Psychiatry at war with itself (II)

Psychiatry is at war with itself. The battlefield is the forthcoming publication of the DSM 5 - the latest version of the diagnostic manual that defines mental illnesses for the industry. At stake is the authority of psychiatry, and our society’s whole approach to the mind and mental illness. This is the second of a three-part piece.
Psychiatry has struggled over the last century to define itself as a serious science, that can claim similar success in treating mental illness as other branches of science have attained in treating illnesses of the body. Over the last 30 years, this effort to establish psychiatry as a legitimate hard science has been taken up by a group of psychiatrists who have come to be known as the Neo-Kraepelinians, so called because they have tried to follow the psychiatric approach of Emil Kraepelin, an Austrian psychiatrist who died in 1926, and who is perhaps the most influential psychiatrist of the 20th century.
Kraepelin tried to define mental illnesses as biological and physiological, and to classify them into discrete, separate entities. In particular, he defined two main types of psychosis: schizophrenia (or dementia praecox as he called it), and manic depression. So, just as there are discrete types of physical illness (tuberculosis, prostate cancer, thrombosis and so on), Neo-Kraepelinians argue there are discrete and recognisable classifications of mental illness (schizophrenia, obsessive-compulsive disorder, bipolar disorder, attention deficit disorder, and so on). And the authority of psychiatry as a hard science rested on its ability to recognise these discrete categories and discover appropriate treatments.

The DSM: the profession’s diagnostic Bible

The main text that the western psychiatric profession uses to classify mental illnesses is the Diagnostic and Statistical Manual (DSM). The DSM is the Bible of the psychiatric industry, defining not just how the psychiatric profession approaches mental illness, but how our entire culture does. Once a diagnosis enters the DSM, it enters the vocabulary of our culture - think how often we now use the words ‘autistic’, ‘ADHD’, ‘OCD’, ‘bipolar’, ‘PTSD’ and so on. These terms have become part of how we think about human behaviour, and that’s in large part because of the influence of the DSM.

Of course, like any sacred text, the eternal word of the DSM has changed over time. Until 1970, for example, it defined homosexuality as an illness. It only included post-traumatic stress disorder after a long political campaign waged by Vietnam veterans. The third edition dropped the word ‘neurosis’ and the illness ‘hysteria’ - much to the chagrin of psychoanalysts, because it meant that, at a stroke, the scientific credibility of these psychoanalytic terms was shattered.

But, despite these historical meanderings, the DSM seemed to find a firmer footing in 1980, with the DSM III, a moment which saw the decline in influence of psychoanalysis and the rise of the biophysical model of mental illness. The DSM III, under the guiding hand of the psychiatrist Robert Spitzer, took a more coherently Neo-Kraepelinian approach to mental illness - defining them as biophysical sicknesses, which required pharmacological treatment, just like other physical illnesses.

As the DSM III and the biophysical model of mental illness rose in influence, so too did the profits of pharmaceutical companies. As Marcia Angell, a prominent critic of Big Pharma’s relationship with the psychiatry profession, has written: “The watershed year was 1980. Before then, it was a good business, but afterward, it was a stupendous one. From 1960 to 1980, prescription drug sales were fairly static as a percent of US gross domestic product, but from 1980 to 2000, they tripled...The top 10 drug companies had profits of nearly 25% of sales in 1990, and except for a dip at the time of President Bill Clinton’s health care reform proposal, profits as a percentage of sales remained about the same for the next decade. (Of course, in absolute terms, as sales mounted, so did profits.) In 2001, the 10 American drug companies in the Fortune 500 list (not quite the same as the top ten worldwide, but their profit margins are much the same) ranked far above all other American industries in average net return. These are astonishing margins. For comparison, the median net return for all other industries in the Fortune 500 was only 3.3% of sales. Commercial banking, itself no slouch as an aggressive industry with many friends in high places, was a distant second, at 13.5% of sales.”

You might think that all this profit would be spent on research into new drugs. But in fact, Big Pharma only spent around 14% of sales on R&D;, with most new drugs being invented by publicly-funded universities before the profit was accrued by private pharmaceutical companies and their shareholders. The companies spent more than double that figure, meanwhile, on marketing and advertizing.

He who pays the piper calls the tune

What does that spending go on? Over to Richard Bentall, psychologist, and author of Doctoring the Mind: Why Psychiatric Treatments Fail:

This marketing takes a variety of forms, some of which are more obvious than others. Many medical journals would be financially unviable without payments received for glossy drug company advertisments, which actively promote a chemical imbalance model of mental illness.

