In this two-part series published in The New York Review of Books under the titles “The Epidemic of Mental Illness: Why?” and “The Illusions of Psychiatry,” Marcia Angell summarizes three books that strongly criticize the pharmaceutical treatment of psychiatric disorders, and particularly the role the pharmaceutical industry has played in shaping public and medical perception of them. The books she reviews include The Emperor’s New Drugs: Exploding the Antidepressant Myth, by Irving Kirsch; Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs and the Astonishing Rise of Mental Illness in America, by Robert Whitaker; and Unhinged: The Trouble With Psychiatry—A Doctor’s Revelations About a Profession in Crisis, by Daniel Carlat.
An early-2000s survey by the National Institute of Mental Health (NIMH) found that 46% of adults had met the criteria established by the American Psychiatric Association (APA) for at least one mental illness at least once in their lives. The majority of psychiatrists today treat patients primarily and often only with drugs. These dual forces have led to a huge share of the population taking psychoactive drugs; for example, 10% of Americans are taking antidepressants, and antipsychotics have replaced statins as the top-selling class of drugs in the U.S.
Angell describes how a variety of changes to our understanding of mental illness drove this shift. In the late 20th century, the widespread medical perception of mental illness shifted from the Freudian view (which considers mental illness as the result of environmental stimuli) toward the view that mental disorders result from chemical imbalances in the brain. The latter view was born shortly after the first psychoactive drugs were introduced in the 1950s. Most of these early psychoactive drugs were not originally developed to treat mental disorders.
During the 1970s, the American Psychiatric Association began to push psychoactive drugs aggressively, leveraging the Diagnostic and Statistical Manual of Mental Disorders (DMS) and influential psychiatrists to broaden the definition of mental illness and establish the need for pharmaceutical treatment. The majority of contributors to the DSM-IV had financial ties to pharmaceutical companies, which benefited from the rapidly increasing number of mental conditions the DSM outlined. These same companies simultaneously promoted campaigns to raise awareness of these conditions, stimulating demand for the drugs.
In an extended analysis of how this period became formative of contemporary practices, Angell writes:
As psychiatry became a drug-intensive specialty, the pharmaceutical industry was quick to see the advantages of forming an alliance with the psychiatric profession. Drug companies began to lavish attention and largesse on psychiatrists, both individually and collectively, directly and indirectly. They showered gifts and free samples on practicing psychiatrists, hired them as consultants and speakers, bought them meals, helped pay for them to attend conferences, and supplied them with “educational” materials. When Minnesota and Vermont implemented “sunshine laws” that require drug companies to report all payments to doctors, psychiatrists were found to receive more money than physicians in any other specialty. The pharmaceutical industry also subsidizes meetings of the APA and other psychiatric conferences. About a fifth of APA funding now comes from drug companies.
Drug companies are particularly eager to win over faculty psychiatrists at prestigious academic medical centers. Called “key opinion leaders” (KOLs) by the industry, these are the people who through their writing and teaching influence how mental illness will be diagnosed and treated. They also publish much of the clinical research on drugs and, most importantly, largely determine the content of the DSM. In a sense, they are the best sales force the industry could have, and are worth every cent spent on them.
Angell also references Carlat’s rationale for why psychiatrists consistently take more money from drug companies than specialists in other fields:
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.
More recently, this state of affairs has manifested in a dramatic increase in the diagnosis of mental illness among children, with 10% of 10-year-old boys taking ADHD medication and diagnoses of juvenile bipolar disorder jumping 40-fold from 1993 to 2004. Many of the medications given for these juvenile conditions are prescribed off-label, and pharmaceutical companies have been repeatedly found guilty of illegally promoting off-label use to physicians.
Angell notes multiple fundamental issues with the “chemical imbalance” theory underpinning the pharmaceutical treatment of mental disorders. In most cases, this theory argues mental illness results from an imbalance of neurotransmitters in the brain; that is, too much or too little (or too much or too little uptake or utilization) of the chemicals that carry signals between neurons. These drugs have significant effects on neurotransmitter levels. However, patients with mental illnesses show normal neurotransmitter levels and neurotransmitter function prior to treatment, with many abnormalities emerging only after treatment has been applied.
This theory came to be accepted through selective interpretation of the scientific process. The FDA requires two clinical trials demonstrating benefit for a drug to be approved, regardless of how many negative trials preceded them. Freedom of Information Act requests showed that the majority of trials testing antidepressant drugs approved between 1987 and 1999 (Prozac, Paxil, Zoloft, Celexa, Serzone, and Effexor) were negative, and in sum, placebos were 82% as effective.
Subsequent, more sophisticated analyses further undermined the purported efficacy of these drugs. When psychoactive drugs were compared to active placebos—that is, placebos that, like the drugs, caused some side effects and thus caused patients to believe they were receiving treatment—there was no difference in benefit between antidepressants and placebos. In other words, due to the highly subjective nature of evaluating mental disease progression, the perceived benefits of psychoactive drugs may have been entirely due to a strong placebo effect.
This is particularly grave given the negative side effects of these drugs. Some induce obesity, metabolic disease, and other conditions. Many cause new mental conditions in those who take them, leading patients to take cocktails of drugs to treat a bouquet of diagnosed mental illnesses. The majority, if taken chronically, disrupt the brain’s ability to naturally regulate neurotransmitter levels, leading to withdrawal symptoms that are often misdiagnosed as a relapse of the original condition.
Angell concludes:
The books by Irving Kirsch, Robert Whitaker, and Daniel Carlat are powerful indictments of the way psychiatry is now practiced. They document the “frenzy” of diagnosis, the overuse of drugs with sometimes devastating side effects, and widespread conflicts of interest. Critics of these books might argue, as Nancy Andreasen implied in her paper on the loss of brain tissue with long-term antipsychotic treatment, that the side effects are the price that must be paid to relieve the suffering caused by mental illness. If we knew that the benefits of psychoactive drugs outweighed their harms, that would be a strong argument, since there is no doubt that many people suffer grievously from mental illness. But as Kirsch, Whitaker, and Carlat argue convincingly, that expectation may be wrong.
At the very least, we need to stop thinking of psychoactive drugs as the best, and often the only, treatment for mental illness or emotional distress. Both psychotherapy and exercise have been shown to be as effective as drugs for depression, and their effects are longer-lasting, but unfortunately, there is no industry to push these alternatives and Americans have come to believe that pills must be more potent.
Together, these books argue that the current ways we diagnose and treat mental illness in the United States is the result of pharmaceutical industry intervention, not academic or clinical evidence. Both our theoretical understanding of mental illness and the existing research data fail to support the effectiveness of psychoactive drugs.
Cover image: An advertisement for Prozac, from The American Journal of Psychiatry, 1995
Marcia Angell on Psychiatry and the Pharmaceutical Industry