If you haven’t already read Marcia Angell’s two review essays on the state of psychiatry in the New York Review of Books, I urge you to do so now. They are absolutely devastating. Angell, the former editor in chief of the New England Journal of Medicine, provides so much evidence of systematic corruption at the heart of the profession that it might just give you a newfound respect for the Church of Scientology. (Okay, maybe not.)
Others have documented the growing number of seemingly common forms of behavior that psychiatrists describe as mental illness, the increasing prevalence of drugs over talk therapy as a preferred method of treatment, and the vast sums of cash that pharmaceutical companies spend marketing their wares. Angell ties these phenomena together. She also raises serious questions about the quality of research that justifies the prescription of anti-depressants and anti-anxiety medications.
This is partly a story of a discipline attempting to attain “scientific” status. During the 1970s, psychiatry faced challenges from an array of skeptics who questioned the reliability of its methods. The response among disciplinary leaders, Angell documents, was to do everything possible to “clinicalize” the field. Psychiatrists moved away from models that stressed childhood development toward ones that emphasized the biological roots of mental illness (what distinguished researcher Leon Eisenberg calls the field’s late twentieth century turn from a state of “brainlessness” to “mindlessness”). Since mental illness were due to chemical imbalances in the brain rather than unresolved unconscious conflicts, medication would be crucial to treating them. By relying more heavily on prescribing drugs than it had in the past, psychiatry seemed to be establishing its expert authority on par with other medical sciences.
As psychiatry’s mid-century romance with Freudian theories of childhood development turned to a focus on “chemical imbalances” in the brain, drug companies stepped in to take advantage. The more illnesses discovered, the more drugs that could be manufactured to treat them. The more pills available for new disorders, the less money insurers would have to spend on costly therapy sessions. Psychiatrists, pharmaceutical companies, and insurers all seemed to benefit from this arrangement.
But what about the patients? The most shocking revelations contained in Angell’s piece are that virtually no peer-reviewed research supports the view that anti-depressants and anti-anxiety medications provide any more effectiveness in treating these conditions than placebos. In fact, some studies suggest these drugs might actually have a negative impact on normal brain functioning. There’s also no evidence whatsoever that mental illnesses are caused by chemical imbalances. This is the case even though large numbers of people, including more and more children, are popping happy pills. What is one to make of all this?
It’s worth noting that leaders in other academic disciplines attempted to make their work more scientific in the 1960s and 1970s. Some historians, for example, argued that the rise of computers would overturn many of the field’s conventions. Rigorous quantitative analysis, they prognosticated, would provide the key to unlock all mysteries. History would finally attain the authority of science.
I think most historians would agree that while some of the methods developed by “cliometricians” deepened our understanding of the past, it was probably for the best that the discipline never abandoned its commitment to the close readings of primary sources. Without attention to the experience of actual people, statistics, by themselves, could give a distorted picture of the past. Fortunately, historians were able to make decisions on the state of their field for themselves: they never faced the temptations of a public looking to them to provide panaceas and an industry willing to sponsor them.
One of the main culprits in psychiatry’s apparent failings appears to be lack of transparency. Drug companies are under no obligation to publish negative research results. And so they usually don’t. While pharmaceutical companies promote their products to doctors in many fields, it turns out that psychiatrists receive more courting than all of the others. Arguably, Angell notes, this might have something to do with the subjective nature of much psychological assessment—it seems harder to gauge a decline in anxiety (and what exactly caused that decline) than the remission of cancer cells. The connections between top research psychiatrists and the drug industry are also extremely close, raising legitimate concerns about conflicts of interest.
The issues raised in Angell’s articles reminded me of some of the questions that I’ve come across in my own research on the history of academic freedom in the United States. Traditionally, professors have justified academic freedom’s special privileges on the ground that they require professional autonomy to discover new knowledge and promote the common good. Without the autonomy academic freedom provides, they insist that outside interests such as large corporations, churches, and labor unions would corrupt research.
During the late 1960s, however, many radicals questioned whether colleges and universities that had become so enmeshed with the state—particularly through research for the War in Vietnam (engaging in weapons development, studying counter-insurgency, manufacturing computers that could launch military attacks), could ever serve as centers of impartial reflection. They demanded, sometimes successfully, that campuses stop conducting classified research. At the very least, activists raised the point that scholars needed to pay close attention to the implications of their work and the role that patronage might play in defining its parameters.
Reading Angell’s piece, it seems that many of the issues that bedeviled campus military research in the 1960s applies to work in psychiatric medicine today (as well as other fields heavily subsidized by corporate money such as bio-technology). Considering the cash-strapped situation of many universities, it’s understandable that some institutions would let standards of openness and independence slip in the hopes of generating income and prestige. Understandable, but probably counter-productive. Corporate research, when conducted without the openness that characterizes traditional scholarship, threatens to undermine the very mission of creating useful knowledge that the university is supposed to promote. This certainly seems to the case with the over-prescription of psychiatric medications. As corruption of this nature gains more attention, the public will be even less likely to support research initiatives than they are today (which, ironically, would force even more solicitations from private industry).
All of which to say, it’s enough to make one reach for the nearest bottle of Prozac.