AT THE bottom of Pandora’s box was hope – a thought worth hanging onto when reading about psychiatry. But read we should, since up to a third of us may at some time sport a label from the psychiatrists’ bible, the Diagnostic and Statistical Manual of Mental Disorder (DSM). And the World Health Organization reckons that by 2020 will be the second largest contributor to the global burden of disease.
Treatment and its failures are the burden of Irving Kirsch’s The Emperor’s New Drugs and Richard Bentall’s Doctoring the Mind. The books’ subtitles signal intent: Kirsch’s is a ballistic “Exploding the antidepressant myth”. Bentall’s, interestingly, differs between US and UK editions: “Why psychiatric treatments fail” for the UK, and “Is our current treatment of mental illness really any good?” for the US.
The latter’s tentative tone may be a wise move since the US psychiatric community seems to be in even more serious meltdown than its British counterpart. Big Pharma faces legal action over the effects of antidepressants, Congress is demanding financial transparency from psychiatrists working on the DSM V due out in 2011, individuals scour the net for help, and activists struggle to find viable alternatives to drugs.
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Bentall’s book is a shorter, more accessible version of his Madness Explained (Penguin, 2004) and is full of stories about his patients. As a therapist, Bentall is a gentle, non-judging voice; as a polemicist, though, he is deeply unimpressed with psychiatry’s progress. We are, he says, still attached to the “myth” of mental illnesses as brain disease, and despite claims of dramatic advances, patients are doing no better than they did 100 years ago.
Shockingly, people in the west are less likely to recover than those in poorer countries. Kindness and empathy are missing from the system. Drugs dominate but they don’t work well: it’s time to prescribe them only on a suck-it-and-see basis, Bentall says.
Kirsch is famous (or infamous) for a more uncompromising stand on psychiatric drugs. In 1998, he made headlines with research showing that the benefits of antidepressants could mostly be due to the placebo effect. Ten years later came more headlines when he published a meta-analysis of data presented to the US Food and Drug Administration that found the new generation of selective serotonin reuptake inhibitors (SSRIs) to be no better than placebo in treating all but the most severely depressed patients – and even that might be down to decreased efficacy of the placebo.
While writing the book, Kirsch stopped believing drugs might benefit even this subset of patients. Now he thinks the belief that antidepressants can cure depression chemically is “simply wrong”, and questions the idea that depression is an illness at all. His case that the drugs’ benefits are due to placebo and enhanced placebo effect is fascinating, and demands urgent research.
“Kirsch questions whether depression is to do with chemical imbalances in the brain, or if it is an illness”
If antidepressants don’t work, shouldn’t we be told? Kirsch says he has been urged to adopt a “don’t ask, don’t tell” attitude: in other words, it is wrong for him to say so in public. But he counters, if placebos work, “depression can be ameliorated without reliance on drugs that have potentially serious side effects”.
Clearly, it’s time for a big rethink of what constitutes mental illness and about how to treat it. For Kirsch, even costly psychotherapy comes out well against years of antidepressants. Then there’s the UK’s 10-year cognitive behaviour therapy (CBT) plan, which the world will be watching critically. And there are plenty more, as yet under-researched, therapies to explore, such as exercise.
The most encouraging take-home message is from Bentall: “Perhaps the most important lesson of the past century for mental health professionals of all kinds is that we must set aside our hubris and be humble in the face of madness.” Now that’s real hope.
Bodley Head
Allen Lane, New York University Press
