Open to abuse
There is a growing unease about the relationship of the medical profession with the companies which research, manufacture and sell the drugs we use. The cost of developing a prescription drug in the US is estimated at $800,000,000. So the pharmaceutical industry is increasingly concentrated in a small group of immensely powerful multinational businesses. The statistics are staggering. It takes on average up to 10 years from isolating and patenting a molecule, through tests and trials to its first routine prescriptions to patients. Only 1 per cent of new molecules make it from test tube to prescription. The research and development budget is consequently enormous. That of Pfizer (the largest pharmaceutical company in 2005) is greater than the whole national research budget of some European states.
Not surprising then that the marketing of these drugs is ruthless. The financial relationships between doctors and these companies are murky. Over half of all educational meetings for psychiatrists in the US are funded by pharmaceutical companies and luxurious hospitality and travel are routinely offered to doctors as barely concealed inducement for them to prescribe. Until recently psychiatry was immune from this as our drugs cost so little. However the new generation antipsychotics and antidepressants are vastly more expensive (newer ‘atypical’ antipsychotics cost $2000–$3,000 a year per patient in the US compared to $100–$200 or less for the older drugs; newer antidepressants also cost several hundred dollars a year as opposed to ‘pennies’ for the old antidepressants such as tofranil and amitryptiline). The patent on a new drug is strictly time limited and the companies have to recoup all their development costs usually within 10–15 years from launch. With the financial muscle of the pharmaceutical companies brought to bear on the profession it is hardly surprising that social and psychological interventions (which have no such financial backing) have a lower profile.
‘Big Pharma’ has been accused of stretching the boundaries of what are treatable psychiatric disorders to increase the sales of its drugs. It has been accused of creating a need for its drugs rather than developing drugs for existing needs. The enormous success of prozac has lead to an expansion of the concept of clinical depression. Milder and milder cases get treated. Prozac’s iconic status has helped reduce stigma against depression but has made it a ‘lifestyle’ drug. Most university students will know class-mates on antidepressants – inconceivable only a generation ago. Diagnostic patterns have changed in response to the marketing of these drugs. There has been a striking increase in the diagnosis of disorders such as PTSD (post-traumatic stress disorder) and social phobia (a disorder which some would consider just extreme shyness) since drugs have been licensed to treat them.
Even more worrying is the massive growth in psychiatric prescribing for children. Once a rarity, child psychiatrists now regularly prescribe psychotropic drugs for children. The most dramatic increase has been in the diagnosis and treatment of ADHD (attention deficit hyperactivity disorder): 7 per cent of US schoolchildren are diagnosed with ADHD (one in ten boys as they are three times more likely to be diagnosed), with half of these on stimulant drugs.
The prescribing of ritalin (methylphenidate) increased six fold in the 1990s in the US and accounts for 85 per cent of world prescriptions but Europe is rapidly catching up (150,000 prescriptions in the UK in 2002). Child psychiatrists insist that the diagnosis is made carefully and that drugs are used only after psychological treatments have been tried but the figures simply don’t stack up. Irrespective of the controversy about the legitimacy of the diagnosis, there can be little doubt that this is an example of psychiatric practice being rushed by commercial agendas. Before leaving the pharmaceutical industry we need to acknowledge its very positive contribution to human health and welfare. It would be naive to ignore the financial imperatives that flow from such staggering R&D costs and to profess surprise at the marketing practices. The dramatic increase in both its scale and power, however, raises ethical problems which are not restricted to psychiatry. They include the exploitation of poorer countries for research where ethical standards may be less strict and where the patients in their trials may never have the resources to benefit from the drugs developed. The temptation to create spurious health needs to sell products is particularly potent in the psychological sphere as almost everyone would like to ‘feel a bit better’. Honest debate and tighter guidelines are needed.
Reliability versus validity
Diagnosis in psychiatry has moved towards a criterion-based system. The traditional approach of pattern recognition and reflective empathy informed by extensive familiarity with normal and abnormal behaviours has been replaced by a process of carefully listing features of the disorder that are present. The change was a response to unacceptable variations in diagnostic practice. The new diagnostic system (laid out in the Diagnostic and Statistical Manual – DSM III, now DSM IV) also strove to avoid relying on the psychiatric theories which had caused such conflicts in the past. Whether one really can have an entirely ‘a theoretical’ diagnostic system is, of course, open to debate.
