The Epidemic of Mental Illness: Why?

By Marcia Angell
The New York Review of Books, June 23, 2011

Edited by Andy Ross

It seems that Americans are in the midst of a raging epidemic of mental illness. A large survey of randomly selected adults, sponsored by the National Institute of Mental Health and conducted between 2001 and 2003, found that 46 percent met criteria established by the American Psychiatric Association for having had at least one mental illness within four broad categories at some time in their lives.

Most psychiatrists treat only with drugs. The shift to psychoactive drugs as the dominant mode of treatment coincides with the emergence over the past four decades of the theory that mental illness is caused primarily by chemical imbalances in the brain that can be corrected by specific drugs. Drugs to treat psychosis are the top-selling class of drugs in the United States.

Is the prevalence of mental illness really that high?

Irving Kirsch is a psychologist at the University of Hull in the UK. He asks whether antidepressants work. When he began, his main interest was in the effects of placebos. Placebos were three times as effective as no treatment. Antidepressants were only marginally better than placebos. He analyzed data from 42 trials of six drugs. Overall, placebos were 82 percent as effective as the drugs. The average difference between drug and placebo was clinically meaningless. The results were unimpressive for all six drugs. In trials using an active placebo, there was no difference between the antidepressant and the active placebo.

Robert Whitaker a journalist and previously the author of a history of the treatment of mental illness. He considers that most psychoactive drugs are not only ineffective but harmful. Even as drug treatment for mental illness has skyrocketed, so has the prevalence of the conditions treated. Psychoactive drugs disturb neurotransmitter function, even if that was not the cause of the illness in the first place. With long-term use, the brain’s compensatory efforts begin to fail. Whitaker sees an epidemic of brain dysfunction caused by the widespread use of antipsychotics with serious side effects.

The theory that mental illness is caused by a chemical imbalance in the brain had its genesis shortly after psychoactive drugs were introduced in the 1950s. The drugs treated psychosis, anxiety, and depression. They were derived from drugs for treating infections, and were found only serendipitously to alter the mental state. Over the next decade, researchers found that the new drugs affected the levels of certain chemicals in the brain. The theory arose that the cause of mental illness is an abnormality in the brain’s concentration of these chemicals that is specifically countered by the appropriate drug. That was a great leap in logic.

But if psychoactive drugs are useless, why are they so widely prescribed by psychiatrists?
 

AR  Because the psychiatrists are following the paradigm expressed by Joseph LeDoux in the 2002 NYAS conference that I reported
here and here.
 

The Illusions of Psychiatry

By Marcia Angell
The New York Review of Books, July 14, 2011

Edited by Andy Ross

The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM), often referred to as the bible of psychiatry, is now heading for its fifth edition.

Leon Eisenberg wrote that American psychiatry in the late twentieth century moved from brainlessness to mindlessness. Before psychoactive drugs were introduced, the profession had little interest in the physical brain. But with their introduction the focus shifted. Psychiatrists began to refer to themselves as psychopharmacologists. By embracing the biological model of mental illness and the use of psychoactive drugs to treat it, psychiatry was able to identify itself as a scientific discipline along with the rest of the medical profession.

The APA was then working on the third edition of the DSM, which provides diagnostic criteria for all mental disorders. When the
DSM-III was published in 1980, it contained 265 diagnoses (up from 182 in the previous edition), and it came into nearly universal use. Its main goal was to bring consistency to psychiatric diagnosis. Each diagnosis was defined by a list of symptoms, with numerical thresholds.

Not only did the DSM become the bible of psychiatry, but like the real Bible, it depended a lot on something akin to revelation. There are no citations of scientific studies to support its decisions. The current version, the DSM-IV-TR (text revised), dates from 2000 and contains 365 diagnoses. The DSM-IV sold over a million copies.

The pharmaceutical industry was quick to see the advantages of forming an alliance with the psychiatric profession. About a fifth of APA funding now comes from drug companies, who are eager to win over key opinion leaders (KOLs) in the profession. Of the 170 contributors to the DSM-IV-TR, almost all of whom would be described as KOLs, 95 had financial ties to drug companies.

The fifth revision of the DSM is scheduled to be published in 2013.

Americans should be concerned about the astonishing rise in the diagnosis and treatment of mental illness in children. These children are often treated with drugs that have serious side effects. We need to stop thinking of psychoactive drugs as the best treatment for mental illness or emotional distress. Both psychotherapy and exercise have been shown to be as effective as drugs for depression. We need to rethink the care of troubled children. Here the problem is often troubled families in troubled circumstances. We need to do better. Above all, we should do no harm.