A while back I did some research on the genetics of mental illness, and was appalled to discover some disturbing things about medical psychiatry (by “medical psychiatry” I mean psychiatry centered on drug therapy rather than talk therapy). First of all, for the vast majority of drugs used to combat mental illness—and especially depression—the doctors had no idea how they worked, yet they pretended they did. Patients were regularly told, when prescribed antidepressants like SSRIs (selective serotonin reuptake inhibitors; Prozac is the classic specimen) that their depression was due to a chemical imbalance in the brain. SSRIs, for example, increase the amount of the neurotransmitter serotonin in the synapses (gaps) between neurons by preventing its reabsorption by the neurons. Because these drugs seemed to work (more on that below), doctors and pharmaceutical companies blithely concluded that depression resulted from a deficit of serotonin. But that’s ludicrous, for just because a drug alleviates a symptom doesn’t allow you to conclude that the symptom was due to the deficit of that drug. It’s like saying that headaches are caused by a deficit of aspirin! As Marcia Angell notes in her reviews below, “. . . instead of developing a drug to treat an abnormality, an abnormality was postulated to fit a drug.”
An acquaintance of mine, visiting a psychiatrist for depression, was told that her “brain was wired up wrong”! That verges on medical malpractice.
I also learned that the genetics of mental illness is a subject rife with uncertainty and unreproduceable results. For every study localizing a “gene” or gene region responsible for a condition like depression, there was a counter-study showing no effect at all. Nevertheless, medical students in psychiatry are taught that the major mental illnesses have a genetic basis (I’ve seen the textbooks).
Despite all this, psychiatry continues to be increasingly “medicalized,” that is, talk therapy is replaced by drug therapy (doctors can make a lot more money prescribing drugs than talking, for during the hour occupied by a talk therapy session, a psychiatrist could see and prescribe meds to three or four patients). And pharmaceutical companies make millions of dollars prescribing drugs for mental illnesses, so they continually try to expand the range of conditions that count as drug-requiring “illnesses,” including obsessive-compulsive disorder, various attention-deficit syndromes, and so on.
The whole mess is encapsulated in the book used by doctors to “diagnose” mental illnesses, the Diagnostic and Statistical Manual of Mental Disorders (DSM), which is now undergoing its fifth revision. If you ever get a chance to look at it, do. You’ll find that “diagnosis” is based on conforming to a certain number of symptoms in a numbered list. To be diagnosed with a “major depressive episode,” for example, you need to have five out of the nine symptoms described by the DSM. But what if you have only three or four? Then you don’t get your meds. It’s all quite bizarre, and I concluded that the whole drug/genetics/diagnosis nexus is driven by three things: the desire of psychiatrists to be like “regular” doctors who treat well defined illnesses with well defined medications, the nebulous and ill-defined character of mental illnesses, and the desire of pharmaceutical companies to milk the public out of as many dollars as possible. This does not deny, of course, that mental disorders are often serious and life-threatening conditions that require some type of treatment or intervention.
And these conclusions—and other ones just as dire—are shared by Marcia Angell, author of two new articles in The New York Review of Books “The Epidemic of mental illness: Why?” and “The illusions of psychiatry” (they’re free, so have a look). Angell is a pathologist with an M.D., studied microbiology, and was the first woman editor of The New England Journal of Medicine. Her piece is basically an essay centered on four books, The Emperor’s New Drugs: Exploding the Antidepressant Myth, by Irving Kirsch, Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America, by Robert Whitaker, Unhinged: The Trouble with Psychiatry—A Doctor’s Revelation about a Profession in Crisis, by Daniel Carlat, and the latest DSM, Fourth Edition, Text Revision (DSM-IV-TR), published by the American Psychiatric Association.
Antidepressants and anti-anxiety drugs are so widely prescribed in America that if you’re not taking them yourself, you certainly know someone who is, so you owe it to yourself to have a look at these articles. Among Angell’s eye-opening statements and conclusions are these:
- Mental disorders are increasing at a furious rate in America, especially for children. While 1 in 184 Americans qualified for government disability aid for mental illness in 1987, the number more than doubled (1 in 76) by 2007. In children, the rise was an astonishing 35-fold! This almost certainly reflects not a genuine jump in disorders, but an increase in the frequency of diagnosis.
- As we all know, psychiatric talk therapy has been largely supplanted by the use of drugs. Medical students are now given minimal training in talk therapy and maximal training in how to prescribe drugs.
- There is no substantive evidence that mental illness is caused by chemical imbalances in the brain.
- Antidepressants are far less effective than people think: in fact, they may not be effective at all. Trials are typically only a month or two long, and I am not aware of any long-term tests of these drugs. More disturbing is that the drugs are barely better than placebos. Pharmaceutical companies doing blind testing of antidepressants are required to submit only two blind clinical studies with positive results, and these could be out of a much larger number of studies showing no positive results. That, in fact, seems to be the case. When Irving Kirsch investigated the studies, he found that while antidepressants were three times as effective as no treatment at all, they were only marginally better than placebo drugs, which “cured” depression at a rate 82% that of real antidepressants. Moreover, when you look at the degree of improvement of antidepressants over placebos, the difference, though statistically significant, is miniscule. Few people taking antidepressants know these depressing statistics.
- Doctors observed that other drugs with no effect on serotonin, like synthetic thyroid hormone, also appeared to relieve depression. What these drugs had in common was that they all had side effects. Was it the side effects, then, that helped depression? Sure enough, when doctors used placebos that had side effects (“active placebos”; one of these is atropine) rather than inactive placebos, they found no difference between antidepressant and placebo. A reasonable conclusion from this study is that patients, when they experience side effects, think that they’ve “broken the blind test,” and are taking the real drug. They then improve simply as a result of realizing that they’re taking something that’s supposed to help them.
