Cracked (21 page)

The results were revealing. Out of the one hundred pseudo-patients who asked their doctors for Paxil, a full thirty-two received Paxil, while out of the ninety-nine pseudo-patients who just made a general request for any antidepressant, only six received Paxil—a result indicating that what doctors prescribe is significantly affected by what patients demand.
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While direct-to-consumer advertising is prohibited in Canada, the UK, and in the rest of the European Union,
153
pharmaceutical companies still manage to get their message across to the public in these countries too, often via the more circuitous routes of media and Internet resources. For example, in the UK today there are an ever-growing number of mental health professionals who receive money from drug companies while at the same time contributing to public debates in prominent newspapers and online magazines, often presenting in these contexts positive messages about antidepressants.

The problem here is that audiences rarely know about their industry ties, because media outlets are not obliged by law to report them. To give you just one example: In 2011 I read an article published on BBC NewsOnline extolling the virtues of antidepressants.
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What concerned me was not its recommendation for wider antidepressant use, but that the citation at the foot of the article stated the author has “given lectures on behalf of a number of pharmaceutical companies.” When I further researched these company ties, I found that the citation omitted that the author had actually received consultancy fees and honoraria from many pharmaceutical companies including Janssen-Cilag, Eli Lilly, AstraZeneca, Bristol-Myers Squibb, Otsuka, and Wyeth. The thousands of people who read this article were not informed that this author was a paid pharmaceutical consultant.

After pressing the BBC, the health editor finally conceded to change the citation to reflect this potential conflict of interest (which can now be seen at the foot of the article at the time of writing). By changing the author's citation I welcomed the editor's implied admission that full disclosure is the proper course of action. But would this single admission stop similar mistakes being made in the future?

I therefore wrote to the BBC Trust requesting that BBC NewsOnline enshrines in its editorial policy the obligation for its editors to disclose whenever authors on mental health issues have financial industry links. I also included an online petition that I had started, which in the first few days of going live was signed by over one thousand mental health professionals (psychologists, counselors, psychiatrists, and psychotherapists). I explained to the BBC Trust why this issue was so important to us, citing further evidence where BBC NewsOnline had failed to declare its antidepressant commentator's financial ties on many occasions. For example, in 2009 alone, I found the following cases:

In the article “Antidepressants ‘Work Instantly'”
(October 2009), the same Dr. Michael Thase (who trained Carlat in New York) was quoted supporting antidepressants. We weren't told he has acted as a consultant to AstraZeneca, Bristol-Myers Squibb, Cephalon, Cyberonics, Eli Lilly, GlaxoSmithKline, Janssen-Cilag, MedAvante, Neuronetics, Novartis, Organon, Sepracor, Shire US, Supernus, and Wyeth; is on the speakers bureaus of AstraZeneca, Bristol-Myers Squibb, Cyberonics, Eli Lilly, GlaxoSmithKline, Organon, Sanofi-Aventis, and Wyeth; and has equity in MedAvant. In the article “Antidepressants Not Overused” (September 2009), Dr. Ian C. Reid was extensively quoted, again supporting the prescribing of antidepressants. We weren't told he's received consultancy and speaker fees from Sanofi-Aventis, Wyeth UK, Eli Lilly, and AstraZeneca. In the article “Drugs can Help Mild Depression” (May 2009), Tony Kendrick was also extensively quoted supporting antidepressant use. Again we weren't told he receives fees and funding from Eli Lilly, Lundbeck, Servier, and Wyeth pharmaceuticals.

Upon discovering these and other undeclared interests, I argued that the BBC was in effect giving the green light to the pharmaceutical industry (albeit unknowingly) to promote and/or advertise antidepressants, via paid consultants on its website, by not informing readers as to their paid status. I requested that the BBC Trust take editorial action to ensure the public will be better protected in the future from such editorial mistakes occurring again.

