Posted on August 21, 2009, Printed on October 16, 2010
http://www.alternet.org/story/142111/
Some
years ago, a friend told me that he had been diagnosed with a major
depressive disorder and that his
psychiatrist had given him a prescription for Forest Laboratories’
popular SSRI antidepressant Celexa (chemical name, citalopram
hydrobromide; $1.5 billion in sales in 2003). Knowing him to be a
vociferous critic of the pharmaceutical companies, I asked whether he
agreed that the origins of his unhappiness were biological in nature. He
replied that he unequivocally did not. “But,” he confided, “now I might
be able to get my grades back up.”
This
guy was, at the time, a full-time undergraduate student who managed
rent, groceries and tuition only by working two part-time jobs. He awoke
before dawn each morning in order to transcribe interviews for a local
graduate student, then embarked upon an hour-long commute to campus,
attended classes until late afternoon, and then finally headed over to a
nearby café to wash dishes until nine o’clock in the evening. By the
time he arrived home each night, he was too exhausted to work on the
sundry assignments, essays and lab reports that populated his course
syllabi. As the school year dragged on, he had become increasingly
disheartened about his slipping grades and mounting fatigue and decided,
finally, that something had to be done. So he’d seen the psychiatrist
and was now on Celexa.
It is worth reflecting on this anecdote, and others like it, as research proceeds on the upcoming revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V),
a
draft of which is slated for release in late 2009. When perceived
through the aseptic lens of statistics, diagnostic rates, and other
seemingly objective metrics, the urgency with which companies like
Pfizer exhort us to monitor ourselves for sadness or restlessness and to
“ask your doctor if Zoloft is right for you” assumes a superficially
unproblematic aspect. According to the National Institute of Mental
Health, over 17 million American adults are afflicted with clinical
depression each year, costing the national economy $30 billion in
absenteeism, inefficiency and medical expenses. Eighty per cent of those
afflicted will never seek psychiatric treatment, despite the American
Psychiatric Association’s regular reassurances that 80-90 per cent of
chronic depression cases can be successfully treated, and 15 per cent
will attempt suicide. Suicide is, indeed, the third leading cause of
death among American youth aged 10 to 24.
Implicit
to the drug companies’ messianic promises of health, happiness and
economic productivity is a spurious parable of linear scientific
progress: in spite of consistently
inconclusive clinical trials, new psychotropic drugs are regularly
marketed as improvements on old ones, ever more specific in their
targeting of neurotransmitters, ever less productive of pernicious side
effects. While revelations that put the lie to the industry’s feigned
beneficence have belatedly crept into the mainstream press in recent
years, the extent to which our lives and livelihoods have been colonized
by the reductive logic of pharmaceutical intervention remains
breathtaking. As Laurence Kirmayer of McGill University has suggested,
the millennial rise of a “cosmetic” psychopharmaceutical industry,
wherein drugs are “applied like make-up to make us look and feel
good,
while our existential predicaments go unanswered,” raises disturbing
questions about the consequences of our willingness to use chemicals to
treat forms of distress that would seem to signal not biological but
social maladies.
Is it adolescent rebellion or “Oppositional Defiant Disorder”?
What
is revealed about a society, in which drugs are touted with increasing
regularity as a treatment of choice for entirely natural responses to
conditions of unnatural stress?
How have we been persuaded to equate such things as recalcitrant despair
(“Dysthymic Disorder,” DSM-IV-TR 300.4), adolescent rebellion (“Oppositional Defiant Disorder,” DSM-IV-TR 313.81) and social apathy (“Schizoid Personality Disorder,” DSM-IV-TR
301.20) with aberrant brain chemistry and innate genetic
susceptibilities rather than with the societal circumstances in which
they arise? What does it mean when increasing numbers of people feel as
though they have no choice but to self-medicate with dubious chemical
substances in order to stay in school, stay motivated, stay employed,
and stay financially solvent?
In the
summer of 2003, a small group of
psychiatric survivors convened in Pasadena, California, to hold a hunger
strike with the aim of forcing the American Psychiatric Association
(APA) and the National Alliance on Mental Illness (NAMI) to admit that
they had no conclusive evidence to support their claim that mental
illness is based in biological dysfunction. Though the APA was, at
first, quite indignant, it did eventually issue a statement, three weeks
into the strike, conceding that “brain science has not advanced to
the point where scientists or clinicians can point to readily
discernible pathologic lesions or genetic abnormalities that in and of
themselves serve as reliable or predictive bio-markers of a given mental
disorder or mental disorders as a group.”