- Whitaker’s book reaches an even more depressing conclusion. He realized that the “natural history of mental illness” has changed over the decades: while schizophrenia and depression, for instance, used to recur episodically, separated by periods of normality, now they are “chronic and lifelong”. Whitaker concludes that psychoactive drugs actually change the brain in a way that prolongs and intensifies mental disorders, for the brain tries to compensate, ineffectually, for the chemical imbalances induced by drugs. Here is a really disturbing passage from Whitaker’s book:
“Imagine that a virus suddenly appears in our society that makes people sleep twelve, fourteen hours a day. Those infected with it move about somewhat slowly and seem emotionally disengaged. Many gain huge amounts of weight—twenty, forty, sixty, and even one hundred pounds. Often their blood sugar levels soar, and so do their cholesterol levels. A number of those struck by the mysterious illness—including young children and teenagers—become diabetic in fairly short order…. The federal government gives hundreds of millions of dollars to scientists at the best universities to decipher the inner workings of this virus, and they report that the reason it causes such global dysfunction is that it blocks a multitude of neurotransmitter receptors in the brain—dopaminergic, serotonergic, muscarinic, adrenergic, and histaminergic. All of those neuronal pathways in the brain are compromised. Meanwhile, MRI studies find that over a period of several years, the virus shrinks the cerebral cortex, and this shrinkage is tied to cognitive decline. A terrified public clamors for a cure.
Now such an illness has in fact hit millions of American children and adults. We have just described the effects of Eli Lilly’s best-selling antipsychotic, Zyprexa.”
- The DSM book resulted from a deliberate decision by the American Psychiatric Association (APA) to “remedicalize psychiatry” in the late 1970s. Each time it is revised, the number of disorders included increases drastically: the latest has 365, more than doubling the 182 in the DSM-II. Angell notes a serious lack of scientific underpinning:
“Not only did the DSM become the bible of psychiatry, but like the real Bible, it depended a lot on something akin to revelation. There are no citations of scientific studies to support its decisions. That is an astonishing omission, because in all medical publications, whether journal articles or textbooks, statements of fact are supposed to be supported by citations of published scientific studies. (There are four separate “sourcebooks” for the current edition of the DSM that present the rationale for some decisions, along with references, but that is not the same thing as specific references.) It may be of much interest for a group of experts to get together and offer their opinions, but unless these opinions can be buttressed by evidence, they do not warrant the extraordinary deference shown to the DSM.”
- The connection between drug companies and psychiatrists has always been congenial—I would call it corrupt. The companies pay for the doctors to go to conferences, often in vacation-y places, they sponsor their research, and give them huge fees as consultants and speakers. Angell notes that in states that must reveal financial connections between drug companies and doctors, psychiatrists get more largesse than any other group of physicians. And 20% of the funding of the American Psychiatric Association (which, of course, publishes the DSM) comes from drug companies.
- More than half of the contributors to the new version of the DSM (95/170) have financial ties to drug companies, “including all of the contributors to the sections on mood disorders and schizophrenia.”
- Drug companies also give a ton of money to patient advocacy groups, like the National Alliance on Mental Illnesses—groups whose agendas include a strong push for drug therapy for mental disorders.
- Perhaps the most disturbing thing in Angell’s articles is the huge increase in drug therapy for mental disorders in children, who are often treated with drugs not approved by the FDA for their diagnosed disorder. “Juvenile bipolar disorder” increased 40-fold between 1993 and 2004, and autism more than fivefold. As Angell notes, “Ten percent of ten-year-old boys now take daily stimulants for ADHD—’attention deficit/hyperactivity disorder’—and 500,000 children take antipsychotic drugs.”
Angell and the authors she reviews describe further disturbing things, like the drug industry’s illegal push to get doctors to prescribe drugs for conditions for which those drugs haven’t been approved by the FDA (American Food and Drug Administration). If you are a patient, or know someone who is, you must have a look. These articles, and the data presented by Angell, have convinced me more than ever that medical psychiatry is largely a scam, a rotten-to-the-core coalition between psychiatrists and pharmaceutical companies. Now I know that many psychiatrists are deeply motivated to help their patients, for mental disorders are among the most frustrating and recalcitrant conditions faced by doctors, and many patients indeed need urgent medical or therapeutic attention. But the way it’s being done now is not only ineffective, but positively harmful—although lucrative for doctors and drug companies. The few researchers and psychiatrists crying out against the madness, as in the three books under review, are largely shouting in the wilderness.
UPDATE: To the readers who are taking medications for mental disorders, do not take this post as an incitement to quit your medications. I hope nobody interpreted my piece this way, but I wanted to make that crystal clear. I am not a physician and am merely recounting my own experience, conclusions, and the article of Dr. Angell. But I do urge you to read that article, whether or not you’re a patient.
I would add, though, that personal testimony that a drug has “helped” a person is not the same thing as positive results in a double-blind study. Many people claim that they have been helped by homeopathic medicine or other “cures” that can’t be documented scientifically. The placebo effect (which must be operative in homeopathy) is well documented.
Finally, for similar views on the self-serving behavior of the pharmaceutical industry with respect to treating mental illness, see Frederick Crews’s (open-access) 2007 NYRB piece, “Talking back to Prozac,” a review of three books on psychiatry and “Big Pharma.”