Thomas Insel’s book Healing: Our Path From Mental Illness to Mental Health is getting a fair amount of media attention, which could be expected given that he was the director of the National Institute for Mental Health for 13 years (2002 – 2015). The book was blurbed by a number of prominent figures, including Rosalynn Carter and Patrick Kennedy, and most reviews have been fairly positive, telling of how “America’s Psychiatrist” has discovered that psychiatry’s somatic therapies—drugs, ECT and such—need to be complemented by social supports that provide “purpose” in life and social connections.
MIA has run two reviews of the book, one by Bruce Levine and the second by Andrew Scull, both of whom offered a more critical assessment. I think it’s fair to say that their reviews reveal how it functions as a work of propaganda.
Personally, I have been mulling over the import of this book ever since it was published. I was focused on a very particular question. Given that Insel opened his book promising to investigate why mental health outcomes in the United States are so poor, would he tell of research, much of which was funded by the NIMH, on the long-term effects of psychiatric drugs?
There was an obvious ethical obligation for him to do so.
There is a basic compact that necessarily exists between any medical discipline and the public. While the public may understand that it is possible for a medical specialty to embrace practices that, at some point in the future, will be found to be harmful, and to do so in good faith, there is the expectation that a medical specialty will be an honest purveyor of scientific findings about the risks and benefits of a medical intervention, and that if its research tells of treatment that is worsening long-term outcomes, then the medical specialty will inform the public of those outcomes and rethink its practices.
For the longest time, psychiatry has failed to fulfill that pact, a failure that Insel had an opportunity to remedy with this book. And I don’t think it is hyperbole to conclude that as he took up his pen, the future of mental health care in the United States—and the narrative that would govern that care—was at stake.
If Insel had decided to direct public attention to the long-term studies, it could have put psychiatry on a new path. Once the public had been informed by “America’s psychiatrist” that there was a history of research that told of how psychiatric drugs worsened long-term outcomes, then our society, with that new narrative in mind, would have been motivated to find alternatives to the drugs as first-line therapies.
But Insel decided to keep the long-term studies hidden, and that means nothing will change, and our society will keep on doing what it has been doing, which has been relying on drugs as our go-to solution for the emotional and mental struggles that may plague us.
Insel Promises to Investigate a Conundrum
I opened my book Anatomy of an Epidemic, which was published in 2010, with this line: “This is the story of a medical puzzle.”
The conventional history of psychiatry tells of how the introduction of antipsychotics in 1955 kicked off a psychopharmacological revolution, a great advance in care. The revolution was then said to take another step forward with the development of a second generation of psychiatric drugs, starting with the marketing of Prozac in 1988. The prescribing of psychiatry drugs soared after that, and as it did, the burden of mental illness in our society, rather than diminishing, noticeably increased. The most visible marker of this could be seen in government disability data. The number of adults receiving a social security payment—either an SSI or SSDI payment—due to a mental disorder rose from around 1.25 million in 1987 to nearly 4 million in 2007, and is now around 6 million, according to Insel’s book.
Usually, a great advance in medicine—and an increase in the number of people treated for the disease—reduces the burden of that illness in society. Here the opposite was true. Why was this so?
This is the question that Insel takes up in his book. In his first chapter, he tells of the worsening of outcomes in this sphere of medicine: rising disability numbers, more suicides, and an increase in mortality, with the mentally ill dying 15 to 30 years earlier than the general population. He then notes how this worsening happened during a period of increased spending on mental health services, with a dramatic jump in people receiving outpatient care and taking psychiatric drugs. He writes:
It’s a pretty safe bet in most of medicine that if you treat more people, death and disability drop. But when it comes to mental illness, there are more people getting more treatment than ever, yet death and disability continue to rise. How can more treatment be associated with worse outcomes?
Now, there may be many factors that have contributed to our society’s worsening mental health. But the correlation between a dramatic increase in treatment and a dramatic increase in disability raises an obvious factor to investigate: What are the long-term effects of psychiatric medications? Do they, in the aggregate, improve long-term outcomes and the functional well-being of those who take them? Or do they, for some reason, have the opposite impact?
