The wonders of placebo response arise from a number of different causes—sometimes independent, sometimes interacting. Most important perhaps is “tincture of time.” Time may not always be the best healer and it certainly doesn’t heal all wounds, but it always has been and still is the most efficient and safest way to deal with many of life’s physical and psychological problems. Time heals so well because many of our ills are short-term, situational, and self-limited—our bodies and our minds are programmed to be resilient without any active effort on our part.
Next comes the enormous power of hope and expectation. People get better if they believe in a treatment and have full confidence that it will help them get better—however irrelevant or even dangerous it may be. Life has always been painful and perilous. The power of positive thinking is part of our psychology because it has conferred such a strong selective advantage on those fortunate enough to have it. Perhaps the swift had the early edge in the evolutionary race, but it was the enduring who made it to the finish line—and survived to become our ancestors. Being able to overcome the discouragements and disadvantages of illness by responding well to fake medicine was a sure path to evolutionary success.
Brain imaging proves that the placebo effect has strong biological as well as psychological roots. My favorite example comes from wine tasting, not medicine. It has long been known that people routinely rate a wine as much better if they are told it costs ninety dollars a bottle, rather than ten dollars. This proves how suggestible we are. But brain imaging tells us something even more fascinating and fundamental about human nature. Your brain’s pleasure centers actually light up more when you think you are drinking the costlier wine, even if you’re not. Expectation isn’t all of experience, but it certainly does shape a goodly portion of it. Similarly, placebo pain pills dampen the brain’s response to painful stimuli; placebo antidepressants mimic the brain effects of real antidepressants; placebo Parkinson’s pills stimulate the brain’s dopamine system; placebo diabetes pills affect blood sugar; placebo caffeine and Ritalin have a stimulating impact on brain centers; and placebos profoundly affect the immune system. Placebo response is an important part of our reaction to everything. And it is very deeply built into the way our brains work—animals are also terrific placebo responders.
The social factor is also important—being a placebo responder helps maintain key relationships and supports precious communal rituals. We are highly social animals who function well only as part of a group and who threaten the group’s welfare when we are not functioning well. The medicine man and his patients have always shared the need to believe in the healing power of the currently fashionable theories, rituals, chants, incantations, diagnostic and testing procedures, and medicines. Even if it had no specific value, a healing ritual offers the great promise of ridding the individual of his illness and the group of the sicknesses in its individuals. Responding well to placebo is essential to remaining a valued member of the group—which made it less likely you would be left behind as too sick when everyone broke camp. And being able to enlist the confidence and hope of the sick patient has always been and still is the most essential skill in a great shaman or a great modern doctor. The technical skills of medicine are becoming increasingly routine and may soon be done better by computer programs—but the shamanic skills of medicine will always be important to patients and to society.
Modern drug companies have made big bucks capitalizing on the power and ubiquity of the placebo response. The best way to get great results with a pill is to treat people who don’t really need it—the highest placebo response rates occur in those who would get better naturally and on their own.38,39 The really brilliant marketing trick was to persuade doctors to treat patients who weren’t really sick, while at the same time convincing normal people that they were really sick. Expanding market share to include the worried well not only greatly enhanced the customer pool, but it also ensured the most satisfied of customers. Placebo responders often become long-term loyalists to medication use even when the medication is perfectly useless, both because they have no way of knowing it played no role in their getting better and because they are often untroubled by side effects—a cunning combination that creates the dream customer base for drug companies and their shareholders.
In surveys, most doctors admit to sometimes using relatively inoffensive pills as placebos—a way of giving the patient something tangible on the way out the door.40 If the prescribing of placebos was ever accepted as ethical practice, they would undoubtedly rise to the very top of the sales charts. To paraphrase Voltaire, the art of medicine sometimes consists in amusing the patient while nature cures the disease.
