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Talking Back to Prozac

As for the frequently rocky initial weeks of treatment, a troubling record not just of “suicidality” but of actual suicides and homicides was accumulating in the early 1990s. The drug firms, Healy saw, were distancing themselves from such tragedies by blaming depression itself for major side effects. Handouts for doctors and patients urged them to persist in the face of early emotional turmoil that only proved, they were told, how vigorously the medicine was tackling the ailment. So, too, dependency symptoms during termination were said to be evidence that the long-stifled depression was now reemerging.

The most gripping portions of Let Them Eat Prozac narrate courtroom battles in which Big Pharma’s lawyers, parrying negligence suits by the bereaved, took this line of doubletalk to its limit by explaining SSRI-induced stabbings, shootings, and self-hangings by formerly peaceable individuals as manifestations of not-yet-subdued depression. As an expert witness for plaintiffs against SSRI makers in cases involving violent behavior, Healy emphasized that depressives don’t commit mayhem. But he also saw that his position would be strengthened if he could cite the results of a drug experiment on undepressed, certifiably normal volunteers. If some of them, too, showed grave disturbance after taking Pfizer’s Zoloft—and they did in Healy’s test, with long-term consequences that have left him remorseful as well as indignant—then depression was definitively ruled out as the culprit.

Healy suspected that SSRI makers had squirreled away their own awkward findings about drug-provoked derangement in healthy subjects, and he found such evidence after gaining access to Pfizer’s clinical trial data on Zoloft. In 2001, however, just when he had begun alerting academic audiences to his forthcoming inquiry, he was abruptly denied a professorship he had already accepted in a distinguished University of Toronto research institute supported by grants from Pfizer. The company hadn’t directly intervened; the academics themselves had decided that there was no place on the team for a Zoloft skeptic.

Undeterred, Healy kept exposing the drug attorneys’ leading sophistry, which was that a causal link to destructive behavior could be established only through extensive double-blind randomized trials—which, cynically, the firms had no intention of conducting. In any case, such experiments could have found at best a correlation, in a large anonymous group of subjects, between SSRI use and irrational acts; and the meaning of a correlation can be endlessly debated. In contrast, Healy’s own study had already isolated Zoloft as the direct source of his undepressed subjects’ ominous obsessions.

Thanks partly to Healy’s efforts, juries in negligence suits gradually learned to be suspicious of the “randomized trial” shell game. The plaintiffs’ lawyers in some of these cases cited his research. But this David doesn’t suppose that he has felled Goliath. As he explains, a decisive improvement in the legal climate surrounding SSRIs came only after Eli Lilly bought the marketing rights to a near relative of its own patent-lapsed Prozac. According to the new drug’s damning patent application, it was less likely than Prozac to induce “headaches, nervousness, anxiety, insomnia, inner restlessness…, suicidal thoughts and self mutilation” (emphasis added). That disclosure by Prozac’s own progenitor neatly illustrates Healy’s belief that the full truth about any drug will emerge only when the income it produces has fallen and its defects can be advantageously contrasted with the virtues of a successor product.

Meanwhile, Healy wonders, who will now be sufficiently strong and uncorrupted to keep the drug makers honest? The FDA, he notes, is timid, underfunded, and infiltrated by friends of industry; even the most respected medical journals hesitate to offend their pharmaceutical advertisers; professional conferences are little more than trade fairs; leading professors accept huge sums in return for serving the companies in various venal ways; and, most disgracefully of all, many of their “research” papers are now ghostwritten outright by company-hired hacks. As Healy puts it, Big Pharma doesn’t just bend the rules; it buys the rulebook.


There is, however, one rulebook that does place some constraint on what the drug makers can claim. This is the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM). Its four editions (plus interim revisions) thus far from 1952 through 1994 specify the psychological ailments that the whole mental health system has agreed to deem authentic. Although “condition branding” by publicists can make normal people feel like sufferers from a given malady, the malady itself must first be listed in the DSM in order for medical treatments to be approved.

Can we rely on this guidebook, then, for independent, objective judgment about the identification and treatment of mental complaints? The compilers of each edition have boasted that their named disorders rest mainly on research findings, and most physicians take that claim at face value, as do medical insurers, epidemiologists, and the funders of empirical studies. An acquaintance with the DSM‘s several versions and with the controversies that shaped them, however, suggests that they tell more about the shifting zeitgeist and the factions within the APA than they do about permanently valid syndromes.5

Human nature has not metamorphosed several times since 1952, but each DSM has included more disorders than the last. The third edition of 1980 alone, liberally subdividing earlier categories, purported to have unearthed 112 more of them than the second edition of 1968, and by the fourth edition of 1994 there were over 350, marked by such dubiously pathognomonic symptoms as feeling low, worrying, bearing grudges, and smoking. Those stigmata, furthermore, are presented in a user-friendly checklist form that awards equal value to each symptom within a disorder’s entry. In Bingo style, for example, a patient who fits five out of the nine listed criteria for depression is tagged with the disorder. It is little wonder, then, that drug makers’ advertisements now urge consumers to spot their own defectiveness through reprinted DSM checklists and then to demand correction via the designated pills.

It would be a bad mistake, however, to assume that the shapers of the DSM have been deliberately tilting the manual away from humane psychotherapy and toward biological and pharmaceutical reductionism of the sort exemplified by the serotonin-deficit theory of depression. That very assumption vitiates Christopher Lane’s conspiracy-minded book Shyness, which begins plausibly enough as an exposé of the campaign to have shy people view themselves as mentally ill. Unfortunately, Lane couples that theme with a histrionic dismissal of the DSM that is too uncomprehending and partisan to be taken seriously.

