Friday, February 15, 2013

The Creation of Psychopharmacology - David Healy(Review)

This is a very difficult subject to address. It is contentious, opinions are divided, and I'm sure David Healy has made more than a few enemies because of this text. Be warned, I have neither time nor inclination to fully assess the merits of his argument. So in the interests of fairness I provide these links for reviews of this work. Be clear, not just because of this text but also because of a longstanding interest in understanding behavior(not professionally) I have to concur with the main thrust of Dr. Healy's argument. As recent posts on this blog have indicated(Psychotherapy and Drugs: A Dangerous Combination? , Psychiatry, Psychology, and Philosophy) I am, like David Healy, challenging some of the fundamental assumptions driving modern psychiatry and psychology.

I cannot address all the issues raised by this text. That would take 10,000 words and this post is 2,000 words. I do strongly advise those who are interested in this matter to find this book, read it, and think very carefully about it. 

BTW, I become very angry at the end of this post.

British Journal of Psychiatry
However he has written a highly stimulating and original book which is brimful of ideas which deserves to be read and debated throughout the psychiatric community and beyond. 
Nonetheless, The Creation of Psychopharmacology is easily the most important book to date on the history of psychopharmacology. It is a scholarly and impassioned argument against a psychiatry whose science and therapeutics are dictated by the interests of the pharmaceutical industry rather than by the interests of those afflicted with psychological distress. Though this book will do little to ingratiate Healy with the drug companies, it is an invaluable work for all of us interested in understanding this important part of our contemporary cultural and medical landscape. 
These are accurate statements about the central thrusts of Dr. Healy's arguments. Please keep in mind that Dr. Healy is an insider, a highly respected psychiatrist who is obviously "kicking against the pricks" and with good justification.

I would have expected that with the publication of this text in 2002 there should have emerged a discussion about Healy's main arguments that would have extended far beyond the relevant professional communities. Alas no it hasn't even received sufficient attention with the relevant professional communities. That is a serious cultural oversight and one for which we are already paying a heavy price. For example, the latest incarnation of DSM V goes so far as to make grief a psychiatric disorder and nail biting an OCD disorder. The psychiatric profession has become unbalanced, too drug addicted and too arrogant to admit its failings. They obviously refuse to critique their own ideas in a scientific fashion, the mereological fallacy(good blog post here on this fallacy and its prevalence in cognitive science) is riddled through their hypotheses, so it is up to us to call them out on their grossly negligent epistemic failures. I am using "negligent" in a very legal sense here. 

To take just one example of the epistemological absurdity that pervades modern psychiatry consider the concept "addiction". There is no clear definition of addiction yet that doesn't stop psychiatrists and psychologists continually waxing lyrical about addiction and its consequences. It is common sense and mandatory in any intellectual endeavour worthy of that appellation that the first step is you make your definitions clear and consistent. Without that we can't make first base, we shouldn't be allowed on the field!

One would think that while the problems of classification of mental illness are obviously very challenging that the mental health professions would not allow this situation to continue without at least being continually addressed in the relevant literature. This challenge is not just some exercise in semantics, in relation to mental health it is an enormous intellectual challenge. This is difficult to explain so please think carefully about it. Behavior is not from the "bottom up", it is impossible to understand behavior by reference to neurotransmitters and various neuro-imaging technologies. As Healy notes:
"There are in fact studies showing that the personality traits of patients can predict up to 50 per cent of their likelihood to respond to antidepressants acting on either the serotonergic or the noradrenergic system and also to antipsychotics.
Now consider his earlier remark:
By the 1970s psychiatrists were increasingly just making diagnoses and writing prescriptions with the psychotherapy work being left to social workers and others.
The absurdity is so obvious it is funnier than The Three Stooges. Furthermore that psychiatrists have reduced their role to such an extent clearly contradicts the APA guidelines:
"Treatment ... is facilitated by a comprehensive understanding of the patient, including his or her needs and goals, intrapsychic conflicts and defenses, coping styles and strengths. The psychiatrist should attempt to understand the biological, interpersonal, social, and cultural factors that affect the patient's adjustment."
What modern psychiatry is attempting to do is understand the patient without any reference to the patient as a person but more like a machine or chemical reaction. Psychiatrists stab in the dark, hoping that by tweaking  this amine or that MAO or those receptors the patient will demonstrate a positive response. So it is not surprising that poly-pharmacy has arisen. Without at least making an honest effort to understand the patient as a person, as an incredibly complex set of interactions involving both internal and external contingencies, the therapist is committing an intellectual fraud. So score one for psychoanalysis, at least the analysts appreciated the great complexity involved in understanding human behavior, which is far more scientific than the pretentious proclamations about amines which becomes nothing more than biobabble replacing psychobabble, a theme Healy asserts with considerable force and abundant justification.

