MAY 19, 2013
1. Ordering Madness, Disordering Civilization
MAY 2013 IS A REMARKABLE MOMENT in medical history. Nearly a quarter century ago, President George H. W. Bush proclaimed the 1990s “the decade of the brain” and, as that decade drew to a close, the American Psychiatric Association began assembling a task force of experts to undertake the long process of completely revising the criteria it uses to diagnose mental disorders. Its charge was to develop a new version of its Diagnostic and Statistical Manual (hereafter DSM) that would bring our understanding of mental illness into conformity with the most recent and remarkable advances in brain science. Nearly a decade and a half later, that enormous cooperative effort, which enlisted the assistance of thousands of skilled mental health professionals, has reached fruition. The partial and flawed manuals of the past have been replaced by a shiny new version, running to more than 1,000 pages. This new version promises to transport us into a brave new psychiatric world — one that takes account of all the enormous progress that has been made in recent decades in neuroscience and psychopharmacology, and that marks a major step forward for the profession of psychiatry and those who need its services.
Or so DSM 5’s architects, and the American Psychiatric Association that employed them and makes millions of dollars a year peddling that enormous tome, would have you believe. But perhaps all is not quite so rosy. Certainly Gary Greenberg (a PhD psychotherapist) and Michael Taylor (who prefers to call himself a neuropsychiatrist) think it is not. Their respective analyses of the DSM project are equally scathing, though they approach the problem of mental illness from opposing points of view. Greenberg is deeply skeptical of psychiatry’s claim “that psychological suffering is best understood as medical illness.” Taylor, on the other hand, regards Freud as a fraud, disdains the notion that mental illness has any meaning, or has its roots in meaning, or could possibly be treated by addressing psychological issues. For him, mental symptoms are so much epiphenomenal noise, the surface manifestations of the disordered brain, which is the sole and singular source of mental troubles. Greenberg, by contrast, views the attempt to reduce human woes to defective brains as what philosophers call a category mistake (he does seem willing to cede a place for biology in the genesis of some kinds of mental disturbance, but insists this remains speculative, not scientific). Taylor minces no words when expressing his disdain for psychotherapeutics, and psychoanalysis in particular. He uses such adjectives as “baseless,” “silly,” “useless,” and “destructive,” and truculently asserts that “if psychodynamic therapies were medications, their support by the U.S. psychiatric establishment would be a scandal.”
Both men, though, see the DSM as a disaster — a psychiatry built upon such foundations as a rickety, unsafe, unscientific enterprise that faces looming catastrophe. And as weird as it is to see two such narcissistic know-it-alls (see DSM IV TR diagnosis 301.81, Narcissistic Personality Disorder) agreeing on anything, in view of their completely divergent starting points and competing grandiose senses of self-importance, they may well be right.
2. The History of the DSM
Let us begin with some brief historical context. The new DSM is by its own count the fifth iteration of American psychiatry’s attempt to create some order out of the chaos of mental illness. Some might quibble and call it the seventh version (there was a DSM III R, or revised edition, and a DSM IV TR, or text revision, which I referred to above). But let us keep the count at five for simplicity’s sake, and confine ourselves to noting that, in its most recent incarnation, the manual has moved from Roman numerals into the Arabic numerology the rest of us use. This is not because its architects wanted to avoid pretension, though that would have been a laudable goal, but because they wanted to borrow from the conventions of the software industry and pave the way for interim revisions: no more III R’s or IV TR’s; now we can switch to DSM 5.1, DSM 5.2, and so on.
The world before DSM III, however, doesn’t really count. The first two editions of the manual emerged in 1952 and 1968, during psychiatry’s infatuation with Freud. Psychoanalysts were focused on what they deemed the psychopathologies of the individual case before them. They had next-to-no interest in the construction of broad nosological categories. Their manuals were thus crudely thrown together, spiral-bound pamphlets. Even the second version ran to no more than 134 pages, a compilation of perhaps 100 different diagnoses that were attached to the most cursory of descriptions. The different disorders were linked to speculations about their likely psychodynamic origins. Of marginal use bureaucratically in the large state hospitals that still housed hundreds of thousands of inmates, the DSM was of little or no interest to most psychiatrists who practiced outpatient psychiatry, now the majority of the profession. It was so insubstantial that it wasn’t even as useful as a paperweight. It cost a mere $3.50, and that was more than most practitioners thought it was worth.
