Mad in America

I dont think its the pysch meds per se, but the fact that many such as anti depressants are given out too freely by family doctors for just mild depression or insomnia. Or add meds are given to children with mild hyperactivity.

There will never be any substantiated evidence that psychotropic drugs actually work. My theory on why they are so over-prescribed without question is that now more than ever we live in a era of instantaneous solutions where quick fixes outweigh interpersonal ones. And it's the interpersonal that is severely lacking in psychiatry. Even when I worked in mental health (not as a therapist or psychiatrist) did I ever see a psychiatrist who had much in the way of social skills themselves when it came to the treatment of an other human being.

People would come in day after day usually with complaints of depression, and by the time they left they had 2 to 4 prescriptions in hand but...what really got to me is the fact that most people could remember the name of the drug they were prescribed but rarely could recall the name of the psychiatrists they just saw three minutes ago.

What an easy job! Just say to someone who is suffering "Here, take this and if this doesn't work come back and take that." As long as the gravy train of Big-Pharma makes stops to the psychiatrists office with dollars blind those with benefits rather than actually give a shit about the human condition I'm not surprised until Dr. Angell's findings that hardly any in the profession ever really questioned the validity AND danger of these drugs.

It doesn't matter who you are in this world when it comes to hiding from the truth; psychiatry can for so long throw around unscientific proven terms like "chemical imbalance" without presenting unbiased documented evidence. I've personally seen the long-term effects of these drugs on human beings and while the doctor may spend their weekends being on their boat their patients no matter the severity of their illness still remain in suffering - only worse by these drugs that the public have been duped to believe that help.

There will never be a quick fix for mental illness. In this age of the lighting fast internet downloads and real time messaging science has yet to solve one of its most cumbersome issues in society. No one had ever said schizophrenia can be eradicated overnight. While I'm not against research for pharmaceuticals that may actually CURE mental illness the public that comes to a psychiatrist office can no longer afford - both hopefully and financially - to have the wool of Big-Pharma pulled over their eyes.

God friggin' bless Dr. Marcia Angell.

Psychotropics work very well preventing psychosis.

"The problem with relapse studies, like that of John Geddes, which is cited by Friedman and Nierenberg, is that they don’t distinguish between a true relapse and withdrawal symptoms that result from the abrupt cessation of drugs."

She mentioned this in passing, but it shows awareness that the ENTIRE research base for antidepressants -- and I do mean ENTIRE -- is confounded by withdrawal syndrome.

Just this alone brings into question the wisdom of prescribing antidepressants -- all the stats showing efficacy and safety are wrong!

I look forward to the day someone makes this explicit (besides me, that is).

Never in any ad for psych meds is other than medication treatment mentioned. "Ask your doctor" is the command, never "consult a therapist". With anywhere from 80%-95% of all persons who appear in settings for mental health treatment/assessment having a social history indicating trauma and traumatic life experience, why isn't treatment for TRAUMA mentioned? Reducing people to symptoms and diagnoses is de-humaninizing--even when those who prescribe medications, only, have compassionate motives.

Go and google "trauma-informed care" and see what IS happening in the world of treatment re this issue and how it relates to the over-prescribing of medication. Prescribing medication ONLY, when a person presents with trauma in their history, is a RE-traumatizing event. Receiving a diagnosis that says "there is something WRONG with you" vs "something HAPPENED to you" is, imo, criminal. People are robbed of their lives when they are JUST medicated and/or over-medicated.

I sit in patient staffing meetings everyday with "prescribers" who use the tired old "you have a chemical imbalance" and "it's just like diabetes". This "disproven" theory is alive and well in human services, inc., USA.

Physicians: examine, then "heal thyself".

Antidepressants supposedly "work" due to three factors -

1) Placebo effect
2) Spellbinding
3) Natural recovery

These three factors account for the testimonies by people saying that were "helped" by antidepressants.

Other than that, they do NOT work.
They are not only worthless.
They are dangerous.... both getting on them, coming off them.

Wake-up NAMI.
Stop pitching these worthless and dangerous drugs!

Duane Sherry, M.S.

Duane, I think we need to be more realistic about presenting this argument. It's not making any sense to people who do feel the effects of antidepressants.

The fact is, antidepressants do "work" in the sense that they change brain chemistry. Some people feel this as a beneficial change, some feel it as an adverse change, and some don't feel it at all.

They "work" in the same sense a hit of LSD or methamphetamine "works." From personal experience I can say you certainly can feel the effects of an antidepressant, often much sooner than 4-6 weeks. It is definitely not a placebo effect or spellbinding. People are not fooling themselves. It is a chemical high.

