worrying world of psychiatry

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).

11 thoughts on “worrying world of psychiatry”

  1. On the first part of your post, that placebos are as effective as antidepressants: aren’t you referring specifically to antipsychotics? I think they were the ‘first line’ of antidepressant decades ago, but they are barely ever prescribed any more for the vast majority of people being treated for depression. It’s all SSRIs now, which I think actually have been shown to be more effective than placebos, which was what helped the boom in prescriptions for (SSRI) antidepressants. They were basically safe, unlike antipsychotics, and seemed to be really effective (if not one brand of SSRI then another would work) in treating a whole range of things people were having problems with (mild depression, anxiety, “social anxiety disorder,” “generalized anxiety disorder,” and a whole host of things). SSRIs are dirt cheap and make a real difference to people’s lives (in a good way), whereas all the other treatment possibilities were of dubious effectiveness (like “talk therapy” or cognitive behavioral therapy or whatever). So it doesn’t seem to me that much of a mystery that they would get prescribed heavily (when combined with America’s unique healthcare system).

    I don’t really get what is so troubling about these developments in psychiatry, though. Essentially, we are talking about miracle pills here, that turn out to help in a significant way for lots of things for many people and are really cheap with few meaningful side-effects. And any alternative treatment we know will most likely be a dud (or at least not nearly as effective, not nearly as fast). So why not start using them a lot in psychiatry, coming up with official names for the “abnormalities” they are now able to cheaply and easily treat? You sound a little bit like you are pinning for the days when psychiatrists did just do “talk therapies”, which were really time-consuming, expensive, and for the most part pretty ineffective, as I understand it (and certainly compared to the effectiveness of SSRIs).

    You can make similar arguments, I think, for the rise of ADHD and the medications that treat it. Sometimes those drugs aren’t cheap, but most of the time the medications used to treat ADHD have been used by doctors for decades and are no longer patent protected, so they actually are really cheap, and can make a significant difference to the quality of a person’s life (and, again, most of the time other treatments are ineffective, or effective at nowhere near the level or quickness that the ADHD meds are). The ADHD meds seem really scary when you consider that: Ritalin is chemically really close to cocaine, supposedly; Adderall is speed (just a mixture of amphetamine salts, which is the exact same as speed); and that there is even an ADHD medication that is basically the exact same as crystal meth (can’t remember its name). But they don’t seem that scary when we consider ritalin has been prescribed for something like 70 years (just not under the brand name ‘ritalin’), with apparently no serious long-term side-effects, and it’s basically totally safe. Aspirin kills thousands of people a year and is a vastly more dangerous drug than ritalin. Also, these ADHD medications that are “stimulants” are “central nervous system” or “CNS” stimulants, which also sounds scary, until we recognize that coffee is a CNS stimulant too and no-one thinks that’s scary. As far as I’ve heard, most ADHD meds at appropriate doses are just kind of like a longer-lasting, strong cup of coffee. And if you don’t like the effects, you just stop taking the drug and it leaves your system in a few hours or so and that’s it. So they don’t seem that dangerous to me, once you strip away all the media frenzy, and once we rightly condemn the giving of ADHD meds to 10 year old kids or whatever, and just reserve them for people old enough to understand what it is they are taking.

    Sorry, this reply has gotten very long and rambling. The bottom line, I think, is that these developments in psychiatry are probably pretty similar to most developments in an institutionalized discipline. To make the obvious point, sociology itself is to some extent an entire discipline made up of legitimizing after the fact whatever interesting new things we have decided to look at, by figuring out how to turn them into social problems worthy of having the empirical methods we have stumbled upon applied to them. Academic disciplines everywhere stumble upon solutions to things that hadn’t been recognized or labelled as problems until the solution came along. Then they just go back and construct the problem that there’s now a solution to.

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  2. As SGS said, I think we have to make a distinction between antidepressants and anti psychotics. Not speaking as a scientist, which I know is the point of this post, but from the point of view of a person who has struggled with these illnesses. As someone who has been on both, and suffered from both depression and bipolar disorder, the difference between the drugs is immense. I happen to believe that depression might be just a part of the natural human condition, but I’m pretty certain that bipolar disorder is not. And I’m also pretty certain that without antipsychotics and mood stabilizers, I wouldn’t still be here. I don’t think that placebos can really stop the mind from running a million miles a minute or stop a person from doing really self-destructive things that feel like they aren’t self destructive but they are. Or end the extremely scary suicidal ideations.