The complexity of behavior is such that we should not expect a clear delineation of symptoms that can be easily classified by some check list or catalogue of symptoms. Across individual the same "neurological deficit" may be manifest in differing behavioral outcomes that may well nigh be impossible to predict. To provide an obvious example consider the famous 3 body problem articulated by the mathematician Poincare. We cannot predict the outcome of the gravitational attraction of 3 large bodies yet psychiatrists would have us believe they can in the spaces of 6 minutes identify a psychopathology in such complex organisms as ourselves. As I stated previously, at least psychoanalysts recognised the challenge and would typically spend many months with a patient. The irony there of course is that the length and strength of this relationship probably did more to help the patient than any specific therapeutic intervention(cue Carl Rogers).

The above argument raises some very difficult question with respect to randomised controlled trials, the epidemiological cornerstone of modern medicine. 

Of course there will be patients where if not the etiology of the pathology is clear at least the pathology is clear. You don't need to be a psychiatrist to recognise some psychoses of OCDs or depression. But we should never assume that will always be the case, we should never assume that because therapy A worked for patient A1 such will be the case for all patients. 

If psychiatry, psychology, and Big Pharma wish to assert that we have made tremendous strides in treating mental illness then we need to ask why mental illness rates have been increasing at alarming rates since the 1950s. There has literally been not only an explosion in the number of diagnoses and the types of pathologies identified. As a society this is another debate we must have. This explosion is not just because of the creation of mental illness diagnoses and types but very possibly reflects some disturbing qualities about modern culture which many have suggested are driving too many people into mental health problems. From Erich Fromm to Oliver James this theme has been re-iterated but once again it never gains traction. It is not within the purview of the mental health professions to address this challenge and as Healy correctly points out the increasing demand from society that the mental health professions treat conditions that may well be the product of a sick society is not only masking the true cause of this explosion in mental health but is allowing the maintaining of forces within our culture that are making too many people mentally ill. This highlights the challenges we face in this regard, our failure to address this issue will overwhelm the mental health professions. That is already occurring. We need to to act now. 

Nonetheless the intellectual and moral failures of modern mental health initiatives is the failure of the mental health professions. They have been intellectually indolent, morally suspect, and therapeutically reckless. That they have chosen to create so many new categories of mental illness, the absurdities in the latest DSM V being a prominent example, is a failure on their part to stand up and declare: Enough! We spend too much time treating people who do not have genuine psychiatric disorders but rather are too lonely or too narcissistic or have completely unrealistic expectations of life. We have too many genuinely mentally ill patients that need much more attention than we can provide because we must waste so much time treating people who would be better off "getting a life" than expecting us to attend to their petty complaints about their inadequacies to deal with the travails of life. 


We must start putting scientists, executives, directors, psychiatrists, and those in regulatory authorities in jail.

Fines are not enough. Over recent years there have been high profile legal cases clearly demonstrating that intellectual fraud, outright dishonesty, and resultant patient harm has caused tremendous damage to individuals and created enormous costs to society. Big Pharma has been caught out time and again telling Big Lies for the sake of Big Bucks. Inexcusable. Where corporations have been found guilty of misconduct the relevant individuals across all levels of that corporation must be brought to trial. From the lab to the boardroom lock them up. If such individuals cannot be identified the government must sequester the intellectual property rights of the product in question and auction it off to the highest bidder with the funds in part being directed to the patients who were so sorely misled by these assholes. That or the relevant product becomes available as a generic product. 

What hasn't happened is the disbarring of psychiatrists who clearly have worked at the behest of Big Pharma and placed mammon before people, who have failed to declare conflicts of interest, who have aggressively promoted empirically bankrupt explanations of mental illness, who have continued to treat and exploit the most vulnerable members of our society as a means to their ends and so created a vast industry predicated on exploiting our deepest fears. Their hubris is sickening, their contempt for patients is sociopathic, they may hide behind their white coats but the evidence is clear: they have been grossly dishonest. I find it inconceivable that a psychiatrist with several years of training can honestly claim that they are remain unaware of the serious shortcomings not only in their treatments but in their facile, supercilious explanations concerning the etiology of mental illness. If they are that ignorant they should be writing Christmas cards not prescriptions. 

Mental health literally goes to the core of our being, the very substance of our soul, the things we hold most dear about ourselves. That so many people for so long have abused our trust, have manipulated public and professional opinion, have engaged in unalloyed lying and fraud to advance their own careers and in the pursuit of mammon is an indictment on the legal frameworks that are supposed to protect us from these sociopathic individuals. 

There must be no toleration of their pusillanimous pleas of ignorance because these are highly trained professionals with decades of experience. Ignorance is no excuse. They are obligated not to be ignorant, not to be swayed by stupidly contrived results, to reveal all the relevant data, to act in the best interests of patients and society, to be constantly in search of new therapies and new avenues of theoretical development. They have failed not only to be good doctors and scientists but to be decent human beings. 

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