Spitzer established twenty-five committees charged with arriving at detailed descriptions of mental disorders. He chose scientifically inclined, and therefore anti-psychoanalytic, psychiatrists to sit on these committees. They were to be guided by data. The data, however, didn’t yet exist. Spitzer sat in on committee meetings and from the mass of psychiatric talk sifted argument and anecdote into the disorders to be included in the DSM-III. New disorders emerged to match the times: attention-deficit disorder which eventually became–together with the rise and rise of Ritalin, the drug which ‘treats’ the disorder in children–attention-deficit hyperactivity disorder (ADHD). The illnesses that characterize our fin-de-siècle took on their full amplitude: autism, anorexia nervosa, bulimia, panic disorders, post-traumatic stress disorder, anxiety disorder, obsessive-compulsive personality disorder–to name the ones, apart from depression, that have grown empires of sufferers.
Each of the DSM-III’s disorders came with a handy checklist of symptoms, and the warning that in order for patients to ‘qualify’ for the disorder (and the attendant insurance monies to pay for the treatment), doctors must make sure that at least a certain number of the listed items were present. For example, for a diagnosis of major depression in DSM-IV R, the patient must exhibit depressed mood over a two-week period, plus five of the following:
Feelings of overwhelming sadness or fear or the seeming inability to feel emotion (emptiness)
A decrease in the amount of interest or pleasure in all, or almost all, activities of the day, nearly every day
Changing appetite and marked weight gain or loss
Disturbed sleep patterns, such as loss of REM sleep, or excessive sleep (Hypersomnia)
Psychomotor agitation or retardation nearly every day
Fatigue, mental or physical, also loss of energy
Feelings of guilt, helplessness, hopelessness, anxiety, or fear
Trouble concentrating or making decisions or a generalized slowing and obtunding [medicalese for deadening] of cognition, including memory
Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide
Other symptoms sometimes reported include:
A decrease in self-esteem
Inattention to personal hygiene
Sensitivity to noise
Physical aches and pains, and the belief these may be signs of serious illness
Fear of ‘going mad’
Change in perception of time.
The checklist aspect of the DSM meant that the American Psychiatric Association now had a manual with a biomedical ‘viability’. The ‘reliability problem’ was solved. Or so they thought. When they spoke of a psychiatric illness, diagnosticians would now all be speaking about more or less the same thing. Patients, too, could recognize themselves, and indeed band together according to a classification, to form support groups–and, if it came to court cases, legally recognized ‘classes’. In its various editions–from the first Spitzer edition, DSM III in 1980, its revision in 1986 (DSM III-R), the new DSM IV in 1994 (by which time Spitzer’s aegis had passed to Allen Frances) and its next revision in 2000–the DSM has had a marked influence on psychiatry worldwide. Indeed, its global intentions are visible in its accompanying case books, which present cases complete with diagnoses from Africa to Latin America to Europe and back home again. The boon of the DSM is that psychiatry now has order in its disorders.
There are side-effects as well. The long, structured diagnostic history-taking interview the DSM puts into place for standard psychiatric practice has given the drug companies the capacity to assemble research populations sharing similar properties for clinical trials. These double blind randomized clinical trials are the standard for drug-testing across medicine. As a result, it is now easier to test psychiatric drugs, and arguably the procedure is more reliable, though statistical results can often fudge matters for all those less than expert in statistics, and this includes doctors. The controversy over Prozac and whether, as the British Medical Journal asserted, its manufacturer had concealed facts about suicide in the trials of the drug, is an example of the way in which results can be either fudged or massaged or overlooked–certainly, they may often not be unambiguous. The kind of advertising to doctors, let alone the public, that the pharmaceutical companies undertake may also confuse independent judgement, even where there is no particular corruption.
