“The treatment of mental disorders with drugs is not the same sort of activity as the use of drugs in medicine. Psychiatric drugs do not target underlying disease or symptom-producing mechanisms; they create an altered state of mental functioning that is superimposed on underlying feelings and behaviours. The ethical implications of the two situations are different.” —Joanna Moncrieff
Since the middle of the twentieth century, the development and widespread prescription of psychiatric drugs has changed the landscape of psychiatry. While the locus of emotional or psychological distress continues to be found within the individual, instead of prescribing a course of psychotherapy, the doctor prescribes a drug with the goal of correcting what is commonly understood to be a chemical imbalance.
Though there have long been questions raised about the veracity of this widely held belief, until very recently, the official line has remained unchanged. Recently, however, scientists at the University College London, led by Joanna Moncrieff, conducted a major review of scientific studies related to depression in which they found “no clear evidence” that depression is caused by an imbalance in brain chemistry. Data from the study shows that scientists studying serotonin levels in test subjects “did not discover any difference between people diagnosed with depression and healthy people.”
A spokesman for the Royal College of Psychiatrists insisted that “antidepressants are an effective… treatment for depression”, and does not recommend that anyone should stop taking their medications “based on this review.” Since one of the issues with antidepressants is the lack of functional guidelines for cessation of the drug, it’s important that the publication of the report’s findings doesn’t result in millions of people spontaneously quitting their medication, but while the Royal College’s statement may act to avert that particular outcome, it fails to address the fact that earlier studies have shown their statement about the effectiveness of antidepressants in treating depression to be untrue.
In his 2021 book Sedated: How Modern Capitalism Created our Mental Health Crisis, James Davies identifies “an array of harms caused by the very professions that purport to help us.” These problems are the predictable outcome of the mass marketing of prescription drugs beginning after the second world war, and the “new style of capitalism” introduced during the 1980s by conservative governments in the UK and the US.
Given the complex nature of psychology and the importance to its subjects of finding successful strategies for managing emotional and psychological distress, it’s difficult to overstate the need for a thorough examination of the intellectual structure upon which treatments are based. It’s both disappointing and alarming, then, to learn that the “aspect of psychology most likely to touch the lives of the ‘ordinary person’ is less a unified discipline than a motley of competing factions trying to demarcate its own domain, patent its own procedures, and prevent intruders from entering its territory”, as David Smail writes. Nor is the field of psychology interested in revealing the uneven power relations that necessitate such jockeying for position while at the same time underpinning much of the psychological distress that people experience through the course of their lives.
Locating the origin of personal distress “inside” the individual takes the spotlight off of the impossibility of living a life of principled integrity under a capitalist system, while at the same time legitimizing a whole host of modalities aimed at “fixing” the “patient.” Smail writes:
Psychology’s rendering as internal to the individual constructs such as motive and will, desire and insight, its isolation of the person from a social world and its “therapeutic” emphasis on his or her own responsibility for personal shortcomings, all serve to provide us with a kind of sanitized technology of conduct which turns totally blind eyes to the crushing and rapacious machinations of power which envelop us as soon as we emerge from the womb.
Pathologizing distress depoliticises and obscures its origins, Smail argues, and places the onus of finding ways to deal with oppression and isolation onto the individual.
To better understand why the mental health field is the single exception to the “astonishing” rate of progress in the medical community over the past 40 years, Davies explores the neoliberal policies of Britain’s former conservative prime minister, Margaret Thatcher, and looks at the relationship between the economy and “those institutions responsible for understanding and managing suffering.”
First, he outlines Thatcher’s belief that in order for the state to create a vibrant economy, it must start by instilling in people a strong sense of personal responsibility. “From now on,” Davies writes, “regulated capitalism would be superseded by a new economic order: a new capitalism, a neo-liberalism, increasing the role of market forces and encouraging the kinds of personal qualities—competitiveness, self-reliance, entrepreneurialism and productivity—esteemed by the Thatcher elite.”
Second, Davies identifies a four-step process by which the economy shapes the institutions tasked with addressing individual distress:
- Conceptualise human suffering in ways that protect the current economy from criticism.
- Redefine individual well-being in terms consistent with goals of the economy.
- Medicalise behaviours and emotions that might negatively impact the economy.
- Turn suffering into a vibrant market opportunity for more consumption.
Smail’s observations about the benefits to the economy of locating the origins of distress in the individual reflect the political climate of the West that came to the fore during Thatcher’s reign. She firmly believed that “self-reliance, independence and self-responsibility” in individuals could first be fostered by economic reform and eventually become the motor that keeps the economy ticking profitably along. “Economic reform would be the surgical procedure,” Davies explains, “and moral and economic health the national reward.”