This is a question vital to public health, and important to every individual who may consider taking psychiatric drugs. It is central to informed consent, both at the societal and individual level. I sought to answer the question by digging through the research literature, and with each class of drugs, basically followed this methodology:
- What was the clinical course of the specific disorder—e.g. schizophrenia, depression, etc. — before the introduction of psychiatric drugs?
- After the first-generation psychiatric drugs were introduced, did clinicians observe any change in the clinical course of their patients?
- In clinical studies that measured long-term outcomes, did the medicated or unmedicated patients have better outcomes?
- Did modern epidemiological studies find that the disorder now runs a more chronic course than before the introduction of psychiatric drugs?
- In response to findings that indicated the medications were increasing the chronicity of psychiatric disorders, did researchers put forth a biological explanation for why the drugs would have this effect?
I was following a process that reviewed a history of research to see whether the different studies, much like pieces of a puzzle, fit together to tell a coherent story about the long-term impact of psychiatric drugs. The conclusion that emerges from that process is that antipsychotics, antidepressants, and benzodiazepines worsen long-term outcomes, and that bipolar disorder, which is regularly treated with polypharmacy, runs a much more chronic course than manic depressive disorder—the diagnostic precursor to bipolar—once did.
That is an upsetting conclusion, and while there was a great deal of pushback from some prominent American psychiatrists (and defenders of the mainstream narrative), the book did help draw societal—and professional attention—to the issue at hand. How do psychiatric drugs impact people over the long-term?
In March of 2015, filmmaker Kevin Miller interviewed Thomas Insel for a documentary he was making, Letters from Generation RX, and he asked him about the “science of psychiatric drugs” that was presented in Anatomy of an Epidemic. Here is what Insel said at that time:
I will take one piece of what he said to heart—and I think it’s an important one. And his comment is to observe that in spite of this enormous increase in the use of antidepressants, antipsychotics, and other neuroleptic or psychotropic medication, which is that broad class, over the last two to three decades—it’s been difficult to demonstrate a commensurate decrease in morbidity, that is, disability or mortality, measured by suicide. Now, in other areas of medicine, if you increase the use of your medication twofold, threefold, sixfold, you will see—we have seen, reductions in morbidity and mortality. Now, we can argue about whether in those people who get the right medication at the right dose for the right duration, there really have been lives saved and there have been reductions in disability. Every one of us has seen people who have done beautifully, and whose lives have been saved by the use of medication. But at a population level, his observation needs to be taken very seriously.
That’s an honest response. Insel, at that time, was validating the question as of great importance to society, and to our public health.
In 2015, when Kevin Miller told me of his response, I felt a moment of optimism. The possibility for a societal rethinking of psychiatric care loomed large at that moment. Insel didn’t even need to review the full collection of research that I had reported on in Anatomy of an Epidemic. If he simply reviewed the NIMH-funded research that I had cited in the book and made those NIMH findings known to the public, then that would prompt societal thinking about the merits of these drugs to undergo a profound shift.
The future of our societal use of psychiatric drugs was in his hands, and in his first chapter of Healing, he raised the puzzle that I had sought to investigate in Anatomy of an Epidemic. He wrote of how there was a stunning correlation between worsening mental health outcomes and increased treatment, and he was going to examine why that was so.
The long-term impact of psychiatric drugs was about to come under review.
Or so it seemed.
Healing is a book aimed at the general public, with the publisher presenting it as a roadmap for change. And while Insel had stated in 2015 that Anatomy of an Epidemic needed to be taken “very seriously,” he took a very different tack in Healing. After setting forth the conundrum—how is that outcomes are worsening when so many more people are being treated?—he quickly dismissed any worry that psychiatric drugs could be a causative factor for those poor outcomes. He did so in three paragraphs:
Some critics, such as science journalist Robert Whitaker, have blamed the mental health crisis on the treatments. Noting the temporal correlation of increased disability with increased medication use, Whitaker argues that antidepressants and antipsychotics create a “supersensitivity” that makes patients dependent and chronically disabled. With claims that long-term outcomes were better before the “psychopharmacology revolution,” he writes that the psychiatric establishment, in collaboration with the pharmaceutical industry, has conspired to overmedicate and overtreat children and adults with disastrous results.
