Part 1 of this article examined the power and control that pharmaceutical companies have over our medical system; Part 2 looked at how the profession of psychiatry is driven, if not controlled, by pharmaceutical companies. Part 3 presents evidence that questions the effectiveness claims of psychotropic drugs.
The 20th century witnessed the development of three quite divergent explanatory systems to account for mental illness, each offering a distinctly different approach to treatment: Psychoanalytic theory and treatment by psychoanalysis and its variants; a genetic theory of chemical imbalances of neurotransmitters in the brain, with treatment by prescription of psychiatric drugs; and a behavioral learning theory, offering treatments designed to eliminate the behaviors that characterize the mental disorders. It is clear that the genetic theory of chemical imbalances has gained predominant status in the medical community, government agencies and general populace.
According to Dr. Joanna Montcrieff, a Senior Professor at the Department of Mental Health Sciences at University College in London, co-founder of the Critical Psychiatry Network, and author of the book, The Myth of the Chemical Cure: A Critique of Psychiatric Drug Treatment, Psychiatry as an institution has long been obsessed with identifying biological causes of mental disorders and with the narrow technical solutions that flow from such a paradigm (Moncrieff & Crawford, 2001). The pharmaceutical industry has helped to reinforce this approach by the promotion of drug treatments, funding biological research and by promoting claims that psychiatric disorders are caused by simplistic biological notions such "chemical imbalances."
The hegemony of biological psychiatry that now exists stifles other approaches to understanding the complex behaviors that constitute psychiatric conditions. It elevates quantitative positivist research methods, borrowed from the natural sciences. This approach depends on the notion that psychiatric conditions can be conceptualized as discrete entities occurring in individuals, which can be defined independently of their social context. Other philosophical and sociological approaches that seek to understand the meaning of psychiatric disorders at both an individual and social level are relegated to the fringes of psychiatric academia. The biological hegemony has consequences at a social and political level too. By locating the problem as a disease within an individual brain, biological psychiatry diverts attention away from the social and political conditions that help to determine how psychiatric disorders occur and how they are identified and defined (Conrad, 1992).
Psychiatric diagnoses are based on behaviors and mental experiences that are deemed to be abnormal or dysfunctional. They are notoriously difficult to define consistently and even the painstaking construction of standardized definitions, such as those first produced in the Diagnostic and Statistical Manual (DSM) version III, and subsequently revised in DSM IIIR and DSM IV, yield fairly poor reliability statistics (Kirk & Kutchins, 1999). Because there are no natural or physical boundaries to the definition of abnormality in relation to behavior and mental experience, psychiatric disorders are particularly fluid and what counts as a disorder is highly dependent on prevalent social norms and beliefs. Thus many commentators are concerned that the incorporation of more and more forms of ordinary difficulties, such as shyness and childhood behavioral problems under a psychiatric umbrella is an example of the encroaching and inappropriate medicalization of everyday life (Moynihan et al, 2002; Double, 2002).
Pharmaceutical companies are actively involved in sponsoring the definition of diseases
and promoting them to both prescribers and consumers. The social construction of illness is being replaced by the corporate construction of disease. Ostensibly engaged in raising public awareness about under-diagnosed and under-treated problems, these alliances tend to promote a view of their particular condition as widespread, serious, and treatable. Because these "disease awareness" campaigns are commonly linked to companies' marketing strategies, they operate to expand markets for new pharmaceutical products. Alternative approaches-emphasizing the self-limiting or relatively benign natural history of a problem, or the importance of personal coping strategies-are played down or ignored.
From one perspective, you could say the drug companies are in the business of marketing mental illness. According to Moncrieff and her colleagues, marketing strategies now include attempts to shape psychiatric thought through the academic arena. This is done by a strategy that is conceived long before a product is officially marketed and may involve the promotion of disease concepts and their frequency. A recent guide to pharmaceutical marketing suggests the need to "create dissatisfaction in the market," "establish a need," and "create a desire". A portfolio of articles which promote the disease concept in question and/or the company's product is constructed for the medical audience. The articles will often be written by a medical writing or education agency and then academic authors will be approached to become authors, a practice known as "ghost writing." Medical "opinion leaders" are also identified and cultivated as part of this strategy to act as "product champions" (Pharmaceutical Marketing, 2002).
