Psychiatry & Big Pharma: Exposed - Dr James Davies, PhD

hello good morning could you all hear me yes excellent it's great to be here thank you now thank you for organizing this and thanks for the for the introduction well done for those of you who've made it on time there's a bit of a marathon getting here this morning wasn't it so sorry sort of the sort of pun might my dad makes but anyway great that you're all here and I'm looking forward to today I hope what I have to present today will make your trip worth it I know for a fact the other presenters will make your trip worth it but I hope mine will also be of use and interest to all of you now before I get on with my presentation I just like to say just a few a few words about me and who I am and my background and so on and so forth so my name is James Davis my doctorate was in medical and social anthropology focusing on mental health and I've trained as a psychotherapist and adult psychotherapist and indeed practiced as a therapist in different organizations such as the NHS and also for the organisation mind when I work for the NHS I worked in an outpatient psychotherapy unit receiving referrals from the wards and also from primary care and it was while working in that setting that I started to become quite concerned with some of the more traditional forms of psychiatric intervention and practice that I was witness to for example when it came to psychiatric diagnosis I often found that these diagnoses created the illusion of understanding among me and my peers I also felt that these diagnoses were generating stigma in the people I was working with and also leading them to become confused about the real nature of their distress when it came to the psychiatric kitchens while it is true and I certainly subscribe to this notion that for some people the most severely distressed members of our society these medications can be experienced as very useful certainly when taken in the short-term and I accept that principle for me working in the NHS it felt that there was a huge amount of unnecessary over prescribing and in addition to that a lot of prescribing that was going on for far too long prescribing that ultimately in my view was doing more harm than good so as a consequence of these experiences which I culminated over a series of years I started to read voraciously the critical psychiatry literature to find out a little bit more about what potentially could be going wrong and after a few years of consulting this literature I decided personally to make my own contribution to this particular Canon and I decided to do that by way of not writing an academic article for clinicians and for fellow academics but rather for writing the kind of book I felt the people I was seeing in the room might benefit from reading so I wanted to write a book for the general reader in order to reach the people who were on the receiving end of psychiatric drugs and diagnosis because in my view it felt that many such people were subjecting themselves to psychiatric interventions without having the satisfactory information in order to make an informed decision as to whether or not to subject themselves to this form of intervention and that's why I decided to write the book I did to provide them with that information I felt they needed in order to make an informed choice as to whether to subject themselves to these interventions or not so that book that that project culminated in a book called cracked why psychiatry is doing more harm than good and I published that a few years ago and when it was published and I think still today that book advanced a position is both countercultural and counterintuitive the position goes like this the Sakaya tree over the last 30 years under the dominance of the biomedical model has started to become bad for our mental health now there are a number of reasons why I argue this to be the case I'm just going to focus on two quickly before focusing on one in particular in the first part of my lecture today the first reason is that psychiatric drugs do not do what they say they do on the tin they're more ineffectual and dangerous than many of us have been led to suppose the second point is that the links between the pharmaceutical industry and psychiatry have become far too cozy in recent decades and this is bias psychiatry towards privileges I close our masu Terkel treatments in the management of emotional distress and indeed that is the argument I'm going to focus on in particular in the second part of today's lecture the final point I want to make and this is the one I'm going to focus on in the first part of today's lecture is that psychiatry has wrongly medicalised more and more people in contemporary society so apparently one in four of us now suffers from a mental health disorder in any given year and I'm going to argue that this figure is so startlingly high because psychiatry has simply renamed more and more of our natural and normal albeit painful human experiences as indicating psychiatric disorders that often times require some kind of psychiatric drug so in effect by reclassifying painful normality as psychiatric abnormality we have created the illusion of a psychiatric epidemic now I'm not suggesting here I'm not suggesting here that the suffering itself is a no that is absolutely real it demands attention and it demands care what I'm contesting is the notion that this suffering is psychiatric in nature okay so what is at the heart of this illusion well I'm going to argue today that at the heart of this illusion sits a book called the DSM the Diagnostic and Statistical Manual of Mental Disorders the book that includes all of the mental disorders that psychiatry believes to exist now there are many interesting things about this book but one in particular that stands out for me is that this book has expanded at a faster rate than almost any other medical manual in history so for example in the early 1960s this book included around a hundred disorders whereas today it includes around 370 so what is going on well that's the question I set out to answer in part of the book I was I was writing but I encountered an immediate problem and it was this there was very little documentary evidence chartering the processes that the committee's who wrote DSM followed when they put that manual together so I quickly realized if I were to write some kind of reconstruction of events then I would have to go and speak to the people who wrote DSM and that's what I did I started with someone called dr. Robert Spitzer who's now generally regarded to be the most influential psychiatrist of the 20th century because he was chairperson of DSM 3 published in 1980 he headed of a team of around nine people which was called the taskforce remember that phrase the taskforce who wrote and put that manual together now the reason I'm going to start with DSM 3 to day and by the way there have been five editions of DSM over its history that the most recent being dsm-5 published in May 2013 but the reason I'm going to start with DSM three is because by far it is the most important edition in the manuals history for the following reasons it established the modern diagnostic system under which we still operate today so it's what we call it the checklist system if you experience this number of symptoms for this amount of time then you warrant this diagnosis right that checklist system was created in DSM three number two DSM 3 introduced 80 brand new mental disorders many of the household name disorders with which you may be familiar disorders like attention deficit disorder or post-traumatic stress disorder or major depression etc and so forth and finally DSM 3 significantly lowered the bar for what constitutes having one of these disorders in other words it made it far easier to get diagnosed with a psychiatric disorder so for these reasons I'm going to focus on DSM 3 first before moving on to DSM 4 but before I get to that I just want to say for a moment in what I'm about to present to you now this is a composite of the interview data I gathered from speaking to the leading members of the DSM task force the interviews I conducted with them and also the archival research I undertook at the American Psychiatric Association in Washington DC where they house all of the DSM documents the documents pertaining to the construction of DSM and I've made two separate trips to those archives in order to familiarize myself with those documents but let me just before I get to that data first set the scene so I'll just tell you a brief story years ago I'm in my office at the University of Roehampton and I you know it really strikes me I really need to speak to this guy called dr. Robert Spitzer so I think well let me go online let me find his let me find his telephone number so I searched online and I find this number and I think well I'll give it a call so I give him a call from my office in London and this lady answers the phone and I just kind of assumed rightly or wrongly I assume that it's it's his secretary so I say oh hello my name is dr. James Davis I'm calling from London I'd love to be able to book an appointment to speak to Professor Robert Spitzer at some point would that be possible and then she's she she respond by saying hold on hold on rather one you're one what this is this is not what I expected actually got someone on the phone and by the way I'm not gonna do any more American accent sir for the rest of the day and suddenly it's oh no what we came back just about that one that's it and it's Robert Spitzer and I say oh hi I'm James Davis oh I'd like to interview you and it so he says well what do you want to know let's have a conversation now so so what can I can I can I record this yeah fine so I get my computer and I did it and we have a conversation for an hour off-the-cuff at the end of that conversation I say to him listen Rob but this has been absolutely fascinating do you mind if we carry on this conversation I'll come to the US why don't I come to the US and meet you and we'll carry on this conversation and he said fine just let me know when and we'll arrange it so I go to my head of department I say listen I've got to speak to this guy could you fund the trip and they say fine we'll fund the trip so I I head off to the United States six months later so six months later I get on a train from New York City take the train out through New Jersey to Princeton University and Robert Spitzer's now lives in in one of those lovely New England homes just northeast of the University so I get it I get a cab and I head out there and the cab pulls up outside and it's just beautiful