Anatomy of an Epidemic (49 page)

According to a 2009 report by the federal Agency for Healthcare Research and Quality, spending on mental health services is now rising at a faster rate than for any other medical category.
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In 2008, the United States spent about $170 billion on mental health services, which is twice the amount it spent in 2001, and this spending is projected to increase to $280 billion in 2015. The public, primarily through its Medicaid and Medicare programs, picks up close to 60 percent of the nation’s spending on mental health services.
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Such is the story of the psychiatric drug business. The industry has excelled at expanding the market for its drugs, and this generates a great deal of wealth for many. However, this enterprise has depended on the telling of a false story to the American public, and the hiding of results that reveal the poor long-term outcomes with this paradigm of care. It also is exacting a horrible toll on our society. The number of people disabled by mental illness during the past twenty years has soared, and now this epidemic has spread to our children. Indeed, millions of children and adolescents are being groomed to be lifelong users of these drugs.

From a societal and moral point of view, that is a bottom-line that cries out for change.

On July 28, 2003, six “psychiatric survivors” associated with MindFreedom International, a patients’ rights organization, announced a “fast for freedom.” David Oaks, Vince Boehm, and four others sent a letter to the American Psychiatric Association, NAMI, and the U.S. Office of the Surgeon General stating that they would begin a hunger strike unless one of the organizations provided “scientifically valid evidence” that the various stories they told to the public about mental disorders were true. Among other things, the MindFreedom group asked for evidence proving that major mental illness are “biologically-based brain diseases,” and for evidence that “any psychiatric drug can correct a chemical imbalance” in the brain. The MindFreedom Six had put together a scientific panel to review the organizations’ replies, an advisory group that included Loren Mosher, and they demanded that if the APA and the others couldn’t provide such scientific evidence, “you publicly admit to media, government officials, and the general public that you are unable to do so.”
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Here’s how the APA responded: “The answers to your questions are widely available in the scientific literature, and have been for years,” wrote medical director James Scully. He suggested that they read the U.S. Surgeon General’s 1999
Mental Health
report, or an
APA textbook coedited by Nancy Andreasen. “This is a ‘user-friendly’ textbook for persons just being introduced to the field of psychiatry,” he explained.
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Only the uneducated, it seemed, asked such dumb questions. But Scully had failed to list any citations, and so the six “psychiatric survivors” began their hunger strike, and when their scientific advisors reviewed the texts that Scully had referred them to, they found no citations there, either. Instead, the texts all grudgingly acknowledged the same bottom line. “The precise causes [etiology] of mental disorders are not known,” U.S. surgeon general Satcher confessed in his 1999 report. MindFreedom’s scientific panel, in its August 22 reply to Scully, observed that the strikers had asked “clear questions about the science of psychiatry,” and yet the APA had brushed them off. “By not giving specific answers to the specific questions posed by the hunger strikers, you appear to be affirming the very reason for the hunger strike.”
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The APA never answered that letter. Instead, after the Mind-Freedom group broke their fast (several started to have health problems), it issued a press release, stating that the APA, NAMI, and the rest of the psychiatric community “will not be distracted by those who would deny that serious mental disorders are real medical conditions that can be diagnosed accurately and treated effectively.”
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But it was clear to all observers who had won this battle. The strikers had called the APA’s bluff, and the APA had come up empty. It hadn’t come up with a single citation that supported the “brain disease” story it told to the public. The MindFreedom Six, along with their scientific panel, then issued a clarion call for help:

The strike, noted MindFreedom executive director David Oaks, stirred articles in the
Washington Post
and the
Los Angeles Times
.
“The purpose of the strike was to educate the public. It was about empowering the public and getting them to talk about these issues, which affect everyone. It was about challenging the corporate bullying of the [public] mind.”
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When I first thought about writing a “solutions” chapter, I figured that I would simply report on programs, both in the United States and abroad, that involve using psychiatric medications in a selective, cautious manner (or not at all), and are producing good results. But then I thought of the hunger strike, and I realized that the MindFreedom group had precisely identified the bigger issue at hand.

