1 Boring Old Man

IS PSYCHIATRY FOR SALE?
^{AN EXAMININATION OF THE INFLUENCE OF THE PHARMACEUTICAL INDUSTRY ON ACADEMIC AND PRACTICAL PSYCHIATRY}
BY JOANNA MONCRIEFF
June 2003
^{This was prepared as a MAUDSLEY DISCUSSION PAPER and is available for £4 as a booklet from the Sarah Smith at the Institute of Psychiatry, de Crespigny Park, London SE5 8AF, tel 0207836 5454, e mail sarah.smith@iop.kcl.ac.uk}

SUMMARY

^{Western society is consuming ever larger quantities of prescription drugs and many of these are for psychiatric complaints. Drugs are central to modern psychiatric practice and to much psychiatric thought about the nature and causation of mental disorders. Psychiatry has therefore become an important target for the large and powerful pharmaceutical industry. Drug companies direct lavish advertising and hospitality towards psychiatrists and provide funding for much medical education and some mental health service initiatives. The industry is now heavily involved in the organisation of research into psychiatric drugs and the dissemination of research findings. This raises questions about the scientific objectivity of this research and the extent to which the industry is able to shape the research agenda. Drug companies also provide funds for pro drug patient and carer groups and address advertising or disease promotion campaigns to the general public. They exert influence at a political level through lobbying and direct funding of political bodies including drug regulatory agencies.}

^{This influence has helped to create and reinforce a narrow biological approach to the explanation and treatment of mental disorders and has led to the exclusion of alternative explanatory paradigms. The coercive function of psychiatry has been strengthened by promoting the idea that psychiatric disorders are akin to medical conditions and that they are amenable to technical solutions in the form of drugs. In addition, alternative treatment approaches are neglected and it is likely that drugs are currently used for overly long periods and in excessive doses. The adverse effects of drugs are neglected.}

^{Psychiatry provides fertile ground for pharmaceutical industry profits because it provides opportunities for expanding definitions of sickness to include more and more areas of social and personal difficulty. This paper gives examples of how the industry has been involved in promoting and expanding concepts such as depression, social phobia, attention deficit hyperactivity disorder and psychosis.}

^{The current extent of drug company influence threatens the integrity of psychiatry and some suggestions are made about steps that could be taken to address this. The influence of the industry must be curbed for political reasons too. We are rapidly becoming a society that seeks a "pill for every ill;" one that looks for simplistic, technical solutions to complex social problems. This helps to divert attention away from the profound social and political changes that have occurred during the last few decades. Psychiatrists should not be colluding in this process.}

…

CONCLUSIONS

^{As a society we are consuming more medicinal drugs than ever and a large proportion of these are for psychological conditions and complaints. This is making a major contribution to spiraling health costs and takes money away from other health services. Psychiatric practice is now firmly centered around drug treatment, and millions of other people, who have no contact with a psychiatrist, are receiving psychotropic drugs in General Practice. In recent years we have been encouraged to view more and more problems that were previously considered to be normal and manageable parts of the human condition as mental diseases that require treatment. The promotion of the idea of technical and professional solutions, the medical colonisation of everyday life, has profound consequences. At the individual level it seems likely to reduce personal coping strategies, to "gnaw away at our self confidence" (Payer, 1992). This is true in the area of mental health more than any other, since mental health involves our view of our own capabilities; the nature of our very selves. At the social level, the medicalisation of various problems obscures the effects of social changes that have taken place in the UK over the last couple of decades. For example, the retraction of the welfare state, increasing working hours, job insecurity and the dismantling of pension schemes have made life more difficult and more uncertain for many ordinary people. A society obsessed with its own navel is unlikely to be able to mount an effective challenge to these trends.}

^{Psychiatry and the pharmaceutical industry make a formidable combination. Modern psychiatry derives its legitimacy from the notion that mental disorders are equivalent to medical diseases and it is this that justifies the coercion of psychiatric patients. Drug treatments that are aimed at specific diagnoses help to endorse this view, and the industry has the financial capacity to ensure that this view becomes accepted and respectable. In turn, the authority of psychiatry enables it to define what is considered as mental disorder and what is appropriate treatment, thus creating markets and opportunities for the pharmaceutical industry.}

