Type
Essay
Category
Care
Drugs
Mental health

Ignorance is bliss?

By now there is enough criticism of the mental health business out there that it seems to me most engaged readers have been informed about the problems: psychiatry makes a false equivalence of the brain and the person, psychiatry pathologises some of the normal problems of human life, psychiatrists enforce highly constrained norms of thought and behaviour, and psychiatrists don’t value patients’ autonomy. There is still however a lot of confusion about the status of the things that psychiatrists treat. These are by no means illnesses, and the medications doctors use to treat them are by no reasonable measure effective. I am going to have to risk setting up a straw man here, but the majority of people don’t believe the claims I’ve just made, even though they have been exposed to the same claims many times. Marcia Angell when she retired as head of the New England Journal of Medicine wrote a pair of scathing reports in the New York Review of Books to the effect that psychiatry is a pseudoscience; and these same claims are repeated in bestselling books like The Emperor’s New Drugs, and magazine articles too numerous to mention. If one moves carefully through the scientific evidence one finds too that a ‘chemical imbalance’ has never been substantiated for any of the things that have been called a ‘mental illness’, and that the prescription of medications for psychiatric problems is always tendentious. The abundance of scientific support for these claims is only equalled by the total absence of their accommodation in the practice of psychiatry and the lay discourse about mental health. Although science does not really support the use of many psychopharmaceuticals in the ways they are represented to be supported, and although there is no acceptable measure by which most of the things treated by psychiatrists qualify as illnesses, the cultural position of the medical profession and their medicines is such that even a scientific refutation of a medical claim appears unscientific. This position of the doctor as super-scientific is perpetuated and co-opted by pharma for profit, and by the state for the purposes of social control. Capital aggrandises the psychiatrist, whose job is to condition the citizens to their labour, or to excise a tax in the form of pharmaceuticals payments. Either way capital wins and we all play along because we have been so immiserated by budget austerity, social precarity and casualised over-employment that the only comfort we can afford is to indulge in a fantasy.

Around one in six Americans, and one in eight Australians is currently prescribed an ‘anti-depressant’; and what the profession calls ‘Major Depressive Disorder’ is one of the most common diagnoses today. This diagnosis in particular has grown to assimilate a large number of human experiences, and the drugs supposed to treat it have also proliferated, because patients are strung-out and desperate, and because there has been a determined marketing campaign – to the effect that all despair is an illness – by the pharmaceutical industry which has insinuated itself into the state and into academia so thoroughly that to find a research project or piece of regulation untouched by their money is almost impossible. To illustrate the point:

University departments are funded by pharma money.1

Researchers are funded by pharma money. Local research stars like Patrick McGorry and Ian Hickey between them have taken money from every major pharma company.

Politicians are funded by pharma money. In 2020 Pfizer donated about 60:40 Democrat/Republican, which is standard for most of the pharma industry.2

The publishers of medical guidelines are funded by pharma money. The UK National Institutes of Clinical Excellence which publishes the NICE guidelines, had panels with 8 of 12 members paid by pharma.3

The writers of psychopharmacology textbooks are funded by pharma money. Stephen Stahl, whose book is the main anglophone psychopharmacology textbook, takes up to USD 3.6 million per year from pharma.4 Copies of his book are given to students for free by drug reps.

Government regulatory panels are stocked with experts funded by pharma money. For instance Professor David Nutt former president of the European College of Neuropsychopharmacology who was on the British Committee on Safety of Medicines inquiry into ‘anti-depressant’ safety despite the fact he and three others on that committee also worked for GlaxoSmithKline who make one of the most commonly prescribed ‘anti-depressants’.5

So-called mental health advocacy organisations act as de facto pharma advertisers who ‘hide behind smokescreen public relations slogans of medical awareness campaigns, while slyly growing drug markets by over-medicalizing everyday experiences such as sadness, anxiety, and shyness’.6 It’s enough to mention Jeff Kennett who when in power defunded psychiatric services, degraded public housing, closed schools, derided the homeless, and once out of office founded Beyond Blue the mental health advocacy organisation that wants to remind you that ‘good mental health is good for business’.

Finally and crucially there is the community of patients-turned-consumers who have been exposed to so much explicit and implicit advertising by pharma that they tend to hold their products in high regard7 even if they are suspicious of pharma corporations themselves.

