. This holds also on the biological level and the causal relation between different brain states and subjective phenomena—similar experiences may be caused by different brain states and vice-versa.
What is crucial is that diagnoses could be considered to be the primary source of stigma, self-stigma, power imbalances within the psychiatric system and an excuse for forced treatment and violations of human rights that effectively produce second-class citizens [
93,
94]. Some studies suggest that using another terminology, e.g., psychosis instead of schizophrenia, could be beneficial and reduce stigma and discrimination [
95]. However, it is unlikely that such an effect would be longstanding. It is reasonable to assume that as soon as the new label is understood to refer to a similar construct, discriminatory beliefs will be added also to the new word. Language in psychiatry is important [
96], yet changing the terms alone will not help if the meanings and practices associated with them stay the same. As one patient said: “(.) since I got sick I still think that it shows and that I have to be careful not to give myself away” [
97]. It is possible that this stress, even according to the stress-vulnerability model, can lead to worse outcomes playing the same role minority stress does for the LGBTQ population [
98]. Framing mental distress not as a deficit or a “malfunction” but as primarily a sign of human potential and opportunity to grow, as in Kazimierz Dąbrowski’s theory of positive disintegration, could mitigate this stigmatizing and self-stigmatizing effect [
94].
Bearing in mind all the negative consequences associated with the reliance on diagnostic classifications and the explicit and implicit meanings behind them [
99], it might be best to replace them with another approach. Diagnoses are already neither necessary nor sufficient for the provision of services [
100], so even the common response that they are indispensable because of administrative reasons or the interests of insurance companies does not seem justified. Services could be provided in a model more resembling social care, where labeling is not necessary. For clinical and research purposes, focus on specific complaints [
14], and the Power Threat Meaning Framework could be utilized [
12]. That is, we should be asking questions such as: what has happened to you? how did it affect you? what sense did you make of it? what did you have to do to survive? instead of going over symptoms checklists to arrive at a diagnosis. This would go in tandem with the focus on the psychoactive properties of drugs sketched earlier, as specific problems could be matched with specific psychoactive properties. It could also help the patients to conceive themselves as active and responsible agents, which would have an empowering effect, in contrast with being a passive victim of an externalized, yet internal and biological abnormality.