I am old enough to remember when psychiatry became biological psychiatry. I have lived long enough to witness the fading of the once lustrous biological psychiatry. I always wanted biological psychiatry to succeed since I have seen the suffering of many patients. Yet over time I have rejected its deceptions about chemical imbalances and its rigid ideology about biological causation.
I will structure this article as a discussion of recent article by Jerome Groopman, MD on “The Troubled History of Psychiatry,” published in the May 27 edition of The New Yorker. There have been several articles like this one in recent years, but this article stands out because he seems to have no biases about psychiatry, and he is a highly esteemed physician and writer who strives for balance. Yet I don’t share his conclusions.
He recognizes some failures of psychiatry, but at the same time minimizes betrayals that have become apparent by both psychiatry and the pharmaceutical industry. He levels bland criticisms that should more rightly be cries of outrage. He ends with the quaint notion that all will be well if we have enough good physicians who are pragmatic and empirical in their clinical practice.
How psychotropics work
Groopman’s article includes a mild acknowledgement that “no one has been able to produce definitive experimental proof establishing neurochemical imbalances as the pathogenesis of mental illness.” This, of course, has been the central claim by pharmaceutical companies and psychiatrists for decades. Prozac and other SSRIs ushered in an era of new generation antidepressants that treat effectively and with fewer side effects by targeting a chemical imbalance in the brain.
The chemical being balanced has changed from one antidepressant to another. Experts have tamped down any concerns about the many chemical imbalances being treated with the unverified claim that differences in the mechanism of action for the drug correspond to the many different sources of depression.
Groopman quotes the esteemed psychiatrist and former director of NIMH, Steven Hyman, as acknowledging that “no new drug targets or therapeutic mechanisms of real significance have been developed for more than four decades.” Groopman points out that some drugs seem to “work well for some people and not others,” but this simply leads him to invoke the familiar argument that prescribing is an art as well as a science.
It is important to remember that the FDA does not need any evidence for how a medication works. What is needed are two randomized clinical trials in which the drug is statistically more effective than a placebo. There is no consideration of how many studies have failed to show positive results, and the medication will be approved even if a larger number of studies could not produce positive results.
Are antidepressants working?
Groopman acknowledges that “clinical trials have stirred up intense controversy about whether antidepressants greatly outperform the placebo effect.” He does not explore this controversy in any detail and instead concludes that psychiatrists must recognize that people respond to medications differently and so prescribing is both art and science.
The literature on placebo effect does not offer this bromide, but rather challenges whether clinical studies fail to demonstrate a clinically meaningful benefit from the drugs being administered. Much of the recent debate is summarized in a brief 2018 article by Nassir Ghaemi, MD, MPH. I am not sufficiently trained in data analysis to weigh in on this debate, but I know enough to make a simple point. This is a major issue that needs attention at the highest levels of academia and the pharmaceutical industry. Instead, it is routinely swept under the rug as a minor dispute or one based on misunderstanding or bias.
The marketing machine
No other advanced country permits the marketing of medications directly to the public as we do in the U.S. It seems to me that this should be re-opened for debate. There may be good arguments on both sides of this issue, but direct marketing clearly drives up the use of medications in this country. The public should allow experts on both sides of this issue argue the pros and cons, and we should then either reaffirm current regulations or change them.
However, any debate in the marketing domain should be led by how pharmaceutical companies created champions in the medical community to promote their fantasies. We have no evidence after more than 60 years for the chemical imbalance theory, but researchers have been desperately searching for that evidence. I sadly remember reassuring patients and family members about the validity of the idea of chemical imbalance decades ago when I was in clinical practice.
We should be clear about an important fact. The chemical imbalance idea never had any evidence, and yet it was embraced as a strong marketing message many years ago. The idea has not really been rejected decades later by psychiatry or the pharmaceutical industry, despite a total lack of evidence. The most outrage that Groopman can muster on the topic is that we have no “definitive experimental proof.” In fact, we don’t have a shred of evidence after decades of claims by advertisers and experts.
How goes biological psychiatry?
Biological psychiatry is an embrace of dogma and ideology over good patient care. In this respect, Groopman and I are completely in synch. I want people that I care about to get access to genuinely effective psychotropics. I want clinicians to always be patient-centered rather than industry-centered. He wants this too. However, I believe that decades of deception need to be called out for what they have been, rather than glossed over as some innocent mistake.
Psychiatrists should be clinicians who embrace all effective solutions. What is the calling for being a biological psychiatrist? Is it the unfounded belief that biology will heal all mental health problems? Is it the comfort and success of a practice based on prescribing medication? I think it may be just a wrong turn in the history of psychiatry.
We need to consistently put science before marketing and clinical theories. We need to embrace all treatments found valid, whether they address our neurochemicals, our thoughts or the social determinants of health. I am not claiming expertise to resolve any of the issues I have raised. I am only asking that we openly discuss two things: 1) the historical failure of a biological model as the primary causation for behavioral health disorders, and 2) a robust evaluation and debate regarding the clinical efficacy of antidepressants in the treatment of depression.
Ed Jones, PhD, is senior vice president of the Institute for Health and Productivity Management.