December 2014 Archives

Mental disorders have become a global commodity. A diagnostic fad heavily promoted first in the US now quickly spreads around the world.

Multinational corporations have perfected the profitable art of international marketing. The reach of pharma stretches everywhere in the world with a sales pitch easily translated into every language: "Sell the ill to sell the pill."

The basic strategy is to expand the market by convincing the healthy that they are sick-that their expectable distress and imperfections are a mental disorder caused by a brain chemical imbalance that requires correction with an overpriced pill.

The very best customers are those who weren't sick in the first place. Their sky high placebo response rate guarantees they will be very satisfied even with treatments that were not really necessary and may even be harmful. This explains how bleeding and purging were the go-to medical treatments for thousands of years, even though they did absolutely no good and instead caused lots of harm.

Once the adult market gets locked up, drug companies direct their marketing guile to recruiting ever younger child customers and the old folks in nursing homes, and it isn't satisfied until it has captured every possible customer in every possible country.

The US is by far the best market because it is big, rich, and the easiest to control and to monopolize. Only in the US has pharma been able to bully and bribe politicians into allowing direct-to-consumer advertising and into disallowing price negotiation even with its biggest buyer (the government). The results in the US are massive over diagnosis and massive over treatment with medication. Sweet profits that make drug companies the most profitable of all industries, but bad for patients.

The pickings are less easy and less lucrative in the rest of the world, but still nothing to sneeze at.

I sought the perspective of Patrick Landman on the progressive globalization of ADHD. Dr Landman is a Parisian child psychiatrist who has just published the book ADHD: The Invention Of An illness. He will describe the international trend and why until recently the French have been more than successful than most in resisting it.

Patrick writes:"We must face the fact that some mental disorders are sold just like industrial or commercial products. Once the US market had become saturated, Pharma concentrated its efforts on developing new international markets that held more promise of promoting possible rapid growth.

"It is no longer just medication that is marketed - now drug companies also market diseases. Psychiatry is particularly well suited to this strategy because the criteria for distinguishing between normality and pathology are not scientifically defined and because mental pathologies are multifaceted and somewhat arbitrary social constructs.

"Attention Deficit Hyperactivity Disorder is a prime example. The US 'market' already has 11% of children aged 7 to 17 diagnosed with ADHD and 6% on medication. Rates tripled in just 20 years and revenues increased 50 fold to almost $10 billion/yr. The US consumes almost 70% of the world's anti-ADHD drugs. The growth of ADHD has been almost equally strong in Canada, Australia, and New Zealand but the rest of the world is there to be conquered.

"Of course, the multinational pharmaceutical companies are not solely responsible for the expansion and globalization of ADHD. We must also include the ways in which information about ADHD can be spread worldwide thanks to internet access; the tests and checklists which enable self-diagnosis and the way self-diagnosis is marketed; the role of the service users and discussion forums; the change in thinking regarding what users demand; the pressure on children to succeed academically; and, lastly, the domination of DSM IV and later DSM 5, which widened the ADHD definition compared to the one in the International Classification Of Diseases.

"Faced with this globalization, we are bound to be interested in any small islands of resistance, and specifically in the French example. Until 2005, the prevalence of ADHD in France had long remained very low- around 1-2% compared to the 11% in the United States and more than 5% in the United Kingdom, the Scandinavian countries, and Spain.

"The reasons for this French particularity are multiple and interconnected. First, French child psychiatry has been strongly marked by psychoanalysis and the psychopathological tradition, and there has been an ideological resistance to prescribing medication to children.

"Secondly, there is a specific French classification of mental diseases based on the European clinical tradition,which does not associate hyperactivity with attention disorder. Many French child psychiatrists therefore see ADHD as a social construct 'made in USA,' one that lacks validity and is based on a narrow biological reductionism.

"Thirdly, for a long time the French education system was fairly tolerant of children's behavioral problems.

"Lastly, the power to prescribe psychostimulants to children was legally restricted to medical specialists and hospital psychiatrists.

"Since the 2000s, many things have changed and the latest figures show that 3.5% of children have now been labeled with ADHD. France is definitely catching up. What are the factors behind this change?

"First is the massive introduction of the DSM into psychiatric training and practice. Second, media campaigns have discredited psychoanalysis and child psychiatry and favored neuropediatrics, whose neurodevelopmental hypotheses are supposedly more 'up-to-date.' The exclusively bio-medical model has made significant inroads. Third, society's demand on psychiatry has also changed, and the focus is now on making the behavioral problems of the disruptive child disappear as quickly as possible. Fourth and most important, drug companies are working hard to sell ADHD. Fifth, the pressure from certain users associations for the recognition of ADHD as a qualification for disability rights.

"And finally, the French education system is undergoing a major crisis: the struggle to integrate children of migrant origins who are often caught up in multiple social, cultural, linguistic and educational problems .More and more often, teachers have to deal with situations that seem to be out of their control; increasingly, they become the pre-diagnostic filters of 'ADHD' -brokers of medical prescription. The effect is to turn school and societal problems into medical disorders in the individual child.

"French child psychiatry is currently moving away from the exclusively psycho-social model of 'brainless' psychiatry (which in some cases turned out to be too reductionist) and towards the (equally reductionist) biomedical model imported from the USA.

"The social role of psychostimulants has changed as well: if for Marx religion was the opium of the people and a way of putting social conflict to sleep, psychostimulants have become the opium of our children, sedating familial, pedagogical, educational, psychical, and social conflicts.