Then, too, the very existence of ‘reliable’ double blind trials demands competition from the talking treatments, who need to prove equal ‘reliability’. The diffuseness of psychoanalysis (which sets out to treat not symptoms but the underlying life) and many other psychotherapies has made the kind of hard evidence that governments and insurers want difficult to extract–though some studies have been done to prove that expense and working hours saved, for example, are not so different in medicalized and talking therapies. For these purposes cognitive behavioural therapy (CBT) is most often the talking treatment of insurers’ and welfare-providers’ choice.
DIAGNOSES AND TREATMENTS: A DOUBLE ACT
CBT in part grew out of the psychological side of the psy professions in America–those which traditionally dealt with standardized testing of children and adults along the ‘normal/abnormal’ divide, or personality tests to serve army and industry, most prevalently along lines developed by Eysenck from an originally Jungian provenance–extroversion or introversion. Fun as parlour games, less so for job applicants, these tests are also serious and supposedly ‘scientific’ business, gathering data on which to build statistics and then reapply them as norms. In Cult of Personality Annie Murphy Paul tells the story of some 2500 kinds of personality tests, which in the USA form a $400-million-a-year industry. One of the most popular tests worldwide is the Myers-Briggs Type Indicator (MBTI), which categorizes psychological types along axes of extroversion/introversion, intuition/sensing, thinking/feeling, judging/perceiving. Twenty minutes will give you a summary of your personality type in some combination of the above. Eighty-nine firms out of the Fortune 100 make use of the Myers-Briggs for hiring and promotion.
Aaron T. Beck, one of the founders of CBT and a longtime critic of the unreliability of psychiatric diagnosis in America during its psychoanalytic imperium, has a test named after him: the Beck’s Depression Inventory, or BDI. First published in 1961, the BDI was revised in 1996 as BDI-II. An objective multiple-choice questionnaire, it is intended to be filled out by the ‘patient’ in the presence of a clinician, who then scores it–in the manner of newspaper quizzes. Above a certain score, the indications are that you need professional help, most likely a course of CBT, plus an SSRI. The questions ask the test-taker to indicate among the four states in each grouping which best describes how she has been feeling during the past few days. The first group runs:
0 I do not feel sad.
1 I feel sad.
2 I am sad all the time and I can’t snap out of it.
3 I am so sad or unhappy that I can’t stand it.
Other questions query the subject’s view of herself as a failure, her guilt, her suicidal thoughts, her irritation, her interest in others, her decision-making, her sleep patterns, appetite, tiredness, weight, interest in sex, and so on. A score of 1 to 10 indicates normal ups and downs; 11–16, a mild mood disturbance; 17–20, borderline clinical depression; 21–30 moderate depression, which goes to severe and extreme at over 40.
There is a kind of challenge, indeed inevitability, for a score of depression to result. We all want to do well, after all. And if a person is taking a test for depression, then there is already the suspicion of a problem. But what young person doesn’t feel depressed?–particularly perhaps after a week of student exams, or a split with a boyfriend, even after a little use of recreational drugs and forgetting to eat; let alone the constant flow of pop songs chanting the emptiness of life, the nowhere we inhabit, the soul assassins, the cavalcade of clowns, the yawning abyss, the
sanity whose upkeep is a full-time job–all to hypnotic rhythms booming in on the inner ear. A sense of hopelessness, a teenage irritability, may be a phase, even if one that lasts several years.
One of the effects of such tools as the Beck’s Depression Inventory and the DSM’s chartable diagnoses is that they can produce the very results they are looking for. Easily replicable not only as tests but as illness behaviours, they bubble on to the Web and into general circulation, spreading the very disorders they were intended to cure. The world of the emotions and the imagination is always open to suggestion and it’s a simple business to tick off a list of ailments for oneself and a group to which one belongs. As a way of assessing personality and its supposed aberrations, the recipe approach, which reduces the complexities of mind and experience, can have an insidious aspect.