or home and it clear they've chosen a lovely place to live I walk up to the to the front door I knock on the door and Robert Spitzer opens the door and he's standing there and he's got this loose sports top on he's wearing shorts and he's wearing sandals and he says James Jenny's coming in and one of the first things he says it's James do you want to stay for lunch and now I just had all those mountainous American breakfast you know so I say yes that would be nice and he said to my great relief look before before we have lunch why don't we sit down so I can tell you what you want to know so I go into his living room we sit down I set up my computer I press record and off we go now one of the first questions I had for Robert Spitzer was this what was the rationale for this huge expansion of the DSM that happened under your watch remember 80 brand new mental disorders went into that manual what was the rationale for that and this is how he responded the disorders we included work really new to the field they were mainly diagnoses that clinicians used in practice but which weren't recognized by the DSM so by including them in the DSM we gave them professional recognition so presumably these disorders have been discovered in a biological sense that's why they were included right no not at all there are only a handful of mental disorders in the DSM known to have a clear biological cause these are known as the organic disorders these are few and far between so let me get this clear there are no discovered biological causes for many of the remaining mental disorders in the DSM it's not for many it's for any no biological markers have been identified and let me just say something here for a moment now the reason why this may sound strange to many people maybe not necessarily people in this room but people out there in wider society it's because people expect psychiatry to work much like the rest of modern mainstream medicine in modern mainstream medicine and of course there are exceptions to this but broadly speaking a name will only be ratified as indicating the existence of a disorder after some kind of pathological roots have been discovered in the body in the cells in the tissues in the organs etc but the surprising thing about psychiatry is that it works in completely the opposite way psychiatry first names a disorder before any pathological roots have been discovered in the body so in effect a new mental disorder can make it into the DSM and become part of our wider culture even though there is no biological evidence whatsoever to support its inclusion so I continued so if there are known known biological causes on what grounds do mental disorders make it into the DSM what other evidence supports their inclusion well psychiatry has to look for other things behavioral psychological we have other procedures I then asked him what these procedures were I guess our general principle was that if a large enough number of clinicians felt that a diagnostic concept was important in their work then we were likely to add it as a new category that was essentially it it became the question of how much consensus there was to recognize and include a particular disorder so it was agreement that determined what went into the DSM that was essentially how it went right another point to make here agreement does not constitute scientific proof right if a group of theologians all get together and agree that God exists this doesn't prove that God exists all it proves is that this group of theologians believe it does so in what sense is dsm committee agreement different why when a group of psychiatrists comes together and agrees upon something should the rest of us accept they have got it right well the obvious answer to that question would be well surely there are other forms of research that are guiding the committee in the agreements they reach and that would be fair enough so let me deal with that point now and let me deal with it by drawing into the conversation a professor of psychology at Harvard Kennedy School someone called Paula J Kaplan now Paul is very interesting because she was a consultant to DSM 3 but more importantly because she lobbied Robert Spitzer not to include a new disorder that was proposed for inclusion this disorder was called self-defeating personality disorder or SDPD for short now she argued that this diagnosis was very dangerous because the characteristics of SDPD were very similar to the characteristics that women displayed when they had been victims of violence so in other words she argued that this diagnosis could be used to pathologize female victims of violence they were suffering because they had a self-defeating personality disorder not because they've just been abused but also it could let the perpetrators of such violence off the hook because presumably they were just doing what these women wanted the women had a self-defeating personality disorder than the men or whomever the abusers were was simply obliging so for this reason she argued it was a dangerous diagnosis and it shouldn't be included but Spitzer remained adamant he did not want to get rid of the diagnosis and when when I was at the DSM archives in Washington DC by the way there are nine lineal feet of documents there I'm sifting through a box and I find this little tag which reads SDPD and I go down and I pull out this document am I find the very meeting in which Robert Spitzer and his team are discussing Paula J Kaplan's argument and I'm just going to show you a transcript of that minuted meeting here verbatim because I think it's quite interesting it says the following they the women percent are narrow gauged but persuasive argument their powerful argument is that it is a political hot potato the feminist issue is a false one that this diagnosis could pathologize female victims of violence think women's arguments seem irrelevant to questions on the table they are obscuring their own good arguments the good arguments being that SDPD is a controversial diagnosis the irrelevant arguments being those posed by kaplan benedek no empirical basis for category but you're right arguments aren't responsive to questions rose we do great disservice by backing off and not acknowledging that this pattern is pathological so from this you see they're saying they know we're going to keep it in the DSM and they do keep us in the DSM but in a last-ditch attempt to try and influence them against doing this Paula J Kaplan launches on the final strategy I decide to scrutinize thoroughly the very research used to justify including SDPD in the DSM let's have a look now of what she found firstly she found only two pieces of research which is a remarkably small amount by anyone's standards but now let's have a look at what that research constitutes in the first piece of research which was conducted by Robert Spitzer a group of psychiatrists at only one University who all accepted that SDPD existed were shown some old clinical case these Kaplan pointed out that just become some psychiatrists at one Hospital all diagnosed their patients with SDPD was not proof that the disorder actually exists all it proves as Kaplan said is that a group of psychiatrists working at the same institution gave the same label rightly or wrongly to a given set of behaviors it proves nothing more than that but if you think that first piece of research is weak then just consider the second piece a questionnaire was sent to a selected number of members of the American Psychiatric Association this asked them whether the diagnosis SDPD should be included in the DSM an official report later conducted by the psychologists cutcenes and Kirk show that only eleven percent voted yes which is surely not a representative sample of the psychiatric community so that is the research basis for including SDPD in the DSM now you could say to me look James fair enough but look surely this is an outlier you're cherry-picking the most extreme example in order to rubbish the whole process that's what you're doing the research basis for the others disorders was far more robust now if you were to make that argument that would be a fair argument to make so let me deal with it now and I'm gonna deal with it by inviting into the discussion somebody called dr. Theodore Miller and by the way dr. Theodore Mullen was a member of the original task force so he was privy to everything that went on in the following quote this is what he says about the research not only supporting the inclusion of dear SDPD but all of the other disorders that went in to DSM this is what he says there was very little systematic research and much of the research that existed was really a hodgepodge scattered inconsistent and ambiguous I think the majority of us recognize that the amount of good solid science upon which we were making our decisions was pretty modest so let me now go back to sitting in robert's pizzas front room back in Princeton I decide to read to Robert this quote to see what he made of it and after a short and a slightly uncomfortable silence Robert Spitzer responded in a way I simply had not expected he said the following well it is certainly true that for many of the disorders that were added there wasn't a tremendous amount of research and certainly there wasn't research on the particular way we define these disorders in the case of millons quote I think he's mainly referring to the personality disorders but again it is certainly true that the amount of research validating data on most psychiatric disorders is very limited indeed so you're saying that there was little research not only supporting your inclusion of new disorders but also supporting how these disorders should be defined there are very few disorders whose definition was a result of specific research data so I was so surprised by this admission that when I returned to the UK some days later I decided to check it out with other members of his task force so on as a rainy english morning I decided to call at his office in New York City someone called professor Donald climb now professor Donald Klein is a really important figure in the history of DSM he was second-in-command to Robert Spitzer but actually from the archives it turns out he probably had in many areas almost more influence than Robert Spitzer so a key player in the history of DSM I called him and I read to him what Spitzer had said to me to see what he made of it and this is how he responded sure we had very little in the way of data so we were forced to rely on clinical consensus which admittedly is a very poor way to do things but it was better than anything else we had so without