The real question regarding psychiatric medications is this: When and how should they be used? The drugs may alleviate symptoms over the short term, and there are some people who may stabilize well over the long term on them, and so clearly there is a place for the drugs in psychiatry’s toolbox. However, a “best” use paradigm of care would require psychiatry, NAMI, and the rest of the psychiatric establishment to think about the medications in a scientifically honest way and to speak honestly about them to the public. Psychiatry would have to acknowledge that the biological causes of mental disorders remain unknown. It would have to admit that the drugs, rather than fix chemical imbalances in the brain, perturb the normal functioning of neurotransmitter pathways. It would have to stop hiding the results of long-term studies that reveal that the medications are worsening long-term outcomes. If psychiatry did that, it could figure out how to use the medications judiciously and wisely, and everyone in our society would understand the need for alternative therapies that don’t rely on the medications or at least minimize their use.

In his 1992 book
How to Become a Schizophrenic
, John Modrow—who had been so diagnosed—wrote the following: “How then are we to help ‘schizophrenics’? The answer is simple:
Stop the lies!”
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In essence, that’s what the MindFreedom Six were demanding, and as their advisory panel observed, this is a perfectly rational request. And that, I think, sums up the challenge that we, as a society, now face. How do we break up the psychiatry-and-drug-company partnership that, as we have seen, regularly does lie to us? How can we insist that our society’s mental health system be driven by honest science rather than by a partnership that is constantly seeking to expand the market for psychiatric drugs?

There is no easy answer to that question. But clearly our society needs to have a conversation about it, and so I thought that the rest of this “solutions” chapter should be devoted to interviews and investigations of alternative programs that could help make that conversation a fruitful one.

David Healy is a professor of psychiatry at Cardiff University and tends to psychiatric patients at the District General Hospital in North Wales, where he has been since 1990. His office is located a few feet from a closed ward, and naturally, he regularly prescribes psychiatric medications. Indeed, although he has come to be perceived by many in psychiatry as a “maverick,” he recoils at that word. In the 1980s, he notes, he researched serotonin reuptake in depressed patients. He participated as a clinical investigator in a trial of Paxil. He has authored more than a dozen books and published more than 120 articles, with much of his writing focusing on the history of psychiatry and the psychopharmacology era. His CV speaks of a psychiatrist and historian who, until he began writing about problems with the SSRIs, was embraced by the psychiatric establishment. “I don’t think I’ve changed much at all,” he said. “I think the mainstream has left me.”
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His thoughts on how psychiatric drugs should be used (and what they really do) have been deeply influenced both by his writings on the history of psychiatry and by a study he has conducted that
compares outcomes of the mentally ill in North Wales a century ago with outcomes in the region today. The population hasn’t changed in this period, with around 240,000 in the area, and whereas all the seriously mentally were treated at the North Wales Asylum in Denbigh a century ago, today all psychiatric patients needing to be hospitalized are treated at the District General Hospital in Bangor. By poring over records of the two institutions, Healy and his assistants have been able to determine the number of people who were treated back then and the number treated today, as well as the frequency of their hospitalizations.

The common belief, Healy notes, is that the old asylums were bulging with lunatics. Yet from 1894 to 1896, there were only forty-five people per year admitted to the North Wales Asylum (for mental problems). Furthermore, as long as the patients didn’t succumb to tuberculosis or some other infectious disease, they regularly got better over the course of three months to a year and went home. Fifty percent were discharged as “recovered” and another 30 percent as “relieved.” In addition, the overwhelming majority of patients admitted for a first episode of illness were discharged and never again rehospitalized, and that was true even for psychotic patients. This latter group averaged only 1.23 hospitalizations in a ten-year period (that number includes the initial hospitalization).

Today, the assumption is that patients fare much better than they used to thanks to psychiatric medications. However, in 1996, there were 522 people admitted to the psychiatric ward at the District General Hospital in Bangor—nearly twelve times the number admitted to the Denbigh asylum a century earlier. Seventy-six percent of the 522 patients had been there before, part of a large group of patients in North Wales that cycle regularly through the hospital. Although the patients spent a shorter time in the hospital than they did in 1896, only 36 percent were discharged as recovered. Finally, the patients admitted for a first episode of psychosis in the 1990s averaged 3.96 hospitalizations over the course of ten years—more than three times the number a century earlier. Patients today are clearly more chronically ill than they were a century ago, with modern treatments apparently having set up a “revolving door.”
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