Psychiatry’s Failure as a Medical Science
Table Of Contents
- Advance Praise
- About the author
- About the book
- This eBook can be cited
- Foreword (By Robert Whitaker)
- 1 Sadness and Depression
- 2 The Medicalizing of Psychiatry
- 3 The DSM-III Data: Truth vs. Truthiness
- 4 Psychiatry’s Brain Disease Theory
- 5 Measuring Antidepressant Effectiveness: STAR*D
- 6 Drug Effects and Placebo Effects
- 7 Antidepressant Drug Safety
- 8 Conflict of Interest
- 9 Big Pharma and the FDA
- 10 Behavioral Science
- 11 Mental Disorder as Learned Behavior
- 12 Behavior Therapy for Depression
I am grateful to many people for helping me to write and publish this book. Most importantly, I want to credit my wife, Carol. Absent her unswerving support during the years it took me to produce a publishable manuscript, this book would not now be before your eyes. I also want to recognize my son Scott’s contribution for his legal expertise and advice in negotiating the contract with the Peter Lang Publishers, as well as for his help in steering me through the pre-publication requirements of the editing process. And I want to thank Dr. Dani Green, the Acquisitions Editor at Peter Lang Publishers, for her availability and help during the evaluation and production process. I also want to thank Robert Whitaker for writing a Forward for this book. There is no more authoritative voice on this subject.
I must thank as well the readers of this book who gave me helpful feedback during various stages of my writing. They include Dr. Peter Roemer, Dr. Susan Drumheller, Dr. Walter Schaffer, Dr. Irving Kirsch, Dr. David Antonuccio, Dr. J. R. Leibowitz, Dr. Karen Kuehl, Katharine and Tom Bethell, Gary Gleason, and Carlo de Joncaire Narten. These readers represent an array of perspectives: several psychologists, a psychiatrist, and a social worker from the field of mental health; a cardiologist who brought a medical perspective; representing the natural sciences are a physicist and a biochemist, the latter having worked as a ←xi | xii→science adviser at the NIH for many years; a teacher and a writer-editor from the field of education; and a banker, from the world of commerce. My expression of gratitude in no way implies that these readers endorsed all of what I have written. They gave me their views, and their training and perspective aided in the construction and narrative of the book.
Finally, I wish to thank Jamie Leventhal and Toby Levine for their great help in solving the myriad mysteries I faced (as someone with little computer knowledge) in preparing this book for publication.
When I was writing Anatomy of an Epidemic, I struggled with making sense of the STAR*D study, which Allan Leventhal writes about in Chapter 5 of this book. I am detailing my own encounter with this study because it illuminates the challenge that Leventhal has undertaken in Grifting Depression, and the expertise he brings to the subject.
In Anatomy of Epidemic, I was focused on investigating the long-term effects of antidepressants and other psychiatric drugs. There is abundant evidence that these treatments worsen long-term outcomes, at least in the aggregate, and yet, at first glance, the STAR*D results contradicted that conclusion.
This NIMH study was the largest antidepressant trial ever conducted, with the NIMH stating at the outset that the results would be used to guide clinical care of depressed patients in the “real world.” The results rolled in, and the NIMH announced that 70% of the 4,041 patients enrolled in the trial had remitted. The key to this success, the investigators concluded, was the clinical care that was provided: patients who didn’t remit on the first antidepressant were switched to a second one, and if that one didn’t work, to a third, and after four such attempts, 70% of patients had found a treatment that worked for them.
Not long after those positive results were published, I overheard a family physician in the locker-room of a local gym explain to a nearby person that ←xiii | xiv→finally, thanks to the STAR*D trial, there was solid evidence that antidepressants “worked.” “You just have to keep on trying until you find the right one,” he said happily.
When I first studied the various STAR*D reports that had been published, it was easy to see that the 70% success rate was, in fact, a finding woven from statistical sleight of hand. When patients dropped out after failing a first, second or third treatment, the investigators—rather than chalk them up as study failures—instead calculated what percentage of those dropouts might have remitted if they had stayed through all four treatments (a calculation based on remission rates for the handful of patients who continued through all four rounds.) That turned a significant number of them into study successes.
There were other statistical machinations that had been employed to inflate the remission rate, but the short-term remission rate wasn’t my primary interest. I wanted to know the long-term outcomes of the patients. There were 4,041 patients who had enrolled in the trial, and of this number, 1,518 had remitted during one of the four treatment periods and been whisked into a one-year follow-up. How many in this group of 1,518 remitted patients had stayed well and in the trial to its 12-month end?