DSM 5 will sell for $100 a copy or more, and will realize profits running into the tens of millions for the organization that owns (and jealously defends) its copyright over its expected lifetime; even as it stood on the brink of being discarded, the DSM IV TR was still contributing $5 million a year to the American Psychiatric Association’s coffers. Any mental health professional who expects an insurance company to reimburse him or her for services must use DSM categories, even if that means jamming the messiness of a patient’s problems into its preordained patterns. Choose the wrong category, and payment will be denied, or reimbursement levels curtailed. Since the verbiage is vague, and the categories broad and overlapping, it doesn’t take much to find something that suits. The reach of the DSM now extends far beyond US borders; drug trials and drug treatments have come to be tied to its diagnostic categories, and so non-Americans increasingly rely on it too.
This shift to a psychiatric world dominated by a book — or rather, to an anti-intellectual collection of categories jammed between two covers — can be dated quite precisely. The publication of DSM III in 1980 ushered in our so-called neo-Kraepelinian world (an era named after the fin-de-siècle German psychiatrist who first distinguished between dementia praecox — later renamed schizophrenia — and manic-depressive psychosis). Each of the ensuing revisions of psychiatry’s manual has codified its own fundamental approach to the universe of mental disorder, and that approach has come to dominate our understanding of mental illness. Not entirely by coincidence, a few years after the appearance of DSM III, the psychoanalytic hegemony in American psychiatry collapsed, to be replaced by an emphasis on biology, neuroscience, and drugs.
As both Taylor and Greenberg make clear, the advent of the DSM III world was a response to a political and epistemological crisis in American psychiatry. A variety of critics, some labeled anti-psychiatrists (though they included at least one prominent psychiatrist, Thomas Szasz) and others from the legal profession and from neighboring social sciences were beginning to attack psychiatry’s scientific credentials, intimating that it operated principally as an engine of social control. Controversies had already erupted about the use of psychiatry in the Soviet Union to silence political dissidents by labeling them schizophrenic. Some psychiatrists began to examine the reliability of their profession’s diagnostic practices, and the data these people produced was disturbing. For instance, even under ideal circumstances, agreement between any two psychiatrists rarely reached 50 percent. It was deeply embarrassing when a careful study of comparative diagnostic practices in London and New York showed a stunningly wide discrepancy between the two groups of professionals: American psychiatrists often saw schizophrenia where their British colleagues diagnosed manic-depressive illness. Drug companies, who were by now making huge profits from drugs designed to treat mental illness (the first so-called antipsychotic, Thorazine, was marketed in 1954 and catapulted its owner, Smith, Kline & French, into the vanguard of pharmaceutical houses) were increasingly disturbed by this state of affairs: how could they develop profitable new compounds, and persuade the Food and Drug Administration to allow them to come to market, if they could not assign homogeneous (or apparently homogeneous) groups of patients to placebo and active treatment groups? This problem grew more urgent as the years passed; to secure regulatory approval, more and more patients were needed across a multitude of cross-national sites to generate the requisite (albeit slight) differences in statistical (not clinical) significance. (Where drug effects are large and unambiguous, small groups suffice to generate statistically significant results; where effects are comparatively tiny, as is generally the case in the psychiatric realm, larger and larger samples are needed. More trials enable a higher probability of finding a couple of stray positive ones; the data on failed trials can then be buried — though not always securely, as we shall see.
Worse was ahead. A Stanford social psychologist, David Rosenhan, decided to put psychiatry’s diagnostic acumen to the test. He recruited a number of pseudo-patients, screened to exclude anyone with a prior history of psychiatric disorder, and instructed them to show up at a local mental health facility and complain they were hearing voices saying things like “empty” and “thud.” Otherwise, they were to behave normally and await developments. All were admitted as inpatients and diagnosed as psychotic — mostly as schizophrenic, an extremely grave diagnosis. Patients recognized the fakery. Doctors did not. When sent home, many were discharged as having “schizophrenia in remission.” One patient had to be rescued after several weeks in confinement.
