The shock waves continue to reverberate from author Robert Whitaker’s explosive work of non-fiction. The book (along with The Emperor’s New Drugs by Doctor Irving Kirsch) was the subject of an article in the New York Review of Books by Doctor Marcia Angell, Senior Lecturer in the Harvard Medical School, former Editor-in-Chief of the New England Journal of Medicine, and author of The Truth About the Drug Companies. The NYRB subsequently published letters from four psychiatrists, all eminently credentialed giants in their field, so whatever they have to say is definitely worth paying attention to. Dr. Angell’s review, published on June 23 and July 14, can be found here and here, while the responses from the four psychiatrists, along with Dr. Angell’s reply, published August 18, can be found here.
Two of the psychiatrists, Richard Friedman, Professor of Clinical Psychiatry at Weill Cornell Medical College, and Andrew Nierenberg, Professor of Psychiatry at Harvard Medical School, accuse Dr. Angell of kicking over a straw man. They write: “Angell uses an outdated and disproven chemical imbalance theory of depression (i.e., serotonin deficiency) as a straw man to deny that depression has any biological basis at all.”
Where do I even begin? In the first place, the authors are kicking over a straw man of their own. Nowhere does Dr. Angell deny that depression has a “biological basis.” It does not follow that psychiatrists know the causes, let alone the cures, of any mental illness.
But that’s not even the main point. Was there ever a fable more widely disseminated than the “fact” that depression is caused by a deficiency of serotonin, and the cure is to take a drug to elevate your serotonin levels, just like getting your brake fluid topped up? I believe everyone in America over the age of six “knows” this. I “knew” it until a couple of years ago, when I began looking into these matters.
We’re not talking about a little harmless fib here, like telling your mother-in-law her tuna noodle casserole was delicious. This “fact” was the very genesis of the “like-insulin-for-diabetes” fable, which in turn provided the basis for a $40-billion-dollar-a-year industry. And now they’re admitting it was all a lie?
In fact, the idea that depression was caused by low levels of serotonin was never anything more than a tentative hypothesis that was rejected back in the seventies, years before Prozac came on to the market. Doctor Eliot S Valenstein made all these points more than a dozen years ago in his book Blaming the Brain, but nobody was listening.
Why was this fable told so widely for so long, and why we should believe anything they tell us now?
Prozac was the drug that ushered in the "like-insulin-for diabetes" era, so its history is instructive. In 1985, after the Bundesgesundheitsamt (the German equivalent of the FDA) ruled that Prozac was of "no value" in treating depression, Eli Lilly cobbled together two six-week (!) trials which found almost no difference between Prozac and a placebo, and that was after weeding all the responders out of the placebo group and all the nonresponders out of the treatment group. But there was a difference, and it was statistically significant, which was all they needed to gain the approval of the FDA. Then they resurrected the already-discredited serotonin theory of depression and presented it to the public as accepted fact.
In general, the antidepressants were approved after rushed, sloppy trials which found almost no difference between the real stuff and a placebo. That's not my opinion, by the way -- it's the opinion of Peter Kramer, a psychiatrist and perhaps the loudest proponent of these drugs in the world today. In a July 2 op-ed piece in the New York Times. Kramer's argued that the results of the trials should not be believed, a position I find utterly bizarre, since these trials were the basis on which these drugs were approved.
By the way, does anyone remember Listening to Prozac, Kramer's book-length hand-wringing soliloquy about whether he and his professional colleagues had the moral right to give us these wonderful pills which, he assured us, had the power to make us "better than well?" In the light of such extrvagant promises made to us in the past, why should we believe anything they tell us now?
We wouldn't know about these trials if Hans Melander of the Swedish Drug Authority hadn't called attention to their existence, and if Irving Kirsch hadn't filed a Freedom of Information Act request to obtain them. The drug companies routinely bury negative results. If you look up the definition of a "lie" in the dictionary, it means "something intended to deceive." Given the drug companies' demonstrated willingness to lie to us, why should we believe anything they tell us now?
But it’s not just a matter of these drugs being expensive placebos. The harmful effects of these drugs are well known. The central thesis of Whitaker’s book is that the proportion of Americans disabled by mental illness has risen dramatically, in lockstep with the increased use of these drugs. This is an astonishing charge, on a par with saying injections of insulin are the main cause of Type I diabetes. If this be false, then Robert Whitaker is an outrageous liar. If it be true, then this is a devastating, potentially fatal, critique of psychiatry. Know how these four eminently credentialed docs deal with this potentially devastating charge?
Doctor John Oldham President of the American Psychiatric Association, ignores it entirely.
Doctor Daniel Carlat, Associate Clinical Professor of Psychiatry at Tufts University School of Medicine, devotes one whole sentence to Whitaker’s central thesis: “While his arguments are intriguing, I agree with Dr. Angell that there are significant weaknesses in the evidence he marshals.” Oh, okay.
And Drs. Friedman and Nierenberg write: “[T]he prevalence of anxiety, mood, and substance disorders has been stable: it was 29.4 percent in 1991 and 30.5 percent in 2003. This is hardly a ‘raging epidemic of mental illness,’ as Angell calls it.”
But Whitaker’s point was not that the number of people LABELED mentally ill had gone up, it was the number of people DISABLED by mental illness. This is a point he makes crystal clear, a point he hammers away at relentlessly for 404 pages. Either these guys lack basic reading comprehension skills (rather unlikely given their positions), or they don’t have an answer.
Instead of refuting Whitaker’s explosive charges, the four docs rely on argument by proclamation.
Dr. Oldham: “[T]hanks to medical and therapeutic advances, there is real help for those who suffer the devastating effects of mental illness”
Dr. Carlat: “But missing from [Angell’s] review is an unequivocal if perplexing truth about psychiatric drugs—on the whole, they work.” As if just putting it in italics makes it true.
And Drs. Friedman and Nierenberg merely assert that psych meds are “safe and effective” and “life-saving.”
I don’t believe we can afford to regard medical interventions as innocent until proven guilty. These drugs have been on the market for years and years, and people have been taking them for years and years. Where is the data that show they are helping? I’m not talking about short-term, biased studies bought and paid for by the drug companies that show tiny effects, or anecdotes which can easily be explained by some combination of the placebo effect and the Stockholm Syndrome. (Oh, by the way, did you know Doctor Walter Freeman used to get boxes and boxes of Christmas cards from his patients?)
Furthermore, I can inundate you with anecdotes about the harmful effects of these drugs. Besides the ones in Whitaker’s book, try Anne Bauer’s heartbreaking essay, “Psych meds drove my son crazy,” or Jeanne Allyn Smith’s blog madinvt. Where are the long-term studies that show these drugs produce robust clinical benefits that outweigh the well-documented harms?
Dr. Kramer doesn’t mention any. Dr. Angell says she doesn’t know of any. The four docs who wrote to the editor to criticize her didn’t cite any.
In closing, I’ll say even if they ever do identify conditions for which these drugs are indicated, that will not constitute vindication for their current position. There is a condition – hereditary hematochromatosis – for which bloodletting is indicated. Does that mean the docs who practiced widespread and indiscriminate bloodletting for centuries were right? No, they were wrong, and they caused an incalculable amount of damage.
My guess is that fifty years from now, this dosing of one out of eight citizens with powerful brain-altering drugs will be regarded the same way we now regard driving an icepick through a child’s eye sockets: how could they have done such a thing? Time will tell.
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