This brief book by well-published professor of psychiatry Joel Paris is a useful summary and critique of the current state of psychopharmacology. While it will certainly not satisfy every reader, especially those who cling to the reductionist biological model of mental illness, it presents many issues of concern to mental health professionals and patients. The book is presented in three sections, the first providing historical and scientific context and an exploration of the pharmaceutical industry, the second a review of practice issues for different classes of drugs and the third covering more general issues of alternatives, medicalization and a look at the future of psychopharmacology. None of the issues discussed are new, as the extensive reference list attests, but Paris has brought all these issues together in an accessible and readable overview.
One of the central points is that relatively little progress has been made in psychopharmacology since the development of the older antipsychotic and antidepressant agents in the 1950s. Talk of greater efficacy of the so called "second generation antipsychotic" agents is rather overstated, perhaps with the exception, but only a qualified exception, of clozapine. The principal advantage of the newer antidepressants is their grater tolerability and safety, not greater efficacy. And the anti-anxiety agents, mainly benzodiazepines are essentially unchanged in the last half century. Paris is at pains to point out that much of this is known to older psychiatrists like himself, but is well understood by younger psychiatrists who have been trained in the era of DSM III and IV, and the proliferation of diagnostic categories beyond any reasonable model of what is an is not a psychiatric illness.
A number of problems beleaguer the use of pharmacological agents in psychiatry, according to Paris. These include: the expansion of DSM categories; the lack of definitive diagnostic tests; the insidious emphasis of the pharmaceutical industry; epidemiological studies that use dubious criteria to 'find' high life time prevalence of mental illness; and the claims of some of Paris's psychiatric colleagues that the neurochemical basis of mental illness provides a scientific rationale for pharmacological treatment is established. It is obvious that these are related problems, and the sum of their parts is unsurprisingly a profession that struggles for legitimacy. Despite these problems Paris offers a view of psychiatry as offering useful pharmacological treatment for limited categories of problems. In the case of depression, for example, several meta-analyses have showed limited effectiveness of antidepressants, but when studies are limited to those with severe depression the picture is rather different. People with severe depression do show a response to medication. Similarly, antipsychotic medication offers genuine relief of symptoms to people with psychosis. The problem is that psychiatric drugs have been over-hyped by psychiatrists and by physicians in primary care. The result is that too many people are prescribed psychiatric drugs, and often for "off-label" indications for which there is no evidence base. A related problem is polypharmacy: the simultaneous prescription of multiple agents whose use in combination has not been adequately tested.
One of the strengths of this book is its comprehensive coverage. Arguments are not reduced to the merits or otherwise of particular drugs as they frequently are in scientific studies. Paris shows how an understanding of the conceptual and empirical weaknesses of psychiatry has been exploited by a cynical pharmaceutical industry, with psychiatrists complicit in touting the merits of various drugs far in excess of the evidence. Academic journals, too, have contributed to these problems, although Paris does not comment on this. Lax editorial policies around declarations of interest and lack of rigorous standards around acceptable research practice all contribute to misleading results.
Paris explores some of the controversies surrounding the more public aspects of debate about psychiatric drugs. He reviews the case of David Healy, whose job offer to the University of Toronto was rescinded following Healy's public lecture strongly critical of the claims of effectiveness of antidepressants. Paris also summarises the case of psychiatrist Fred Goodwin who failed to declare substantial payments for his work as an opinion leader. However this book is different to many others critical of psychiatry in that Paris is also prepared to critique the critics, such as Healy and Joanna Moncrieff, whose arguments he does not always support.
Late in the book Paris makes the mistake, common to many psychiatrists, of lumping authors critical of psychiatry together under the rubric of 'antipsychiatry'. These days 'antipsychiatry' owes its life as a concept more to defenders of psychiatry than to any spokesperson or group who identifies with 'antipsychiatry'. In Paris's case, the usual suspects of Foucault, Laing and Szasz are cited as the core of antipsychiatry. But Foucault was never part of the old antipsychiatry movement however much it might have drawn inspiration from his ideas. Szasz has always been as dismissive of antipsychiatry as he is of the idea of mental illness. Laing was definitely an anti-establishment psychiatrist, albeit one who continued to practice and attempted a reformulation of the concept of psychosis. Given the more nuanced critique of psychiatry over the past four decades (much of which is cited by Paris) 'antipsychiatry' is something of a paper tiger.
The Use and Misuse of Psychiatric Drugs deserves a place in every health sciences library. Prescribing clinicians should be aware of the influences behind the construction of diagnostic categories, and the modest evidence for the effectiveness of many commonly prescribed drugs. The long awaited revised DSM is unlikely to address the problem of proliferating "illnesses". Paris's recommendation to psychiatrists to "watch and wait" could lead to less unnecessary and futile prescriptions. Those responsible for the education of health professionals should be aware of the issues Paris raises, and should be appropriately cautious in reaching for the prescription pad in the belief that they are correcting a "chemical imbalance". Instead, they may be medicalizing distress and playing their own small part in extending the reach of psychopharmacology to problems with which it is ill-equipped to help.
© 2013 Tony O'Brien
Tony O'Brien is a lecturer in mental health nursing at the University of Auckland, New Zealand