This
acknowledgement raises interesting
questions. Although medical textbooks and even drug advertisements have,
for years, admitted evidentiary uncertainties in psychiatric research
(as a 2004 advertisement for a Pfizer antidepressant oddly proclaimed,
“While the cause [of depression] is unknown, Zoloft can help”), the
notion that mental disorders are ubiquitously and irrefutably founded in
genetic, neurochemical and physiological anomalies is a mainstay of
Western popular culture. The psychiatric fixation on brains and genes,
vaunted in newspaper headlines on weekly basis, has quite deftly
captured the public imagination, leading many people to view even mild
forms of social maladjustment as pharmaceutically remediable. Today, we
are everywhere urged to repackage
ourselves into medicalized identity categories whenever we discover that
we do not fit the productive, gregarious norm: the 8-year-old who
cannot focus on her spelling exercises because of an energetic
imagination has an attention-deficit/hyperactivity disorder, remediable
with the aid of psychostimulants such as Ritalin or Adderall; the mother
who cannot overcome her grief at losing her son in Iraq has clinical
depression, readily dispatched with regular doses of Paxil, Prozac, or
Lexapro.
Psychiatrist Joel Paris admits in his recent book Prescriptions for the Mind,
that, “in reality, psychiatrists are treating conditions that they
barely understand. Our diagnoses are, at best, rough and ready, and do
not deserve the status of categories in other specialties. We have no
laboratory tests that can reliably identify any mental disorder, and the
measures we use are entirely based on clinical observations.” So, how is
it that psychiatric diagnoses are now the driving force behind a
multibillion-dollar international industry? “The force driving
psychiatry today,” Paris readily grants, “is its wish to be accepted as a
medical specialty.” Indeed, the history of this wish reveals much more
about the inordinate preoccupations of psychiatrists than of their
supposed beneficiaries.
Psychiatry
did not always suffer from biology envy. The project of systematically
categorizing and enumerating
types of mental illness, in fact, began in the United States not as a
medical venture but a criminological one. As philosopher of science Ian
Hacking writes, in the wake of the Industrial Revolution, the increasing
stratification of wealth and resources in Western societies prompted an
exciting new pastime for the educated classes: the scientific
documentation of social misery. Starting with “an avalanche of numbers
that begins around 1820,” physicians developed a raft of new medical
categories within which to group such behaviours as suicide,
prostitution, drunkenness, vagrancy and petty crime. Informal attempts
at condensing these data into diagnostic manuals were made in the
ensuing decades: the 1840 national census documented occurrences of
“idiocy/insanity,” while the 1880 census split these figures into seven
discrete categories: mania, melancholia, monomania, paresis, dementia,
dipsomania and epilepsy. Unsurprisingly, this precipitated a sharp
increase in diagnoses of what became homogeneously known as
“feeblemindedness,” and, by 1918, mental hospitals and asylums
everywhere were bursting with inpatients. The earliest official medical
nosologies of mental illnesses were then adopted in order to better
manage the incarcerated populace.
When the DSM Began
The first editions of the DSM would have been unrecognizable to modern practitioners of psychiatry. The DSM-I,
published in 1952, conceptualized mental disorders as dysfunctions of
personality rather than of neurobiology, following a former president of
the American Psychiatric Association’s advocacy of “mental hygiene,” and
the DSM-II, published in 1968, consisted of 180 categories of
illness framed in a flowery psychoanalytic cant that drew scorn from the
medical community, which viewed it as something of an unscientific
embarrassment. In their 1997 exposé, Making Us Crazy, Herb Kutchins and Stuart Kirk point out that the DSM-II was, in fact, a slim guidebook of dubious analytic value that clinicians could purchase for $3.50, designed to describe, rather than to prescribe, current psychiatric practices.
Things
began to change in the next decade. Following the public outcry over
thalidomide, a tranquilizer that was linked to thousands of birth
defects despite originally being proclaimed safe by its manufacturers,
the U.S. Food and Drug Administration initiated new regulations in 1962
covering the drug industry’s activities: companies were now required to
establish a direct
correlation between the physiological effects of newly designed
compounds and particular medical diseases. This was a fateful moment for
the psychiatric enterprise, which at the time lacked standardized
disease entities to which specific compounds could be tailored.
