Psychiatry Under the Influence
On the corruption of an institution
Posted May 7, 2015
New York Times bestselling author Robert Whitaker and University of Massachusetts Professor Lisa Cosgrove have written an important new book in the field of mental health, Psychiatry Under the Influence: Institutional Corruption, Social Injury and Prescriptions for Reform. I interviewed them last week.
MW: How did you become interested in the topic of institutional corruption?
LC: I was doing research on how academic-industry relationships can affect psychiatric research and practice. Then I was advised that the Edmond J. Safra Center for Ethics (Harvard University) was starting a lab on “institutional corruption” which would focus on how such industry influences can corrupt an institution. I was a residential fellow in 2010-2011, the first year of the lab, and retained a relationship with the lab through its five years of existence.
RW: After Lisa read Anatomy of an Epidemic, she asked me if I would like to apply to the Safra Center to collaborate on writing a monograph on the American Psychiatric Association as viewed through the lens of institutional corruption. As we worked on that topic, during the fellowship year 2011-2012, we decided to expand it into a book-length study of the institution of psychiatry. We look at both the influence of pharmaceutical money and guild interests on the institution. For the purposes of this study, we conceptualized the institution as being comprised of the American Psychiatric Association and academic psychiatry.
MW: What is the difference between institutional corruption and individual corruption?
LC and RW: Individual corruption is quid pro quo corruption, where an individual engages in clearly unethical and often illegal behavior. A state official taking a bribe would be a classic example of quid pro quo corruption.
Institutional corruption is of a different sort—it’s about the bad barrel rather than the bad apple. It is systemic corruption. As the result of “economies of influence” that act on the institution. The institution, in its collective behavior, then turns away from its mission to serve the public in an ethical manner. The “economies of influence” normalize behaviors within the institution that those outside the institution would see as ethically dubious, or wrong. (For example, a psychiatrist serves as a member of a panel that develops a clinical practice guideline. That psychiatrist also serves on a speaker’s bureau for a drug company that manufacturers a drug treatment which the panel then recommends as a first-line treatment in its guidelines).
MW: Most people believe that psychiatric and mental health diagnoses are based on actual science. Is this belief correct?
LC and RW: There is an attempt within psychiatry to use a scientific method to diagnose and treat emotional distress. However, understanding the origins of “emotional distress” and other psychiatric problems, and then treating these problems, is very different from trying to understand the origins of heart disease, cancer etc. and treating these illnesses. Psychiatry is different from other medical specialties because there are no biomarkers for any psychiatric disorder. Most people are not aware of the fact that there is no blood test or scanning technique that can be used to identify any DSM disorder--even ones that are assumed to be neuro-biologically based such as schizophrenia and bipolar disorder.
Even so, the public has been led to believe that these diagnoses have been scientifically validated as real diseases. However, as psychiatrists who are experts in diagnosis will admit, the diagnoses are “constructs,” and research has failed to validate them. So the science that has been done has, in fact, revealed that the DSM lacks “validity” which a diagnostic manual should provide if it is going to be useful.
MW: Psychiatry’s core mission is to help patients. How did that mission become corrupted?
LC and RW: In 1980, when the APA published the third edition of its Diagnostic and Statistical Manual, it adopted a “disease model” for diagnosing and treating psychiatric disorders. At that point, the APA launched a public relations effort to sell this new model to the public. Ever since then, the APA has been telling the public of the validity of its disorders, of advances in understanding the biology of these disorders, and of “safe and effective” new drug treatments for the disorders.
The problem is that psychiatry’s own research didn’t support the story of discovery and progress. In truth, research failed to validate the disorders; the field made very little progress in discovering the pathology of the disorders (the chemical imbalance theory failed to pan out); and clinical studies failed to show that the second generation drugs were any better than the first generation drugs.
Many studies also suggested that the drugs may impair patient outcomes in the long-term. Psychiatry had an ethical duty to tell the public of these scientific findings. However—and this is due to the influence of its own guild interests and pharmaceutical influence—it has instead relentlessly promoted its public-relations “success” story. Psychiatry’s mission became corrupted because of the need to protect its guild interests. .
MW: Did the authors of the various iterations of the DSM since the DSM-III in 1980 believe that the diagnoses they created were based on scientific research?
Yes, at least to a certain extent. They knew the diagnoses were constructs; but at the same time they believed there was a scientific rationale behind their constructs. They reasoned that they were grouping people with similar “symptoms” together. They may have found some loose genetic associations and they charted the “course” of those with a similar diagnosis. They conducted epidemiological studies to assess the “prevalence” of the various “diseases. This was research that at least provided the trappings of science, and of course the creators of the DSM were invested in the idea that theirs was a scientific enterprise.
LC and RW: Starting with DSM III and then in successive iterations of the DSM, the APA set forth diagnostic criteria for ADHD that made it easy to diagnose any child who was fidgeting in class, or not paying attention, or simply not doing well in school. Such “symptoms” are of course fairly common in children, and thus the diagnostic boundaries were set in a way that they described a significant percentage of children. The point here is that fidgeting and being inattentive, rather than being understood to be behavioral problems that show up in school environments, were re-conceptualized as symptoms of a disease. That is a radically different understanding of childhood from what we had before DSM III.
MW: To establish a new paradigm for mental health treatment, how would psychiatry programs in medical schools have to change?
Psychiatry programs would need to foster critical thinking in medical students, which the students could then apply to diagnoses, research findings, and drug results. They would also need to foster an awareness of the profession’s own guild interests. In short, medical schools would need to nurture psychiatrists who could think critically instead of simply mastering the conventional wisdom. The problem with current training is that the conventional wisdom is out of sync with the scientific literature.
Marilyn Wedge is the author of A Disease called Childhood: Why ADHD became an American Epidemic.