The Tuesday, May 17, Health and Science section of the Washington Post carried a Consumer Reports Insights article on depression. The article’s commentary regarding depression has little to do with insight, health, or science. In fact, the article is a very good illustration of how disinformation routinely is disseminated to the public. It is an unabashed commercial for psychiatry that overstates how psychiatrists function, ignores their limitations, and fails to report on problems with psychiatric treatment.
Not to be missed here is that this bad information is coming from Consumer Reports, an organization devoted to consumer protection. And, if my attacking Consumer Reports strains your credulity, I will ask you to accept something even harder to believe: Much of Consumer Reports problem is traceable to the NIMH, which is putting out public information not to be trusted.
Let’s take a look at the article’s first paragraph, which sets the stage for considerable nonsense:
A 46-year-old teacher saw a psychiatrist on referral from his primary-care doctor because he felt so depressed he couldn’t function at work. The psychiatrist asked about his past relationships, his symptoms, his medical history and more. And then he ordered some blood tests. Medical history? Blood tests? Absolutely. Feeling depressed can mean many things, and not all of them represent true depression. A doctor needs to pay attention to all the patient’s symptoms and consider all possible causes for them.
While this description may appear eminently reasonable, it creates a quite false impression of what we know about mental disorder and what we have reason to do in treatment. Although the psychiatrist asks about relationships, the importance of life experience factors is all but lost in the medical posturing. Psychiatry, in concert with the pharmaceutical industry, has promoted a genetic chemical imbalance theory for mental disorder. The theory is a mythology because there is no good empirical basis for the theory or the claims being made. There are no peer-reviewed studies that corroborate the serotonin hypothesis for any mental disorder, including depression. Research results are not simply non-supportive, they are contradictory to the theory. Despite more than 100 years of research seeking to uncover physical causes for mental disorders, aside from the discoveries a century ago related to general paresis (from syphilis) and Karsakoff’s syndrome (from alcohol abuse) no underlying physical cause has been found for any mental disorder.
Blood tests? There are no blood tests for mental disorder. Psychiatrists do blood tests not because they help to diagnose mental disorder (they don’t), but because the drugs they prescribe (which outcome studies have found to be ineffective) can be lethal if the dosage is too high. While these blood tests prevent psychiatric prescriptions from killing patients, they are not sufficiently sensitive to detect harm. Robert Whitaker, in his book, Anatomy of an Epidemic, discusses data concerning how disability rates have soared since the widespread prescription of antidepressants. Many primary care doctors have been deceived along with the public because the published psychiatric research is highly biased toward drugs (this has been documented), giving a misleading impression to doctors and the public of their effectiveness.
Medical histories? Consumer Reports also assigns undue weight to physical illness as a cause of mental disorder and gives an exaggerated picture of psychiatrists as possessing broad medical diagnostic competency. Both are overstatements that appear to be an attempt to justify the necessity and importance of a medical degree to treat mental disorder. There is an abundance of evidence that mental disorders are of environmental, not physical origin. It is true some physical illnesses (for example, hormonal problems) can produce symptoms that sometimes have been misdiagnosed as depression, and all therapists need to be aware of this possibility and make appropriate referrals. But this is an atypical occurrence and far more likely to be within the diagnostic competency of the patient’s primary care physician. It is simply false that psychiatrists, with their meager training in internal medicine, are geared to make complex differential diagnoses. The patient’s primary care physician is much better trained and experienced than the psychiatrist to discover an illness that is responsible for negative emotional reactions.
Consumer Reports Insights goes on to convey additional misinformation by conflating sadness with depression. Prior to DSM-III (published in 1980), sadness and depression were viewed as different. Whereas depression was regarded as a mental disorder, sadness was recognized as a normal, temporary response to loss. Losses occur throughout life and a lot of research establishes the connection between loss and sadness. Sadness is simply a part of experiencing life, but we get over it, even when it has the intensity of grief. Now sadness/depression is diagnosed as an illness – an illness, we are told, that is best treated medically. The pharmaceutical industry has become extraordinarily profitable as a result of this psychiatric construction. Abandonment of the distinction between sadness and depression has led to many people being prescribed drugs who would get better and be better off if left alone. When treatment for sadness is warranted, more effective help comes from a doctor who pays close attention to the patient’s life circumstances rather than one who prescribes drugs. The same point applies to depression, particularly when treated by a behavior therapist who is trained to know what to pay attention to (research results bear this out).