As Bob Whitaker has noted, in the short run, antidepressants do "work."

Antidepressants don't "work" in the sense that statistically, over large groups of people, they are not more effective than placebo.

IMO, this is probably due to the natural course of so-called depression, which tends to naturally resolve; plus the contamination of relapse statistics by withdrawal syndrome in treated populations; plus, to a minor degree, people convincing themselves that the medications work due to cognitive dissonance ("I've invested in this and by golly, it's gonna work") and the placebo effect.

I'm afraid Dr. Kirsch has gotten himself in a corner by speculating those who can feel the effects of antidepressants are fooling themselves via the placebo effect. It doesn't help our cause to keep digging in that hole.

A more valid argument that "antidepressants don't work" is the emerging evidence that long-term, remission rates are lower than in untreated populations. This is a serious and very frightening outcome.

I usually don't comment on the comments, but the point being made here by Iatrogenia is animportant one, and so I can't resist. There is a natural remission rate for depression, both short term and long-term, and more attention needs to be given to that fact.

Now, in the drug trials, the placebo group is often composed of people who have been on antidepressants, and then they are pulled off the drug, and if they get better during the placebo washout phase, then they are not randomized into the trial. If they don't get better during the washout, then they are either randomized to drug or continued on placebo. So the placebo response rate in a drug trial is really a rate of response among people who have been on drug (and all that implies re changes to the brain), and then have been switched to placebo, so to speak. The placebo group is not a drug naive group.

So if you really want to ask the question of "do antidepressants work," it would be good to flesh out the response rate for a never-exposed group over the short term, and then a stay well rate for that group over the long term too. You want to know the natural history of unmedicated depression.

And if you go back into history and seek an understanding of depression's natural course--and this is the course of depression so severe it resulted in hospitalization--you see that psychiatrists expected it to lift with time (see quotes in Anatomy of an Epidemic.) The thought was that antidepressants could speed up a natural recovery process.

And so Iatrogenia's point here is an important one. It's not that people in the placebo group are doing well solely because of a placebo effect; there is a natural recovery process, and what longitudinal studies have shown, is that natural recovery process can be pretty robust for many people, and that long-term remission rates are indeed higher than for drug-maintained groups (or even for drug-exposed groups, who then withdraw from the drugs. For a period of time, those withdrawn patients are clearly at high risk of relapse.)

So, in any discussion of the merits of antidepressants, we need to try to flesh out some understanding of natural outcomes. And this goes to the Hippocratic oath of "Do no Harm." In order to do no harm, Hippocrates noted, physicians first have to figure out what is the natural capacity to get well from an illness or condition. And then you need to have an intervention that improves on that rate, both short-term and long-term, in order to do no harm.

I certainly don't think the literature shows that antidepressants meet that standard--of improving on the natural course of depression-- when it comes to long-term outcomes.

Iatrogenia,

By using the term "spellbinding," I do not mean to imply that the drugs are inert. In fact, I agree with you, they alter the brain chemisty, big-time. A doctor in our area advertises on the radio for "ADHD" "treatment". On the adds, he mentions that the "medications" (amphetamines, in this case) work "immediately," and that the brain "begins to work differently." The problem is that listeners are led to assume that "differently" means "better." Antidepressants do the same thing... They make the brain work "differently" by causing injury to the brain. In terms of "iatrogenic" responses... If we began to tell people that antidepressants make you fat and asexual... We wouldn't have to exhuast ourselves with explaining that they can cause such things as "manic epsisodes"... "Fat and asexual" gets the job done, especially during swim-suit season... Ha!

Robert Whitaker,

If pharmaceutical researchers had HALF the love of science that you apparently have... we would not have found ourselves in this position... with 1 in 10 adults (according to Mark Hyman, M.D.) on antidepressants.... BEGINNING to have an honest debate on antidepressants (along with neuroleptics, amphetamines, and the other classes).... We would have had that discussion YEARS ago! And the open debate, looking at the real science would have led us to an obvious conclusion: the drugs cause more harm than good. In fact (IMO), MUCH more harm than good. We would not have allowed 1 in 10 chimpanzees to have been placed on antidepressants before we reached that conclusion! Thank-you for all you've done!

I await the response of Dr. Memphis, with bated-breath.
Or not.