Not everyone buys this conspiracy theory. Others see the problem as ineffective treatment. They claim current treatments are necessary, but they are not sufficient to cure complex brain disorders. In a call to arms entitled “Revolution Stalled,” Steven Hyman, my predecessor as NIMH director, notes that we need to know much more about the biology of mental illness before we “can illuminate a path across very difficult scientific terrain.” Dr Hyman’s point is that we don’t know enough about the mechanisms or causes of mental illness to develop medications that are as effective as insulin or antibiotics.
There is a third perspective that I think explains the more-care-but-worse-outcomes conundrum. I suspect that clinicians are helping the people they see, that they are seeing more people than ever, and that they are probably more effective today than twenty-five years ago. Why aren’t they bending the curve? The majority of people with mental illness are not in treatment, those in treatment receive little more than medications (which, as Dr. Hyman says, are not adequate), and many of the people receiving medications do not take them . . . so the crisis of care is not just lack of access (to treatment), but lack of engagement [with treatment.]
Those three paragraphs provide the framework for the narrative that is to follow. The idea that psychiatric drugs might worsen long-term outcomes has been dismissed as a conspiracy theory. At the same time, by quoting Hyman, Insel is presenting himself as open-minded about the merits of psychiatric drugs by stating that they are not curative—he is telling readers he will be a sober reviewer of the evidence. Yet, in that same paragraph, he assures readers that such medications are necessary, and in the third paragraph, he ups the ante: clinicians are helping their patients and individual outcomes may be better than 25 years ago. The blame for the poor outcomes, it seems, falls on society for not investing in necessary social supports and on patients who fail to take their drugs and stay engaged in treatment.
There is nothing in that narrative that could be expected to harm psychiatry’s guild interests or pharmaceutical interests. Insel then describes himself as taking on the role of a journalist as he explores humanistic supports that are needed as a complement to drugs and other psychiatric therapies in order to promote lasting recovery.
This is a win-win position to take. Anyone with a heart and common sense is going to welcome societal efforts that provide those struggling with psychiatric difficulties with social support, meaning in life, and a safe place to live. Indeed, critics of psychiatry have been advocating for such efforts for decades, and Insel was now positioning himself as the advocate for this societal response.
In short, his inquiry into the “puzzle”—why have societal mental health outcomes worsened even as more people got treated for psychiatric disorders?—was over before it ever began. His roadmap to “mental health” would not be upsetting to psychiatry’s guild interests; the pharmaceutical companies would have no reason to complain; and nearly all readers could agree that it would be helpful if our society could build a system of care that provided the “mentally ill” with decent housing, a social community, and purpose in life.
And with that framework in place, there would be no place in his 300-page book for research that told of drug treatments that, in the aggregate, worsen long-term outcomes.
The Drug Information Fit To Print
The third chapter in Insel’s book is titled “Treatments Work.” He opens the chapter in this way:
The current state of mental health care is sobering, yes. But there is good news, and it is not just that we can take lessons from the incomplete successes of the past. Perhaps even more important, we also have treatments that work right now. In contrast to so many complex, chronic health problems, here we have solutions. Yes, we have more to learn, and future treatments will likely be even better than what we have today. But crucial to ending America’s crisis of care is understanding that right now we have treatments that can improve outcomes, treatments that help people recover. We can solve so much of the care crisis, because solving the care crisis requires nothing more than a wider application of the best care we can offer.
Psychiatric drugs, ECT, transcranial magnetic stimulation, psychotherapy—all of these current treatments “work.” Antidepressants have an “overall effect size” that is as high and often higher than medications used in other areas of medicine, Insel writes. So too the top-selling antipsychotic, Abilify. Stimulants, benzodiazepines, they all “work.” And in those instances where psychiatric drugs only help people get “better but not well,” then “other forms of treatment, psychological, neurotechnological, or rehabilitative interventions can pave the path to recovery.”
Such was Insel’s inquiry into the merits of psychiatric treatments. His description of the short-term merits of psychiatric drugs could be easily critiqued, but that is not the point of this essay. What is notable is that he didn’t cite a single study that told of psychiatric drugs providing a long-term benefit.
Insel, of course, knows the research literature well. The glaring omission leads to a simple conclusion: the former director of the NIMH, in a chapter titled “Treatment Works,” was unable to find a single study to cite that told of the drugs improving long-term outcomes. And this was after the drugs had been on the market for 65 years.
