Psychiatry Now Admits It's Been Wrong in Big Ways - But Can It Change?

Wednesday, 05 March 2014 10:05 By Bruce E Levine, Truthout | 


When I interviewed investigative reporter Robert Whitaker in 2010 after the publication of his book Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America, he was not exactly a beloved figure within the psychiatry establishment. Whitaker had documented evidence that standard drug treatments were making many patients worse over the long term, and he detailed the lack of science behind these treatments.

Whitaker's sincerity about seeking better treatment options, his command of the facts, and his lack of anti-drug dogma compelled all but the most dogmatic psychiatrists to take him seriously.

For Anatomy of an Epidemic, Whitaker won the 2010 Investigative Reporters and Editors Book Award for best investigative journalism. This and other acclaim made it difficult for establishment psychiatry to ignore him, so he was invited to speak at many of their bastions, including a Harvard Medical School Grand Rounds at Massachusetts General Hospital, where he faced hostile audiences. However, Whitaker's sincerity about seeking better treatment options, his command of the facts and his lack of anti-drug dogma compelled all but the most dogmatic psychiatrists to take him seriously.

In the past four years, the psychiatry establishment has pivoted from first ignoring Whitaker to then debating him and attempting to discredit him to currently agreeing with many of his conclusions. But will Whitaker's success in changing minds result in a change for the better in treatment practices?

I was curious about Whitaker's take on the recent U-turns by major figures in the psychiatry establishment with respect to antipsychotic drug treatment, the validity of the "chemical imbalance" theory of mental illness and the validity of the DSM, psychiatry's diagnostic bible. And I was curious about Whitaker's sense of psychiatry's future direction.

Bruce Levine: In 2013, the director of the National Institute of Mental Health (NIMH), Thomas Insel, announced - without mentioning you -  that he agreed with your conclusion that psychiatry's standard treatment for people diagnosed with schizophrenia and other psychoses needs to change so as to better reflect the diversity in this population. Citing long-term treatment studies that you had previously documented, Insel came to the same conclusion that you had: In the long-term, not all, but many individuals who have been diagnosed with psychosis actually do better without antipsychotic medication. Was it gratifying for you to see the US government's highest-ranking mental health official agreeing with you? 

Robert Whitaker: Shortly before Thomas Insel wrote that blog, I had posted my own on madinamerica.com, related to a recent study by Lex Wunderink from the Netherlands. Wunderink had followed patients diagnosed with a psychotic disorder for seven years, and he reported that those randomized, at an early date, to a treatment protocol that involved tapering down to a very low dose or withdrawing from the medication altogether had much higher recovery rates than those maintained on a regular dose of an antipsychotic.

I wrote that in the wake of Wunderink's randomized study, if psychiatry wanted to maintain its claim that its treatments were evidence-based, and thus maintain any sort of moral authority over this medical domain, then it needed to amend its treatment protocols for antipsychotics. I don't know if Dr. Insel read my blog, but his post did nevertheless serve as a reply, and as you write, he did basically come to the same conclusion that I had been writing about for some time.

I suppose I took some measure of personal gratification from his blog, for it did provide a sense of a public acknowledgment that I had indeed been "right." But more important, I felt a new sense of optimism, hopeful that maybe psychiatry would now really address this issue, which is so important to the lives of so many people. A short while ago, The New York Times published a feature story on Dr. Insel, noting that he had recently raised a question about the long-term use of antipsychotics, which had caused a stir in psychiatry because it contradicted conventional wisdom. That is a sign that perhaps a new discussion is really opening up.

In Anatomy of an Epidemic, you also discussed the pseudoscience behind the "chemical imbalance" theories of mental illness - theories that made it easy to sell psychiatric drugs. In the last few years, I've noticed establishment psychiatry figures doing some major backpedaling on these chemical imbalance theories. For example, Ronald Pies, editor-in-chief emeritus of the Psychiatric Times stated in 2011, "In truth, the ‘chemical imbalance' notion was always a kind of urban legend - never a theory seriously propounded by well-informed psychiatrists." What's your take on this?

 

The "disease model," as a basis for making psychiatric diagnoses, has failed.