Duane Sherry, M.S.
discoverandrecover.wordpress.com

One thing that bothers me in this discussion is the adherence to the paradigm of "depression" as one syndromic condition. Same goes for other mood and anxiety disorders outlined in our dearly beloved diagnostic manuals. Where's the science in those diagnoses? Can we really reduce different individuals' mental states to one universally definable condition based on a narrow set of "symptoms"? Is that really how the mind works? What is the "natural course of depression"?

To me, there's no _one_ depression, no one group of symptoms, no one treatment method, because every case is different.

Pointing to the crimes of the psychopharmaceutical industry as a (the?) cause of increases in psychopathology while simultaneously reasoning from the psychiatric condition of "depression" is, to me, treacherous. Not questioning things like depression (among other products of medicalization) is exactly what makes people fling themselves into the hands of clinicians upon every little mental change that they perceive. Of use here is Rotter's theory of locus of control, in that these classifications and diagnoses have transformed people's attributions of their own mental states from internal or controllable to external or uncontrollable, causing vicious cycles of helplessness etc. etc.

I find this very basic and understandable, yet the goal of contemporary discourse, even in psychology, seems only to be to aggravate the problem.

I just came across this article by doing a google search on the recent exchange in the NYRB, and I have to say that I find Whitaker's extrapolation of government disability data to prove the supposed detrimental effects of psychoactive drugs to be quite feeble. Here is the relevant passage:
[So let’s do the math. If you look up census data for the number of adults in 1990 and 2003, and then do the relevant prevalance-and-treatment calculations, you find that the number of people treated for mood disorders and substance abuse rose from 11.16 million adults in 1990 to 21.77 million in 2003. At the same time, the number of people receiving SSI or SSDI due to mental illness more than doubled, from 1.47 million people in 1990 to 3.25 million in 2003.]
By using the phrase "more than doubled" (in italics no less) Whitaker attempts to shock the reader by appearing to point out a drastic increase in the prevalence of people undergoing treatment who are so impaired that they qualify for SSDI. In point of fact, the only relevant calculation can be represented by percentages: In 1990 13.2% of people receiving treatment (and Whitaker never specifically points out if the numbers he's citing include people undergoing psychotherapy or people taking drugs or both) were on SSI or SSDI and in 2003 that number was 14.9%. Whitaker might want to pull out his calculator, but that's a 1.7% change.
And is that change significant? Better yet is looking at the number of people receiving SSI or SDI for mental illness even a helpful way to measure the effectiveness of psychiatric treatment? A quick glance at this article http://www.nber.org/aginghealth/fall06/w12436.html would seem to throw an affirmative response to that question in serious doubt. For starters it states that the number of people receiving SSDI FOR ANY REASON has risen from 2.2% of the population in 1985 to 4.1% in 2005. This represents an 86% increase in people receiving SSDI benefits for any reason.
Most importantly it points out the liberalization in the SSDI screening process that occurred after a 1984 law and directly led to a significant, sustained increase in the number of people with mental disability eligible to receive benefits. According to this report (http://tinyurl.com/3jl6t6p) the 1984 law resulted in sufferers of low-mortality, chronic conditions like mental disorders and back pain to become eligible for SSDI benefits in greater and greater numbers. Indeed, if you look at Table 1 in the report you will find that the percentage increase in people suffering from musculoskeletal disorders who receive SSDI between 1983 and 2003 is actually greater than the increase in those receiving SSDI for mental health issues. Perhaps Whitaker's next book could be about the back pain lobby/conspiracy.
This makes sense because like chronic back pain, mental illness can be a lifelong disease that is ameliorated rather than cured by medical attention.
I should conclude by saying that I have no strong opinion on the efficacy of psychicatric medication, never having taken it myself, and not being a psychiatrist. I have been in therapy before, and have had friends who I have seen visibly improve in mood and behavior who were on psychiatric drugs but since they were also in therapy I can't say for sure one way or the other which form of treatment is responsible for their better health.
I only wrote this because I think if you write an article accusing others of peddling misinformation you should take great care to be as accurate as possible.

The relevant point here is that according to the surveys cited by Dr. Nierenberg, the prevalence of people with mood disorders and substance abuse problems remained the same between 1990 and 2003, and that what changed was the percentage of those with a mood disorder who were treated. So the relevant percentage here is not disability as a percentage of those treated, but disability as a percentage of the prevalence numbers, and how that changed as more people were treated.

Here is the relevant data:

In 1990, number of people with mood and substance abuse disorders: 55 million.
In 1990, number of people with those disorders who were treated: 11.16 million.
In 1990, number of people on disability due to mental illness: 1.47 million.
In 1990, disability numbers as percentage of prevalence numbers: 2.7%.

