Neutralising Suffering: How the Medicalisation of Distress Obliterates Meaning and Creates Profit

Joanna Moncrieff, MD
18
460

People have used psychoactive substances to dull and deaden pain, misery and suffering since time immemorial, but only recently, in the last few decades, have people been persuaded that what they are doing in this situation is rightly thought of as taking a remedy for an underlying disease. The spread of the use of prescription drugs has gone hand in hand with the increasing medicalization of everyday life, and a corresponding loss of the previous relationship that people had with psychoactive substances.

Elizabeth Gaskell’s novel Mary Barton was originally to be named after Mary’s father John Barton, a working class factory hand addicted to opium1. The novel depicts the unimaginable poverty and exploitation of industrial Manchester that made opium-induced oblivion an appealing escape. Although Gaskell clearly disapproved of John ‘s addiction, the reader is left in no doubt that opium use in 19th century Britain was a symptom of a deep social malaise. John is a victim of his social environment, coupled with the overwhelming grief of losing his beloved wife, both of which are understood to have contributed to John’s gradual decline into drug-induced torpor and belligerence.

Nowadays, John Barton would undoubtedly be diagnosed with depression, and he would be offered Prozac and Zopiclone in place of opium. He would be told that although ‘social factors’ might have precipitated his feelings, he suffered from an underlying chemical imbalance, which drugs could help to remedy. Instead of taking a substance whose properties he was familiar with, however destructive they turned out to be, he would be taking something whose effects on the human psyche have never been properly investigated, and are barely even described. He would be discouraged from evaluating how the drugs affected him, from working out whether they helped or hindered his daily activities, or whether their effects were pleasant or disagreeable. Moreover, by suggesting that the problem lay in his brain, he would be led to believe that the circumstances he lived and worked in, the loss of his wife and the loss of his job were merely incidental details, and that challenging his situation would be quite pointless and irrelevant to his state of mind. When the first lot of pills inevitably failed to eradicate his despair, he would be offered other miracle cures to enhance or replace the first ones.

Readers of the modern version of Mary Barton would not be roused to righteous ire and indignation about the state of the urban poor, as the readers of writers like Gaskell and Dickens were intended to be. They would only pity the unfortunate character whose defective make-up led to his downfall.

We have been fed a myth about the nature of psychiatric drugs for decades now, the myth that they can rectify mental disorders by targeting an underlying mechanism. We have been told that they are specific treatments, in the same vein as insulin for diabetes, which act by reversing the abnormalities that give rise to the symptoms of a particular disorder.  As this idea has taken root we have come to understand more and more of our daily troubles in terms of our brain chemicals2, in the process further contributing to the demise of the previous lay understanding of the nature of psychoactive substances and how they modulate psychological states.

Drugs have now been starkly divided into the good and the bad: the prescribed medication which people must take however awful it makes them feel, and the ‘recreational’ substances that are increasingly and often hysterically vilified3. At the same time that people are told they should not stop taking their antidepressant, they are constantly reminded of the dangers of alcohol and cannabis. People are encouraged to seek licit and prescribed emotional suppressants, but disparaged (and prosecuted if it’s the wrong substance) for seeking pleasure through chemical means. The modern citizen is caught in a constant flux of contradictory messages.

David Healy has described the transformation of ‘everyday nerves’ over the early 1990s through the marketing of the new Selective Serotonin Reuptake Inhibitor (SSRI) antidepressants like Prozac and Seroxat4. Problems that had previously been conceived of as anxiety, to conform to the stereotypes portrayed in the marketing of benzodiazepines, started to be understood as a mood disorder, and the notion of ‘depression’ expanded to encompass almost all forms of dissatisfaction and discontent. The drug companies were careful to market their new range of drugs for depression as medicines, which worked by reversing the individual’s defective biochemistry. The tardy acknowledgment that the benzodiazepines were dependence-inducing, coupled with criticism of their widespread use as a chemical pacifier for the over-burdened or frustrated usually female recipient, had threatened to bring the whole enterprise of the mass treatment of common-or-garden misery into disrepute. The SSRIs had to be presented as something different, as a new and miraculous cure for a bona fide disease, a disease which by mysterious coincidence had only been fully recognised when the SSRIs arrived on the scene. So the drug companies went about marketing the serotonin theory of depression, sweeping much of the psy professions along with them, with only a few lonesome voices belatedly pointing out that the emperor had no clothes5.