Reported in the august pages of Science, the most important general circulation science journal published in North America, under the title “On Being Sane in Insane Places,” Rosenhan’s study caused a furor. In vain, psychiatrists tried to complain that the study was unfair and methodologically flawed. They were flayed in the court of public opinion as charlatans — as incapable of making even basic judgments about health and illness. Psychiatry seemed a joke, an arbitrary business with horrendous potential consequences for those given a psychiatric diagnosis. If psychiatrists were incapable of judging who was mad and who was sane, why should anyone think they were any better at treatment? The legitimacy of the entire profession hung in the balance.
That was the context in which the group of psychiatrists led by Robert Spitzer of Columbia University came together in the 1970s, charged with revamping psychiatry’s approach to diagnosis. In many respects, their efforts must be judged a remarkable success. Early on, they disdained any concern with validity — that is, with making sure that the distinctions among psychiatric diagnoses corresponded to real differences out there in the world or, to put it another way, that they were cutting nature at the joints. Few of us doubt that the distinctions between, say, pneumonia and tuberculosis are grounded in real pathological differences between the two, and real internal commonalities in the pathology of each disease. We would be wise not to invest as much confidence in differences among psychiatric labels. But if validity was to be set aside, reliability was not to be jettisoned. Reliability is the statistically demonstrable ability of any two clinicians confronted with the same patient to assign him or her the same diagnostic category. This was where Spitzer and his team concentrated their efforts.
To accomplish their ends, the DSM III task force adopted a “tick the boxes” approach to assigning illness labels. Find any six from a list of 10 symptoms, and voilà, a schizophrenic. Why six? Well, as Spitzer later put it, that felt about right. How many categories of illness to accept, and which ones? Here, too, there was much politicking at work. And so the number of mental illnesses proliferated, a process that has continued unchecked all the way down to the publication of DSM 5, which will now for the first time contain such new “diseases” as “Hoarding Disorder,” “Disruptive Mood Dysregulation Disorder” (proneness to outbreaks of violent, uncontrollable rage), and in an Appendix, “Attenuated Psychosis Symptom Syndrome” — a category likely to be applied to young children, supposedly identifying those with a greater potential to become full-blown psychotics, though the vast majority of those so labeled do not proceed down that pathway. With each iteration, the manual has grown larger, as has the range of human behavior brought within psychiatric profession’s ambit. The latest version, for example, controversially erases a distinction between bereavement and depression, accentuating the danger, as other critics have commented, that ordinary sadness and other human emotions will be pathologized and then treated with powerful (and profit-making) pills — powerful and dangerous, but not necessarily effective. These pills are certainly not psychiatric penicillin.
In 1994, a task force led by Allen Frances published the fourth edition of the DSM. In many respects, it followed dutifully in Spitzer’s footsteps, though continuing to add new diagnoses, and to broaden and weaken the criteria that had to be met for a particular diagnosis to be assigned. Frances would later issue a mea culpa, confessing that the epidemics of autism and depression that followed the issuance of DSM IV were largely iatrogenic — the product of a series of well-intentioned mistakes on his part. It would prove a highly controversial claim, sparking angry responses, not just from fellow-psychiatrists but from the families of patients with children diagnosed with Asperger’s syndrome or autism, who saw him as belittling or denying the troubles and difficulties they and their offspring faced. They also saw it as a threat: access to needed social and educational services depended on their children’s diagnosis.
3. A Profession in Crisis
Greenberg’s The Book of Woe is a journalistic account of how DSM 5 came into being. It rests upon many interviews, his own very marginal involvement in the field trials designed to test a portion of the book, and attendance at seminars and meetings where the work proceeded and where it came under withering criticism. It is a convoluted but fascinating tale of professional conflicts and jealousy, backbiting and backstabbing, allegations of cupidity and greed, and maneuvers by the American Psychiatric Association. Irony of ironies, it reminded me of nothing so much as the campaigns of legal harassment and the attempts to undermine critics’ reputations undertaken by psychiatry’s powerful enemy, the Church of Scientology. By turns brash and self-consciously populist, Greenberg’s prose is also marred by his constant need to inject himself into the story. He pirouettes and preens, exaggerating his own importance, which distracts the reader from the underlying seriousness of the issues his account raises. But, this said, his reporting adds up to a serious indictment of the disturbing details behind the construction of an extremely consequential document, and raises major questions about the future of American psychiatry.