The Research That Insel Dared Not Mention
There is not enough space in this essay to lay out the full collection of evidence, composed of many different elements, that lead to a conclusion that psychiatric drugs, in the aggregate, worsen long-term outcomes. That took a book-length inquiry. However, it is possible to summarize the highlights of such research findings for antipsychotics and antidepressants, which are the two classes of psychiatric medications that have been most extensively researched. A similar summary of research for stimulants is also provided below.
To a significant extent, this review provides a brief history of NIMH research into the long-term effects of psychiatric medications. Whereas pharmaceutical companies fund the studies that tell of their short-term efficacy, it has been the NIMH, dating back to the 1970s, that funded studies on their long-term effects.
After antipsychotics were introduced in the mid 1950s, clinicians began speaking about the “revolving door syndrome” that now appeared in asylum medicine. First-episode patients would be discharged and then return in droves, which led the NIMH, during the 1970s, to fund four studies to assess whether antipsychotics were increasing the chronicity of psychotic disorders.
Here were the results:
Bockoven reported that the rehospitalization rate for discharged patients was higher for patients treated after the arrival of antipsychotics in asylum medicine, and that the medicated patients were also more “socially dependent” than those treated before 1955. Carpenter, Mosher, and Rappaport reported superior outcomes for unmedicated patients at the end of one, two, and three years respectively, which led Carpenter, who had conducted his study at NIMH’s clinical research facility in Bethesda, Maryland, to write that “we raise the possibility that antipsychotic medication may make some schizophrenic patients more vulnerable to future relapse than would be the case in the natural course of the illness.”
By this time, researchers were fleshing out the “adaptive” brain changes stirred by antipsychotics. The drugs block dopamine receptors in the brain, and the brain responds by increasing the density of its dopamine receptors. Two Canadian researchers, after studying their medicated patients, concluded that this drug-induced dopamine supersensitivity “leads to both dyskinetic and psychotic symptoms. An implication is that the tendency toward psychotic relapse in a patient who has developed such a supersensitivity is determined by more than just the normal course of the illness.”
This understanding of how the brain “adapted” to antipsychotic medication provided a biological explanation for why the drug treatment increased the chronicity of psychotic disorders, and thus provided a causal explanation for the research findings reported by Bockoven, Carpenter, Mosher and Rappaport.
More such findings followed.
The World Health Organization, in two studies that compared longer-term outcomes in three “developing countries”—India, Nigeria, and Colombia—with outcomes in the United States and five other developed countries, found that outcomes were much better in the three developing countries, where only 16% of schizophrenia patients were regularly maintained on antipsychotics.
Next, Nancy Andreasen, the long-time editor-in-chief of the American Journal of Psychiatry, in a large MRI study of schizophrenia patients, reported that antipsychotics shrink brain volumes over time, and that this shrinkage is associated with a worsening of negative symptoms, increased functional impairment, and, after five years, cognitive decline.
A Canadian researcher, Philip Seeman, who in the 1970s had helped flesh out how the brain responded to antipsychotics by increasing the density of its dopamine receptors, reported that this adaptive response was why antipsychotics “fail over time.”
Then came the findings reported by Martin Harrow and Thomas Jobe. In the late 1970s, with funding from the NIMH, they had launched a long-term study of 200 patients diagnosed with schizophrenia or other psychotic disorders, most of whom were experiencing a first or second episode of psychosis. All were treated conventionally in the hospital with antipsychotics, and after they were discharged, Harrow and Jobe periodically assessed how they were doing and whether they were using antipsychotics. They found that the outcomes of those who got off the medications by year two began to dramatically diverge from those who stayed on the drugs, and that at the end of 15 years the recovery rate for the off-med patients was eight times higher than for the medication-compliant patients (40% versus 5%). “I conclude that patients with schizophrenia not on antipsychotic medication for a long period of time have significantly better global functioning than those on antipsychotics,” Harrow announced at the 2008 meeting of the American Psychiatric Association.
Harrow and Jobe also reported that the medication compliant patients were much more likely to remain psychotic over the long term than those who got off the medication, and it was the off-medication patients who had dropped out of treatment that had the better outcomes. Harrow and Jobe referred to drug-induced dopamine supersensitivity as a likely reason for this difference in outcomes.
