-
The Emperor’s New Drugs: Exploding the Antidepressant Myth by Irving Kirsch
Dr. Marcia Angell, a former editor of the New England Journal of Medicine, used the platform of book review to criticize the field of psychiatry for issues that have long been recognized within our field and are thus targeted by current research: psychiatric diagnoses are based on symptoms rather than pathophysiology, our treatments are insufficiently effective, newer medications have provided limited [if any] benefit over older medications, the pharmaceutical industry has had inappropriate relationships with individuals and organizations within our profession, there are problems in access to psychosocial treatments for psychiatric disorders, psychiatrists prescribe medications to treat symptoms rather than correcting known biological abnormalities, our understanding of the neurobiology of psychiatric symptoms is limited, and there are not objective biomarkers to guide diagnosis or to match individual patients with particular drugs.
In his introduction, he lists Dr. Angell’s criticism that "the pharmaceutical industry has had inappropriate relationships with individuals and organizations within our profession," an understatement at best. In fact it could be reversed for emphasis, "individuals and organizations within our profession have had inappropriate relationships with the pharmaceutical industry." Dr. Krystal goes on to rebut Dr. Angell’s critique point by point, not quite reaching Dr. Schatzberg’s level of ad hominem nastiness [but coming close]. But he never mentions the pharmaceutical industry or the role conflict of interest has played in matters psychopharmacologic for decades. It’s a glaring omission. Prominent members of the ACNP were investigated by Senator Grassley; an editor of their Journal, Neuropsychopharmacology, was forced to step down over failing to reveal industry connections in a [ghostwritten] article; many of their members have been involved in the articles and programs that lead to the massive fines levied against the pharmaceutical companies for fraud [Study 329, TMAP, etc]. His silence on these points is deafening.
She stigmatizes psychiatry, but fails to address the consequences of stigma for psychiatrists and patients, including discouraging medical students from entering psychiatry or dissuading suffering people from seeking needed treatment. The absence of a positive agenda in Angell’s essay was unfortunate. After all, what value is there in critiquing psychiatry, if not to call for actions that address the needs of psychiatric patients and society? Angell’s article was an example of bad journalism. It is shocking that it was written by a former editor of the New England Journal of Medicine, a journal renowned for impartiality and rigor. Angell has written an article filled with half-truths that would seem to call for society to abandon psychiatric diagnoses, antidepressant medications, and psychiatric neuroscience. Angell shows utter disregard for the negative impact of each of these actions on individuals with psychiatric disorders and society. She provides no alternatives to the status quo or a constructive agenda that might ultimately speed the alleviation of human suffering. Instead, she attacks the one clear path to better diagnoses and more effective pharmacotherapies, translational neuroscience. By stigmatizing a field progressing toward a scientific foundation and by disparaging treatments that show signs of efficacy, Dr. Angell’s facile criticism of psychiatry could do harm. Perhaps, in this case, doing harm in the name of ethics is, to borrow a phrase from Angell, a form of illusion.
I’ll pass on fully commenting on this sentence, "Instead, she attacks the one clear path to better diagnoses and more effective pharmacotherapies, translational neuroscience." It deserves a full hearing in its own right at some later date [in fact, on close reading that sentence actually makes no sense]. But I can’t pass on this phrase in the next one, "treatments that show signs of efficacy." Treatments that "show signs of efficacy" don’t become the top selling drugs in all of medicine! And "treatments that show signs of efficacy" should only be used in patients where that "efficacy" has been clearly demonstrated. Those "signs of efficacy" don’t trump adverse effects and events, particularly when they’re minimized, unacknowledged, or actually hidden. As a for instance, there’s a whole literature about "Treatment Resistance Depression" that actually rests on the premise that the polyglot of patients diagnosed with the umbrella term Major Depressive Disorder should respond to anti-depressants, and if they don’t, they fall into a special case and need some other biological treatment [eg STAR*D and CO-MED]. That doesn’t sound like "signs of efficacy" to me. It sounds like "so efficacious that non-response is the exception."
I found the three books reviewed by Dr. Angell as well as her own comments painful too. But her synopsis of the course of events is an accurate accounting of the major trend in psychiatry over the last twenty-five years as I’ve experienced it. I was one of those "talk therapy" people she mentions, and her criticisms weren’t aimed directly at me. Yet it was painful, first, because I’ve felt many of the criticisms she makes of the state of the specialty and have felt impotent to do anything about the course of events she describes. And secondly, some of the people in the field of biological psychiatry are right-thinking, solid scientists working in a very hard corner of the medical world – taking an undeserved hit because of the gross misbehavior of others. But I found the comments from Dr. Krystal much more painful than either the books themselves or even Dr. Angell’s reviews. Neither his attack on the critics nor his pleas for help have anything to do with the facts. Psychiatry has dramatically overplayed biology in general and the efficacy, safety, and breadth of indications for the current medications in the specific, fostering the illusion of a knowing unmatched by knowledge. And a significant number of the scientists in the audience at any given ACNP meeting have actively participated in grossly corrupt science, unacceptable conflict of interest, and collusion at various levels with the drug-makers who profited wrongly from the phenomenal sales [as did the scientists themselves].
Your posts are therapeutic for me. I don’t want to have a black and white view of psychiatry; but to me the bio-bio-bio approach is a black and corrupt art wearing a white hat and acting as if it had been shot in the back anytime someone reasonably critiques or questions it. The degree to which it is ingrained in the psychiatric community, is why (I think) that at least half of the staff on the lock-down ward for my one and only commitment did not even try to hide their effect. I spent a good deal of time studying them and could see their neuroses from across the room at times. Patients sick, staff well— much like Dr. John Krystal’s petulant whining shown here, it seems at times like psychiatrists and their minions see themselves as completely different from mental patients.; but they just aren’t that different.
