Cracked (26 page)

But as this patient continues to relay her symptoms to her doctor, something unusual happens: the doctor tells her that she may not be suffering from nervi after all, but rather from something called “depression”—a mental disorder that can be treated by a new wave of “antidepressant” pills.

At the same time as this young woman is hearing the surprising news, other victims of nervi around the country are receiving the same message: their nervi may be better understood and treated as depression. And as more and more cases of nervi are reconfigured as depression, the nation's rates of depression unsurprisingly increase. But what had happened to instigate this change? Why were local doctors now regarding nervi differently?

When social anthropologist Vieda Skultans tried to unravel this mystery, she found that this shift coincided with two seminal events: the translation of the
ICD
's classification of mental disorders (the World Health Organization's version of the
DSM)
into Latvian, and the organization of conferences by pharmaceutical companies, which were aimed at educating psychiatrists and family doctors about the new diagnostic categories.
198
Skultans showed that once the new language of depression was made professionally available through the
ICD
, the pharmaceutical industry could then disseminate the new language to patients and the wider public through educational programs.

This shift away from understanding distress in the more socio-political terms of “nervi” toward the more biological terms of “depression” not only meant that new markets opened up for pharmaceutical treatments, but that people also started to hold themselves responsible for their distress—no longer were they suffering from the strains of living in a fraught socio/political environment but from a condition located within the internal recesses of their brains.

5

What happened in Argentina, Japan, and Latvia provides just three examples of how pharmaceutical companies managed during the 2000s to capture new foreign markets throughout Asia, South America, and Eastern Europe via directly transfiguring local languages of distress. What the multinationals had learned was that you needn't wait for local symptom pools to become Westernized through spontaneous processes of globalization; you could actually take the matter into your own hands by
intentionally
creating new markets, either by recasting existing local complaints and conditions in terms of Western mental health categories or by giving labels to feelings for which local populations had no existing disease categories. By funding conventions and vast marketing offensives, by co-opting huge numbers of prominent psychiatrists and manufacturing the supporting science, increased sales could be almost guaranteed. I say “almost” because there is always a risk an investment won't deliver.

But risk is worth it, as Watters put it, “because the payoff is remarkable when the companies get it right. And it seems that with each new culture they go into, they get a little better at getting it right!”

To say that companies were behind many new and spreading mental health epidemics is not to deny the reality of psychological distress. Of course emotional suffering is universal, but we also know it is susceptible to being culturally shaped and patterned by the meanings we ascribe to it. If a company can convince enough local people that their way of understanding and treating distress needs a radical makeover, then the rewards can be staggering if locals take the bait.

Just consider the facts: IMS, a provider of health-care data, has shown that the global antidepressant market has vaulted from $19.4 billon in 2009 to $20.4 in 2011, and the global antipsychotic market from $23.2 billion in 2009 to $28.4 billion in 2011. This means that the global psycho-drug market grew from $42.6 billion in 2009 to $48.8 billion in 2011—an expansion of over $6 billion in just two years.
199

Of course, increased European and US consumption can partly account for this exorbitant rise, but it certainly can't account for it entirely. Consumption is rapidly escalating in developing, emerging, and non-Western economies. In 2010 the Japanese antidepressant market, for example, had a value of $1.72 billion, up 10.7 percent from 2009,
200
while in China the annual growth figures have been around 20 percent for the last few years.
201
Recent estimates of antidepressant usage in Brazil now put the figure at 3.12 percent of the entire population, a significant increase over previous years.
202
If reliable data were available for other foreign markets (Mexico, Argentina, Chile, India, South Africa, Thailand, etc.) we would no doubt witness similar, escalating rates.

While the global expansion of Western psycho-drugs would hardly be possible without robust pharmaceutical and psychiatric sponsorship, there are other organizations that are giving this expansion a significant boost. In 2001, the WHO publically backed the globalization of psycho-pharmaceuticals by publishing a major report on the state of global mental health. After synthesizing years of research on psychiatric problems in developed and developing countries, the report stated that depression will be the world's second-leading health problem after heart disease by the year 2020.