Drug company promotion to the public includes disease awareness campaigns that can be run in countries that do not permit direct to consumer advertising as well as those that do. Patient groups are recruited to give the campaign a human face and supply stories for the media. In some cases high profile celebrities have been included to help the campaigns reach prime time television audiences (BMJ News, 1st June, 2002).
The pharmaceutical industry has helped to promote the idea of the "hyperactive child" since Ritalin, manufactured by Ciba pharmaceuticals (which merged with Sandoz to become Novartis), was approved for use in children in the 1950s. In an early study Schrag & Divoky (1975) catalogued Ciba's aggressive promotional tactics in the United States, including presentations to Parent Teacher Associations and other parent groups, at a time when direct to consumer advertising was illegal in the US.
There is currently an epidemic of stimulant use among school age and younger children. One survey in the United States in 1995 found that 30 to 40% of school children were taking stimulants (Runnheim, 1996). Prescription rates in the United Kingdom are also rising rapidly. Numbers of prescriptions increased by 30% in 3 years between 1998 and 2001, and the cost of these prescriptions more than doubled (Department of Health, 2002). Although common stimulants are relatively cheap drugs, drug companies have recently been producing new and expensive preparations. This has fuelled huge growth in costs of stimulant prescribing. Stimulants showed the largest increase in financial sales, at 51%, between 2000 and 2001, of all classes of prescription drugs in the U.S. (NIHCM, 2002).
The marketing of drugs for other types of anxiety disorders such as panic disorder, generalized anxiety disorder and obsessive compulsive disorder and of drugs for alcohol problems, drug misuse, bulimia, post traumatic stress disorder, menstrual dysphoric disorder, compulsive shopping and intermittent explosive personality disorder, have helped to convince more and more people that they have a mental disorder that needs treatment. In the process, a market for drug treatments has been created in areas where they were formerly not frequently used. The common factor is the identification of a diagnosis or concept that is constituted by behaviors and emotions that have a substantial overlap with normal experience. The condition is then inherently expandable, which allows the drug companies and their advocates to claim that they abhor the inappropriate over-prescribing of their drugs (Barrett, 2002), safe in the knowledge that this will almost certainly occur anyway.
A confidential draft document leaked from a medical communications company, In Vivo Communications, describes a three year "medical education program" to create a new perception of irritable bowel syndrome as a "credible, common and concrete disease."
A "practical guide" published by Britain's Pharmaceutical Marketing magazine last year explicitly emphasized that key objectives of the pre-launch period were to "establish a need" for a new drug and "create the desire" among prescribers. The guide instructed drug marketers that they might need to "initiate a review of the whole way in which a particular disease is managed."
Yet there is no doubt that the expansion of the definitions of psychiatric illness, which now has one in every eight Americans taking a psychotropic medication, has been exceeding profitable. Drug company sales of psychotropic medication went from half a billion in 1987 to over 40 billion dollars in 2008. Atypical antipsychotics, once reserved for the most severely ill patients, are now the top revenue producer for drugs companies, helped by the psychiatric profession's willingness to even prescribe them to two-year olds.
There is no objective test for external validation of psychiatricdisorders. This means the boundaries of normality anddisorder are easily manipulated to expand markets for drugs.For example, the Defeat Depression campaign, in part supported by the pharmaceutical industry, advocated increasedrecognition and treatment of depression in general practice.This coincided with a sharp rise in prescriptions for anti-depressants.The value of the widespread drug treatment of unhappiness inprimary care is now being questioned (National Institute for Clinical Excellence, 2003).
In the U.S., drug companies haveconducted campaigns to promote the idea that conditions includingsocial anxiety disorder, post-traumatic stress disorder andpremenstrual dysphoric disorder are common psychiatric disordersrequiring drug treatment. This practice has been criticizedfor medicalizing social and personal problems (Moynihan etal, 2002).Empirical research has shown how the design, conductand reportingof psychiatric research sponsored by industrycan be shapedto convey a favorable profile of the sponsor'sdrug(Safer, 2002; Melander et al, 2003).
Depression was once viewed as a state of mind caused by stressful life factors, but today the majority of Americans believe depression is a biological disease caused by chemical imbalance in the brain. This shift in the way "mental disorders" like depression and anxiety are viewed has resulted in profound social and cultural changes.
