Cathy's entry into a clinical trial on "The Big C" reminds me that we still need to talk about Marcia Angell's NYRB series on treating mental illness

It was a rough episode for both Paul (Oliver Platt) and Cathy (Laura Linney) last night on The Big C.

by Ken

I really loved last night's episode of The Big C, the fourth of the second season, which revolved around the arrival of the long-awaited day of Cathy's first treatment (for her otherwise-untreatable Stage IV melanoma) as part of a clinical drug trial. Probably I should be writing about that, but with all the importance the Jamisons attach to getting Cathy into Dr. Sherman's clinical trial, it has bothered me that so far no mention has been made of the number of people in that trial who are receiving a placebo rather than the drug(s) being tested; is it really possible to do drug trials without a double-blind control group>

Which in turn has reminded me that I still need to write about Marcia Angell's recent two-part series in the New York Review of Books: "The Epidemic of Mental Illness: Why?" (June 23) and "The Illusions of Psychiatry" (July 7).

Now trials for cancer treatment, I hope, at least, have more scientific basis than I now understand trials of drugs for treating mental illnesses to be. In the first part of her NYRB Angell notes:

Nowadays treatment by medical doctors nearly always means psychoactive drugs, that is, drugs that affect the mental state. In fact, most psychiatrists treat only with drugs, and refer patients to psychologists or social workers if they believe psychotherapy is also warranted. The shift from "talk therapy" to drugs as the dominant mode of treatment coincides with the emergence over the past four decades of the theory that mental illness is caused primarily by chemical imbalances in the brain that can be corrected by specific drugs.

In the second part of her article Angell relates the explosion of reliance on drugs for treating mental illness to a transformation in the practice of psychiatry -- based, she suggests, not on advances in the understanding of mental illness, but on a transformation in the market for mental health treatment:

When psychoactive drugs were first introduced, there was a brief period of optimism in the psychiatric profession, but by the 1970s, optimism gave way to a sense of threat. Serious side effects of the drugs were becoming apparent, and an antipsychiatry movement had taken root, as exemplified by the writings of Thomas Szasz and the movie One Flew Over the Cuckoo’s Nest. There was also growing competition for patients from psychologists and social workers. In addition, psychiatrists were plagued by internal divisions: some embraced the new biological model, some still clung to the Freudian model, and a few saw mental illness as an essentially sane response to an insane world. Moreover, within the larger medical profession, psychiatrists were regarded as something like poor relations; even with their new drugs, they were seen as less scientific than other specialists, and their income was generally lower.

In the late 1970s, the psychiatric profession struck back -- hard. As Robert Whitaker tells it in Anatomy of an Epidemic, the medical director of the American Psychiatric Association (APA), Melvin Sabshin, declared in 1977 that "a vigorous effort to remedicalize psychiatry should be strongly supported," and he launched an all-out media and public relations campaign to do exactly that. Psychiatry had a powerful weapon that its competitors lacked. Since psychiatrists must qualify as MDs, they have the legal authority to write prescriptions. By fully embracing the biological model of mental illness and the use of psychoactive drugs to treat it, psychiatry was able to relegate other mental health care providers to ancillary positions and also to identify itself as a scientific discipline along with the rest of the medical profession. Most important, by emphasizing drug treatment, psychiatry became the darling of the pharmaceutical industry, which soon made its gratitude tangible.

At the time, Angell writes, "The APA was then working on the third edition of the DSM [Diagnostic and Statistical Manual of Mental Disorders], which provides diagnostic criteria for all mental disorders." The DSM is now up to a heavily revised fourth edition, with the fifth famously in the works -- the whole psychiatric community seems to be involved, though actual control of content seems to be safely and securely in the control of eminent personages in the psychiatric industry (it does seem now to have developed into an "industry" rather than a "profession") who are business partners of the pharmaceutical industry, which has come to provide financial support for all aspects of the psychiatric industry.

To return to the first part of Angell's argument, concerning "the epidemic of mental illness and the drugs used to treat it," she takes a highly skeptical look at "the epidemic of mental illness and the drugs used to treat it." Really, you can't judge her argument on the basis of my high-points synopsis. If you believe, as I formerly did, that mental illness is a matter of brain chemistry, and chemistry that we have increasingly come to understand, then you need to read the article.