The new system emphasizes reliability (i.e. ensuring that different psychiatrists faced with the same symptoms will always come to the same diagnosis) more than it does validity (i.e. ensuring that patients with a particular diagnosis will have similar outcomes and responses to treatment). The goal would be, of course, maximal reliability and maximal validity. Good reliability does not, however, necessarily guarantee good validity. The fact that we all agree on the defining characteristics doesn’t mean it really is ‘something’. For example, 17th-century witch-finders were very reliable - they all agreed on the tell-tale signs and so consistently agreed on who was a witch before they burnt her. We would not now say that they had really ‘identified’ a witch, because we don’t believe in them, but their methods were certainly very reliable.
Reliability can mistakenly imply validity so that a condition gets accorded the status of a diagnosis essentially because psychiatrists can agree on how to define and recognize it. I have already mentioned a couple of these controversial diagnoses – social phobia and ADHD – but there are several more which really stretch credibility. Nicotine and caffeine ‘use disorders’ are now both official psychiatric disorders, but few of us would consider these mental illnesses. Similarly there is a range of behavioural patterns which have acquired the highly questionable status of a diagnosis (and therefore may receive ‘treatment’). An example is adolescent ‘oppositional defiant disorder’, which is suspiciously close to the description of a difficult teenager who simply refuses to do what his parents want.
Psychiatrists on the whole are trusting souls. They tend to take their patients’ stories at face value. This was vividly demonstrated by the psychologist David L. Rosenham’s famous study, ‘Being Sane in Insane Places’. In 1973 he got eight volunteers to go to emergency rooms in America complaining of a voice in their head which said ‘empty’, ‘hollow’, or ‘thud’. All eight were admitted to psychiatric units where they then behaved absolutely normally. The most amazing thing was that they stayed in hospital for an average of just under three weeks each before they were discharged. Even worse, most of them got a diagnosis on discharge of ‘schizophrenia in remission’. Not surprising then that there is such a call for reliability. So there are several forces acting on psychiatry (including the natural curiosity of researchers) which threaten continued expansion. Whether this is a desirable development is one that should not be left to the profession alone to decide but requires debate within the broader society (i.e. you).
Personality problems and addictions
Psychiatrists have always dealt with the consequences of drug and alcohol addictions. They have also always recognized that there are groups of individuals whose personalities are markedly abnormal and can cause endless problems. The degree of human misery associated with these problems is beyond dispute, and such individuals are found in large numbers in mental health services. There are, however, strong arguments for and against whether these are primarily psychiatric disorders and whether psychiatrists should be responsible for treating them. This is no simple academic argument that could allow both sides to just make individual decisions that suit them. People with these problems may be, and are, treated against their wishes.
Coercion in psychiatry
Compulsory treatment is permitted in psychiatry in every society - including Western societies whose very founding principles are respect for individual liberty before the law. This very striking exception stems from the observation that during periods of illness an individual’s judgement is impaired and they are not able to make rational decisions; mental illnesses often involve a ‘break’ with normal functioning and a change that estranges the patient from their normal self. Unlike, for instance, a learning disability where the individual may also not be able to make informed and rational decisions because they have never developed the capacity, the striking characteristic of mental illnesses is the change. Most societies have sanctioned a paternalistic provision for coercive treatment from a humane desire to protect an individual who is clearly ‘not themselves’. This resolve is strengthened by the repeated observation that patients recover and express the same concerns as the rest of us about their behaviour when unwell. Many are even grateful that they were forcibly treated.
Lawyers find these areas difficult. The standard assessment of ‘capacity’ to make treatment decisions (the ability to understand the information, the ability to trust the individual giving the information, and the ability to retain and make a decision based on that information) works well for children, the learning disabled, and those with dementia. However, it doesn’t work well where the problem is one of judgment and mood rather than intellectual ability. Imposing treatment against a patient’s will rests ultimately on the psychiatrist’s conclusion that the patient is suffering from a mental illness such that their current decisions are not those they would usually express. Note that this involves the psychiatrist making a judgment on what he believes that the patient would usually do or want when well. Compulsion is also sometimes used as a brief safety measure with people who are ‘temporarily unbalanced’ – a terrified individual in a strange place or young people attempting to kill or harm themselves in despair after a relationship break-up.