data to guide you how was this consensus reached I asked for an example we thrashed it out basically we had a three-hour argument there would be about 12 people sitting down at a table usually there was a chairperson and there was somebody taking notes and at the end of each meeting there would be a distribution of events and at the next meeting some would agree with the inclusion and others will continue arguing if people were still divided the matter would be eventually decided by a vote a vote really sure that is how it went right so they're voting here I'm interested so the next person I speak to dr. Henry Pinsker again a member of the original nine I decide to raise the issue of voting with him and this is what he said some things were discussed over a number of different meetings which would sometimes be followed by an exchange of memoranda about it and then there would simply be a vote vote people would raise hands there weren't that many people regarding the legitimacy of this method Pinsker continued we never had any question that that was how we should proceed I had no reservations at all about working that way and just to confirm this was the case when I was in the archives I managed to source with the archivist 12 minute task force meetings and we could only source 12 because that's all we could find and out of those 12 minute a task force meetings there is evidence clear evidence of votes taking place in 10 of them and we're not talking about one or two votes here lots and lots of votes on a whole host of different topics in one of the documents was about twenty four votes unloaded evidence how to define the disorders where to set symptom thresholds whether or not to include the disorders in other words the archival evidence absolutely supports what the oral history is saying Oh what one point I just want to make about all of this voting isn't scientific activity its it what is it it's a cultural activity when anything is voted into existence whatever it may be whether it's a new President of the United States whether it's a new union leader whether or not it's a new mental disorder the likelihood we've got it wrong is never far away okay so let me give you aa yes could I just introduced you to Rennie Garfinkel for a moment very interesting woman she during the construction of DSM 3 she'd just finished her training as a psychologist so she was very young very green very naive and innocent as we all are before we go out there into the big wide world and she got a kind of internship at the APA and she turned up at one morning and she says what do I have to do and they said oh there's this this thing going on upstairs called the DSM could you go up there and just help out make coffee photocopy usual sorts of things fine so she goes like they shouldn't know what she's part of and she's sitting in the task force meetings and that's things well and she starts to realize she's actually part of something quite important here and she's pretty took some quite fascinating dynamics so 30 or so years later I decide to interview her what was going on what was happening what did you observe this is what she said you must understand what I saw happening on these committees wasn't scientific it more resembled a group of friends trying to decide where they want to go for dinner one person says I feel like Chinese food another person says no no no I'm really more in the mood for Indian food and finally after some discussion and collaborative give-and-take they all decide to go have Italian she then gave me an example of how far down the scale of intellectual respectability she felt these meetings could sometimes fall on one occasion I was sitting in on a task force meeting and there was a discussion about whether a particular behavior should be classed as a symptom of a particular disorder and as the conversation went on to my great astonishment one task force member suddenly piped up oh no no no we can't include that behavior as a symptom because I do that and so it was decided that that behavior wouldn't be included cause presumably if someone on the task force does it it must be perfectly normal all right so let me just give you some more impressions of these these these meetings gathered by way of my interviews and other people other sources I consulted according to other members of the task force these meetings will often haphazard Affairs suddenly these things would happen and there didn't seem to be much basis for it except someone just decided all of a sudden to run with it said one participant it seemed another member admitted that the loudest voice is usually won out with no extensive data one could turn to the outcome of taskforce decisions often depended on who in the room had the strongest personality but the problem with relying on consensus reiterated Garfinkel is that in the discussion some voices will just get quieter either because they don't want to fight or because they see they're in the minority and snap that's when the decision is made admittedly when the task force lacked expertise on a particular disorder Spitzer would consult the relevant leaders in the field and the archives are full of these letters he was writing back and forth to you the experts but this also led to chaotic meetings that members often found difficult to participate in one of the only British members of the task force a psychiatrist called David Schaffer recalled how such meetings often unfolded in these meetings of the so-called experts or advisors people be standing and sitting and moving around people would talk on top of each other but Bob Robert Spitzer would be too busy typing notes to chair the meeting in an orderly way now in 2005 a very interesting article was published in The New Yorker magazine and the title of that article was a dictionary of disorder and it was a biographical study of Robert Spitzer's influence on global psychiatry and midway through that article there's a section on the construction of DSM 3 which I just want to read to you very briefly Roger Peale and Paul asada psychiatrist and since Elizabeth Hospital in Washington DC wrote a paper in which they used the term hysterical psychosis to describe the behavior of two kinds of patients they had observed Spitzer read the paper and asked Peale masada if he could come to Washington to meet them during a 40-minute conversation the three decided that hysterical psychosis should really be divided into two disorders brief reactive psychosis and factitious disorder then Bob asked for a typewriter Peale says to peel surprise Spitzer drafted the definitions on-the-spot he banged out criteria sets for factitious disorder and for brief reactive psychosis and it struck me that this was a productive fella he comes in to talk about an issue and walks away with diagnostic criteria for two different mental disorders and by the way both of those disorders went into the DSM with only very minor modification from the original criteria written up there and then in that room let me just read you two paragraphs before we move on as Spitzer's dsm 3 was published in 1980 it became a sensation overnight the almost 500 page long manual sold out immediately the manuals purchase not only by psychiatrists but by nurses social workers lawyers psychologists psychotherapists etc and the enthusiasm quickly spread far beyond the United States in Britain for example the manual had such impact that by the end of the 1980s most British psychiatrists were being trained to use DSM furthermore Spitzer's DSM categories quickly became those that guided all research into psychiatric disorders internationally this meant that the disorders that were studied by researchers in Germany Australia Canada Britain Scandinavia and so on and so forth with those defined and listed in Spitzer's DSM in short the book ultimately changed the fundamental nature of research and practice within the field not to mention the lives of tens or countless millions diagnosed with the psychiatric disorders listed there in and yet as the influence of the manual spread the truth about its construction remained obscure most professionals using the manual simply did not know and I would say still do not know today the extent to which biological evidence or solid research failed to guide the choices the taskforce made they did not know that the definitions of the disorders contrived the validity of the disorders included and the symptom thresholds people must meet in order to receive the diagnosis were not decided on the basis of rigorous research but with a product of committee decisions which at best reflected the well-meaning profession opinions of a small subset of psychiatrists in short most people did not know that the fundamental changes Spitzer brought to global psychiatry only required the consensus of an extremely small group of people nine people and indeed as Robert Spitzer openly confirmed to me in our interview and actually I think this is this is my this is my favorite quote of all he said the following our team was certainly not typical of the psychiatric community and that was one of the major arguments against DSM 3 it allowed a small group with a particular viewpoint to take over psychiatry and change it in a fundamental way what did you make of that criticism what did I make of that chart well it was absolutely true it was a revolution that's what it was we took over because we had the power quite a striking confession I actually I actually got that quote the day after I was leaving and I was at the hotel and I was having breakfast the day after I interviewed and I was really frustrated with myself because there were two or three questions I just didn't get in to the interview so I thought you know what just call him this guy usually answers the phone so just call him so I called him back and and I said I'm so sorry over the couple of things I just want to ask which I forgot and I said go ahead go ahead what are they what are they and I asked him about the criticisms of DSM and this is what he said and I recorded this on a fountain outside of one of those you know best inns or something you know sitting and I recorded it there and this is what he said to me that morning and I think it's really really quite a powerful statement because it's true it's absolutely true so much another point I just want you to make it so much of what goes on in mental health is to do with who has the power it is absolutely to do with who has their power and don't let anyone tell you otherwise shocking the extent to which this happens not just on death but on all the committee's that define how we are meant to