"For psychiatry, the future lies in refusing all of such extreme and reductionistic theories and treatments. We must use common sense in combining a humanistic tradition with scientific discovery. We can avoid the over diagnosis and over treatment of ADHD by taking a rounded view and resisting drug company manipulation."

Thanks so much, Patrick. It is crucial that parents everywhere become informed consumers in order to protect their kids from over diagnosis and unnecessary meds.

All medicine should be bio/psycho/social. Illness is never just a biological phenomenon; more than 80 percent of health outcomes are determined by economic, social, and behavioral factors, and the psychosocial part is especially important in psychiatry. As Hippocrates pointed out 2500 years ago, it is more important to know the patient who has the disease than the disease the patient has. 


In recent years, psychiatry has embraced what a former president of the American Psychiatric Association has despairingly called a "bio/bio/bio" model. The enormous research budget of the National Institute Of Mental Health has been totally invested in biologically reductionist brain and genomic research.

Pat Bracken is an Irish psychiatrist and philosopher who would like to put the mind and soul back into psychiatry. Pat writes:

"I believe that psychiatry finds itself in a pernicious position. Pharma has used its financial power to mould psychiatry into something that serves corporate needs, not the best interests of patients, and the massive investment in genetic and neuroscience research has yielded practically nothing of clinical value for our patients. In fact, we have gone backwards. The narrow focus on biological research has led to a profound neglect of the social, cultural and psychological dimensions of mental illness.

"In the United States, where Pharma has had most influence and the perverse payment system has operated, there is evidence that, to a large extent, psychiatric care has become equated with the provision of a DSM diagnosis and a prescription. 
The New York Times carried a story in 2011 in which a psychiatrist spoke of having to train himself not to get too close to his patients and 'not to get too interested in their problems'. His role was simply to check the diagnosis and adjust meds.

"The reductionism that now dominates psychiatric theory and practice is ideological in nature: it does not stand up to conceptual challenge and is not supported by the results of empirical investigation. Its dominance is sustained through finance from Pharma allied to a professional quest to be more 'medical' than the rest of medicine.
 What we have to grasp is that when we put the word 'mental' in front of the word illness, we are doing something important. We are delineating a territory of human suffering that is primarily about relationships, meanings and values. And, while we cannot experience anything without a functioning nervous system, knowledge of the brain will not help us a great deal in understanding the nature of this territory. The brain is a necessary, but not a sufficient cause of human experience.

"We are embodied beings but we are also encultured. We grow to become human in the midst of language, culture, history and relationships with others. These shape the way we experience ourselves and how we encounter the world around us and cannot be reductively explained in biological terms.
 

"The demand that psychiatry should simply become a 'clinical neuroscience' is nothing more than an assertion of dogma and is not based on a genuinely questioning scientific approach to the sort of problems that face us. We need to nurture the development of a psychiatry that sees relationships, meanings and values as its primary focus. I have used the word 'hermeneutic' to describe this.

"How to get there is the challenge. Evidence-based medicine (EBM), with its focus on controlled studies and meta-analyses, has not proved robust enough in protecting psychiatry, and medicine in general, from corruption. It has been said that EBM itself is 'broken.' With our colleagues from other medical disciplines we will need to develop a much deeper form of critical appraisal.

"I believe that any profession that has power in the lives of ordinary people should seek to critically reflect on its own history, assumptions, values and practices in an organised and sustained way. A mature profession should not be afraid of this. We need practitioners who are trained to question and to doubt, to challenge their teachers and to see financial ties to third parties as an aberration.


"On a more positive note, our discipline has a rich history of grappling with conceptual issues before the rise of 'neuromania' and the DSM.  The work of Karl Jaspers stands out in this area but many of our predecessors struggled to develop a theory and a practice of psychiatry that was not reductionist. The great Swiss psychiatrist, Medard Boss, for example, sought to develop a specifically hermeneutic psychiatry in the post World War II era. We do not have to re-invent the wheel. A growing movement of critical psychiatry is now emerging as a positive force for change within the profession.

"I believe that we need to develop a practice that is centered on relationships and we need to acknowledge the limitations of a diagnosis-guided practice in our field. This is not anti-medical but simply an acceptance that mental health work demands something different. We need to nurture negotiation skills in our trainees and encourage them to engage with the growing consumer movement in a positive and non-defensive way. We need to accept that psychiatry has done a great deal of harm to many of its patients and professional arrogance should be stigmatised and fought against. We need to nurture doubt, questioning and critical reflection in our academic and clinical practice.

"Hermeneutic psychiatry would be one where doctors, patients, carers and other professionals struggle together to determine what research, teaching and service models are appropriate. I also believe that we should struggle to shed the power to order coercive interventions. This is not to say that sometimes people need to be cared for safely and even against their will, but there is no scientific or moral reason why the medical profession should be in charge of this.

"I do not claim to have an answer to all the problems of psychiatry but the following moves will be essential if we are to find a cure for our current ills: 1) collaborate with other doctors who are struggling to free medicine of Pharma corruption, 2) find ways of working positively with, and learning from, the growing international consumer movement, 3) balance our involvement with the biological sciences with an equal involvement with the humanities and social sciences, 4) nurture the development of a clinical discourse that is centered on relationships, meanings and values, 5) seek to shed the coercive powers that are now invested in us and promote an open debate about how people can be looked after safely through times of crisis."


Thanks, Pat. We must get back to treating the whole person, not just his brain circuits. The brain is involved in all we do and what we are, but it is also itself influenced by our psychology and social context. We must equally counter those who err in recommending an opposite and equally extreme psychosocial reductionism.  Mindless psychiatry and brainless psychiatry are equally misguided and harmful.