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THE New York Review of Books isn’t necessarily where you expect to see a former editor-in-chief of the New England Journal of Medicine deliver a blistering critique of contemporary psychiatric practice.
But that is what Dr Marcia Angell, who now teaches at the Harvard Medical School, has done in a two-part review, concluding this week, of three new books that argue mental illness is over-diagnosed and over-medicated.
America, she writes, is in the midst of a “raging epidemic of mental illness”, at least as measured by numbers treated — a large random survey a decade ago found 46% of adults met American Psychiatric Association criteria for having had a mental illness at some point in their lives.
And that is one of the points where Dr Angell would take issue with the psychiatric profession, questioning what she would see as its constant broadening of diagnostic criteria that sees more and more people being drawn into the treatment net.
A counterargument could be that an increase in diagnosis is a good thing, at least to the extent that it represents a destigmatising of mental illness, greater awareness by clinicians and more willingness by people to seek help (whether that help is always available is another question).
Dr Angell, however, puts much of it down to what she calls the “baleful influence” of the pharmaceutical industry, which has an obvious interest in promoting medication for a growing raft of mental conditions.
She argues that, through relationships with key doctors and professional associations, support for patient advocacy groups and selective reporting of studies, the industry has built a lucrative business on some fairly shaky foundations.
Suggestions that SSRIs (selective serotonin reuptake inhibitors) may be little better than placebo in treating depression are not new, but Angell takes the argument further, questioning whether they offer any advantage at all.
The fact that the drugs perform slightly better than placebo in clinical trials could be due to an “enhanced placebo effect”, she writes, resulting from patients receiving the drug experiencing side effects they have been warned might occur and thus guessing they are in the active treatment arm.
Treating doctors swear by the drugs because they see genuine improvement in patients, but that could be a placebo effect too, she suggests.
The psychiatrist’s bible, the Diagnostic and statistical manual of mental disorders (DSM), also comes in for criticism, accused of being too cosy with the industry, overly willing to expand diagnoses and of not adequately referencing its recommendations.
Like the real Bible, it has depended a lot on “something akin to revelation”, Dr Angell writes.
The revised edition of the DSM-V, due out in 2013, is expected to broaden diagnoses further, including precursor conditions as well as wider definitions of some disorders.
Perhaps the most disturbing point Dr Angell raises is about the increasing medication of disadvantaged American children when their desperate parents are driven to seek a psychiatric diagnosis as a way of accessing health insurance or social security.
That, at least, is something we are spared here, but Dr Angell’s review does raise questions of relevance to Australia too.
There’s no doubt mental health has long been neglected in this country, with inadequate funding and access to treatment and support. And there’s little doubt too that many clinicians in the area would have their own criticisms of Dr Angell’s views (for one such critique see psychiatrist Professor Peter Kramer’s recent article in the New York Times).
But is it worth considering whether the treatment of mental illness has become too reliant on medications of doubtful efficacy, neglecting other potentially useful approaches in the process?
Jane McCredie is a Sydney-based science and medicine writer.
Posted 11 July 2011
Mental illness is definitely being overdiagnosed and overtreated. There is no social capital in western societies, a significant proportion of the population grows up confused and grieving for stable identity figures as their parents move from one relationship to another. Life is not treasured any more, very little is what it is supposed to be. Ugly capitalism puts more and more in the hands of less and less, and its march is relentless. How can anyone be happy? We need a complete paradigm shift and psychiatry needs to be downsized.
Ah Dr Joe and ‘anonymous psychiatrist’ what a breath of fresh air. The sooner we return to more human principles to cope with all of life’s events the better. Not all of human symptoms and feelings need to be measured, named, pathologised, analysed and then medicated! That is – unless you want a larger slice of a finite ‘health provision pie.’
I’m a psychiatrist and speaking with colleagues find many are now highly sceptical of the pharmaceutical industry driven or at least related drive to diagnose depression and bipolar disorder. This drive extends to adjustment type disorders.
Drug company documents have surfaced to indicate the extent of data massaging by Big Pharma is systematic and we don’t have a true evidence-based literature for psychotropics.
As Dr Joe states – there is a problem with the “medicalisation of life”. And it is worthwhile reading Angell’s original articles (there’s two of them).
Nonetheless people need help with their stress management and suffering. How to keep the broad perspective without becoming mindlessly focussed on tweaking neurotransmitters or brainlessly focussed on saying it’s all in the mind?
What is mood for? Anxiety, sadness, anger – all have meaning in their context. When are they excessively intense or prolonged and pathological? Only a deeper rapport and full history can help answer that, not a DSM checklist! (though it is still a necessary but insufficient on its own guide).
An ecological perspective suggests we evolved for smaller tightly knit supportive societies with greater daily exercise, less or no time pressure and very healthy diet and exercise. Supports for parents and children are more extensive in hunter-gatherer societies. Reflection and grieving time was once abundant too. To the extent we help our patients recover some of that and provide talking therapies – the symptoms of anxiety, sadness and anger can often be restored to a healthier range.
The problem we have is the medicalisation of life. Many people have stress or problems to deal with. When they come to the doctor we reclassify life problems as a mental health illness and give them pills. Many of these people need some support to get on with their lives.
If resources were reserved for those with genuine illness there would be no “crisis”.
Anyone interested should read Prof Peter Kramer’s response in the New York Times Sunday Review (available online). It very nicely reviews the actual evidence regarding the efficacy of antidepressants. He also talks about situations when he uses psychotherapy first – milder depression. This is a practice which I think most psychiatrists in Australia would follow.
I work as a psychiatrist in the public sector. With the vast majority of patients I see there is no doubt that they have a mental illness, eg, people with severe schizophrenia. I worked in private practice for years and again the vast majority of people I saw were very clearly not just “the worried well”. Dr Angell is an academic and at Harvard. It is highly likely the limited clinical work she does is not representative of what most psychiatrists see.
On the other hand there is a tendency in the media for all antisocial behaviour and all suicides to be seen as due to mental illness. This is not supported by the evidence. As usual all extreme positions are rarely justified by the evidence.
In a modern society with breakdown of traditional “counselling methods” people need a structured debriefing and counselling service. In a society where everyone puts their every move and thought on Twitter, there is less and less time to listen to another. That is what people need – to be listened to – so now they pay someone.
In a health system where the dollars count, it is easier to prescribe a pill than sit for hours counselling a patient or accessing counselling services. Patients with real mental health issues (which this increased awareness is supposed to identify and treat) is still underdiagnosed – they are not the type of person to come and seek advice easily and with mental health being a “popular, flavour of the month” diagnosis they will avoid seeking advice even futher. The concept that their real issue is now commercialised is not helping them have confidence in the health system and their providers. It is not easy for a bloke who plucks up the courage to mention his issues to be told – oh, that’s OK, everyone has mental health problems now adays – pop a pill and you will get over it.
This report of a mental illness epidemic is obviously an under estimate “all world is queer except thee and me, and even thou art a little queer” (Robert Owen1771-1858)
It is the promotion of information about the prevalence of mental illness and its effects on sufferers and the community by the psychiatric profession and mental health advocates that may create the perception of an ‘epidemic’ of mental illness. The Beyondblue and Black Dog organisations have public education and promotion of these matters as their goals, along with other interest groups in the field. Despite the perception of an ‘epidemic’ the truth lies elsewhere – cases of genuine mental illness are still undiagnosed and under-treated. I doubt that the pharmaceutical industry is entirely responsible for the perceived situation.