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For decades the medical profession has largely treated addiction as as a chronic brain disease. The US government's National Institute on Drug Abuse characterises addicts as compulsive drug seekers and users who continue taking drugs despite harmful and unwanted consequences. "It is considered a brain disease," the institute says, "because drugs change the brain; they change its structure and how it works."

Dr Marc Lewis, a developmental neuroscientist - perhaps most famous for detailing his own years of drug addiction and abuse in Memoirs of an Addicted Brain - strongly refutes this conventional disease model of addiction. His new book, The Biology of Desire: Why Addiction is not a Disease, argues that considering addiction as a disease is not only wrong, but also harmful. Rather, he argues, addiction is a behavioural problem that requires willpower and motivation to change.

Lewis's theory has divided the medical profession and those suffering from addiction. He has been lauded by some for putting the theories challenging the disease model together into one book; others have labelled his ideas dangerous, and him a zealot.

Guardian Australia sat down with Lewis before his appearance at Melbourne writers festival on Sunday and the festival of dangerous ideas in Sydney to talk about the controversy, as well as his theories on how addiction can be treated and overcome.
Through your years as an addict, were you questioning the idea that addiction was a disease you were suffering from? Or is this book purely a result of your later studies and expertise in this area?
Well my training was as a developmental psychologist, so I studied child development, cognitive development, emotional development, and personal development. So I really had a strong developmental framework for thinking about all human psychological phenomena.

When I started thinking about addiction in my first book, it was more or less descriptive. So, 'This is what happens to your brain when you become addicted,' and, 'This is what drugs do to your brain.' But in this latest book, I wanted to really try to explain addiction, and it just came crashing down that this was a developmental phenomenon. You grow into addiction. It takes place in a sequence or a progression through repeated trials, through repeated exposure, repeated actions, and through practice.
So it wasn't until you started writing about what addiction is that you really began to think describing it as a disease didn't make sense to you?
When I was doing drugs, I wasn't thinking about it in any kind of analytical way, well except, you know, trying to analyse, 'Why the hell am I doing this to myself?' But no, I think in writing The Biology of Desire ... put it this way. It never occurred to me that addiction was anything other than a developmental phenomenon. The whole idea that addiction is a disease never made sense to me either personally, scientifically, nor through my discourse with other people who are addicted.
Have people been supportive of your arguments that addiction is a behavioural problem, but not a medical one?
It's been mixed. There's certainly been negativity. I just had a review in the Washington Post where I was called a "zealot".

But what really moves me is the addicts who get in touch and say, 'Don't take this away from me. If you take away the disease label, then basically I won't be able to get better, if you don't let me understand myself as having a disease.' It's a very strange argument, to have to think of yourself as having a disease because that's the only way you can live with yourself and deal with the addiction. And then I feel badly, because I don't want to harm these people or take away something that they need conceptually or motivationally.

There is this idea that the addiction label is the only thing that is going to save them and stop them from being blamed and denigrated as addicts by society. They feel that if it is a disease, they don't have to feel that burden or shame, because it's not their fault. It's hard to pull the rug out from under that without causing some upset.

Is there anyone for whom addiction is a disease? Are there a small portion of people who are unable to stop taking these drugs, who are wired to be reliant no matter what kind of treatments or motivation they have? Or do you believe that for anyone, addiction should not be labelled a disease?
That's a really good question. I guess that's why I've been called a zealot in the last day or so. I guess there is a point where the devastation of addiction, combined with the situation of people's lives - whether through poverty or crime and social isolation - and when those factors hook up they get really hard to stop, really, really hard to stop.

I was in Vancouver a couple of weeks ago at a supervised injecting room, so these were the most down and out people, really long-term street people. Most of them had grown up in foster homes, they had no property, no money. They didn't connect with the world like most normal people, they lived on the street and their whole lives were organised around getting the next fix.

Given the way their lives are structured I think its very, very hard for them to stop. Does that make it a disease? Well, no, I don't think it does. I think that makes it a social problem that's terribly entrenched. It has to do with dislocation, alientation, poverty and all these sort of factors and a lack of care by the larger society for people who are suffering. When you put all those factors on the table, then you don't have to use the disease label to explain why some people can get really deeply stuck in addiction.
OK, but there are also high-functioning, middle-class and wealthy people with jobs and social support who would describe themselves as addicts, and for whom those social factors you talk about don't resonate. Despite having all the resources in the world available to them, they feel they can't stop.
Well I think those people have a better chance of quitting. They have family, they can afford therapy, they can talk to people. But of course no, I don't want to say people who are riding high in society can not become very deeply addicted. So what's left then in the formula? Probably the fact that addiction includes a very strong compulsive property, so when people have been addicted to something for some period of time, the psychological process moves from impulse to compulsion.