In 2003, number of people with mood and substance abuse disorders: 66 million.
In 2003, number of people with those disorders who were treated: 21.77 million.
In 1990, number of people on disability due to mental illness: 3.25 million.
In 2003, disability numbers as percentage of prevalence numbers: 5%.

Now this data doesn't include psychotic disorders, and so it is incomplete. But it is people with mood disorders that is driving the disability numbers upward, not psychotic disorders, and so this speaks to that population. And what you are seeing here is that as more and more people with a mood disorder are treated, more and more people go on disability.

As to the other point in the above post, there can of course be changes in ssi and ssdi law that will drive changes in disability numbers. But in my book, I look at the rise in disability numbers as a starting point for asking a question: how do psychiatric medications affect the long-term course of major mental disorders, including mood disorders like depression and bipolar. What does the science show? And the science shows that outcomes for mood disorders like depression and bipolar disorder have notably worsened in the past 40 years, and that the medications both increase the chronicity of those disorders over the long term and increase the risk of disability.

So, the disability numbers are just a starting point for an inquiry. And my post here was in response to Dr. Nierenberg's letter, in which he stated there was no epidemic of mental illness, because the prevalence numbers for mood disorders hadn't risen. And my point is yes, prevalence may not be up, but treatment is way up, and rather than treatment then leading to a lowering of numbers on disability, the disability numbers have gone way up, as a percentage of the prevalence numbers.

Bob Whitaker

I guess there are still some fundamental points of your argument that I don't understand. First off why looking at the disability numbers as a percentage of the prevalence numbers instead of the treatment numbers is a more helpful way of examining the issue. If I'm following it correctly your argument is that, prevalence staying roughly the same, an increase in those receiving psychiatric treatment (and here again I have a big question that seems awfully relevant to your contention that psychiatric drugs do harm over the long term: are these numbers that you cite for treatment indicative of prescription medication use, psychotherapy, or both?) should lead to a decrease in disability numbers. I just don't understand why this is the case.
In order to receive SSDI benefits extensive medical documentation of mental illness is required (with no relevant medical history your chances of getting benefits are next to nil). It follows then that if more people receive treatment, more acquire the paper trail necessary to receive benefits. As the stigma around mental health issues has decreased over the past couple of decades it makes sense that more people, previously suffering in silence, would feel comfortable entering therapy or taking psychiatric medication and that more would become aware of and apply for the government aid at their disposal to help them get through life.
The numbers I used to illustrate my point, percentage of patients undergoing treatment and percentage of patients undergoing treatment and on SSDI, indeed seem to me to disprove the point you are trying to make. If there has been an explosion in the amount of prescription medication prescribed for patients over the past couple of decades, and if that medication is harmful, shouldn't the percentage of people receiving treatment and suffering severe disability have skyrocketed?
I should state again that I find the practice of using SSDI numbers to gauge the efficacy of mental health treatments problematic in many ways, given the numerous political and social variables that can cause them to inflate or deflate. That being said even pretending for a moment that they are concrete indicators of a treatment's success or failure, I find the evidence you have marshaled in this case to be unpersuasive.
Your overall contention that psychiatric medication can have deleterious long-term effects may very well be true, but your present example does little to bolster this view.

There are two parts to your questions, and perhaps best to separate them out.

In Anatomy of an Epidemic, I use the disability numbers as a jumping off point. At least at first glance, the numbers tell of a problem for society, in the sense that spending on disability for mental disorders is growing so rapidly. But I don't think they prove anything about the effects of medications on long-term outcomes. I think they just raise a question that says, we need to look about what science has to say about those questions. And there you will find many relevant studies, and a history of science really, about how this paradigm of care affects long-term outcomes, functional outcomes, disability rates, etc. But the SSDI data just raise a question.

Now, the prevalence data.

There is a history behind the letter sent by Dr. Nierenberg to the NYRB re Marcia Angell's piece. Earlier this year, I was asked to give a grand rounds at MGH, and Dr. Nierenberg presented this same data, albeit in less accurate form at that Grand Rounds, to say that my book was wrong. He was citing it as proof there had been no rise in mental illness or in disability rates. And so I am responding here to his attempt, once again, to use this data to show that there has been no explosion in the burden of mental illness in our society.

IN terms of treatment, you are right, the survey did not clarify what treatment, whether psychotherapy, medication, etc. But given the frequency with which people are put on antidepressants today, it is fair to assume that most were on antidepressants.

