In this book, Breggin and Cohen continue to develop the neo-antipsychiatry stance which Breggin has outlined in several previous books. In spite of mildly worded disclaimers, the book is an outright attack on the use of medicines to treat people who have been diagnosed with psychiatric disorders. In my view, many of the arguments in the book are unfair and some of the logic is highly suspect.
The book begins with six pages of testimonials. In the body of the book, the authors argue against medicines, starting with a discussion on how difficult it can be to stop taking these medicines, listing psychiatric and physical problems which medicines may cause, and then adverse effects of specific medicines, and listing reasons for not using these medicines and reasons why physicians allegedly tell their patients so little about adverse effects. They then provide chapters on planning discontinuation of medicines, possible withdrawal reactions, and a chapter on stopping children's medicines. They end the book with a discussion of understanding one's therapist's concerns about stopping medicines, guidelines for anti-medicine therapists, and principles of self-help for people who will not take medicines. They include appendices about organizations they head, journals they edit, and ways to contact them.
I undoubtedly bring some unwitting bias to this review. I have been practicing psychiatry for over twenty-five years and have conducted studies of drugs which may be useful for patients with bulimia nervosa and obsessive-compulsive disorder. While I greatly value psychotherapy and enjoy doing it, I believe that psychiatric medicines have a large role to play in the treatment of a great many patients.
Breggin and Cohen vilify psychiatrists, and I am loathe to be included in the view of the profession which they present. If they presented some of their criticisms more moderately, I would find several areas of agreement with them. Some psychiatrists spend too little time with their patients and prescribe medicines without having even an approximate view of the patient as a person. Attention deficit disorder is, in my opinion, greatly overdiagnosed, and too many children are taking stimulants. Drug companies do emphasize biological aspects of disorders in contrast to psychological and social components, and they do promulgate the idea that we know more about the biological bases of many disorders than we actually do. The concept of "chemical imbalance" in the brain, so often discussed by doctors and drug companies, is often poorly defined and usually involves a lot of fuzzy thinking. Advertisements by drug companies can be egregious. Patients should be encouraged to play a major role in treatment decisions about them. There are adverse effects of psychiatric medicines, and, often, doctors do a poor job of explaining these to patients. A great many psychiatrists would agree with me about these concerns, but few psychiatrists I know would support the extreme arguments which Breggin and Cohen advance. Given their premise that medicines are bad, the suggestions about how to stop the medicines are quite good, but we do need to examine the premise itself.
Throughout the book, the authors consistently write of "drugs" rather than "medicines". They also put quotation marks around types of drugs - "antipsychotics" - and around diagnoses. They catastrophize: "Without a doubt, Prozac and other antidepressants are causing tens of thousands of psychotic reactions that can ruin the lives not only of the afflicted individuals but also of their family members." Prozac can sometimes cause people to become overly energetic and lacking in judgment; this is usually a very short-term situation and does not ruin lives.
They overgeneralize: "Their lives have been emptied by their reliance on drugs. They must rebuild from scratch their faith in God or other ethical convictions, their trust in other people, and their reliance on themselves and their love of creative work or nature." In fact, major depression destroys faith and ethical convictions; its treatment does not. Creativity is restored, not abolished, by the medical treatment of this disorder. I have treated many artists and writers who have been thrilled that medical treatment of their disorder has allowed them to regain their creativity and creative productivity.
The book contains many errors of fact. The authors state that if a patient mentions any "feeling" to a doctor, he or she will receive a psychiatric label. This is nonsense. The authors state that "non-drug, caring approaches work better for severely disturbed people." Severely disturbed people with depression or schizophrenia do much better with a combination of medicines and a therapeutic relationship, as has been well demonstrated. Patients with severe obsessive-compulsive disorder do poorly with a caring relationship and well with a combination of medicines and cognitive-behavioral therapy. In spite of the authors' insistence, psychiatric drugs do not work by "producing enough brain malfunction to dull the emotions and judgment or to produce an artificial high;" and this statement is inconsistent with a large amount of evidence. Furthermore, the statement that "most of the seminars that doctors attend are sponsored by drug companies" is questionable. I have never attended a meeting sponsored by a drug company, and that is true of a great many of my colleagues. Most of us attend meetings sponsored by professional societies. The statement that long-term use of psychiatric medicines "tends to teach people how to relate at a lower emotional, psychological, and cognitive level" would be laughed at by a great many people who are successfully treated with the medicines. The statement that children who take these medicines are artificially maintained at a lower developmental level than they should be, for their age, is also laughable: a major problem with children with true attention-deficit disorder, for example, is that they advance to middle adolescence at too early an age. In a slam of books about drugs written for doctors, the authors state that "they were written by strongly committed advocates of drugs. They rarely cite literature or opinions critical of drugs." Even among the books he lists, there are lengthy listings and discussions of adverse effects.