understand and respond to emotional difficulties okay alright I've got ten minutes left of this section is that okay before we have a quick break because I want to move forward now into dsm-4 so not that much more to go but but stay with me please so in 1994 dsm-4 reaches the end of its shelf life and it's replaced dsm 3 story and is replaced by DSM 4 which remains the DSM in use for 20 years right up until May 2013 when it's replaced by dsm-5 yeah ok so in 2013 I had the opportunity to talk to interview the new chairperson of DSM for dr. Alan Francis who took over from Robert Spitzer on two separate occasions and so I the first one of the first questions I had to him was with the benefit of hindsight was there anything you did when constructing DSM for that you now regret and this is what he had to say well the first thing I have to say about that is that DSM 4 was a remarkably unambitious and modest effort to stabilize psychiatric diagnosis not to create new problems this meant keeping the introduction of new disorders to an absolute minimum what did he mean by that well his team only introduced eight new mental disorders into the main manual which is a modest amount compared to the 80 introduced by Spitzer however from another standpoint this claim to modesty is very shaky because it excludes the following his team actually created 30 new mental disorder but put them in the appendix and subdivided many existing conditions in effect creating new ones so if you count the appendix inclusions and the subdivisions all of which people can and are diagnosed with then his team expanded the DSM from around 270 disorders to around 370 disorders which is the very opposite of modesty and conservativism so we carried on yet despite that conservativism francis said and i let the comment slip we learned some pretty tough lessons we learnt overall that even if you make minimal changes to the DSM the way the world uses the manual is not always the way you intended it to be used can I just pick up on that just for one moment I'm sorry I have to do but the way the world uses the manual so it's the world who's at fault right if they're any men mental health professionals here in the room who in good faith use these manuals and you do in good faith it's your fault it's not their fault it's your fault by the way okay so the way the world uses the manual is not always the way intended it to be used for instance we added bipolar to Asperger's disorder and finally we added ADHD and well these decisions help promote three false epidemics in psychiatry I asked him what he meant by that well we now have a rate of autism that is twenty times what it was fifteen years ago by adding bipolar to a milder version of bipolar we also doubled the ratio of bipolar versus unipolar depression resulting in lots more use of antipsychotic and mood stabilizer drugs rates of ADHD also tripled partly because new drug treatments were released that were aggressively marketed so every decision you make has a trade-off and you can't assume the way you write the DSM will be the way it will be used there he goes again so the way the DSM is being used has led to the zatia of a number of people who really don't warrant their diagnosis exactly can you put a figure on how many people have been wrongly medicalized there is no right answer to who should be diagnosed there is no gold standard for psychiatric diagnosis so it's impossible to know for sure but when the diagnosis rates triple over the course of 15 years my assumption is that medicalization is going on powerful statement for him to make he was the chairperson of DSM 4 but could the situation be even worse than this I would argue absolutely it could be and it is because he's only talking about the eight disorders he put into the main manual he's not talking about the subdivisions and the appendix inclusions all of which medicalised more and more painful normality he's also not talking about the existing problem of over medicalization he allowed to live on created by DSM 3 allowed to live on into DSM for right he allowed DSM 3 to carry on he's not talking about that either think of some of the disorders he allowed to live on we had disorders like female orgasmic disorder yeah caffeine related disorders stammering stuttering transsexualism or positional defiant disorder which is something i evidently acutely suffer from look nobody is suggesting that these things aren't experienced as problems by certain people I'm sure they are but whether or not they constitute psychiatric illnesses it's another matter entirely so my final question for Alan Francis was this with the benefit of hindsight why isn't it you just simply scrapped a lot of what went on before on the basis of number one it enjoyed woeful scientific support and on the number basis number two that it was many of this stuff much of this stuff was frankly eccentric and this is how he responded if we were going to either add new diagnoses or eliminate existing ones there had to be substantial scientific evidence to support that decision and there simply wasn't so by following our own conservative rules we couldn't reduce the system any more than we could increase it now you could argue that that is a questionable approach but we felt it was important to stabilize the system and not make arbitrary decisions in either direction but one of the problems with proceeding in that way I said is that it assumes the DSM system you inherited from Spitzer was fit for purpose for example it assumes that the disorders Spitzer included and the diagnostic threshold splits his team set were themselves scientifically established we did not assume that at all we knew that everything that came before was arbitrary francis quickly corrects himself we knew that most decisions that came before were arbitrary I had been involved in DSM 3 I understood its limitations probably more than most people did but the most important value at that time was to stabilize a system not change it arbitrarily so you are essentially saying that you set out to stabilize the arbitrary decisions that were made during the construction of DSM 3 in other words corrected Frances it felt better to stabilize the existing or decisions than to create a whole new assortment of new ones and I thought that was a very good place to bring the interview to a close all right so let me one final paragraph before we have a very short break so during this part of the lecture to a close what I have discussed today I believe poses a serious challenge to those who embrace the conventional view that mental disorders are discrete patterns of biologically rooted pathological feeling and behavior identified by way of objective research processes what an inspection of the construction of DSM rather reveals is that the separate disorders into which DSM organized diverse behavioral and mental phenomena were largely the outcome of vote based judgments settled by a small culturally homogeneous subset of mental health professionals who were socially positioned at a given time to have their judgments ratified by the institutional apparatus of the American Psychiatric Association now while such judgments may indicate that a group of professionals sharing similar socio cultural beliefs biases persuasions and interests may see some things in the same way at a given point in time they do not confirm that what they see is either objectively true Universal or indeed stable in air at any verifiable sense we're going to move on to a slightly different territory now in the second part so in the first part we looked at the construction of DSM and the argument was essentially that we've expanded the definition of mental disorder to encompass more and more domains of human experience now what are the consequences of that of course is that we've created a larger and larger market for psycho pharmaceutical medications right because the more people out there in society who are disordered the more people out there who are going to need treatments now this has happened in an era when there has been a dearth of psycho-social alternative provision so the inevitable consequence of that has been more and more prescribing as a consequence of more and more over medicalization let me just give you a sense of scale last year in the NHS 500,000 people were given psychological therapy as an intervention last year in the NHS 7.4 million people were prescribed an antidepressant so you can see the imbalance in provision here this is made all the more concerning given that the research shows that when people go to see their GP because they're suffering from emotional problems or acute emotional distress the vast majority of those people actually want some kind of psychological or social intervention not an antidepressant but what they invariably get is an antidepressant because provision for the alternatives are at an all-time well they're actually better than it was but it's still comparatively speaking very low and this can partly explain why and I want you this statistic to stay with you over 20% of the adult population in England was prescribed a psychiatric drug last year alone over 20% of the adult population of England was prescribed a psychiatric drug 16 percent were prescribed antidepressants the rest antipsychotics stimulants anxiolytics etc and so forth and this figure has doubled in the last 15 years in addition to that not only are we prescribing double the amount of drugs we did to 15 years ago but the average duration of time as person spends for example and an antidepressant has also doubled 10 years ago it was about a year today it is around two years in fact half of all antidepressant users in England have been taking antidepressants for at least two years so not only is prescribing going up but we're staying on the drugs for longer and longer and this is particularly concerning given the following facts that long-term use is not associated with good stuff okay increase severe side effects the impairment of autonomy and resilience increased weight gain worsening outcomes for some people poor long-term outcomes for major depressive disorder greater relapse race increase mortality and an increased risk of developing neuro degenerative diseases such as dementia so we should be concerned about these current trends this epidemic of over prescribing so how then does the relationship between over medicalization which manuals like DSM have encouraged and rising drug consumption actually operates what mechanisms of influence does industry exert to expand psychiatric drug consumption via over medicalization putting it in the least varnished