Tuesday, June 28, 2011

Marcia Angell on the Corruption of American Psychiatry

Dr. Marcia Angell, perhaps the leading critic of the pharmaceutical industry, has written a powerful two-part critique of American psychiatry in the New York Review of Books.

The articles review three books that cast major doubt on the effectiveness of psychiatric medications and the hypothesis that disordered neurotransmitters cause psychiatric ailments. "The Emperor’s New Drugs: Exploding the Antidepressant Myth" by Irving Kirsch carefully analyzes research on antidepressant medications and concludes that virtually all of the impact comes from the placebo effect. "Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America" by Robert Whitaker goes much further. Whitaker argues that the enormous increase in diagnosis of serious psychiatric illness is caused by the deleterious impact of medications. In Whitaker's view the problem isn't that medications don't help - it's that they exacerbate the conditions they're being used to treat!

The second article moves beyond medications to take on psychiatry itself, taking off from discussions of "Unhinged: The Trouble with Psychiatry — A Doctor’s Revelations About a Profession in Crisis" by Daniel Carlat and the American Psychiatric Association's "Diagnostic and Statistical Manual of Mental Disorders" - the world-famous "DSM."

When I did my psychiatry residency in the mid 1960s, medications were just coming into use. The predominant model was psychoanalytic - that mental disorders were caused by psychological conflicts ultimately derived from childhood experience. But fom the 1980s to the present, and especially since the introduction of Prozac in 1987, the paradigm has shifted to one that sees "chemical imbalances" as the cause of mental disorders. In the wise words of the late Dr. Leon Eisenberg, psychiatry went from being "brainless" (conflict was everything) to "mindless" (neurotransmitters are everything).

It's difficult, however, to find clinicians who've been deeply immersed in treating people with psychiatric ailments who don't believe in their hearts that nature and nurture are both involved. Quite apart from the question of whether the neurotransmitter hypothesis holds water, twin studies definitively show that inherited physical mechanisms contribute to the causation of mental disorders. And quite apart from whether psychoanalytic hypotheses about the causative role of childhood experience pan out, it's easy to observe that emotions and relationships influence the way symptoms are expressed and treatment proceeds.

What Dr. Angell's discussion brings out is the role of money. There are enormous profits to make from the sale of branded psychiatric drugs. Pharmaceutical companies have invested hundreds of millions in marketing. Angell details just how much leaders in my profession, alas, have earned from these marketing efforts, all-too-often at the cost of integrity, and how the psychiatric profession has reclaimed its role as a medical specialty by emphasizing brain over mind.

But the financially-driven corruption that has demonstrably occurred has ready receptor sites in our wish for simple explanations for why we are the way we are. Ambiguity and uncertainty invite anxiety. Certitude and closure reassure us. The combination of huge profits to be made, professional status to be enhanced, and what the poet Wallace Stevens called our "blessed rage for order" to be satisfied by decisive answers, have driven a powerful medicalization of the human psyche.

The pendulum had swung way too far in the psychoanalytic direction in the post World War II period. The necessary correction has swung way too far in the direction of "chemical imbalances" at present. I may be a cockeyed optimist, but I believe the books Dr. Angell reviews, and her own writing, are steering us towards a more complex, balanced view of human nature that respects both "brain" and "mind" without limiting our choice to oversimplified, rival pseudo-truths.

(I'm lucky to have Marcia Angell and Danny Carlat as colleagues and friends. I've written posts about Danny Carlat's work here and here. For Marcia Angell's New York Review articles see here and here.)

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