I highly recommend the two-part article by Marcia Angell in recent issues of the New York Review of Books. In June, she wrote a piece entitled ‘The Epidemic of Mental Illness: Why?’; then in the July issue, she followed up with another piece entitled ‘The Illusions of Psychiatry.’ In these two articles, she discusses several important books that address the “epidemic” of mental illness in this country, including Robert Whitaker’s book
Anatomy of an Epidemic which I reviewed in three separate posts: one about the theory that mental illness is caused by a chemical imbalance in the brain, another concerning the actual effects of psychiatric medications and the third addressing the entirely false belief that treating psychological disorders with such drugs is like taking insulin for diabetes. Marcia Angell is a Senior Lecturer in Social Medicine at Harvard Medical School and a former Editor in Chief of the New England Journal of Medicine; these lengthy articles are thorough and scholarly.
The other two books under review are The Emperor’s New Drugs: Exploding the Antidepressant Myth by Irving Kirsch and Unhinged: The Trouble with Psychiatry — a Doctor’s Revelations About a Profession in Crisis by Daniel Carlat. I haven’t yet read these two latter books, but here is Marcia Angell’s description of them:
“The authors emphasize different aspects of the epidemic of mental illness. Kirsch is concerned with whether antidepressants work. Whitaker, who has written an angrier book, takes on the entire spectrum of mental illness and asks whether psychoactive drugs create worse problems than they solve. Carlat, who writes more in sorrow than in anger, looks mainly at how his profession has allied itself with, and is manipulated by, the pharmaceutical industry. But despite their differences, all three are in remarkable agreement on some important matters, and they have documented their views well.”
Their first point of agreement is that the companies who manufacture psychoactive drugs have had a disturbing influence upon how we define the mental illnesses their drugs supposedly treat. Angell covers this subject in detail. For anyone unfamiliar with how drug companies test drugs, apply for and then receieve FDA approval, her discussion should be an eye-opener. Other authors, including Joseph Glenmullen in Prozac Backlash, have also covered this territory. I recommend you to inform yourselves on this important subject as it concerns not only psychoactive medications but every other drug currently being prescribed.
Second, none of the authors subscribes to the theory that mental illness is caused by a chemical imbalance in the brain. As I discussed in my earlier posts, Whitaker has addressed and debunked this theory in the Anatomy of an Epidemic. Angell briefly reviews the science of brain chemistry, which I also discussed, and goes on to explain how this theory evolved: because certain drugs were found to affect neurotransmitter levels in the synapse, and to have an affect on psychosis, anxiety or depression, scientists developed a theory that those disorders were caused by abnormalities in neurotransmitter levels.
As Angell puts it, “instead of developing a drug to treat an abnormality, an abnormality was postulated to fit a drug.” She points out the large leap in logic involved in such a theory. As author Carlat explains, “‘By this same logic one could argue that the cause of all pain conditions is a deficiency of opiates, since narcotic pain medications activate opiate receptors in the brain.’” All three of these authors document the complete failure of scientists to discover any empirical evidence for the chemical imbalance theory.
Nor do psychoactive drugs have the dramatic effects that have been advertised. Angell provides a great deal of information about the way drug companies selectively publish studies that demonstrate a positive outcome. Then she summarizes Kirsch’s review of ALL the double-blind placebo studies on anti-depressants, including those obtained from the FDA under the Freedom of Information Act (and of course, never published). What he found, for readers of Whitaker, will come as no surprise:
“the relatively small difference between drugs and placebos might not be a real drug effect at all. Instead, it might be an enhanced placebo effect, produced by the fact that some patients have broken [the] blind and have come to realize whether they were given drug or placebo. If this is the case, then there is no real antidepressant drug effect at all. Rather than comparing placebo to drug, we have been comparing ‘regular’ placebos to ‘extra-strength’ placebos.”
Thereafter follows a discussion of Whitaker’s book; as I’ve already covered Anatomy in earlier posts, I’ll omit her synposis of its main points. She concludes the first part of her review with the following question: “Why is the current against which Kirsch and Whitaker and … Carlat are swimming so powerful?” She addresses this subject in the July issue of the New York Review, with particular reference to the extraordinary influence
within our society of the American Psychiatric Association’s Diagnostic and Statistical Manual IV (DSM-IV).
In this second part of her review, Angell covers the story told in detail by Whitaker, about how the APA “launched an all-out media and public relations campaign” to re-invent and “remedicalize” itself during the 1970s when the profession’s reputation was at its nadir:
“Since psychiatrists must qualify as MDs, they have the legal authority to write prescriptions. By fully embracing the biological model of mental illness and the use of psychoactive drugs to treat it, psychiatry was able to relegate other mental health care providers to ancillary positions and also to identify itself as a scientific discipline along with the rest of the medical profession. Most important, by emphasizing drug treatment, psychiatry became the darling of the pharmaceutical industry, which soon made its gratitude tangible.” She ties this PR effort to the release of the DSM-III in 1980, which shifted the focus of earlier versions from Freudian explanations of mental illness to a biological/medical model.
According to Carol Bernstein, last year’s President of the APA, “It became necessary in the 1970s to facilitate diagnostic agreement among clinicians, scientists, and regulatory authorities given the need to match patients with newly emerging pharmacologic treatments.” In other words, the revision to the DSM-III was driven, not by
scientific discoveries or advances in our biological understanding of mental illness, but by the need to legitimize the APA’s efforts to medicalize mental health treatments in conjunction with the drug companies and to secure its hegemony over the profession. The DSM-III went on to become the bible of psychiatry. And like the “real Bible, it depended a lot on something akin to revelation. There are no citations of scientific studies to support its decisions.” Subsequent revisions did little to remedy this defect.
Angell then takes up the symbiotic relationship between the APA and the pharmaceutical industry, ground also covered by Glenmullen in Prozac Backlash. While drug companies support other medical specialties and professional societies, the psychiatric profession is its special darling because, as Carlat notes, “Our diagnoses are subjective and expandable, and we have few rational reasons for choosing one treatment over another.” That is to say, given the lack of “rational reasons” to choose one medication over any other, Key Opinion Leaders in the profession recommend drugs from the pharmaceutical company that supports their research and lavishes benefits upon them.
The second part of her review concludes with a long description of revisions to the upcoming DSM-V, the enlargement of diagnostic categories and the creation of entirely new ones, along with conflicts of interest (i.e., ties to the drug companies) within the community of professionals responsible for this revision. It makes for disturbing reading.
Regardless of whether you intend to read these books, I recommend Dr. Angell’s thorough and rigorous review. If you’re not already a psychopharmacology skeptic, this look at three important critiques of the psychiatric profession ought to make you one.