This is a thoughtful, well-documented, critique of American psychiatry by journalist Whitaker (Mad in America and Anatomy of an Epidemic) and psychologist Cosgrove (U. Massachusetts; co-author, The Ethics of Pharmaceutical Industry Influence in Medicine). Among 11 chapters are "Economies of Influence," "Psychiatry's New Drugs," and "A Society Harmed." There are 16 helpful figures and tables, e.g., American Psychiatric Association (APA) annual revenues 1980-2012. The Diagnostic and Statistical Manual of Mental Disorders(DSM) first appeared in 1952, has worldwide influence and is a source of income for the APA.
Whitaker and Cosgrove cite DSM-III, released in 1980, as the turning point in American psychiatry from the psychoanalytic causal paradigm to one of symptoms--single and multiple. Modern psychiatry has evolved from a Freudian psychoanalytic orientation to one that catalogs deviant thinking, emotion and behavior. Pharmacology
The authors emphasize the growing influence of drug companies on psychiatric practice and teaching. Thus, "During the past 35 years, psychiatry has transformed American culture. It has changed our view of childhood and what is expected of 'normal' children, so much so that more than five percent of school-age youth now take a psychotropic drug daily." Many infants have been exposed to antidepressants in utero, and many elderly Americans in nursing homes are given these drugs even without a psychiatric diagnosis. Spending on psychiatric drugs rose from $800 million in 1985 to $40 billion in 2011 (pp. 7, 9).
The authors begin with history, going back to Benjamin Rush in 1812 and the founding of a psychiatric organization in 1844 that became the APA. By 1885, there were eight kinds of insanity recognized: mania, melancholia, monomania, dementia, general paralysis of the insane, epilepsy, toxic insanity and congenital mental deficiency. After 1900, inpatients in the U.S. were likely to be demented, epileptic, retarded, syphilitic or alcoholic. By1918 a standardized nosology listed 22 categories of illness, of which all but two were attributed to biological causes: syphilis, alcohol, arteriosclerosis, etc. Psychoanalysis, which began to attract physicians in the 1920s, dominated psychiatric training for decades, but by 1956, Thorazine and Miltown were in the picture. Psychiatry training residencies then neared 3,000, up from 758 a decade earlier. The profession ceded therapy to others. By 1977 clinical psychologists gained full status as psychotherapists without need for medical supervision.
The DSM-III of 1980, almost 500 pages, listed 265 disorders. Psychoanalysis became less fashionable as insurance covered only short-term therapy. Psychiatrists donned a metaphorical white coat and wrote more prescriptions, emphasizing medical causes and cures. Pharmaceutical companies thrived with the introduction of new drugs--Xanax, Prozac and other anti-depressants, all heavily advertised. APA revenues went up with ads for drugs in its journals. The industry sponsored symposia at meetings and developed continuing education programs.
In 1985, Fred Gottlieb, M.D., then APA treasurer, expressed dismay about "millions of dollars of drug house money" coming in for ads, exhibits, lectures, and social events. "We seem to discount available data that drug advertising promotes irrational prescribing practices...We persist in ignoring an inherent conflict of interest." (p. 37) The APA board did nothing; some members praised the partnership with industry. DSM-5 came out in 2013: over two-thirds of its task force had received funds from drug companies. (p. 40).
DSM codes are part of billing for insurance payments. While "reliable," the diagnoses lack validity and are not useful for research. Researchers have a nomenclature, "but probably the wrong one" said Nancy Andreasen, M.D., former editor of the American Journal of Psychiatry, in 2007. (p. 60) Whitaker and Cosgrave allege that "the APA helped promote a false notion--that psychiatric drugs corrected chemical imbalances in the brain." (p. 62)
After Valium was launched in 1961--for over a decade the most prescribed medication in the Western world--came Xanax (1981). But benzodiazepines, while reducing anxiety, were addictive. Their use dropped from 103 to 71 million prescriptions in five years (1975-80). Then the diagnosis Panic Disorder gave new impetus to Xanax. In double-blind trials, patients on the drug had fewer symptoms after a month than the control group, but in the second month the placebo group caught up! Those taking the drug got worse in the tapering-off phase while the placebo group improved. Investigators fudged the report by reporting only the first week's data. Evidently, Panic Disorder was invented to promote a drug that was worse than useless.