DSM 5 was supposed to be different from its predecessors. Those put in charge of the enterprise announced that the logic underpinning the two previous versions was inherently flawed, and that they would fix things. Drawing on the findings of neuroscience and genetics, they would move away from the symptom-based system they now acknowledged was inadequate, and build a manual linking mental disorders to brain function. They would also take account of the fact that mental disorder is a dimensional, not a categorical, kind of thing: a matter of being more or less sane, not a black and white world with sanity in this corner and mental illness in that. It was a grand ambition. The only problem was that it was an ambition impossible to fulfill. All the pretty pictures conjured up by neuroscientists playing with functional magnetic resonance images could not and did not provide what the architects of the DSM needed. Crude measures of blood flow to different regions of the brain (which is what fMRI images are built on) were a poor substitute for tying together behavioral symptoms and brain defects in a robust causal fashion. Nor was genetics any better at providing the necessary answers. Having initially thrashed about pursuing this chimera, those running the task force were ultimately forced to concede defeat, and by 2009 they were back to tinkering with the descriptive approach.
Then the fun started. The architects of DSM III and DSM IV, men who had built their careers on this very approach, launched an increasingly fierce attack on the work of their successors. Robert Spitzer began the assault, but he was ailing with a bad case of Parkinson’s disease. Soon Allen Frances, who had retired to Southern California to take care of his wife, took up the cause. Frances proved a tenacious critic who moved beyond purely intra-professional criticism and launched a sustained campaign of vilification in the mainstream media. Relentlessly, he and Spitzer attacked the science (or lack of science) that lay behind the proposed revisions, and raised warnings that they would further reveal psychiatry’s tendency to pathologize normal human behaviors. For orthodox psychiatrists, it was a deeply embarrassing spectacle. It is one thing to be attacked by Tom Cruise and the Scientologists, quite another to come under withering assault from one’s own. Wounded, the leaders of American psychiatry struck back with ad hominem attacks, alleging that Spitzer and Frances were clinging to past glories, and going so far as to suggest that the latter, by far the more energetic of the two, was motivated by the potential loss of $10,000 a year in royalties he still collected from DSM IV. (Left unmentioned was how dependent their professional association had become on the multimillions in royalties a new edition promised to provide.) The prolonged spat forced a delay in the issuance of the new manual, but seems to have done little to alter its basic structure and contents.
Frances, in particular, has been one of Greenberg’s key informants, though an increasingly reluctant one because, for all his noise, he remains at heart loyal to the psychiatric enterprise in ways Greenberg is not. But there have been plenty of others willing to share information about the sausage-making. Not many of them, though, have come from within the charmed circle actually working on the new edition of the manual. The APA made everyone who joined the enterprise sign a non-disclosure agreement, and it has aggressively sought to enforce this policy. Interim documents posted by the task force on the web have later vanished: a futile attempt to manipulate history. (Greenberg is not the only one who took the precaution of downloading these documents to prevent their being airbrushed away.) An amateur British blogger, Suzy Chapman, had the chutzpah to start a site devoted to linking the critics of the revisions and assembling their objections. She found herself threatened by the APA’s corporate lawyers — told that the very name “DSM” was protected by US trademark law, and if she used it, she should expect to be sued. Again, the bullying backfired. Word of what had happened leaked, and , renamed, attracted more traffic than ever.
4. Godot Psychiatry
All this suggests a profession in crisis. One particular diagnosis of that crisis, and a suggested way forward for the profession, is offered by Michael Alan Taylor in Hippocrates Cried: The Decline of American Psychiatry, who suggests the need to reengage with biology, coupled with an insistence on psychiatry’s exclusively medical identity. As far as he is concerned, such a reorganization of the profession has not happened to date. Thus, his book is a lament, as its subtitle indicates, for “the decline of American psychiatry.” It is an interesting notion, because to speak of a decline suggests that once upon a time — who knows quite when? — the profession was in healthy shape, only to fall victim to bad choices and fall away from its previous state of grace.
True or not, Taylor’s cri de coeur is for a world he claims we have lost. His story mixes personal experience and partially disguised anecdotes about individual patients with sweeping characterizations of changes in the psychiatric universe. Virtually all of them, if he is to be believed, are changes for the worse, betrayals of the one true path that ought to have characterized his profession. Naturally, everyone except Michael Taylor and a handful of other enlightened psychiatrists (or neuropsychiatrists, as he would prefer) has ignored the arduous path of true psychiatric science. Taylor’s first chapter is titled “The Origins of Indignation,” and his book is in many ways an unrelieved jeremiad.
