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Anger and Forgiveness"Are You There Alone?"10 Good Questions about Life and DeathA Casebook of Ethical Challenges in NeuropsychologyA Companion to BioethicsA Companion to BioethicsA Companion to GenethicsA Companion to GenethicsA Companion to Muslim EthicsA Cooperative SpeciesA Critique of the Moral Defense of VegetarianismA Delicate BalanceA Fragile LifeA Life for a LifeA Life-Centered Approach to BioethicsA Matter of SecurityA Mirror Is for ReflectionA Natural History of Human MoralityA Philosophical DiseaseA Practical Guide to Clinical Ethics ConsultingA Question of TrustA Sentimentalist Theory of the MindA Short Stay in SwitzerlandA Tapestry of ValuesA Very Bad WizardA World Without ValuesAction and ResponsibilityAction Theory, Rationality and CompulsionActs of ConscienceAddiction and ResponsibilityAddiction NeuroethicsAdvance Directives in Mental HealthAfter HarmAftermathAgainst AutonomyAgainst BioethicsAgainst HealthAgainst MarriageAgainst Moral ResponsibilityAgency and 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How Much?Why Some Things Should Not Be for SaleWisdom, Intuition and EthicsWithout ConscienceWomen and Borderline Personality DisorderWomen and MadnessWondergenesWould You Kill the Fat Man?Wrestling with Behavioral GeneticsWriting About PatientsYou Must Be DreamingYour Genetic DestinyYour Inner FishYouth Offending and Youth Justice Yuck!
In the growing genre of anti-pharmaceutical industry books, this one is focused on psychiatry, rather than general medicine, and here the biological approach to psychiatry gets added to the target list. Prophecies of doom ("pharmageddon") appear to have become a trade publishing standard, and this prominently published book is no exception. I find the rhetorical tone of many such books off-putting, but debate about their content is nonetheless important.
This book has more merits than many of its peers. The author is a psychiatrist, recently graduated from his specialty training, with a preceding decade of experience as a counselor to the homeless mentally ill. He thus has the advantage of knowing that there is such a thing as serious psychiatric disease; his critique is not meant, by him at least, to argue against medications in general or even biological psychiatry per se. Rather, he thinks things are being overdone, and medications used in those without mental illnesses in a manner that is not effective and perhaps harmful. There are interesting data to support this claim, some of which are not in the book: For instance, a recent epidemiological study (the National Comorbidity Survey) found that about one-half of persons diagnosable with mental illness were not currently in treatment, but also about one-half of persons currently in treatment were not diagnosable with current mental illnesses. The proposal then becomes not the one-sided claim that psychiatry is overmedicating everyone, but rather that the wrong people are getting medicated.
This question is more interesting to me than the increasingly well-worn critique of the pharmaceutical industry and "corporate psychiatry" and puts the book into another genre: books which promote (most famously Peter Kramer's 1993 Listening to Prozac, and Kramer's 2005 Against Depression) versus those which oppose (most prominently, David Healy's 1998 Antidepressant Era, Carl Elliott's 2006 Better than Well, Hurwitz and Wakefield's 2007 Loss of Sadness, among others) antidepressants. The anti-antidepressant books seem to outnumber the pro-antidepressant books, and Kramer comes in for some pointed criticism here: Barber writes is that we should be listening to patients, not Prozac. Yet Kramer's point was that after years of listening to patients in psychotherapy, he achieved more success for their character traits (not severe depression) after giving them Prozac as well. "Nobody writes about Prozac like that anymore!", notes Barber as he argues that a massive change happened in the 1990s, whereby antidepressant use surged and the biological approach to psychiatry took over our culture. Perhaps, since his training is more recent than mine, I have more of a sense of continuity. Psychiatry seemed quite biological to me in 1991 when I first entered the field, and it is still so. We used a lot of medications then; we still do, they just have different names. The implication that Kramer is something like a psychopharmacological Luddite conflicts with my experience that there is still a lot of interest in Prozac and antidepressants among rank-and-file psychiatrists, many of whom saw the limits of the psychotherapy era in prior decades.