Next, think of this from society's point of view. You have a certain percentage of your people suffering from an illness (around 30% according to the survey.) Now over the course of 13 years, you get many more of that 30% into treatment, and you dramatically increase your spending on that treatment. And that treatment is supposed to be effective, which presumably means helping people work, etc. So if the number of people who have the disease stays the same, but more people get effective treatment, shouldn't you expect that the disability burden to society, as a result of providing access to effective treatment, would stabilize or go down?

However, if you actually look at studies on this, such as one by Carolyn Dewa, you find that treatment is associated with an increased risk of going on disability. For example, in Dewa's study of people in Canada who went on short-term disability due to depression, the percentage who then went onto long-term disability was twice as high for those who took an antidepressant as those who didn't. The NIMH conducted a study of this sort in the 1990s, and they found that those who got treated for depression, compared to a depressed group who didn't get treated, were three times more likely to suffer a cessation of their primary social role, and seven times more likely to become incapacitated. And thus you see that treatment seems to increase the risk of going on disability, and based on those studies, you would expect then that as more patients got treated for mood disorders, you would have a sharp rise in disability numbers, even though the prevalence didn't increase.

Now, as to your point on the percentage of people being treated who end up on disability, you would probably expect that percentage to stay roughly the same. Let us imagine that one in every seven patients who is treated for a mood disorder ends up going on disability. In 1990, you would expect that roughly 14% of the treated cohort would be on disability, and then as more and more people got treated over the next 13 years, you would expect that 14% of those newly treated folk would go on disability too, and so the disability numbers would climb because the number treated had climbed. You would expect an increase in the percentage of those treated going on disability only if the treatment worsened in that period as compared to treatment in 1990.

In a post like this, I didn't have tgime to go through the whole story, but maybe I should have. The whole story is that there is other research that shows depressed patients who are treated with antidepressants have a greater risk of going on disability than those who eschew the medications. Something akin to that was found in a large WHO screening study by the way. So you take that research, and then you look at data that shows that mood disorders are not increasing in prevalence, but the percentage being treated is increasing, and then you would expect the disability numbers to climb.

I hope that makes sense. I suppose I should have gone over the other studies that detail this increased risk of disability with treatment, but with blog posts you tend to be quick.

Here in Australia, the government once actively encouraged long-term unemployed people with chronic medical problems (including mental illness and musculoskeletal conditions) to apply for disability benefits to artificially reduce a high unemployment rate. They're now doing the reverse - increasingly tightening disability benefit eligibility criteria, and shifting people on disability to unemployment benefits. My own experience matches that - strongly encouraged to apply for disability when I tried to register for an employment service, gave in several months later because it would actually increase my income, taken off disability benefits in January (still no employment income, still disabled - no major psych problems for 10 years but refractory epilepsy, brain injury, autism spectrum, hemiplegia).

I don't know if any of that is relevant to the US.

I want to thank you for your book. I admire your honesty and courage given the likely "immune reaction" from the psychiatric community.

I picked your book up in a local book store and started reading, bought it, and finished it in a couple of days. I have told my friends that I would compare it to Rachel Carson's "Silent Spring" and have urged my friends in the field of psychiatry/psychiatric nursing to read the book.

Thankfully, I have never suffered from mental illness, but my mother had a lifelong struggle with it right up until her death. Sadly, it seems that the course of her illness coincided closely with the "natural history" of psychotropic drugs and modern psychiatry.

Her illness first appeared in 1959/1960 under conditions that would have made anybody "crazy". She was diagnosed with paranoid schizophrenia and treated with Thorazine and ECT. She always maintained that these treatments made her worse. Her illness was chronic, and she resisted hospitalization and medication. Her diagnoses (like her medications) also changed with the times as each new theory appeared ranging from paranoid schizophrenia (Thorazine/ECT), to monopolar depression (MAOI), to bipolar disorder (Lithium/Ativan). Each time she was diagnosed and treated with the absolute certainty that only a doctor seems to hold in the face of these difficult illnesses.

She finally died in 2006 after being hospitalized during her last bout with depression. She died (most likely from a stroke) while home on a temporary release from the hospital.

Of course, that's a personal story. But, your book puts this very personal story in the larger context. If Eisenhower could warn of the dangers of a Military-Industrial Complex, surely we should try to understand the dangers of a Social Security/Psychiatric/Pharmacological complex.

I'm sure your work will be extremely valuable, not only to our society in general, but for so many people who's lives have been touched in one way or another by mental illness.