Jake from State Farm's blog: "War On Drugs"

When the DSM Began

The first editions of the DSM would have been unrecognizable to modern practitioners of psychiatry. The DSM-I, published in 1952, conceptualized mental disorders as dysfunctions of personality rather than of neurobiology, following a former president of the American Psychiatric Association’s advocacy of “mental hygiene,” and the DSM-II, published in 1968, consisted of 180 categories of illness framed in a flowery psychoanalytic cant that drew scorn from the medical community, which viewed it as something of an unscientific embarrassment. In their 1997 exposé, Making Us Crazy, Herb Kutchins and Stuart Kirk point out that the DSM-II was, in fact, a slim guidebook of dubious analytic value that clinicians could purchase for $3.50, designed to describe, rather than to prescribe, current psychiatric practices.

Things began to change in the next decade. Following the public outcry over thalidomide, a tranquilizer that was linked to thousands of birth defects despite originally being proclaimed safe by its manufacturers, the U.S. Food and Drug Administration initiated new regulations in 1962 covering the drug industry’s activities: companies were now required to establish a direct correlation between the physiological effects of newly designed compounds and particular medical diseases. This was a fateful moment for the psychiatric enterprise, which at the time lacked standardized disease entities to which specific compounds could be tailored. Increasingly attacked by its critics as unscientific, passé, inadequately somatic, and borderline illegitimate, psychiatry was in danger of slipping into medical irrelevance and was in dire need of reinvention. Enter Robert Spitzer, head of biometrics research at Columbia University’s Psychiatric Institute. Under Spitzer’s direction, an aggressive initiative to revise the DSM was launched, new diagnostic instruments were devised, and quantification became the disciplinary catchword. When completed in 1980, the DSM-III was, in every sense, an entirely new document. Whereas the DSM-II was 134 pages long, the DSM-III ran to nearly 500 pages and described 265 mental disorders in fastidious, grocery-list-like detail. Spitzer, in fact, vehemently pushed for the DSM to classify “diseases,” though the editorial board ultimately settled on the term “disorders” in order to placate the APA-member psychologists who found Spitzer’s overly clinical zeal disturbing.

Theodore Millon, one of the original members of the DSM-III revision task force, has acknowledged that the editors’ intentions were, in fact, to “embrace as many conditions as are commonly seen by practicing clinicians,” and, in so doing, expand psychiatrists’ access to fiscal coverage from third-party insurance providers. The rhetorical paraphernalia of the DSM-III, through which entirely normal forms of human behavior were transformed into somatic ailments, thus equipped psychiatrists with an unprecedented level of authority over problems of mental health throughout civil society, in fulfillment of a longstanding wish to attain the prestige of other medical specialties. By reconceptualizing everything from unhappiness to inefficiency to social anxiety as discrete illnesses, each indexed with formally objective criteria, fixed etiologies and clear-cut prognoses, the DSM-III’s authors – many of whom were recipients of major research grants from pharmaceutical companies – secured for themselves a substantial gift in the form of guaranteed insurance remittances, and furnished the drug barons with an equally lucrative gift: a slate of well-defined diagnostic entities at which to market their concoctions and, thus, an elegant solution to the challenges posed by the regulatory pressures of 1962.

In 1994, the DSM-IV was published to considerable acclaim, with a text revision released in 2000. A quick glance through its list of contributors is revealing. As was reported in a 2006 study, lead-authored by Lisa Cosgrove of the University of Massachusetts, 56 per cent (95 of 170) of the researchers who worked on the manual had at least one monetary relationship with a drug manufacturer between 1989 and 2004. Twenty-two per cent of these researchers received consulting income during that period, and 16 per cent were paid spokespersons for a drug company. The percentages are even higher – 100 per cent in some instances – for researchers who contributed to the manual’s subsections on psychotic disorders such as schizophrenia. While Cosgrove and her coauthors were not able to determine the percentage of researchers who received funds from the drug industry during the actual production of the DSM-IV, the chorus of protest that arose following their paper’s publication was telling. “I can categorically say,” roared the DSM-IV’s text and criteria editor, Michael First, “that drug-company influence never entered into any of the discussions, whatsoever.”

First’s objection is probably accurate. The implementation of commercial agendas in medical research rarely takes the form of industry agents archly ordering doctors around. While it’s true that the annual conventions of the APA have become glitzy trade fairs, at which attendees spend much of their time absorbing product pitches, it is the subtler forms of influence that have the most impact. As Joel Paris points out, “Although nothing forces us to prescribe their products, marketing strategies work. And the industries know it.” By sponsoring the scholarly activities of researchers – such as conferences, whose keynote speakers are often booked by industry representatives – companies are able to clinch remarkable levels of good will from academic faculty and medical residents. The psychiatric literature is, additionally, infested with a voluminous amount of corporate ghostwriting, wherein drug companies invite doctors to add their names and, thus, their scientific imprimatur, to pre-written articles. (In return, naturally, these doctors get to pad their publication histories.) Many medical journals, moreover, manage their operating expenses by occasionally publishing corporate-sponsored “supplements,” which readers are not always able to distinguish from the journal’s regular issues. Finally, because of governmental agencies’ lack of interest in funding clinical trials, the companies have a virtual monopoly on pharmacological research, and have been free to regularly suppress negative results and finesse methodologies in order to generate favorable outcomes. The drug companies are now de facto members of the medical research community, and it has become virtually impossible to determine where the academy ends and the industry begins.