Another problem, for me, is the suggestion of conspiracy among drug companies, the National Institute of Mental Health, and scientists who study medicines. There is absolutely no evidence for this. NIMH urging "aggressive treatment" in childhood and adolescence does not suggest any subornation by drug companies but a defined and well-studied need to help an undeserved population. Similarly, NIMH's designation of "Anxiety Awareness Week" is an effort to urge people with severe syndromes to seek treatment, not an effort to gain profits for the drug companies. This set of arguments is very annoying: "nearly all the research in this field is paid for by drug companies and conducted by people who will 'deliver'
" This is simply not true. The statement that "the drug companies and the drug researchers
share a set of values about the kinds of statistical manipulations that can be tolerated" sounds ominous, and it is true - they shared the values of statistical analysis of medication studies which have been established throughout medicine.
There is annoying repetition throughout the book that there is no evidence for a neurologic basis for any psychiatric disorder. There is, in fact, growing and abundant evidence for brain pathology in some psychiatric disorders.
The authors resort frequently to the logical fallacy of post hoc ergo propter hoc. Depressed patients, it is said, often become more depressed on antidepressants. Well, patients with congestive heart failure often develop further heart failure on medicines designed to prevent heart failure. This is one of the vicissitudes of practicing medicine - the medicines cannot always halt the progress of the syndrome. The reader is informed that numerous patients have committed suicide while taking antidepressants; my retort is the same. People can become psychotic or depressed when medicines are stopped: of course they can; that is a function of their disease process and a reason for them to take the medicine.
Another unfair argument in which the authors indulge is to present the rare as common. "One person may 'feel nothing' after a
dose of Prozac, while another person may develop severe agitation
" This is true but is incredibly rare. The authors imply that it is commonplace.
Some of the statements in the book are simply unfair and greatly lower the level of discourse. While it is true that, a great many years ago, schizophrenic patients were given Ritalin experimentally with bad results the statement that "this practice should be considered unethical" is irrelevant - no Institutional Review Board would allow such experiments now - of course they would be unethical. No one is proposing to do them! Similarly, monoamine oxidase inhibitors are said to be "again in vogue" because of "the disappointing results obtained with other antidepressants". The results obtained with mainline antidepressants are generally good, and, because they require strict adherence to a difficult diet, monoamine oxidase inhibitors are generally held in reserve. They are hardly "in vogue", but they continue to be a valued resource when other medicines do not work well. There are many similar stories in other medical fields. Again, we are told that veterinarians do not like to use neuroleptics because they are "too dangerous". No one likes to use neuroleptics, but we use them for people who are psychotic; not many veterinarians treat psychotic animals. Pediatricians, family practitioners, gastroenterologists and internists who use Compazine to treat nausea do not seem to feel that it is "too dangerous" even though it is a neuroleptic. The statement that "after a fifteen- to thirty-minute visit with the doctor, you were started on drugs" is most unfair. While some psychiatrists have very short initial evaluations, new evaluations typically take ninety minutes to two hours. Sometimes, doctors defer starting a medicine until they have seen the patient several times. Finally, there is a strange statement that "psychiatrists as a group are more controlling, authoritarian, and emotionally distant" than other mental health professionals, and that they "tend to seek power", have a lobby which "is one of the most powerful in the nation's history", and that "to gain the enmity of a biological psychiatrist in a professional institution
is to risk one's job and career", and this all seems ludicrous to me. Psychiatrists as a group are like most other people, in my view, and many of them share humanistic values, kindness and empathy. Our lobby has done a very poor job of advocating for our patients, who do not achieve insurance parity, for the most part. A very large number of department chairmen in this country continue to be psychoanalysts - therapists - and I have never heard of biological psychiatrists generally having the power to wreck peoples' careers.
Finally, such statements as "your child should be withdrawn from psychiatric drugs of any kind as soon as possible" can be harmful. Severely impaired children can benefit greatly from medicines. Schizophrenic adults can become psychotic without them. Depressed adults can commit suicide without them. This kind of general, doctrinaire advice, coming from a book, without any knowledge of the patient, seems to me to be potentially very harmful and certainly highly unethical.
In conclusion, I found this book troubling. It raises some good points in an exaggerated way. These points are better dealt with by Mender, in his excellent book about the limits of neuropsychiatry, Valenstein, in his more polemical book (reviewed in Metapsychology January 1999). Your Drug May Be Your Problem seems tawdry in its arguments. I cannot recommend it.
Lloyd A. Wells is a child and adolescent psychiatrist at the Mayo Clinic in Minnesota. He has a particular interest in philosophical issues related to psychiatry and in the logic used in psychiatric discourse.
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