Last week Charles Barber, a Yale Medical School Psychiatrist, wrote a provocative article for Salon.com:
Are we really so miserable?
Antidepressant use has doubled, and anxiety is at a troubling high. Blame TV, Big Pharma -- and possibly yourselfAug. 26, 2009 | Earlier this month the Archives of General Psychiatry released a much publicized study that one in 10 Americans is now taking antidepressants within the course of a year, making antidepressants the most prescribed kind of medication in the country. The number of Americans on antidepressants doubled between 1996 and 2005, and the number of prescriptions written for these drugs has increased each year between 2005 and 2008. One has to wonder: Are we really that miserable?
Manipulated might be a better word than miserable. If we were to pick one factor that explains the dramatically increased number of selective serotonin reuptake inhibitors (the technical name for drugs like Prozac, Paxil and Zoloft) that now run through our collective bloodstream, it would be direct-to-consumer advertising, otherwise known as television commercials for prescription drugs. An obscure rule change by the FDA in 1997 allowed Big Pharma to advertise its products on TV and bring them into our living rooms, and our daily consciousness. The pharmaceutical companies concentrated on their best-selling “blockbuster” drugs — Lipitor, Claritin, Nexium, Viagra, as well as the psychiatric drugs Prozac, Paxil and Zoloft, and more currently, Effexor and Lexapro — and soon enough these drugs became, quite literally, household names, the celebrities of pharmaceutical agents. Psychiatric drugs featured prominently in these ads because psychiatric drugs are very good sellers, among the best in the industry, for which there is a simple reason: Legitimate psychiatric illnesses are chronic (if episodic), and the legitimate sufferer needs to take the medication for a long time, if not for life.
In his article Dr. Barber focuses on how Big Pharma uses direct to patient advertising to present a rosy picture of how their chemical ministrations can lift our spirits and bring the warmth and light of sunshine back into unhappy lives. He also offers some anecdotal evidence that the explosion of antidepressant use coincides with one of our periodic upsurges in cultural angst:
But there is something dark and undeniable shifting in our cultural mood, too. Sure, there is manipulation in the advertising and confusion about what constitutes legitimate “serious and persistent mental illness” (a formal term to describe the afflictions of the very small percentage of people who suffer from severe bipolar disorder, major depression or psychotic disorders) as opposed to the far more normative, if often very painful, stressors and issues of living life in the early 21st century. Yet I would also say that misery and — if one were to use a slightly more clinical word, anxiety — are at one of their periodic high points. Arguably we have entered a new age of anxiety, a term associated with the post-World War II era through the 1960s, when the prevailing belief was that the world might blow up at any moment (and on the medication front, Valium was king). Maybe there’s some weird synchronicity that the hottest thing in our present cultural moment, "Mad Men," is set firmly in that era. In any case, I have written widely about mental health and have traveled the country in the last couple of years and, given the nature of my writing, have been sought out by all kinds of troubled souls. I can claim confidently that there is, right now, a high-water mark of worry and suffering on numerous fronts — economic, of course, but also social, with our ever-increasing isolation and Internet-driven loss of human connection and the ongoing trauma of wars and crises that just don’t seem to end.
Dr. Barber overstates the impact of the zeitgeist on anti-depressant use (or, at least, focuses on the wrong aspect of the zeitgeist.) Since the 1960s, the idea that pharmacological interventions can, and should, solve problems with a minimum of effort, has become deeply ingrained in our culture. For example, when people are unhappy (and please note, I am not considering Major Depressive Disorders, which exist on a different continuum from unhappiness) their Physicians and insurance companies are far more likely to recommend a pill than an exploratory Psychotherapy. Pills are cheaper, often work more quickly, and have the added virtue of not requiring the patient to actually make any significant changes in their life. But although I may take some issue with Dr. Barber's emphasis, he commits a much more egregious omission. Nowhere in his article does he reflect upon the contribution that organized Psychiatry has made to the medicalization of unhappiness.
Organized Psychiatry is in the process of revising the DSM, the Diagnostic and Statistical Manual which has described the official diagnostic criteria for various Psychiatric illnesses since the 1950s and is currently on its 4th iteration. The DSM has taken an interesting path.
DSM-I (1952) was heavily influenced by the Psychoanalytic community, which in the 1950s was extremely influential in American Psychiatry. The DSM-I discussed and described various traditional Psychiatric diagnoses (Neurosis, Schizophrenia, Manic-Depressive Illness) with an attempt to elucidate the etiology of the various conditions. In other words, the attempt was made to explain what actually caused the symptoms which were causing suffering and suggest treatment approaches for alleviating suffering. The DSM-II (1968) carried forward the emphasis on etiology while adding a number of additional diagnostic entities and offering support for a more biological emphasis for certain serious disorders. Nonetheless, it maintained a continuity with the DSM-I's attempt to understand the underlying psychodynamics of behavior and the causation of Psychiatric disorders. This all changed when the third revision took place in the late 1970s.
By the time the DSM-III task forces were established, it was correctly recognized that the Psychoanalytic understanding of etiology was insufficient to explain serious Psychiatric illness. Two elements became crucial. First organized Psychiatry, in reaction to the burgeoning use of Psychiatric medications and the relative disconnect between traditional Psychoanalysis and Psychiatry, as well as concerns about viability in an environment of increasing third party compensation, determined to make Psychiatry more clearly a Medical discipline rather than a Psychological discipline. This led to an over-emphasis on biological (pseudo) explanations for behavior. As a result the DSM-III was a document that made diagnoses based almost solely on collections of symptoms and symptom complexes (often referred to as the "Chinese Menu" style of diagnosis.) The unintended consequences of the decision to base Psychiatric diagnosis on symptoms rather than etiology slowly grew and metastasized.
[It must be emphasized that when the DSM-III was being developed, the well meaning Psychiatrists involved failed to recognize that symptoms were not merely biological responses to levels of neurotransmitters. Just as the Psychoanalysts in the first flush of their success in curing Neurosis with the "talking cure", over-explained all behavior as resulting from conflicts and deficits in the mind while neglecting the brain, the biological Psychiatrists, in their first flush of excitement at managing Psychiatric illnesses with their new Medication, over-explained all symptoms and behavior as being the result of the interplay of neurochemistry in the brain, while neglecting the mind. Finding the proper balance, when our understanding of the Psyche and the brain remains relatively rudimentary, is a long term task which we have barely begun.]
The unintended consequences of the shift to a symptom based diagnostic manual, an over-emphasis on biological determinism, and the medicalization of unhappiness will be the subject of Part II.
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