One Nation of Self Medicators (under Shrinks and Drug Companies)

As the history of the DSM makes clear, it is not possible to speak of modern psychiatric nosologies without speaking of the professional interests from which they have arisen. The serviceability of this branch of the medical-industrial complex to the neoliberal fetishization of state noninterference, finally, should not be underestimated. With the innovation of increasingly marketable psychotropic drugs over the past four decades, public health officials have been free to legitimize healthcare budget cuts, hospital closures, and the widespread dismantlement of social services, by devolving responsibility for mental health to the individual and by transforming happiness into a problem of consumer choice. Miserable people – the exhausted assembly-line worker, the desperate college student, the alcoholic veteran – no longer pose a threat to the status quo so long as they agree to self-medicate and to keep themselves, thereby, in a state of artificial equanimity. As sociologist Nikolas Rose says, “In the majority of cases, such treatment was not imposed coercively upon unwilling subjects, but sought out by those who had come to identify their own distress in psychiatric terms, believe that psychiatric expertise would help them, and were thankful for the attention they received.” And this is the crux of the matter.

A common objection to criticisms of our society’s growing infatuation with psychopharmaceuticals is that distressed people should be free to undertake whatever course of action they feel is necessary to dispel their misery. I cannot dispute this contention. No one who is familiar with the texture of crushing, existential despair can fail to sympathize with another person’s decision to resort to whatever is available to help them through the day, and it is not my intention to indict the personal logics that underpin these choices.

The rationality of consumer choice, however, is inevitably limited insofar as authentic data on the health risks of specific compounds are rarely available in the public domain, and insofar as the drug companies continue to inundate airwaves, newspapers, magazines and billboards with mollifying untruths about the efficacy of their products. As Alexander Cockburn has recently revealed in this newsletter, as much as a third of consumers who view an advertisement for a particular prescription drug go off and talk to their doctors about it, and nearly half of those who ask for a drug end up getting a prescription for it. How many of these consumers know of the plethora of peer-reviewed studies that have demonstrated that selective serotin re-uptake inhibitors (SSRI) compounds are closely linked with violence and suicide? What percentage of those who have come to conceptualize their pain in biological terms are aware that definitive links have yet to be established between neurotransmitter action and complex, culture-bound emotional states such as grief, anguish and loneliness?

Data manipulation and elision are rampant in psychopharmaceutical research. The list of revelations, both current and years-old, is extensive and can be elaborated only in brief. In the 1990s, the litigation-averse Los Angeles Times killed an investigative report coauthored by Alexander Cockburn and former Scientific American editor Fred Gardner, in which evidence was presented linking Prozac to, among other things, domestic violence and tumor growth. Journalist Evelyn Pringle has, more recently, reported on the CounterPunch website that Janssen-Cilag’s antipsychotic Risperdal (chemical name, risperidone; $3.5 billion in sales in 2005) induced severe side effects, including strokes and death, in 1,207 children between 1993 and 2008. Two recent studies, conducted independently in the United States and Great Britain, have additionally revealed that newly released antipsychotics differ from their predecessors only in price, not in efficacy or safety.

But a question remains. What if, in some hypothetical future, a new generation of unambiguously safe and effective psychotropics could be developed? Would it become ethically acceptable to urge the depressed and the despondent to take drugs?

When psychiatrists lament that over half of depressed people are “treatment-resistant,” what they do not consider is this. It is not the “stigma” of being labeled mentally ill that discourages many people from seeking medical help; it is a strenuous aversion to being told that one’s existential grievances are irrational, a mere result of a pathological neurochemical imbalance. It is the fear of being coerced into ingesting foreign substances, whether safe or dangerous. Since 1997, the National Alliance on Mental Illness has sought to expand a medication compliance program first developed in the 1970s, wherein mental health workers visit outpatients on a daily basis to confirm that they’ve taken their drugs, and to forcibly administer drugs if necessary.

We are at a strange point in history. It should come as no surprise that the exhausting and alienating conditions in which we live and labor are productive of myriad forms of psychological suffering. Yet, critics of biological psychiatry are commonly subjected to the fallacious accusation that, because we reject the equation of unhappiness with sickness, we must believe that it is a weakness. This is a false dichotomy. Is it so difficult to understand the pain engendered by life under neoliberal capitalism as something worthy of dignified reflection, irreducible to either sickness or weakness? Is it so hard to grasp that to detrivialize the social conditions that give rise to despair or the ideologies that equate difference with disease is not to trivialize despair or difference?

Let’s be candid. The drug barons’ ongoing campaign to pathologize entirely natural emotional responses to hunger, humiliation, financial insecurity, racism, sexism, overwork and isolation is a mercenary tactic, designed to create markets, maximize profits and minimize dissidence. Whether intended or unintended, the consequence is that we have come to reflexively view ourselves – our bodies, brains, and genes – rather than our societal environment as pathogenic, against all evidence to the contrary. As the DSM-V looms, we have to explore the dire implications of this trend and contintue to raise the alarm.