Increasingly attacked by its critics as unscientific, passé,
inadequately somatic, and borderline illegitimate, psychiatry was in
danger of slipping into medical irrelevance and was in dire need of
reinvention. Enter Robert Spitzer, head of biometrics research at
Columbia University’s Psychiatric Institute. Under Spitzer’s direction,
an aggressive initiative to revise the DSM was launched, new
diagnostic instruments were devised, and quantification became the
disciplinary catchword. When completed in 1980, the DSM-III was, in every sense, an entirely new document. Whereas the DSM-II was 134 pages long, the DSM-III
ran to nearly 500 pages and described 265 mental disorders in
fastidious, grocery-list-like detail. Spitzer, in fact, vehemently
pushed for the DSM to classify “diseases,” though the editorial
board ultimately settled on the term “disorders” in order to placate the
APA-member psychologists who found Spitzer’s overly clinical zeal
disturbing.
Theodore Millon, one of the original members of the DSM-III
revision task force, has acknowledged that the editors’ intentions were,
in fact, to “embrace as many conditions as are commonly seen by
practicing clinicians,” and, in so doing, expand psychiatrists’ access
to fiscal coverage from third-party insurance providers. The rhetorical
paraphernalia of the DSM-III, through which entirely normal
forms of human behavior were transformed into somatic ailments, thus
equipped psychiatrists with an unprecedented level of authority over
problems of mental health throughout civil society, in fulfillment of a
longstanding wish to attain the prestige of other medical specialties.
By reconceptualizing everything from unhappiness to inefficiency to
social anxiety as discrete illnesses, each indexed with formally
objective criteria, fixed etiologies and clear-cut prognoses, the DSM-III’s
authors
– many of whom were recipients of major research grants from
pharmaceutical companies – secured for themselves a substantial gift in
the form of guaranteed insurance remittances, and furnished the drug
barons with an equally lucrative gift: a slate of well-defined
diagnostic entities at which to market their concoctions and, thus, an
elegant solution to the challenges posed by the regulatory pressures of
1962.
In 1994, the DSM-IV
was published to considerable acclaim, with a text revision released in
2000. A quick glance through its list of contributors is revealing. As
was reported in a 2006 study, lead-authored by Lisa Cosgrove of the
University of Massachusetts, 56 per cent (95 of 170) of the researchers
who worked on the manual had at least one monetary relationship with a
drug manufacturer between 1989 and 2004. Twenty-two per cent of these
researchers received consulting income during that period, and 16 per
cent were paid spokespersons for a drug company. The percentages are
even higher – 100 per cent in some instances – for researchers who
contributed to the manual’s subsections on psychotic disorders such as
schizophrenia. While Cosgrove and her coauthors were not able to
determine the percentage of researchers who received funds from the drug
industry during the actual production of the DSM-IV, the chorus of protest that arose following their paper’s publication was telling. “I can categorically say,” roared the DSM-IV’s text and criteria editor, Michael First, “that drug-company influence never entered into any of the discussions, whatsoever.”
First’s
objection is probably accurate.
The implementation of commercial agendas in medical research rarely
takes the form of industry agents archly ordering doctors around. While
it’s true that the annual conventions of the APA have become glitzy
trade fairs, at which attendees spend much of their time absorbing
product pitches, it is the subtler forms of influence that have the most
impact. As Joel Paris points out, “Although nothing forces us
to prescribe their products, marketing strategies work. And the
industries know it.” By sponsoring the scholarly activities of
researchers – such as conferences, whose keynote speakers are often
booked by industry representatives – companies are able to clinch
remarkable levels of good will from academic faculty and medical
residents. The psychiatric literature is, additionally, infested with a
voluminous amount of corporate ghostwriting, wherein drug companies
invite doctors to add their names and, thus, their scientific
imprimatur, to pre-written articles. (In return, naturally, these
doctors get to pad their publication histories.) Many medical journals,
moreover, manage their operating expenses by occasionally publishing
corporate-sponsored “supplements,” which readers are not always able to
distinguish from the journal’s regular issues. Finally, because of
governmental agencies’ lack of interest in funding clinical trials, the
companies have a virtual monopoly on pharmacological research, and have
been free to regularly suppress negative results and finesse
methodologies in order to generate favorable outcomes. The drug
companies are now de facto members of the medical research community, and it has become virtually impossible to determine where the
academy ends and the industry begins.
One Nation of Self Medicators (under Shrinks and Drug Companies)
As the history of the DSM
makes clear, it is not possible to speak of modern psychiatric
nosologies without speaking of the professional interests from which
they have arisen. The serviceability of this branch of the
medical-industrial complex to the neoliberal fetishization of state
noninterference, finally, should not be underestimated. With the
innovation of increasingly marketable psychotropic drugs over the past
four decades, public health officials have been free to legitimize
healthcare budget cuts, hospital closures, and the widespread
dismantlement of social services, by devolving responsibility for mental
health to the individual and by transforming happiness into a problem of
consumer choice. Miserable people – the exhausted assembly-line worker,
the desperate college student, the alcoholic veteran – no longer
pose a threat to the status quo so long as they agree to self-medicate
and to keep themselves, thereby, in a state of artificial equanimity. As
sociologist Nikolas Rose says, “In the majority of cases, such treatment
was not imposed coercively upon unwilling subjects, but sought
out by those who had come to identify their own distress in psychiatric
terms, believe that psychiatric expertise would help them, and were
thankful for the attention they received.” And this is the crux of the
matter.