Anti-depressants are now the most widely prescribed class of medications in the U.S., and many states have enacted parity legislation requiring insurance coverage for mental illness equal to physical illness. Soldiers returning from Iraq are encouraged to seek treatment for post-traumatic stress, and Congress may pass a "Mothers Act" to promote screening new moms for postpartum depression. In many classrooms more than half the students are on medications for attention deficit and similar disorders, and the number of
U.S. children diagnosed with bipolar disorder has risen an astounding 4,000% in the past ten years. Almost weekly we hear of yet another school shooting, with headlines clamoring for early intervention and mandatory treatment of "at risk" individuals.
Since the boom of psychiatric prescriptions began in 1987, adults on disability for mental illness more than tripled to 4 million. Amongst those on disability, the percentage of children has risen from about 5% in 1987 to over 50% today.
Peter Breggin, author of Medication Madness: A Psychiatrist Exposes the Dangers of Mood-Altering Medications, and Kelly Patricia O'Meara, author of Psyched Out: How Psychiatry Sells Mental Illness and Pushes Pills That Kill, outline in detail the dangerous trend to make psychotropic drugs more prevalent in the general population.
Psychiatric drugs have repeatedly proven to not only be extremely hazardous to one's health but can be life-threatening and even fatal. Now the Archives of General Psychiatry has released scientific proof that antipsychotic drugs shrink brain tissue.
Science journalist and author, Robert Whitaker, an award-winning medical writer, and author of Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs and the Astonishing Rise of Mental Illness in America, reports that long-term use of psychiatric medications is actually causing more mental illness -- not less. He states "what you find with them when you look at long term outcomes, you see more people having chronic symptoms long term than you do in the unmedicated."
Whitaker asks a simple question: Why, if psychiatric drug treatments are so efficacious, has the number of people on disability for mental illness more than tripled in the last 25 years? And then, while poring through the psychiatric scientific literature on treatment effectiveness for the last fifty years, he found an even darker question beginning to emerge. "Is it possible that psychiatric drugs are actually making people much worse?" Could it be that far from "fixing broken brains", the drugs being offered actually are worsening, and even causing, the very illnesses they claim to heal?
If psychiatric medications worked the way they are supposed to, and the way the drug companies and psychiatric industry tells us they do, why are so many people still severely depressed and anxious? At the start of the psychopharmacological "revolution", when it became popular to blame all illness on "imbalanced brain chemistry", the percentage of bipolar patients who could return to work was 85 percent. Now it is less than 30 percent.
In 1987 about half a billion dollars were spent on psychiatric medications, by 2010 the figure is closer to 40 billion. If the number of adults diagnosed as mentally disabled has tripled, it's not because they weren't exposed to the medication. Actually, in children the disability figures are far more frightening. In 1987 there were less than 20,000 severely mentally disabled children, now there are almost 600,000. That is a 30-fold increase. Part of that is due to the diagnosis of autism, while more is due to the even newer diagnosis of bipolar disorder in children, which has increased 40-fold in the last 10 years! Most frightening are the number of children under six receiving SSI drugs, which has tripled over the last ten years to more than 65,000 under the age of six.
Adverse effects of drugs represent a major public health problem with recent estimates indicating that 1.5 million Americans are hospitalized and 100,000 die each year, making drug related adverse effects one of the leading causes of death (Lazarou & Pomeranz, 1998). Almost 51% of drugs of approved drugs have serious adverse effects that are not detected prior to approval (U.S. General Accounting Office, 1990). It has been suggested that the system for monitoring adverse effects in the United States and elsewhere is inadequate (Moore et al, 1998; Woods, 1999). For example, neither the Food and Drug Administration in America, nor the Medicines Control Agency in Britain, collect routine data on the prevalence and consequences of adverse effects.
The alliance between psychiatry and the drug industry also helps to strengthen the more coercive aspects of psychiatry. The coercion enshrined in much mental health legislation is justified on the basis that psychiatric conditions are discrete medical entities that respond to specific treatments. The most dangerous reflection of this position are legislative proposals for universal mental health screening of children. Once put into place, this would undoubtedly be quickly allied to the use of drugs as appropriate treatment of those determined to be not mentally "healthy."
