Cracked (30 page)

Outcomes for serious mental illness are disheartening, despite increasing use of antipsychotics. Many psychiatrists often blame these poor results on the nature of the disorder itself. As one senior psychiatrist put it to me, “Schizophrenia and bipolar disorder are chronic, life-long conditions, so relapses are to be expected.” This psychiatrist did not ask whether such chronicity could be partly or entirely drug-related, an interpretation supported by studies showing that schizophrenia often has much better outcomes in places where antipsychotics are less aggressively and frequently prescribed.

As I have hardly been able to do full justice to the controversial and counter-intuitive points discussed above, fortunately there are many sources that can help you explore these important matters further. Here are some particularly well-researched and trustworthy books:

Breggin, P. R., and Cohen, D. (1999)
Your Drug May Be Your Problem: How and Why to Stop Taking Psychiatric Drugs
. Massachusetts: Perseus Books.

Healy, D. (2008)
Psychiatric Drugs Explained
. London: Churchill Livingston.

Moncrieff, J. (2009)
The Myth of the Chemical Cure: a critique of psychiatric drug treatment
. London: Palgrave Macmillan.

Whitaker, R. (2010)
The Anatomy of an Epidemic
. New York: Broadway.

W
hile most psychiatric drugs have harmful side effects, they also can have powerful withdrawal effects. Therefore, any precipitous or sudden withdrawal is always dangerous. It is therefore crucial that anyone deciding to withdraw from any kind of psychiatric medication do so under the supervision of an experienced physician who is, of course, well-informed and thus able to respect fully any patient's desire to explore non-medication alternatives.

I
have so many people to thank. First off, let me offer my sincere gratitude to many people who set aside time out of their busy schedules to grant me interviews. Without their generosity, this book simply would not have been written. I also must thank those who closely read this book from beginning to end, holding me to task on every sentence. Particular thanks to Paula Caplan, Razwana Jabbin, and of course Alexandra Davies, my wife (I'll come back to her in a moment).

I also benefitted from informative conversations with so many trusted colleagues, including Rosie Rizq, Lyndsey Moon, Istvan Praet, Richard House, Del Loewenthal, Ann MacLarnon, Garry Marvin, Stuart Semple, Todd Rae, and many others in the areas of anthropology and psychology at the University of Roehampton. Others who left their mark, as always, Matias Spektor (the most positive force in so many ways), Benjamin Hebbert (sorry we didn't go for yellow), Richard Schoch (a mentor in the true sense of the term), Mark Knight (it goes without saying). Nancy Browner, James Wilkinson—I still think of you and the work we did (which has colored every page—thank you). I must also especially thank Andrew Lownie for your enthusiasm and belief—his support and advice means a great deal. Also, my sincere gratitude for the excellent team at Pegasus Books.

Finally, my gratitude to my students and clients, who have taught me so much; and to my loving and supporting family (Mike, Lyn, Alicia, Natalie, Helen, Andy, John, Alistair, and Jean). Lastly, my apologies to my wife, Alexandra, for writing yet another book! Without her love, support, and brilliant editorial skills, I would have not gotten through. This book is dedicated to my daughter, Rose, the most joyous solace in difficult times.

1
Here I paraphrase from Adam Curtis's brilliant BBC documentary,
The Trap
(2007).

2
Carlat, D.
Unhinged: the trouble with psychiatry
. London: Free Press, 2010 (p. 52).

3
See: Cooper, J. E. et al.
Psychiatric Diagnosis in New York and London.
Maudsley Monograph, no 20. Oxford: Oxford University Press, 1972.

Also see:
International Pilot Study of Schizophrenia.
Geneva: World Health Organization, 1973.

4
Such was the problem at that time that each psychiatrist had his own personal system of classification. see: Kendell, R. E.
The Role of Diagnosis in Psychiatry
. Oxford: Blackwell, 1975.

