Cracked: Why Psychiatry Is Doing More Harm Than Good
Dr James Davies at the Conway Hall Ethical Society on 13 April 2014
Why is psychiatry such big business? Why are so many psychiatric drugs prescribed, and why has the number of mental disorders risen from 106 in 1952, to around 370 today? In this talk, Dr James Davies takes us behind the scenes of how the psychiatrist’s bible, the DSM, was actually written — did science drive the construction of new mental disorder categories like ADHD, major depression and Aspergers? – or were less-scientific and unexpected processes at play? Has the rapid medicalization of everyday life been justified, and who is this really helping? His exclusive interviews with the creators of the DSM reveal the answer.
Psychiatric drugs do not do what they say they do on the tin and yet they’re prescribed at a remarkable rate. Psychiatry and the pharmaceutical industry are too close, and has wrongly medicalized more and more people: it is claimed that 1 in 4 of us will suffer from a mental health condition (Davies 2014:1), creating the illusion of a psychiatric epidemic. At the heart of this is the Diagnostic and Statistical Manual of Mental Disorders (DSM), which has expanded faster than any medical manual in history.
There is very little documentary evidence available on how the DSM is put together so he had to speak to the creators of the manual, including Dr Robert Spitzer, one of the most influential psychiatrists of the 20th century, responsible for DSM-III. This came out in 1980 and was by far the most important edition: it established the modern diagnostic system and also vastly expanded the number of disorders.
What was the rationale behind the huge expansion? Were these new disorders discovered in a biological sense? No, only a handful of disorders are known to have a biological cause, and in fact no biological markers have been identified.
We expect psychiatry to work like mainstream medicine, where a name is only given after pathological roots have been discovered in the body. The surprising thing about psychiatry is that it works in completely the opposite way: first, name the disorder even though there may be no biological evidence to support its inclusion, and then look for any pathological roots.
He asked Spitzer: On what grounds do mental disorder make it into the DSM? Apparently, they have “other procedures”: if a large enough number of clinicians felt that a diagnostic concept was useful, if there was a sufficient consensus to recognize a particular disorder, then it could get included.
Davies was astonished by this admission. Agreement does not constitute scientific proof. If a committee of theologians agree that God exists, that does not prove that God exists. In what sense is psychiatric agreement any different?
Professor Paula Caplan was similarly disturbed and decided to scrutinize the research behind the inclusion of one particular disorder, SDPD (self-defeating personality disorder). There was very little, and it was of poor quality.
Spitzer admitted that research was “very limited indeed” and that there were very few disorders whose definition was a result of specific research data. Klein told Davies that they relied on “clinical consensus”: but without data to guide them, how was this consensus reached? Basically, said Klein, “we had a three-hour argument — we eventually decided by a vote, sure, that is how it went.”
Voting isn’t a scientific activity.
Renee Garfinkel gave Davies a concrete aspect of how far down the scale of intellectual respectability she felt these meetings could sometimes fall (30). She quotes one Taskforce member, who suddenly piped up:
“Oh no, no, we can’t include that behaviour as a symptom, because I do that!”
The loudest voices and the strongest personalities usually won out.
DSM-III became an overnight sensation when it was first published (it took six months to catch up with orders). It was bought widely and was a book that changed the lives of tens of millions of people who suddenly found themselves “suffering” from diagnoses contained therein.
Most professionals using the manual did not and still do not know the extent to which biological evidence failed to guide the choices the Taskforce made. In short, most people do not know that it’s all based on the consensus of a group of eight people.
It was a revolution… We took over because we had the power.
Only eight new mental disorders were introduced in DSM-IV (there were 80 in DSM-III), but this hides the fact that there are 30 in the appendix and there are also many subdivisions, so that the DSM was actually expanded from 292 to 374 disorders.
Dr Allen Frances was the psychiatrist who replaced Spitzer as Chair of the new DSM. According to him, the decisions to include bipolar II, Asperger’s disorder and ADHD “helped promote three false epidemics in psychiatry” (48).
Davies asked Frances how many people he thinks have been wrongly medicalized. Frances replies (49):
“There is no gold standard for psychiatric diagnosis. So it’s impossible to know for sure, but when the diagnosis rates triple over the course of fifteen years, my assumption is that medicalisation is going on.”
For Davies, this was a thunderclap confession.
Frances allowed DSM-III to live on through the next edition: there was already lots of existing medicalizations, and the reason he gave for leaving it in (51):
“In other words, it felt better to stabilise the arbitrary decisions than to create a whole assortment of new ones.”
Davies concludes that the dramatic medicalization of “normal human reactions to the problems of everyday life was allowed to proceed unchecked” (52).
The DSM committee did not actually discover mental disorders, at least not in any traditional scientific sense. Rather, they contrived them, by drawing lines between painful emotional experiences. Mental disorders are also human-made maps, created like astrologers characterizing patterns in the sky as constellations (36).
What does good research look like in psychiatry?
If we reduce the DSM to disorders that are based only on biological markers, e.g. Huntington’s disease or Alzheimer’s, there wouldn’t be much left. DSM represents itself as a more scientific text than it is. On the big topic of what is good research, he’s not really qualified to answer.
Why do these things catch on?
Pharmaceutical marketing has a lot to do with it. One sign of how powerful this marketing is can be judged from the 530,000 copies of DSM sold in six months: it’s not a great read and it’s expensive, but it’s being bought in bulk by the industry and then dispensed to clinicians for free. The manual pathologizes most behaviours, and the rise in childhood disorders is linked to this industry. Unsurprisingly, there’s a reluctance to embrace evidence that meds cause more harm than good. DSM has got out of hand, and it needs to be more modest and scale back on the diagnoses: it should be possible to boil down 370 to 11.
One questioner said it was really useful for her to have a diagnosis of her symptoms.
Davies is not convinced that diagnosis always helps, although he recognizes that putting a name to it can be a relief. There is also the diagnostic effect, which can lead a patient to become fatalistic about their disorder, and to think that it will be with them forever. Too often diagnoses are made on the basis of short assessments. Basically, he thinks we’re over diagnosing.
Psychotropic medication is actually very expensive and comes with both side effects and withdrawal effects. The costs add up to £6–7 bn being spent a year on drugs. Psychotherapies could be cheaper, but there is poor provision in the NHS.
Is there such a thing as an RCT for psychotropic drugs?
Yes, but one problem with trials is that lots of data gets buried. The main regulatory body, the MHRA, is entirely funded and staffed by big pharma, so the tendency is for the regulators to be too lenient and to serve the interests of industry.
Chemical imbalance theory has not been proved by a single piece of evidence since it was first proposed in the 1960s.
By taking the biological route, psychiatry has been the greatest driver of stigma: the best way to challenge stigma is to challenge the biological view. [This is in the sense of medicalizing ``normal'' psychological states; in the sense of discovering biological causes for disorders, psychiatry singularly fails to take the biological view.]
Ritalin can appear to have remarkable effects in treating ADHD, so some are helped by drugs.
There was a comment broadly in agreement from a consultant child psychiatrist who has become disillusioned over the past 10 years, and who barely prescribes medication. There have been very few times when drugs have worked, though ritalin has worked occasionally. He faces dilemmas every day.
The media tend to prefer single-cause explanations and ignore the complexity of multicausal factors.