This is quite interesting and revealing, I would say. In a sense, Ronald Pies is right.Those psychiatrists who were "well informed" about investigations into the chemical imbalance theory of mental disorders knew it hadn't really panned out, with such findings dating back to the late 1970s and early 1980s. But why, then, did we as a society come to believe that mental disorders were due to chemical imbalances, which were then fixed by the drugs?

Dr. Pies puts the blame on the drug companies. But if you track the rise of this belief, it is easy to see that the American Psychiatric Association promoted it in some of their promotional materials to the public and that "well informed" psychiatrists often spoke of this metaphor in their interviews with the media. So what you find in this statement by Dr. Pies is a remarkable confession: Psychiatry, all along, knew that the evidence wasn't really there to support the chemical imbalance notion, that it was a hypothesis that hadn't panned out, and yet psychiatry failed to inform the public of that crucial fact.

The low-serotonin theory of depression has been so completely discredited by leading researchers that maintaining the story with the public has just become untenable.

By doing so, psychiatry allowed a "little white lie" to take hold in the public mind, which helped sell drugs and, of course, made it seem that psychiatry had magic bullets for psychiatric disorders. That is an astonishing betrayal of the trust that the public puts in a medical discipline; we don't expect to be misled in such a basic way.

But why now? Why are we hearing these admissions from Dr. Pies and others now? I am not sure, but I think there are two reasons.

One, the low-serotonin theory of depression has been so completely discredited by leading researchers that maintaining the story with the public has just become untenable. It is too easy for critics and the public to point to the scientific findings that contradict it.

Second, a number of pharmaceutical companies have shut down their research into psychiatric drugs [see Science, 2010], and they are doing so because, as they note, there is a lack of science providing good molecular targets for drug development. Even the drug companies are moving away from the chemical-imbalance story, and thus, what we are seeing now is the public collapse of a fabrication, which can no longer be maintained. In the statement by Dr. Pies, you see an effort by psychiatry to distance itself from that fabrication, putting the blame instead on the drug companies.

Challenging the validity of DSM is, in many ways, potentially much more of a paradigm-changer than are the scientific reports that detail how the medications may be causing long-term harm.

And recently, establishment psychiatrists have even been challenging the validity of psychiatry's diagnostic bible, the DSM. Last year, NIMH director Insel, citing the DSM's lack of scientific validity, stated that the "NIMH will be re-orienting its research away from DSM categories." And psychiatrist Allen Frances, the former chair of the DSM-4 task force, has been talking about how the DSM is a money machine for drug companies ("Last Plea To DSM-5: Save Grief From the Drug Companies"), and Frances thoroughly trashed the DSM-5 in his 2013 book Saving Normal.

I think this challenging of the validity of DSM is, in many ways, potentially much more of a paradigm-changer than are the scientific reports that detail how the medications may be causing long-term harm. Our current drug-based paradigm of care, which presents drugs as treatments for the symptoms of a "disease," stems from DSM III. The APA [American Psychiatric Association] and its leaders boasted that when DSM III was published in 1980, that the field had now adopted a "medical model," and thus its manual was now "scientific" in kind.

In fact, the APA had adopted a "disease model," and if you carefully read the DSM III manual, you saw that the authors acknowledged that very few of the diagnoses had been "validated." The APA's hope and expectation was that future research would validate the disorders, but that hasn't happened. Researchers haven't identified a characteristic pathology for the major mental disorders; no specific genes for the disorders have been found; and there isn't evidence that neatly separates one disorder from the next. The "disease model," as a basis for making psychiatric diagnoses, has failed.

We are now witnessing, in Insel's statements and those by Allen Frances, an acknowledgment of this failure. And here is why this is potentially such a paradigm-changer: The foundation of any medical specialty begins with its diagnostic manual, which should be both reliable and valid. If the disorders listed in a manual haven't been validated, then you can't conclude they are "real," in the sense of the disorders being unique illnesses, and the diagnoses being useful for prescribing an appropriate treatment.

Thus, when Insel states that the disorders haven't been validated, he is stating that the entire edifice that modern psychiatry is built upon is flawed, and unsupported by science. This is like the King of Psychiatry saying that the discipline has no clothes. 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, and that could prove to be fertile ground for real change.

So do you feel you have accomplished your mission? And can dissident mental health professionals - who have for years been talking about invalid diagnoses, pseudoscientific theories of mental illness, and drug treatments that cause moderate and acute problems to become severe and chronic ones - now have reasons to be optimistic about their profession? Or are you pessimistic that the recent admissions of establishment psychiatry will result in substantive changes in treatment? 

My "mission" would be to see that our society would actually build a system of care that was truly "science" based, particularly in its use of psychiatric drugs.

This is a good question, and I vacillate in my personal response between guarded optimism and complete pessimism. From an intellectual, scientific standpoint, I think psychiatry is facing a deep crisis. There is an understanding, within psychiatric research circles, that the DSM diagnoses haven't, in fact, been validated. And, at the very least, there is a recognition that psychiatry's drug treatments are inadequate. In 2009, Insel wrote an article stating: "For too many people, antipsychotics and antidepressants are not effective, and even when they are helpful, they reduce symptoms without eliciting recovery." And I do think that my book Anatomy of an Epidemic has contributed to an awareness of the limitations of the drugs, and at least a discussion, in some psychiatric circles, that the drugs may be worsening long-term outcomes.

But in terms of accomplishing my mission, well, I guess my "mission" would be to see that our society would actually build a system of care that was truly science-based, particularly in its use of psychiatric drugs. I think this is such an important story for our society and one of extraordinary moral importance when it comes to medicating children and adolescents, none of whom could be said to have really "consented" to such treatment. I turned madinamerica.com into a webzine with the hope that by providing a forum for a community of writers interested in "rethinking psychiatry" and combining their voices with reports of research that provide a foundation for such rethinking, it could become a real force for change. We'll see if that happens, but our readership is steadily increasing.

I should note, as you say, that dissident mental health professionals have been plugging away at promoting such change for a long time. I hope that madinamerica.com is providing that community a forum for voicing their criticisms and making them known to a larger audience.

And now for why I can be so pessimistic. Even as the intellectual foundation for our drug-based paradigm of care is collapsing, starting with the diagnostics, our society's use of these medications is increasing; the percentage of children and youth being medicated is increasing; and states are expanding their authority to forcibly treat people in outpatient settings with antipsychotics drugs. Disability numbers due to mental illness go up and up, and we don't see that as reason to change either. History does show that paradigms of psychiatric care can change, but, in a big-picture sense, I don't know how much is really changing here in the United States.

I think dissident mental health professionals also have to confront this question. Can they be hopeful that their professions will change their ways, and their teachings? I think so, but there is so much that needs to be done.

Any medical specialty has guild interests, meaning that it needs to protect the market value of its treatments.

Is it really possible for psychiatry to reform in any meaningful way given their complete embrace of the "medical model of mental illness," their idea that emotional and behavioral problems are caused by a bio-chemical defect of some type? Can they really reform when their profession as a financial enterprise rests on drug prescribing, electroshock and other bio-chemical-electrical treatments? Can psychiatry do anything but pay lip service to a more holistic/integrative view that includes psychological, spiritual, social, cultural and political realities?

I think we have to appreciate this fact: any medical specialty has guild interests, meaning that it needs to protect the market value of its treatments. If it is going to abandon one form of treatment, it needs to be able to replace it with another. It can't change if there is no replacement in the offing.

When the APA published DSM III, it basically ceded talk therapy to psychologists, counselors, social workers and so forth. Psychiatry's three domains, in the marketplace, were diagnostics, research and the prescribing of drugs. Now, 34 years later, 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.

Yet, as you suggest, this is why it is going to be so hard for psychiatry to reform. Diagnosis and the prescribing of drugs constitute the main function of psychiatrists today in our society. From a guild perspective, the profession needs to maintain the public's belief in the value of that function. So I don't believe it will be possible for psychiatry to change unless it identifies a new function that would be marketable, so to speak. Psychiatry needs to identify a change that would be consistent with its interests as a guild.
The one faint possibility I see - and this may seem counterintuitive - is for psychiatry to become the profession that provides a critical view of psychiatric drugs. Family doctors do most of the prescribing of psychiatric drugs today, without any real sense of their risks and benefits, and so psychiatrists could stake out a role as being the experts who know how to use the drugs in a very selective, cautious manner, and the experts who know how to incorporate such drug treatment into a holistic, integrated form of care. If the public sees the drugs as quite problematic, as medications that can serve a purpose - but only if prescribed in a very nuanced way - then it will want to turn to physicians who understand well the problems with the drugs and their limitations.