Expressions of suffering under this new economic arrangement were defined as manifestations of “selfish entitlement” to be cured by the satisfaction of a hard day’s graft, or as proof of a psychological deficiency, the root of which could be found in the individual who suffered. Since suffering is widespread and antidepressants are the cheapest and the most accessible treatment option available, their use has become pervasive, functioning much in the same way that, according to Marx’s observations, organised religion functions. By blunting negative emotional responses to exploitation and alienation, pathologized distress and antidepressant use disrupt the natural push for social reform that such suffering would normally provoke, leaving the exploitative economic system intact and its victims disarmed.
Smail is not the first critic of what he calls “the incipient moralism of so-called ‘psychotherapeutic’ approaches, which, however subtly, manage to ‘blame the victim.’” It’s not reasonable, he suggests, to expect professionals whose identity and livelihood depend on the individual model of suffering to reliably champion the view that, actually, capitalism is the real culprit, and they are its enablers. Unfortunately, Smail concludes, “we are looking not so much at a breakthrough in enlightened understanding of distress as at the success of an empire.”
Davies agrees. In chapter two of Sedated, Davies takes on “the new culture of proliferating debt and drugs” that characterised the neoliberal governments of Thatcher in the UK and Reagan in the US during the 1980s. Debt and drugs are both commodities, he explains, and both of them are personal band-aids employed to disguise underlying problems, like the ones revealed in a 2007 paper published in the Journal of Nervous and Mental Disease.
The study, conducted by Martin Harrow, was the most comprehensive review of long-term psychiatric drug use conducted until that point. The results were both unexpected and, it seems, unwelcome. “While all the patients started out with the same diagnosis, the patients who improved most were not those who had remained on their medication over the years, but those who had stopped earlier on,” Davies recalls. In fact, no matter how one looked at the results of the study, it was clear that “the longer people remained on the drugs, the worse their outcomes on every measure.”
Robert Whitaker, an American journalist and author who published Mad in America, a critical history of psychiatric treatments, in 2002, was one of the few to take notice of Harrow’s study. Whitaker’s own research had revealed how often treatments that at one time were celebrated as breakthroughs in psychiatry, ended up proving very harmful to patients, and he wondered if psychiatric drugs would go the way of lobotomies and insulin comas now that they had been shown over the long-term to be not only ineffective, but harmful.
Davies quotes Whitaker: “Harrow’s paper appeared to confirm not just something I’d hypothesised in Mad in America, but what so many patients had told me since: that during their long-term treatment their conditions got worse, not better.” Whitaker’s continued research following the publication of Harrow’s 2007 report uncovered what he called a “bemusing” state of affairs: every country assessed as part of his research had experienced a meteoric rise in mental health disability since the 1980s that coincided with a huge rise in the number of psychiatric drugs being prescribed.
To ensure that his observations were not just correlation, Whitaker gathered together all studies undertaken since the 1950s on the effects of long-term drug regimens on people who had been diagnosed with a mental disorder. These studies confirmed that, on average, people who continue to take psychiatric medications do much worse over the long term than those who stop the drugs.
While it seems like the recent announcement from the University College London disproving the chemical imbalance theory of mental illness should mark a profound change in the prescription and use of psychiatric medications, statements like the one made by the Royal College of Psychiatrists in response to the report suggest that the report’s revelations may have fallen on willfully deaf ears.
As evidenced by the Harrow study, Mad in America, Whitaker’s second book Anatomy of an Epidemic, and multiple other studies published in the 2010s, information about the harmful effects of antidepressants has long been available to the medical community, but prescriptions for psychiatric drugs, in concert with mental health disability claims, just keep rising. So, why don’t governments intervene?
In Sedated, Davies concludes that “since the 1980s, successive governments and big business have worked to promote a new vision of mental health that puts at its centre a new kind of person: resilient, optimistic, individualistic and above all, economically productive—the kind of person the new economy needs and wants.” The kind of person who falls easily in line with the four-step process Davies identified by which the economy shapes our institutions.
As anyone familiar with the fable about the Pied Piper of Hamelin can tell you, who pays the piper calls the tune. Because pharmaceutical companies are the ones financing the clinical trials, they’re also the ones deciding which trials are undertaken, and ultimately, which drugs are produced. With that level of control, companies like Pfizer and Johnson & Johnson can dictate the narrative around illness in such a way that it corresponds with the sale of their products.