Take the recent ‘Teen Screen program’ emanating from highly respectable Columbia University. This has been unfurled in some four hundred communities across the USA. It sets out to screen youths between the ages of eleven and eighteen for the ‘likelihood’ that they may be prone to depression or constitute a suicide risk. In some ten minutes or so, the youths fill out a fourteen-item self-completion questionnaire, which asks them about ‘depression, suicidal ideation and attempts, anxiety, alcohol and drug use, and general health problems’. Teen Screen also provides a general-purpose fifty-two-item computerized interview that can be administered and scored by trained non-professionals. This indicates the likelihood of a youth having a significant mental health problem.
The young are offered Big Macs and various incentives to fill out the forms. Although Columbia has emphatically denied any link with finances from Big Pharma in the running of the project, there is an inevitable down-the-line feeding of the mental health industry in such predictive work. The good intention may be to ‘catch them early’. The result may well be that ‘in making mental health a priority’ and ‘offering all youth an opportunity for voluntary screening’, more learn the brackets and language into which they can wedge their often inchoate feelings. These are then arranged into today’s fashionable diagnoses: panic disorder, social phobia, generalized anxiety, social anxiety disorder, for which Paxil has been widely sold. The programme may indeed also have helped edge the common teenage ‘social anxiety’ into the category of illness. Other oft-diagnosed conditions, now that medication exists to better them, include OCD with its ritualization of common anxieties (Do I have bad breath? Did I brush my teeth? Did I turn off the iron, lights, cooker?) and, of course, depression–which, it is hardly astonishing to hear, can be treated with antidepressants and quick courses of CBT.
Outside the mental health world, it comes as no surprise that most young people at some time or another are anxious, harbour suicidal thoughts or behave, feel, or fantasize in ways which form-ticking professionals may find aberrant; though when out of their own bureaucratic straitjackets, they may have listened to the same songs, gone to the same websites, taken the same ‘recreational’ drugs and felt the same tug of anomie after the fall from rapture. Teen Screen sounds like yet another formula for medicalizing and then somehow getting rid of adolescence itself by naming it ‘disordered’. Indeed, one study has shown that three brisk thirty-minute walks each week have greater effects on reducing depression than drugs from the Prozac family. Out of 156 subjects monitored by Duke University, only eight following this regime saw their depression return. Perhaps Teen Screen might ease more depression and suicidal thoughts if it were transmuted into a ‘build up Teen Steam’.
Clearly, locating a mental illness or a disorder in people will create a demand for an ever-expanding range of treatments and drugs that can contain or ameliorate the illness. Simultaneously the very existence of a Big Pharma drug can help to name a condition. Elizabeth Wurtzel writes that from the start her psychiatrist, although she had never specifically said so in the course of a therapy which began with pronounced suicidal conduct, had suspected Wurtzel’s cache of feelings and behaviours fell into the category of ‘atypical depression’. But there had been no reason to ‘name’ her condition unless a medication were to be prescribed. When Fluoxetine appeared on the market and was said by many doctors, including famously Peter Kramer in his Listening to Prozac, to make patients with just such life symptoms ‘better than well’, it made sense for her psychiatrist to offer a diagnosis.
It seems oddly illogical. Rather than defining my disease as a way to lead us to Fluoxetine [Prozac], the invention of this drug has brought us to my disease. Which seems backward, but is a typical course of events in psychiatry–that the discovery of a drug to treat, say, schizophrenia, will tend to result in many more patients being diagnosed as schizophrenics.
Writing in 1999 some six years after the first appearance of her book, Wurtzel noted how much had changed in the mental health world since her initial diagnosis. The psychiatrist who had first put her on Prozac now ran a mentalhealth clinic in California where no long-term therapy or counselling of the kind Wurtzel herself had had was on offer. Instead, a great deal of prescription-writing was taking place. The psychiatrist felt that this way, instead of a very few people getting a lot of help, many got some. Then, too, the exhaustion of talk therapy with suicidal patients was averted and she at long last had the ‘emotional wherewithal’ to deal with her family. Wurtzel concludes: ‘It is not just patients who are desperate for whatever relief Prozac can provide–doctors too are overwhelmed; the needs that their deracinated, unstable and alienated clients bring to therapy in an age of divorce are almost too much to be handled without non-human intervention.’