It took ten months for the Trust to respond. I finally received a response on November 19, 2012, from Francesca O'Brien, head of editorial standards at the BBC Trust. Here is what it said:

Dear Dr. Davies,

Thank you for raising your concerns as to how the BBC signals that contributors have competing personal, professional, or financial interests when they appear in BBC content …

The Trustees found the issues you raised following your complaint in January 2012 thought-provoking and helpful.

The Committee considered your concerns in the light of your complaint about the transparency and accuracy of science coverage. The Committee appreciated that you wanted the Trust to consider the general question of whether the Editorial Guidelines should be revised.

The Committee agreed that there was nothing in principle to prevent the Guidelines being amended prior to their scheduled revision. However, the Committee was satisfied that the issues raised were covered by the current Editorial Guidelines in their totality. The Committee felt that if the Guidelines needed to be more explicit, then that was something to consider at the time of the next revision. I will ensure that this is an issue that is included upon the agenda at the next revision.

In the meantime, however, the Committee agreed that there would be a benefit to the Executive reminding BBC News of its obligations to make careful editorial judgments about signposting any potential conflicts of interest among its contributors.

The Committee therefore agreed to ask the BBC's Director of Editorial Policy & Standards, David Jordan, to remind BBC News of these obligations.

Yours sincerely,

Francesca O'Brien

Head of Editorial Standards, BBC Trust

The result could have been better (i.e., there is no admission that the current editorial guidelines fail to oblige editors to cite financial conflicts of interest). But on the other hand, it could also have been worse (there is at least an expressed commitment to tighten editorial judgments in the future). So all that remains is to continue to monitor closely BBC News articles to ensure these obligations are kept, as well as to continue lobbying for a change of guidelines at the next review.

As for the countless other news outlets regularly reporting on antidepressants, things look far less sanguine. Short of a national media commitment to making these ties entirely transparent, we must continue to be wary of what we read in the news.

5

When we pull together the facts of all the preceding chapters, an underside of psychiatry begins to emerge with which most people are unfamiliar. The underside is that whenever someone ostensibly benefits from a psychiatric prescription, the pharmaceutical industry and many within psychiatry benefit too. The question must be, therefore, who benefits more?

Once again, where you sit will determine your answer. After all, those who enjoy industry ties usually defend their importance robustly, stating they inform research and facilitate the creation of better drugs, which in turn can only better serve struggling patients. But that is not the story here. Our story reports a different version of events, one that gets far less publicity and one that you must decide for yourself how far you are willing to subscribe. That alternative vision in its most unvarnished form goes like this:

The categories of mental disorder (rather than painful experiences themselves) are psychiatric constructions and not scientifically discovered biological entities. As these categories have greatly proliferated in number in the DSM and ICD, psychiatry has reclassified more and more of our natural human behaviors and feelings as psychiatric disorders requiring treatment. By doing so, psychiatry has not only expanded its jurisdiction over more of us (one in four of us apparently now suffers from a mental disorder) but has also, by inflating the number of mental disorders, created a huge market for psychiatric treatments.

The preferred treatments are pharmaceutical treatments such as antidepressants and antipsychotics. But the emerging reality is that these treatments don't actually work in the way most people believe. In the case of antidepressants, mostly they have placebo effects, negative effects, and sometimes mind-numbing effects. But never can we assume they have curing effects, largely because for the vast majority of disorders listed in the
DSM
there is no discernable “disease” that these pills target and treat. So while suffering is a reality, and people deserve help, that is worlds away from justifying the assumption that most or all emotional suffering is caused by disease, brain disorder, or chemical imbalance.

These inconvenient facts are not generally known, partly because pharmaceutical corporations have promoted misinformation through concealing negative data, through powerful marketing campaigns costing billions of dollars a year, and through conducting research that regularly chops the figures in ways advantageous to company interests. One reason why psychiatry has tolerated this more than it should is because too many doctors, research centers and researchers, and too many
DSM
committee members—that is, too many leaders within the psychiatric profession—have had their objectivity compromised by the pharmaceutical funds upon which they have come to depend.