In veiled form, placebos are already the great, if unrecognized, success story of drug company marketing. A good deal of medication use in psychiatry (and in medicine) is based on the tried-and-true leveraging of the placebo effect. There are only two differences between now and shaman times or medieval alchemy. First, the marketing of what are essentially expensive placebo products has become well-oiled, massively financed, worldwide, and devastatingly effective. Second, you now need to have a DSM diagnosis to get a prescription for an expensive pill that often has no more usefulness than would a placebo—a great boost to diagnostic inflation. And the crowning irony is that, like wine tasting, it may be that the higher the price, the more effective the otherwise useless pill. How great for the drug companies.
Two brilliant marketing successes illustrate the financial as well as healing, power of placebo. Almost three fourths of the 11 percent of the U.S. population now taking antidepressant drugs have no current symptoms of depression.41 Some of these people would soon get quite sick again were they to stop the pills—they need them as prophylactic protection against the return of a chronic or recurring depression. But many loyal customers are unwitting placebo responders who got well spontaneously (but don’t know it) and are afraid to rock the boat. A significant portion of the $12 billion spent each year on antidepressants in the United States rewards the drug companies for promoting the overly widespread use of what to many patients are no more than highly advertised, oversold, and very expensive placebos prescribed for a fake diagnosis.
And here’s another case in point—the strange success story of Buspar, how it became one of the surprise best-selling drugs of all time despite having little or no efficacy. When Buspar first came on the market, I told its drug company executive that it surely would be a huge flop because it didn’t work. He said nothing but smiled knowingly, probably because he understood something that was beyond my naive comprehension. The seeming great disadvantage of having little (if any) efficacy against anxiety was more than counterbalanced by Buspar’s also having almost no side effects. Being the perfect, easy-to-use, and expensive placebo was just the right prescription for bringing in huge profits.
Let’s do an interesting thought experiment. Suppose we could eliminate the magic of placebo response, or at least reduce through education its impact on patient behavior. The immediate effects would be both bad and good—dramatically reduced perceived efficacy of many medicines, but also dramatically reduced unnecessary diagnosis and treatment. Of course, this thought experiment will never become real—magical thinking is too much a necessary and useful part of human nature. But it would be nice if people could be more skeptical of drug company claims that the worries and miseries of everyday life are just a “chemical imbalance” that can be cured with a pill.
How Primary Care Took Over Much of Psychiatry
Primary care physicians (PCPs) now do most of the prescribing of psychiatric drugs: 90 percent of antianxiety drugs; 80 percent of antidepressants; 65 percent of stimulants; and 50 percent of antipsychotics.42 Pharma did the math—there are only forty thousand psychiatrists in the United States but about ten times as many PCPs. Why not recruit PCPs to write prescriptions for psychiatric drugs? The message to them was loud, clear, and heavily promoted—psychiatric disorders are often missed and easy to treat with a magic pil
l. This was clinical nonsense but marketing gold. The message went down easily because the new pills went down easily—with relatively few immediately troubling side effects for patients and uncomplicated directions for use by doctors. Who needs a psychiatrist when the medicine is so safe and easy to use? Insurance companies pitched in by preferring PCPs over psychiatrists because they were cheaper (at least in the short run), especially once they were squeezed by diminishing reimbursements into doing seven-minute visits.
Anywhere between 25 to 50 percent of patients seen in primary care present with at least some emotional distress as part of the reason for coming to the doctor.43 Most of the patients treated by PCPs have mild disorders—precisely the ones most likely to have a placebo response. Once recovered, the patient will usually misattribute his improvement to a medicine that did nothing and feel compelled to stay on it unnecessarily and for prolonged periods. This represents the perfect market opportunity—an army of patients primed by advertising to ask the doctor for a pill. And the doctor primed to respond promptly, since most of his education in psychiatry had come from the helpful drug company salesperson—who also happened to have a handy supply of free samples. Harried PCPs are underpaid and overworked, and have minimal training in psychiatry. Convenience sometimes trumps good care, and the quickest way for them to speed the patient out of the office is to reach for prescription pad or free sample. Psychiatric medications can do a lot of good when properly prescribed, but a lot of harm when handed out so casually and after such incomplete diagnostic evaluations.
