The Architects of Misery

With a new review from the University of Southampton urging clinicians to be mindful of the link between prescribed antidepressants and increased risk of Type 2 diabetes, it may be time to persuade psychiatry to seek a ‘check up from the neck up’.

Let me begin by stating that I do not wish to overplay the relevance of this latest study (people taking antidepressant medication often put on weight thereby increasing risk of developing diabetes while antidepressants themselves may yet be shown to be interfering with blood glucose control), but given our increasing over-reliance on antidepressants – 46.7 million scripts for antidepressants were written in the UK in 2011 – the report’s key findings merit careful consideration.

In the US, the increase in antidepressant use is startling. 1 in 10 Americans are now prescribed antidepressant medication. This number leaps to 1 in 4 among women in their 40’s and 50’s.

Such an increase is not a new phenomenon, albeit it’s growth may now be considered exponential. A study of 233,144 adult patient records who made doctor appointments between 1996 and 2007 discovered that the percentage of prescriptions written by non-psychiatrists had more than doubled over the twelve year period, and included close to ten thousand prescriptions for antidepressants given to patients without any diagnosis of depression being present. 

Coupled with these findings, we see a marked increase in the use of antidepressants to treat a far wider range of symptoms such as bulimia, panic disorder, generalised anxiety disorder, social anxiety and those conditions considered either to be components of the ‘affective spectrum disorder’ or members of the group known as ‘functional somatic syndromes’ among others.

The insidious expansion of antidepressants as a ‘silver bullet’ to be fired indiscriminately and at will is all the more alarming given that antidepressants have been shown to be shockingly ineffective when it comes to treating depression.

Study after study reveals antidepressants to be no more effective than placebos in all cases other than the most severe conditions of depression. The only reason for the continued approval of new antidepressants by regulatory bodies is that negative tests are not taken into account before approving any new drug.

In fact, only two clinical trials, requiring nothing more than demonstration of effectiveness marginally greater than that of a placebo are needed to gain approval from both the Food and Drugs Administration (FDA) and the Medicines and Healthcare Regulatory Agency (MHRA). This remains the case even if fifteen negative trials provide different results entirely. All negative trials are simply ignored. Even the basis upon which a trial may be classed as positive is less than the standard required by serious scientific study, needing only to demonstrate a one or two point improvement on the Hamilton Scale, where three would normally be required.

An increase as slight as a one or two point increase could be equally attributable to a good night’s sleep, an hour listening to Sam Cooke, or sitting down and popping bubble wrap for five minutes.

So what is responsible for the current upsurge in antidepressant prescription?

The moral wasteland that is the pharmaceutical industry is a key driver, despite it’s protestations to the contrary but allow me to introduce you to the DSM. Or DSM-5, as it is known in it’s current incarnation.

The DSM, or the Diagnostic and Statistical Manual of Mental Disorders was ostensibly, an attempt to standardise the symptoms characteristic of any given mental illness but served first and foremost as an attempt to shield psychiatry from the considerable backlash it experienced in the early 1950’s.

The public perception of psychiatry’s benefits was further eroded twenty years later by an astonishing experiment conducted by Dr. David Rosenhan and a group of eight volunteers. Rosenhan’s team set out individually, arriving at psychiatric hospitals across America with the claim that they heard a voice repeating the word ‘thud’ over and over. They were to respond truthfully to all other questions, and behave entirely normally in all other aspects. Each member of the team was immediately admitted, heavily medicated and diagnosed with severe mental health problems.

The experimenters had naively assumed that they would be held for only a matter of days before they were able to convince their captors of their sanity and be released to reveal their findings. All the experimenters however, were held for weeks and in some cases months. Their attempts to persuade doctors that they were sane fell on deaf ears and their supplications that they were conducting an experiment on the state of psychiatry in America only served to convince those responsible for their care of their madness. Eventually, the only solution left to them was to pretend they were insane and then pretend to get better. When they did finally get out, there was understandable uproar.

When one major hospital challenged Rosenhan to repeat the experiment, confident that they would spot any impostor sent their way, Rosenhan agreed. A month later, after the hospital proudly declared they had spotted 41 fakes Rosenhan revealed he had not sent anybody.

Psychiatry’s inferiority complex may have been the catalyst for the resultant DSM but it’s problems are more deep seated than that alone. Setting aside the organic disorders (epilepsy, Alzheimer’s and Huntington’s), psychiatric disorders have no objective biological cause. Psychiatry then, is based solely on that flimsiest of foundations, consensus.