Central to pharma advertising is the idea that the causes of so-called mental illnesses are locatable in the body; yet no identifiable pattern in the brain or blood of sufferers has ever been identified. There are nevertheless some weakly useful medicines for a number of the problems we describe as mental. . It is clear that lithium does something for mania, it is clear that chemicals that lower the amount of dopamine activity in certain areas of the brain do something for the problems that bring the schizophrenic into contact with the psychiatrist. However what exactly is ‘happening’ when these drugs ‘do something’ is complex, tendentious, dependent on ‘the interpretive flexibility of personal experience’ ,7 not analogous to what happens when an antibiotic cures pneumonia by eradicating the germ that’s causing it, and not justified by the notion that they are reversing some deficiency in the body ‘like a vitamin’. The term ‘anti-depressant’ is only a marketing term; there is nothing else that could possibly tie together the disparate range of chemicals that have come to be known by this term except that they are all marketed together as supposed cures for the same supposed problem. These drugs have never been shown to be treating any particular thing in the brain that can be consistently linked to the disorder we say a patient has, and often enough the side-effects of the drugs are worse than the disease itself.

Staying within the logic of psychopharmacology, if better medications were to be developed we would first need better taxonomies to link specific kinds of thinking and feeling to specific states of the body. Since the late 19th century various systems of classification of ‘mental illnesses’ have been developed, with varying degrees of success. The most successful of these has been the Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric Society (APA). The APA has published a new version of the DSM roughly every twenty years since 1952. These taxonomies name the apparently associated differentiating features of mental disorders, so that patients presenting with these features can be diagnosed as having one problem or another, and so researchers can test specific treatments against specific diagnoses. To judge the success of a diagnostic system we need to look at two overlapping concepts, validity and reliability.

The simplest formulation for validity is that ‘an attribute out there, somewhere in the long and complicated chain of events leading up to the measurement outcome, is playing a causal role in determining what values the measurements will take’.8 In common usage it may mean that a particular diagnosis is ‘supported by the evidence’ and we can be justified in the opinion that a distinct, discrete, thing exists, is well described by the diagnosis, and behaves in a reliable manner.

The reliability of a diagnosis refers to the quantity of agreement between different psychiatrists as to whether or not a particular ‘mental illness’ can be diagnosed in a particular patient. Reliability has to do with statements like ‘8 out of 10 psychiatrists believe the patient has depression’. If a diagnosis is valid, it is likely to be reliable, but there can also be invalid diagnoses that psychiatrists will reliably agree upon.

Improvements to the validity of psychiatric diagnoses have been especially important to the discipline since the 1970s in order to justify the place of psychiatry in the scientific medical community, and in order to facilitate the prescription of the very small number of drug classes that were available, for a relatively large number of problems of living, behaving, thinking and feeling. This latter because social workers and psychologists had started pinching their turf, and only the ability to dispense drugs justified psychiatrists’ higher pay and greater standing. There were also a number of famous whoopsies like the Rosenhan experiment9 and the US-UK study that had very publicly demonstrated the groundlessness of psychiatric diagnosis and degraded trust in psychiatrists.10

Because by the 1970s validity in psychiatric diagnoses was already considered an unachievable dream, Robert Spitzer who led the production of the DSM-III10–12 said his aim was to improve the validity of mental health diagnosis by improving reliability.10, 13 To that end he gathered consensus from eminent clinicians and researchers in order to compose seemingly precise checklists of symptoms to define diagnoses. Notably in the checklist for ‘major depressive disorder’ there is no item that would require a psychiatrist to ask a patient ‘Why are you depressed?’

In 1974, before starting work on the DSM-III, Spitzer did a survey (what would now be called a ‘meta-analysis’) of all the reliability research for common psychiatric diagnoses 10 and made estimates of how reliable each of the diagnoses were. He found that psychiatrists agreed around 4 to 15 per cent of the time about the presence of depression in a patient; that’s less than two out of ten psychiatrists agreeing.

Field-testing of the DSM-III-R in 1992, yielded some improvements; ‘Major Depressive Disorder’ had improved considerably to 35 to 63 per cent agreement which is still not particularly good, and schizophrenia improved marginally.14 There were big problems with these studies which suggest these numbers are wildly overblown, but bogus as they might have been, they at least seemed to prove Spitzer’s idea that the symptom checklist approach to diagnosis of the DSM-III was working.

So, a taskforce with sub-committees for each diagnosis was appointed to keep ‘refining’ the checklists in the years between each new edition. In 1994 the DSM-IV was published and the field trials showed that their twenty years of refining hadn’t changed the reliability of any of the major diagnoses at all.15

Testing of the provisional DSM-V happened between 2010 and 2012 and consisted of 279 clinicians at 11 academic centres in the US and Canada. 16–18 They made use of more accurate testing methods than had been used to test the DSM-III and IV and in the end they showed huge decreases in reliability in all major domains, with some diagnoses, like mixed anxiety-depressive disorder showing 0-4% agreement.19 Schizophrenia also dropped considerably and ‘major depressive disorder’ dropped back to 4 to 15 per cent agreement. This means that the reliability of a diagnosis of schizophrenia is at or below the pre-DSM-III level, and the DSM ‘Major Depression’ category is also at or below the values for the various pre-DSM depression diagnoses that proliferated before we started using checklists. It doesn’t look like the DSM taskforce managed to ‘refine’ very much in the period between 1974 and 2013.

