Psychiatry Under the Influence: Institutional Corruption, Social Injury, and Prescriptions for Reform by Robert Whitaker and Lisa Cosgrove aspires to be an important book, but is a misleading one that covers little new ground. The authors repeat the oft-told story of the American Psychiatric Association (APA) claiming it knows the cause of mental illness, creating a Diagnostic and Statistical Manual (DSM) that sometimes defines essentially normal people as being ill, medicines not working for those normal people and wraps it in a narrative that claims the APA does this to create jobs for members and because it is under the influence of pharmaceutical company money. The practice of pharmaceutical companies paying psychiatrists for bad research and then leveraging it in marketing campaigns designed to get normal people to buy their medications is an important story that the authors do try to tell. But because they include any snippet of a fact to support their case, exclude so many other interpretations and facts, and largely ignore serious mental illness, Psychiatry Under the Influence misses its mark.
The story of the DSM defining some normal people as having an illness was previously well told by Dr. Allan Frances in Saving Normal. In DSM 5, some barely symptomatic normal people, especially children, now qualify for a psychiatric diagnosis--often minor depression, anxiety, or ADHD. Cosgrove and Whitaker repeat this. They also go further. Because two doctors can look at the same patient and not agree on the diagnosis, they seem to suggest all mental illness, including serious mental illness does not exist. Nonsense. DSM is clearly an inadequate tool to differentiate two similar illnesses, but serious mental illnesses do exist, psychiatrists can treat them, and the medications--side effects not withstanding, do help. They hurt their arguments by their failure to explicitly recognize the existence of serious mental illness and its devastating impact on those who have it.
The story of psychiatry getting the cause of mental illness wrong was recently well documented by former APA President Dr. Jeffrey Lieberman in Shrinks: The Untold Story. Lieberman focused on the failure of Freudian theories to explain illness, while Cosgrove and Whitaker focus on the failure of the serotonin theory to explain depression. The serotonin theory--and it was always a theory--may not have withstood the test of additional research, but the neural connective pathways that serotonin effects are still thought to be involved in depression, as are genetics. We simply don't know enough yet. Brain imaging is still in its infancy and we can't remove live brains to analyze them. Psychiatry Under the Influence uses the fact that the exact causes of mental illnesses are not yet known to position mental illnesses as being neither chemical imbalances, diseases, disorders, illnesses, or medical. It's a claim that few who have met people with serious mental illness, or suffer from serious mental illness would make.
One part of the book does deserve wider attention. It is the authors' documentation on how pharmaceutical company-funded medication studies and abstracts play up the positive findings and minimize the negative. They provide good examples of pharmaceutical companies, aided and abetted by psychiatrists, mining the data: reexamining it after it is in to find some obscure positive result to report--a process the authors describe as being akin to throwing a dart at the wall and drawing a bulls eye around it after it has landed. "Torture the data enough and it will confess to anything." It's good stuff. But to make the point, the authors do the exact same thing they criticize: reanalyze studies to come to the conclusion they want. For example, the authors spend multiple pages examining the efficacy of a particular class of depression medicines, SSRIs, and find them wanting. But buried in the text is the line it "was only for severely depressed patients...that the SSRIs had provided a benefit." And elsewhere, they report "True drug benefits were nonexistent to negligible among depressed patients with mild, moderate and even severe baseline symptoms, whereas they were large for patients with very severe symptoms."
That's the honest narrative the authors should have followed: antidepressants don't work in people who do not have major depression, but do work in those who do. And while minor mental illness may be invented, serious mental illness is not.
When Psychiatry Under the Influence turns to serious mental illness, it does a good job of showing how pharmaceutical companies mismarketed new generation atypical antipsychotics as being superior to haloperidol (Haldol). But the efficacy of haloperidol itself in helping people with schizophrenia, or lithium in helping people with bipolar, is not highlighted, presumably because it would destroy the narrative that mental illnesses are made up and medicines don't work. Likewise, the authors largely ignore the fact that atypicals are less likely to cause tardive dyskinesia, which makes them a worthy alternative for some, even if their efficacy is not superior to other medications and they have side effects of their own. They tell how antipsychotics "shrink" brain tissue, but people with schizophrenia who have never been medicated also experience this change. They also fail to state that changes in brain structure may be why medicines work, not a sign of a problem.
The section on solutions suggests reducing the influence of pharmaceutical companies by pooling research dollars and blinding researchers as to who is funding their research. That's a neat idea. But the authors also argue psychiatry should "share authority over 'psychiatric problems' with other parties, such that its voice becomes one among many, rather than the ruling one." That would compound the problem not fix it. Other groups that want to "share authority" over psychiatry define mental illness far more expansively than the APA, and their proposed treatments are even more dubious. One major group believes anyone who has a "lived-experience" is worthy of support from public mental health dollars. Their suggested fix for "lived-experience" is "Emotional CPR," a pop-psychology educational program the organization describes as a "Tool of Peacekeeping and Bringing Healing to Communities" based on the idea that "inner peace creates global peace." Is that what we want the purview of psychiatry to become? Creating inner peace for all rather than helping people with schizophrenia? As the Director of the National Institute of Mental Health, Dr. Tom Insel, told a recent conference, there is no oversight of psychotherapies, so anyone can claim they have one that works. These groups should definitely not be given authority over psychiatry.
DJ Jaffe is Executive Director of Mental Illness Policy Org and author of the upcoming book, How the Mental Health Industry Kills the Seriously Mentally Ill: A Handbook for Change.