The problem with consensus is that it offers nothing by way of proof. Consensus is no indication of existence (see Virgin Birth, transubstantiation), and more often than not, consensus comes about through the oppression of one or more dissenting voice in deference to the most indomitable opinion. The publication of the DSM is overseen and undertaken by a DSM task force, usually consisting of twelve or so individuals who sit around a table and argue over definitions until consensus is agreed or will is broken, whichever comes first.

By way of illustration as to the dangers inherent in consensus…

In DSM-II, homosexuality was listed as sexual deviation and placed in same category as ‘paedophilia’. In 1973, the APA (American Psychiatric Association) asked all attending members at an APA convention to vote on whether to remove homosexuality from DSM-III. 5, 854 voted to remove it while an incredible 3,810 voted to retain it.

The current edition of the DSM – while considerably more enlightened than some of it’s predecessors – is fundamentally as flawed. Please follow dx revision watch or read the superb post by Suzy Chapman here. Ms Chapman, in a devastating analysis warns against the lumping of what once were classed as Somatoform disorders under the new catch-all category of Somatic Symptom Disorder (SSD), arguing that by doing so, millions more patients could soon find themselves stigmatised by a mental health diagnosis.

Under the latest revision, Ms. Chapman writes,

a person will meet the criteria for SSD by reporting just one bodily symptom that is distressing and/or disruptive to daily life and having just one of the following three reactions to it that persist for at least six months: 1) ‘disproportionate’ thoughts about the seriousness of their symptom(s); or 2) a high level of anxiety about their health; or, 3) devoting excessive time and energy to symptoms or health concerns.

Chapman goes on to point out that field trials conducted by the DSM-5 Somatic Symptom Disorders Working Group showed ‘one in six cancer and coronary disease patients met the criteria for DSM-5 ‘Somatic Symptom Disorder.’ Further field trials revealed that ‘more than one in four of the irritable bowel and chronic widespread pain patients who comprised the ‘functional somatic’ study group were coded for ‘Somatic Symptom Disorder”.

The additional stress of being stigmatised with a mental health disorder to someone undergoing treatment for cancer brings the inherent failings of the DSM into keen focus.

James Davies’ essential book, ‘Cracked: Why Psychiatry is Doing More Harm Than Good‘, quotes Paula J. Caplan as she compares mental disorders to constellations. There can be no more beautiful and perfect analogy for the DSM. Man’s attempt to find patterns in often unrelated meaninglessness.

The DSM task force do not discover disorders. They create them.

Rather than uncovering new insights and growing our understanding of ourselves, the DSM task force have become architects of misery, serving only to placate the insatiable avarice of a handful of pharmaceutical conglomerates. It is the medicalisation of society and of the human condition. Where our grief, our anxiety, our fears, our joy and our despair are medicalised by the consensus of the few to the absolute detriment of the masses.

Andrew S. Loveland’s, ‘The Sound of Abundance of Rain’, can be purchased from the Kindle store here.

  1. Nance said:

    What an amazing blog.. So true

  2. I am one of the few women I know in my age group — yes, the most prescribed group — who is not on anti-depressants.

    Love the cartoon.

    Thanks for the follow. Nice to meet you!

  3. Congratulations on a great post.
    I do suffer from a major depressive disorder and anxiety disorder, but am NOT a fan of the DSM model of psychiatry, for precisely the reasons you have outlined above. As you point out, the analogy or model of biological disease simply does not translate well to mental unwell-ness; it just doesn’t work. Furthermore, even the definitions of certain mental health conditions in DSM-IV-tr are so contradictory as to be laughable. Take these two parts of the diagnostic criteria for a major depressive episode:
    * Insomnia or hypersomnia nearly every day
    * Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day
    Hmmmm … so I, who sleep ‘too much’ when majorly depressed and put on weight rapidly, am given the same label as another person who cannot sleep and loses their appetite. WT?
    My personal opinion is that psychiatric disorders, to be meaningful, would need to acknowledge the etiology of the condition – but that would be a violation of patients’ rights to privacy, so could not be done.
    Last words? When you’re dealing with viral or bacterial infections, you’re dealing with pathogens entering the human body. When you’re dealing with non-organic mental illness, you’re dealing with a person. There’s an ocean of difference between the two.

    • Thank you for taking the time to read the article and leave your comments. I agree wholeheartedly with the points you raise. An ocean is correct. Unfortunately, the psychiatric community are attempting to cross it in a two person dinghy.

      • There are some who are making good headway, I believe: those who are trained in traditional psychiatry but practice as psychotherapists. Foot in two camps; I like that.

