‘The Illusions of Psychiatry’ - John Oldham, Daniel Carlat, Richard Friedman, and Andrew Nierenberg, reply by Marcia Angell

This is an interesting series of responses from some very well-known people in regard to two different articles about the current state of psychiatry. The original articles are both highly critical of modern psychiatry and its reliance on drugs. There are many who might agree, but the letters here are from people who also are critical of psychiatry, so it's informative.

‘The Illusions of Psychiatry’: An Exchange

August 18, 2011

John Oldham, Daniel Carlat, Richard Friedman, and Andrew Nierenberg, reply by Marcia Angell

In response to: 

The Illusions of Psychiatry from the July 14, 2011 issue

The Epidemic of Mental Illness: Why? from the June 23, 2011 issue 

To the Editors:

In its June 23 edition, The New York Review chose to review three books that are highly critical of modern psychiatry. We regret that a more balanced approach was not taken.

Dr. Marcia Angell writes of a “raging epidemic” in mental illness, citing the fact that there are more individuals receiving disability payments for mental illnesses than ever before. While this is accurate, her article suggests that this is a false crisis that owes its existence to the discovery of psychotropic drugs starting in the 1950s. This creates the impression that Americans are overtreated for mental illnesses. Nothing could be further from the truth. The National Institute of Mental Health reports that currently only 36 percent of those who suffer from mental illnesses actually seek and receive treatment. This is especially concerning given the fact that comprehensive, biopsychosocial treatment of mental illnesses is increasingly effective, comparable to or at times greater than the effectiveness of treatment for many other medical disorders, such as heart disease and diabetes.

Dr. Angell and the authors she reviews also suggest that psychiatry, in general, regards mental illnesses through the reductionist lens of an imbalance of chemicals in the brain. Although psychotropic medications have been found to alter the balance of neurotransmitters in the brain, there is no consensus on whether these imbalances are causes of mental disorders or symptoms of them. The bottom line is that these medications often relieve the patient’s suffering, and this is why doctors prescribe them. It does not mean, as Dr. Angell suggests, that mental disorders were invented in order to create a market for psychotropic drugs. The disorders that these medications (and other therapies) treat have been around for all of recorded history. The difference is that today, thanks to medical and therapeutic advances, there is real help for those who suffer the devastating effects of mental illness.

John Oldham, M.D.

President, American Psychiatric Association

Houston, Texas

To the Editors:

In her two articles, “The Epidemic of Mental Illness: Why?” [NYR, June 23] and “The Illusions of Psychiatry” [NYR, July 14], Marcia Angell takes aim at modern American psychiatry, and finds plenty of shortcomings. Her argument is correct in its essentials. Psychiatrists often overdiagnose disorders of questionable scientific validity, they have become overly fixated on medication solutions to life’s problems, and many have accepted a steady flow of drug industry money, creating so many conflicts of interest that it is impossible to know who we can trust.

But missing from her review is an unequivocal if perplexing truth about psychiatric drugs—on the whole, they work. Antipsychotics for schizophrenia, stimulants for ADHD, hypnotics for insomnia, benzodiazepines and SSRIs for anxiety disorders—in all these cases, drugs are robustly more effective than placebos in double-blind controlled trials. Even Robert Whitaker, in his Anatomy of an Epidemic, concedes that these drugs are effective in the short term—it is the potential long-term effects that he discusses. Whitaker makes the argument that used long-term, all psychiatric drugs are essentially poisonous to the brain and have led directly to skyrocketing rates of psychiatric disability. While his arguments are intriguing, I agree with Dr. Angell that there are significant weaknesses in the evidence he marshals.

Dr. Angell makes much of the fact that we do not understand the mechanism of mental illness, nor of the drugs we use to treat it. While this is true, it does not mean that the drugs are ineffective—only that as psychiatrists, we should stop overselling ourselves as possessors of a sophisticated neurochemical knowledge of our craft.

My chief criticism of Dr. Angell’s review is an uncritical acceptance of the premises in Irving Kirsch’s book, The Emperor’s New Drugs. Dr. Kirsch, in reviewing his lifetime of research on antidepressant efficacy, concludes that antidepressants are no more effective than placebo pills for depression. But his actual research demonstrates quite the opposite. In his meta-analysis of six drugs, he found that active drugs were, in fact, significantly more effective than placebo. Kirsch then dismisses this statistical difference as having no “clinical significance,” with which Dr. Angell concurs.

Other researchers disagree. For example, Erick Turner and colleagues (with no industry funding) conducted an even larger analysis, examining all available data, published and unpublished, on twelve of the most commonly used antidepressants. They found an almost identical benefit of drug over placebo as did Kirsch. While acknowledging that drug companies had boosted the apparent effectiveness of antidepressants by selective publication, they still found that, even including the negative data, all twelve antidepressants were statistically superior to placebo. Furthermore, in an editorial, they pointed out that Dr. Kirsch’s judgment about the lack of “clinical” significance was based on an arbitrary cut-off point suggested by the UK’s National Institute for Health and Clinical Excellence, a cut-off point with little if any scientific validity.

There is no question that among the medical professions, psychiatry is the most scientifically primitive. We have no more than the most rudimentary understanding of the pathophysiology of mental illness and we have resorted to tenuous and ever-shifting theories of how our treatments work. Dr. Angell’s review highlights these truths well, but at the same time gives short shrift to the very real benefits that we still provide our patients.

Daniel Carlat, M.D.

Associate Clinical Professor of Psychiatry

Tufts University School of Medicine

Boston, Massachusetts

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