5
I was often told that poor diagnostic reliability was not the only driver for the
DSM
's reform. There was also a need to match
DSM
terminology to that used in the
ICD
. However, Robert Spitzer, Melvin Sabshin, and other leaders in the APA knew that the reliability issue was paramount and that the
DSM
must make that issue its priority.

6
Caplan, Paula J. (1995)
They Say You're Crazy.
New York: Da Capo (p. 53).

7
Quoted in Carlat, D. (2010)
Unhinged: the trouble with psychiatry
.

8
Quoted in
Kirk
, S. A., and Kutchins, H. “The Myth of the Reliability of DSM,”
Journal of Mind and Behavior,
(1994) 15(1&2): 71–86.

9
Spiegel, A. “The Dictionary of Disorder: how one man revolutionized psychiatry,”
The New Yorker,
January 3, 2005.

10
Aboraya, A. “Clinicians' Opinions on the Reliability of Psychiatric Diagnoses in Clinical Settings,”
Psychiatry
, (2007) 4 (11): 31–33
.

11
The psychologist Paula J. Caplan argues that one study showed when different psychiatrists were diagnosing patients from the Axis II group of disorders (basically the personality and developmental disorders), their diagnoses were the same only about two-thirds of the time (66 percent), whereas for the remaining disorders they were only the same about half the time (54 percent). see: Caplan,
They Say You're Crazy,
(pp. 197–20).

12
Aboraya, A. et al. “The Reliability of Psychiatric Diagnosis Revisited.”
Psychiatry,
(2006) 3(1): 41–50.

Also, for a summary of diagnostic reliability research undertaken in the 1980s and 1990s, please see: Caplan,
They Say You're Crazy,
pp. 197–20.

13
Aboraya, A. et al. “The Reliability of Psychiatric Diagnosis Revisited,” 41–50.

14
See: Andrews, G., Slade, T., & Peters, L. “Classification in Psychiatry: ICD-10 versus
DSM-IV.” British Journal of Psychiatry
, (1999) 175: 3–5.

15
NICE prefers
DSM-IV
because the evidence base for treatments refers, to a larger extent, to
DSM
criteria. See: http://www.cks.nhs.uk/depression/management/scenario_detection_assessment_diagnosis/assessment_and_diagnosis/basis_for_recommendation.

16
Andrews, G., Slade, T., & Peters, L. “Classification in Psychiatry,” 3–5.

17
Caplan,
They Say You're Crazy,
pp. 205–6.

18
Kutchins, H., & Kirk, S. A.
Making Us Crazy
. New York: Free Press, 1997.

19
Ibid.

20
Quoted in: Angell, M. “Drug Companies & Doctors: A Story of Corruption,”
The New York Review of Books,
January 15, 2009.

21
Spiegel, “The Dictionary of Disorder: how one man revolutionized psychiatry.”

22
Lane, C.
Shyness: how normal behaviour became a sickness
. New Haven: Yale University Press, 2009, 44.

23
Spiegel, “The Dictionary of Disorder: how one man revolutionized psychiatry.”

24
Andreasen, N. C. “DSM and the Death of Phenomenology in America: an example of unintended consequences.”
Schizophrenia Bulletin
, 33(1) (2007): 108–112.

25
Macaskill, N
.,
Geddes, J
., &
Macaskill, A
. “DSM-III in the Training of British Psychiatrists: a national survey.”
International Journal of Social Psychiatry,
37(3) (1991):182–6.

26
Polanczyk, G. et al. “The worldwide prevalence of ADHD: a systematic review and metaregression analysis.”
The American Journal of Psychiatry,
164 (6) (2007): 942–8.

27
Waddell, C. “
Child Psychiatric Epidemiology and Canadian Public Policy-Making: the state of the science and the art of the possible
.”
Canadian Journal of Psychiatry,
47 (9) (2002): 825–832. Also see: Merikangas, K. R. et al. “Prevalence and Treatment of Mental Disorders among US Children in the 2001–2004 NHANES.”
Pediatrics
, 125 (1) (2010): 75–81.