The solution proposed for this looming epidemic was to make Western psycho-drugs more widely available. Poorer countries would save millions a year treating people with pills in the community rather than in costly hospitals. Pills would also stem the negative consequences of mental health on the economy: by medicating people, they would be more likely to remain economically productive, which in turn would ensure wider economic productivity. On the other hand, the argument went, if depression weren't treated, the economic cost could, in the final analysis, be prohibitive.
203

This all sounds very logical, and perhaps even chivalrous, and of course when our Western psycho-technologies genuinely help, it would be wrong to keep them for ourselves. But even if we accept that psychotropic drugs can work in some cases, the jury is out on whether medicating vast swaths of foreign populations helps anyone other than the pharmaceutical companies themselves.

We have already heard in chapter 4 how antidepressants work no better than placebos for the majority of people, but we also know there are serious problems with the more powerful antipsychotics. In fact, one of the most damning criticisms of the 2001 WHO report comes from data gathered some years earlier, ironically enough by the very same organization.

This separate WHO study was undertaken by a team of more than a hundred psychiatrists who researched, among other things, how quickly psychiatric treatment was helping patients in developed countries.
204

To explore this question, they compared the recovery rates of patients in developed countries (like the United States, Denmark, and UK) with patients being treated in developing countries (like Nigeria, Columbia, and India). The findings were troubling.

In the two-year follow-up study after treatment, only 15.5 percent of patients in the developed world had completely clinically recovered, compared to a full 37 percent of patients from the developing countries. Also, a full 42 percent of patients in the developed countries experienced impaired social functioning throughout the follow-up period, whereas only 16 percent from the developing countries experienced the same social impairment.

The most worrying statistic of all was that while patients in developing countries did far better than patients in developed countries, patients in the developed countries were taking far more medication: 61 percent of patients in the developed countries were on continuous antipsychotic medication, compared to only 16 percent in the developing countries. So who was getting better quicker? Not the patients in developed countries like the UK and the United States who were taking far more pills, but the patients in developing countries like Nigeria and India where psychiatric resources and pill-taking were comparatively meager.
205
How do we explain this?

One possible reason is that we in the developed world are doing worse because we are under different kinds of social pressures. Maybe the social conditions of the contemporary West simply aren't conducive to good mental health—and indeed the authors of the study directly pointed to cultural differences being the most important factor in our poorer outcomes.

Yet the differences they emphasized weren't only related to differing levels of social stress (it would be churlish to argue that somehow life is far more difficult for
us
); rather, in non-Western cultures there appeared to be better community support for the emotionally and mentally distressed. This insight accords with numerous studies showing how crucial good relationships, community acceptance, and support are in recovery.
206

We already know that when people can be assisted in a non-hospital environment, close to home, with lower doses of medication, their recovery is far better.
207
We also know from studies in Finland of new “open dialogue” approaches (where treatment is focused on supporting the individual's network of family and friends, as well as respecting the decision-making of the individual) that community-based care works far better than conventional biochemically heavy interventions. Could research like this help explain why patients in developing countries are doing far better than their more medicated Western counterparts, for whom community relations are increasingly atomized, unsupportive, and individualistic?

If so, could the exportation of individualized chemical treatments and biological understandings of distress be to the detriment of these less individualist communities? A biological vision so intimidating to most people that they feel there is nothing to be done other than hand over the sufferer to the so-called experts so they can do their work?

Western psychiatry has just too many fissures in the system to warrant its wholesale exportation, not just because psychiatric diagnostic manuals are more products of culture than science (chapter 2), or because the efficacy of our drugs is far from encouraging (chapter 4), or because behind Western psychiatry lies a variety of cultural assumptions about human nature and the role of suffering of often questionable validity and utility (chapter 9), or because pharmaceutical marketing can't be relied on to report the facts unadulterated and unadorned (chapter 10), or finally because our exported practices may undermine successful, local ways of managing distress. If there is any conclusion to which the chapters of this book should point, it is that we must think twice before confidently imparting to unsuspecting people around the globe our particular brand of biological psychiatry, our wholly negative views of suffering, our medicalization of everyday life, and our fearfulness of any emotion that should bring us down.