Prozac (fluoxetine), the next "wonder drug", had major flaws in protocols submitted to the FDA by manufacturer Eli Lilly. Zoloft, Pfizer's anti-depressant, was similarly promoted with cherry-picked protocols. FDA data on Celexa, Paxil, Zyprexa and Seroquel showed little difference between drug and placebo, but supportive studies went unpublished. The authors call this "institutional corruption," a partnership between psychiatry and industry that compromised ethical medical practice for private profit.
Whitaker and Cosgrove have a dim view of DSM, with its collection of some 300 psychiatric diagnoses. There are no categories of illness based on etiology or mechanism of pathology, but the APA claims brain involvement whenever possible. Thus with the rise of Attention Deficit Hyperactivity Disorder, methylphenidate (Ritalin), was prescribed because stimulants were known to calm hyperactive children. By 1980 150,000 young patients were taking the drug. By 1994 ADHD was estimated to affect up to 5% of children. After the Ritalin patent expired came Adderall, Concerta, and Strattera, with many paid ads in professional journals. By 2012, 10% of American children and adolescents had the diagnosis and 3.5 million were on methylphenidate.
U.S. adults filled 264 million prescriptions for antidepressants in 2001, up from 30 million in 1980 and greater than any other class of medication. (p. 93) In 2004 the FDA revealed that 12 of 15 pediatric trials of SSRI showed no benefit in trials and found a doubling of suicidal thoughts among teens. Published articles showed only benefits; failures were not published. The majority of psychiatrists working on DSM-5 had financial ties to drug companies. The authors conclude:
"DSM-5--from a commercial perspective--will provide a diagnostic rationale for treating more children with an antipsychotic; more teenagers and adults with a stimulant; more menstruating women with an SSRI...more teenagers and other young adults seen as 'pre-psychotic' with an antipsychotic; and more forgetful older folks with a drug of a type yet to be determined." (p.113)
Spending on psychiatric drugs in the U.S. jumped from $800 million in 1987 to over $35 billion in 2010. The influence and power of the pharmaceutical industry is obvious, but the guild factor in psychiatry can be corrupting (133).The APA first published Clinical Practice Guidelines (CPGs) in 1991, and since then over a dozen more.
Over the last 20 years most academic leaders in psychiatry have had industry ties. Psychiatric CPG panels allowed--indeed, invited--conflicts of interest. Clinical trials should be objective, yet negative studies of antidepressants were not published. APA did not report that antidepressants beat placebo only with a small group of very depressed patients, as reported by psychologist Irving Kirsch. (PLOS Med 5, 2008;, 260-268)
"Our society, over the past 35 years, has organized itself in response to a narrative told by American psychiatry that was, in so many of its details, misleading. Our understanding of the biology of mental disorders, our use of psychiatric drugs, our spending on psychiatric services, and even our social policies arise from a story that has been shaped by guild and pharmaceutical interests, as opposed to a narrative told by a medical profession that has shown an adherence to scientific principles and a commitment--at all times--to the best interests of patients." (p. 155)
Psychiatrists are only four percent of U.S. physicians: most prescriptions of psychotropic drugs come from other physicians. The authors sympathize with psychiatrists who feel betrayed by APA leadership. Drug ads in the monthly journal and bi-weekly magazine support the organization.
As a lifetime APA member I am dismayed by our institutional dependence on drugs. I hope most APA members will view this critical book as constructive and much-needed. The U.S.is the only country that allows prescription drugs to be advertised to the public on television. Older drugs--generics--are less costly and safer: they have a track record. American Physicians and their professional organizations have an ethical obligation to educate patients targeted with television ads, who assume that newer must be better.
© 2016 E James Lieberman
E James Lieberman, M.D., M.P.H., Clin. Prof. Psychiatry, George Washington University, [email protected]