To focus on ‘Major Depressive Disorder’, this means the DSM-V field trials showed that psychiatrists agree on the diagnosis of ‘Major Depressive Disorder’ 4 to 15 per cent of the time and the APA decided it was worth printing yet another book that implicitly reifies the ‘Major Depressive Disorder’ construct as an illness and justifies it’s treatment with medications. Because the DSM has been used in research since its third edition, in a clinical trial of ‘anti-depressants’, the researchers can only be less than 15 per cent sure that the people they have included in the trial even have ‘Major Depressive Disorder’. If you consider this abysmal reliability alongside the fact that no feature of the body has ever been shown to be awry in depression, that is no ‘chemical imbalance’ has ever been demonstrated even though people have been looking extremely hard for nearly a hundred years, how can a scientist set about determining whether the drug they are testing ‘cures depression’ when they have nearly no idea whether the people they are testing it on have ‘Major Depressive Disorder’ or whether that construct has any meaningful use in the first place?

The DSM-V field trials were supposed to proceed in two stages. The first stage was intended to address reliability and the second stage to evaluate quality control. The first stage revealed these significant problems with reliability and the authors called for ‘Greater attempts to improve both the reliability and validity of these diagnoses’.19 Nobody at the APA made a move to ‘improve reliability and validity of these diagnoses’ instead they just cancelled the stage two trials and tried to ignore the stage one results. If reliability was the really the aim, the field-test results would have been taken as evidence of failure.

So why was the DSM-V published at all? It is because the DSM-V taskforce was fertile ground for a powerful group of vested interests and bureaucratic forces to push their unscientific agendas.24–27 More than 70 per cent of the DSM-V Taskforce members declared a relationship with the pharmaceutical industry. According to their own guidelines the DSM-V task force members were allowed to earn up to $10,000 per annum in honoraria from the pharmaceutical industry and to keep up to $50,000 worth of shares in pharmaceutical companies. It’s clear however that committee members receive perks worth many thousands of dollars that they do not declare, and they also funnel pharma funds towards the institutions and laboratories they head rather than receiving them personally so as to avoid having to declare. Drug companies groom and fund lab heads who in turn support pharma on the task forces. In all instances it is in pharma’s interests to degrade reliability, because that means more patients are diagnosed and treated. It’s also worth mentioning that the DSM manuals are bestsellers; the DSM-IV made the APA USD 5 million per year during its run, and the DSM-5 made more than USD 20 million in its first printing. The DSM story is exemplary of the way a confluence of academic and financial interests can come together to make good money.

For the past 30 years while pharma have been stitching-up diagnosis in order to sell more drugs, the demonstrable effects of ‘anti-depressants’ have actually been decreasing in drug trials.28 This is mainly because the trials have been getting more accurate. Over the years we have had more subjects stay in trials for longer even if they’re on a placebo which means the data is better,29 and more people who have common forms of ‘Major Depressive Disorder’ have been enrolling in trials so that it’s no longer just extremely severe asylum patients reflected in the data.30 The biggest change is that since 2013 drug companies have been forced to pre-register their trials in the US so they can’t take advantage of what is called ‘publication bias’ anymore.31 Drug companies used to contract many separate trials of a single drug, sometimes tens of studies, and then only publish the ones that showed their drug did something. It is a highly unscientific practice, akin to flipping a coin twenty times, getting heads five times and then reporting that you flipped the coin five times and heads came up every time. There are other ways that drug companies can manipulate study design to favour a positive result that have not yet been outlawed which they continue to use 34, 38. Despite the fact that as science gets better the support for ‘anti-depressants’ is melting away, surveys have shown that GPs still believe they work.22, 23 Professor of Medicine John Ioannidis of Stanford University describes antidepressant efficacy as ‘a living myth … one of the major manifestations of medicalization of modern society’.32

In a paper published earlier this year 33 Constantin Volkmann working at The Charité University of Medicine in Berlin found that on average anti-depressant prescriptions lead to a drop of about 2 points in the 52 point Hamilton Depression Rating Scale (HAM-D) which in their words ‘lies below clinical relevance’. They concluded ‘Since the average treatment effect of antidepressants falls short of clinical relevance, the current prescribing practice should be re-evaluated.’