Barber's basic thesis has validity: if we grant the utility of antidepressants for severe depression, we can still critique their widespread usage for "subsyndromal depression" in Barber's phrase, or "community nervousness" as Healy puts it. This basic misery of human life is an existential, not a medical, fact, and Americans are culturally prone to trying to medicate it away. I think there is truth to this interpretation. What might be added is that the concept was legislated away in DSM-III in 1980, when "neurotic depression" was removed from our diagnostic lexicon, and only "Major depressive disorder" was left (with a compromise to create "dysthymia" and "generalized anxiety disorder" to partially capture the prior neurotic depression group, as Healy describes well in his book). Neurotic depression was the bread-and-butter of psychoanalysis. After 1980, one had to reinterpret any depression as major depression, and the move to widespread antidepressant usage only awaited drugs which were safe in overdose, the first of which was Prozac. Now with a decade of research, I would say that we can conclude that antidepressants have little if any efficacy in neurotic (or mild) depression, justifying a return to using that diagnostic label so as to differentiate those with depression severe enough to need antidepressants from those who do not benefit for their mild symptoms. Barber seems to be approximating this same conclusion, though with cultural critique as his main method, and the profession of psychiatry as his primary target.
On the other hand, despite the emphasis in the second half of the book on psychotherapies like cognitive behavioral therapy (CBT), motivational interviewing (MI), and stages of change (SC), I do not believe that the evidence is there that these psychotherapies actually improve neurotic depression either.
Another theme is Barber's endorsement of the "recovery" approach to mental illness, as opposed to the medical model. The recovery approach has its origins in the 12 step movements in substance abuse and in the rehabilitation world. The recovery model is driven by the person while the medical model is seen as driven by the doctor. While not inherently opposed to the "medical model" in the sense that medications can be part of managing symptoms, it has been my observation that many proponents of the recovery model are explicitly anti-psychiatry, seeing professionals like psychiatrists as problems or obstacles. If recovery is defined as taking medications to treat disease and then to realize that the patient is also a person and thus requires attention to social context and personal meaning, then there is little to criticize. Indeed William Osler's medical humanism model, it seems to me, captures much of that approach. If however, the diagnosis and treatment of disease is put aside altogether, in place of whatever the person with the symptoms wants to do, then the medical profession has a problem. The Hippocratic/Oslerian tradition is about taking seriously the responsibility to diagnose and treat disease appropriately in the interests of the patient. Sometimes the interest of the patient is not same as the stated wish of the patient. I will tell my patients frequently: My job is not to make you feel good, it is to make you well. Barber and other proponents of the recovery model will reach some of the same conclusions as I do: for instance, with my Hippocratic medical model, I will not give amphetamines to someone who simply wants it. But talk of replacing the medical model with the recovery approach may not be as straightforwardly sensible as it might seem at first glance.
The final chapter reviews recent evidence about neuroplasticity, especially the work of Eric Kandel, supporting the view that psychotherapy can result in neuronal changes. Widely known among psychiatrists, these ideas may be novel to the general public. Though important and relevant, there is some irony, in a critique of biological psychiatry, to seek support for psychotherapy based on its neurobiological effects.
After finishing the book, I found that an op-ed piece by the author in the Washington Post provided something new: The author suffers from obsessive-compulsive disorder (OCD), severe enough to drop out of college. He recovered with medications, along with psychotherapy. In an NPR interview, he seemed to downplay his own experience taking SRIs. But readers might have benefited from some discussion of his own personal experience using SRIs, as opposed to the more abstract anti-medication tone of much of the book.
To sum up the book's argument in practical terms: For mild depression, use medications less, psychotherapy more -- a simple message, with which I agree. But the matter can be oversimplified, and there is some danger, indeed a probability, that anti-psychiatry activists and their fellow-travelers will draw extremist conclusions based on some of the material presented in this book. Nuance cannot be ignored: Psychiatry should not be all about biology, but the era of psychotherapeutic hegemony arguably was worse; and "recovery" may be nothing but a reaction to the confusions of our current confused eclecticism. Especially given the author's own experience with antidepressants, a purely anti-biological chorus fails to satisfy. The book's postscript, however, where Barber draws on the ideas of the writer Walker Percy, well captures the complexities involved. Let psychiatry become more aware of the mystery of human existence, and corresponding humble; and let psychiatry's critics do the same.
© 2008 Nassir Ghaemi
Nassir Ghaemi, M.D., M.A., M.P.H., Director, Mood Disorders Program, Tufts Medical Center, Dept of Psychiatry. Dr. Ghaemi is author of The Concepts of Psychiatry: A Pluralistic Approach to the Mind and Mental Illness, Johns Hopkins University Press, 2003.