It is hard, however, to know quite where to locate the missing Age of Gold. Certainly it did not exist when Taylor joined the profession in the 1960s, the last decade of a psychoanalytic dominance he deplores. Nor can it be found, as he is at pains to make clear, in the years since.
At one point in his reflections, he does suggest a time and a place in which his psychiatric paradise might be found. Astonishingly (at least so far as this psychiatric historian is concerned), he points to the late 19th century as that paradise lost — a period, he asserts, when “U.S. psychiatry, at least in the northeastern part of the country, was as good as any in the world.” The narrow geographical focus is, I think, an attempt to make plausible what otherwise would seem a bizarre claim. After all, as the 19th century drew to a close, America’s mental hospitals, like their counterparts elsewhere, were widely seen as little more than cemeteries for the still-breathing. The alienists who ran them (the term “psychiatrist” had not yet been embraced by the asylum superintendents) explained that mental illness was hereditary and hopeless; their charges were a bunch of degenerates. The primary justification for vast mental hospitals was their crude ability to isolate these defectives and prevent them from reproducing more of their own kind. That sort of late 19th-century psychiatry would be an odd sort of nirvana.
In the northeast United States, however, a new group of specialists had emerged in the aftermath of the Civil War, and these men appear to be the object of Taylor’s veneration. They called themselves neurologists, and, like Taylor and his embattled coterie of the enlightened in the early 21st century, they “understood behavioral symptoms to be reflections of brain or nervous disorder.” “The medical model of diagnosis prevailed,” Taylor writes; psychiatric disorders were seen “as reflections of different brain diseases that were only waiting the detailing of their neuropathology.” Here is “the neuropsychiatric alternative” that is the otherwise obscure object of Taylor’s desire, and at the root of the prescription he offers his profession as it seeks a way forward out of what he regards as its current epistemological and clinical swamp.
This choice is still, I think, a curious one, and not just because we are still waiting — like the poor folks waiting for Godot — for those mysterious and long rumored neuropathological causes of mental illness to surface. After all, Taylor’s heroes — he seems particularly enamored of William Hammond and Edward Spitzka — had no scientific warrant for their claims that mental illnesses were brain diseases. Theirs were claims based on faith, a wager on what medical science would discover at some uncertain point in the future. It is a wager that has yet to pay off (save in the important case of the syphilitic origins of what used to be called General Paralysis of the Insane). The same objection can be raised about Taylor’s assertion that he knows the one true way forward for his profession. As for therapeutics — those fin-de-siècle gentlemen’s prescriptions for their “brain diseased” patients — they ran the gamut: the use of shiny machines made of polished brass and chrome to deliver jolts of static electricity to stimulate nerves; enforced bed rest and high calorie diets to build up “fat and blood” and restore the elasticity of the nervous system; nerve tonics, not to mention the extracts from animals’ testicles that William Hammond peddled on a large and profitable scale to his many anxious patients.
That was a rum sort of Golden Age.
Leaving Taylor’s strange quest aside, how does he justify the claim that his is a profession in decline? As I’ve suggested, if Taylor loathed the psychoanalytically-inclined profession he joined in the 1960s, he is no more enchanted by what has succeeded it. In his eyes, the DSM from the third edition forward — and of course the less said about its Freudian predecessors the better — has been:
[A] political rather than a scientific document […] [T]he process was and is very much like congress writing legislation. The procedure is messy and the results are wanting. Instead of “earmarks” we have new never validated labels and distinctions, such as shared psychotic disorder, identity disorder, schizophreniform disorder, bipolar I, II, III as separate diseases, and many other “bridges to nowhere.”
Diagnoses have proliferated, but not because of any advances in the profession’s scientific understanding of mental illness. “The explosion of diagnoses […] is a fabrication of the political process […] The pharmaceutical industry adores the explosion of conditions, because as ‘medical diagnoses’ the DSM categories provide the rationale for prescribing drugs.”
Most outside observers looking at American psychiatry since 1980 see a profession seemingly wedded to biological reductionism, one that insists that all mental illness is rooted in the brain and is thus a disease like any other. But Taylor is convinced that these assertions are no more than ideological window-dressing. There is no serious attempt, he asserts, to pay proper attention to brain pathology and to connect it to the diagnostic process, and to treatment. Residents are not trained as they should be, and still get instruction in the ridiculous enterprise that is psychotherapy, which he dismisses as a useless form of treatment that they will generally abandon when they become professional adults. In day-to-day practice, his colleagues have become wedded to a descriptive manual that is founded on pseudo-science, and have sold out to the blandishments of the drug companies, becoming little more than glorified pill-pushers.