The U.S. federal government's New Freedom Commission supports early mental health screening in the schools. The New Freedom Commission, using the Texas Medical Algorithm Program (TMAP) as a blueprint, subsequently recommended screening of American adults for possible mental illnesses, and children for emotional disturbances, thereby identifying those with suspected disabilities, who could then be provided with support services and state-of-the-art treatment, often in the form of newer psychoactive drugs that entered the market in recent years.
The TeenScreen program (self described as The TeenScreen National Center for Mental Health Checkups) has been implemented in specific locations in nearly all 50 states and, yet, a review of five TeenScreen participation parent consent forms for the mental health screening in various towns in Florida, Indiana, New Jersey, Ohio and Missouri make no mention of the psych-screen failure rate. TeenScreen is a very controversial so-called diagnostic psychiatric service, aka suicide survey, done on children who are then referred to psychiatric treatment. The evidence suggests that the objective of the psychiatrists who designed TeenScreen is to place children so selected on psychotropic drugs.
"It's just a way to put more people on prescription drugs," said Marcia Angell, a medical ethics lecturer at Harvard Medical School and author of The Truth About Drug Companies. She says such programs will boost the sale of anti-depressants even after the FDA in September ordered a "black box" label warning that the pills might spur suicidal thoughts or actions in minors. (The New York Post, December 5, 2004)
The psychiatricprofession has been inclined to favor biologicalmodels ofmental disorder and physical treatments as a meansof bolsteringits credibility and claims to authority in themanagement ofmental disorder (Moncrieff & Crawford, 2001).Drugs so dominate psychiatric practice that it is not easy to develop alternative forms of treatment, even though some research suggests that patients with severe mental disorders may do well without drugs (Mosher, 1999; Lehtinen et al, 2000).
Research funding to develop behavior therapy has been miniscule compared with the investment that has been made studying psychiatric drugs. Nevertheless, outcome studies for a wide range of disorders show behavior therapy to be at least the equal of drug treatment. Studies have shown behavior therapy is more effective in the treatment of depression (less than half the relapse rate), obsessive-compulsive disorder, and borderline personality disorder. Studies indicate no difference in effectiveness for drugs versus behavior therapy in the treatment of some other disorders, for example, in the treatment of phobias and generalized anxiety disorder.
Drug treatment has not yet crashed, but there are ominous signs that we may be headed toward widespread mental disability as a consequence of this misguided treatment of mental disorder. In contrast, behavior therapy is safe and more effective. Given the superior substantive base and the greater promise offered by treatments based on a behavioral approach, more support is warranted for training behavior therapists and for pursuit of basic behavioral research. As a society we need to invest far more in developing this model for treating mental disorder.
Recent studies suggest that talk therapy may be as good as or better than drugs in the treatment of depression, but fewer than half of depressed patients now get such therapy compared with the vast majority 20 years ago. Insurance company reimbursement rates and policies that discourage talk therapy are part of the reason. A psychiatrist can earn $150 for three 15-minute medication visits compared with $90 for a 45-minute talk therapy session. Competition from psychologists and social workers - who unlike psychiatrists do not attend medical school, so they can often afford to charge less - is the reason that talk therapy is priced at a lower rate. But there is no evidence that psychiatrists provide higher quality talk therapy than psychologists or social workers.
We are rapidly becoming a society that seeks "a pill for every ill"; one that looks for simplistic, technical solutions to complex social problems.
Moncrieff and her colleagues argue that the alliance between psychiatry and the pharmaceutical industry has several important negative consequences. Firstly, it helps to reinforce a narrow biological conception of the nature of mental disorder. Secondly, it drives the expansion of this conception into more and more areas of everyday life. Thirdly, it is likely to play down the impact of the adverse effects of psychiatric drugs.
This is what makes the marketing of psychiatric drugs into a force for social control and conformity. Personal or social problems are defined as diseases and the authority of psychiatry, backed by the financial muscle of the drug companies, is used to reinforce this view. In the process we are encouraged to radically alter our view of the world and ourselves. We are encouraged to aspire to narrow norms of behavior and taught that anything else is not only undesirable but also unnatural or diseased. We are encouraged to think that changes should be effected not by ourselves on our environment, but by technology on ourselves.
We may be headed to a "Brave New World," where acceptable definitions of normal behavior are very narrow, and controlled by the drug companies.