Comfortably Numb: How Psychiatry Is Medicating a Nation
While we've now become accustomed to the barrage of prescription drug commercials on prime-time TV, it's jarring to learn that this advertising is legal only in the United States and New Zealand. The pharmaceutical industry doesn't just target Americans directly, but also spends roughly $25,000 per physician per year. With the aid of information from data mining companies, a pharmaceutical representative knows exactly how many prescriptions for what medication a doctor has written, allowing the industry to individually target them.
How Americans came to this fraught relationship with the pharmaceutical industry and its drugs -- particularly antidepressants -- is the subject of Charles Barber's new book, Comfortably Numb. A veteran of mental health programs in homeless shelters and a lecturer in psychiatry at the Yale University School of Medicine, Barber trains his eye to the confluence of science and culture that have led to the widespread prescribing of medications once reserved for the most serious cases.
While the field of neuroscience continues to churn out new data about the way our brains work, Barber is quick to remind us how much more is yet to be understood. Barber recently spoke with AlterNet about how less sexy treatments like social interventions and therapies can be just as effective in changing the brain.
Onnesha Roychoudhuri: What led you to write the book?
Charles Barber: When I started in the mental health field in the late '80s there wasn't really a name for what I did. If I talked to professional, educated people, they didn't understand psychiatric diagnoses or medications. Then, 10 years later, people were very up on diagnoses, they were sympathetic to what I was doing, and there was now a name for the field: mental health. Many of them were taking the same medications that my clients were. There was a series of events over the late '80s and early '90s that set all that up. The main thing being Prozac and its cousins Paxil and Zoloft, which became totally mainstream; the TV advertising of drugs in the mid-'90s, well-known figures going public with their clinical depression, and a lot of subsequent pop culture stuff: The Sopranos and A Beautiful Mind, for example. All of this brought psychiatry, particularly medications, into the fore.
OR: Can you talk about your involvement in the mental health field and what it has enabled you to observe?
CB: I fell into the field for a lot of different reasons. I worked in psychiatric homeless shelter programs for about 10 years in New York -- Bellevue being the most well-known. So I was working with the really seriously mentally ill, many of whom had been in and out of prisons and state psychiatric facilities and homeless shelters. What I found was that psychiatry, at least for certain diagnoses, has confused the really serious forms of the illness with the far lesser forms. The best example is depression. Many of the folks that I worked with suffered from severe depression. I make the distinction in the book between big "D" depression and small "d" depression. In its severe forms, it's an absolutely brutal, horrific and malevolent illness where people are at dire risk of hurting themselves.
It's jarring to go to a cocktail party and hear people talking about being bummed out or hear that they're going through a divorce, and their family doctor put them on an antidepressant. There has been a confusion and conflation of this diagnosis that confuses serious disorders with far lesser conditions or, in many cases, life problems. We've medicalized a lot of life issues that are not mental illnesses.
OR: Just to be clear, this book is not about medication as a "bad" thing.
CB: Absolutely not. I think I make clear in the book that for serious disorders, I've seen the medications work really, really well. However, there are often side effects that the field has overlooked and is becoming more aware of these days. And these medications still don't work a good percentage of the time for people with serious disorders. My critique is that the further you get away from serious or moderate disorders, where you're treating nondisorders or marginal disorders with medication, the risk/reward calculus of the medications becomes more iffy -- particularly antidepressants.
When the SSRI (selective serotonin reuptake inhibitor) antidepressants like Prozac and Zoloft and Paxil first came out, they were considered pretty much side-effect-free, largely because the previous generation of antidepressants had a lot of side effects. But in the past few years, people have become more aware that they have more side effects. These effects are seen most when people are getting on and off the drugs.
OR: You write that, in 2002, more than 11 percent of American women and five percent of American men were taking antidepressants. I was struck by the high percentages, but also the fact that more than 1 in 10 women are on these medications.
CB: Depression does affect women more than men, and the marketing has capitalized on that. So women's magazines are a place where you see a lot of ads for antidepressants and sleep aids. The U.S. accounts for two-thirds of the market for antidepressants. I don't think anybody knows the exact utilization figures, but the finances are largely driven by the U.S. It's a very American phenomenon in that most of the drugs were developed here. Also an American thing is the television advertising of drugs, which is illegal everywhere in the world except for New Zealand and the U.S.
OR: Throughout the book, you connect what's going on culturally with what's going on scientifically. You write, for instance, that SUVs and SSRIs have similar stories.