The evidence also shows that anti-depressants are harmful, but that doctors and patients don’t believe it. A study published earlier this year by researchers from Curtin University and Adelaide University34 found that ‘there is clear evidence that more young Australians are taking antidepressants, and more young Australians are killing themselves and self-harming, often by intentionally overdosing on the very substances that are supposed to help them’. This confirms in Australia what has been known for nearly two decades anyway. In the early 2000s a series of US studies showed that anti-depressants increase suicidality such that the US Food and Drug Administration have required a warning on anti-depressant labelling since 2004.

It’s not clear to us exactly why ‘anti-depressants’ have so consistently been associated with an increase in suicidality. Some have proposed that it is to do with the common side-effect of severe restlessness, also known as ‘akathisia’, that – in combination with whatever got them prescribed the drug in the first place – drives people mad enough to kill themselves. I believe this is inflected by the fact that patients go to psychiatrists to have the singularity of their distress heard, understood and ministered to, and what they get instead is a mix of pharmaceutical salesmanship, cookie-cutter doctor-splaining about non-existent chemical imbalances, and a prescription for a useless chemical that demoralises them further. Patients are so saturated in advertising by ‘advocacy’ groups like Beyond Blue to the effect that only a doctor can help them that when they leave the doctor’s office with their hopes freshly dashed they are quite confused as to what has happened and promptly relocate the blame within themselves.

The commonest responses when I talk about the misgivings I have with the so-called scientific support of ‘anti-depressants’ are of two kinds; firstly ‘How can you say depression doesn’t exist when I or a loved one have suffered terribly for years?’, and secondly ‘But the medication fixed the problem, surely you agree I had depression because it was cured by an anti-depressant.’

To the first question I will answer that I do believe the diagnosis of ‘depression’ has a meaningful use (for instance as something a psychotherapist or psychoanalyst might consider in directing a long treatment), but I don’t believe the DSM construct as it stands is meaningfully useful in the clinic or in research. I would ask also: As a patient what is the use of having this or that diagnosis for whatever condition of sadness, distress, loneliness, loss, heart-ache, pain, weakness, guilt, demoralisation, degradation, destitution, unhappiness, balefulness, moodiness, irritation, frustration, powerlessness, imprisonment, hopelessness, or melancholy that you or a loved one is or was experiencing? Assimilating into the word ‘depression’ the infinity of ways the human being can find itself in darkness can only get in the way of understanding the unique experience of each new patient who deserves to be heard fully.

To the second question I will say, all manner of things might cheer a person up, or reverse their ill fortune, but only some of them should be marked with the stamp of medical authority to be prescribed by doctors, and I do not believe that ‘anti-depressants’ are one of these things. There is no convincing science that supports their use, and just because there exist anecdotes of their success here and there doesn’t mean that they qualify as medicines. This phenomenon can be observed in reverse when doctors start ‘prescribing’ things like yoga or hiking because some people have felt better after doing yoga or going for a hike. I would claim that not everybody responds the same way to these activities, because they don’t mean the same thing to everybody, and because not everybody has the same body, brain or mind; and I think it’s patent that while hiking and yoga might make someone feel better these activities are not medicines. Similarly if somebody told me that big wave surfing was the only thing that got them out of a prolonged funk, I wouldn’t then start prescribing extreme sports that occasion a risk of death to every patient. The so-called ‘anti-depressants’ should be re-classified as either poisons or research chemicals, and then people may do what they will with them, without believing them to be supported by medical science.

This year when the Nordic Cochrane Centre reviewed the top websites people in English speaking or Nordic countries encounter when they search ‘depression’ or ‘anti-depressant’ they found that all the websites they reviewed, WebMD for instance, claimed ‘anti-depressants’ are effective, and 74 per cent of the websites they reviewed linked depression to a ‘chemical imbalance’. Only one of the websites they reviewed mentioned that ‘anti-depressants’ can be addictive, and only 64 per cent of the websites mentioned an increase in suicidality. They concluded that ‘The information was generally inaccurate and unhelpful and has the potential to lead to inappropriate use and overuse of antidepressants and reduce the likelihood that people will seek better options for depression like psychotherapy’.35 As the internet is where the majority of patients go for information I think it’s clear what effect this misleading information has. One has to wonder why commercial self-diagnosis websites, so-called ‘health information’ websites, and the websites of ‘mental health advocacy’ groups would espouse so frequently such bullshit.