Perhaps in the last analysis, we are ultimately investing vast wealth in researching and treating mental illness because, unlike in many other cultures, we have gradually lost our older belief in the healing powers of community and in systems that once gave meaning and context to our mental discontent. This is a view that commentators like Ethan Watters urge the mental health industry to start taking very seriously: “If our rising need for mental health services does indeed spring from a breakdown of meaning, our insistence that the rest of the world think like us may be all the more problematic. Offering the latest Western mental health theories, treatments, and categories in an attempt to ameliorate the psychological stress sparked by modernization and globalization is not a solution; it may be part of the problem. When we undermine local conceptions of the self, community, and modes of healing, we may be speeding along the disorienting changes that are at the very heart of much of the world's mental distress.”
208

At the end of my interview with Watters, he had one final message he wanted to impart. “I believe that the rest of the world has as much to teach us about how to live a healthy human life as we have to teach them,” he said passionately, “but we need a good deal more humility in order to understand that.” Without that humility, the flow of ideas will continue in a one-sided direction. And even if that does not mean that the rest of the world will end up thinking just like us, it does mean that the rest of the world's way of understanding, managing, and experiencing emotional suffering will imperceptibly change.

As to how it will change will differ from place to place, but whatever changes ensue, the best we can hope for is that these changes are undertaken with full awareness of the serious problems afflicting psychiatry in the West. Others realizing that our so-called solutions have created vast new problems in the places where they were devised may be the only bulwark against the ill-advised dash to import a system that may bring as many problems as it purports to solve.

HOW TO FIX THE CRACKS?

T
oward the end of my long series of interviews, I walked through one of London's most exclusive neighborhoods toward the illustrious Belgrave Square. The sky lent a crisp, blue backdrop to the tapestry of autumnal leaves rippling in the trees overhead. As I reached the end of Pont Street and turned into the grand, Regency-era square, there on my left, nestled against the Austrian Embassy, sat the grande dame of British psychiatry—the Royal College of Psychiatrists. Like a posh wedding cake, it proudly ascends an elegant five stories from the broad and leaf-dappled pavement, painted in a creamy magnolia with Doric columns holding up the portico entrance. It was stately, elegant, and oddly edible.

After making a couple of failed attempts on the intercom system, I put my ear closer to the brass speaker and tried to decipher the whispered and garbled fizzing. At once the system kicked in. “Push the door!” someone boomed. Shocked, I pushed far too hard, almost falling into the lobby. A demurely dressed receptionist smiled innocently. “Can I help you?”

“I have an appointment with Professor Sue Bailey,” I mumbled, rubbing my ear.

“Ah, yes, Dr. Davies.” The receptionist smiled. “Please do wait in the members room. She'll be with you shortly.”

Five minutes later, my hearing returned, I was escorted up five flights of stairs to Professor Bailey's office, which is neatly tucked away on the top floor. It is a modest office compared with what I had come to expect and considering that Professor Bailey is, after all, the president of the Royal College of Psychiatrists.

Bailey is a straight-talking and no-nonsense psychiatrist with a grounded Manchester accent. Her handshake is firm, her voice steady, and I sensed right away when she said “I know your work” that she wanted to cut right to the chase.

I had come to talk to the president of the Royal College of Psychiatrists to discuss the future of psychiatry. I started by raising with her a crucial event that was about to occur in the profession. This concerned an editorial that would soon be published in the
British Journal of Psychiatry
, one of the most respected and widely read psychiatry journals internationally. The editorial was written by twenty-nine senior consultant psychiatrists, all members of the Royal College of Psychiatrists, and all of whom expressed deep concern about the current state of psychiatry. Their article is so significant because it runs counter to the growing professional belief, many times articulated in the same journal, that the current crisis in psychiatry can be best solved by reaffirming psychiatry's identity as a discipline essentially concerned with studying, diagnosing, and pharmacologically treating essentially “brain-based” mental diseases.

Although the authors of the editorial do not deny that the brain sciences and psychopharmacology have a role to play in psychiatry, they insist that the dominant “medical model,” which sees the diagnosis of brain disorders and the prescription of drugs as psychiatry's primary task, has not only failed the test of science but is not getting the clinical results it promised. They therefore insist that the “medical model” must take a backseat to interventions and methods that really
do
work. In essence, the editorial requests a paradigm shift away from the medical model and toward an approach that prioritizes healing relationships with people, helping people find meaning in their lives, and using therapies and other social/humanistic interventions as the first line of treatment.