CB: That was referencing a point that Malcolm Gladwell made in an article in the New Yorker on SUVs and how many American products have been guilty of what he calls "over-performance." In other words, what they're maximally capable of doing is much more than we really need on a day-to-day basis. SUVs can drive you up the Himalayas, but really we just need them to go to the grocery store. The same can be said of the antidepressants. They can be wonderful for people that really need them, but they've been indiscriminately given out to people and the utility is arguable. It's this very American thing of focusing on the technology and sexy high-tech solutions, and not really looking at what is really needed.
OR: You say that the drugs came along at a culturally ripe moment, at a time when we had socially and politically moved away from collectively approaching problems.
CB: The arrival of Prozac in 1988 was a perfect storm, culturally and just in terms of the drug itself. In the '70s Valium paved the way for Prozac. It was the first psychiatric drug for anxiety that became mainstream. The earlier generation of antidepressants had a lot of side effects and could be fatal in overdose, and Prozac seemed very clean by contrast. It was the first drug that you didn't have to be crazy to take. You could be a judge or a journalist and take Valium and obviously millions of people did. It entered the culture, from the Rolling Stones' "Mother's Little Helper," Valley of the Dolls to celebrities talking about their Valium use.
Culturally, the '80s were the time when we gave up on collective enterprises of doing things. The country had experienced multiple recessions, and there was a sense that a college education really didn't get you a good job anymore. With the Reagan revolution, it was time to straighten up and "pull up your bootstraps" and do things as individuals. I think that transferred into how we took our drugs. There's not such a huge difference between illicit and licit drugs. In the early part of the '60s, when there was a spiritual aspect to the drug taking, people took drugs together. One of the hallmarks of the Prozac revolution is that people take them individually, and even the treatment is individualized. It used to be that if you were taking a psychiatric drug, you were probably working with a therapist, and now the large majority of people taking psychiatric drugs are in no ongoing dialogue with a caregiver.
OR: As a contrast to the American cultural relationship to antidepressants, you talk about the sale of SSRIs in Japan.
CB: There wasn't really a term for depression in Japan. The drug companies invented one [kokoro no kaze, or "one's soul catching cold"]. There weren't any sales of antidepressants in Japan until the late 1990s, because they didn't really think that depression was that much of a problem. I'm sure people were depressed in Japan, and part of it was probably underreported, but in any case, there was a different attitude. A cultural minister in Japan said they didn't really think of depression, in its milder forms, as anything bad. Rather, they saw it as a sign of awareness and artistic sensitivity.
The drug companies put on a brilliant advertising campaign and, sure enough, the sales of antidepressants went up five-fold in a very short time. But our American sensibility is to be uncomfortable with unhappy feelings and root them out as quickly as possible. I want to be very clear not to romanticize suffering, but there can be a utility to some difficult emotions.
The American notion of happiness is a very recent phenomenon in human history. You could argue that only since WWII and really since the '60s and '70s has happiness been the goal. Ironically, I think if you set happiness to be your primary goal, it tends not to work out very well. The late Canadian novelist Robertson Davies said that happiness is a byproduct, and that you become happy when you're engaged in productive activity or when you're in a relationship with someone you love. So this idea that we have to be happy is a highly American thing and highly problematic concept.
OR: The British health [service] recommendations reveal a pretty different relationship to depression.
CB: The clinical guidelines to the National Health Service for mild depression recommend watchful waiting, diet and exercise, self-help and counseling, cognitive behavioral therapy, and then if all those things don't work, to try antidepressants. Our de facto practice in the United States is pretty much the opposite. I think a critical development that coincides with the Prozac entry into the culture is that family doctors now prescribe most antidepressants. It used to be that psychiatric drugs were primarily prescribed by psychiatrists. Family doctors just realistically aren't going to know cognitive behavioral therapists to refer people to. Or they don't know the research on diet and exercise on even severe depression. So, managed care is yet another factor in the move towards the quick and expedient approach, which is hastily writing antidepressant prescriptions rather than plumbing the larger issues.
OR: And you say that only 20 percent of those prescribed a medication then have a follow up.
CB: The reality is that in most cases a family doctor is writing the prescription, and maybe you'll see them six months or a year later. In most cases, no one is really following the treatment. There are people who have difficulties going on and off the medication, and it seems to me irresponsible that there's no regular monitoring. I would argue that psychiatrists should really be the people prescribing and monitoring, as well as therapists who will be talking to a patient about how the drugs are going and then can relay that to a doctor.
OR: In the analysis of the FDA under the Bush administration, you quote a scientist who says, "There is a remarkable amount of pressure placed on reviewers to find creative ways to approve problematic drugs." This was an eerie echo of the drive to find intelligence to justify the Iraq war. Also disconcerting was the information on the Prescription Drug User Fee Act (PDUFA). Can you explain its impact?