Severe personality disorders
Psychiatry’s attitude to psychopathic and antisocial personality disorder usually in men, and borderline personality disorder, usually in women, presents ethical and conceptual concerns. Psychopaths are cold, callous individuals who lack empathy for others and consequently can commit awful crimes. They give no thought to the consequences for others and show no remorse afterwards. They are often recognizable early on (death of pets, arson, etc.). Being self-centered and not caring about others’ feelings they can be extremely successful; it is jokingly proposed that mild psychopathy is an essential for being a successful politician. Psychopaths are often lumped together with explosive and violent individuals as antisocial personality disorder. This group is a massive problem for the prisons and criminal justice system. In some countries psychiatrists detain these individuals under the same conditions as the mentally ill and this has been criticized as an abuse of power. Compulsory treatment is justified mainly by the belief that the patient is not making the decisions that they would normally make and which they will make again after recovery. To warrant coercion the condition is usually time-limited and it is believed with some confidence that the treatment will speed recovery. None of these conditions are met for severe personality disorders. Their behaviour reflects their personality – their real identity; they are not aberrant or temporary, and to date there is no convincing evidence that forced treatments will significantly change them.
Such people pose profound challenges for society. They have often committed serious sexual and violent crimes and it is obvious to prison staff that, as little has changed, they will offend again. In England they are labeled as having a dangerous severe personality disorder (DSPD) and highly staffed new units have been built to treat them. But is their potentially indefinite detention by psychiatrists (as opposed to a prison sentence when they break the law) any less an abuse than the detention of political prisoners in the Soviet system was? The humanitarian sentiments of those involved do not remove the ethical dilemma.
The Western world has experienced an upsurge in chaotic self damaging behaviour in young women. Overdosing and cutting have become common features of female inmates of mental hospitals and prisons. Patients seem out of control, are clearly distressed, and damage themselves in what often seems like a mixture of anger and a desperate plea for help. Psychiatrists feel responsible but impotent and often try to ‘contain’ the situation by keeping the patient compulsorily on a ward offering supervision and support. Unfortunately things may go from bad to worse – the patient self harms more and the psychiatrist increases the restrictions to control the situation. A vociferous pressure group argues that what these women do to their bodies is their own affair and psychiatry is overstepping the mark in treating them against their will. They point to the cultural precedents for self-mutilation (religious and ritual scarring are common in many societies) and underline how medicine, and psychiatry in particular, has consistently denied women’s self-determination over their own bodies.
Drug and alcohol abuse
A similar set of arguments holds for drug and alcohol abuse. Both can be associated with mental illness and both can also cause mental illnesses. Fine for psychiatry to be involved then. But are drug or alcohol abuse mental illnesses in themselves? The rebranding of addictions as illnesses was a humanitarian impulse in the 1940s after the founding of Alcoholics Anonymous in 1939, to provide help to detoxify addicted individuals and support sobriety. The world’s largest self-help groups (Alcoholics Anonymous, AA, and Narcotics Anonymous, NA) both consider addiction a lifelong illness, although they rely on personal and spiritual support rather than medical treatment.
AA and NA view the addict as fundamentally different from other individuals, never able to use drugs or alcohol sensibly. Within psychiatry, however, there are divided views. Many view addiction as an illness to be treated like any other mental disorder. Others see drug and alcohol abuse as dangerous habits that can lead to mental illnesses but are not themselves illnesses, and ultimately are the responsibility of the individuals themselves. The medicalization of substance abuse is criticized as a distraction from effective public health measures such as raising the price and restricting access. Both of the latter have been shown to reduce drinking and drink-related illnesses and deaths. Offering help such as prescribing medicines to cope with withdrawal and support to build up a sober lifestyle are uncontroversial. Concerns arise from the use of compulsion which is common to a limited degree in most countries. In much of Scandinavia, Eastern Europe, and Russia, however, there has been extensive use of specialized mental hospitals for longer term detention and treatment of alcoholics and drug addicts. Can this be justified? The consequences of heavy drinking or drug abuse can undoubtedly be disastrous, even fatal. But many of us make foolish decisions and suffer the consequences – smoking is probably more dangerous than drinking but we don’t compulsorily treat smokers. The confused thinking and poor judgment when intoxicated is also a questionable justification for psychiatric intervention as the express purpose of becoming intoxicated is to alter judgments by blurring an unattractive reality.
Increasing sophistication in genetics and epidemiology has helped identify those who are at greater risk of alcoholism and drug abuse. There are well recognized ethnic variations in the ability to tolerate and metabolize alcohol. These findings strengthen the contention that these are not simply personal choices but disorders, much in the same way that schizophrenia is a disorder – we just don’t yet know as much about it as we do about schizophrenia. Some even propose that self-destructive drinking and drug use must be the result of a mental illness. Clearly the issue is still open and psychiatric engagement with drug and alcohol abusing patients will continue to attract some controversy.