terms how do pharmaceutical companies influence processes of medicalization to aid wider consumption of their products and in order to address this question head-on I want to distinguish momentarily between two different forms of pharmaceutical industry influence which we will call direct influence and in act influence so focusing firstly on direct influence here's a definition of what that would mean the undertaking of activities explicitly designed to increase psychiatric prescribing such as direct marketing and advertising initiatives to both the public and the medical establishment fortunately in the UK it's illegal to market drugs to the general public it's not illegal in the US it's not illegal in New Zealand but here it is but pharma companies nevertheless invest heavily in marketing campaigns targeting professionals psychiatrists and medical professionals and that goes on very widely but allow me for a moment just to give you an illustration of direct marketing to the consumer and this concerns a new diagnosis that was introduced into the dsm-4 in the year 2000 and this diagnosis was called premenstrual dysphoric disorder apparently up to 8% of women were said to suffer from the condition and its main symptoms occurred two weeks before menstruation and the symptoms included things such as feelings fatigue anxiety emotional instability distress in daily activities and difficulty in concentrating in short premenstrual dysphoric disorder was a slightly mitigated version of PMT premenstrual tension now by the early 2000s the number of women being diagnosed with premenstrual dysphoric disorder went up exponentially and one of the key reasons for this was that the pharmaceutical company Eli Lilly had begun investing tens of millions of dollars promoting this so-called disorder and its so-called corrective something they called Seraphim and what I want to show you now is one of the commercials with which Eli Lilly was flooding the airwaves during this time there are about four commercials in total this was one of them this is this was perhaps the most popular one let me just play it to you [Music] [Music] [Music] okay hands up the woman in this room that don't have premenstrual dysphoric disorder I mean really we were talking about the over medicalization of normality I mean this is astonishing is it not and this is just one of four commercials that were going around the United States at that time promoting Sarah fat as a drug for a presume that the presumed mental disorder now I just want to stay with this commercial just for a little while longer because there are a couple of other interesting things that need to be said about it first the word Seraphim interesting is it not it's a Hebrew play on the word Seraphim a word with female associations attached also think of the packaging used this particular pill Seraphim was encased in a very pretty pink and lavender pill and so was the packaging in these sort of traditionally female symbolism this is all standard fare of marketing but what about to tell you now actually gets far more interesting what Eli Lilly initially concealed from the hundreds of thousands of women who started to take Seraphim was that Seraphim is actually prozac prozac and Seraphim are both made by Eli Lilly and chemically they are exactly the same hundreds of thousands of women were taking Prozac and they didn't know it they just repackaged the pill now I've given you that example because I don't want you to go away thinking that direct marketing is good and pure because it's direct because it's obvious everything's fine we can laugh at this stuff isn't it funny we're not that stupid but you didn't know what I just told you did you and nor did the women who were taking seraphim no they were taking Prozac so direct marketing is problematic but I don't want to focus too much on direct marketing today because I want to actually focus on something that is even more problematic and that's it's more clandestine alternative what we will call in direct marketing and here's a definition of what it means a form of financial influence that invariably operates by proxy and/or purposeful dis fault via the financial sponsoring of persons institutions or apparatuses deemed sympathetic and/or potentially advantageous to the expansion of psycho pharmaceutical markets so what I want to do now is give you three examples just three out of plethora of how indirect influence actually works the first example I want to give you is perhaps the most obvious example and this occurs by way of industry financially sponsoring what are called key opinion leaders these are senior members of the medical or psychiatric profession who get paid and will do and say things consistent with industry interests and to get a sense of how common these financial conflicts of interests are a couple of years ago a respected at watchdog charity in the United States in fact one of the most respected in the u.s. called Pro Publica looked at all of the payments that were made from the whole of the pharmaceutical industry to the whole of medicine and what they found was that half of the highest payments made by the whole of farmer to the whole of US medicine were made to doctors in a single speciality and that was psychiatry Sassicaia tree was taking more of the higher payments than any other area of medicine another example when researchers at the University of Massachusetts inspected the financial interests of the people who sat in and helped construct the DSM at DSM for this is what they found and this is the piece of research I'm I'm alluding to here by cosgrove what they found was that 56% of the people who were involved on the advisory panels and the consultancy groups for the construction of DSM for 56% of them had one or more financial tie to the pharmaceutical industry and then get this on the panels that considered the disorders for which drugs or the first line of treatment a hundred percent had financial ties to the pharmaceutical industry now this form of influence is so powerful due to how typical and routine it has become within the psychiatric profession a typicality that has seemingly inoculated many to the depths of the biasing effects an example of this was was dramatically illustrated to me a few years ago in the houses of parliament there was a debate around at DSM and Alan Francis had been invited to it and during that I decided to point out to him how many people on his dsm-4 had financial conflicts of interest with respect to the pharmaceutical industry and his response was this well you know I know what you're saying James but ultimately we were all real good guys that was the phrase used we were good guys we were just trying to do what we thought was best but I have to admit it was remiss of dsm-4 not to have a conflict of interest policy at that time well following DSM for dsm-5 did have a conflict of interest policy and the reason for that was post DSM for medicine became more and more concerned about financial ties to industry and there was a lot more pressure for them to be transparent and there was certainly a lot of pressure on dsm-5 to be more transparent regarding its triad ties so it was more transparent so let's have a look at what we can find of the 29 members of the dsm-5 task force the people who wrote and put it the manual together 21 it turns out had financial ties to the pharmaceutical industry including the chair of the DSM task force David Kaufer and the vice chair Dowell Reagan now while of course those possessing financial ties to industry often dismiss or downplay their biasing effects and I should know this because I've interviewed so many of them the research is very clear that they bias those receiving them both individuals and institutions towards favoring psychopharmaceuticals in their clinical educational and research activities in other words such payments biased clinicians researchers and institutions in industry friendly directions now given that DSM medical eyes huge waves of pork painful normality driving up drug prescriptions as a consequence it's concerning that those responsible for the creation of DSM were at the same time receiving money from industry they're going to be less concerned about one of the major consequences of over medicalization than somebody like me who wouldn't ever take money from industry so that's the first and most obvious example of how indirect influence works but let me now give you another example by bringing things slightly closer to home and I'm going to do that now by referring to and by the way here's the research some of the research is an awful lot out there but some of the research into the biasing effects of such conflicts of interest I want to now refer you to these two documents used in the NHS now these are two of the most powerful documents in mental health and the reason for that is because these two documents have been used for the last 15 years throughout primary care to help doctors determine whether or not the people sitting in front of them have either anxiety or depression it's depression as phq-9 anxiety is GAD 7 so you give these to your patient they tick some boxes and depending on the score they get determines the intervention you you offer now one of the very interesting things about these documents and one of the most powerful arguments against them is that they set the bar very low for what constitutes having a form of depression or anxiety for which a drug should be prescribed and by the way 90% of people who fill in these questionnaires get prescribed medications as a consequence now what the tens of millions of people who have filled in these questionnaires in the NHS and I've got prescribe drugs as a consequence almost certainly did not know was that these documents were developed by their distribution throughout the NHS was paid for by and their copyright was owned by Pfizer Pharmaceuticals which incidentally makes two of the most prescribed anti anxiety and antidepressant drugs in the NHS so here you have a company setting the bar very low for what constitutes needing a drug what at the same time as manufacturing and profiting from those drugs and this as we're going on within the NHS for 15 years in fact if you go onto Google if any of you online now and you type in sort of depression NHS etc nine times out of ten you're going to you're going to find the phq-9 coming up first and that's the document you have to fill in to assess whether or not you have depression and if so how severely okay so another example of how industry indirectly is promoting over medicalization and as a consequence over prescribing can