Do We Need a Fresh Start to Liberate Our Minds?
It is time to rethink how we categorize and treat mental disorders.
Posted Jun 06, 2019
In early 2014, as a clinical psychologist sitting among a throng of college psychiatrists, Thomas Insel, then Director of the National Institute of Mental Health (NIMH), announced forthwith the NIMH would not fund research for antidepressant drugs.
Moreover, he continued, over the past 60 years, significant breakthroughs had been made in medical research, yet progress in mental health had been at a standstill. The medical model for mental health, encapsulated in the Diagnostic and Statistical Manual of Mental Disorders (DSM), which divides mental distress into multiple diagnostic categories, was not working. At NIMH, it was back to the drawing board, looking for new ways to understand and treat mental disorders based on basic biological mechanisms (genes, cells, and brain circuits).
In her new book, Mind Fixers: Psychiatry’s Troubled Search for the Biology of Mental Illness, Anne Harrington, professor of the history of science at Harvard, writes a well-documented account of the revolt among psychiatrists against Freudian views, favoring “scientific constructs” for the DSM catalogue of diagnoses. Yet, like Insel, she sees the constructs as still lacking validity.
Harrington focuses on the need for a fresh start for both diagnosing and treating mental illness, particularly those burdened with depressive and anxiety disorders.
Although she chronicles what has gone awry with diagnosing and treating those with schizophrenia, our most severe and least understood mental disturbance, her primary target is Big Pharma’s forays into treatment for depression disorder (formerly known as melancholia). Depression disorder was rarely diagnosed following World War II, but today, along with anxiety disorder, is epidemic among both young and older adults.
First was the Benzedrine lift, along with Dexedrine for mild depression, both amphetamines, with annual sales of some four million nasal inhalers available over the counter. Then minor tranquilizers, Miltown and Valium were introduced, which did not treat depression but the anxiety believed to be at the heart of neurotic complaints. Sales skyrocketed for these tranquilizers, prompting pharmaceutical companies to step up their sales efforts through prescribing physicians. Next came the "new" antidepressants, Prozac, Zoloft, and Paxil, all promoted to correct a chemical imbalance in the brain.
Although the consensus among independent researchers was that chemical imbalance theories are too simplistic, if not outright wrong, public skepticism began to arrive only in the past 10 years, not just because the drugs do not always work but because they could have serious side effects, including obesity, high blood sugar, and diabetes (as well as addictive qualities).
Following the agreement of the FDA to allow direct-to-consumer advertising of prescription drugs, pharmaceutical sales increased from less than $800 million in 1996 to $4.9 billion in 2007 (with generous help from TV ads claiming miraculous benefits). And to justify renewing otherwise expiring patents on the drugs, Big Pharma identified DSM categories previously not targeted for specific medications, such as panic disorder, social anxiety disorder, and generalized anxiety disorder.
But the major takeaway was Big Pharma’s published trials underestimating the placebo effect. A college research psychologist and graduate student happened to study the magnitude of the placebo effect in its own right. After performing a meta-analysis of clinical trials, they found placebo groups experienced substantial relief, that 75 percent of the improvement of people taking the active medication could be attributed to the placebo effect.
Big Pharma responded that the findings were cherry-picked and spurious; the researchers countered by recruiting additional colleagues and used the Freedom of Information Act to compel the FDA to provide them the trial data it had received prior to its approval for six of the most widely prescribed drugs (Prozac, Paxil, Zoloft, Effexor, Serzone, and Celexa).
To their surprise, they found that only 43 percent of the trials had placed the medications at an advantage over the placebos; in other words, in 57 percent of the trials the medications had failed to outperform the placebos. Moreover, even in the trials where drugs outperformed the placebos, “82 percent of the drug response was duplicated by the placebo response,” leaving a mere 18 percent attributable to the medication.
Harrington sees this data as a final blow to overhyped theories of a chemical imbalance in the brain. She cites an attempt by Big Pharma to save face by blaming the DSM diagnostic categories for being unreliable. However, the European Medicines Agency advised drug companies that their approval of any new drug would depend upon its having to outperform placebos, outperform an existing drug known to be efficacious, or identify a predictive biomarker.
A few years ago, I learned that researchers at New York-Presbyterian's Youth Anxiety Center found that childhood anxiety disorder was present in 9 percent of preschoolers starting at age 4, separation anxiety by age 6, generalized anxiety disorder by age 10, with an overlay of social anxiety during this time period. It was believed that these early anxieties build upon one another, becoming the gateway to adult mental disorders, including depression disorder, bipolar disorder, and schizophrenia.
It remains to be seen if focusing on the etiology and treatment of early childhood anxieties can lead to a better understanding of young adult and adult mental disorders. At the very least, it might bring forth the creative insight and practices necessary for a new start and help remedy much of what has gone awry over these past six decades.
This blog was co-published with PsychResilience.com