Psychiatry by Prescription

This is the cover article for the July and August 2006 edition of Harvard Magazine. While sympathetic and pro-psychiatry in many regards, it points out that modern psychiatry is in a crisis, precisely because of the drugs. It is probably a useful article to approach someone who is a hard-core advocate of psychiatric services.

For example, there is this snippet:

Consider the case of Dora, described by Joseph Glenmullen in his book Prozac Backlash. When Dora, a schoolteacher, retired, she expected to enjoy her new freedom, especially the chance to spend time with her grandchildren. But after six months, she began to feel down. She missed her job and the sense of purpose it had provided. Her primary-care doctor told her that she was suffering from depression and, after a 20-minute consultation, gave her a year’s prescription for Prozac. He did not schedule a follow-up appointment. The medicine relieved Dora’s immediate symptoms of depression, but also left her feeling fatigued. When the year was up, she called her doctor’s office, wondering whether she should continue the treatment. The secretary told her to leave a voicemail message letting him know she was running out of medication. To Dora’s dismay, the doctor simply called in a renewal of her prescription without seeing her.

Dora eventually sought an opinion from Glenmullen. He learned that she had witnessed the murder of her parents by Nazi soldiers as a child in Budapest, and had then been shipped to Auschwitz with her grandmother, who was sent straight to the gas chambers. After the war, Dora moved to the United States, married, raised a family, and taught for 30 years. “All her life, she worked hard to survive and to put the horrible Holocaust memories out of her mind,” Glenmullen explains. But she had more time on her hands after retiring, and the painful memories returned.

During a six-month course of psychotherapy, Dora was able to address her long-suppressed feelings. She eased off the drugs and her depression did not return. Talking about the secrets from her past was a relief—and so was overcoming dependence on medication. “How could [Dora’s] HMO have failed to inquire even minimally into her psychological state and life history?” Glenmullen writes. “Are Holocaust memories really a ‘disease,’ a ‘biochemical imbalance’ that should be ‘corrected’ with a pill?”

Then there is this

As professor of health economics Richard Frank explains in a recent article in the Milbank Quarterly: “Prescription drugs are ‘free inputs’ to the specialty mental-health delivery system, and [...] vendors have a strong economic incentive to substitute drug treatments for other mental-health services when possible. They do this by making it easier for patients to obtain referrals for medication management and psychopharmacology than referrals for psychotherapy.” According to Frank, carve-out arrangements—under both private insurance plans and Medicaid—have increased overall prescription rates for psychotropic drugs.

In other words, they go with the drugs because it's cheaper.

There is also an extensive discussion of the marketing and money angle in the psych drug industry.

The amount the pharmaceutical industry spent on television and print advertisements aimed at the public grew exponentially during the 1990s, particularly after the Food and Drug Administration released guidelines for the practice in 1997. (In 2004, drug companies spent $193 million on direct-to-consumer advertising for antidepressant medications, up from $85 million in 1999.) A Prevention Magazine survey in 2002 showed that 90 percent of the public have seen prescription-drug advertisements, and, according to a 2004 study published in the journal Medical Care, exposure to ads increases the likelihood of using a psychotropic medication to treat depression.

There is this from the conclusion:

Drug companies and health insurers are not the only ones responsible for our growing dependence on psychopharmaceuticals. “We’re all unindicted co-conspirators,” as Monrad professor of the social sciences Charles Rosenberg, an historian of science, puts it.

Americans are living in a cultural moment when the idea of a quick, material solution to psychic and emotional pain is extremely appealing. “As a society,” Rosenberg says, “we’ve never been more infatuated with visions of molecular and neurochemical—ultimately genetic—truth.” If our children are unmanageable, we are thankful for a diagnosis that shifts the blame from us to nature and offers the prospect of a tangible cure. If our fears of underperforming in our jobs or our marriages make us less productive, the lure of medication may be hard to resist. (If the guy in the next cubicle is on it, shouldn’t I be?)

The Harvard-educated physician in New York City reports that requests for antidepressants have increased most recently among her Wall Street patients. “They’re stressed about work, about their mortgages, about their kids’ school problems,” she says. “They want to stay competitive.” Psychotherapy takes time and may not work — and who can afford to fall behind?

Psychiatry’s crisis is not simply a problem of diagnostic precision or of misplaced economic priorities; it is also a moral predicament that reflects our times. How much of ourselves are we willing to give over to forces of scientific and technical control? [...] At some point, we will have to look beyond immediate symptoms if we hope to address the reasons for so much anxiety and dysphoria in our society.

Jerome Kagan offers a useful analogy:

There’s a place in a large city with very bad drinking water, and kids are always getting sick with dysentery. So you keep treating the dysentery, but meanwhile it would be much better to clean up the drinking water…. The drugs work on the dysentery for about 48 hours, but you’re not treating the problem. And the problem is not genetic.