And that also involves in part, brain changes. The parts of the brain that become activated when craving is triggered by cues changes. So there's something going on that makes it hard to stop for very good neurological reasons. So then, do you want to call addiction a disease? Well, maybe, then you're getting close I think, because you could call it a pathology I guess. Because obsessive compulsive disorder, that's a pathology right? So yeah, I think there is a point at which the line betweens those definitions starts to blur.
So it sounds like it comes to a point where perhaps addiction does fall into disease territory then?
[Pauses]. I wouldn't say disease. I would call it disorder. Or even the adjective, "pathological". But I just don't like those words because there're all part of this particular framework, and that's the dominate framework in the US and parts of Europe, that this is in fact a chronic brain disease. It's hard to talk about it as if sometimes it's a disease or sometimes it's not. Then the argument starts to get kind of mushy. But when you are in the grips of compulsion, yeah, there is a process going on that of course isn't healthy and requires a certain amount of cognitive and emotional and probably therapeutic work to get out of. So yeah, OK, I'll grant you that you could call that, certainly, a disorder.
Why does it matter? Disease, disorder, behavioural problem? Does it affect the way we might think about treating those suffering from an addiction?
It sure does. The whole campaign to see addiction as a disease is that it works against people's sense of empowerment. If you have a disease, you're a patient. If you're a patient, you have to take instructions from your doctor and do what you're told. So people line up for rehabilitation centres and often have to wait for a long period of time, long after they've lost the motivational rush to actually quit.

Then if you do get into rehab, you're putting yourself in somebody else's hands and you're going with the program. But the best way to combat addiction is through setting different goals for yourself and setting your own goals. "I want this for my life, I don't want that, I want to change." That kind of self-perspective change and self-development of future goals and orientation is critical.
That's been an argument against rehabilitation, that it doesn't always set people up to meet personal goals and readjust to society.
That's right. It really hinges on the idea of who is setting the goals here. Who is telling you what to do? Are you telling yourself what to do, or are you being told? If you're being told what to do, you fall into a position of helplessness or disempowerment, which makes it hard to develop this head of steam, this effortful strength and self-control and willpower. I mean really, a lot of it is about willpower to master this thing, to take it in hand and change it. The best way to combat addiction is by setting goals for yourself.
Different types of rehab programs are needed for different types of drugs, for example it might take someone longer to get off ice than say, heroin, and therefore programs should be tailored to recognise that. But given what you're saying, would the model of treatment be relatively the same across all drugs, because it's more about willpower and setting goals than the type of drug being abused?
A good question. I don't think so. Even though it has those goals in common, people are very different and there are many ways to quit. Some people will need to focus more on cognitive tricks to self-program to modify their behaviour, others will need to change their environment to make sure they don't drive home past the liqour store, and for other people it's much more of a motivational thrust, more mindfulness and meditation. For others, it's about deeply connecting intimately and honestly with loved ones. Those are really different ways of getting better, even though what they all have in common is that theme of empowerment of self-motivation.
I can see why people with an addiction resist this way of thinking. No one likes to think of themselves of having a lack of willpower, or being to blame. Some members of the medical establishment are resistant to this idea too. Why do you think that is?
Right, but we need some kind of diagnostic framework. Are you criticising the medical profession for needing to label patients? Because don't we need to label people to some extent in order to narrow down treatments?
I think it's partly ownership, it's partly they way they've been trained to operate. I don't hate doctors, there are wonderful doctors. But doctors are trained to look at things in terms of categories, diagnoses, which have a certain set of possibilities for treatment or certain sequence of things to try. It's a really strongly inbred way of looking at very serious problems. And it's hard for them to shake it.
So what would you say to those who read your book, have an addiction, and have taken in what you have to say and want to know what to do?

Sure we do. I've had a number of medical issues in the last few years and I'm damn glad my doctors have had a diagnosis and a treatment strategy. So yes, doctors do need to function like that. But it's just I don't think addiction is a medical problem. It has a medical side to it. So doctors should be involved in an adjunct capacity, particularly with drugs that produce withdrawal systems when you stop taking them. So doctors should help people with the medical problems associated with addiction, but addiction itself is not a medical affliction.

I've had dozens of emails specifically to ask that. People saying, "My son is addicted to heroin," or "I've been addicted for many years." I say that well, there are many different ways for people to kick their habit and it is important to think about where that habit comes from and social factors. The person's developmental stage is important, for example addiction is a different beast for someone in their 20s compared to in their 40s. Some people outgrow addiction and spontaneous recovery is just another way of saying people stop when it gets too much. They can't handle it, and that often taken place when emerging through their 20s and into their 30s and wanting to start taking responsibility for their life in a different way. Treatment depends entirely on who I think they are, and what they are going through.

