- Home
- Addiction In The News
- Comfortably Numb: How Psychiatry Is Medicating a Nation
Comfortably Numb: How Psychiatry Is Medicating a Nation
- By Misc Author
- Published 04/17/2008
- Addiction In The News
- Unrated
By Onnesha Roychoudhuri, AlterNet
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: How Psychiatry Is Medicating a Nation.
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.
Second half of article continued on AlterNet April 17, 2008
http://www.alternet.org/story/82455/
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: How Psychiatry Is Medicating a Nation.
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.
Second half of article continued on AlterNet April 17, 2008
http://www.alternet.org/story/82455/