Biopsychiatry is the worst of psychiatry’s privileged white male past. The objectification goes entirely too far and the pedestal it’s on is entirely too high.
It gives me hope that the up and coming crop of students are questioning the overuse of medication. They could learn a lot from you, through your stories, I think. It’s not a flow chart or check list that is needed to improve the therapeutic relationship between mental health professionals and patients, it’s the relationship itself.
Sigh… you would hope the chairman of psychiatry at Yale could do better.
Barney Carroll’s comment on Krystal’s blog is worth a read. Among other things Carroll points out that there has never been a College press release affirming ACNP values after any of its supporting corporate members were convicted and fined billions for felony offenses.
…their affect…all that emoting…
In addition to Dr. Carroll’s comment on Krystal’s blog [above], Dr. David Healy has weighed in saying, “This is astonishing on a few levels. Herbalism and a range of other fields could be characterized as progressing toward a scientific foundation with treatments that show signs of efficacy. Dr. Krystal seems to have consigned psychiatry to a lower level in the pecking order than physiotherapy and other paramedical disciplines. Many in other branches of medicine will likely smile wryly. If psychiatry is only progressing toward a scientific foundation and its treatments only show signs of efficacy, the harm lies in the fact it has sold itself as a fully scientific discipline with treatments that work and save lives. If this isn’t the case, people need to be told.“
No surprise that besides Dr. Carroll’s tepid response to Krystal’s, Custard’s “circle the wagons” desperate last stand attempt @ American College of Neuropsychopharmacology; is a long comment line of psychiatric blind mice; goose stepping in unison to the same old predictable professional funeral procession theme song…
Psychiatry’s leaders have never been particularly strong in logic. Every time they open their mouths, physicians in more rigorous disciplines laugh.
No wonder Krystal didn’t want to mention the COI, corruption, & pharmaceutical industry influence in his status quo psychiatric cheer-leading opinion piece.
John Krystal American College of Neuropsychopharmacology disclosure listings: Aisling Capital, LLC, Astra Zeneca, Biocortech, Brintall & Nicolini, Inc, Easton Associates, Inc., Gilead Sciences, Inc., GSK, Janssen, Lundbeck, Medivation, Merz, MK Medical Communications, , F. Hoffman-LaRoche, Ltd., SK Holdings Co., Sunovion, Takeda Industries, Teragenex, Teva, Part 1; Biological Psychiatry Editor, Part 2; Janssen Research Foundation, Part 4
This supposedly just covers the last two years….Who knows how up to his neck in payola he was in the hay-days of pharmaceutical industry corruption…
Perhaps he was unclear and imprecise and it took a year for him write his ill-conceived response because his illusion is shattered—he is lost. It’s obvious he really liked the illusion,and is missing how important it made him feel before it was shattered…his statement is garbled but it seems to me the harm he refers to is to himself. He feels harmed by Marcia Angell’s review—he is saying it was unethical of her to have harmed him by shattering his illusion. That’s my take on it.
btw I personally believe there is some people who do not know what ethics are—not really. people are complex and broken in all sorts of ways. it is obvious that honesty and integrity are not valued by everyone, and equally plain neither are required to achieve financial, social or political success. I agree with wiley–your blog is therapeutic for me as well. Be well.
The ACNP Public Information Committee’s comment to the blog includes (among other things) the assertion that “The biological basis for psychiatric illness is now well established.” But as far as I’ve heard, psychiatry has never been able to reliably determine the actual nature or specifics of that biological basis.
My layperson’s 2 cents: For the secularists among us, I believe it’s also fairly well established that all mental activity (thought, emotion, motivation, etc.) is “biologically based”: to oversimplify, the patterns of neurons firing, synapses strengthing or weakening, dendrites growing, glial cells supporting, etc., in a fantastically complicated network individualized by a person’s unique experiences as well as genetics, etc. (Some more spiritually-inclined will say that there must be something beyond the biological brain for thought and consciousness to occur; that’s a debate for another day.) Neuroplasticity, to my thinking, is the bridge (or at least a major bridge) between the psychology and the biology. Some biological change underpins any change in our thoughts, though we may never be able to discern where those changes are in any given individual, amidst their unique wiring of billions of neurons and trillions of synapses.
So to me at least, the experts claiming a “biological basis” for psychiatric illness in particular holds no special appeal, especially if they’re unable to say much at all about what that biological basis is.
Mickey, you say that you “found the three books reviewed by Dr. Angell…painful too.” I am sure you have more than enough to be doing, but I for one would very much value your thoughts/critique on these three.
This post piqued. I note that Dr. Angell was beating the pharma drum before her NEJM run. It’s good to see that she is causing discomfort in the guild – no pain/no gain.
The links to her reviews (probably in Mickey’s post somewhere that I simply didn’t find):
June, 2011
http://www.nybooks.com/articles/archives/2011/jun/23/epidemic-mental-illness-why/?pagination=false
July, 2011
http://www.nybooks.com/articles/archives/2011/jul/14/illusions-of-psychiatry/?pagination=false
re philroy, if the ACNP is relying on the fact that mentation occurs in the the body as the biological basis of psychiatric illness, it’s stooped to proposing an reductio ad absurdum for the foundation of the profession. They must be suffering from collective anosognosia.