* Marc Lewis: Learning Addiction; Sydney, Sunday 6 September, 2pm, Playhouse Theatre

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Marc Lewis: the neuroscientist who believes addiction is not a disease

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For decades the medical profession has largely treated addiction as as a chronic brain disease. The US government's National Institute on Drug Abuse characterises addicts as compulsive drug seekers and users who continue taking drugs despite harmful and unwanted consequences.

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British scientists have begun testing a radically new approach to treating schizophrenia based on emerging evidence that it could be a disease of the immune system.

The first patient, a 33-year old man who developed schizophrenia after moving to London from Cameroon a decade ago, was treated at King's College Hospital in London on Thursday, marking the start of one of the most ambitious trials to date on the biology of the illness and how to treat it.

During the next two years, 30 patients will receive monthly infusions of an antibody drug currently used to treat multiple sclerosis (MS), which the team hopes will target the root causes of schizophrenia in a far more fundamental way than current therapies.

The trial builds on more than a decade's work by Oliver Howes, a professor of molecular psychiatry at the MRC London Institute of Medical Sciences and a consultant psychiatrist at the Maudsley Hospital in south London. Howes's team is one of several worldwide to have uncovered evidence that abnormalities in immune activity in the brain may lie at the heart of the illness - for some patients, at least.

"In the past, we've always thought of the mind and the body being separate, but it's just not like that," said Howes. "The mind and body interact constantly and the immune system is no different. It's about changing the way we think about mental illnesses."

Recent work by Howes and colleagues found that in the earliest stages of schizophrenia, people experience a surge in the number and activity of immune cells in the brain. As well as fighting infection, these cells, called microglia, have a "gardening" role, pruning unwanted connections between neurons. But in schizophrenia patients, the pruning appears to become more aggressive, leading to vital connections being lost.

"We studied people in that [initial] phase of the illness and saw microglial changes," said Howes. "It shows that it's something [happening] very early on and seems to be driving the illness."

The most extensive pruning appears to occur in the frontal cortex, the brain's master control centre, and also the auditory regions, which could explain why patients often hear voices. The frontal cortex indirectly controls the brain's levels of dopamine - a surge in this brain chemical is thought to explain the delusions and paranoia experienced by those with schizophrenia.

Nearly all existing medications work by blocking dopamine, which can bring psychotic symptoms under control, but fail to protect the brain's basic architecture from damage.

"The current drugs are based on 1950s technology; they all still work in exactly the same way," said Howes. "They are only able to target the delusion side of things. It's like getting a sledgehammer and squashing it down."

There is a growing appreciation that other, perhaps less well-known, symptoms associated with schizophrenia - memory and cognitive problems, and lack of motivation - can have an equally profound impact on patients, and existing drugs do little to help this side of the disease. "It's typically [these other] symptoms that are the most disabling," said Toby Pillinger, a psychiatrist and King's College London researcher involved in the study.

The latest trial, a collaboration between MRC scientists and King's College London, involves treating patients with a monoclonal antibody drug, called Natalizumab, that is already licensed for MS. In MS, the brain's immune cells go awry by attacking a different aspect of the brain's wiring. And although the diseases manifest in very different ways, apparent parallels in the underlying biology raise the possibility that the MS drug might help schizophrenia patients.

The drug works by targeting microglia and restricting their movement around the brain, which scientists hope could prevent the over-pruning of vital connections. In doing so, it could potentially address the disease's full spectrum of symptoms.

The first participant, Leopold Fotso, 33, received his first dose of treatment on Thursday. Fotso, who lives in south London after moving from Cameroon in 2007, was diagnosed with schizophrenia four years ago. He has been admitted to hospital several times with psychotic episodes. His illness also forced him to abandon his studies in accountancy - which he had moved to the UK to pursue - and his part-time kitchen job.

He currently has monthly injections of an antipsychotic drug, and his condition is now stable. He feels "on the way" to being himself again and is looking to - slowly - start working again. "It's quite hard," he said.

At some time during their life about 1 in 100 people will suffer an episode of schizophrenia. In the UK, about 220,000 people are being treated for the condition by the NHS at any one time.

In total, in this first trial, 60 patients will be treated for three months, attending clinic once a month for hour-long infusions - half will receive the antibody, half a placebo. The patients' symptoms will be tracked and, along with 30 healthy volunteers, they will be given a series of brain scans, cognitive assessments and tests of immune activity. The hope is that, even if symptoms do not improve, the study should also answer fundamental questions about the role of the immune system in the illness.