The inevitable result has been diagnostic inflation and massively excessive medication use. It makes absolutely no sense to do most of our psychiatric diagnosis and treatment in primary care settings. Accurate diagnosis requires expertise and simply can’t be done properly in the seven minutes most PCPs now get to spend with patients—especially when the patients have been primed by false advertising to demand the wrong thing. Overprescription of psychotropic medication by PCPs has become a serious threat to public health, but has pushed Pharma revenue through the roof. There is almost never a justification for the use of antipsychotic and antianxiety medication in primary care, but it is done all the time.
The fault lays mostly with the system, not the doctor. Ideally primary care should be the valued linchpin central to all medical treatment; instead, our skewed specialist-happy care delivery has left it devalued and terribly underfunded. PCPs man the crucial entry point to the healing world and are forced to deal with the widest array of medical, surgical, and psychiatric problems—a very tall order indeed. Often the PCP is the caregiver with best overall and longest term familiarity with the patient and the one to whom the patient goes for the aches and pains of his life as well as his body. He is the health provider of first, and perhaps last, resort, as often the patient can’t afford specialty care or it may be unavailable.44 Some PCPs handle their role as “psychiatrists” beautifully, but many are dangerous amateurs who do more harm than good—especially when they arettt pressured by the misleading drug company marketing and are forced to shoot from the hip by insurance industry time constraints.
Bad Consequences of Diagnostic Inflation
Where Have All the Normals Gone?
In the early 1980s, about a third of Americans qualified for a lifetime diagnosis of mental disorder.45 Now about half do.46 And Europe is catching up fast at well over 40 percent.47 Some people think these are underestimates—more carefully done prospective studies actually double the lifetime prevalence. If you believe the results, our population is almost totally saturated with mental disorders. One study found that by age thirty-two, 50 percent of the general population had already qualified for an anxiety disorder; more than 40 percent for mood disorder; and more than 30 percent for substance dependence.48 And another study moved even closer to the proposition of almost ubiquitous sickness—by the tender age of twenty-one, more than 80 percent of young adults had already met criteria for a mental disorder.49 The trumpeting of inflated rates has fueled drug company claims that we are underdiagnosed and undertreated—keeping the vicious cycle spinning.
Evidence of diagnostic inflation is everywhere. There have been four explosive epidemics of mental disorder in the past fifteen years. Childhood bipolar disorder increased by a miraculous fortyfold50; autism by a whopping twentyfold51; attention deficit/hyperactivity has tripled52; and adult bipolar disorder doubled.53 Whenever rates skyrocket, some portion of the rise represents previously missed true cases—people who really need the diagnosis and the treatment that follows from it. But more accurate diagnosis can’t explain why so many people, especially kids, suddenly seem to be getting so sick.
The Glut of Drugs
Psychotropic drugs are now among the very top best sellers for the drug companies. Their stock prices would be cut by more than half were it not for the antipsychotics, antidepressants, stimulants, antianxiety agents, sleeping pills, and pain meds Each year, 300 million prescriptions are written for psychiatric drugs in the United States alone.54 At the very top of the Pharma hit parade are the antipsychotics at a resounding $18 billion a year. Antidepressants produce a hardy $12 billion a year, despite the fact that many are now off patent and sold in cheaper generic versions. Fifteen years ago, stimulants were a rounding error in drug company sales at a measly $50 million a year. Now with direct-to-consumer advertising and heavy marketing to doctors, sales have been juiced up to a hefty $8 billion a year.55 And because primary care doctors love to prescribe them, antianxiety agents are eighth in sales among drug classes—even though they probably do much more harm than good.