CB: This dates to the early '90s. Before then, the money for drug evaluation was public money. Now, about 50 percent of the money to evaluate drugs is paid for by the drug companies. In the latest iteration of PDUFA, it even called for some of the drug company money to pay for the rent at a new FDA facility in Silver Spring. The fact that the drug companies are paying the bills can affect one's judgment. I would call for two reforms: One would be getting the drug ads off television and fully public financing of FDA drug evaluation.
OR: How successful are those TV ads in increasing demand?
CB: I think they've been extraordinarily effective. The evidence shows that they influence patient habits and prescribing habits. They also focus on the top 20 or so blockbuster drugs -- a billion or more in sales. We all know the names of these: Nexium, Prozac, Zoloft, Lipitor. They have become household names and at times household staples. The fact that they're advertised next to toothpaste and Chevrolet makes them seem like they're toothpaste and Chevrolet. But drugs are powerful agents.
While illicit drug use has declined among younger people in the last 10 to 15 years, the abuse of prescription drugs has soared. Part of that is their omnipresence, and part of it is the perception of kids who grow up on these ads that make the drugs seem like toothpaste.
At a more technical level, there are studies showing that when doctors are asked for antidepressants, they're more likely to prescribe them even if the patient isn't genuinely depressed. The patient request makes a huge difference. The advertising of drugs is unpopular among many doctors, because they feel like patients have really incomplete and naive information about the drugs and yet put pressure on them to prescribe it.
OR: You also talk about how there is so much money going into these drugs that there is a pressure to come up with as many uses for the drug as possible. You cite the irony of Zoloft's slogan "No. 1 for millions of reasons."
CB: Drug companies can't advertise for diagnoses that aren't FDA prescribed, but there has been a huge expansion of diagnosis. The first Diagnostic and Statistical Manual of Mental Disorders (DSM) came out in the 1950s, and it had 50 or 60 diagnoses; the latest one has over 300. There is also off-label prescribing, which means prescribing by an individual doctor for use that's not FDA approved. That has also gone up a lot.
OR: You also write that it seems as though diagnoses follow the pills available to treat them.
CB: Over the course of the '90s, SSRIs were allowed to be prescribed for a number of conditions. I think at a cultural level, when Valium was king in the '60s and '70s, if people talked about a kind of societal disorder, it was anxiety. It was the "age of anxiety." Then, when Prozac was king in the 1990s, if people talked about a broad issue, it was depression. And so our perception of what bothers us follows the drugs that are most in currency at that time.
OR: You mention the dramatic increase of diagnoses in the DSM. Can you give some examples of what diagnoses are now included?
CB: For example, adjustment disorder is a diagnostic category in the DSM, and essentially it's having a difficult time dealing with a major life change. There are categories such as "phase of life problem" and "sibling relational problem." These might be very painful issues, but are they mental illnesses? A hundred years ago psychiatry included a lot of treatments that were brutal, but it concentrated on serious disorders, schizophrenia, bipolar disorder, major depression. Psychiatry has been sufficiently diluted by the expansion of diagnosis and the way that it has entered the culture, that we've created people with far lesser conditions and arguably no conditions whatsoever.
The great irony is that there hasn't been much traction in people with severe mental illness -- the kind of people that I've worked with. The rates of their retention and treatment haven't really improved much in the last 20 years. You could argue that your chances of being in treatment go up as the severity of your condition goes down. I think there should be an emphasis, in any branch of medicine, on the most ill people first. In psychiatry, it has sort of been the opposite of that.
OR: In addition to the $22 billion that the pharmaceutical industry spends a year to market directly to doctors, I was shocked to read about the role that data mining plays in targeting doctors with marketing.
CB: The level of access struck me as remarkable. Data mining companies track individual doctors and what they're prescribing, and then sell this information to pharmaceutical companies. They can then target doctors. Nobody knows about this, least of all the patient.
OR: We all know about the massive scope of the pharmaceutical industry and yet, despite all this money, you talk about how there haven't been many new drugs. Rather, we're seeing a lot of what you call "me-too" drugs that are slight variants of the same old thing. It echoes the publishing industry in terms of larger companies not wanting to take chances on anything new when they have a formula for what makes a lot of money.
CB: They call it the "pipeline problem." There haven't been many breakthrough drugs in psychiatry. The breakthrough drug happened in the 1950s with Thorazine, and most of the anti-psychotics have been variations one way or the other on that original. It's so expensive to develop a drug that it's much easier and economically reasonable to just play with existing paradigms. The creativity of new drugs has come from small biotech firms and universities. The big industry has been stuck in these existing paradigms for the most part.