I give you the third and final example now this concerns a personal anecdote so twelve months after dsm-5 was published in May 2013 actually wasn't twelve months it was six months excuse me six months after I was in New York City and I was in one of those Airbnb apartments I was up on the upper end of near Columbia University in in one of these apartments one evening and I'm checking my emails and I decided to go online and actually look up you know what's going on in the publishing market what books are selling well in the United States at the moment so I go to Amazon and I open the page and I stop and I look and I can't believe what I'm seeing at that point six months after dsm-5 was published the highest selling book in the whole of the United States was dsm-5 that just to give you a sense of scale Harry Potter yeah very popular I have two little kids and they're really into it at the moment very and this was the time when Harry Potter was really big Harry Potter was at number seven fifty shades of gray some of you may know that one number nine again very popular dsm-5 was number one but in addition to that guess how much a paperback version of dsm-5 cost the cheapest version eighty eight dollars a copy so who was buying this book right who's buying it so the next day I'm interviewing a prominent medical anthropologist at New York University we do our interview and at the very end and she works in mental health so she knows the system very well I asked her what was going on I said I've been online last night I found out this information what's going on is she stopped it said James you don't know and I said well no tell me what I don't know and she said from my experience in the New York state area where I work in primary care what's happening is the pharmaceutical industry is buying DSM in bulk and then distributing it for free to clinicians up and down the country and that is why the sales are so high why would industry do that it just makes complete business sense they're more people who are being medicalized the greater the market you have for your own products now I try to verify this so I contacted Amazon they would not declare who was buying the books they're not legally obliged to do so so when I went to the American Psychiatric Association I tried so optically to discover what had been going on and I got confirmation that the vast majority of DSM sales were bought in bulk when I asked who was buying them in bulk the door immediately shut and I couldn't find it so I haven't been able to get definitive proof of this but given everything else we know I'll leave it for you to make up for yourselves your own minds the extent to which this is going on and indeed it is absolutely consistent with what industry has been doing in relation to psychiatry over over the last 20 years or so and I just want to read very quickly this this paragraph to summarize a lot of points and the research relating to the points being made pharmaceutical industry has been a major financial sponsor of UK and US academic Sakaya tree significantly influencing psychiatric research training and practice this this influence has been exerted through many heads of psychiatry departments receiving departmental income from drug companies but at the same time as receiving personal income through nearly all clinical trials into psychiatric drugs antidepressants neuroleptics tranquilizers being pharmaceutically financed or commissioned through most academic drug researchers receiving research funding consultants fees speakers fees or other honoraria from industry and through leading psychiatric organizations such as the American Psychiatric Association the publisher of DSM receiving most of its operational costs from industry eg with such report the AP A's annual revenues rose from 10.5 million in 1980 to 50 point 2 million by 2000 to bring this closer to home in 2012 I did a Freedom of Information request to our eight leading psychiatry departments universities departments in the UK to see how much money they were receiving from industry one of the department simply failed to respond to the quest and two of the departments had simply not gathered any data at all so I only got information regarding four of our leading psychiatry departments and this is how much money they received for research funding alone only research funding from industry between 2009 2012 5.5 million from the University of Newcastle 1.5 nine million from University of Edinburgh 687 thousand from Oxford and Institute of Psychiatry 1.87 million this doesn't sound like a lot of money actually to many people it may not but it is for academics this is a lot of money you can pay for salaries you can pay for PhD students pay for seminars etc and so forth for an academic department this is a lot of money but by the way this only relates to the research funding being received private industry income received by faculty isn't gathered by the University so money for consultancy work speakers fees and other honoraria as British universities are simply not obliged to gather this information this is what Liverpool University stated psychiatrists are not required to report individual payments to the University so we don't hold any information which could be provided in response to this part of the request but even if universities commit to gathering this information I identified irregular reporting one prominent and psychiatry Department stated their faculty had received no payments at all despite a clear obligation to do so if they had received such payments and despite three of its senior psychiatrists having reported receiving payments so I went on to their published research it was clear they reported their payments they hadn't reported those to their University even though they were obliged to do so the important point I'm trying to make here is that through the era of psycho pharmaceutical expansion neither universities nor any other private or public body in the United Kingdom has been legally obliged to declare the names of individual psychiatrists and the precise levels of Industry income they receive each year and this is concerning given such payments have demonstrably biasing effects on both clinical research and practice they foster professional industrial dependencies and allegiances and in the case of speakers fees and consultancy fees and other honoraria these payments are seen by pharmaceutical companies as investments from which immeasurable return is expected they don't just give this money out for nothing they give it out for an effect and if an individual doctor isn't delivering then the money will be taken away and it will be given to a doctor who is and there's lots of documentary evidence supporting this these are investments from which a return is expected and yet doctors do not have to report their financial conflicts of interest to any agency or any authority in the UK is absolutely in my view unacceptable that pharmaceutical companies have actively used these extensive financial ties to shape practice and ideology within the mental health field driving up prescription rates as a consequence this should surprise no one but the extent to which such companies have promoted increased prescribing by corrupt means is still not fully appreciated so I'd like to focus very briefly on this issue now by drawing upon a case study and by the way I've just got about ten minutes left before we can you know finally have our Q&A but I just want to focus on a case study because I think it's quite illustrative of some of the problems we encounter in this area in May 2000 dr. Charles Schultz a psychiatrist at the very height of his powers walks up to a podium at the annual meeting of the American Psychiatric Association and announces a breakthrough in anti-psychotic drug research the breakthrough amounts to the development of a new drug that has quote dramatic benefits over its competitors it's name is seroquel and because of its superiority quote patients must receive these medications first two months before this commanding announcement was made at the APA and to the national media the pharmaceutical company that manufactures seroquel Astra Zeneca was in disarray they had just discovered that further research into seroquel had revealed that the drug was far less effective than its arch rival drug a drug called Haldol the document containing this finding was being circulated among senior staff at the company who were now not quite sure what to do an internal email written at the time and later released by the company during litigation captures the mood very well so this is the email going around Jeff and Mike here's the analyses I got from Emma I've also attached a message I sent to her yesterday asking for clarification the data don't look good in fact I don't know how we can get a paper out of this my guess is that we all including Schulz saw the good stuff and then thought further analyses would be supportive and that the paper was in order but what seems to submit was to be the cases that we were highlighting only the good stuff and that our own analysis now supports the view out there that we are less effective than Haldol and our competitors once you've had chance to digest this let's get together or teleconference and discuss where to go from here we need to do this quickly because Schulz needs to get a draft ready for the APA and he needs any additional analyses we can give him well before then so this is the company thinking you know what we're gonna do and look at the relationship between Schulz the psychiatrist who's going to present it as a independent academic at an APA academic conference look at the relationship between him and the company here so in this email the publications manager at AstraZeneca casts about for a solution he knows the research into seroquel doesn't look good yet he also realizes that Schulz has to present a paper on seroquel at the American Psychiatric Association's meeting in two months time if Schulz reports the negative data the drug is presumably doomed a way out is needed and fast so what does the company do how in just two months does it move from privately despairing over the failings of Seroquel to making a public declaration about its exceptional advantages does the company rapidly undertake a new study that finally secures seroquel superiority does it we analyzed the old data only to discover that its previous negative interpretation was wrong the company does neither there is no time and even if there were time the existing data is definitive the drug is weaker than its competitors in many areas that it seems is plain