The biggest puzzle is the huge success of antipsychotic drugs. Despite their dangerous side effects and narrow indications, they are being given out like candy. Antipsychotics have proven usefulness only in treating the disabling symptoms of schizophrenia and bipolar disorder, but this has not stopped drug company seduction promoting their general use for anyone having trouble sleeping, or run-of-the-mill anxiety, or depression, or irritability, or eccentricity, or the temper tantrums of youth, or the crankiness of old age. More than 3 million Americans are already on board, with a (shareholder satisfying) growth rate of 20 percent a year. The number of prescriptions for antipsychotics has doubled in ten years, up to 54 million and counting. Off-label use has also doubled—undeterred by the big fines that don’t seem so big when you consider the ill-gotten gains they enable. How could this happen? Big bucks. An advertising budget of $2.4 billion per year spent on Abilify and Seroquel has catapulted these two very so-so and not-so-safe drugs to fifth and sixth place as revenue producers among all of the many medicines sold in America. The full court press on primary care doctors has them inappropriately prescribing an antipsychotic for 20 percent of all their anxiety disorder patients.56, 57, 58 This massive misuse of antipsychotics is crazy and shameful—a triumph of marketing might over common sense and good medical practice.
There is no way of knowing what should be the optimal level of prescription drug use in our society. Enthusiasts argue that the high rates of pill taking reflect the advances in psychiatric diagnosis and treatment—providing benefits heretofore unavailable to people previously ignored and in need. To some degree, this is true. But I have no doubt there has been a wild overshoot of false demand promoted by false drug company advertising, gullible doctors, careless prescribing habits, and the wholesale transfer of psychiatric diagnosis and treatment to untrained and harried primary care doctors. We have become a pill-popping society, and very often it is the wrong people who are popping the wrong pills as prescribed by the wrong doctors.
Its undue influence over medical practice is not Big Pharma’s fault; it is ours. A drug company does not begin life or maintain itself as a nonprofit or charitable entity chartered with the goal of promoting public health in the most efficient and effective way. Quite the opposite. A drug company is a multinational corporation whose main goals are profit, market share, and survival. In any conflict between shareholder greed and customer need, be
t on the shareholder. This is the predatory nature of the beast—it is not the tiger’s fault it is a carnivore. But it is our collective fault for allowing the drug companies free rein to prey on our weakness. Government, doctors, patients, the media, advocacy groups—all were largely bought off by drug company money and power. Drugs used well are a powerful tool of psychiatry and a godsend for the patients helped. But too often, drugs are used promiscuously in a way that approximates the quackish practice of medieval alchemists. Thomas Sydenham must have had in mind trigger-happy prescribers when he said: “The arrival of a good clown exercises a more beneficial influence upon the health of a town than twenty asses laden with drugs.”
Too Much Polypharmacy
It has become distressingly common for doctors to prescribe multiple psychotropic drugs, often in high and dangerous doses and without any rhyme or reason. It is no surprise that drugs prescribed by doctors now account for more emergency room visits for overdoses than do street drugs and are also increasingly responsible for accidental iatrogenic deaths.59 The interacting sedating side effects of the combination of narcotic pain medicine and psychotropic drugs can be especially deadly (a particular problem in the military).60
There are many tributaries to this surging river of polypharmacy. Sometimes it represents treatment creep—the previous drugs aren’t working very well so new ones keep getting added without ever sunsetting the ineffective ones. Sometimes it results from diagnostic creep—exuberance in making multiple diagnoses followed by enthusiasm in prescribing multiple medications. Sometimes the cause is doctor creep—a drug-seeking patient getting all the meds he can from different doctors blind to one another’s prescriptions. Then there is Pharma creep—aggressive marketing that encourages promiscuous prescription. And finally, there is the easy availability of diverted prescription drugs, which encourages polypharmacy by self-prescription—people who decide to add their friend’s stimulant or Xanax or narcotic pain medicine to their own often already bloated treatment regimen.
Saving Normal : An Insider's Revolt Against Out-of-control Psychiatric Diagnosis, Dsm-5, Big Pharma, and the Medicalization of Ordinary Life (9780062229274) Page 12