I offer the above as a hypothesis that I believe the facts presented in the preceding chapters oblige us to take very seriously. But whatever the extent to which you subscribe to this hypothesis, there is one proposition that most of us, wherever we stand, would find very hard to discount: that “biological” or “pharmaceutically sponsored” psychiatry has slowly, imperceptibly, but most assuredly begun to alter the way in which many of us now manage, respond to, and experience our emotional discontent.

Precisely what form this alteration has taken and what its implications may be is a matter that I will now pursue in the next chapter.

THE PSYCHIATRIC MYTH

I
n the late 1890s, it was time for a brilliant young medical student called Carl Gustav Jung to decide his professional future.
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What branch of medicine would Jung specialize in? The decision was difficult, as every door was open to him. If he chose one of the more established branches of medicine, his future would enjoy all the trappings of financial security and professional prestige. But then Jung was never a conventional man; and what is more, through marrying into a wealthy family he could afford to make unconventional professional decisions. So Jung followed his inclination and decided to do something that his peers, his seniors, and his family believed to be very foolish. He chose to specialize in psychiatry.

Why on earth, they asked, would he do that? After all, psychiatry at that time had still not been established as a legitimate medical specialism. It suffered from very low status among the medical professions for a variety of reasons. In the first place, psychiatric treatment just wasn't very successful. While researchers and doctors practicing general medicine were gaining headway in understanding and treating the disorders of the body, psychiatry continued to slumber far behind in terms of its clinical success rate.
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Furthermore, the main subject matter of psychiatry (our internal mental lives) was far less accessible to medical study and treatment than were the disorders of the physical body. The mind was decidedly more complicated, not least of all because its problems could be caused by multiple factors—spiritual, moral, environmental, social—things not easily explained in terms of biological problems. Psychiatrists were dealing with something different, and were struggling to know what to do.

This was the state of affairs in the late 1800s when Jung shocked those close to him by choosing psychiatry. At that time, little did he know that the fortunes of psychiatry would soon change dramatically.

A key player in this change was a doctor called Emil Kraepelin. In the early 1900s, Kraepelin gained international repute by arguing that our emotional problems were not really problems of the soul or the mind or anything else that was difficult to pin down scientifically. Rather, underlying every mental disorder, he claimed, there was surely a specific brain or biological pathology. If psychiatrists were to treat mental problems successfully, therefore, they should direct their efforts at finding these underlying biological malfunctions.

With the help of this new biological vision, Kraepelin believed that psychiatrists would not only be finally free to explore new procedures that treated mental distress via the body, but could also better align their work with the general medical preference for biological explanations and treatments. Psychiatry, went the argument, was like the rest of medicine—it had just been looking in the wrong place. Jung might not have made a poor decision after all.

Kraepelin's biological convictions gave momentum to the development of a barrage of new psychiatric treatments during the first half of the twentieth century. In the 1920s, these included interventions not for the squeamish: surgically removing parts of the patient's body—their teeth, tonsils, colons, spleens, and uteri. The rationale for these highly painful and sometimes fatal treatments was that bacteria living in one of these bodily areas caused mental illness. So, it was thought, if you remove the body part, you cure the problem.

As Joanna Moncrieff's work makes clear, this was the rationale behind other similar treatments being reported at this time in reputable psychiatric journals as reasonable cures for mental illness.
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These included injecting patients with horse serum, using carbon dioxide to induce convulsions and comas, injecting patients with cyanide, and giving them hypothermia. Again, the aim of using these procedures was to target the underlying virus or disease that psychiatrists were convinced must be at the root of the trouble.

