What does it tell us about the state of psychiatry when some of the biggest names in the psychiatric establishment are distancing themselves from psychiatry’s diagnostic system and its treatments?
In 2013, National Institute Mental Health (NIMH) director Thomas Insel, citing the lack of scientific validity of psychiatry’s official diagnostic manual, the DSM, stated that the “NIMH will be re-orienting its research away from DSM categories.” In response, Robert Whitaker, investigative reporter and author of Anatomy of an Epidemic, observed, “This is like the King of Psychiatry saying that the discipline has no clothes.”
“When Insel states that the disorders haven’t been validated,” Whitaker points out, “he is stating that the entire edifice that modern psychiatry is built upon is flawed, and unsupported by science. . . If the public loses faith in the DSM, and comes to see it as unscientific, then psychiatry has a real credibility problem on its hands.”
Other establishment psychiatrists are also distancing themselves from psychiatry’s diagnostic manual. Psychiatrist Allen Frances, the former chair of the DSM-4 task force, now writes about how the DSM is a money machine for drug companies (“Last Plea To DSM-5: Save Grief From the Drug Companies”).
Frances, emeritus professor of psychiatry at Duke University, was until recently among the most inside of insider psychiatrists. However, in an April 11, 2014 New York Times article (“Idea of New Attention Disorder Spurs Research, and Debate”) about “sluggish cognitive tempo,” which would add 2 million more children to the already 6 million diagnosed with attention deficit hyperactivity disorder (ADHD), Frances stated, “Just as ADHD has been the diagnosis du jour for 15 years or so, this is the beginning of another. This is a public health experiment on millions of kids.”
Public health experiment on millions of kids—that’s the kind of language that once so marginalized mental health professionals critical of establishment psychiatry that we were not quoted in the New York Times or any other mainstream media.
NIMH director Insel has also increasingly been distancing himself from standard psychiatry drug treatments. In 2009, Insel wrote: “For too many people, antipsychotics and antidepressants are not effective, and even when they are helpful, they reduce symptoms without eliciting recovery.”
The sad fact is that treatment resistant depression is increasing, and there is a great deal of evidence that the reason for this increase is long-term use of antidepressants. A review of the research in 2011 in the journal Medical Hypotheses concluded: “Depressed patients who ultimately become treatment resistant frequently have had a positive initial response to antidepressants and invariably have received these agents for prolonged time periods at high doses.”
In 2013, Insel announced that the latest research shows that psychiatry’s standard drug treatment for people diagnosed with schizophrenia and other psychoses needs to change. In February 2014, the New York Times published a feature story on Insel, noting that his questioning the long-term use of antipsychotics caused a major stir in psychiatry.
But while politically astute establishment psychiatrists such as Insel, Frances, and others are calling for reform, the institution of psychiatry may well be so damaged by a generation of drug company corruption that it cannot be reformed in any meaningful way.
The DSM is published by the American Psychiatric Association (APA), and according to the journal PLOS Medicine, “69% of the DSM –5 task force members report having ties to the pharmaceutical industry.” The corruption of the APA by Big Pharma is nothing new. In 2008, the New York Times reported the following about APA: “In 2006, the latest year for which numbers are available, the drug industry accounted for about 30 percent of the association’s $62.5 million in financing.” Congressional investigators in 2008 also discovered that then president-elect of the APA (Alan Schatzberg of Stanford University) had $4.8 million stock holdings in a drug development company.
Perhaps Big Pharma’s biggest bang for their buck has come through “thought leader” psychiatrists who popularize new diagnoses and drug treatments. One of psychiatry’s most influential thought leaders is Harvard’s Joseph Biederman who put pediatric bipolar disorder on the map. Due in great part to Biederman’s influence, the number of American children and adolescents treated for bipolar disorder increased 40-fold from 1994 to 2003.
Biederman’s financial relationships with drug companies was discovered by the public in 2008, when Congressional investigations revealed that he was on the take for $1.6 million in consulting fees from drug makers from 2000 to 2007. As part of legal proceedings, Biederman was forced to provide documents about his interactions with Johnson & Johnson, the giant pharmaceutical company; Biederman pitched Johnson & Johnson that his proposed research studies on its antipsychotic drug Risperdal would turn out favorably for Johnson & Johnson—and then Biederman delivered the goods.
Biederman is not alone among psychiatrists lining their pockets with drug company money. The New York Times (“Top Psychiatrist Didn’t Report Drug Makers’ Pay”) reporting on the 2008 Congressional investigation of psychiatry, stated this about Charles Nemeroff: “One of the nation’s most influential psychiatrists earned more than $2.8 million in consulting arrangements with drug makers from 2000 to 2007.”
While psychiatrists have grabbed the big money from drug companies, a few thought leader psychologists are picking up Big Pharma loose change. A major popularizer of sluggish cognitive tempo (SCT) is psychologist Russell Barkley. The New York Times recently reported Barkley saying that “SCT is a newly recognized disorder” and that Barkley received $118,000 from 2009 to 2012 from Eli Lilly for consulting and speaking engagements, and that Barkley has stated that Lilly’s drug Strattera’s performance on SCT symptoms was “an exciting finding.”
Psychiatrists routinely dominate ProPublica’s “Dollars for Docs” list of large payments from pharmaceutical companies. And being on the take from Big Pharma affects prescribing practices. The New York Times reported in 2007, “Psychiatrists who took the most money from makers of antipsychotic drugs tended to prescribe the drugs to children the most often.” A 2007 analysis of Minnesota psychiatrists revealed that psychiatrists who received at least $5,000 from makers of newer-generation antipsychotic drugs wrote, on average, three times as many prescriptions to children for these drugs as psychiatrists who received less money or none.