    I don’t think psychiatry is perfect. I wish doctors weren’t taking money from drug companies. And I acknowledge that my doctors didn’t know which drugs were going to work for me until a particular cocktail started working. But I also know that no drugs was not a superior treatment option than drugs. Maybe some day, it will be possible for me to live without medication. But in the meantime, I’m more concerned about making sure that the drugs are not going to seriously harm me than worried about exactly what the mechanism is that makes them work. I think they save lives.

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  3. Any responsible mental health-care professional knows that a combination of medication and talk therapy of some sort is the most effective treatment for mental illness. Since LaToya and sociologygradstudent spoke about medication, I’ll address the therapy component. In short, talk therapy is essential for people with serious mental illness, both in terms of the neuroscience and the pragmatics of patient care.

    On the neuroscience, we know from Hebb that neurons that fire together wire together. Thus, we have reason to believe that consistent therapy facilitates the learning process or biologically speaking, the development / reinforcement of the neural networks that are necessary for normal cognitive function. Practically speaking, therapy provides the patient with a stable relationship that is focused specifically on the stability and improvement of the patient’s mental health. The therapist can assist the prescibing doctor by monitoring that the patient is taking his/her medication and properly caring for him or herself, providing information on the effectiveness of the course of treatment, and offer insight on the consistency of the patient’s behavior with regards to warning signs symptomatic of the patient’s diagnosis. More importantly, the therapist can help the patient understand and deal with their mental illness and its implications on a regular basis. Stability is essential.

    Clinical mental health is typically stages behind its research counterpart, but ultimately, neuroscience simply cannot yet tell us how the brain works. Unlike other areas of medicine, we cannot eradicate the cause, we can only address the effects. This is a challenge that all patients with serious mental illness (and their families) understand all too well.

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  4. Others have spoken more knowledgeably than I have. I just wanted to say that, on the one hand, I do personally believe that some medicines are being over-prescribed and some ailments are being over-diagnosed. And that that drugs are sometimes prescribed for issues that would be better helped with talk therapy or other life interventions. What I’ve read says that there is evidence that talk and behavior can change brain chemistry. Saying that something is in the brain chemistry is more or less the same as saying that it is in the brain. Which all thoughts and moods are, by definition. But that does not imply that the best way to fix the problem is an external drug. I’ve also read that the combination of talk and drug is best. And it has been my experience that the cost cutting in mental health has led to too much drug and too little talk, because the talk is a lot more expensive than the drug.

    On the other hand, I’ve talked to some people in the middle of very serious mental health crises who desperately needed some kind of fix to what was going on in their brains. We all talk about feeling “depressed” or “anxious” for transient moods of sadness or stress. That is just a totally different phenomenon from a full-blown depressive episode with suicidal ideation, obsessive compulsive disorder, or other serious mental health issue. It’s like using the same word for a hangnail and having your arm chopped off.

    Talk that stigmatizes the use of psychoactive drugs is a problem because it makes people who need help unwilling to ask for it. It’s like criticizing people for having cancer. My son has Crohn’s disease and will spend the rest of his life on medication. Needing drugs to keep your brain working right should be no more stigmatizing than being Remicade-dependent.

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  5. So, the data I referenced about effectiveness are from anti-depressants. It includes a study of “antidepressant drugs approved between 1987 and 1999—Prozac, Paxil, Zoloft, Celexa, Serzone, and Effexor.”

    Talk that stigmatizes the use of psychoactive drugs is a problem because it makes people who need help unwilling to ask for it. It’s like criticizing people for having cancer. My son has Crohn’s disease and will spend the rest of his life on medication. Needing drugs to keep your brain working right should be no more stigmatizing than being Remicade-dependent.

    I entirely disagree. There is a difference between criticizing the treatments of diseases than criticizing people with those diseases. My post was not meant to suggest, in any way, that mental health isn’t a disease — that it’s just some fantasy.

    Your cancer analogy is apt. I don’t think we’d tolerate ineffective treatments for cancer patients. That these diseases are so prevalent and can be potentially painful for individuals, families, and communities means to me that we should be VERY critical of treatments that are proposed to us if there is evidence that they aren’t effective. I haven’t looked closely at these studies; I’m reporting, basically, what Angell is reporting. And I wouldn’t be surprised if there are large variations in the responses to drugs.

    I’m just outraged at these industries and the elite researchers here, in part because it is a problem that is so close to home.

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    1. Sorry I wasn’t clear. I wasn’t accusing you or anyone of “stigmatizing” in your specific comments, rather referencing the general problem. In the world I move in, the discussion about whether too many young people are on anti-depressants can easily (and even unintentionally) shade into the implication that someone experiencing a serious mental health episode should not need meds. I’ve personally watched this unfold in dialogues I’ve been in. I think comments like MY comments have this risk.

      I personally do think that the word “depression” is over-used and that a lot of what I personally call depression and hear others call depression is a vastly different mental state from a serious episode of clinical depression.

      To draw out the analogy, there’s a similar kind of thing going on with gastro-intestinal upset, where a huge proportion of the population experiences transient symptoms and there is a rise in prescription and non-prescription drugs for these symptoms that may not help and may (some argue) actually make the problem worse. Talk about how this kind of stuff may better be dealt with by a change in diet or lifestyle can lead to a failure to appreciate that Crohn’s disease or colitis are different.

      To get back to close to where you started, even for IBD (the collective name for the two diseases), the drug companies are pushing drug solutions that may lead to a decline in interest in locating the environmental factors that have to be involved. (There are definite genetic markers for Crohn’s, but the epidemiological patterns indicate that genetics has to be interacting with something in environment or lifestyle as the disease is more prominent in northern and wealthier areas and immigrants show the pattern of matching the host country after a generation.)

      Cancer has a similar pattern: it’s a real disease and the cancer treatments are serious, at the same time as the focus on drug treatments reduces the emphasis on environmental factors.

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      1. My apologies right back! I think you’re right — that the complaints that “everybody has X — 10 years ago they didn’t” (where X could be IBS, wheat allergies, lactose intolerance, mental illness) creates harmful dismissals.

        I also think you’re right — that “depression” is thrown around too easily. I, for one, have not suffered from depression through this point in my life. But I described myself as “depressed” fairly often. Yet living with others with depression, I know that my episodes are a very different experience.

        To put it differently (and to continue the cancer analogy), when tired and unwell, I would never say to my mom, “I’m feeling like I have leukemia” (as she DOES have it).

        In some ways, it’s good that the experience is universalized — insofar as I think it’s good to acknowledge that depressive episodes are common and can impact anyone. But in others, this can trivialize the experience of those for whom such experiences aren’t part of an episode here-or-there, but instead a daily aspect of life.

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  6. Thanks for the post. I recommend a good review of a bunch of books by Louis Menand in the March 1, 2010 New Yorker (but can’t link to it). He says SSRIs were mostly developed for anxiety, which was the disease of the moment. But by the time they came on the market, they were pitched as treating depression, because the anti-anxiety drugs (e.g., Valium) had acquired such a bad name since they were addictive and over-prescribed. So one of the reasons we treat “depression” more than “anxiety” today is that legacy, when in fact the SSRIs were (and still are) often prescribed for anxiety. My impression is that anxiety remains less slippery to diagnose and treat chemically than depression, at least at low or moderate levels.

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  7. One of the nicest things anyone ever said to me was by a psychiatrist who said: “Sometime anxiety is a reasonable response to your situation.”

    It’s more of the same problem: distinguishing between an emotional state that is a reasonable consequence of circumstances and a medical problem with emotion or ideation that don’t fit the circumstances. The critique of Valium et al in their day was they were used to “treat” the problem that women were unhappy in the roles consigned to them.

    Which is not to be dismissive of a possible beneficial role of drugs in helping people cope with external events like stressful life circumstances or grief. But I think there are a lot of debates about when, whether and how the drugs actually help when the underlying problem is a life situation, not a mental illness.

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  8. I think some of the initial commentators do not understand Angell’s arguments and how they apply to anti-psychotics versus antidepressants. The NYRB pieces are reviews of 3 books each with different foci. One, by psychologist Irving Kirsch, makes the claim that antidepressants are not much more effective than placebos and may indeed only work because they are “active placebos.” His metanalysis includes recent SSRIs and is not about the early anti-psychotics. So this critique applies to current drugs and is not old news about earlier treatments for depression. Further Angell’s review cites studies that suggest that our current drugs are not much more effective than talk therapy, exercise, or other things.

    All three authors (Kirsch as well as Robert Whitaker and Daniel Carlat) argue that there is little evidence for the chemical imbalance theory of mental disorders (all disorders, not just depression) — as described in the post. i.e. The drugs may alleviate symptoms and also change brain chemicals but that does not mean a neurochemical imbalance is the cause of the original disease.

    The rest of Angell’s review shows that Whitaker argues these drugs produce way more harm than they do benefits. Carlat suggests that the influence of the pharmaceutical industry (combined with the hard-science aspirations of psychiatry) explains why treatment is now so drug dependent (so to speak). Meika Loe’s Rise of Viagra does a nice job of showing how pharmaceutical influence shapes (to put it mildly) both diagnostic categories and treatment orientations in another medical field.

    Those who don’t get the concerns about psychiatry should read Angell’s piece. I found it quite troubling.

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