The success of Prozac inspired a frenzy of activity, with companies vying to take a piece of the massive antidepressant market. When the capacity for persuading people they were depressed was saturated, new disorders were promoted to draw in further swathes of the population and extend the patents on the new antidepressants. Disorders like social anxiety disorder and premenstrual dysphoric disorder were promoted by glitzy campaigns orchestrated by public relations companies masquerading as grass-roots organizations6.

In the late 1990s the makers of atypical antipsychotics started to eye this market too, and set about constructing an essentially new problem, which they concealed under the old concept of ‘manic depression’. The new thinking suggested that ‘depression was only half the story’7 (P 190), and that emotional ups and downs were a pathological condition which went under the rubric of ‘bipolar disorder’. People were encouraged to monitor their moods with ‘mood diaries’ to detect the condition, and hoards of people started to identify their experiences in this way, egged on by the endorsement of celebrities like Stephen Fry.

Eli Lilly obtained a licence for the use of Zyprexa in bipolar I disorder (the new name for the old concept of manic depression) in 2000, but the target population was never the small number of people with this rare and serious condition. The target, as revealed in advertisements as well as the leaked internal documents known as the ‘Zyprexa papers,’ was the huge population of people who currently identified themselves as depressed, worried, unhappy, unstable, or almost anyone who could be persuaded there was something wrong with their life8.

‘Zyprexa balances the chemicals naturally found in the brain’, we are told of Lilly’s new blockbuster9, a statement that provides no hint of the serious metabolic consequences, massive weight gain and brain volume reduction the drug can produce10, or the large settlements Lilly has made with litigants in the United States and Canada11.  Lilly is not alone. The makers of Seroquel, another ‘atypical’ antipsychotic have also positioned their product in the depression and bipolar market, successfully ensuring that it too becomes one of the top-selling drugs of all time12. The combination of obtaining licences for vague and easily expandable conditions, with illegal marketing for unlicensed indications13 has ensured that the antipsychotics, once reserved for the treatment of the most severely disturbed, have broken out of the now metaphorical asylum and into the community. They are the newest ‘opium of the people.’

People living in western societies may no longer suffer from the desperate material deprivations of the likes of John Barton, but the demands and pressures of modern life, the competitiveness, the performance management, the increasing insecurity, the inequality, the constant broadcasting of wealth, extravagance and power into the homes of ordinary people, contribute to a society where everyone feels inadequate and dissatisfied, and no one is secure:  fertile ground for the pharmaceutical industry and the psy professions. From this point of view, John Barton’s tragedy was that in revenging himself on the mill owner’s son, he left the system not only intact, but strengthened. At least he did not think the enemy was his brain!

This essay was first written as a tribute to Professor Mark Rapley, RIP, for a special memorial edition of Clinical Psychology Forum.

References:

(1) Gaskell E. Mary Barton. London: Penguin Books; 1848.

(2) Rose N. Becoming neurochemical selves. In: Stehr N, editor. Biotechnology, Commerce and Civil Society.New Brunswick, New Jersey: Transaction Publishers; 2004. p. 89-128.

(3) DeGrandpre R. The Cult of Pharmcology. How America became the world’s most troubled drug culture. Durham, NC: Duke University Press; 2006.

(4) Healy D. Shaping the intimate: influences on the experience of everyday nerves. Soc Stud Sci 2004 Apr;34(2):219-45.

(5) Lacasse JR, Leo J. Serotonin and depression: a disconnect between the advertisements and the scientific literature. PLoS Med 2005 Dec;2(12):e392.

(6) Koerner BI. Disorders made to order. Mother Jones 27[July/August]. 2002.

(7) Healy D. Mania: a short history of bipolar disorder. Baltimore, MD: John Hopkins University Press; 2008.

(8) Spielmans GI. The promotion of olanzapine in primary care: an examination of internal industry documents. Soc Sci Med 2009 Jul;69(1):14-20.

(9) Eli Lilly. How Zyprexa works. www zyprexa com/schizophrenia/pages/howzyprexaworks aspx 2011 [cited 2011 Mar 25]; Available from: URL: www.zyprexa.com/schizophrenia/pages/howzyprexaworks.aspx

(10) Dorph-Petersen KA, Pierri JN, Perel JM, Sun Z, Sampson AR, Lewis DA. The influence of chronic exposure to antipsychotic medications on brain size before and after tissue fixation: a comparison of haloperidol and olanzapine in macaque monkeys. Neuropsychopharmacology 2005 Sep;30(9):1649-61.