for all to see at this point you'd probably expect the company to cut its losses and with regret to publish the whole truth but the company does not take that route presumably there's too much money at stake and anyway perhaps there's another way out sure it's not an ideal route to take or even an honest one but given the money that could be lost it has to be worth a go the company therefore opts for a strategy known in drug research as cherry-picking in other words it picks and publishes the data that makes the drug look effective while leaving aside the data that does not and this was the solution that Astra Zeneca opted for in early 2000 rather than admitting that after a year on seroquel patients suffered more relapses and worse ratings on various symptoms scales than patients on Haldol not to mention gaining an average of 5 kilograms in weight which put them at an increased risk of diabetes the company rather honed in on one shred of positive data about the drug faring slightly better on some measures of cognitive functioning and it was on the basis of these data that public claims were made that seroquel has quote greater efficacy than Haldol a fact hopefully leading physicians to quote better understand the dramatic benefits of newer medications like seroquel the company had favoured the practice of cherry-picking for some time indeed in the following email again internal again released during litigation we hear how cherry-picking had been used in the previously berry trial called trial 15 again going among the senior echelons of the company please allow me to join into the fray there has been a precedent set regarding cherry-picking of data this would be the recent vela grim presentations of cognitive functioning data from trial 15 one of the berry trials thus far I'm not aware of any repercussions regarding interest in the reported data that does not mean that we should continue to advocate this practice there was growing pressure from outside the industry to provide all data resulting from clinical trials conducted by the industry thus far we have buried trials 1530 156 and now considering Koster the largest issue is how do we face the outside world when they begin to criticize us for suppressing data one could say that our competitors indulge in this practice however until now I believe we have been looked upon by the outside world favorably with regard to ethical behavior we must decide if we wish to continue to enjoy this distinction obviously AstraZeneca decides not to plunge for the ethical option rather it continues to risk its reputation and the health of patients by cherry-picking the positive data and burying the negative data to sell the advantages of Seroquel over Haldol this finally backfired in 2010 when so many people taking seroquel were suffering from such awful side effects that about 18,000 of them were officially claiming that the company had lied about the risks of the drug these claims were finally vindicated in 2010 when Astra Zeneca paid out 125 million to settle a class-action out-of-court for de fording the public but you know this isn't this isn't an outlier let me very quickly run through a few a few other case studies just to just to let you know before we finish I'm running out of time Glaxo SmithKline it's drug Paxil and Ciroc sac did three trials one trial showed mixed results another trial showed that it was no more effective than a placebo and trial 3 suggested the placebo was actually more effective with certain children but this is children by the way let's just so the company published only the most positive study publicly declaring that the drug is effective for major depression in children company officials actively suppressed negative results from one study because as they said it would be commercially unacceptable to include a statement that the efficacy had not been demonstrated as this would undermine the profile of paroxetine there was a lawsuit filed against GlaxoSmithKline in 2004 jeep SK settled out of court two months later when the company paid 2.5 million for charges of consumer fraud a meager sum considering that GlaxoSmithKline made four point nine seven billion in worldwide sales from the drug in 2003 alone by the way this is a drug for children forest laboratories charged by the US Justice Department for defaulting the government of millions of dollars for hiding a clinical study showing that their antidepressants celexa and lexapro were not effective in children and might even pose dangerous risks to them at worst these risk included causing some children to become suicidal process has said that by failing to disclose the negative results which they buried forests have kept crucial information hidden from physicians and from the wider public preventing them from having all the information they require to make right treatment decisions for young children Pfizer robach certain marketed as atronics by the drug giant our friend Pfizer again is no more effective at countering major depression than a placebo sugar pill Pfizer withheld negative trials from publication on 74% of the patients the article surveyed were actually left unpublished authors concluded in the BMJ that if the excluded data had been included the evidence would have showed that the risks of taking the drug far exceeded the benefits yet reboxetine has been approved for marketing in many European countries since 1997 and is still being taken by thousands of patients in the UK today finally New England Journal of Medicine 2008 this article reviewed 70 of the major clinical trials into antidepressant and it and it asked how many of these trials had been published the answer 38 showed positive results for antidepressants slightly better outcomes compared to placebos and nearly every one of these positive studies have been published by the companies that undertook them 36 studies actually showed negative results out of these a full 22 had been buried that is never published 11 had been published in a way to convey a positive outcome and only three have been published accurately conclusion a total of 33 negative studies had either been buried or manipulated to convey a positive outcome so to bring things to a conclusion one final paragraph of course where psychopharmaceuticals genuinely helped people they may have some currency however research has also shown that the safety and efficacy of psychiatric drugs in particular has been exaggerated by both industry and those professionals whom industry funds and that growing consumption of such drugs has been less driven by their clinical success than by good marketing concealing bad science the manipulation and burying of nigut negative clinical trials data lacks medicines regulation and I've said nothing about that today but that's a whole other story the manipulation for non drug alternatives strong financial allegiances between industry and psychiatry and the aggressive medicalization of everyday human distress in short the argument that psycho pharmaceutical promotion has placed sufferers needs before those of its shareholders is very very difficult to substantiate and I will leave the presentation there and I'm happy to take any questions you may have thank you [Applause] yeah okay well we'll just ought ism is an interesting Catholic is that the research basis for for the neurobiology of autism is probably stronger than for any other area and it's a very involved literature and you know to be honest with you to go into all of that now would be rather difficult I suppose all I'd say is that Alan Francis who created DSM 4 and who included the diagnosis of Asperger's which is essentially a mitigated form of autism argued that by including that mitigated form of autism more and more people got medicated unnecessarily so his conclusion was by expanding the definition of autism to capture these these you know very mild versions of certain characteristics that certain people have labeled as characteristic autism we expanded the drug epidemic so that would be his argument and I think he's probably in that respect by the way autism no longer exists it was abolished by dsm-5 so people who have autism don't really have it anymore that was interesting to remember remember also homosexuality right you know that was a psychiatric disorder until 1974 and then post 1974 it seems to be one and you know that you know if you if you're homosexual today then you're okay now you're not you know you're not suffering from the psychiatric condition but you know that I think it's quite illustrative the cultural processes behind decisions as to whether or not to keep things in or out yeah oh well no no this is this is a highly contested area I mean one of the the most common arguments that we heard and then early 22,000 s was the chemical imbalance theory of depression you know it wasn't championed as a theory it was champion as a clinical truth of fact the biological facts the fact of the matter is it's been disproven and no credible neurobiologists would subscribe to the notion that depression is caused by a deficiency in serotonin it's just gone the Royal College of Psychiatrists last year publicly disavow the theory after after much lobbying so we've moved on from that there's not to say there's a biological element in in depression of course there is there's a biological accompaniment to any state of mind the question is is whether or not there's a dysfunction that can be traced as the cause of something called depression and thus far there is no evidence for that yep yep okay there's a gentleman at the back and just trying to reconcile our seroquel is not effective but also antipsychotics don't do what they say on the tin so is that that is the tranquilizer or sedative or stimulant whatever it is it's not as strong or the side effects are just less do you see what I'm getting at yeah I mean I suppose what I remember that phrase is that though there was an argument made that psychiatric drugs cure or remedy biological malfunctions or varying sorts so that the the medical model was recruited to explain the drug action of psychopharmaceuticals and it turns out that that particular model is incorrect and Joanna Moncrief a psychiatrist at UCL has proposed an alternative which is called the drug centered model psychiatric medications alter people's states of mind absolutely true no one's going to dispute that which may or may not be experienced by those individuals in question as positive some people experience them as positive and we have to honor that and respect that but a lot of people don't experience them that way a lot of people experience them as