It’s said that between its introduction in 1988 and Eli Lilley’s loss of the patent, Prozac was prescribed to over thirty-five million people worldwide. In 1999 one million children in the USA were reported to be taking antidepressants, including mint-flavoured Prozac. In 2000 alone, Prozac earned its parent company $2.6 billion. Eli Lilley are hardly alone in the antidepressant bonanza. Promotional budgets for the large pharmaceutical companies continue to be huge, larger than the amount spent on research and development.
Now that the risk of suicide for those under nineteen on antidepressants has been found to be twice as likely as for those who are unmedicated (and those on antidepressants are fifteen times as likely to complete the act), wholesale prescribing of antidepressants to the young has slightly fallen off. The size of the depression problem has not, and for most, antidepressants continue to be both prescribed and desired. As for therapy, CBT remains the recommended insurable and efficacious accompanying treatment. In Britain, the Layard report noted that there weren’t enough trained therapists to meet demand. Luckily, in case none of the preferred CBT therapists are available, there is now a computerized CBT package available for depression: you can engage in ‘Beating the Blues’ on your very own computer screen…which may have given you the depression in the first place.
One of the difficulties of the cognitive therapies is an underlying assumption that people are rational beings always and ever capable of self-assessment, without any self-deception, and that a good dose of problem-solving pep talks and strategies for getting rid of ‘negative thoughts’ will sort things. It may, and it’s always good to learn a little more about the self, but the promise of happiness and a short-term fix may be far more than can always be delivered. Patients usually re-engage with CBT after a first round; and after a second. Many also find a need to stay on their antidepressant, the habit of which is difficult to beat. Coming off can be a slow process, not always achievable.
Even if help is what one wants when vulnerable or depressed, in evaluating the way in which the marketing of diagnoses and therapies can spread the disorder itself, it is well worth remembering that many of the most common depressions will disappear after some eight months on their own and without treatment. The Royal College of Psychiatrists affirms this on its website. Nor, in the usual British and understated fashion, do they recommend seeing a psychiatrist for depression, when a GP for prescriptions and a co
urse of talk therapy will do. One would be hard put to find similar recommendations in a fee-paying mental health economy.
As for antidepressants, the Royal College spells out the odds. All trials have shown that 24–35 per cent of people will get better with a placebo after three months; whereas of the 50–65 per cent who improve with drug treatment in that time, some of that benefit, too, is due to the placebo effect. Care helps, it seems, as long as it is well intentioned. And placebos produce fewer side-effects, such as that radical decrease in sexual desire associated with SSRIs. Since the World Health Organization reckons that 33 per cent of diseases today are caused by medical treatment–that is, are iatrogenic, or doctor-induced–it may be safest to have less drug-related care, particularly after the exposure of some of the hidden aspects of the Big Pharma drug trials and the fiddling that creates our ‘safe drugs’.
THE CHEMICAL SOCIETY
One of the difficulties of our chemical society is that the leap from illicit recreational drugs to what Peter D. Kramer aptly dubbed ‘cosmetic psychopharmacology’ is just a hop across the street. Not only are the patterns of taking drugs to alter moods well established on both sides of the road, but it’s sometimes hard to tell whether having taken one kind may in fact help to bring on the mood swings and the underlying depression which lead to taking the other; or whether an underlying neural proclivity to depression of the atypical or cyclical variety makes individuals more likely to seek out and be sensitive to the effects of street drugs, so that in taking them they are effectively self-prescribing, as doctors may do for them later on. The traffic between street and prescription drugs is rarely one-way. The SSRIs are, after all, mood enhancers, just as many of the street drugs are. Though hypotheses of how they work and why they work on some and not others are rife, no scientists have produced conclusions that have lasted more than a few years. Meanwhile, Big Pharma is now researching one of Britain’s favourite club drugs, ketamine, initially used to dope horses, for its medical potential.
Mad, Bad, and Sad: A History of Women and the Mind Doctors Page 56