Psychiatry’s Flight From Psychiatry’s Flight From ScienceScience

W. Joseph Wyatt, Ph.D.

Marshall University

Huntington, WV

Wyatt@Marshall .edu

Presented at the Association for Behavior Analysis

Atlanta, May, 2006

““Psychiatry’s Anxious Years”Psychiatry’s Anxious Years”

NY Times (Nelson, 1982)Residency drop from 1970-1980, 11% to

5% of medical school grads.– Relatively low pay– Family practice emphasis– Psychoanalytic confusion– Fringe Treatments & loss of esteem– “Intruder” professions

Psychiatry’s response to this Psychiatry’s response to this crisis?crisis?

Strategy conferences held.

Solution: Become more medical, and

Attack the intruders

Examples of such attacksExamples of such attacks

Hospital & Community Psychiatry (Bursten, 1981):

“Medicalization” of disorders is useful “to rally the troops…to thwart the attackers…Economics demands that we be medical…we use the term to rout the enemy within.”

Another exampleAnother example

American Journal of Psychiatry (Havens, 1981)

“(Psychiatrists must) speak with a united voice…to buttress (our) position against the numerous other mental health professionals seeking patients and prestige.”

AnotherAnother

Paul Fink, President-elect of Am. Psychiatric Assn. 1988:

“(Non-psychiatrists) don’t have the training to make the initial evaluation and diagnosis…(and) are not trained to understand the nuances of the mind…”

And anotherAnd another

Melvin Sabshin, Medical Director of the American Psychiatric Assn., testimony before the New York State Legislature, 1988:

“Do the grave and inevitable risks to the quality of patient and medical care in hospitals outweigh the dubious, purported benefits associated with hospital privileges for these non-physician practioners?”

Our first conclusion today:Our first conclusion today:

Organized psychiatry’s 30-year emphasis upon biological causation has been motivated, in part, by non-science based factors including:– Protection of its turf from “outsider”

professionals– Re-establishing its esteem

Pharmaceutical Company Pharmaceutical Company Financial InterestsFinancial Interests

Question: How to achieve symbiosis with organized psychiatry?

Answer: Promote the biological causation model of disorders.

Simultaneous marketing of drugs Simultaneous marketing of drugs andand the biological model—the the biological model—the

“Celexa helps to restore the brain’s chemical balance by increasing the supply of a chemical messenger in the brain called serotonin.”

“In people with depression and anxiety, there is an imbalance of serotonin…Lexapro blocks the serotonin from going back into the first nerve cell.”

More examples…More examples…

“When you’re clinically depressed…the level of serotonin…may drop…the medicine doctors prescribe most is Prozac.”

“Paxil works to correct the chemical imbalance believed to cause (depression).”

“…depression may be related to an imbalance of natural chemicals…Zoloft works to correct this imbalance.”

Lacasse & Leo, 2005, PLoS Medicine

Evidence for a serotonin-depression Evidence for a serotonin-depression causal connection?causal connection?

The experts speak:

“Some have argued that depression may be due to a deficiency of …5-HT (serotonin) because enhancement of serotonergic neurotransmission improves the symptoms. However, this is akin to saying that because a rash on one’s arm improves with use of a steroid cream, the rash must be due to a steroid deficiency.”

Delgado & Moreno

J. of Clinical Psychiatry, 2000

“In fact, we cannot measure brain serotonin levels in living human beings so there is no way to test this theory (that a serotonin deficiency causes depression).”

David Burns, 2003

Note: Burns is a Stanford University psychiatrist, winner of the A.E. Bennett Award given by the Society for Biological Psychiatry for his research on serotonin metabolism.

“We have hunted for big simple neurochemical explanations for psychiatric disorders and have not found them.”

Kenneth Kendler, 2005

Note: Kendler is coeditor-in-chief of Psychological Medicine.

“The incongruence between the scientific literature and the claims made in FDA-regulated SSRI advertisements is remarkable, and possibly unparalleled.”

Lacasse & Leo, 2005

PLoS Medicine

Direct to Consumer & Direct to Direct to Consumer & Direct to Professionals AdvertisingProfessionals Advertising

Legalized in 1995TV, newspaperPhysician Journals

– Pediatrics: Full-page ads for ADHD drugs 1990 7 ads 1995 12 ads 2000 15 ads

Lucey, 2002

The marketing of psychotropic The marketing of psychotropic medications: Successful?medications: Successful?

2001-2004:– 49% increase in Rx of ADHD drugs in children

under 5 years.– 23% increase in overall usage of ADHD drugs.