5. The Marketplace of Mental Illness and Diagnosis
Both Taylor and Greenberg are at pains to point out just how blatant this corruption of psychiatry has become. More than half of those working on DSM IV had undisclosed ties to the drug industry. In the group working on mood disorders, that included 100 percent, while for the groups working on anxiety disorders, it was 80 percent. Though the DSM 5 Task Force has made pro forma declarations of financial ties, close ties between clinicians and industry remain the norm. They have risen, in fact, from 57 percent of those who worked on DSM IV to 80 percent this time around — a pattern that is not unique to psychiatry, but is particularly pernicious here because the very definition of what constitutes psychiatric illnesses remains subjective.
Unsurprisingly, in the latest iteration, as Taylor reports:
Guidelines were weakened for identifying several conditions, raising concerns that the mental health system would be overwhelmed by persons meeting the new diagnostic criteria but who would not be ill. Standards for acceptable reliability were also watered down so that the present field trials of the proposed system yielded results that were worse than what was experienced in previous versions, including DSM II. The watering down will help the pharmaceutical industry because as more persons are identified as ill, the justification grows for increased numbers of prescriptions.
The problem runs deeper than professional corruption, however. In at least one highly publicized instance, the draft of DSM 5 proposed to tighten a set of definitions. The label of “autism” (and of a number of related “illnesses”) was to be replaced by the global category of “autism spectrum disorders;” in the process, “Asperger’s syndrome,” a widely used diagnosis, was slated to disappear. Many people presently receiving such a diagnosis were likely to find themselves cast adrift. For such patients and their families, the loss of the label implied potentially catastrophic consequences, since access to an array of publicly funded social and educational services is conditional on being given the requisite medical diagnosis. The backlash was predictable and fierce. It turns out that it is easy to broaden the criteria of psychiatric disability. To reverse the process is extraordinarily hard.
In fact, as some troubling passages in Greenberg’s book make clear, the insidious and corrupting influence of Big Pharma and its allies on the practice of psychiatry has run much deeper than its influence on the manuals themselves. Not content with the vast array of “diseases” they were already licensed to identify, “opinion leaders” in the profession have constructed still more disorders from which to profit. A particular target of Greenberg’s ire is Joseph Biederman, a leading child psychiatrist at Harvard who, together with his associates, masterminded the construction of childhood bipolar disorder, and began to prescribe particularly dangerous and often life-threatening drugs to children “off-label” — that is, without even a modicum of testing for safety and efficacy in such patients.
It is one of the peculiarities of American medicine that once drugs have undergone the long and expensive process of licensing for one purpose, clinicians may prescribe them casually for others despite the lack of scientific data to warrant such practices. Drug companies themselves are forbidden to overtly endorse this practice — more on that anon — so the work-around has been to get “opinion leaders,” by way of prominent academic physicians, to tout the off-label uses and encourage their sheep-like followers (and desperate consumers) to embrace the new magic bullet. Biederman, along with Charles Nemeroff, who was then at Emory University, and Alan Schatzberg of Stanford (the 116th President of the American Psychiatric Association) are in many ways poster boys for this sort of behavior. Ironically, it was Schatzberg, during his presidency in 2009, who responded vehemently to Allen Frances’s criticisms of the DSM 5 task force by pointing to the $10,000 in royalties Frances was still receiving from DSM IV. Apparently, the $4.8 million in stock options Schatzberg had in a drug development company, or the fat fees he received from such companies as Pfizer, had no similar distorting effect on his judgment — just as the $960,000 Charles Nemeroff received from GlaxoSmithKline (while reporting only $35,000 to his university) had no influence on him. And just as the millions of dollars that Biederman and his associates at Harvard received for creating a new diagnosis and a massive new market for antidepressants and second-generation antipsychotics among young children (drugs associated with massive weight gain, metabolic disorders, diabetes, and premature death) had nothing to do with their behavior!