That is what I think must happen for psychiatry to change. Psychiatry must see a financial benefit from a proposed change, one consistent with guild interests.  

Aspirin could beat cancer spread

By Agence France-Presse
Tuesday, February 14, 2012

Aspirin and other household drugs may inhibit the spread of cancer because they help shut down the chemical “highways” which feed tumours, Australian researchers announced on Tuesday.

Scientists at Melbourne’s Peter MacCallum Cancer Centre said they have made a biological breakthrough helping explain how lymphatic vessels – key to the transmission of tumours throughout the body — respond to cancer.

“We’ve shown that molecules like the aspirin… could effectively work by reducing the dilation of these major vessels and thereby reducing the capacity of tumours to spread to distant sites,” researcher Steven Stacker said.

Doctors have long suspected that non-steroidal anti-inflammatory drugs such as aspirin may help inhibit the spread of cancer but they have been unable to pinpoint exactly how this is done.

By studying cells in lymphatic vessels, the researchers found that a particular gene changed its expression in cancers which spread, but not when the cancer did not spread.

The results published in Cancer Cell journal reveal that the gene is a link between a tumour’s growth and the cellular pathway which can cause inflammation and dilation of vessels throughout the body.

Once these lymphatic vessels widen, the capacity for them to act as “supply lines” to tumours and become more effective conduits for the cancer to spread is increased.

But aspirin acts to shut down the dilation of the vessels.

“So it seems like we have found a pivotal junction point in a biochemical sense between all these different contributors,” Stacker said.

The discovery could lead to new and improved drugs which could help contain many solid tumours, including breast and prostate cancer, as well as potentially provide an “early warning system” before a tumour begins to spread.

Last year, a study published in medical journal The Lancet found that rates of cancer of the colon, prostate, lung, brain and throat were all reduced by daily aspirin use.

Many doctors recommend regular use of aspirin to lower the risk of heart attack, clot-related strokes and other blood flow problems. A downside of extended daily use is the risk of stomach problems.

Pres. Jimmy Carter: Call Off the Global Drug War

Friday, June 17, 2011 by the Minneapolis Star Tribune
by Pres. Jimmy Carter

In an extraordinary new initiative announced earlier this month, the Global Commission on Drug Policy has made some courageous and profoundly important recommendations in a report on how to bring more effective control over the illicit drug trade.

The commission includes the former presidents or prime ministers of five countries, a former secretary general of the United Nations, human rights leaders, and business and government leaders, including Richard Branson, George P. Shultz and Paul A. Volcker.

The report describes the total failure of the present global antidrug effort, and in particular America's "war on drugs," which was declared 40 years ago today. It notes that the global consumption of opiates has increased 34.5 percent, cocaine 27 percent and cannabis 8.5 percent from 1998 to 2008.

Its primary recommendations are to substitute treatment for imprisonment for people who use drugs but do no harm to others, and to concentrate more coordinated international effort on combating violent criminal organizations rather than nonviolent, low-level offenders.

These recommendations are compatible with U.S. drug policy from three decades ago. In a message to Congress in 1977, I said the country should decriminalize the possession of less than an ounce of marijuana, with a full program of treatment for addicts.

I also cautioned against filling our prisons with young people who were no threat to society, and summarized by saying: "Penalties against possession of a drug should not be more damaging to an individual than the use of the drug itself."

These ideas were widely accepted at the time. But in the 1980s President Ronald Reagan and Congress began to shift from balanced drug policies, including the treatment and rehabilitation of addicts, toward futile efforts to control drug imports from foreign countries.

This approach entailed an enormous expenditure of resources and the dependence on police and military forces to reduce the foreign cultivation of marijuana, coca and opium poppy and the production of cocaine and heroin. One result has been a terrible escalation in drug-related violence, corruption and gross violations of human rights in a growing number of Latin American countries.