On the 3rd of July, 2022, a Twitter account with the handle @atomicaceso tweeted: “I went to the doctor this week and part of my intake was the phq-9, a depression scale invented by Pfizer to sell more antidepressants. This is one example of why it is so hard for me to take the medical field seriously. It felt like a Black Mirror episode.” @atomicaceso includes a link in her tweet to a Pfizer press release from 2010 containing the following announcement:
As part of its commitment to improving the quality of patient care, Pfizer today announced that it will make available assessment scales used by physicians and others in the healthcare community to support the evaluation and diagnosis of patients suffering from certain mental disorders. For the first time, these users can directly access and download the Patient Health Questionnaire (PHQ) and the General Anxiety Disorder questionnaire (GAD-7) without copyright restriction and at no charge, providing unprecedented access to these valuable and widely used tools for evaluating certain mental disorders.
The statement dovetails perfectly with other aggressive marketing tactics employed by pharmaceutical companies, including their association with and promotion of the Diagnostic and Statistical Manual of Mental Disorders (DSM), the fifth volume of which was published in May 2013. Shortly after publication, the DSM-5 appeared at the top of the Amazon.com bestseller list by virtue of the fact that key players in the pharmaceutical industry were buying up all the copies they could get at $88 each and handing them out free to clinicians. Davies writes that according to a professor from the Department of Psychology at New York University, “as almost any kind of suffering is caught by the DSM, disseminating it is just good business [because] it drives up diagnosis rates and prescriptions.”
Considering that the DSM-5 approved the definitions of 370 mental disorders—compared to 106 in the early 1970s—Davies was curious about how this enormous expansion had come about. Amid growing international criticism of the famous guide, Davies undertook extensive research into its history. What he uncovered is that “by progressively lowering the bar for what constitutes a psychiatric disorder” and then reclassifying “everyday painful human experiences” as pathologies, the DSM—“without any real biological justification”—had rebranded most of human suffering as symptoms of psychiatric illness, in spite of the fact that “there are simply no discovered biological abnormalities for which to test.” Davies writes that the disorders listed in the DSM-5 are not based on verifiable scientific data, then, but rather on the consensus opinion of a select group of DSM psychiatrists, almost all of whom have ties to the pharmaceutical industry. In the event that they can’t come to an agreement among themselves, the decision goes to a vote.
In an article posted on Mad in America following the announcement from the Royal College of London, Robert Whitaker says that he initially wondered if he should bother to report on the study’s findings, given that “Mad in America readers know well that the low-serotonin theory had long ago been debunked.”
The mainstream media, on the other hand, were all over the announcement, Whitaker writes, hyping Moncrieff et al’s study “as a “landmark” finding [and] a “game changer” … [that has] shaken up accepted wisdom about antidepressants.” Still, given the humdrum responses of psychiatrists on both sides of the pond, it seems clear that many have long known the truth, but have carried on prescribing antidepressants with a disinterested shrug.
Whitaker’s article makes a case for starting a class action lawsuit on behalf of the many thousands who have suffered long-term iatrogenic harm from psychiatric medications taken as prescribed. Considering the extent of the damage that has been done to some individuals and the diminished quality of life that they lead as a result, I suspect that there will be a great deal of support for such a suit now that the cat is out of the bag, so to speak.
Certainly, the attention attracted by a large class action lawsuit against pharmaceutical giants like Pfizer and Johnson & Johnson would help to shine a light on the rapacious greed fueling the aggressive marketing tactics employed by the pharmaceutical industry as a whole, and financial compensation for those affected could mitigate at least some part of the harm done. But the question remains: what can be done at the level of service to relieve the suffering that brings people to their doctors in the first place?
In 2016, in response to patient protests and opposition to mainstream psychiatry, the health ministry in Norway ordered “medication free” treatment options to be introduced into psychiatric hospitals in four regional health authorities. Patient groups with meticulous evidence—garnered primarily from Robert Whitaker’s work—lobbied the government and caught the attention of the health minister, Bent Høies.
Davies cites Høies: “For me it was the clearly expressed need from the patients that triggered my decision. Medication free treatment is an important step in changing and modernising mental health services.” Patient advocacy groups were inspired by increasing numbers of patient-led movements that were helping even severely distressed people without medical intervention.
For example, the Open Dialogue initiative, operating in Lapland since the 1990s, was “achieving at the very least comparable levels of recovery by way of offering community and interpersonal support with a clear emphasis on reducing medication early on,” Davies writes. By allowing grassroots concerns to shape public policy, Norwegian politicians have opened the door to finding genuine and long-lasting resolutions to emotional and psychological distress that don’t involve drugs. Given the scope of the problem and the sheer volume of people seeking relief, it’s impossible to understate the importance of Moncrieff et al’s study having caught the attention of the mainstream media. An educated public has a much better chance of advocating from the grassroots for safe and effective treatments in the face of a pharmaceutical industry more interested in profits than people.
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.