To Greenberg’s credit, he is fiercely skeptical of such disingenuousness. Biederman seems a particular target of his ire. He quotes another child psychiatrist, David Shaffer of Columbia, on the epidemic Biederman helped spawn: “Biederman was a crook. He borrowed a disease and applied it in a chaotic fashion. He came up with ridiculous data that none of us believed” — but that was, I would add, swallowed wholesale by many in the media and by desperate parents. “It brought child psychiatry into disrepute and was a terrible burden on the families of the children who got that label.”
The sentiments are clearly ones Greenberg shares. But crook or not, Biederman remains ensconced at Harvard, as influential as ever, and Schatzberg is still at Stanford (though perhaps coincidentally, perhaps not, he ceased chairing its department of psychiatry in 2010). Emory at first did nothing about complaints directed at Nemeroff, but in the aftermath of intense political pressure from the United States Senate, and from Senator Chuck Grassley in particular, he was subsequently stripped of his department chairmanship and forbidden from accepting more drug company largess. He soon left the university. Not to worry, though; he has since resurfaced as chair of psychiatry at the University of Miami. The reality is that these academics attract boatloads of funding for their research, and America’s research universities have learned to turn a blind eye to ethical failings if the money on offer is sufficiently tempting.
If all these shenanigans provide ample support for Taylor’s claim that his profession is in crisis, the rot does not stop there. Antipsychotic and antidepressant drugs routinely rank among the top five most profitable classes of prescription drugs on the planet, and, as always, the great bulk of those profits are earned in the United States. In pursuit of them, the multinational drug industry has been ruthless and unscrupulous. There has been much talk in recent years about evidence-based medicine, but for such an approach to work, the evidence has to be what it seems.
And it is not. The drug companies own the double-blind controlled trials on which we rely to assess the worth of new medications lock, stock, and barrel. They own the data. They manipulate the data. They conceal the data they don’t like and that are at odds with their self-interest. Their public relations flacks ghostwrite scientific papers that then appear in even the most prestigious medical journals — Journal of the American Medical Association, New England Journal of Medicine, The Lancet — with the names of the most prominent academic researchers appended. Data about side effects, even fatal side effects, are suppressed and hidden, and then see the light of day only through the discovery process provided by class-action lawsuits. Meanwhile, direct-to-consumer advertising increasingly drives drug sales, and neither physicians nor their patients seem to grasp or act upon the difference between statistical significance and clinical significance.
Greenberg and Taylor at best only mention in passing this whole sorry aspect of the mess that constitutes contemporary psychiatry. It has recently been dissected at length by David Healy, an Anglo-Irish psychiatrist who ranks high on Big Pharma’s most-hated list. His Pharmageddon (University of California Press, 2012) deserves much more attention than it has received to date.
Problems of this sort are most certainly not unique to psychiatry, as anyone who recalls the scandals over the Vioxx painkiller will know. But they have been a notable feature of the psychiatric landscape over the past decade, creating an avalanche of bad publicity, and on occasion the award of swinging damages. GlaxoSmithKline, for example, pled guilty to criminal charges and paid $3 billion (yes, that’s with a “b”) to settle accusations of consumer fraud in the marketing of its antidepressant, Paxil, whose annual sales, it should be noted, were $2.7 billion. Pfizer paid $430,000 in damages in a single lawsuit over its illegal promotion of the off-label use of Neurontin, an antiseizure drug, for psychiatric disorders — a sales campaign that had propelled the drug to $2.7 billion in sales in 2003; it now faces a class-action federal lawsuit brought by Aetna Insurance for the same behavior that may well result in massive damages. Bristol-Myers Squibb settled similar claims in 2007 about its marketing of its drug Abilify, a so-called atypical antipsychotic, for $519 million. Johnson & Johnson was fined $1.2 billion for concealing the risks of weight gain, diabetes, and stroke associated with its antipsychotic drug Risperidone. And so it goes. Other lawsuits have brought to light the deliberate suppression of data pointing to a higher risk of suicide among children and adolescents prescribed selective seratonin reuptake inhibitors (SSRIs), the most widely prescribed group of antidepressants. For years, Big Pharma had denied that such data or risks existed.
Perhaps these awards, and the associated unfavorable publicity, help to explain why Big Pharma now seems reluctant to fund further research in psychopharmacology, and has sharply cut the financial subventions it used to provide to the American Psychiatric Association. Greenberg reports of the APA:
[Its] income from the drug industry, which amounted to more than $19 million in 2006, had shrunk to $11 million by 2009, and was projected to fall even more [….] [In addition] journal advertising by the drug companies was off by 50 percent from its 2006 high.