In the past two decades, longer term studies of psychotic patients conducted in the Netherlands, Finland, Australia, Denmark, and Germany all told of higher recovery rates for those off antipsychotic medication. Similarly, users of antipsychotics tell of how these drugs “compromise functional recovery” over the long-term.
The antidepressant history is much the same. Prior to the introduction of this class of drugs, major depression—and this finding came from studies of hospitalized patients—was understood to be an episodic disorder. Patients could be expected to recover, and perhaps half of patients who suffered a first episode would never be rehospitalized for depression.
However, after the introduction of antidepressants, at least a few clinicians observed that the use of these drugs appeared to be causing a “chronification” of the disorder. In the 1970s, a Dutch researcher, after studying the case histories of 94 depressed patients, some who took antidepressants and some who did not, concluded that “systematic long-term antidepressant medication, with or without ECT, exerts a paradoxical effect on the recurrent nature of vital depression. In other words, this therapeutic approach was associated with an increase in cycle duration.”
In the 1980s, a number of studies found that relapse rates were high for depressed patients treated with antidepressants, so much so that a panel of experts convened by the NIMH concluded that, in contrast to older studies of mood disorders, “new epidemiological studies [have] demonstrated the recurrent and chronic nature of these illnesses.”
Two NIMH studies in “real-world” patients, who were treated in outpatient settings, subsequently confirmed that this was indeed the long-term course for medicated patients. In 2004, Rush and colleagues treated 118 outpatients with a wealth of emotional and clinical support “specifically designed to maximize clinical outcomes,” and only 13% got well and remained well for any length of time. Next, in the NIMH’s STAR*D trial, which was heralded as the largest antidepressant trial ever conducted, only 108 of the 4,041 who entered the trial remitted and stayed well until the end of the one-year follow-up. That’s a 3% recovery rate; the other 97% either failed to remit, or relapsed, or dropped out before the end of one year.
This 3% stay-well rate stood in sharp contrast to the outcome in an NIMH funded trial that sought to identify the longer-term course of untreated depression in modern times. In that study, 85% recovered by the end of one year. “If as many as 85% of depressed individuals who go without somatic treatment spontaneously recover within one year, it would be extremely difficult for any intervention to demonstrate a superior result to this,” the researchers concluded.
Numerous studies over the past 35 years have compared outcomes for medicated and unmedicated patients over longer periods of time. Here is a quick rundown of these findings:
- In a NIMH study conducted during the 1980s that compared the antidepressant imipramine to two forms of psychotherapy and to placebo, at the end of 18 months the stay-well rate was highest for the cognitive therapy group (30%) and lowest for the imipramine exposed group (19%).
- In a NIMH study that compared six-year outcomes for depressed people who got treated for the disorder and those who eschewed medical treatment, those who were “treated” were three times more likely than the untreated group to suffer a “cessation” of their “principal social role” and nearly seven times more likely to become “incapacitated.”
- A World Health Organization study of depressed patients in 15 cities found that at the end of one year those treated with a psychotropic medication had worse “general health” and were more likely to still be “mentally ill” than those who weren’t exposed to such drugs.
- A Canadian study of 1,281 people who went on short-term disability due to a depressive episode determined that 19% of those who took an antidepressant went on to long-term disability compared to 9% of those who never took such medication.
- In a five-year study of 9,508 depressed patients in Canada, medicated patients were depressed on average 19 weeks a year, versus 11 weeks for those not taking the drugs.
- Two reviews of the long-term outcomes of patients diagnosed with depression found that exposure to an antidepressant was associated with worse outcomes at nine years (U.S. study) and at 30 years (Swiss study).
As these findings have piled up, researchers—led by Italian psychiatrist Giovanni Fava—have pointed to drug changes induced by SSRI antidepressants as a likely explanation for the “bleak long-term outcome of depression.” These drugs may “worsen the progression of the disease in the long term, by increasing the biochemical vulnerability to depression. . . use of antidepressant drugs may propel the illness to a more malignant and treatment unresponsive course,” Fava wrote.