Belinda Lennox, senior clinical lecturer in psychiatry at the University of Oxford, whose work also focuses on the role of the immune system in schizophrenia, said the concept behind the latest study was exciting - although at a very experimental stage. "There's a lot of emerging evidence that the immune system is going wrong [in schizophrenia]," she said. "If reducing inflammation acts to improve psychosis in this study it will open a new range of treatment possibilities, which is very exciting for the field, and desperately needed."
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Radical new approach to schizophrenia treatment begins trial

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British scientists have begun testing a radically new approach to treating schizophrenia based on emerging evidence that it could be a disease of the immune system.

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JD suggestions H&C Psych notes November 17

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TWEAKED - An argument against a reductionist approach to treating Major Depressive Disorder

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An argument against a reductionist approach to treating Major Depressive Disorder

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Urgent action is needed to tackle drink and drug misuse among baby boomers, experts have warned, with a growing body of data from around the world suggesting that substance misuse is increasing among those in their mid-50s and older.

The call follows the release of recent figures which revealed that in 2015/16 more than half a million adults aged between 55 and 74 were admitted to English hospitals with alcohol-related injuries, diseases or conditions - more than for any other age group.

What's more, while risky drinking is on the wane in the UK and Australia, those in the over-50 age bracket buck the trend. By 2020 the number of people receiving treatment for substance misuse problems are expected to double in Europe, and treble in the US, among those aged over 50.

"Overall, whether you look at [hospital] admissions, whether you look at daily drinking, whether you look at deaths, older people - particularly baby boomers - are pulling away significantly in their health risks from millennials," said Dr Tony Rao, a consultant old age psychiatrist at South London and Maudsley NHS Foundation Trust and co-chair of the Older People's Substance Misuse working group at the Royal College of Psychiatrists.

Alcohol-related hospital admissions

Writing in the British Medical Journal ahead of the publication of a forthcoming 2018 report from the Royal College of Psychiatrists, Rao and Ann Roche - director of the National Centre for Education and Training on Addiction at Flinders University in Australia - argue that more needs to be done to tackle the problem.

But, Rao warns, the issue goes beyond drinking. "It is not just about alcohol, it is also about illicit drugs such as cannabis, and it is also about commonly prescribed medications such as opioid painkillers," he said. "It is not just a problem in the UK, it is an international problem."

Indeed, the authors write, "In Australia, the largest percentage increase in drug misuse between 2013 and 2016 was among people aged 60 and over, with this age group mainly misusing prescription drugs." Those over the age of 50, they add, have higher rates of illicit drug misuse, particularly cannabis, than younger Australians.

Among their suggestions to tackle the problem, the authors argue that programmes should be developed to cater especially for older adults. "Addiction services [in the UK] are being dismantled piecemeal at the same time as older people are experiencing more substance misuse problems," said Rao.

Better integration of healthcare is crucial, Rao added, pointing out that those visiting services relating to liver disease or dementia, for example, could also be screened for issues relating to alcohol or drugs and be offered help if needed.

Rao added that a 2011 report from the Royal College of Psychiatrists, which he co-authored, advises that due to age-related physiological and metabolic changes, older people should drink no more than 11 units per week; current guidelines recommend no more than 14 units for all adults.

Katherine Brown, director of the Institute of Alcohol Studies said alcohol consumption among baby boomers is a huge worry.

"This is the first generation of home-drinkers who are far more likely to buy cheap supermarket alcohol than visit their local pub. They are drinking more than their parents and it's no surprise that their health is starting to suffer as a result," she said, adding that price increases and tighter controls on alcohol promotions are needed.

Karen Tyrell, from the alcohol and drug misuse charity Addaction, agreed that better integrated services, as well as those specifically aimed at older adults, are needed to help tackle the issue, pointing out that work from the Drink Wise Age Well project has shown that older adults have different needs to younger people. "[Older adults'] drinking and drug use tends to be around age-related issues, so things like retirement, bereavement [and] being quite lonely," she said.

Ultimately, said Tyrell, the situation among baby boomers is a serious concern. "It tends to be that society imagines that drink and drugs are problems of the young but actually there are massive problems in older populations," she said.

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Baby boomers' drink and drug misuse needs urgent action, warn experts

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Urgent action is needed to tackle drink and drug misuse among baby boomers, experts have warned, with a growing body of data from around the world suggesting that substance misuse is increasing among those in their mid-50s and older.

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The case of depressive disorders in DSM-5

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the evolution of the cognitive model of depression and its neurobiological correlates

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Historical and Conceptual Issues assessment plan