6. Is It All A Con Game?
Last year, in a piece published in the Times Literary Supplement, I commented that the American Psychiatric Association’s decision to issue yet another flawed version of its Diagnostic and Statistical Manual was a huge gamble. I argued that it had, over the years, built a vast and ramshackle superstructure on impossibly frail foundations, and so it had to be praying that the whole Rube Goldberg contraption didn’t collapse in a heap of rubble. Like most prayers, the APA’s have gone unanswered —or else they have received an answer that the organization’s sins deserve. On May 6, just two weeks before DSM 5 was due to hit the marketplace, there came an announcement from Thomas Insel, the director of the National Institute of Mental Health. The manual, he proclaimed, suffered from a scientific “lack of validity […] As long as the research community takes the DSM to be a bible, we’ll never make progress. People think everything has to match DSM criteria, but you know what? Biology never read that book.” NIMH, he said, would be “reorienting its research away from DSM categories [because] mental patients deserve better.” Ouch. In the spirit of piling on, one of his predecessors as director of the Institute, Steven Hyman, added his assessment of the whole enterprise. It was, he opined:
totally wrong in a way [its authors] couldn’t have imagined […] [W]hat in fact they produced was an absolute scientific nightmare. Many people who get one diagnosis get five diagnoses, but they don’t have five diseases — they have one underlying condition.
Robert Spitzer and Allen Frances, not to mention Michael Taylor and Gary Greenberg, appear to have found sympathetic ears for their criticisms.
Actually, it is a bit more complicated than that. Insel, I think, would have no issue with the approaches to mental disorders that underlie Gary Greenberg’s critique. His sympathies lie firmly with the brand of neuropsychiatry that Michael Taylor argues is the way forward for the profession: an emphasis on the putative biological bases of mental disorder to the exclusion of any other approach. It is a pretty fantasy, one that aligns nicely with President Obama’s announcement on April 2nd, 2013 that he planned to fund a $100 million initiative — BRAIN, or Brain Research Through Advancing Innovative Neurotechnologies — to unlock the “enormous mystery” of the human brain. There’s only one problem: as yet we lack even the rudiments of the knowledge we would need to reconstruct psychiatry on such a biological foundation. We don’t even possess enough knowledge to allow us to put all our eggs safely in this basket. Indeed, many of us would agree with Gary Greenberg that it is highly unlikely that the complexities of mental illness can be reduced to such crude over-simplifications.
We’re stuck. Descriptive psychiatry is a shambles, as both Taylor and Greenberg’s books help to show, and as the events of this month (May 2013) have made even more dramatically obvious. But, at present, it has no plausible rival.
Speaking to Greenberg some moths ago, Thomas Insel, the self-same person who has now given the official thumbs-down to DSM 5, commented casually that most of his psychiatric colleagues:
actually believe [that the diseases they diagnose using the DSM] are real. But there’s no reality. These are just constructs. There is no reality to schizophrenia or depression […] we might have to stop using terms like depression and schizophrenia, because they are getting in our way, confusing things.
Some might argue that to hear the head of NIMH saying such things is a trifle confusing, or even a little destabilizing. Surely, if someone in his position keeps uttering such unpalatable truths, he threatens the very legitimacy of the psychiatric enterprise. Remarks like these suggest it’s all a con game. Scientologists and their ilk must be rubbing their hands with glee.
Imagine a world like the one Insel seems to invite, in which psychiatrists actually leveled with us about the limits of their knowledge. Greenberg has outlined such a thought experiment:
What would happen if [psychiatrists] told you that they don’t know what illness (if any) is causing your anxiety or depression, or agitation, and then, if they thought it was warranted, told you that there are drugs that might help (although they don’t really know why or at what cost to your brain, or whether you will be able to stop taking them if you want to; nor can they guarantee that you (or your child) won’t become obese or diabetic, or die early), and offer you a prescription [for these substances].
Psychiatry’s status is precarious enough as it is. One can only guess to what depths it might sink in such a transparent world.
Perhaps on reflection both doctors and patients would prefer to cling to their illusions. But it seems they may not be able to do so for much longer. And then what?