Consumer Reports Insights then discusses “true depression” (whatever that is, since the article never defines depression properly) as distinguished from “atypical depression,” which “usually responds well to SSRI antidepressants and psychotherapy.” In actuality, outcome studies find little or no support for the SSRIs as being effective in the treatment of depression. When measured short-term (after three months of treatment), SSRIs produce results no better than placebos (and for this reason are properly regarded as placebos); measured long-term, the SSRIs are found to be no good at all. Results indicate that after a year’s time all but a small fraction of patients on antidepressants have either relapsed or dropped out of treatment (because not only do antidepressants not work, they have aversive side effects).
Finally, lest you have missed getting their point, Consumer Report Insights ends the article by stating that the 46-year-old teacher who sought help from a psychiatrist because he felt depressed was found to have a “mild long-term panic disorder that had been worsened by an under-active thyroid gland. With the help of thyroid pills and anti-panic medication, he soon felt much better.” Are we to believe that the psychiatrist, not the primary care physician, discovered (and treated?) the thyroid problem? How odd that would be. Cases with hormonal deficiencies or other physical causes for emotional disorder certainly exist, but as stated above, (a) physical illnesses are infrequent causes of mental disorder, (b) depending on psychiatrists to make this diagnosis would be a mistake, and (c) drugs don’t reliably treat anxiety conditions any more than they do sadness or depression. And, incidentally, not mentioned in this recounting of the teacher’s experiences, those anti-panic meds are habit forming (there are more than ten million addicts from anti-anxiety meds in this country) and they have been found to be a major cause of deaths from automobile accidents and when combined with drinking alcohol.
The medicalization of psychiatry began roughly thirty years ago when psychiatry switched from a psychological (psychoanalytic) theory of mental disorder to a biological theory (the chemical imbalance theory). From its inception this medicalization of psychiatry has been aimed at two goals. First, increasing the respectability of psychiatry within the medical community by becoming “real doctors” who prescribe drugs to their patients, rather that offering talk therapy. Second, was the challenge of overcoming the stiff competition psychiatry faced from other mental health professionals, primarily psychologists, which by the 1980s threatened to put psychiatry out of business. People need to know that the medical claims that were made then, and which continue to be made now, have failed to be validated. Psychiatry has achieved success and respectability on the basis of marketing, not science. The Consumer Reports Insights article is representative of a great deal of misleading public information that needs to be set straight. Fundamentally, the article is a false credentialing of psychiatry to the public and to the rest of medicine, and a not very subtle unfounded attack on the competency of non-medically trained mental health practitioners, many of whom are operating on a far more solid research foundation.
The medicalization of psychiatry has been highly successful for the profession of psychiatry – far less so for patients. As described briefly above, outcome research has revealed that drug treatment produces poor results. Patients initially interpret the side effects of these drugs to mean the drug is helping (a placebo effect). However, since the drugs do not produce changes in the conditions or behaviors that have given rise to the patient’s problem and because they also induce noxious side effects (weight gain, constipation, loss of sexual desire), with time many patients lose faith in the drugs and stop taking them. For those, who continue on the drugs there is increasing evidence that long-term use of these drugs makes people worse (more prone to relapse). Particularly alarming in this regard is prescription of these drugs to children. As indicated earlier, the explosion in prescriptions of the SSRIs has been accompanied by a very significant increase in the number of people diagnosed as mentally disabled. Contrary to the rosy, benign picture of psychiatric practice painted by Consumer Reports Insights, there is reason to believe psychiatrists are providing poor treatment in the short run and injuring their patients when prescribing drugs long-term. In terms of both effectiveness and safety, outcome research indicates the medicalization of psychiatry has led us astray.
A great deal of research points to how the development of faulty responses to life’s challenges constitutes the basis for mental disorder. Correction of problems with this kind of origin can’t be done medically. The best treatments we have today for a wide range of mental disorders are behavioral (non-medical) treatments, all of which have been derived empirically. These promising results have taken place despite the fact that the amount of grant research devoted to behavioral treatment has been miniscule compared with drug research. We need therapists who possess the more trustworthy expertise of understanding how mental disorders are acquired and maintained as a consequence of people having learned debilitating behaviors in response to difficult conditions in their lives.
The Consumer Reports Insights column has contributed to the problem, not the solution. That aside, most importantly, we need to get over our wishful thinking that we can get rid of our problems simply by taking a pill. Although many doctors encourage this fantasy, it’s just not that easy. Help is available, but as is the case with most of our accomplishments in life, effort is required to make it happen.
If you are interested in reading more about the background of history and research on which these comments are based, including NIMH’s role in disseminating disinformation, read my article entitled, “What Underlies Psychopharmacology?”