Another treatment was malaria therapy, injecting the patient with the malaria parasite in the hope that the high temperatures malaria produced would kill the virus then thought responsible for mental disease. You wouldn't be surprised to hear that the effects of this “therapy” were often devastating, because many patients failed to recover from the malaria disease.
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Because success rates of these early treatments were so poor, a suite of new procedures was developed during the 1930s. These included treatments like “insulin coma therapy.” This involved putting patients into a coma for two hours with high doses of insulin, then suddenly waking them with glucose. The aim here was to generate in patients powerful seizures, which were thought to be somehow therapeutic. After this procedure, granted, patients would appear to feel calmer, but they would often show memory loss and other neurological abnormalities such as loss of speech. Five percent of all patients actually died from this treatment, so once again psychiatrists found themselves grappling for alternative treatments.
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Hope was kindled in the 1940s with the development of what was called at the time a ground-breaking new psycho-technology—otherwise known as the lobotomy. This involved surgically removing parts of the brain that were thought responsible for acute mental distress. This new treatment was so widely celebrated in psychiatry at the time that its inventor, António Egas Moniz, was actually awarded the Nobel Prize in 1949 for its invention.
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About one million people in the United States were lobotomized by the 1970s, before the treatment was finally abandoned because of its appalling effects (which are still being experienced by thousands of people still alive today). Fortunately, however, as lobotomies decreased in popularity, other treatments were ushered in.

One that grew in popularity during the 1940s (and which is still in use) is electroconvulsive therapy (ECT), which was brought to popular attention by the cult classic
One Flew over the Cuckoo's Nest
. This procedure involves inducing severe seizures in depressed patients by administering intense electric shocks to the brain.

Although many psychiatrists still swear by the healing effects of this controversial intervention, their claims about success are more than offset by the reams of research illustrating ECT's pernicious side effects, poor remission rates, and responsibility for widespread neurological damage.
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Furthermore, recent reviews of electroshock research have not shown significant differences between real and “sham” electroshock after the treatment period (i.e., sham ECT administers no electricity at all, without the patient's knowledge). On the contrary, research assessing the improvement rates of fake versus real ECT after six months have actually revealed a two-point difference on the Hamilton Scale
in favor
of the fake treatment—suggesting that if ECT has any positive effects at all, these are largely placebo effects.
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The point of listing some of psychiatry's more outlandish treatments is that they all won impetus and legitimacy from psychiatry's enduring conviction that there must be a physical basis for mental disorder. As you will recall, this originated with Kraeplin's assumption: if our emotional maladies are biologically caused, then the body is where our efforts must be directed.

Of course, for psychiatrists such as Carl Jung who felt these practices verged on barbarism, there were alternatives. Jung was part of a growing tribe of psychiatrists in Europe, the UK, and the United States who rejected Kraepelin's biological vision and embraced the more interpersonal and less invasive talking cures. During the 1940s, '50s, and '60s, this group became very powerful indeed, especially in American psychiatry. In fact, the taskforces of the first and second editions of the
DSM
(in the 1950s–1960s) was largely comprised of these psychoanalytically informed psychiatrists.

But the talking cure and biological psychiatry were always strange bedfellows, and always antagonistic. After all, psychotherapists did not share the same biological convictions that Kraepelin used to save psychiatry from complete obscurity in the early 1900s—biological convictions that helped align psychiatry, intellectually at least, with neighboring streams of medicine.

Therefore, when criticisms of psychotherapy gained momentum in the 1970s the ground was set to reject the talking cure and once again embrace Kraepelin's early vision. This was reflected by the fact that Spitzer's
DSM-III
taskforce only included one psychoanalyst, who was included, as Spitzer put it to me, “as a token gesture.” This neo-Kraepelinian revolution, as it was called, was given a significant boost by allegedly exciting new developments in drug treatments.

As I discussed in chapter 5, in the 1950s drugs were seen at best as soothing tonics, but as drug company sponsorship of psychiatry gained pace in the 1970s, 1980s, and 1990s, they were soon marketed as medical cures that targeted and cured discrete diseases. Many senior psychiatrists, who were often funded by the drug companies, legitimated this view in medical journals and the popular media while at the same time receiving financial rewards.