Some points that really stuck with me:

* There really doesn't seem to be much actual science behind these supposedly scientific claims. To the extent that they have won acceptance, it's largely based on the supposedly demonstrated efficacy of the new generations of brain-affecting drugs.

* But despite the scientific-sounding claims, the drug developers really don't know what their drugs are doing, and the drugs' "efficacy" is, plain and simple, unproved. Angell reminds us that in the development and testing stage drug manufacturers can do as many trials as they like, and then when it comes to submission to the FDA they can include only the trials they wish -- obviously the ones that seem to show drug success. But in cases where it has been possible to get access to all the trials, the success rate is little or even no better than that of the placebos, especially when the placebos are of the "active" variety, meaning that they do something.

* And this was a real eye-opener for me: Angell documents the belief of researchers who seem pretty credible that the determining effect in many drug trials, especially where the results affect the "mind" rather than actual physical symptoms, relate not to successful treatment of symptoms, which is all but impossible to measure, but to the drugs' having side effects. This sounds weird at first, but as Angell unfolds her argument, it makes sense. When patients are expecting, or hoping for, results, drugs that produce side effects give the patients a real physical sense that something is happening. Again, if this draws your attention, you need to read Angell's argument, in the June 23 article, rather than my synopsis.

Crucially, the drug enthusiasts' hypothetical "explanations" for the drugs' therapeutic workings have little or no basis in actual physiological understanding. Especially in the cases of the broad range of mental conditions that have been defined (one is tempted to say "invented") by the people who control the psychiatric definitions, the one thing that seems scientifically true is that the drugs are doing something to the brain, and there seems to be lots of reason to think that these un-understood physiological consequences aren't desirable -- that, in other words, they may in fact be creating mental impairments rather than relieving them.

Which brings us back to that crucial matter of the psychiatric industry has now given its business over to the creation of diagnoses that make virtually everyone who draws breath a candidate to consume, on an indefinite basis, expensive drugs of undemonstrated usefulness, and possible negative effect.

Especially vulnerable are children, whose systems are so much more susceptible to side effects.

What should be of greatest concern for Americans is the astonishing rise in the diagnosis and treatment of mental illness in children, sometimes as young as two years old. These children are often treated with drugs that were never approved by the FDA for use in this age group and have serious side effects.

And a whole industry has developed around matching poor children who may display signs of overactivity or irritability to government funds for drug treatment -- and only drug treatment. "[T]o qualify nearly always requires that applicants, including children, be taking psychoactive drugs. According to a New York Times story, a Rutgers University study found that children from low-income families are four times as likely as privately insured children to receive antipsychotic medicines." Remember too that it is totally legal for doctors prescribe drugs for uses and patients other than those covered by the FDA's certification of efficacy and safety; the drug companies just can't market those off-label uses, but they've become highly proficient at getting other people to do their promotion of unapproved uses for them.

"At the very least," Angell argues,

e need to stop thinking of psychoactive drugs as the best, and often the only, treatment for mental illness or emotional distress. Both psychotherapy and exercise have been shown to be as effective as drugs for depression, and their effects are longer-lasting, but unfortunately, there is no industry to push these alternatives and Americans have come to believe that pills must be more potent. More research is needed to study alternatives to psychoactive drugs, and the results should be included in medical education.

In particular, we need to rethink the care of troubled children. Here the problem is often troubled families in troubled circumstances. Treatment directed at these environmental conditions -- such as one-on-one tutoring to help parents cope or after-school centers for the children -- should be studied and compared with drug treatment. In the long run, such alternatives would probably be less expensive. Our reliance on psychoactive drugs, seemingly for all of life’s discontents, tends to close off other options. In view of the risks and questionable long-term effectiveness of drugs, we need to do better. Above all, we should remember the time-honored medical dictum: first, do no harm (primum non nocere).

UPDATE: BACK FROM HIGHBRIDGE PARK

Except for the autumn foliage, this was very much our first view of the High Bridge approaching from the south on the path along the upper edge of Coogan's Bluff overlooking the Harlem River in Highbridge Park.

In case anyone is wondering, I've just made it home from the Highbridge Park hike with Prof. Sidney Horenstein which I wrote about in my post last night. I've added a brief update there.

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