A common objection to
criticisms of our
society’s growing infatuation with psychopharmaceuticals is that
distressed people should be free to undertake whatever course of action
they feel is necessary to dispel their misery. I cannot dispute this
contention. No one who is familiar with the texture of crushing,
existential despair can fail to sympathize with another person’s
decision to resort to whatever is available to help them through the
day, and it is not my intention to indict the personal logics that
underpin these choices.
The
rationality of consumer choice, however, is inevitably limited insofar
as authentic data on the health risks of specific compounds are rarely
available in the public domain, and insofar as the drug companies
continue to inundate airwaves, newspapers, magazines and billboards with
mollifying untruths about the efficacy of their products. As Alexander
Cockburn has recently revealed in this newsletter, as much as a third of
consumers who view an advertisement for a particular prescription drug
go off and talk to their doctors about it, and nearly half of those who
ask for a drug end up getting a prescription for it. How many of these
consumers know of the plethora of peer-reviewed studies that have
demonstrated that selective serotin re-uptake inhibitors (SSRI)
compounds are closely linked with violence and suicide? What percentage
of those who have come
to conceptualize their pain in biological terms are aware that
definitive links have yet to be established between neurotransmitter
action and complex, culture-bound emotional states such as grief,
anguish and loneliness?
Data
manipulation and elision are rampant in psychopharmaceutical research.
The list of revelations, both current and years-old, is extensive and
can be elaborated only in brief.
In the 1990s, the litigation-averse Los Angeles Times killed an investigative report coauthored by Alexander Cockburn and former Scientific American
editor Fred Gardner, in which evidence was presented linking Prozac to,
among other things, domestic violence and tumor growth. Journalist Evelyn Pringle has, more recently, reported on the CounterPunch
website that Janssen-Cilag’s antipsychotic Risperdal (chemical name,
risperidone; $3.5 billion in sales in 2005) induced severe side effects,
including strokes and death, in 1,207 children between 1993 and 2008.
Two recent studies, conducted independently in the United States and
Great Britain, have additionally revealed that newly released
antipsychotics differ from their predecessors only in price, not in
efficacy or safety.
But a question
remains. What if, in some hypothetical future, a new generation of
unambiguously safe and effective psychotropics could be developed? Would
it become ethically acceptable to urge the depressed and the despondent
to take drugs?
When psychiatrists
lament that over half of depressed people are “treatment-resistant,”
what they do not consider is this. It is not the “stigma” of being
labeled mentally ill that discourages many people from seeking medical
help; it is a strenuous aversion to being told that one’s existential
grievances are irrational, a mere result of a pathological neurochemical
imbalance. It is the fear of being coerced into ingesting foreign
substances, whether safe or dangerous. Since 1997, the National Alliance
on Mental Illness has sought to expand a medication compliance program
first developed in the 1970s, wherein mental health workers visit
outpatients on a daily basis to confirm that they’ve taken their drugs,
and to forcibly administer drugs if necessary.
We
are at a strange point in history. It should come as no surprise that
the exhausting and alienating conditions in which we live and labor are
productive of myriad forms of psychological suffering. Yet, critics of
biological psychiatry are commonly subjected to the fallacious
accusation that, because we reject the equation of unhappiness with
sickness, we must believe that it is a weakness. This is a false
dichotomy. Is it so difficult to understand the pain engendered by life
under neoliberal capitalism as something worthy of dignified reflection,
irreducible to either sickness or weakness? Is it so hard to grasp that
to detrivialize the social conditions that give rise to despair or the
ideologies that equate difference with disease is not to trivialize
despair or difference?
Let’s be
candid. The drug barons’ ongoing campaign to pathologize entirely
natural emotional responses to hunger, humiliation, financial
insecurity, racism, sexism, overwork and isolation is a mercenary
tactic, designed to create markets, maximize profits and minimize
dissidence. Whether intended or unintended, the consequence is that we
have come to reflexively view ourselves – our bodies, brains, and genes –
rather than our societal environment as pathogenic, against all
evidence to the contrary. As the DSM-V looms, we have to explore the dire implications of this trend and contintue to raise the alarm.
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