Medco Health

Johnson, 2004

2001-2002:2001-2002:

Top ten revenue producing drugs included:–Zyprexa–Zoloft–Paxil

$7.5 billion in sales in the U.S.Vaczek, 2003

AdultAdult use of ADHD drugs: use of ADHD drugs:

100% increase – 2000 to 2004

Medco Health Solutions

AP, 9-16-2005

Children* taking anti-psychotic drugs:Children* taking anti-psychotic drugs:

1995-96 500,0002001-02 2.5 million Ambulatory Pediatrics

March/April, 2006

*Ages 2-18, Mean=13 years

Drug industry jobs: Where Drug industry jobs: Where does the money go?does the money go?

Boston University Health Reform Project (Sagar & Socolar, 2001)*Boston University Health Reform Project (Sagar & Socolar, 2001)*

The number of research &

development jobs fell 2%

*Data obtained from website of PhRMA, drug lobby organization

The number of marketing jobs rose by 59% to over 100,000

—double those in R & D.

Does direct-to-consumer Does direct-to-consumer advertising influence physicians’ advertising influence physicians’

Rx’ing?Rx’ing?Journal of the American Medical Association

Kravitz, Epstein, Feldman, Franz, Azari, Wilkes, Hinton & Franks, 2005

Subjects & Method:

152 family doctors were visited unannounced 298 times by actors posing as patients.

The “patients” pretended to have symptoms of either major depressive disorder or adjustment disorder with depressed mood.

At some visits the “patients” said, “I saw an ad At some visits the “patients” said, “I saw an ad for Paxil on TV. Doctor, do you think Paxil for Paxil on TV. Doctor, do you think Paxil could help me?”could help me?”

At other visits the “patients” said that they had seen an ad for “an anti-depressant” on TV, but didn’t specifically mention Paxil.

At still other visits the “patients” made no reference to medication.

ResultsResults

Rx of Paxil when the “patients” exhibited major depressive disorder*:

Mention of “Paxil” 27.4% Mention of “a drug” 2.0%No mention of drugs 4.2%

*Similar percentages for adjustment disorder

Our second conclusion today:Our second conclusion today:

The pharmaceutical industry’s marketing efforts (including direct-to-consumer advertising) have increased dramatically since 1995.

Sales of medications, including psychotropic medications, have escalated at the same time.

MarriageMarriage

Psychiatry Pharmaceutial Industry

Cementing this marriage Cementing this marriage together is:together is:

Biological causation theory

Reinforcers of this marriage:Reinforcers of this marriage:

Money and power

The “reach” of this marriage, The “reach” of this marriage, in headlinesin headlines

“Drug firms still sponsor doctors’ classes, but not so visibly” Vrazo, 2005

“Drug firms play major role in defining disease” Kelleher & Wilson, 2005

“Experts on mental illness manual linked to drug companies” Graham, 2006

•““Medical journals are an extension of the Medical journals are an extension of the marketing arm of pharmaceutical marketing arm of pharmaceutical companies”companies” RichardRichard SmithSmith

Health Letter, 2005Health Letter, 2005

“Journals have devolved into information laundering operations for the pharmaceutical industry.”

Richard Horton, Editor

Lancet, 2004

Question: What is theQuestion: What is the empirical empirical evidence that biology accounts for evidence that biology accounts for

specific disorders?specific disorders?

Depression Anxiety Child conduct problems Schizophrenia ADHD

The “Mind Freedom” The “Mind Freedom” challenge to organized challenge to organized

psychiatry (2003)psychiatry (2003)Q: What is Mind Freedom?

A: A loose-knit federation of professionals and former patients.

Q: Whom did Mind Freedom challenge?

A: The American Psychiatric Association; Office of the Surgeon General of the U.S.; NAMI.

Q: What was the challenge?Q: What was the challenge?

A: To produce any scientifically valid evidence to show that:

1. Schizophrenia, depression or other disorders (apart from the obvious such as Down’s Syndrome, autism, tumor-related, etc) are biologically based.

2. There is any physical diagnostic test which can distinguish those so diagnosed from “normals.”

The challenge, continued…The challenge, continued…

3. There exists evidence of a chemically balanced “normal” personality against which a neurochemical “imbalance” may be compared.

4. Any psychotropic medication can correct a “chemical imbalance” or decrease the likelihood of violence or suicide.

The American Psychiatric The American Psychiatric Association RespondsAssociation Responds

August 12, 2003August 12, 2003

Letter to Mind Freedom from James H. Scully, Jr., Medical Director of the American Psychiatric Association:

Letter from Dr. Scully:Letter from Dr. Scully:

“The answers to your questions are widely available in the scientific literature and have been for years…”

Scully’s letter cited five sources: A report by the Surgeon General; two well-known books; and any recent issues of The American Journal of Psychiatry and/or Archives of General Psychiatry.