In one of the STAR*D reports there was a graphic that seemingly showed these numbers, but I couldn’t make sense of it, and there was no explanation in the discussion section that could enable you to do so. The best I could make out was that at most 800 patients—from the initial group of 4,041—were still well and in the trial at the end of one year. This was a documented stay-well rate of less than 20%, which, in fact, was fairly consistent with other research showing that over the long-term relatively few patients treated with antidepressants stay well.
Shortly after Anatomy of an Epidemic was published, Allan Leventhal, Ed Pigott and John Boren published a paper that thoroughly deconstructed the STAR*D study and made sense of the very graphic that had left me befuddled. Of the 4,041 enrolled patients, there were only 108 patients who were still in remission and in the trial at the end of one year. That was a documented “long-term” stay-well rate of less than 3%. All the rest of the enrolled patients had either never remitted, relapsed after remission, or dropped out.
I have told this story for one reason: It illustrates the extraordinary gap between what is told to the public about psychiatry and its treatments, and what can be found through a careful study of the research literature. The public had been told of care that enabled 70% of patients to get well; the data told of a stay-well rate at one year that was the worst outcome I have ever seen in a study of depressed patients.←xiv | xv→
At the same time, the STAR*D story illustrates the challenge that Leventhal has undertaken in this book. Our society has organized itself around a narrative that tells of great advances in psychiatry. Researchers, we were told, had discovered that major psychiatric disorders are “illnesses” of the brain and that new drugs brought to market in the 1980s and 1990s fixed the chemical imbalances that cause such illnesses. If this were so, given the complexity of the brain, it could be seen as the greatest medical discovery of all time.
And we, as a society, believed it to be true.
What Leventhal does in the first two-thirds of this book is explain to readers, with a thorough review of the relevant science, that it was all a grift. A swindle. However, when readers first encounter a deconstruction of a conventional narrative, there is a natural reaction: could this possibly be true? And so Leventhal begins where he must, with the publication of DSM III in 1980.
This was the book that gave us the “disease model” and served as the foundation for the narrative of progress that was then told to our society. Once readers understand that there never was a scientific basis for this model, the narrative starts to crumble, and it fully collapses with the dismantling of the chemical imbalance myth.
From that point on, it’s easy for readers to get on board with details of the swindle. The STAR*D study? That just elicits a knowing wag of the head. Of course the public was told of a 70% remission rate with antidepressants, because if the real results had been publicized, then the grift would have been revealed.
The final third of this fine book takes readers into an exploration of a fundamental question: what do we know about ourselves? As a species? The disease model sold to us by psychiatry told of how we were little more than dancing marionettes controlled by our neurotransmitters: these molecules determined our moods, our behaviors, and our thoughts.
Leventhal presents a much different picture. He explores how animal life evolved on this planet, and how we humans learned to shape our behaviors in response to our environments. He writes: “Far more effectively than any other animal, we learned what behaviors worked under different circumstances, we remembered those behaviors, and we communicated this information to others of our kind.”
It is with this understanding, informed by behavioral science, that Leventhal argues for the merits of therapies that take advantage of this capacity of ours. We can learn new behaviors, which can help alleviate emotional pain, and we can seek out environments that are more supportive of our well-being. We are ←xv | xvi→not prisoners of our neurotransmitters, but rather capable of learning new ways of being.
That is what makes Grifting Depression much more than a take-down of psychiatry and a detailing of the harm it is causing us with its false stories. Leventhal asks the vital question: what should replace that narrative that tells of people who have chemical imbalances and thus are powerless to remake their lives? The last third of his book offers an optimistic vision of what is possible.
Health, and that includes mental health, is an essential aspect of human life, and it has preoccupied individuals from the earliest societies until the present. Thanks to science, we have made critical progress in the areas of physiological and public health during the last hundred plus years, a progress that has, for example, changed our expectation of life span drastically. From the Spanish flu in 1918 until the Covid-19 pandemic in 2020, life expectancy has doubled. Medical care for physical illnesses has advanced dramatically. “Apoplex” (stroke) and “Dropsie” (swelling) have been replaced by diagnoses and treatments that are informed by science, routinely reducing suffering and saving lives. Infant mortality rates have plummeted and diseases that we had little hope of conquering at the turn of the 20th century, like malaria, tuberculosis and even leprosy are now eminently treatable and, in many cases, even curable. These medical advances were driven by systematically tracking health data and subjecting these data to objective analyses. Good health care depends on science.
