|An interview with Charles Barber, author of Comfortably Numb: How Psychiatry is Medicating a Nation|
Q. About two-thirds of the money spent globally on antidepressants is accounted for by the United States. What drives Americans to become "comfortably numb"?
A. Americans have always liked the quick-fix, and overwhelming the enemy with technology – whether it’s a foreign country or a medical problem. But we like it more than ever – probably fueled by our ever-shortening attention spans, and the expectation that everything will or must occur at the click of a mouse. Another factor driving American drug-taking is our increasing isolation from each other, accompanied by a simultaneous pressure to achieve and perform, including the achievement of happiness. The result of all of this is Americans are rushing to the medicine cabinet, in particular for antidepressants – the most prescribed drug in America – in record numbers. We think that what we find there will eradicate our distress, numb out our internal discord, and help us keep with the Jones’s – or the Gates’s.
Q. During the last decades, the public began to view mental illness as common and easily treated with medication: celebrities declaring their problems, ordinary people talking about their pills. Do you believe that attitudes toward the truly mentally ill have changed?
A. No. The truly mentally ill – people with schizophrenia and bipolar disorder, for example – are just as stigmatized as they’ve ever been. It may now be acceptable and even cool to talk about taking antidepressants at a party, and it certainly is cool for an actress to talk about her bout with depression on Oprah (as long as it’s now well under control and she has a new hit movie) but see what happens if you talk about hearing voices or having visions. People will move away as fast as they can. And with all the increased rates of psychiatric drug-taking by the masses, the number of people with really serious mental illnesses who are in proper treatment remains very low.
Q. Recently, there has been a considerable increase in cases of depression, bipolar disorder and other psychiatric conditions. Do you believe that these illnesses have become better diagnosed or simply overdiagnosed?
A. As usual with these kinds of things, it’s a bit of both. Certainly in the past, the great uncle who was just considered a little weird or isolative was really suffering from schizophrenia and nobody knew, or wanted to know. But things have gone very far in the other direction. Now everyday troubles are medicalized -- and medicated. Psychiatry has expanded the number of diagnoses so hugely in the last 30 years that one can now receive diagnoses and labels like “adjustment disorders” and “sibling-relational problems” and “phase of life problem.” Having a hard time adjusting to a new situation, or having difficulties with one’s family can be painful and disruptive – but they are absolutely not medical problems. Major studies find that a quarter of Americans suffer from a psychiatric disorder annually, and most will be mentally ill at some point. I reject that view. Serious mental illness is a terribly serious condition that affects a rather small proportion of the population.
Q. You describe the difference between depression and Depression, the former being a part of human life, and the latter a major illness with specific symptoms. Why do you believe that the wrong people are taking the medications?
A. It is often the case that the less severe one’s condition, the more likely one is to be medicated and in treatment. Major Depression is a life-threatening medical disorder which has nothing to do with “feeling blue,” “bummed out,” and “having a hard time with the winter.” Confusing the two -- serious mental illness versus everyday life problems -- has led more than anything to the over-medicating of people with no true psychiatric conditions. Furthermore, even for serious conditions, drugs are not the only approach. Cognitive-behavioral therapy has been shown to be as effective and possibly more effective than drugs for mild to moderate depression, and without the side effects and with lower relapse rates. Diet and exercise also can make a huge difference, even for Major Depression. In our zeal for the drugs, we overlook these approaches, which are highly effective but not as simple as taking a pill.
Q. You note that “each new generation of Americans either chooses a favorite drug or creates one…The War on Drugs will likely never be won because Americans don’t want it to be won.” How is the war on illegal drugs is different or similar to the reliance of Americans on antidepressants?
A. The difference between legal and illegal drugs can be a much thinner line than one would think. The pharmacological profile of Ritalin, for example, is very similar to that of Cocaine. We also tend to blame our drug problems (whether legal or illegal) on others -- the Colombians, for example, for our cocaine addiction -- rather than looking inward and trying to identify why we are depressed and anxious and so drawn to drugs.
Q. You note that the combined profits of the top ten drug companies in 2002 were greater than the profits of all the other 490 Fortune 500 companies together. What is the role of commerce in the mental health field—for example, doctors being paid by drug companies to publish articles in medical journals?
A. The Mental Health industry now involves big money. Many of the top psychiatric drugs are among the best-selling drugs in the world. Antidepressants were the most profitable product in the most profitable industry in the world during the 1990s. Of course the mixture of all this money with medicine can have disastrous results. Studies show that drug trials conducted by people with a financial conflict of interest with the drug they are evaluating are almost five times more likely to report positive results.
Q. The role of drugs and children is a hot topic. What are the risks for children on these drugs, and for families who view the pills as having only positive effects?
A. The medicating of children is particularly worrisome. Medicating kids involves changing their brains as they are developing in ways that nobody understands. Rates of medicating kids have soared in the last decade, as have the use of controversial psychiatric diagnoses for children. As with adults, I think there is a small percentage of truly ill children who have true diagnoses and need the drugs. ADHD drugs can be quite broadly effective, but the rise in the use of powerful antispychotics and mood stabilizers, and their combination, is disturbing and largely inappropriate.
A. While the drug companies have been highly manipulative in their marketing practices, ultimately I blame the doctors. The insurance and drug companies are doing what industry is supposed to do in America: make a profit. Attacking these industries for that is a little like criticizing a cougar for attacking a deer. Unlike the doctors, Big Pharma and the insurance industry have not taken a Hippocratic oath.
Q. The alternative approaches that you suggest—Stage of Change, Motivational Interviewing, and peer engagement—necessitate a paradigm shift: “recovery can exist within the context of illness.” You also say we need to listen closely to those who are mentally ill about what works for them. Could you summarize these approaches and the need for a reversal in how we view illness and treatment?
A. The lessons of the “recovery movement” -- led by people who have suffered from severe mental illness and improved -- are much different than the messages and marketing that comes from the drug companies about how to treat illness. Former patients say that getting better involves not the removal of all symptoms but learning how to live a meaningful life, even in the presence of on-going, if hopefully reduced, symptoms. Former patients also say that the social context is critical to getting better -- the strength of their relationships and supports makes a huge difference, as does finding something or somebody that makes one want to get better in the first place. They also say that they improve most when they are put “in charge” of their recovery, rather than being the passive recipient of a pill or merely being told by a doctor what to do.
Motivational Interviewing (MI) and the Stages of Change model are interventions and ways of looking at illness that have come to fore in the last 20 years, since Prozac was introduced, but nobody knows about them because there’s no marketing money attached to them. They involve, in a phrase, listening to patients instead of listening to Prozac. The Stages of Change model looks at change as cyclical rather than linear process (one make have to go through various cycles to ultimately change a behavior) and MI, first developed as a way to engage substance abusers, is a way of meeting clients “where they are at” and then helping them identify their own, internal reasons to get better. The MI approach is the exact opposite of the old way involving the confrontation of patients, but it is highly strategic and uses very specific techniques to find the things that a person can use on their own to change. Research shows that MI is effective in changing patients’ behavior towards a whole range of unhealthy behaviors, including depression and anxiety.