harmful and we need to pay more attention to that group of the patient population so it was really to contest the traditional understanding of drug action as something correcting an imbalance that is not the case I think we should follow Joanna Moncrief personally in in her particular perspective on this topic seroquel just had not as good outcomes for the people who took it and they just didn't like it as much yeah well well in this case it was side effects it was the the adverse drug effects that people were experiencing which they weren't warned they were going to experience because the necessary data had been buried by the company that was the problem in that case yeah yeah well there was I mean that's a good question it's there were a lot there lots of them things that can be done I mean going back to the DSM is a very good question actually because it's a pragmatist question and that's what matters in this area the DSM there's an element to the DSM I'm quite sympathetic towards I mean I think it's fundamentally human to want to categorize experience you have classified experience since time immemorial anthropologists have documented that the various ways in which different societies across the globe partition different features of the natural world different species of bird and animal etc classifying phenomena is a fundamentally human experience and I think you know doing that with respect to different species of emotional suffering makes sense however that's not what the DSM only does the DSM does something more than that what it does it then pronounces upon the meaning of the experience it classifies calling it dysfunction disorder disease in other words it brings to these classifications the medical philosophy it claims to derive from them it assumes to be the case what it should rather demonstrate to be the case that these different patterns of suffering indicate disorder and disease there is no evidence to support that that is a cultural move that is an interpretive move which is hugely problematic in my view a lot of the spirit experience is captured by DSM or just natural and normal again painful reactions to living in a difficult world and that's not to undermine the severity of these experiences you know you can suffer deeply acutely as a consequence of the traumatic things you've been subject to that isn't a disordered reaction that's a fundamentally human natural reaction I don't think it's doing anyone any favors by calling it illness dysfunction I think it's very stigmatizing actually I think the medical model is more responsible for stigma in society than anything else we've been led to believe the origins of stigma reside in ABBA knighted public who are prejudiced against people who suffer I think that prejudice if there is any to the extent exists has been exacerbated by the models of distress that have been foisted upon us over the last thirty years so yes to some kind of classification system but Adi medicalized classification system that also recognizes the extent to which patterns of suffering are culturally situated they change over time an excellent example of this is self harming behavior back in the 1970s clinically speaking this was very rarely encountered because self harming behavior wasn't the kind of style of suffering that people unconsciously selected to communicate their distress it wasn't around but from the 1990s onwards suddenly people start to select this behavior unconsciously as a communicative mechanism think of hysteria back in the early 20th century very similar it was the epidemic problem and it disappears think of anorexia nervosa in the early 90s in Japan in Hong Kong excuse me there were very few cases of it by the end of the 90s it was at the epidemic levels it was to do with the ways in which people were being socialized to think about their distress and socialized to communicate it so a category system that that is non-medical that recognizes cultural specifics the specificity and that patterns of suffering change something like that yeah I'd go for but I think that's going to happen anytime soon that's just with DSM and I could talk about that farmer as well but maybe you have said enough for now who should I go for huh yeah it's a very good question I I was astonished the extent to which they were honest and I member calling my wife and saying you wouldn't believe what Rob Robert Spitz has just said I was really surprised and I think what I quickly learned was that there's a huge disjunct between what the people who sat on these committees thought about the process and how this process was represented by the private corporation the American Psychiatric Association which incidentally makes a lot of its operational costs funds a lot of its operational costs from publication of DSM DSM makes the APA about six million dollars a year in publication revenue and the APA had a vested interest in representing this as a piece of science whereas the people on the committees were quite clear that it was a hugely problematic endeavor and important endeavor as they believed an endeavor that would improve the state of psychiatric diagnosis improve its reliability etc and so forth but not to the extent that it was being represented by the APA so I think what I encountered was what the APA had sort of covered over and led people to believe didn't exist and could I give you another example of how the APA does this I wanted to speak to the people who wrote dsm-5 so I come to the a contacted the APA and said could I do so I want to understand the processes that went on behind the scenes as I did with DSM 3 and DSM 4 and it turns out that I wasn't allowed to speak to anyone involved in dsm-5 because all of them were asked to sign confidentiality agreements prohibiting them from speaking to anybody any academic any journalists about what went on behind the scenes in the construction of dsm-5 so I said well can I just consult the archives then yeah I mean I'm a researcher and they said ah we can't do that either and I said well why not because they've all been embargoed for twenty years post-publication so we cannot work out what went on behind the scenes and so the APA has a vested interest in keeping this hidden and I think what I discovered was that when you get behind the scenes things look a little different - have they been represented oh there's a man I can't I can't see clearly I don't know who it is but there's big was an arm at their back yeah so sorry I'm sorry I to do with antidepressants and then connected with blood pressure which often goes together then thing of having high potassium - high potassium as a result of long-term taking an antidepressant and blood pressure pill so you know then you get high potassium yeah which is pretty frightening yeah that's what the these things yeah I I think the long-term the effects are taking the medications long term we're finally now beginning to discover and the situation doesn't look good let us remember that these drugs were approved for public use on the basis of clinical trials that only followed people on the medication for around eight weeks yeah all the clinical trials that Haley yeah yeah demonstrate efficacy were trials between eight to twelve weeks okay so Jennifer remember the cipriani meta-analysis published in 2018 there was lots of coverage saying antidepressants work this all this sort of stuff well actually what that analysis showed was that they work almost hardly better than placebos for the most severely distressed members of societies and actually you could explain away that difference in terms of the drug effects producing side effects that boost the placebo effect etc but also what that headlining didn't report was that the studies surveyed in that meta-analysis were between eight and twelve weeks long so they told us nothing about the vast majority of people taking antidepressants in the UK today who hadn't taken them for eight or twelve weeks you prescribed them for at least six months so we're a situation where engaging in a vast public experiment with more and more people taking these drugs for longer and longer and we really still don't know the extent to which that this kind of prescribing is harming people but the evidence we're getting in already is indicating it is it is problematic very problematic so what can the public do about that it's another well just finally and I've been told this is the last question I and I should stop and I'm sorry to those I've been unable to to answer what the publisher did well we need brave journalists don't we we need brave journalists covering this kind of thing we need brave clinicians and academics speaking up about it we need greater regulation of links between farmer and psychiatry and we've outlined in fact we've found an organization by the way we don't make any money from this organization its operating costs we pay for out of our own pocket so I'm promoting this organization now because it's an organization that disseminates information to the public we think they should have there's no money involved at all we've never made it I've lost a lot of money by way of this organization by the way but I'm going to promote it now to you it's called the Council for evidence-based psychiatry Council for evidence-based psychiatry oh sorry can you hear me the count it's called the Council for evidence-based psychiatry I get to plug it four or five times now the Council for evidence-based psychiatry yeah and we we've put on a website we put lots of information online for people we have a Twitter accounts and we regularly tweet things we think are important around issues of mental health we're a very critical organization we comprise academics psychiatrists pharmacologists except for what all united in the belief that we are dramatically over prescribing these medications and under estimating the extent to which they can cause people people harm so if you so what I'm going to say to you is I'll refer you because I don't have time to answer the question I refer you to the website and there'll be information on there and and follow us on our Twitter feed we actually don't have that many followers so if we get a few after today I'll be really pleased but I bet I've got to stop there if other people want that questions address please come and come and see me now thank you very much thank you [Applause]

Channel: The Weekend University

Views: 503,280

Keywords: the weekend university, psychology lectures, psychology talks, psychology lecture, Big pharma exposed, Psychiatry, The DSM

Id: -Nd40Uy6tbQ

Length: 107min 53sec (6473 seconds)

Published: Sun Nov 24 2019