^{The influence of the pharmaceutical industry over political processes and research is an example of what George Monbiot has termed the corporate take-over of Britain (Monbiot, 2000). The power of the pharmaceutical industry is particularly worrying, because the commercial incentive to promote disease and sell pills potentially changes our view of what it is to be human. Fortunately, there are signs of unease within the medical community about the degree and consequences of drug company influence. It is time for the psychiatric profession to reflect on its relationship with the pharmaceutical industry and attempt to reclaim its integrity.}

I feel like I came in at the end of stories. After training in Internal Medicine, I found myself practicing as an Air Force doctor on a large American Air Force base in Europe – having come in at the end of "the draft." People in the Air Force and their young families aren’t a very sick lot, so a good three out of four patients I saw [on referral] had problems in their lives manifested as physical symptoms rather than "disease." I hope it’s different now, but back then, referral to the mental health services was almost uniformly resisted for fear in wouldn’t look good when promotion time came around, so I became something of a junior psychiatrist whether I wanted to or not. But, truth be told, I kind of liked doing it.

So, when my tour of duty wound down, I returned to start a Psychiatric training program. Psychiatry is actually two things – the treatment of the severely mentally ill [Schizophrenia, Manic Depressive Illness, etc.] and the "walking wounded" [the rest of us with our various knots and lumps]. In 1974, the modern antipsychotic drugs were in their heyday, and the large State Mental Hospitals were being emptied. Psychiatry was pretending that these drugs "cured" psychotic people. As amazing as those drugs actually are, they’re a long way from "cure." Another "end of a story" for me [the largest mental hospital in the US now is the LA County jail].

I had come to learn about the "mind" and the dominant paradigm then was psychoanalysis and related psychotherapeutic thinking, and that’s where my interests centered. During my Psychoanalytic training, I was directing the Psychiatric Residency at Emory. We taught psychopharmacology, community psychiatry, and psychotherapy side by side without seeing them as in conflict with each other. Just parts of the package. But then things changed.

Another ending – the community health movement, put in place to create outpatient services for the patients with severe mental illnesses no longer hospitalized just evaporated for lack of funds. But there was more ending – Psychiatry was to be medicalized it seemed. In my case, it was the coming of a new chairman of Psychiatry. Frankly, I was pretty dumb. It took me a year to figure out that this was a wave of some magnitude. Psychotherapy took to long, was based on unprovable ideas, was costly, etc. etc. The era of biological psychiatry was upon us. I was a dinosaur and still in my early forties. I didn’t fit so off I went into private practice.

It was another "ending." Insurance payments to Psychiatry disappeared – the age of "managed care" was upon us. Psychotherapy isn’t cost effective. I guess I was lucky in that there was more than enough work for whatever I did, and I was strangely insulated from the changes that were felt profession-wide. I still had occasional contact with Psychiatry Residents and felt kind of sad that when they talked, locked into a narrow path of structured medical sounding diagnoses and psychopharmacology. Many of my colleagues were bitter about the new paradigms – Psychiatrists prescribing drugs, other disciplines doing therapy. It didn’t bother me so much. I didn’t much care who was doing the work – so long as it got done.

But then it began to dawn on me that it wasn’t only cost effectiveness that was driving things. There was another force – PHARMA – the Pharmaceutical Industry. I guess I’m a slow learner. It wasn’t until after I retired and started doing some volunteer work in a rural clinic that I realized how profoundly things had changed. So even though I work in clinics where the front line is medication, the medications people are taking, mostly prescribed by well-meaning Primary Care Physicians, was like cold ice water in the face. Two or three antidepressants, an atypical antipsychotic, with maybe an anticonvulsant because "I might be bipolar." I spent more time stopping drugs than starting them for the first year I worked there. If that kind of prescribing has made it to rural Georgia, it’s everywhere. The 2003 article posted above is anachronistic. Today, it would be better titled "Having been bought, can Psychiatry be reclaimed?"

Addressing threats to health care’s core values, especially those stemming from concentration and abuse of power.