The insanity defense
The coercion controversies in psychiatry are about unfairly depriving individuals of their rights. An important motive in early mental health legislation, however, was to protect patients from being punished for crimes they committed when unwell. Society has always felt uncomfortable about such punishments. The crime of infanticide was distinguished from murder because 19th-century juries refused to convict and send to the hangman mothers who killed their babies while suffering post-partum psychoses. The importance of establishing criminal intent (‘mens rea’ or ‘guilty mind’) has guaranteed a long and tortured relationship between psychiatrists and the courts. Agreeing whether or not someone was insane at the time of the crime (i.e. unable to judge the significance of their acts and realize that they were wrong) has in principle been fairly straightforward. However it is often far from easy in the individual case. Similarly floridly ill patients, unable fully to understand what is going on in court, may be judged unfit to plead and admitted to hospital for treatment. Most countries will accept the decision of unfit to plead on the basis of a psychiatric assessment or will return a not-guilty verdict on the grounds of insanity.
The real problems in court concern diminished responsibility on the grounds of mental illness – particularly where the criminal behaviour itself is the clearest manifestation of the disorder. It is less a problem with a grossly disturbed individual whose crime is just one among many signs of the illness (such as a manic patient in court for reckless driving but who also at that time is not sleeping, dressing in outrageous clothes, and spending all his money). Proposing personality disorders as a defense (i.e. because a psychopath does not notice or care about the distress caused) strikes at the concept of free will and personal responsibility that is the very foundation of criminal justice systems. Most criminals have had dreadful childhoods. Many have been abused. Few have skilled jobs or stable families to fall back upon. So it is not surprising that we may temper justice with mercy. But is there not circularity in citing the very qualities that give rise to the crime as an excuse for a reduced punishment? This ethical dilemma is particularly sharp in individuals with Asperger’s syndrome (a mild form of autism) who cannot see the world from the other’s perspective and cannot interpret others’ motives even though they may desperately want to. In practice the more serious the crime and the greater the risk, the easier the decision. Where the alternative to a guilty verdict and prison is hospital care (and sometimes secure hospital care) courts and juries feel more comfortable to make the allowance. In lesser cases, where punishment is not so severe, and might just deter a repetition, it is argued that a psychiatric defense is unjustified and probably does the individual no favours in the long term. Thomas Szasz insists that the psychiatric defense is a denial of the fundamental rights and obligations of the individual. A psychiatric defense is generally accepted for individuals where the disorder is plainly there for all to see.
Sometimes the only evidence of a disorder is the crime. There have been several high-profile cases of murder where the perpetrator denies any memory, claiming it occurred during an ‘automatism’ (a dream-like or dissociated state). In even more extreme cases ‘multiple personalities’ have been proposed where a single individual has several fully developed identities, each completely independent of each other. This is a very attractive concept which captures the popular imagination (e.g. Robert Louis Stevenson’s 1885 novel Dr Jekyll and Mr Hyde, and the 1957 film The Three Faces of Eve).
The postulated mechanism is that some mental functioning is so successfully repressed that it is only accessible through deep psychotherapy or ‘triggered’ in highly specific situations. This is of enormous psychiatric/legal significance in cases of alleged childhood sexual abuse. The extent to which children are exposed to sexual abuse by family members has long been controversial in psychiatry. The pendulum has swung back and forth between considering it a common trauma that causes neuroses to the alternative belief that it is rare and most reports are ‘false memories’ arising from current distress and confusion. Currently the presumption is in favour of believing the adult who complains of child sexual abuse. This has resulted in high-profile cases splitting families when ‘recovered memories’ have been unearthed. Psychiatrists appear on both sides of the case, stressing either the damaging impact of abuse, repressed over many years, or, conversely, the patient’s suggestibility in over-enthusiastic therapy.
Psychiatry: a controversial practice
Psychiatric practice will probably always be risky and controversial. Many psychiatrists argue for a more limited approach, restricting it to clearly identifiable and agreed mental illnesses: ‘We should stick to treating diagnosed illnesses, schizophrenia, anorexia nervosa, depression and accept that there are many other causes of human distress beyond mental illness.’ ‘We should leave the social policy and ethics to the politicians and philosophers.’ This is an attractive argument. The history of psychiatry is full of examples of overstepping the mark. But as we have seen in this text it is not simply up to the psychiatrists - there are other stakeholders and powerful forces at play with broad ethical issues and significant potential benefits in the balance.
Scientific developments are expanding what we can do; families and patients have steadily rising expectations from us; governments and the pharmaceutical industry challenge us with new demands, inducements, and opportunities. We could only possibly avoid controversy and the risk of potential mistakes if we turned our back on progress and innovation. But that means not fulfilling either psychiatry’s promise or its obligations. Straddling hard science and the field of human behaviour and ambitions, it is simply impossible for psychiatry to be uncontroversial.