In a recent two part piece in the New York Review of Books, former New England Journal of Medicine editor Marcia Angell reviews three books focusing on the state of modern psychiatry in America. In different ways, the three authors all sally forth against the profession. Angell, an eminent scholar and seasoned critic of the pharmaceutical industry in her own right, does not do much to temper them. The result is a scathing survey presenting modern psychiatry as a corrupted and pseudoscientific practice.
Angell begins with a discussion of Irving Kirsch, a psychologist who devotes his book to an investigation of antidepressant medications. Using unpublished FDA data, Kirsch finds that the benefits of antidepressants when compared with placebo are middling at best. He then goes further, breaking down the concept of the double-blind placebo controlled trial as it applies to psychiatry. Given that active antidepressants cause anticipated side effects and placebos do not, Kirsch argues that the double-blind in psychiatry is a myth: If a patient experiences side effects, he will know he is on active medication, and is therefore liable to experience the therapeutic benefits of expectation. On this basis, Kirsch claims that antidepressants are nothing but “‘extra-strength’ placebos.”
Robert Whitaker, a journalist, focuses on all classes of psychoactive medications and claims that they are not only useless, but also in fact quite dangerous. He argues that psychoactive medications hijack normally functioning neurocircuitry and cause substantial alterations, the results of which leave the drug taker addicted and afloat in uncharted neurochemical territory. Symptoms of withdrawal are liable to be mistaken for a reemergence of mental illness, so patients attempting to wean are likely to be put back on a psychoactive medication. And thus continues a pernicious cycle.
In the second part of her review, Angell presents the work of Daniel Carlat. Carlat is a psychiatrist who is nevertheless highly critical of the profession. Although he acknowledges that he regularly prescribes psychoactive medications to good effect, Carlat regards psychiatric science skeptically. Around her discussion of Carlat Angell narrates a modern history of psychiatry since the mid 20th century. Suffering from a lowly reputation and increasing competition from other mental health providers, the profession, she tells us, undertook significant change. Bolstered by the advent of new drugs and armed with an expanded diagnostic manual, psychiatry presented to the world a new understanding of mental illness: The afflictions are diseases of the brain, rather than of the mind, and are best treated with medications that address putative neurochemical deficiencies. Upon acceptance of this thinking, psychiatrists showered new treatments on a growing patient population. Standing directly behind them, Angell will remind us, were the drug companies, all too eager to ply the doctors with consulting payments, honoraria, and the latest and greatest pharmaceutical products.
What is wrong with Angell’s piece? Angell has presented a thoughtful and measured review of the books in question. Many of her suggestions are well argued, damningly so. Psychiatry’s closet is in no shortage of skeletons, some of which are entirely ignored here.
Angell’s telling, however, is too simple. Her piece is conveniently tidy, covering all the necessary scientific, economic, and social bases. She paints us a picture of a profession struggling for legitimacy and profit, schilling voodoo medicine as a result of dubious science and aggressive courtship by a pharmaceutical industry that everybody loves to hate.
But the picture must be more nuanced. Angell ignores rich swaths of research that explore the undeniable neurobiological correlates of mental illness. She sells psychiatrists short, highlighting a few incriminating examples while ignoring a plurality of doctors who make every effort for their patients amid constrained resources and a limited toolkit. One cannot rightly argue that all of psychiatry looks upon non-pharmaceutical treatments with contempt. Angell herself once claimed that there cannot be two kinds of medicine, alternative and conventional. There is only medicine that has been shown to help and medicine that has not. It’s unfair to claim that the bulk of practitioners do anything other than make due with what they have and hope for better options to come.
Perhaps more importantly, Angell glosses over the anguish and autonomy of those who live with mental illness. Patients, the suffering of whom is scantily acknowledged until Angell’s closing paragraphs, are portrayed as helpless in the face of a churning conspiracy. Angell leaves no space for the informed and empowered patient. Doubtless there are many like Robert David Jaffee and Andrew Solomon, knowledgeable critics who know well the pain of mental illness and the options, although imperfect, that offer relief.
For these reasons Angell’s analysis falls short. She’s given us compelling story lines while ignoring the messy reality of mental health today. The labels that psychiatrists append to symptom clusters may be imagined, but the pain of those who suffer from mental illness is not. Myriad treatments – pharmaceutical or otherwise – exist. Plenty of caring professionals stand at the ready to serve with integrity. The ultimate danger of Angell’s piece is that in highlighting only those arguments that are conducive to an engrossing narrative, she invites hostility toward mental health services and supplies anecdotes to those who argue that the psychiatric variety of pain is somehow less real. In doing so, she pushes the individual who suffers in silence further away from help.
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