Wednesday, January 2, 2013

Drug Companies and Their Psychiatrists Say Grief Is Now a Mental Illness

The drug companies seem to be continuing to make progress in the attempt to bring the entire nation within their net of dependent drug users. Peter Whorisky provides a fine summary of a recent development in an aptly titled article in the Washington Post: Antidepressants to treat grief? Psychiatry panelists with ties to drug industry say yes

Whorisky alerts us to an official change in policy approved by the American Psychiatric Association (APA). Previously, the APA recommended that the grief that occurs normally after the death of a loved one should be allowed to run the natural course in which the vast majority of sufferers move on and resume normal lives. Now policy is shifting towards allowing the grieving to be classified as mentally ill and subjected to mind-altering drugs in order to treat their condition.

"In what some prominent critics have called a bonanza for the drug companies, the American Psychiatric Association this month voted to drop the old warning against diagnosing depression in the bereaved, opening the way for more of them to be diagnosed with major depression — and thus, treated with antidepressants."

"The change in the handbook, which could have significant financial implications for the $10 billion U.S. antidepressant market, was developed in large part by people affiliated with the pharmaceutical industry, an examination of financial disclosures shows."

"The association itself depends in part on industry funding, and the majority of experts on the committee that drafted the new diagnostic guideline have either received research grants from the drug companies, held stock in them, or served them as speakers or consultants."

Whorisky focuses on the corruption in the psychiatric "industry" caused by the mutual dependency between psychiatrists and the money-laden drug industry. That is a topic worthy of greater discussion, but here we will focus on the ramifications of allowing grief to be defined as mental illness.

Severe depression was once a rare condition that usually regressed over a period of time allowing sufferers to resume a more or less normal life—unencumbered by psychoactive drugs. Since the advent of drug treatment, the condition has become common, chronic, and increasingly debilitating. The degree to which a "drug culture" has developed in our society is evident in some data provided by the National Center for Health Statistics (NCHS) covering the years 2005-2008.

"Antidepressants were the third most common prescription drug taken by Americans of all ages in 2005–2008 and the most frequently used by persons aged 18–44 years. From 1988–1994 through 2005–2008, the rate of antidepressant use in the United States among all ages increased nearly 400%."

"Eleven percent of Americans aged 12 years and over take antidepressant medication."

"More than 60% of Americans taking antidepressant medication have taken it for 2 years or longer, with 14% having taken the medication for 10 years or more."

"Less than one-third of Americans taking one antidepressant medication and less than one-half of those taking multiple antidepressants have seen a mental health professional in the past year."

"Twenty-three percent of women aged 40–59 take antidepressants, more than in any other age-sex group."

"About 8% of persons aged 12 and over with no current depressive symptoms took antidepressant medication."

"Slightly over one-third of persons aged 12 and over with current severe depressive symptoms were taking antidepressants. According to American Psychiatric Association guidelines, medications are the preferred treatment for moderate to severe depressive symptomatology."

The numbers are slightly uncertain because some antidepressant medications are prescribed to treat other issues, often side effects from medications treating other forms of mental illness.

What is striking is the presumed prevalence of depression today. About 11% are under medication for the condition, and that is only a third of those captured by the APA guidelines. Can it be that almost half of us are suffering from depression? Has depression always been such a serious and expensive problem? How did society survive prior to the arrival of these "miracle" drugs that are now so common? Are we in the midst of a modern epidemic?

For guidance on these issues we will turn to an article published in the New York Review of Books by Marcia Angell: The Epidemic of Mental Illness. Why?Marcia Angell is a Senior Lecturer in Social Medicine at Harvard Medical School and former Editor in Chief of The New England Journal of Medicine.

Angell provides insights from her own findings as well as discussions of three relevant books.

The Emperor’s New Drugs: Exploding the Antidepressant Mythby Irving Kirsch
Basic Books, 226 pp., $15.99 (paper)

Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America
by Robert Whitaker
Crown, 404 pp., $26.00
Unhinged: The Trouble With Psychiatry—A Doctor’s Revelations About a Profession in Crisis
by Daniel Carlat
Free Press, 256 pp., $25.00

Unlike other illnesses, mental illness has no diagnostic by which it can be detected and categorized. Its existence is determined via observation by psychiatrists and by self-reporting of symptoms by patients. In other words, mental illness is whatever symptoms or behaviors psychiatrists have decided to define to be representative of mental illness. One should be aware that in various courts of law, disagreeing with your psychiatrist’s diagnosis has been viewed as evidence of mental illness.