Once I had outlined the editorial's main arguments to Sue Bailey, I asked her whether she would like to comment.

“Okay,” said Bailey, sitting up presidentially, “I prefer
not
to comment because I think their vision is quite limited, really. So while I am very fond of them, I think we can have a better vision than the vision they've got.”

I gently pointed out that their position simply builds upon the mounting evidence that the current medical model is under considerable strain. While there are still no biological markers found for the majority of mental disorders, the medical model is also leading to the widespread over-medicalization of our problems and to the over-prescribing of often dangerous and ineffective drugs. I asked what she made of those charges.

“Let's pick those points off,” said Bailey impatiently. “It is quite interesting that over-medicalization is leveled at psychiatry [i.e., the idea that psychiatry is wrongly recasting many normal and natural human responses into medical conditions requiring drug treatment]. It would probably be better leveled at primary care and GPs. When you go into a profession where you want to help people, and you don't have the tools to help them, the temptation is to medicalize them.”

I tried to ask Bailey why she held GPs responsible when it was psychiatry that had put these drugs on the map, promoted their value to GPs, and dramatically expanded the number of mental disorders for which these pills can be prescribed. But as I began to speak, Bailey raised her hand, indicating she had more to say. And while what she said did not make for easy listening, it is still worth quoting in full:

“So let's focus back on the critical psychiatrists. They are saying that many problems [treated as mental health problems] are not medical issues. They may be right, but does it actually make any difference to the person who is in distress? The person is in distress for
some
reason, and that may be because they have had a bad day, or it may be that they have been traumatized and abused by Jimmy Savile
209
, for instance. And it's now in the newspapers and they are worried about it.

“Now, it may not need medical treatment, but they need
some
support, to be listened to. I have no problem with that. I have a problem with [Bailey names a senior critical psychiatrist] accusing us of over-medicalizing problems. But you'd need to talk to a neuroscientist about that. There isn't much evidence about biomedical markers [for mental disorders]. I am more on the side of social science; that is what I do, I do qualitative research. But actually there is increasing evidence of biomedical markers. But it would be really useful if the neuroscientists on one end, the social scientists somewhere in the middle, and the critical psychiatrists at the other end would all get over themselves and actually look at this properly.

“You've got a human in front of you who has come to you for a reason, and who wants help. And the job is to listen to them and to try and disentangle it, and some of it will be about social support, some will be about advice about how they are living their life, and some of them temporarily
will
have a distress—however that is diagnosed in the new classification system. Some of them will sit there with a rancid depression that no one has yet taken any notice of. What we are about is a patient-doctor dyad that's trying to understand the dilemma that comes into the room, and that's what we have got.

“And I think that's what we do in mental health. We care and treat. So over-medicalization, yes, may be happening, but at the other end we've got [suffering people]. I mean, this morning I've been to Deaths in Custody where 200 young people have committed suicide whilst in juvenile prisons. So the father of one of these very bravely came and told the young man's story, and probably the main reason why he committed suicide was that nobody recognized he had ADHD …

“So I suppose I don't have a lot of time for people who are fixed to one theory and one point of view. We are in the business of understanding human nature and then doing what we can, within the evidence base, whether it's from a medication evidence base, a talking therapies evidence base, an alternative therapies evidence base—we do the best we can.”

I took a deep breath. I was not sure where to go from here. I was struggling to understand what Bailey was actually saying. Was she saying that GPs are medicalizing our normal and natural responses to the problems of living, but not psychiatrists? And was she saying that the writers of the editorial are “fixed to one theory” by arguing that psychiatry relies too heavily on the medical model, which privileges diagnosis and medication?

As the interview continued, I therefore tried harder to pinpoint precisely where the institutional leader of British psychiatry exactly stood. As we went back and forth, what gradually emerged was that Bailey viewed the writers of the editorial as indeed “fixed to one theory”; a theory that she felt contradicted her more eclectic vision: that we must use medication, diagnosis, the insights of social science, psychotherapy, neurobiology, and social care as combined resources to help patients.

