Big Pharma's Role in Promoting DSM Disorders
Big Pharma has played an outsize role in promoting DSM disorders.
Posted August 19, 2010
Several readers of Nassir Ghaemi's response to me have already weighed in on our debate, reminding Dr. Ghaemi of the enormous influence on American psychiatry of works like Peter Kramer's Listening to Prozac. Just one of several international bestsellers that waxed enthusiastic about the possibilities of using Prozac for "mood brightening" and "cosmetic pharmacology" years before the FDA was forced to add a black-box warning to the drug for its role in increasing suicidality, Kramer's book contributed vastly to the euphoria surrounding SSRI antidepressants. That euphoria was everywhere in the late 1980s and throughout the 1990s. It included an astronomical number of pro-Pharma articles that appeared in scholarly journals at the time. Dr. Ghaemi surely has not forgotten about them.
That there are now a sizable number of books warning that that euphoria was thoroughly misplaced is chiefly, I'd wager, because of the drug companies' role in withholding key information from psychiatrists, doctors, and the general public--information that made clear that the track record of such drugs was spotty, to say the least, and often downright dangerous to vulnerable populations, including the young and the elderly. Dr. Ghaemi knows all this, of course; he even thinks that pointing it out is old hat. I disagree. I also think it's disingenuous on his part to pretend that such books have no evidence to support them, as if they were published without cause or accreditation. In fact, they draw on a vast amount of evidence pointing to a far-more complex picture of hype and distortion than Dr. Ghaemi seems willing to acknowledge.
He writes, "Show me the connection between the DSM-III task force and the Pharma makers of antidepressants before 1980. I have not seen such evidence. I don't believe it exists." Seriously? Does he not know the role that, say, Merck played in the early 1960s in promoting and distributing books like Frank Ayd's Recognizing the Depressed Patient? In case not, Merck bought and freely distributed to psychiatrists tens of thousands of copies of the book. Dr. Ghaemi must be similarly unaware of the role of comparable actions by SmithKline Beecham, Lilly, Upjohn Pharmaceuticals, and so many others. Indeed, of the hundreds of millions of dollars in funding that Congress has given the pharmaceutical industry since it passed the Mental Health Study Act in July 1955, including for the industry to promote its products in alignment with DSM categories and disorders. Presumably he also has not read about the extensive promotional campaigns for Miltown, Meprospan, Nardil, and Valium that long-preceded the multimillion dollar ones for today's antidepressants and antipsychotics.
If that's really the case, I recommend that he start with Mickey C. Smith's Social History of the Minor Tranquilizers (PPP, 1991) and David Healy's well-praised and meticulous study The Antidepressant Era (Harvard, 1997), just two sources immediately refuting his assumptions that drug company involvement in DSM categories began after 1980. (Dr. Ghaemi is relatively unusual in opening conceding the extent of that involvement post-1980.) Smith's book, in particular, charts how the drug companies influenced the media into giving the drugs terms such as "Wonder Drug" (Time, 1954); "Happiness Pills" (Newsweek, 1956); "Aspirin for the Soul" (Changing Times, 1956); "Mental Laxatives" (Nation, 1956); "Don't-Give-A-Damn Pills" (Time, 1956); "Peace of Mind Drugs" (Mental Health, 1957), and even "Turkish Bath in a Tablet" (Reader's Digest, 1962), all the way to "Bottled Well-Being" (Time, 1980). All these inconvenient facts--and many others like them, pointing to decades of mutual dependence between American psychiatry and the pharmaceutical industry--are documented clearly in my book Shyness: How Normal Behavior Became a Sickness (Yale, 2007). They of course include GSK's $92.1 million campaign to promote Social Anxiety Disorder as a condition for its spotty, overhyped, and side-effect ridden drug Paxil.
Finally, Dr. Ghaemi either misread or misunderstood my comment about Isaac Marks, so I need swiftly to correct the record. Marks was (as I wrote) strongly opposed to the transformation of panic into Panic Disorder rather than approving of the move. An expert on fear and panic still committed to treating both, Marks was also strongly critical of Upjohn Pharmaceuticals' role in promoting Panic Disorder as a condition for its drug Xanax. He realized (as Dr. Ghaemi did in his opening post, "The Disorder of ‘Disorder'") that the redefinition of panic would transform the ontology of the reaction, turning a perceptual and situationally specific problem (say, fear of flying, horror of spiders, or panic over riding in elevators) into a presumptively innate and lifelong condition--one for which drugs were being pushed aggressively as more or less the sole remedy. We're still dealing with that legacy today; its influence is far from over.
It may be worth reminding readers: My exchange with Dr. Ghaemi began precisely in support for his frustration with colleagues' loosely applying the term "disorder" to these and many similar conditions. Now, after several exchanges, I'm much clearer about what he would add to the DSM, as distinct from what he'd delete from it. That seems to be an editorial process that no one at the APA seems willing to discuss, much less start. I continue to be perplexed about why, given the existence in the DSM of simply ridiculous "psychiatric conditions" such as "Mathematics Disorder," "Caffeine Intoxication Disorder," and even "Sibling Relational Disorder"! The situation fairly beggars belief, especially given the manual's worldwide importance. Still, I continue to salute Dr. Ghaemi's concern about the term "disorder" and his willingness to rethink it, at least to remind the DSM-5 task force of the term's intrinsic problems and limitations.