"A large survey of randomly selected adults, sponsored by the National Institute of Mental Health (NIMH) and conducted between 2001 and 2003, found that an astonishing 46 percent met criteria established by the American Psychiatric Association (APA) for having had at least one mental illness within four broad categories at some time in their lives....Most met criteria for more than one diagnosis."

There is no valid explanation for what causes mental illness. Drug companies have been trying for decades to prove that "chemical imbalances" within the brain are the cause, but to no avail. Nevertheless, they have successfully propagated the myth that their drugs are a valid treatment for depression and other mental illnesses.

"Nowadays treatment by medical doctors nearly always means psychoactive drugs, that is, drugs that affect the mental state. In fact, most psychiatrists treat only with drugs, and refer patients to psychologists or social workers if they believe psychotherapy is also warranted. The shift from "talk therapy" to 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. That theory became broadly accepted, by the media and the public as well as by the medical profession, after Prozac came to market in 1987 and was intensively promoted as a corrective for a deficiency of serotonin in the brain. The number of people treated for depression tripled in the following ten years...."

"What is going on here? Is the prevalence of mental illness really that high and still climbing? Particularly if these disorders are biologically determined and not a result of environmental influences, is it plausible to suppose that such an increase is real? Or are we learning to recognize and diagnose mental disorders that were always there? On the other hand, are we simply expanding the criteria for mental illness so that nearly everyone has one? And what about the drugs that are now the mainstay of treatment? Do they work? If they do, shouldn’t we expect the prevalence of mental illness to be declining, not rising?"

The books Angell discusses focus on different issues related this explosion of mental illness.

"Kirsch is concerned with whether antidepressants work. Whitaker, who has written an angrier book, takes on the entire spectrum of mental illness and asks whether psychoactive drugs create worse problems than they solve. Carlat, who writes more in sorrow than in anger, looks mainly at how his profession has allied itself with, and is manipulated by, the pharmaceutical industry".

However, all three authors are in agreement on some fundamental concerns.

"First, they agree on the disturbing extent to which the companies that sell psychoactive drugs—through various forms of marketing, both legal and illegal, and what many people would describe as bribery—have come to determine what constitutes a mental illness and how the disorders should be diagnosed and treated. This is a subject to which I’ll return."

"Second, none of the three authors subscribes to the popular theory that mental illness is caused by a chemical imbalance in the brain."

Since the main topic here is depression, we will concentrate on the findings directly relevant to that topic.

Kirsch spent fifteen years trying to discover whether antidepressant drugs actually work. His interest arose from a study of the effect of placebos. In reviewing a large number of published clinical trials he discovered:

"Most such trials last for six to eight weeks, and during that time, patients tend to improve somewhat even without any treatment. But Kirsch found that placebos were three times as effective as no treatment. That didn’t particularly surprise him. What did surprise him was the fact that antidepressants were only marginally better than placebos. As judged by scales used to measure depression, placebos were 75 percent as effective as antidepressants."

The placebo effect is well-known. If one is told that one is receiving a drug that might help them feel better, one will generally begin to feel better. Still, the strength of the placebo effect was unsettling in this case. Intrigued by the efficacy of providing placebos, Kirsch undertook the task of wrestling from the FDA additional data that the drug companies chose not to publish. He examined data on six drugs.

"Kirsch and his colleagues used the Freedom of Information Act to obtain FDA reviews of all placebo-controlled clinical trials, whether positive or negative, submitted for the initial approval of the six most widely used antidepressant drugs approved between 1987 and 1999—Prozac, Paxil, Zoloft, Celexa, Serzone, and Effexor. This was a better data set than the one used in his previous study, not only because it included negative studies but because the FDA sets uniform quality standards for the trials it reviews and not all of the published research in Kirsch’s earlier study had been submitted to the FDA as part of a drug approval application."

"Altogether, there were forty-two trials of the six drugs. Most of them were negative. Overall, placebos were 82 percent as effective as the drugs, as measured by the Hamilton Depression Scale (HAM-D), a widely used score of symptoms of depression. The average difference between drug and placebo was only 1.8 points on the HAM-D, a difference that, while statistically significant, was clinically meaningless. The results were much the same for all six drugs: they were all equally unimpressive. Yet because the positive studies were extensively publicized, while the negative ones were hidden, the public and the medical profession came to believe that these drugs were highly effective antidepressants."

This phase of his research indicated that when all the data submitted to the FDA were analyzed, there was even less difference in the performance of antidepressant drugs relative to placebos. Kirsch then considered another surprising test result:

"In his earlier study and in work by others, he observed that even treatments that were not considered to be antidepressants—such as synthetic thyroid hormone, opiates, sedatives, stimulants, and some herbal remedies—were as effective as antidepressants in alleviating the symptoms of depression. Kirsch writes, "When administered as antidepressants, drugs that increase, decrease or have no effect on serotonin all relieve depression to about the same degree." What all these "effective" drugs had in common was that they produced side effects, which participating patients had been told they might experience."