These adverts often make scientific-sounding claims, such as ‘proven to achieve remission of symptoms in 32 double-blind comparative trials with over 7,000 patients’ - a claim that appeared in a multi-page advert for the antidepressant Effexor, made by Wyeth. This claim was scrutinised by the American psychologist Timothy Scott, who found that the only evidence for the claim came from the company itself, and Wyeth refused to provide the evidence to Scott.
Pharmaceutical companies are also big sponsors of psychiatric conferences. They throw parties, they provide free food and drink at their stalls, they pay to fly psychiatrists out business class, they pay for their accommodation.
They also pay psychiatrists substantial bonuses when they prescribe their medications. And psychiatrists may be able to inflate their incomes by acting as paid consultants to the industry. Or they can set up private research organizations to carry out clinical trials for pharmaceutical companies. In one study of five psychiatric journals, 60% of the trials published were partially funded by pharmaceutical companies, although a financial interest was only declared by the psychiatrists in 47% of the trials. Bentall writes: “It is not uncommon for US psychiatrists to earn hundreds of thousands of dollars each year for these kind of activities.”

The ‘independent’ trials paid for by pharmaceutical companies, unsurprisingly, tend to conclude that the sponsor company’s products are the best treatment. For example, in trials that compared two drugs, 90% of the trials concluded that the better drug was the one manufactured by the company sponsoring the trial.

An example of the weakness of much scientific evidence for chemical treatments is the supposedly cast-iron evidence for Prozac and other SSRIs - which were hailed as wonder-drugs in the 1990s, and which led to a huge surge in Big Pharma profits. But it was only in 2008 that psychiatrists started to examine trials which pharmaceutical companies made but did not publish - and these unpublished trials showed that SSRIs were no more effective at treating depression than placebos.

Does the pharmaceutical industry’s profit agenda have an impact on the DSM and its definition and classification of mental illnesses? Of course it does. Marcia Angell wrote in the New York Review of Books:

Of the 170 contributors to the most recent edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM), ninety-five had financial ties to drug companies, including all of the contributors to the sections on mood disorders and schizophrenia. Perhaps most important, many members of the standing committees of experts that advise the FDA on drug approvals also have financial ties to the pharmaceutical industry.

Angell gives one by-now notorious example, of Dr Joseph Biederman, professor of psychiatry at Harvard Medical School, and one of the main campaigners to include and expand the diagnoses of bipolar disorder for children. In June 2009, Senator Grassley on the US Senate Finance Committee revealed that drug companies, including those that make drugs he advocates for childhood bipolar disorder, had paid Biederman $1.6 million in consulting and speaking fees between 2000 and 2007, which he failed to fully disclose.
The sense that the psychiatric industry has been captured by Big Pharma is now widely felt by psychiatrists, including those at the height of the profession. This is the former president of the American Psychiatric Association, Stephen Sharfstein: “As a profession, we have allowed the biopsychosocial model [of mental illness] to become the bio-bio-bio model...Drug company representatives bearing gifts are frequent visitors to psychiatrists’ offices and consulting rooms...We should have the wisdom and distance to call these gifts what they are - kickbacks and bribes.”

The battle over DSM 5

This takes us to the heart of the current crisis, over the new DSM, volume 5. The new edition looks set to expand the diagnoses of mental illness further, and to expand the possibility for medication, with a new diagnoses called ‘psychosis risk syndrome’. This would mean that a person who is considered at risk of becoming psychotic in the future would be prescribed antipsychotics, just in case. It’s the pharmaceutical equivalent of the film Minority Report, in which a person is punished for a crime they might one day commit.

Leading the criticism of DSM 5, surprisingly, is the psychiatrist who was in charge of DSM IV, Al Frances, and the psychiatrist who was in charge of DSM III, Robert Spitzer. Frances, interviewed in an excellent article in Wired magazine, clearly feels bad about the direction psychiatry has taken, and which he helped it to take. He says: “We made mistakes that had terrible consequences” - particularly the huge leap in diagnoses of autism, ADHD and bipolar disorder, and the surge in medication for these supposed epidemics. And he decided he couldn’t stand back and watch while DSM 5 led to another “bonanza for the pharmaceutical industry”. The prospect of more “kids getting unneeded antipsychotics that would make them gain 12 pounds in 12 weeks hit me in the gut. It was uniquely my job and my duty to protect them. If not me to correct it, who? I was stuck without an excuse to convince myself.”

But antipsychotics work, don’t they? Well, they work in the short-term, to dampen psychotic symptoms, about two thirds of the time. But they can have side-effects: Parkinsonianism (stiffness and the shakes); involuntary movements, usually of the jaw; impotence; rapid weight-gain; difficulty concentrating; loss of energy and motivation. And the drugs, while they do seem to help in suppressing psychotic symptoms during psychotic episodes, do not appear to help many people actually recover from psychosis - at least if used on their own. But what are the alternatives?

In part 3 of this article, coming shortly, I will look at alternatives to the present treatment of psychosis.