“The problem with putting labels on people is that it ends up medicalising problems that are not medical in nature.”
- Dr. Sami Timimi, psychiatrist
May 6, 2013
From depression to anxiety and ADHD, more of us now suffer from mental health problems and need pills to treat them — or so we’re told. But in this shocking indictment of modern psychiatry, JAMES DAVIES suggests that this rise in mental illness is down to the greed of drug companies and the pursuit of medical status. The author is a psychological therapist who has worked for the NHS and the mental health charity Mind.
When I meet Sarah Jones, a mother of two and a care worker in West London, her love for her family and work clearly shine through. But when we talk about her seven-year-old son Dominic, she seems overcome with anxiety.
‘Dominic is a lovely boy, but last year he started getting agitated and aggressive. He was doing badly at school and then he got into a fight,’ she says.
The school psychologist wanted Dominic to have a doctor’s assessment. After seeing the boy for 25 minutes, the doctor said he was suffering from attention deficit hyperactivity disorder, or ADHD.
‘Dominic is on pills,’ says Sarah. ‘He seems less distracted sometimes, but he also doesn’t seem himself either. It feels as if a part of his spirit has gone.’ Sarah’s distress is palpable.
Year on year, increasing numbers of children like Dominic are having mental disorders such as ADHD diagnosed. In the past ten years, ADHD diagnoses have risen so sharply that around 5 per cent of children in Europe are thought to have it.
This vaulting rise in ADHD is consistent with a growth in childhood psychiatric disorders. It’s estimated up to 15 per cent of children fall under the criteria of a diagnosable mental disorder in any year.
These figures pale in comparison with those for the adult population. On the subject of ‘psychiatric morbidity’, the UK Office for National Statistics reckons that in any given year a quarter of all adults qualify as suffering from at least one disorder.
This is as defined in manuals such as the psychiatrists’ ‘bible’, the Diagnostic and Statistical Manual of Mental Disorders (DSM) or its close equivalent, the International Classification of Diseases (ICD), which they use as the basis of making diagnoses.
In the Fifties, the figure was more like one in 100. So why in just a few decades have we apparently all become so psychiatrically unwell?
The explanation lies in an unhappy truth at the heart of mainstream psychiatric practice: much of the profession’s claimed knowledge about diagnosing mental illness is scientifically baseless.
Unlike in other areas of medicine, where a doctor can conduct a blood or urine test to determine whether they have reached the correct diagnosis, in psychiatry no such methods exist.
Such scientifically objective tests don’t exist because psychiatry has yet to identify any clear biological causes for most disorders listed in the DSM, which has grown bigger and bigger with each edition.
When we look into the manual’s origins, we uncover some disturbing evidence.
I interviewed Dr Robert Spitzer, the Columbia University psychiatrist, who was in charge of compiling the third edition of the DSM, which set the trend for modern psychiatric practice. When it was published in 1980, it became a sensation and sold out immediately.
In the manual, his team had defined 80 new mental disorders. These became household terms. For example, post-traumatic stress disorder and major depression became as real in the popular imagination as the common cold.
In Britain, the manual had such impact that by the end of the Eighties most British psychiatrists were being trained to use it.
Yet, as its influence spread, the truth about its construction remained obscure. Most professionals using it didn’t know the extent to which biological evidence or solid research failed to guide the choices its authors made.
SCIENCE? NO, IT’S A SHAMBLES
When I spoke to Dr Spitzer, he told me matter of factly: ‘There are only a handful of mental disorders in the DSM known to have a clear biological cause. These are known as the organic disorders [such as epilepsy and Alzheimer’s]. These are few and far between.’
‘So, let me get this clear,’ I pressed. ‘There are no discovered biological causes for many of the remaining mental disorders in the DSM.’
He replied: ‘It’s not for many, it’s for any! No biological markers have been identified.’
In other words, the definitions were based purely on what the committee who drew up the DSM-III decided should go in. And these discussions were far from rigorous.
Renee Garfinkel, a psychologist who participated in two committees that helped to compile the DSM-III, told me: ‘What I saw happening on these committees wasn’t scientific — it more resembled a group of friends trying to decide where they want to go for dinner.
‘One person says “I feel like Chinese food,” and another one says “No, no, I’m really more in the mood for Indian.” Finally, after some discussion and collaborative give and take, they all decide to have Italian.
‘On one occasion there was a discussion about whether a particular behaviour should be classed as a symptom of a particular disorder.
‘To my astonishment, one committee member piped up: “Oh no, no, we can’t include that behaviour as a symptom, because I do that.”
‘So it was decided that behaviour would not be included because, presumably, if someone on the committee does it, it must be normal.’
Allen Frances, who led the compiling of the next edition, DSM-IV, has seen how this process of adding new diagnoses can run out of control.
The fourth manual added Asperger’s syndrome (covering people who don’t have full-blown autism), ADHD and bipolar II — broadly speaking, a milder form of bipolar disorder, or manic depression as it used to be known, in which the ‘up’ swings never reach full-blown mania.
‘These decisions helped promote three false epidemics in psychiatry,’ he told me.
‘We now have a rate of autism that is 20 times what it was 15 years ago. By adding bipolar II, that has resulted in lots more use of anti-psychotic and mood- stabiliser drugs.
‘We also have rates of ADHD that have tripled, partly because new drug treatments were released that were aggressively marketed.’
TURNING GRIEF INTO AN ILLNESS
This month we are due to see the publication of a new edition, called DSM-5. ‘The situation is only going to get worse,’ Frances told me.