The commission's facts and arguments are persuasive. It recommends that governments be encouraged to experiment "with models of legal regulation of drugs ... that are designed to undermine the power of organized crime and safeguard the health and security of their citizens." For effective examples, they can look to policies that have shown promising results in Europe, Australia and other places.

But they probably won't turn to the U.S. for advice. Drug policies here are more punitive and counterproductive than in other democracies, and have brought about an explosion in prison populations. At the end of 1980, just before I left office, 500,000 people were incarcerated in America; at the end of 2009 the number was nearly 2.3 million.

There are 743 people in prison for every 100,000 Americans, a higher portion than in any other country and seven times as great as in Europe. Some 7.2 million people are either in prison or on probation or parole — more than 3 percent of all American adults!

Some of this increase has been caused by mandatory minimum sentencing and "three strikes you're out" laws. But about three-quarters of new admissions to state prisons are for nonviolent crimes.

And the single greatest cause of prison population growth has been the war on drugs, with the number of people incarcerated for nonviolent drug offenses increasing more than twelvefold since 1980.

Not only has this excessive punishment destroyed the lives of millions of young people and their families (disproportionately minorities), but it is wreaking havoc on state and local budgets. Former California Gov. Arnold Schwarzenegger pointed out that, in 1980, 10 percent of his state's budget went to higher education and 3 percent to prisons; in 2010, almost 11 percent went to prisons and only 7.5 percent to higher education.

Maybe the increased tax burden on wealthy citizens necessary to pay for the war on drugs will help to bring about a reform of America's drug policies. At least the recommendations of the Global Commission will give some cover to political leaders who wish to do what is right.

A few years ago I worked side by side for four months with a group of prison inmates, who were learning the building trade, to renovate some public buildings in my hometown of Plains, Ga. They were intelligent and dedicated young men, each preparing for a productive life after the completion of his sentence. More than half of them were in prison for drug-related crimes, and would have been better off in college or trade school.

To help such men remain valuable members of society, and to make drug policies more humane and more effective, the American government should support and enact the reforms laid out by the Global Commission on Drug Policy.

End the 'War on Drugs'

Thursday, June 16, 2011 by The Nation

by Peter Rothberg

Tomorrow's 40th anniversary of President Nixon's declaration of the War on Drugs comes amid growing recognition that the policy, and all that it wrought, is a complete disaster.

Shifting priorities toward a more sensible approach that offers treatment rather than punishment for addicts may seem like a daunting task but public opinion is increasingly opposed to the war on drugs, and many states facing tight budgets are de-emphasizing expensive criminalization in favor of strategies that decrease the penal population.

As Sasha Abramsky explained in an extensively reported and still-timely 2009 piece, "out of economic necessity and because of shifting mores, the country will likely get more selective, and smarter, about how it uses incarceration and whom it targets for long spells behind bars."

Last week, the Global Commission on Drug Policy issued a report declaring unreservedly: 

“The global war on drugs has failed.” 

This strong criticism of the status quo was endorsed by the three former Latin American presidents who organized the commission — Fernando Henrique Cardoso of Brazil, César Gaviria of Colombia, and Ernesto Zedillo of Mexico — along with 16 other prominent world leaders, including former Secretary of State George Shultz, former Federal Reserve Chairman Paul Volcker, Greek Prime Minister George Papandreou, former UN Secretary-General Kofi Annan, former head of NATO Javier Solana, Peruvian novelist Mario Vargas Llosa, and Virgin Group founder Richard Branson.

Meanwhile, in the US, Law Enforcement Against Prohibition, a group of police officers, judges and related professionals, held a well-attended DC rally this past Tuesday, citing its own report criticizing the Obama Administration for doing precious little to reframe drug abuse as a matter of public health rather than one of criminal justice. The report calculates that the war on drugs has brought us 40 million arrests at a cost of one trillion dollars without making even a tiny dent in drug use.

The transpartisan coalition of people who want to end the drug war is one of the most diverse, broad-based alliances in America today, drawing from all regions and most spots on the political spectrum.