I will give an Australian example, which I think is illustrative, in what the Sunday Age referred to as the ‘McGorry lobbying machine’. Back in 2011 the Sunday Age spoke to several mental health clinicians who claimed prominent psychiatrist and Australian of the Year (2010) Patrick McGorry used his position on the government’s mental health expert working group to push for funding for programs that he had founded. In particular he was pushing for so-called ‘Early Intervention’ – which is really just early prescribing – for young people with psychosis and along with his close colleague and fellow self-dealing lobbyist Ian Hickey, they were pushing for the provision of brief psychological interventions for young people through their Headspace foundation.

The early prescribing model at Orygen depends on loosening the diagnostic criteria for psychosis even further to encompass something they call ‘attenuated psychosis’ and then going hard with anti-psychotics, especially Olanzapine (Eli Lilly), much earlier than is prudent.

After the recent Royal Commission into Victoria’s Mental Health, both Orygen and Headspace managed to receive an increase in funding even though many of us believe these services are inferior, and more harmful than other options.

Earlier this year in an article in the journal Australasian Psychiatry, McGorry addressed attacks by claiming his critics were living in an ‘illusion’ and were suffering a ‘hidden bias’ 36 against medications. On the topic of hidden bias, I note that at the end of that paper, as is required by most scientific journals, McGorry reported no conflicts of interest, even though in his time as a researcher developing the ‘Early Intervention’ model he has taken money from Janssen-Cilag, Eli Lilly, Bristol-Myers Squibb, Astra-Zeneca, Pfizer, and Novartis. Ian Hickey who is now also selling mental health apps to government, has taken money from Bristol-Myers Squibb, Eli Lilly, Pfizer, Wyeth, Servier, AstraZeneca, and stands to be enriched by the success of the mental health apps he’s had a hand in creating. The point is, these men and women are all over the place; they swim in the rich waters surrounding governmental and industrial funders and live in harmonious symbiosis with them.

McGorry himself explained why lobbyists like him hold so much sway with government when he wrote that ‘Early intervention is … considered among the best buys in health care, due to its repeatedly demonstrated ability to deliver a substantial return on investment.’36 The tenor of the language and the broadness of the claim are both operative here. The language of consumerism and capitalism establish that so-called ‘Early Intervention’ is a ‘good buy’ and then evoke fiscal prudence by claiming it is also a good ‘investment’. Even though the singular subjective experience of a patient seeking help has nothing to do with the uniform and repetitive purchasing of commodities, and is more than often a cry of distress at their insertion into an inhumane economic structure where their body and soul are already considered investments. Nevertheless this language appeals to politicians and within the logic of political ‘investing’ McGorry is actually telling the truth here. If as a Minister for Health your aim is to boost your stats and demonstrate that ‘more people are getting the treatment they need’ or ‘we’ve decreased wait times to see a psychologist’ then what McGorry and Hickey offer is in fact a high quality service for governments who need to generate such headlines. It doesn’t really matter if the treatment a patient receives is truly the one they need, seeing as the enigmatic nature of the psyche and the problematic nature of the DSM-based measurements mean outcomes can easily be fudged; and it doesn’t really matter if the psychologist a patient gets to see for ‘psychotherapy’ is poorly trained, and forced to rush through the ‘therapeutic interaction’ in six sessions in order to stick to one of the recipe-book treatments offered by Headspace; the headlines are generated anyway.

Mental Health is broken; it has been broken by psychiatrists who are not scientists but who have scientific pretensions; patients who are desperate, who for reasons of expediency may prefer not to confront the truth of their symptoms, and who have no-one more trustworthy to turn to; and corrupt businesses that have snake oil to sell. The diagnosis of ‘Major Depressive Disorder’ (as representative of many psychiatric diagnoses) has grown malignant and come to subsume myriad forms of human experience into a monolithic and compromised diagnosis.37 It happened because of covert drug-marketing and drug-boostering driven by the powerful but unscientific forces to be found on government committees, professional panels, and in other places of power, and because doctors and patient-consumers have turned a blind eye to this corruption despite it being quite obvious and well publicised. Each and every person will have their own reason for ignoring or accepting information about ‘anti-depressants’ and ‘Major Depressive Disorder’ but one can’t deny that these things have proven eminently marketable (by pharmaceutical companies), billable (by doctors), and their horoscope like inclusiveness has offered patients the illusion of an explanation for their distress.25, 26, 38 There is an emancipatory and compassionate potential within psychiatry, but it has not found its expression in the reification of certain culture bound states of distress as ‘illnesses’ nor in the prescription of toxic and useless ‘medications’; rather it finds its expression in listening to patients, and in providing patients with the opportunity, not much afforded them elsewhere, to listen to themselves.

 

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Sam Lieblich is a writer and psychiatrist working in Melbourne, Australia and conducting neuroscience research at the University of Melbourne.

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