‘DSM-5 is suggesting changes that will dramatically expand the realm of psychiatry and narrow the realm of normality — converting millions more people from being without mental disorders to being psychiatrically sick.
‘It will have many unintended consequences, which will be very harmful. I am particularly concerned about those that will lead to the excessive use of medication.’
DSM-5 proposes to make ordinary grief a mental disorder. Feelings of deep sadness, loss, sleeplessness, crying, inability to concentrate, tiredness and low appetite, if they continue for more than two weeks after the death of a loved one, could warrant a diagnosis of depression.
Frances is also worried by the new ‘generalised anxiety disorder’, which threatens to turn the pains and disappointments of everyday life into mental illness.
Then there is ‘disruptive mood dysregulation disorder’, which will see children’s tantrums become symptoms of disorder.
Wherever this manual is used we can expect vaulting numbers of people to become yet more statistical droplets in the ever expanding pool of the mentally unwell.
They will very often then be prescribed drugs. With conditions such as depression, those drugs are purported to remedy so-called ‘chemical imbalances’ in the brain.
But despite nearly 50 years of investigation into the theory that chemical imbalances are the cause of psychiatric problems, studies in respected journals have concluded that there is not one piece of convincing evidence the theory is actually correct.
And if the evidence for the biological causes of this growing number of mental health conditions is almost non-existent, the evidence for the drugs being used to treat them is also most often unconvincing.
This is particularly true of anti-depressants. The pharmaceutical industry makes more than £13 billion worldwide each year from anti-depressants. Doctors are convinced of their effectiveness. But solid scientific research shows otherwise.
To find out why, I visited Professor Irving Kirsch, an associate director at Harvard Medical School and perhaps the most talked-about figure in antidepressant research.
Kirsch’s reputation stems from an analysis he performed that gathered all the clinical studies he could find that compared the effects of anti-depressants to sugar-pill placebos on depressed patients. He pooled all the results to get an overall figure, which led to a startling conclusion.
‘What we expected to find was that people who took the antidepressant would do far better than those taking the placebo. We couldn’t have been more wrong,’ said Kirsch.
In fact, the difference in improvement between placebo and anti-depressant groups was clinically insignificant. So why are so many psychiatric drugs prescribed when the evidence underpinning them is so scant, and when the illnesses diagnosed have no biological basis?
Nearly all research into psychiatric drugs is sponsored by the pharmaceutical industry. This has led to the compromise of scientific standards, and the manipulation of research with the aim of maintaining or increasing profits.
In one notorious example, the British company GlaxoSmithKline conducted three studies of its anti-depressant, Seroxat. These investigated whether this drug could reduce major depression in adolescents.
One trial showed mixed results, another that Seroxat was no more effective than a placebo, while the third suggested the placebo may be more effective with certain children.
A COVER-UP BY THE DRUG GIANTS
Despite these results, the company published only the most positive study. An internal company document, leaked to the Canadian Medical Association, showed that company officials had suppressed negative results from one study because, as they said: ‘It would be commercially unacceptable’.
A U.S. lawsuit was filed against GlaxoSmithKline in 2004 for intentionally hiding negative findings. This was settled out of court two months later when the company paid $2.5 million for charges of consumer fraud; a meagre sum considering it made $4.97 billion in worldwide sales from the drug in 2003.
It’s hardly an isolated case. An article published by the New England Journal of Medicine in 2008 reviewed more than 70 major studies of antidepressants’ efficacy and found 33 that showed negative results had been buried or manipulated to convey a positive outcome.
But pharmaceutical companies’ influence runs deep. In the past 20 years the industry has become a major financial sponsor of psychiatry, with unprecedented influence over psychiatric practice and research.
Nearly all research into psychiatric drugs is pharmaceutically financed. Nearly 90 per cent of all clinical trials in the UK are conducted or commissioned by the industry.
The influence of drug companies also reaches into the latest editions of the psychiatrists’ bible. A study by the University of Massachusetts showed that of the 170 panel
members of DSM-IV, 95 (or 56 per cent) had one financial association or more with the pharmaceutical industry.
This trend has continued with the writers of the forthcoming DSM-5. Of the 29 members of the task force that oversees it, 21 — including the chairman and vice-chairman — have received consultancy fees or funding from pharmaceutical firms.
Funding psychiatrists at the top of the professional pyramid is a strategy essential to how the pharmaceutical industry markets its pills.
Companies know they must recruit senior psychiatrists to convince less senior doctors to spread the message to medical students, junior doctors, primary care physicians and GPs.
In fact, the vast majority of antidepressants are prescribed by GPs, not psychiatrists.
But there is one positive trend. A small band of vociferous psychiatrists is beginning to question the ‘more diagnoses and drugs’ approach. One is Dr Sami Timimi, a consultant psychiatrist and director of medical education in the NHS.
He told me: ‘The current framework of diagnoses doesn’t help patients at all. In fact, it seems to do the opposite.’
What the evidence shows, according to Timimi, is that what matters most in mental healthcare is not diagnosing problems and prescribing medication, but developing meaningful relationships with sufferers with the aim of cultivating insight into their problems. Sometimes the right care means giving drugs, but often it does not.
The problem with putting labels on people, he believes, is that it ends up medicalising problems that are not medical in nature.
This isn’t helped by successive expansions of the DSM and ICD, which encourage practitioners to wrongly medicalise more and more emotional troubles as mental disorders.
CRACKED by James Davies, is published by Icon Books on Thursday at £10.99. ©2013 James Davies. To order a copy for £8.99 (incl P&P) call 0844 472 4157.