  4. SSRIs and so-called antipsychotics are just another part of the whole DSM scam. Neither category of drug ever worked…or had any reason to. There was never any proof, and much to the contrary, or altered serotonin or dopamine levels in depression or psychosis. Yet that dastardly myth persists of the Chemical imbalance…and so many buy it. Why? Because they want to! They WANT to believe that all they need to do is take a pill and all their problems will go away. God forbid it take any work or hard thinking on anyone’s part…at least here in the U.S. We suffer from a national laziness i feel and a resistance to doing anything difficult…argh…i could go on and on. Including a diatribe on the dsm authors and their financial ties to the big pharma companies. But instead I want to thank you for your wonderful blog and assure you that i intend to follow it. Thanks for visiting mine. Glad you found it!

  5. As someone in the field, the one thing I’ll say in “defense” of the DSM is that the diagnoses are, within our current (stupid) system, useful for *billing.* (Though, really, we tend to use the ICD- same basic concept though.) I could go on and on about all the things I *dislike* about the DSM and psychiatry- and about the little bits of good and genuine utility here and there, as well (and believe me, there *are* psychiatrists who do genuinely care, and unfortunately there *are* people who are genuinely mentally ill and who don’t seem to be able to keep it together without intervention)- but won’t launch into that. Instead, 2 further comments:

    1. It’s interesting to consider how much of a link there may or may not be between the uptick in obesity, and the uptick in use of medications that cause weight gain, like antidepressants.
    2. Recommended reading, if you haven’t already: Creating Mental Illness, by Horwitz. It was required reading in one of the classes for my Master’s, and with good reason.

  6. admindxrw said:

    Thank you, Andrew, for the link to my SSD commentary and for your kind words.

    As you might be aware, ‘Somatic symptom disorder’ and ‘Illness anxiety disorder’ are destined for insertion into the U.S.’s forthcoming ICD-10-CM – unless NCHS rejects the proposals submitted in September. I was amongst those who have put in public submissions in opposition to this move.

    A new construct proposed to be called ‘Bodily distress disorder’ with SSD-like characteristics is being developed for potential inclusion within ICD-11, to subsume and replace seven of the existing ICD-10 ‘Somatoform disorders’ categories.

    In this recent post, here, on Dx Revision Watch:

    I have noted that APA slipped another codable diagnosis into DSM-5 before going to press. Between closure of the third DSM-5 draft review and publication of the final code sets, a “Brief somatic symptom disorder,” where duration of symptoms is less than 6 months, was added under new category, “Other specified Somatic Symptom and Related Disorder.” [DSM-5, Page 327]. This “Other specified” category can be used for symptom presentations that do not meet the full criteria for any of the disorders in the Somatic symptom and related disorders diagnostic class.

    This means that as little as a single, distressing physical symptom plus just one psychobehavioural symptom from the Somatic symptom disorder “B type” criteria with a duration of less than 6 months would meet criteria for a codable mental disorder.

    A “Brief illness anxiety disorder” diagnosis for less than 6 months chronicity has also been inserted under this code – neither of which were in the third draft.

    With regard to medication for the so-called ‘Somatoform disorders’ and so-called ‘Functional somatic syndromes’ you might be interested in this chapter preview – the link for which is at the end of post

    Polypharmacy in Psychiatry Practice, Volume I: Multiple Medication Use Strategies, Ritsner, Michael S (Ed.) 2013

    Chapter 11: Multiple Medication Use in Somatic Symptom Disorders: From Augmentation to Diminution Strategies

    Most of Chapter 11, Pages 243-254 (pp 247-249 omitted) can be previewed on Google Books.


    PS I see you are using WP Enterprise Theme. Good choice :o)

    Suzy Chapman
    Dx Revision Watch

  7. Yuri said:

    I was told I might have BED and to be honest, it hepeld me come to the realisation that I had to do something to help myself. It made it ok to act as I did, because it wasn’t my fault it was the disorder. As soon as I accepted that, it was a lot easier to accept everything else as well. Now, talking to dieticians, etc, I can say that I (mostly) eat when I’m hungry, eat at a table, acknowledge that I am eating, eat things I like in moderation ..I agree it’s not helpful to everyone to think it’s a disease, but I was able to look at it in the framework that if I had a broken leg, I would do certain things to ensure it got better why then would I not do the same with my disordered eating, which has a least as much, if not more, impact on my general health and well being.It hepeld me might not help others. I agree with the point about the US healthcare that will be beneficial to people, as long as they don’t say that losing weight cures BED as well!!

Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

%d bloggers like this: