The Illusions of American Psychiatry
Americans' faith in antidepressants and psychiatric diagnosis is misplaced.
Posted Jun 21, 2011
"It seems that Americans are in the midst of a raging epidemic of mental illness," writes Marcia Angell in the current issue of the New York Review of Books, "at least as judged by the increase in the numbers treated for it."
Angell, whose superb two-part review essay came fully online yesterday, kicks off with some startling facts: The number of Americans who qualify for Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI) because of mental health diagnoses "increased nearly two and a half times between 1987 and 2007—from one in 184 Americans to one in seventy-six." For children, she adds, "the rise is even more startling—a thirty-five-fold increase in the same two decades." At the same time, a Rutgers University study found that "children from low-income families are four times as likely as privately insured children to receive antipsychotic medicines."
With mental illness "now the leading cause of disability in children" and a large survey of American adults—sponsored by the National Institute of Mental Health between 2001 and 2003—finding that "an astonishing 46 percent met criteria established by the American Psychiatric Association for having had at least one mental illness within four broad categories at some point in their lives," Angell is right to ask, "What is going on here? ... Is it plausible to suppose that such an increase is real? Or are we learning to recognize and diagnose mental disorders that were always there? On the other hand, are we simply expanding the criteria for mental illness so that nearly everyone has one? And what about the drugs that are now the mainstay of treatment? Do they work? If they do, shouldn't we expect the prevalence of mental illness to be declining, not rising?"
Angell, who is Senior Lecturer in Social Medicine at Harvard Medical School, former Editor in Chief of The New England Journal of Medicine, and author of The Truth About the Drug Companies, is rightly skeptical that such an epidemic exists independently of several key variables. They include: the pharmaceutical industry that sponsors vast amounts of psychiatric research (including "about a fifth" of American Psychiatric Association funding); the researchers themselves, who are increasingly beholden to their corporate sponsors, generating an almost insurmountable conflict of interest over the presentation of evidence, for and against; and the APA itself, under whose direction the number of official mental disorders more than doubled in the space of thirty-two years, from 180 in 1968 to 365 in 2000, with the publication of DSM-IV-TR (text revised)—an increase in scale never before seen in the history of medicine.
The review article comes in two parts, "The Epidemic of Mental Illness: Why?" and "The Illusions of Psychiatry," and it focuses on three prominent books that are themselves highly skeptical of the direction, funding, and intellectual underpinning of American psychiatry: Irving Kirsch's The Emperor's New Drugs: Exploding the Antidepressant Myth; fellow PT blogger Robert Whitaker's Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America; and fellow PT blogger Daniel Carlat's Unhinged: The Trouble with Psychiatry—A Doctor's Revelations about a Profession in Crisis. Given the scale and importance of the issues in question, what follows can be just a snapshot of the emerging consensus among these books:
"First, they agree on the disturbing extent to which the companies that sell psychoactive drugs—through various forms of marketing, both legal and illegal, and what many people would describe as bribery—have come to determine what constitutes a mental illness and how the disorders should be diagnosed and treated."
"Second, none of the three authors subscribes to the popular theory that mental illness is caused by a chemical imbalance in the brain." Instead, they argue that rather than "developing a drug to treat an abnormality, an abnormality was postulated to fit a drug."
Such findings are wholly consistent with my own research on the history of social anxiety disorder, which was first classified as an illness in 1980, rebranded (sorry, renamed) in 1987, then marketed to the tune of tens of millions of dollars because the FDA (composed of researchers whose income was greatly supplemented by the drug companies) agreed to license the drug Paxil for the disorder on thoroughly open-ended evidence. Such findings also corroborate the words of DSM-III editor Robert Spitzer, who told me, years later, that such an approval process in the DSM is partly "a function of ‘Do you have a treatment?' If you have a treatment, you're more interested in getting the category in [the DSM]. If you have no treatment for it, there's not as much pressure to put the thing in"—i.e., to approve the condition as a bona fide mental illness.
Concerning the key question, "Do the drugs work?," the three authors are similarly doubtful. Based on several extensive meta-analyses, including of the data submitted to the FDA that led to the approval of blockbuster antidepressants yielding billions of dollars in revenue, Kirsch found that "placebos were 82 percent as effective" as the drugs themselves. The finding comes from forty-two trials of six blockbuster antidepressants, for which most of the results were either negative or clinically meaningless. From this and considerable additional evidence, Kirsch concludes that "the relatively small difference between drugs and placebos might not be [due to] a real drug effect at all," but rather from an "enhanced placebo effect." "Rather than comparing placebo to drug," he surmises, "we have been comparing ‘regular' placebos to ‘extra-strength' placebos."
Regarding Daniel Carlat, who openly concedes in his book that "our diagnoses [as psychiatrists] are subjective and expandable, and we have few rational reasons for choosing one treatment over another," one could be left wondering why his practice consists only of drug treatments. As he is quick to burst "the illusion that we understand our patients when all we are doing is assigning them labels," why does Carlat persist with drug treatments riddled with side effects whose limited efficacy, Kirsch and Whitaker show conclusively, is owing almost entirely to placebo? As Carlat puts it, "To a remarkable degree, our choice of medications is subjective, even random. Perhaps your psychiatrist is in a Lexapro mood this morning, because he was just visited by an attractive Lexapro drug rep." Most readers won't find that admission very reassuring. Carlat is nonetheless highly critical of overmedication and what he calls the current "frenzy of psychiatric diagnoses."
In summing up the two halves of her excellent article, Angell writes: "The books by Kirsch, Whitaker, and Carlat are powerful indictments of the way psychiatry is now practiced. They document the 'frenzy' of diagnosis, the overuse of drugs with sometimes devastating side effects, and widespread conflicts of interest." "At the very least," she concludes, "we need to stop thinking of psychoactive drugs as the best, and often the only, treatment for mental illness or emotional distress. Both psychotherapy and exercise have been shown to be as effective as drugs for depression, and their effects are longer-lasting, but unfortunately, there is no industry to push these alternatives and Americans have come to believe that pills must be more potent. More research is needed to study alternatives to psychoactive drugs, and the results should be included in medical education."