(11) Boyle T. Class action settlement in drug for schizophrenia. healthzone ca 2010 June 30 [cited 12 A.D. Nov 30]

(12) Thase ME, Macfadden W, Weisler RH, Chang W, Paulsson B, Khan A, et al. Efficacy of quetiapine monotherapy in bipolar I and II depression: a double-blind, placebo-controlled study (the BOLDER II study). J Clin Psychopharmacol 2006 Dec;26(6):600-9.

(13) United States Department of Justice. Pharmaceutical company Eli Lilly to pay record $1.415 billion for off label drug marketing. www justice gov/usao/pae/News/Pr/2009/jan/lillyreleaase pdf 2009 January 15:1-4

 

18 COMMENTS

  1. My Hero – basically psychiatry has but two functions (gross simplification, but there you go):

    1 to be the delivery agent for multinational drug companies
    2 to make sure no one thinks about why someone is distressed

    I’m constantly disgusted by meeting friends in the looney bin, or in, “The community,” damaged by psych drugs and with stories of blatant oppression (such as surviving rape and family violence) that the services have ignored. I ain’t that brilliant a counselor (ok, maybe I am? ) but my friends tell me about this stuff in half an hour, they’ve used services for years and sometimes decades and no staff know about their history. The workers get a nice salary and I get tax credits – bah.

    Nuff said……Bring back Dickens and Gaskell

    • Great stuff, as usual, Joanna. (Though I would not necessarily agree that “People living in western societies may no longer suffer from the desperate material deprivations of the likes of John Barton” – there are fewer but such suffering continues to exist, even in industrialized nations.) I have often said exactly what you do here – there is nothing particularly new or scientific about discovering that ingesting substances can change one’s mood or thinking. I often refer to alcohol as “the poor man’s Prozac.” But the medicalization process is clearly one of blaming the victim and sparing the oppressor, much as Alice Miller so eloquently outlines in her writing (in particular, her book, “For Your Own Good,” appears particularly applicable to this strategy of emotional suppression.)

      John, I have many times experienced the same thing. I once spoke with a developmentally delayed 17-year-old (mentally about 6) who had been raped. She was depressed for about a year before disclosing her abuse, and almost immediately after telling what happened, started to act out physically. The diagnosis? “Bipolar disorder.” Another psychiatrist was treating a woman for 15 years with every drug he could think of, said he’d “tried everything,” but never bothered to ask her what had happened in her life that she was depressed about. My own son went through a difficult time as a teen, involving a short stint of drug abuse and a sexual assault by a roommate, leading to some serious depression and suicidal thoughts. A doctor tried to prescribe him antidepressants without even bothering to ask him why he’d thought about killing himself. Didn’t even bother to find out he was in withdrawal from abusing substances, not to mention having to disconnect from all of his “friends” whom he realized were only interested in using drugs and who abandoned him the moment he quit.

      I could go on. It amazes me how incredibly stupid this medical paradigm allows people to be. Even an untrained 6 year old who saw someone crying would at least know enough to ask them, “Why are you so sad?”

      You probably are a brilliant counselor, for the simple reason that you actually are interested in the perspective and experiences of the person you’re trying to help. And yet these morons get paid hundreds of dollars an hour to invalidate and suppress people’s normal reactions to adverse circumstances. It is disgusting!

      —- Steve

    • Hi John: That is a brilliant 2-step summary of Psychiatry. I’m going to use that if I may.

      Hi Joanna: Thanks for another great post. You are in a minority of Psychiatrists who I respect for doing the right thing and basing your care on evidence and empathy.

  2. There was a time when psychiatry warned itself not to conflate effects of PTSD with bipolar disorder. Part of PTSD is forgetting triggers that leaves you feeling like there is no reason to be feeling so bad because you’re blocking traumatic feelings in self-defense. It’s a time when a good counselor would remind you that you have PTSD and help you navigate it as safely as possible while helping you keep it together so that you don’t lose yet more ground and give yourself more reasons to suffer. It’s a fine wire to balance on, and a good counselor would help, rather than throwing drugs at a person as if that were really all that could be done for them.

  3. Thanks for the link articulate poet. Remembering back many years ago when I was searching the net for like minded people I came across an article by Joanna and thought, now she seems like someone I can relate to.

    The message comes through pretty loud and clear that certain dispositions/emotional states that interfere with productivity (among other things) – is something that should be dealt with. This could involve anything from not conforming in specific ways at school (possibly bringing about a label of ADHD etc) to grieving too deep and long.