I think the other part of it is moving away from really severe conditions that only affect a very small portion of people. It's more profitable to hit a larger market base with people with lesser conditions or lifestyle issues. So, some of the big drugs of recent years arguably are not really about serious disorders, they're about lifestyle issues: Viagra, Cialis, Lipitor, and antidepressants. You're going to hit 10 percent of the population as opposed to the 2 percent that have serious depression.
OR: Throughout the book, you talk about the irony that, in the neuro-science age, psychotherapy can now be viewed as a biological treatment along with pharmaceuticals.
CB: There are a lot of very simple, straightforward approaches to depression and anxiety that can be very effective either alongside of or apart from medications, but they're not marketed like the medications, and they don't sell.
In a study done in 1993 at UCLA, antidepressants were given to people with Obsessive Compulsive Disorder. Half of the patients they gave the antidepressants to and the other half they gave cognitive therapy, which is also a proven treatment for OCD. Then they did brain scans, and they found that, in the part of the brain that is associated with OCD, the activity levels had been reduced in very similar ways. There have now been many studies using the brain technology showing that psychosocial interventions and psychotherapy are capable of changing the brain in similar and different ways as the drugs. In other words, to dismiss psychotherapy as unscientific and having no durable or easily assessable impact is no longer the case. That's not really understood by the public and even in the field there's still this notion of "hard science" and then the rest of the people who do this mushy headed stuff that isn't consequential.
OR: You write extensively on Cognitive Behavioral Therapy (CBT). Can you give a quick explanation of what it entails?
CB: It's usually 12 to 15 highly focused, goal-oriented sessions, in which the patient collaborates with the therapist to look at the thoughts, beliefs and attitudes behind their anxiety or depression. It has also been proven to be effective for a range of conditions like Post-Traumatic Stress Disorder (PTSD), insomnia and OCD. It allows the patient to analyze what the core beliefs are behind their issues and to look at ways of replacing them or examining them in a more accurate way. The founder of cognitive therapy found that there were a great deal of cognitive distortions or thinking errors associated with his depressed patients. They particularly had a very negative view of themselves, the future, and the world, but a lot of it based on erroneous perceptions: thinking that if something bad happened, it was always related to them. When it's successful, cognitive therapy allows the patient to clear up some of those thinking errors, and that can have a direct effect on mood. It has since been generalized to many conditions and is the most empirically validated form of psychotherapy in the world.
OR: I think these notions of a "cure" are in part propagated by oversimplified science journalism. In the book, you write that "in just one edition of the Times, four articles appeared, each of which offered genetic and neurological explanations for behavior that a decade or two ago likely would have been analyzed in social or cultural terms. What's the risk in couching these behaviors in genetic and neurological terms?
CB: In the '90s, these terms and concepts started showing up like "hard-wired" for some behavior. Mental illnesses were thought of as the product of chemical imbalances, or that you're genetically programmed a certain way. Those concepts have completely entered the culture, and you can't pick up a publication without some latest genetic explanation of, for instance, schizophrenia. Writing about the science and talking to scientists, you learn that it's more complicated that that. Genetic transmission can be heavily influenced by the environment itself, and so these cartoonish versions of what directs our behavior are facile. The best scientists are not prone to making these sweeping and simplistic judgments.
Eric Kandel, probably the most eminent psychiatrist in this country, writes a lot about the social influence on genes. This can be very dangerous to think of in such simple terms. In psychiatry in particular, it sets up this division of a house divided against itself: genes versus environment, psychotherapy versus drugs, or nature versus nurture. The sophisticated thinkers understand that these things work together in an infinite dance.
The pendulum is always swinging, and in the last 20 years or so it has been genetic focused. The leading genetic researcher on depression talks about depression being 50 percent genetic; that means it's 50 percent environmental. But the way the studies are reported, it's all hard wired and chemical imbalance-related. These things are just cartoons of the science. There is no clear chemical imbalance for any mental illness. There is no one to one relationship between any neurotransmitter.
OR: The research you cite in the book points to the fact that the brain has an incredible capacity to create new neural connections. At the same time, I recall that one study showed that the placebo effect has increased 7 percent each decade. This seems like a fascinating example of the power of faith in medicine.
CB: And also just the perception of psychiatric drugs having more and more entered the consciousness. Prozac is portrayed as a wonder drug, so people taking it think, wow, it has got to be doing something. It absolutely speaks to the cultural ways in which we regard science. These are incredibly influenced by the social dialogue. In the mid-'90s, the term "chemical imbalance" became en vogue. I was running facilities for people with severe mental illness, and a client would say to me, "I can't go to my treatment program today, because I've got a chemical imbalance." There's a social context to all of this that is not written about much.