28
Kessler, R. C. “Prevalence, severity, and comorbidity of twelve-month DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R).”
Archives of General Psychiatry
, 62(6) (2005): 617–27.

29
Singleton, N., Bumpstead, R., O'Brien, M., Lee, A., and Meltzer, H. “Psychiatric Morbidity among adults living in private households,”
The Office for National Statistics Psychiatric Morbidity report
, London: TSO, 2001.

30
See chapter 12 on recent well-being rates in Britain.

31
For interview, see Adam Curtis's BBC documentary
The
Century of the Self
(2002).

32
This discussion is paraphrased from my book:
The Importance of Suffering
(Davies, 2012).

33
DSM-IV
was published in 1994, while a slightly revised edition called
DSM
IV–TR
, under the chairmanship of Frances, was issued in 2000.

34
Much higher standards were applied when it came to adding new diagnoses. Eight were added out of the more than one hundred proposed. Four others were reformulated. An additional thirty were included in an appendix for further study.

35
See the
Lancet
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)60248-7/fulltext.

36
It was pointed out to me that, although it was right for Frances to indicate the danger of these new inclusions, he failed, however, to discuss how disorders in his
DSM-IV
, like Generalised Anxiety Disorder, similarly led to the pathologization of many ordinary responses—in this case, stress reactions.

37
See: http://www.ipetitions.com/petition/dsm5/

38
While I have been long aware of Kirsch's research, I am grateful for an excellent piece on Kirsch by CBS News, entitled
Treating Depression: is there a placebo effect
—Their interviews with Walter Brown and Tim Kendall prompted me to interview them for this book.

39
I have gathered this biographical information from Wikipedia, which I have double-checked for its accuracy.

40
For original graph, see: Kirsch, 2009: 10.

41
Kirsch, I.
The Emperor's New Drugs: exploding the antidepressant myth
. London: Bodley Head, 2009, 54.

42
Ibid., 62.

43
Kirsch, I. “Challenging Received Wisdom: Antidepressants and the Placebo Effect.”
Mcgill Journal of Medicine,
11(2) (2008): 219–222.

44
Khan, A., Redding, N., and Brown, W. A. “The persistence of the placebo response in antidepressant clinical trials.”
Journal of Psychiatric Research,
42 (10) (2008): 791–796.

45
But this is not all. For a trial to be considered “positive,” the difference between placebo and antidepressant does not have to be clinically significant (e.g., it can be just 1 or 2 points on the Hamilton Scale), which essentially means it can be small enough to make no real difference in people's lives.

46
Mojtabai, R., and Olfson, M. “Proportion of Antidepressants Prescribed Without A Psychiatric Diagnosis Is Growing.”
Health Affairs,
30:8,(2011): 1434–1442.

47
Blanchflower, D. G., and Oswald, A. J. Antidepressants and Age. IZA Discussion Paper No. 5785. Available at SSRN:
http://ssrn.com/abstract=1872733
[accessed Sept. 2011].

48
Middleton, H., and Moncrieff, J. “They won't do any harm and might do some good: time to think again on the use of antidepressants?”
British Journal of General Practice
, (1) (2011): 47–9.

49
PMDD was originally called “late luteal phase dysphoric disorder” (LLPDD). It was renamed PMDD by the American Psychiatric Association in its May 1993 revision of the
DSM-IV
.

50
Eli Lilly television broadcast advertisement (aired 2000). As part of its routine monitoring and surveillance program, the Division of Drug Marketing, Advertising, and Communications at the FDA reviewed this advertisement and concluded that it is misleading, lacking in fair balance, and therefore in violation of the Federal Food, Drug, and Cosmetic Act and its applicable regulations. Unfortunately, this advert was widely aired before the DDMAC requested its removal.

51
Nathan Greenslit makes this point. see: Greenslit, N. “Depression and Consumption.”
Culture, Medicine and Psychiatry,
29 (2005): 477–501.