    It also can include reactions to physical problems which I was reminded of very recently when the worsening physical symptoms I had been suffering from for some time prompted a referral to a neurologist where I am still undergoing tests. In the meantime I am finding it increasingly difficult to cope with the very physically demanding job I have. I told the neurologist of this and his suggestion was that I take antidepressants. I felt rather insulted by his proposal for a few reasons, not least because of its invalidating overtones, and of course, the likelihood that it may do me more harm than good.

    Although I find his suggestion troubling due to current agendas etc (I turned the offer down) I suppose there are some who still would nonchalantly see this as being practical – just another way to ‘help’ with my immediate dilemma where I presume the intention is to alter the state of my mind to ‘better cope’ with/mask what I am experiencing.

    (I liked your article too Robert)

  4. Joanna,

    This is a very creative way to point out that a drug centered model of care would be infinately more logical and honest than psychiatry’s current model of care, which is based upon their “lacking in validity” DSM stigmatizations. And I agree, treating patients based on honest information regarding the actual effects of the drugs would be infinately more beneficial to the patients.

    Especially since trying to speak to a psychiatric professional about one’s real life concerns today, gets you defamed with one of the many DSM disorders, whacked out of your mind on God awful toxic and unneeded drugs, and ultimately results in your real life being declared a “credible fictional story” in your medical records. How is such ridiculous maltreatment remotely beneficial to any patient? It’s not.

    Dealing with psychiarists who believe all life’s problems are “chemical imbalances” in their patients’ heads, is complete insanity. But the psychiatrists get away with this maltreatment of patients, by compulsively lying to their patients, and because the patients have no clue how insane the psychiatric practitioners are, until they read their medical records.

    Thank you for working to point out the completely backward and detrimental nature of today’s psychiatric approach, and the horrendous toxcicity of the “bitterest of pills.”

  5. I want to believe the arguments presented in this article. It makes sense and I totally would believe it if not for my experiences with mental illness. Every time I have gone off my meds, I became severely psychotic and needed to be hospitalized. Every time any of my mentally ill friends went off their meds, the same thing happened. I do like the idea that maybe these states of mind aren’t pathological, but I became violent in several cases – I wanted to hurt people because of the delusions I was having. People who never wronged me at all.
    On the other hand, I see how it could be possible that “mental illness” is anything that doesn’t conform to society’s standards. Also, the movement to question psychiatry is awesome in my opinion. I feel like change is inevitable.
    But I just can’t reconcile those ideas with my own experiences. Maybe I’m missing something. I don’t know.

    • Hi mathguy,

      What you are missing is that when many people cold turkey psych meds or go off of them too quickly, they experience withdrawal symptoms that look like a return of the illness but aren’t. Obviously, I can’t say that is what happened to you but it sure sounds like it from your description.

      In the future, if you want to go off of your meds, I would strongly urge you to visit http://survivingantidepressants.org/index.php?/index. Please don’t be fooled by the site as there are posts there on how to very slowly get off antipsychotics.

      Additionally, there is a list of providers who help folks get off of psych meds in a slow safe manner. Hopefully, one is in your area.

      By the way, this site is not beholden to any commercial interest and depends on financial donations.

  6. Thanks mathguy
    I had the same experience when I tried to come off Modecate depot injection (it was disabling me) : 4 hospitalizations in 5 months. I settled for lighter oral medication which didn’t disable me, and a slow taper with non drug support.
    Doctors at my then Psychiatric Unit have written published papers on this drug and its convenience. They described the high ‘relapse’ rate of people that quit and ended up in hospital as recidivism. I would call it withdrawal syndrome.
    The long term solutions were to be found in Psychotherapy.

  7. What bothers me is that I believe coping mechanisms exist for a reason. We use them (healthy or otherwise) until we can find our footing and continue. The most basic problem with the medical model is that drugs don’t allow for any natural coping. How can a board of doctors not see the problem here? If you don’t cope or learn to cope the problem is never addressed so of course you would relapse once you stop taking the medication. The best thing I ever did was stop taking 6-8mg of attivan a day (a good day) and start looking for the cause for my panic attacks. They had never gone away. In fact, the longer I took the attivan, the more frequent they became, but without it, I was able to learn some of what caused them and to make allowances in my life. Sometimes those are big allowances. Sometimes I can’t, just physically can’t, leave the house, but I feel like I have a measure of control.