Marcia Angell has written a fascinating two-part (here and here) review in the New York Review of Books on the transformation of the psychiatric profession over the last 50 years — my post is mostly a rehash of her longer argument. What I find most fascinating is that the theory that depression is caused by chemical imbalances in the brian has little empirical support. That theory was developed because of the effects of drugs developed in the 50s. Those drugs initially were meant to treat infections. But they also seemed to influence patients’ mental state. Doctors wondered how. And they discovered that these drugs impacted chemical levels in the brain. So was born the theory that serotonin levels (or dopamine, or other chemicals) influenced our mental health — or more accurately, that abnormal levels of chemicals in the brain are responsible for our psychic states. The logic of this conclusion requires some herculean leaps.
How do we know that levels of chemicals in the brain are responsible for mental health? Because drugs that influenced such chemicals seemed to influence our mental states. As Angell states, “instead of developing a drug to treat an abnormality, an abnormality was postulated to fit a drug… “By this same logic one could argue that the cause of all pain conditions is a deficiency of opiates, since narcotic pain medications activate opiate receptors in the brain.” Or similarly, one could argue that fevers are caused by too little aspirin.”
Still, the theory could be correct. Though constructed on incredibly weak evidence, subsequent study could prove it correct. Unfortunately, that doesn’t seem to be the case. In a meta-analysis of drug studies, Irving Kirsch shows that in all trials (which last from 6-8 weeks) patients tend to improve even without any treatment. Still, placebos are three times as effective as no treatment. Antidepressants are only marginally better (placebos are 82 percent as effective as antidepressants).
Now that’s still a result. But there’s a problem with these studies. And the problem is this: patients who were given the “real” drugs often experienced side-effects. Those who were given the placebo didn’t. And so patients could guess that they were getting the real thing. In studies where patients were given drugs that had no impact upon serotonin (like herbal treatments) yet produced side-effects, the differences between them and anti-depressants is non-existent. Or put differently, “active placebos” (that produce a dry mouth) and “real drugs” (like prozac) have no difference in outcomes.
This is particularly worrying because antidepressants have considerable side-effects. Such drugs produce, “substantial and long-lasting alterations in neural function… One well-respected researcher, Nancy Andreasen, and her colleagues published evidence that the use of antipsychotic drugs is associated with shrinkage of the brain, and that the effect is directly related to the dose and duration of treatment.” Beyond such impacts, these drugs are often associated with weight gain, exhaustion, increased rates of diabetes, higher blood sugar and cholesterol levels, and emotional disengagement. In short, such drugs might not only be useless. They could actually be pretty harmful.
So why are they still used? The answer, it seems, is organizational: a strong set of ties that emerged between the psychiatry and the pharmaceutical industry. That story is told in part two of Angell’s piece. Basically, relatively low-status (and low paying) psychiatry sought, through its association with pharmacology, to re-medicalize itself through abandoning talk therapy and experiential explanations and moving toward greater physiological/chemical based explanations of psychic phenomena. The DSM was a huge part of this move. And over 55% of the contributors to the DSM have financial ties to drug companies who increasingly produce the recommended treatments for the mental disorders.
Psychiatrists now lead the pack of medical specialties when it comes to taking money from drug companies. As Angell points out, ““Our diagnoses are subjective and expandable, and we have few rational reasons for choosing one treatment over another.” Unlike the conditions treated in most other branches of medicine, there are no objective signs or tests for mental illness—no lab data or MRI findings—and the boundaries between normal and abnormal are often unclear. That makes it possible to expand diagnostic boundaries or even create new diagnoses, in ways that would be impossible, say, in a field like cardiology. And drug companies have every interest in inducing psychiatrists to do just that.”
To compound these worries, recent work has found that children in low-income families are four times as likely as privately insured children to be on antipsychotic medicines. Why? As Angell explains,
As low-income families experience growing economic hardship, many are finding that applying for Supplemental Security Income (SSI) payments on the basis of mental disability is the only way to survive. It is more generous than welfare, and it virtually ensures that the family will also qualify for Medicaid… Hospitals and state welfare agencies also have incentives to encourage uninsured families to apply for SSI payments, since hospitals will get paid and states will save money by shifting welfare costs to the federal government. Growing numbers of for-profit firms specialize in helping poor families apply for SSI benefits. But to qualify nearly always requires that applicants, including children, be taking psychoactive drugs.
Disturbing. Needless to say, the pieces are worth looking through.
A series of things from the review that I found interesting:
- The tally of those who are so disabled by mental disorders that they qualify for Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI) increased nearly two and a half times between 1987 and 2007—from one in 184 Americans to one in seventy-six.
- For children, the rise is even more startling—a thirty-five-fold increase in the same two decades. Mental illness is now the leading cause of disability in children, well ahead of physical disabilities like cerebral palsy or Down syndrome
- 46% of Americans have had a psychological illness at least once in their lives
- Ten years after the release of Prozac in 1987, the number of people treated for depression tripled. 10 percent of Americans over age six now take antidepressants.
- Antidepressants are the top selling class of drugs in the US.
- The mechanism by which the FDA approves drugs is incredibly worrying. Companies submit the results of trials to the FDA. If two trials show that the drug is more effective than a placebo, the drug is generally approved. But companies may sponsor as many trials as they like, most of which could be negative—that is, fail to show effectiveness. All they need is two positive ones.
- In the first quarter of 2009 alone, Eli Lilly gave $551,000 to NAMI [National Alliance on Mental Illness] and its local chapters, $465,000 to the National Mental Health Association, $130,000 to CHADD (an ADHD [attention deficit/hyperactivity disorder] patient-advocacy group), and $69,250 to the American Foundation for Suicide Prevention. And that’s just one company in three months
- The apparent prevalence of “juvenile bipolar disorder” jumped forty-fold between 1993 and 2004, and that of “autism” increased from one in five hundred children to one in ninety over the same decade. Ten percent of ten-year-old boys now take daily stimulants forADHD—”attention deficit/hyperactivity disorder”—and 500,000 children take antipsychotic drugs. These children are often treated with drugs that were never approved by the FDA for use in this age group and have serious side effects.
- The FDA approves drugs only for specified uses, and it is illegal for companies to market them for any other purpose—that is, “off-label.” Nevertheless, physicians are permitted to prescribe drugs for any reason they choose, and one of the most lucrative things drug companies can do is persuade physicians to prescribe drugs off-label, despite the law against it. In just the past four years, five firms have admitted to federal charges of illegally marketing psychoactive drugs. AstraZeneca marketed Seroquel off-label for children and the elderly (another vulnerable population, often administered antipsychotics in nursing homes); Pfizer faced similar charges for Geodon (an antipsychotic); Eli Lilly for Zyprexa (an antipsychotic); Bristol-Myers Squibb for Abilify (another antipsychotic); and Forest Labs for Celexa (an antidepressant).