In a two-part series recently published in the The New York Review of Books, Marcia Angell, MD, reviews the state of mental illness in the United States and the disturbing relationship between pharmaceutical companies and American psychiatry. Were it not for Dr. Angell's strong academic credentials (she is a Senior Lecturer at Harvard Medical School and the former Editor in Chief of The New England Journal of Medicine), I would have mistaken her writings for that of a conspiracy theorist. Her research, however, is solid and the questions she poses about the influence of pharmaceutical companies on psychiatry need to be asked.
We are still not entirely sure how psychoactive drugs work on the brain. As Angell notes, the very first drugs used to treat psychosis were in fact discovered completely by accident. Early anti-psychotics were originally designed to treat infections but were soon discovered to also alter patients' mental states. Further research revealed that these drugs worked on neurotransmitters in the brain, a discovery that represented an important leap in the field of psychiatry. Unfortunately, the "chemical imbalance theory" of mental illness, so widely accepted, is not always supported by current scientific evidence.
In reviewing this evidence, Angell cites the work of Irving Kirsch, PhD, a professor of psychology at the University of Hull. Kirsch is well known for his research on the effectiveness of antidepressants. In his book, The Emperor's New Drugs: Exploding the Antidepressant Myth, he expounds upon earlier work he and his colleagues conducted while reviewing studies submitted by pharmaceutical companies to the U.S. Food and Drug Administration (FDA). Using the Freedom of Information Act, Kirsch reviewed forty-two placebo-controlled clinical trials that had been previously classified and unpublished.
Kirsch's research reveals that psychoactive drugs are not nearly as effective as the pharmaceutical industry would lead us to believe. In fact, of the 42 studies cited above, placebos were found to be 82 percent as effective as the drugs being tested. According to Kirsch, the average difference between the reviewed drugs and placebos was 1.8 points, which, according to Angell, may be "statistically significant," but "clinically unimpressive." In light of this information, why do psychiatrists continue to prescribe antidepressants so frequently to their patients? The answer, suggests Angell, has more to do with the pharmaceutical industry's success at marketing to psychiatrist than the actual clinical effectiveness of such drugs.
As I have written elsewhere, the history of modern psychiatry can be traced through the evolution of the Diagnostic and Statistical Manual (DSM). First published in 1952, the DSM originally reflected the Freudian notion that mental illness was rooted primarily in unconscious conflict. In 1980, however, the manual was revamped and began to reflect psychiatry's movement from a conflict-driven model of the mind to a more biologically based model. This shift, we are told by Angell, was a conscious decision by the American Psychiatric Association (APA) to align themselves with the medical model taught at most American medical schools. It also corresponded, not accidentally, with the proliferation of a new generation of psychoactive drugs known as SSRI's.
Authors such as Robert Whitaker--whose book, Anatomy of an Epidemic, is also reviewed by Angell--makes a compelling argument for the over-diagnosis and medication of mental illness in the United States. His book stems from earlier research he conducted for an article on the connection between the number of adults receiving federal disability payments for mental illness and the release of Prozac (an SSRI) in 1987. What he discovered in his research was that the number of adults on federal disability due to mental illness jumped over three-fold from 1987 to 2007. This "epidemic," as he refers to it, has also impacted children in this country. During this same time period, according Whitaker, there has been a 35-fold increase in the number of children receiving federal disability due to mental illness.
How are we to make sense of these numbers? Do these numbers represent an improvement in our ability to diagnosis mental illness, or have we have just broadened our definition of what a mental illness is? And what about all these drugs being prescribed to treat mental illness? It would seem that if such drugs were actually working, wouldn't we expect to see the prevalence of mental illness declining, not rising?
These questions are taken up by all of the authors Angell reviews in her article. Each one emphasizes different aspects of the debate but all of them come to the same alarming conclusion, namely, that pharmaceutical companies have been largely responsible for our current mental health "epidemic." With more and more individuals being diagnosed every year with psychiatric illnesses, pharmaceutical companies have realized hundreds of millions of dollars in profits--profits they have gladly shared with the American Psychiatric Association and many of its members. According to Angell's research, about one fifth of APA's funding currently comes from pharmaceutical companies. Likewise, many of those who currently sit on the APA's task force for revising the DSM have also financially benefited from the industry. According to financial records provided by the APA, over half of all DSM-5 Task Force members have significant industry interests.
These alarming findings are cause for concern. What Angell has documented in her reporting is something that has been widely know throughout the mental health field for some time. For over three decades, the pharmaceutical industry has been successful at convincing us that illnesses such as depression and anxiety--not to mention normal human emotions such as sadness, shyness, and stress--can be alleviated with a pill. Unfortunately, the psychiatric field has allowed itself to be co-opted by the industry and failed to fully question the scientific merits of those psychoactive drugs in which they prescribe. While there is certainly a place for pharmaceuticals in the treatment of mental illness, drugs are not always the answer and certainly they are not a panacea for all that ails us. What is needed is a more nuanced and sophisticated approach to mental illness, one that does not rely solely on pills to cure.
Tyger Latham, Psy.D is a licensed clinical psychologist practicing in Washington, DC. He counsels individuals and couples and has a particular interest in sexual trauma, gender development, and LGBT concerns. His blog, Therapy Matters, explores the art and science of psychotherapy.