Mind Freedom Replied to Dr. ScullyMind Freedom Replied to Dr. Scully

The Surgeon General’s report: “the precise causes of mental disorders are not known” (p. 49)

The first textbook: “…validation of the diagnostic categories as specific entities has not been established.” (p.43)

The second textbook: “…the goal (of identifying etiology of major mental illnesses)…has been achieved for only a few disorders (Alzheimer’s disease, multi-infarct dementia, Huntington’s disease and substance induced syndromes…” (p.23)

The American Psychiatric Association The American Psychiatric Association responded with a position statement:responded with a position statement:

Mental disorders are “neurobiological” (There has been) “…remarkable scientific and

clinical progress (in the ) understanding of disorders that afflict and are mediated by the brain…” (No citations)

“…brain science has not advanced to the point where scientists or clinicians can point to readily discernible pathologic lesions or genetic abnormalities that…serve as reliable biomarkers of a given mental disorder or mental disorders as a group…”

Our third conclusion today:Our third conclusion today:

The American Psychiatric Association is engaging in self-serving promotion of biological causation theory, in the absence of scientific evidence.

Thinking critically about research Thinking critically about research often cited as evidence of often cited as evidence of

biological causationbiological causation

Two major lines of research:Two major lines of research:

Family studies:

Especially studies of Identical twins reared apart.

Studies of brain chemistry/structure/

function– On autopsy– PET & fMRI scans

Identical twin studiesIdentical twin studies

The bio-enviro confounds:– Physical attractiveness– Rate of physical maturation– Family & adoption agency practices– Age at adoption

Monitor on Psychology, Monitor on Psychology, 2004:2004:

“Despite the popularity of twin studies, some psychologists have long questioned assumptions that underlie them…

Winerman, 2004

Studies of brain Studies of brain chemistry/structure/functionchemistry/structure/function

Neuroplasticity and direction of causation

“The now overwhelming evidence that experience can alter neuronal structure and function should make it clear that it is dangerous to assume that any anatomical or physiological characteristic found in brains of people with mental disorders was the cause of that disorder.”

Valenstein, 1998

Consider the depressed Consider the depressed “couch potato”“couch potato”

Changes in muscle tone, reflexes, energy level, heart rate, metabolism, etc., resulting from such a lifestyle.

Would it be surprising if there were concurrent changes in brain chemistry?

Consider the high pressured Consider the high pressured business personbusiness person

Changes in heart rate, muscle tension, stomach acid secretion, etc.

Q: Would it surprise us to learn that there were concurrent changes in brain chemistry?

Other methodological issues in Other methodological issues in studies of brain studies of brain

chemistry/structure/functionchemistry/structure/functionThe subtraction method of data collectionComparison of percentage vs. absolute

numbers of base rates.

Our fourth conclusion today:Our fourth conclusion today:

The “evidence” usually cited in support of biological causation of “mental” and behavioral disorders is weak.– In studies of identical twins who have been reared

apart, the biological and environmental variables are hopelessly confounded.

– In studies of brain chemistry/structure the brain’s neuroplasticity leaves the direction of causation unknown. Did brain abnormality cause the behavioral disorder, or the reverse?

Conclusions and Recommendations:Conclusions and Recommendations: Organized psychiatry’s 35-year embrace of

biological causation of behavioral disorders has been based largely on non-science factors including its loss of esteem and protection of its “turf.”

The pharmaceutical industry has pushed biological causation well beyond the data--evident in its direct-to-consumer advertising.

Organized psychiatry and the pharmaceutical industry have become symbiotic: each continues to engage in self-serving, non-data-based advocacy of biological causation theory.

Conclusions & Recommendations…Conclusions & Recommendations…

The evidence of biological causation of most abnormal behaviors, such as most depressive and anxiety disorders, schizophrenic disorders, child conduct disorders, etc., is weak.

More than three decades ago B. F. Skinner wrote, “…genetic sources sometimes become a kind of dumping ground: any aspect of behavior which at the moment escapes analysis in terms of contingencies of reinforcement is likely to be assigned to genetic endowment…” Skinner’s observation remains true today.

Conclusions & RecommendationsConclusions & Recommendations……

Patients/clients are daily being shortchanged as a result of the unwarranted emphasis on biological causation. Research tells us that they are less likely to believe that they can improve with appropriate help, when they assume biological causation (Phelan, 2002).

It is time for a paradigm shift, away from extreme biological causation and toward an environmental causation model—one which recognizes that at least some disorders (autism, a modest number of cases of depression, etc.) are biologically caused.

Conclusions & Recommendations…Conclusions & Recommendations…

Such a paradigm shift is unlikely to occur in the near future. Reasons:– Money & power of the pharmaceutical and psychiatry

industries– Layperson preference for biological causation.

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There could be no better evidence of the environment’s impact upon us, than the far-reaching influences of psychiatry’s flight from science.