Back in June and July Marcia Angell wrote reviews for four books [one a manual] - each of her reviews was critical of the psychiatry profession and the way that antidepressant type drugs are dished out.
The reviews for all four publications appeared in The New York Review of Books, a fortnightly magazine with articles on literature, culture and current affairs.
The Emperor’s New Drugs: Exploding the Antidepressant Myth
by Irving Kirsch
Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America
by Robert Whitaker
Unhinged: The Trouble with Psychiatry—A Doctor’s Revelations About a Profession in Crisis
by Daniel Carlat
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR)
by American Psychiatric Association
Daniel Carlat, author of Unhinged: The Trouble with Psychiatry—A Doctor’s Revelations About a Profession in Crisis, came under particular fire from Marcia Angell. So much so that he felt the need to respond to Angell's criticism.
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
Others to respond were
Richard A. Friedman, M.D.
Professor of Clinical Psychiatry
Director, Psychopharmacology Clinic
Weill Cornell Medical College
New York City
John Oldham, M.D.
American Psychiatric Association
Andrew A. Nierenberg, M.D.
Bipolar Clinic and Research Program
Associate Director, Depression Clinical and Research Program
Massachusetts General Hospital
Professor of Psychiatry
Harvard Medical School
There appears to be a game of ping pong going on here. One critic gives her views whilst her opponents return her serve with little, or no, meat behind their return of service.
It's fascinating to read MD''s, professors and psychiatrists offer opinion...because at the end of the day, that's really all their whole profession is based upon.
One only has to pick up a copy of the Diagnostic and Statistical Manual of Mental Disorders [DSM] to see how utterly absurd some of the invented disorders are.
I do have to applaud the aforementioned for going public with their beliefs, quite often the field of psychiatry digs itself an even deeper hole when trying to protect their theories. It remains to be seen if that is the case here.
I have asked many times what the benefits are of taking antidepressant medication. Carlat's last line goes someway to answering that question but again, it's just a personal opinion. He writes: "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."
He failed to clarify what the benefits actually are.
Marcia Angell has, as one would expect, come back with a rebuttal. It makes fascinating reading and I'm sure will add further fuel to the psychiatry fire.
Her response to the criticism can be read, along with letters to the Editor from Carlat etc, HERE
ORDER THE PAPERBACK
'THE EVIDENCE, HOWEVER, IS CLEAR...THE SEROXAT SCANDAL' By Bob Fiddaman
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