Participants and researchers in double-blind clinical studies are not supposed to know if they are receiving a placebo or the drug under study. The presence of a discernible side effect from the drug was allowing participants to correctly guess that they were receiving the actual drug.

"To further investigate whether side effects bias responses, Kirsch looked at some trials that employed ‘active’ placebos instead of inert ones. An active placebo is one that itself produces side effects, such as atropine—a drug that selectively blocks the action of certain types of nerve fibers. Although not an antidepressant, atropine causes, among other things, a noticeably dry mouth. In trials using atropine as the placebo, there was no difference between the antidepressant and the active placebo. Everyone had side effects of one type or another, and everyone reported the same level of improvement. Kirsch reported a number of other odd findings in clinical trials of antidepressants, including the fact that there is no dose-response curve—that is, high doses worked no better than low ones—which is extremely unlikely for truly effective drugs."

Kirsch was moved to state that the small differences reported between active drugs and placebos are consistent with the conclusion that that there is no antidepressant effect, merely a misinterpretation of the placebo effect.

"That is a startling conclusion that flies in the face of widely accepted medical opinion, but Kirsch reaches it in a careful, logical way. Psychiatrists who use antidepressants—and that’s most of them—and patients who take them might insist that they know from clinical experience that the drugs work. But anecdotes are known to be a treacherous way to evaluate medical treatments, since they are so subject to bias....Kirsch is a faithful proponent of the scientific method, and his voice therefore brings a welcome objectivity to a subject often swayed by anecdotes, emotions, or, as we will see, self-interest."

Kirsch has questioned the effectiveness of what are being sold and prescribed as antidepressant medications. Whitaker questions whether the antidepressants are not only ineffective, but also whether they are dangerous.

He begins by reminding us that things have changed since the introduction of psychoactive drugs.

"He considers all mental illness, not just depression. Whereas Kirsch concludes that antidepressants are probably no more effective than placebos, Whitaker concludes that they and most of the other psychoactive drugs are not only ineffective but harmful. He begins by observing that even as drug treatment for mental illness has skyrocketed, so has the prevalence of the conditions treated....’

"Moreover, Whitaker contends, the natural history of mental illness has changed. Whereas conditions such as schizophrenia and depression were once mainly self-limited or episodic, with each episode usually lasting no more than six months and interspersed with long periods of normalcy, the conditions are now chronic and lifelong. Whitaker believes that this might be because drugs, even those that relieve symptoms in the short term, cause long-term mental harms that continue after the underlying illness would have naturally resolved."

Let us consider some data Whitaker provides to support this contention.

The World Health Organization (WHO) has produced several studies of mental illness and outcomes in a variety of countries. The results have been consistent. Those who have been diagnosed as suffering from depression and treated with antidepressant drugs are the least likely to recover from the malady. In other words, a person suffering from depression in the poorest village in India with only the support of family and friends is more likely to recover and lead a normal life than the wealthiest person in the US laboring under the burden of the most expensive medications the drug companies can provide.

Whitaker has also found data in the scientific literature that support his hypothesis.

This result out of Canada indicates that those suffering sufficiently from depression to go on short-term disability were much more likely to end up on long-term disability if they were treated with medications. 

The data also support the notion that most depression sufferers will recover on their own unless inhibited by the effects of medication. A cynical interpretation could be that those on medication might have been tempted by the benefits of long-term disability as opposed to inconvenience of working for a living. But even that interpretation still precludes any indication of benefits from medication.

A second study was performed by NIMH and concluded that after six years those tracked who suffered from severe depression were likely to have worse health outcomes if treated with medications than those who were not medicated.

Such conclusions are lost in the blizzard self-written scientific papers that drug companies bribe doctors and medical researchers to put their names on, and countered by the activities of the best marketers, public-relations experts, and lobbyists that billions of dollars can buy.

One should note that the policy of suggesting medication from those suffering grief after loss of a loved one will be packaged by the APA in a manual that is available to all doctors, psychologists, social workers, and teachers. It will be presented in a cookbook form that will allow any of these untrained people to make a diagnosis of severe depression and recommend medication. One can only imagine the blitz of TV commercials. And anyone who wishes medications can find someone who will prescribe them.

Marcia Angell and the authors whose results are discussed have sufficient credibility to leave us frightened at the prospect of more millions of people subjected needlessly to drugs that appear ineffective and harmful.

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