Ending the Era of Mass Psychiatry

The number of Americans who are diagnosed or diagnosable with a serious mental illness has skyrocketed. Social Security claims for disability due to mental illness have also exploded. In 1987, the number was one in eighty-four Americans; whereas in 2007 the number increased to one in seventy-six. In children, the picture looks even bleaker: there was a thirty-five- fold increase in disability claims for mental illness between 1987 and 2007. What is going on? Why are Americans suffering a mental health epidemic that is unique among the countries of the developed world?

In a recent article in The New York Review of Books, physician Marcia Angell looks to three recent books to answer these questions: The Emperor's New Drugs: Exploding the Antidepressant Myth, Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America, and Unhinged: The Trouble with Psychiatry-A Doctor's Revelations about a Profession in Crisis.

The authors of all three books are in agreement on a rather startling view. Based on many years of researching the burgeoning epidemic of depressive, anxiety and psychotic disorders, all of the authors argue that it is pharmaceutical companies, rather than unbiased medical research that decides what constitutes mental illness and how each illness should be treated. I have recently made a similar argument specifically for children's mental health problems in Suffer the Children: The Case against Labeling and Medicating and an Effective Alternative.

One intriguing issue that seems to fly in the face of the view that most mental illnesses are convenient fictions spun by drug companies is that many psychotropic drugs seem to work. Like most therapists, I have seen the light go on in the eyes of many a depressed patient a few weeks after she has started to take an antidepressant. If depression is not actually a chemical imbalance curable by a drug, as authors Whitaker, Kirsch and Carlat argue, why do many people feel better a week or so after they begin taking medication?

Daniel Carlat provides one cogent answer: according to clinical trial data obtained from the FDA, in cases of depression, placebos were between 75 percent and 82 percent as effective as the antidepressants tested. The negative data from these trials, which idicated that placebos were almost as effective as the popular drugs Prozac, Paxil, Zoloft, Celexa, Serzone, and Effexor, was conveniently hidden by the manufacturers of the drugs. The placebo effect thus offers a cogent alternative explanation to the theory that psychotropic drugs work by correcting a serotonin deficiency in the brain. As Angell points out, there is no hard evidence for the latter hypothesis, nor is there consensus among doctors and sceintists that depression is caused by a serotonin deficiency.

There is an additional factor that may provide us with the answer as to why psychiatric drugs seem to "cure" depressive, anxiety, and even psychotic disorders. This answer was first proposed two centuries ago by Philippe Pinel, a French physician who is credited with releasing the mentally ill from their chains and the appalling conditions in which they were confined. Dr. Pinel believed that the curative factor in even the most severe emotional and mental disorders was the patient's relationship with a benevolent and compassionate human being. In Pinel's hospitals, known as moral treatment asylums, the benevolent human beings who treated the mentally ill were physicians. But the curative element was not that they were doctors but that they cared enough about curing their patients that they were willing to have relationships with them. They saw their patients as moral equals not as "crazies" with whom they had nothing in common. Moral treatment therapists often took meals with their patients, and took walks in the grounds of the asylums with them as well.

Although the vast majority of psychiatrists today are dispensers of psychotropic drugs during fifteen-minute appointments, it is at least possible that a good doctor-patient relationship--in which the patient views his physician as respectful and compassionate for his situation--might well be a significant curative factor. After all, many primary care doctors dispense psychiatric medications to their patients after having a doctor-patient relationship with them for many years. The placebo effect, combined with the patient's relationship with a benevolent and compassionate doctor, might well account for the curative properties of psychiatric medications. In fact, Kirsch makes a persuasive argument that a good relationship with a primary care doctor is an important component of the placebeo effect.

Of course, this possibility has not been a subject of medical research since positive results would not be profitable to the drug companies which are the major funders of psychiatric-pharmaceutical research.

The nineteenth century moral treatment asylums were small by their very nature, in order to provide a high doctor-patient ratio. And moral treatment doctors were remarkably effective, even with patients who suffered from severe mental and emotional problems such as mania and chronic depression. While moral treatment asylums might not be practical for the large scale mental illness epidemic of today, the therapeutic principles of respect, compassion, and regarding patients as moral equals, however troubled they may be, might well be worth pondering and researching in the era of mass psychiatry.