Lane is not a psychiatrist but a psychoanalytic literary critic who aligns himself with such empirically insouciant authorities as Jacques Lacan, Elisabeth Roudinesco, and Adam Phillips. Like many another Freudian, he is still in shock over DSM-III of 1980—the edition that consigned the “neuroses” to limbo, favored descriptive over depth-psychological accounts of disorders, and established the uniform symptom-tallying procedure for certifying a diagnosis.

For Lane, the very attempt to clarify disorders according to their detectable traits constituted a spiteful purging of “almost a century of [psychoanalytic] thought” and thus a reversion to “Victorian psychiatry.” He assumes that anyone who hesitates to endorse etiologies based on quarrels between the homuncular ego and superego must be hostile to all mental complexity and hence to psychotherapy in general. That is his charge against DSM-III and DSM-IV. In fact, however, the manual has never stated or implied a preference between talk therapy and pills. If it had done so, it could hardly have served as the consensual guidebook for such a heterogeneous organization as the APA.

In The Loss of Sadness Horwitz and Wakefield discuss the same 1980 change of direction by the DSM that leaves Christopher Lane fuming. As these authors show, the APA leadership’s intentions in the late 1970s had nothing to do with pushing drugs and everything to do with lending greater scientific respectability to the psychiatric field. What was wanted thenceforth for the DSM was improved validity and reliability, by virtue of identifying disorders more accurately and providing means of detection that would render several diagnoses of the same patient less divergent.

This remains the DSM‘s formal goal, however elusive, and it is plainly appropriate and irreversible. What we should really be asking is whether the DSM has approached that goal or merely gestured toward it through the false concreteness of checklists, implying that newly minted disorders are as sharply recognizable as diabetes and tuberculosis. As Horwitz and Wakefield put it, “the reliability might just represent everybody together getting the same wrong answer.”

Horwitz and Wakefield’s argumentation is as understated as Lane’s is melodramatic. Because these collaborators maintain a constructive, scholarly tone and display a total command of the pertinent literature, they will gain a respectful hearing from psychiatrists. Those readers will discover, however, that The Loss of Sadness amounts to a relentless dismantling of the DSM—one that seems confined at first to a single inadequacy, only to blossom into an exposure of the manual’s top-to-bottom arbitrariness. I am not sure, in fact, that the authors themselves understand the full gravity of the challenge they have posed for American psychiatry.

At the core of their book lies a demonstration that episodic sadness has always been a socially approved means of adjusting to misfortune and that much is lost, both medically and culturally, when it is misread as a depressive disorder. Yet as Robert L. Spitzer, the chief architect of DSM-III and Christopher Lane’s bête noire, concedes in a generous foreword, the manual has propagated that very blunder by failing to clarify the difference between environmentally prompted moods—those responding to stress or hardship—and dysfunctional states persisting long after the causes of stress have abated. In no sense, however, can that indictment be confined to just one disorder. The Loss of Sadness implies that nearly every nonpsychotic complaint is subject to overdiagnosis unless contextual factors—familial, cultural, relational, financial—are weighed in the balance.

As might be expected, then, Horwitz and Wakefield end by begging the compilers of DSM-V (now projected for 2012) to teach their colleagues the need for inquiry into each patient’s circumstances before concluding that they are faced with a bona fide disorder. The bar for authentic pathology must be set higher. If this is done, the authors declare, the DSM will be more scientifically respectable; its users, instead of regarding disadvantaged classes as infested with mental illness, will gain an appreciation of socioeconomic reasons for unhappiness; and a brake will be placed on the expensive middle-class hypochondria that the drug companies have so assiduously encouraged and exploited.

All of which would be wonderful, but the scenario is shadowed by Horwitz and Wakefield’s own shrewd analysis of the status quo and its beneficiaries. The DSM‘s laxity about winnowing vague discontents from real maladies is, in financial terms, highly functional for many of its practitioners and their patients. As the product of a guild whose members seek payment for treating whatever complaints are brought to them, the manual must be biased toward overmedicalizing so that both doctors and patients can be served under managed care. As Horwitz and Wakefield themselves observe:

The DSM provides flawed criteria…; the clinician, who cannot be faulted for applying officially sanctioned DSM diagnostic criteria, knowingly or unknowingly misclassifies some normal individuals as disordered; and these two errors lead to the patient receiving desired treatment for which the therapist is reimbursed.

What motive would the APA, as a practitioners’ union, have for bringing that arrangement to an end? And wouldn’t the drug makers, whose power to shape psychiatric opinion should never be discounted, add their weight on the side of continued diagnostic liberality?

Horwitz and Wakefield’s admirable concern for scientific rationality points us toward some uncomfortable insights about American psychiatry and its role within a far from rational health care system. That system is too cumbersome and too driven by profit considerations to meet the whole society’s medical needs; but citizens possessing full insurance, when they feel mentally troubled in any way, won’t be denied medication or therapy or both. Nothing more is required than some hypocrisy all around. As for psychiatry’s inability to settle on a discrete list of disorders that can remain impervious to fads and fashions, that is an embarrassment only to clear academic thinkers like these two authors. For bureaucratized psychological treatment, and for the pharmaceutical industry that is now deeply enmeshed in it, confusion has its uses and is likely to persist.


Branded By Pharma May 1, 2008

Prozac and Sexual Desire March 20, 2008

The Truth About Prozac: An Exchange February 14, 2008

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    See two important collaborative critiques by Herb Kutchins and Stuart A. Kirk: The Selling of DSM: The Rhetoric of Science in Psychiatry (Aldine de Gruyter, 1992) and Making Us Crazy: DSM: The Psychiatric Bible and the Creation of Mental Disorders (Free Press, 1997).

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