In a 2011 paper, American psychiatrist Rif El-Mallakh observed that 40% percent of depressed patients initially treated with an antidepressant were now ending up in a chronically depressed “treatment resistant” state. “Continued drug treatment may induce processes that are the opposite of what the medication originally produced,” he wrote. This may “cause a worsening of the illness, continue for a period of time after discontinuation of the medication, and may not be reversible.”
Given this literature, it is no surprise that major depression is now the leading cause of disability in the U.S. for people ages 15 to 44, and that in country after country that has adopted widespread use of SSRIs, the number of people on government disability due to a mood disorder has increased in lockstep with the increased use of those drugs.
Stimulants in Children and Adolescents
In the early 1990s, the NIMH mounted what it called the Multisite Multimodal Treatment Study of children with ADHD (MTA) to assess the longer-term impact of stimulants. At the end of 14 months, youths treated with stimulants by ADHD experts had a greater reduction of ADHD symptoms than those randomized to behavioral therapy (there was no placebo group), which was seen as evidence that stimulants provided a long-term benefit to youth so diagnosed.
However, that was not the end of the study. The NIMH researchers continued to follow the youth, who during this follow-up were free to go on or off stimulant medication if they so chose. At the end of three years, being on a stimulant “was a significant marker not of beneficial outcome, but of deterioration. That is, participants using medication in the 24-to-36 month period actually showed increased symptomatology during that interval relative to those not taking medication.” The medicated youth also had higher delinquency scores at the end of three years, and were shorter and weighed less than their off-med counterparts.
At the end of six to eight years, the results were much the same. Medication use was “associated with worse hyperactivity-impulsivity and oppositional defiant disorder symptoms,” and with great “overall functional impairment.” The medicated youth were also more likely to have been diagnosed with depression or anxiety.
As one of the NIMH investigators later confessed, “We had thought children medicated longer would have better outcomes. That didn’t happen to be the case. There were no beneficial effects, none.”
A Compact Broken
As can be seen, a review of the research literature tells of how antipsychotics and antidepressants increase the chronicity of the disorders they are used to treat, and it tells too of how at least a few researchers, seeking to explain the poor outcomes, fleshed out a biological explanation for why that would be so. Stimulants as a treatment for ADHD failed the long-term test too. The same is true of benzodiazepines; outcomes for bipolar disorder have similarly worsened in the modern era.
A longer list of studies that tell of these outcomes can be found on MIA resource pages for antipsychotics, antidepressants, benzodiazepines, polypharmacy for bipolar disorder, and stimulants for juvenile ADHD. There are more than 100 journal articles that populate those lists.
But none of this history is found in Insel’s book. This history is also missing from psychiatric textbooks and the NIMH’s website. Search for Martin Harrow on the NIMH website and nothing turns up. Search for STAR*D and you’ll find a press release on short-term results that tells of “particularly good results” with antidepressants that “highlight the effectiveness of high-quality care.” What you will not find on the website is that the documented one-year stay-well rate for patients treated with antidepressants was a dismal 3%. (That information was, in fact, hidden in the journal article that reported one-year outcomes.) Nor does the NIMH website inform parents that in the MTA study, medication use was a marker of “deterioration” by the end of year three, and that at the end of six years those taking stimulants had worse ADHD symptoms and were more functionally impaired.
This is the real source of the poor mental health outcomes in the United States: the psychiatric establishment, which includes the NIMH, is not an honest broker of information related to the merits of psychiatric drugs. Indeed, ever since the American Psychiatric Association adopted a disease model for categorizing psychiatric disorders when it published DSM-III, it has told a story to the public that promotes that model and the prescribing of psychiatric drugs, regardless of whether the elements of that story were grounded in good science. We were told that major psychiatric disorders were caused by chemical imbalances in the brain and that antipsychotics and antidepressants fixed those imbalances, like insulin for diabetes. We were told that the major disorders in the DSM had been validated as discrete diseases, and that those who doubted that were like members of a Flat Earth Society. When the SSRIs and the atypical antipsychotics came to market, we were told they were “breakthrough medications.”
None of this was true, and yet our society organized itself around that false narrative, and the prescribing of psychiatric drugs soared and to all ages, from the young to the elderly. And as that took place, the burden of mental illness in our society dramatically increased.