The drug revolution solved many problems for psychiatrists. The profession could now put a legacy of embarrassing clinical failures and devastating treatments to rest and embrace drugs as the first line of treatment. Psychiatry now possessed the psycho-technologies that not only brought it in line with the rest of medicine, thus increasing psychiatry's status in the eyes of other medical doctors, but which also rendered psychiatrists distinct from the barrage of psychologists, counselors, pastoral counselors, family and marriage therapists, and other kinds of psychotherapists who were beginning to flood the treatment market in the 1980s and 1990s. Psychiatrists and doctors were largely the only professionals, after all, who had legal authority to assign psychiatric diagnoses and prescribe psychiatric drugs. So long as these activities remained exclusively in their hands, their distinctiveness and authority were assured.

Furthermore, psychiatrists now had a new and immensely powerful ally—the pharmaceutical industry—whose financial sponsorship would see the profession move from a medical backwater during the middle of the twentieth century to one of the most powerful medical specialties by its close. In short, the drug revolution advantaged psychiatry in many ways: ideologically, professionally, and financially. It is no wonder that many psychiatrists now regard the pharmacological revolution as a high point in psychiatric history.

Yet there were problems with this revolution. I refer not to those already covered (drugs not working as well as claimed; reductive biological theories remaining unsubstantiated; normality being medicalized through successive
DSM
and
ICD
manuals; and pharmaceutical industry sponsorship corrupting medical objectivity). I am talking about something far less easy to identify and for that reason far more difficult to challenge. I am talking about how this new biological vision began to seep into popular consciousness and began to alter our very understanding of emotional suffering.

In order to explain precisely what I mean by this, I'll have to be a little philosophical for a while. But you can be sure this momentary change in tone has nothing to do with authorial indulgence, but is a necessary preface to all that follows in the remainder of this book.

2

As the idea began to take root that increasing forms of emotional suffering are essentially
biological
problems best treated with pills, psychiatry committed itself to stripping much emotional suffering of its spiritual, psychological, and moral meaning. After all, if much mental suffering is a result of biological misfortune, then it must be a purposeless experience best swiftly removed.

As this new “negative vision” of mental suffering began to gain currency, many previous and more positive cultural associations attached to suffering (e.g., that it can be purposeful and necessary if handled productively or simply that it is often an unavoidable part of life) began to lose their hold. As I wrote about and defined the differences between negative and positive visions of suffering elsewhere, let me quote what I wrote:

The positive vision holds that suffering has a redemptive role to play in human life; as if from affliction there can be derived some unexpected gain, new perspective, or beneficial alteration. If this vision could have a motto, then Thomas Hardy captured it well: “If a way to the better there be, it first exacts a full look at the worst.” The positive vision of suffering, thus considered, sees pain as a kind of liminal region through which we can pass from a worse to a better place. A region from which can thus be derived something of lasting value for individual life. But the negative vision of suffering, on the other hand, asserts quite the opposite view—namely, that little of value can come of suffering at all. It says there is no new vista or perspective to be gleaned at its end, nor any immured insights to be unlocked from its depths. It is thus something to be either swiftly anesthetized or wholly eliminated, for what good is an experience whose most obvious features are pain and inconvenience.
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While this negative view of mental suffering is still controversial today, it has nevertheless served many psychiatrists well because it fits so neatly with their biological myth of mental distress: Since mental suffering is largely caused by biological problems, it is by implication largely purposeless. It is therefore right and proper to mitigate it in any way possible. And insofar as pills can achieve this, to deny their usage would be a basic dereliction of duty.

This simple equation gave many psychiatrists a growing sense of confidence in their own moral and clinical authority, as well as a rationale for claiming to be better equipped than other professionals to help improve our mental health.
But this equation also has its faults. As we have seen, the view that suffering is caused by our biology still does not enjoy scientific backing. And this has led many critics to argue that the biological view is less a scientific reality than a convenient professional myth.