When I pointed out that the authors of the editorial also seemed to share this more eclectic view (aside from their request for the medical model to take more of a backseat), her eyes suddenly narrowed. “I say I am different from them because they are zealots in their own model. And I think any zealot-driven model is a bad idea.”

This seemed to me a strong statement to make. So I asked Dr. Sami Timimi, a British consultant psychiatrist, a director of medical education in the NHS, and a contributor to the editorial, whether he felt such a statement was fair.

“Positioning critical psychiatry as extreme and zealous,” responded Timimi coolly, “seems to me to reflect a possible misunderstanding of our position. She seems to think that we are proposing an alternative, one-dimensional model that can be applied across psychiatry. But that is what we are arguing against, because that is what the medical model has done: prioritized a narrow focus on the diagnosis of symptoms and prescribing. It also sounds like she is having great difficulty imagining that psychiatric services could exist if diagnosis, for example, didn't play a central role.

“Now as far as I can see, all the evidence says that diagnosis hasn't helped in terms of forwarding the science; there is virtually no concrete evidence linking our diagnostic categories to either biological or even psychological markers. But even if we put that to one side and look at how clinically useful our current diagnostic system is, all the evidence suggests that in terms of helping us make useful clinical decisions, the current diagnostic framework doesn't help at all. In fact, it seems to do the opposite.”

What the evidence shows, according to Timimi, is that what matters most in mental health care is not diagnosing problems and prescribing medication, but developing meaningful relationships with sufferers with the aim of cultivating insight into their problems so the right interventions can be individually tailored to their needs. Sometimes this means giving meds, but more often it does not. The problem with simply putting labels on people, Timimi believes, is that it ends up often medicalizing problems that are not medical in nature. And this isn't helped by successive expansions of the
DSM
and
ICD
, which encourage practitioners to wrongly medicalize more and more emotional troubles as mental disorders that only warrant pharmaceutical treatments.

As this last criticism had been also made by many other people I'd interviewed (you'll recall the chair of
DSM-IV
, Allen Frances, saying
DSM-IV
created three new false psychiatric epidemics), I decided to ask Sue Bailey whether she agreed that the expansion of
DSM
and
ICD
was a driver of medicalization.

Bailey seemed irritated by the question. “Look, I think there are frankly better things people should be doing with their time. I haven't actually got a lot of truck with these discussions, if I am honest with you. The majority of people I look after are living in poverty, with inequality, and have experienced abuse. They've got undiagnosed, unrecognized mental illnesses. So I actually think that we should focus on the reality of what we can do as doctors rather than having erudite discussions about the various situations of what
DSM
should have done.”

Again, I was surprised to hear this. So I quoted Bailey's response to Dr. Timimi. He was less surprised than incredulous. “These debates about medicalization are debates about
real things
that affect
real people
in everyday practice. I think what she said shows a staggering intellectual complacency, and a real desire to avoid thinking about the clinical implications of medicalization.”

After all, for the twenty-nine authors of the editorial, the more people whose suffering is wrongly medicalized, the more will be prescribed often dangerous and inefficacious drugs, the more will suffer the stigma of unnecessarily being labeled “mentally ill,” and the fewer will be offered non-medical alternatives. For authors of the editorial like Timimi, then, it is understandable why Bailey's dismissal of medicalization provoked incredulity, especially because, as Timimi summarized, the evidence shows that the medical model (without which there'd be no medicalization) is not working.

To illustrate this final point, Timimi revealed the results of some research he had recently undertaken. He compared two different mental health teams working in the NHS. One team followed the usual medical model—where diagnosis and drug treatment took precedence—while the other team adopted a “non-diagnostic” approach—where medication is given only sparingly, where diagnosis is hardly used at all, and where individual treatment plans are tailored to the person's unique needs. Timimi then gave me two clinical examples of how the “non-diagnostic”' approach actually works in practice.

In the first example, a young man enters the consulting room displaying behavior that would traditionally warrant the diagnosis of ADHD. But rather than assign the diagnosis, the psychiatrist invites the mother in and takes some family history. It turns out that the son and mother had been living for many years with domestic violence, until the abusive man eventually left. But the boy had been so scarred by the experience that his behavior was now understandably chaotic.