This means that, as a society, we are acutely aware of the need to base good health care on sound scientific principles, and we have established protocols—or rules—that healthcare scientists and providers know are crucial. Gone are the days when diagnoses and treatments depended on custom, intuition and ←1 | 2→anecdotal evidence. Scientific protocols apply to mental health just as they do to physical health.
Any good health care practitioner who sees scientific rules violated has a duty to examine the transgressions minutely and to make every effort to correct them. This happened, for example, in the practice of lobotomy, a draconian and dreadful “treatment” for mental disorder that gained great popularity in the 1930s, 1940s, and into the 1950s. When the procedure did not kill them, it turned patients into infants, destroying their sense of identity. This did not prevent lobotomy from being embraced with great enthusiasm by the medical profession of the day.
It is the contention of this book that mental health care has once again taken a dangerous turn. This time, by a mistaken reliance on psychiatric drugs that often are more harmful than helpful. Doctors have been misled about these drugs to the detriment of patients. Depression is the subject of this book because it is the best example of the problem, having become in just a few decades and without scientific justification, the #1 psychiatric diagnosis.
Explaining what has gone wrong with mental health care is a matter of science. So, this is ipso facto a book about science. If it is about science, it is therefore about data, since science is about data. This should not alarm the lay reader. Basic scientific principles are eminently accessible, and I have done my best to explain them clearly. The data analyses are very understandable. Concepts are explained and applied in everyday language. The only prerequisite is an open mind on the part of the reader as well as a willingness to reason logically and, when necessary, to apply good common sense to facts.
The critical question at this juncture then concerns the qualifications of the author of this book. It is essential to share with you an outline of the training, experience, and focus that I believe have provided me with the knowledge to write this book which challenges the currently established and accepted protocols for the diagnosis, explanation, and treatment of depression.
Let me be clear: I am not the first or alone in my critical examination of a subject that is significantly affecting the lives of so many millions of people. This book quotes many authorities, whose names are more recognizable than mine. That said, I am the author of this book and therefore, the reader must be concerned with my qualifications.
I am an academic and a practitioner, now retired. I earned a PhD in Clinical Psychology at the University of Iowa in 1958, where the PhD programs in Experimental and Clinical Psychology were chaired by Kenneth Spence. Dr. Spence was a leading authority in advocating and conducting psychological ←2 | 3→research on animal and human behavior, both normal and abnormal, insisting on this research meeting strict scientific standards. He was one of the pioneers of research on how learning experiences determine animal and human behavior. For many years, PhDs from the University of Iowa ranked first in the annual number of publications in scientific journals.
My first job was at the University of Maryland, where I became the Assistant Director of the University Counseling Center and was promoted from Assistant to Associate Professor in the Department of Psychology. The Director of the Counseling Center was Thomas Magoon. He, too, was a mentor. Dr. Magoon was legendary in his field for normalizing counseling services to college students, exerting great influence in this regard nationally.
In 1968, I was recruited by Dr. Donald Bowles, Dean of the College of Arts and Sciences at American University in Washington, DC (AU), to initiate the creation of a new behaviorally oriented PhD program in Clinical Psychology in the Department of Psychology at AU and to expand and improve the University Counseling Center. Dean Bowles also recruited Dr. Stanley Weiss, an experimental psychologist, to establish as well, a new behaviorally oriented PhD program in Experimental Psychology at AU. Nine years later, after the Counseling Center and these academic programs were well-established, I resigned from my position as Director of the Counseling Center, remaining a Professor in the Psychology Department. Together with three colleagues, we established the Washington Psychological Center (WPC) in Washington, DC, an outpatient psychological treatment facility. WPC also offered workshops to mental health professionals and we supervised interns from local PhD programs who provided low cost or no cost therapy to those who could not otherwise afford treatment.
In my practice as a psychologist, I made my orientation clear to patients in a written statement that I provided in our first meeting together. I stated that my practice reflected a behavioral orientation to mental health care that had a solid research basis. I made clear that I rejected widely endorsed and accepted mental health practices that had been medicalized in the absence of good science, and that often were detrimental to patients. Those who sought my help who were taking psychiatric drugs were advised they must first return to their doctors and get off medication under medical supervision.
- XVIII, 288
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- ISBN (Hardcover)
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- Publication date
- 2022 (February)
- Mental health Antidepressant drugs Behavior therapy DSM-III Depression Psychiatry Psychology Placebo Pharmaceutical industry Chemical imbalance theory Conflict of interest Behaviral science Grifting Depression Allan M. Leventhal
- New York, Bern, Berlin, Bruxelles, Oxford, Wien, 2022. XVIII, 288 pp.