Today, most elements of that story, at least within psychiatric research circles, have been abandoned. The chemical imbalance story is now derided as a hypothesis that fell out of favor decades ago, with Ronald Pies, former editor in chief of Psychiatric Times, describing it as an “urban legend—never a theory seriously propounded by well-informed psychiatrists.” Allan Frances, who chaired the DSM-IV task force, and other prominent figures in the field, including Insel and his predecessor at the NIMH, Steven Hyman, acknowledge that the disorders in the manual have never been validated as discrete illnesses, and that the diagnostic categories are properly understood to be constructs. In Healing, Insel admits that the second-generation psychiatric drugs are really no better than the first, the notion that they were “breakthrough medications” having been put to rest some time ago.
The narrative that our society organized itself around, starting in the late 1980s, has collapsed. Yet, the prescribing of psychiatric drugs rolls on, with psychiatry touting results from short-term studies of the drugs as evidence of their efficacy, and it is the hiding of the results from long-term studies that now sustains this enterprise. If the scientific narrative that is to be found in the research literature were told to the public, of drugs that don’t fix chemical imbalances but rather induce them, and that researchers have pointed to that drug effect as a likely reason that that the medications increase the risk that a person will become chronically ill and functionally impaired over the long-term, then psychiatry would have to completely reorganize its care.
This is the bridge that psychiatry, as a guild, cannot cross. The prescribing of drugs is psychiatry’s primary therapeutic act, and if its drugs cause long-term harm, then what would the profession do? The profession needs to keep this history out of sight, even to itself, and so it is not presented in psychiatric textbooks, or in continuing medical education seminars. By keeping this history hidden, the field is not just breaking its compact with the public, but with itself—with every prescriber and all those who enter the field.
However, one could have hoped that Insel, writing as the former director of the NIMH, would have dared to cross this bridge of no return. He had the opportunity to turn the profession in a new direction, and while doing so, chart a true roadmap to better “mental health” in our country. His was a bully pulpit, and the NIMH is not subject to the same guild impulses as the American Psychiatric Association.
The NIMH is funded by the public. We funded the Harrow and Jobe study of long-term outcomes for schizophrenia patients; we funded the STAR*D trial; and we funded the MTA study of stimulants. As the funders, we deserve being told the long-term results from those studies, and to have the results widely publicized.
That is what the NIMH—and Thomas Insel—owed to us.
Searching for a Solution
In 2015, Lisa Cosgrove and I published Psychiatry Under the Influence, a book that arose from our time as fellows at the Safra Center for Ethics at Harvard University, in a lab devoted to studying “institutional corruption.” In a democratic society, the expectation is that institutions that serve a public interest—and this is particularly true for medical disciplines—will adhere to ethical standards. We wrote:
Our society thinks of medicine as a noble pursuit, and thus it expects a medical profession to rise above financial influences that might lead it astray. The public expects that medical researchers will be objective in their design of studies and their analysis of the data; that the results will be reported in an accurate and balanced way; and that the medical profession will put the interests of patients first.
In a 2009 essay, Daniel Wikler, a professor of ethics at the Harvard School of Public Health, told of how a medical discipline that fails to adhere to this standard doesn’t deserve to retain its privileged place in society. He wrote:
Erosion of medical integrity is not a mere detail, but rather strikes at the heart of what it is to practice medicine. The basis for medicine’s claim to be a profession rather than a trade, exchanging a degree of self-governance and autonomy to be trusted experts, is the assurance that the trust will not be misplaced.
The erosion of medical integrity is, in this instance, complete. The past is prelude to the future, and psychiatry is not going to alter its behavior in this regard. It is not going to tell the public of research findings that would undermine public confidence in psychiatric drugs. Nor will the NIMH.
This is why Insel’s book makes a case for abolishing psychiatry, or perhaps more aptly stated, for removing psychiatry from its position of authority over this domain of our lives. Our society needs to put its trust and authority into those who will tell of this research, and that means putting its trust and authority into an organization or agency that isn’t moored to psychiatric drugs.
That is the roadmap for moving from “mental illness to mental health” that Insel’s book leaves us with. We need to have leadership that we can trust to tell us the truth about the merits of psychiatric drugs.
MIA Reports are supported, in part, by a grant from the Open Society Foundations.
Photo credit: Creative Commons, World Economic Forum