In her book The Truth about the Drug Companies (2004), Marcia Angell, physician and former editor in chief of The New England Journal of Medicine, documents the corruption of medicine by Big Pharma, with some of the most egregious examples being in psychiatry. Angell details how the head of the psychiatry department at Brown University Medical School made over $500,000 in one year consulting for drug companies that make antidepressants; Angell remarked, “When The New England Journal of Medicine, under my editorship, published a study by him and his colleagues of an antidepressant agent, there wasn’t enough room to print all the authors’ conflict-of-interest disclosures. The full list had to be put on the website.” In Surviving America’s Depression Epidemic, I document several areas in which Big Pharma has corrupted psychiatry, including funding university psychiatry departments (for example, Harvard Medical School’s psychiatry department at Massachusetts General Hospital received $6.5 million from four drug companies).
Insane and Ridiculous
The Oxford dictionary defines insane as “a state of mind that prevents normal perception, behavior, or social interaction; seriously mentally ill.” Has the institution of psychiatry become insane, and is that why politically astute psychiatrists are trying to distance themselves from it?
Besides drug company payoffs, another way that psychiatry as an institution has been prevented from having “normal perceptions” is that most psychiatrists no longer talk to their patients to discover the context of why they are behaving as they do. Robert Spitzer, perhaps the most inside of all insider psychiatrists in the 1980s and the chair of the DSM-3 task force, is now critical of the DSM’s inattention to context that results in the medicalizing of normal reactions.
In 2011, the New York Times (“Talk Doesn’t Pay, So Psychiatry Turns Instead to Drug Therapy”) reported, “A 2005 government survey found that just 11 percent of psychiatrists provided talk therapy to all patients.” As the article points out, psychiatrists can make far more money primarily providing “medication management.” A typical medication management session consists of checking symptoms and updating prescriptions, and patients are usually in and out with a new prescription in five or ten minutes.
When Big Pharma is paying thought leader psychiatrists who invent and popularize “illnesses” such as pediatric bipolar disorder, and when most psychiatrists are only conducting medication managements, tragically insane treatments become the “standard of care.” The high-profile case of Tufts-New England Medical Center (a bastion of the psychiatric establishment) and Rebecca Riley, covered by “60 Minutes” reveals that standard of care in psychiatry has become insane.
When Rebecca Riley was 28 months old, based primarily on the complaints of her mother that she was “hyper” and had difficulty sleeping, psychiatrist Kayoko Kifuji diagnosed Rebecca with ADHD. Kifuji prescribed clonidine, a drug with significant sedating properties, a drug that Kifuji also prescribed to Rebecca’s older sister and brother. The goal of the Riley parents—obvious to many people in their community and later to juries—was to attain psychiatric diagnoses for their children that would qualify them for disability payments and to sedate their children making them easy to manage. But apparently this was not obvious to Kifuji who, when Rebecca was three years old, added a bipolar disorder diagnosis and prescribed two additional heavily sedating drugs, the antipsychotic Seroquel and the anticonvulsant Depakote. At the age of four, Rebecca died due to the toxicity of these drugs. After Rebecca’s death, Tufts-New England Medical Center, Kifuji’s employer, told “60 Minutes,” “The care we provided was appropriate and within responsible professional standards.”
Psychiatry has a long history of ridiculous and invalid disorders and insane and dehumanizing treatments. Until the early 1970s, homosexuality was an official DSM mental illness and was treated with aversive conditioning, which included electro-shocking same-sex attraction.
Since 1980, the DSM has pathologized stubborn, rebellious, and noncompliant young people, diagnosing them with opposition defiant disorder (ODD); symptoms include “often actively defies or refuses to comply with adult requests or rules” and “often argues with adults.” And once again, a ridiculous and invalid “illness” has a dehumanizing and insane treatment. In December 2012, the Archives of General Psychiatry reported that, between 1993-2009, there was a seven-fold increase of children 13 years and younger being prescribed antipsychotic drugs, and that “disruptive behavior disorders”—which includes ODD—were the most common diagnoses in children medicated with antipsychotics, accounting for 63% of those medicated.
In the 1970s, before Big Pharma corrupted and virtually annexed psychiatry, and when most psychiatrists learned something about their patients’ lives, it was not all that radical for psychiatrists to make connections between emotional suffering and societal problems. With Big Pharma corruption of psychiatry, a denial of the importance of society, politics, and culture to our emotional well being has ensued.
As I described in 2013 (“What’s Behind ‘Substantial Increases’ in Suicide Rate for Middle-Aged Americans? Bad Economy Is Likely Culprit”), the Centers for Disease Control (CDC) reported on May 3, 2013 that the suicide rate among Americans age 35–64 years increased 28.4 percent between 1999-2010. The Lancet estimates that the three-year recessionary period from 2008 thru 2010 was a source in the United States for “4,750 excess suicide deaths.” But how much has the American public heard from psychiatry that suicide and depression are related to a crappy economy and societal misery?
A generation ago, the institution of psychiatry, with the backing of Big Pharma, began to exclusively focus on patients’ symptoms, and stopped focusing on anything but superficial aspects of their patients’ lives, while at the same time self-promoting its progress in diagnostics, research, and the prescribing of drugs. Today, as Robert Whitaker puts it, “We see that its diagnostics are being dismissed as invalid; its research has failed to identify the biology of mental disorders to validate its diagnostics; and its drug treatments are increasingly being seen as not very effective or even harmful. That is the story of a profession that has reason to feel insecure about its place in the marketplace.”
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Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.