52
About this case, a colleague usefully pointed out: Since there is no scientific evidence that there actually is a premenstrual mental illness, if taking this drug helped her, then neither she nor her therapist would know why or be able to discuss why. Furthermore, by treating her based on the PMDD diagnosis when there is no evidence that PMDD even exists, the doctor was subjecting her to experimental treatment without her knowledge or consent.

53
Patent protections for most pharmaceutical products are not lifelong, but only last for around seven years.

54
Quoted in Greenslit, “Depression and Consumption,” 477–501.

55
Ibid.

56
Ibid.

57
Meyer, B. et al. “Treatment Expectancies, Patient Alliance, and Outcome: Further Analyses from the National Institute of Mental Health Treatment of Depression Collaborative Research Program.”
Journal of Consulting and Clinical Psychology,
70(4) (2002): 1051–1055.

58
The meaning the healing environment has for the patient has been shown to increase the placebo effect to varying degrees. see: Moerman, D. E.
Meaning, Medicine and the ‘Placebo Effect.'
Cambridge: Cambridge University Press, 2002.

The presence of a doctor also increases expectancy, which in turn increases therapeutic outcome, especially if the doctor is warm and/or enthusiastic about the treatment. In one study, the response to a placebo increased from 44 percent to 62 percent when the doctor treated them with “warmth, attention, and confidence.” see: Kaptchuk, T.J. et al. “
Components of Placebo Effect: randomized controlled trial in patients with irritable bowel syndrome.
”
British Medical J
ournal,
336 [7651] (2008): 999–1003.

My statement “up to 40 percent” is based on the likely outcome of adding doctor/patient expectancy to environmental expectancy. Admittedly, not all patients will experience 40 percent placebo improvement, but most will react positively to environments triggering expectations for recovery. For an extended analysis of expectancy, see: Kirsch, I. “Response Expectancy as a Determinant of Experience and Behavior.”
American Psychologist,
40(11) (1985): 1189–1202.

59
Experiment cited in: Moerman, D. E., and Jonas, W. B. “Deconstructing the Placebo Effect and Finding the Meaning Response.”
Annals of Internal Medicine,
136 (2002): 471–47.

60
Branthwaite, A., and Cooper, P. “Analgesic effects of branding in treatment of headaches.”
British Medical Journal
, 282 (1981): 1576–8.

61
Moerman, D. E., and Harrington, A. “Making space for the placebo effect in pain medicine.”
Seminars in Pain Medicine
, 3 (2005): 2–6.

62
Anton de Craen, J. M. et al. “Effect of Color of Drugs: systematic review of perceived effect of drugs and of their effectiveness.”
British Medical Journal
, 313 (1996): 21–28.

63
See: Adam Curtis's BBC documentary
The
Century of the Self
(2002).

64
Moncrieff, J.
The Myth of the Chemical Cure: a critique of psychiatric drug treatment
. London: Palgrave Macmillan, 2009, 14.

65
Recent research has shown that the most commonly reported drug-induced psychoactive effects of the antidepressants fluoxetine and venlafaxine were sedation, impaired cognition, reduced libido, emotional blunting, activation (feelings of arousal, insomnia and agitation) and emotional instability. see: Goldsmith, J., and Moncrieff, J. “The Psychoactive Effects of Antidepressants and their Association with Suicidality.”
Current Drug Safety
, 6 (2) (2011): 115–21.

Also see: Healy, D.
Let Them Eat Prozac.
New York: New York University Press, 2006, chapter 7.

66
Sobo's article makes this point—that drugs don't heal us but alter us. see: http://simonsobo.com/a-reevaluation-of-the-relationship-between-psychiatric-diagnosis-and-chemical-imbalances

67
Price, J., Cole, V., & Goodwin, G. M. “The Emotional Side-Effects of Selective Serotonin Reuptake Inhibitors: qualitative study.”
The British Journal of Psychiatry
, 195 (2009): 211–217.