Abstract
Reviewed by: Jeanne Marecek, Swarthmore College, USA
This important book offers a compelling and highly readable account of the institutional corruption of psychiatry and the social harms that flow from this corruption. Robert Whitaker and Lisa Cosgrove painstakingly chart the twin influences of psychiatry’s guild interests and its lucrative entanglement with the drug industry. Their investigation centers on the American Psychiatric Association (APA) and the USA, but the deleterious consequences of these influences stretch around the world.
It is hard to imagine a better pair of authors to undertake this investigation. Robert Whitaker is an investigative journalist who has written about psychiatry and mental healthcare for 15 years. Lisa Cosgrove, who is a clinical psychologist and professor in the Counseling Program at University of Massachusetts-Boston, has studied psychiatrists’ financial conflicts of interest for several years. The authors draw on the framework devised by Lawrence Lessig at Harvard’s Safra Research Lab on Institutional Corruption to tell a story that stretches back at least four decades. Institutional corruption, they say, is not about a few “bad apples”; it is about a bad barrel. They document in close detail how the APA and its leadership sought to “grow the market” (as one prominent psychiatrist put it) for psychiatry. This included efforts to position psychiatrists as “real” doctors and to re-define psychological suffering as biomedical disease. With reimbursements from heath insurers hanging in the balance, business considerations—not scientific or humanitarian ones—guided these maneuvers.
As early as 1974, money from the drug industry began to flow into the coffers of institutional psychiatry. Institutional psychiatry, far from offering resistance, leapt at the chance to cash in. The amoeba’s kiss of Big Pharma led to a virtual takeover of the field. The drug industry lavished money on the APA’s annual convention, flooding the exhibit halls with its products. More covertly, drug companies have underwritten symposia, journals, conferences, and continuing medical education seminars, all camouflaged as genuine scientific proceedings. The story that Whitaker and Cosgrove tell is a sordid one and, as they show, psychiatry’s pact with the drug industry came at a steep price in scientific and professional integrity.
A key chapter in the book examines clinical trials research on four classes of psychoactive drugs—anti-anxiety drugs (such as alprazolam); the SSRIs (originally marketed as anti-depressants but now prescribed for a variety of conditions); the “atypical” anti-psychotic drugs; and drugs for ADHD. In all these cases, new drugs were heralded as “breakthroughs,” signifying a significantly improved “new generation” of remedies for psychological suffering. Sadly, the hype, it turns out, far exceeded the reality. Drawing on their own analyses, as well as those of Ed Pigott, Irving Kirsch and others, Whitaker and Cosgrove elucidate numerous ways in which research on these drugs was rigged: studies were designed to yield positive findings; data were analyzed to conceal unfavorable outcomes; damning details were buried or omitted; and scientific reports routinely inflated positive findings. Once you have read Whitaker and Cosgrove’s careful account, you will wince whenever you hear randomized clinical trials referred to as the “gold standard” of clinical research. Furthermore, although studies paid for by drug companies might be the worst offenders, independent studies were not immune to biased practices. It is only now—after more than 20 years of glowing reports about these drugs in the scientific literature, the professional literature, and the popular press—that the “dirty little secrets” of limited effectiveness and disturbing and dangerous side effects are coming to light. Many of us have witnessed distressed friends or family members ride a merry-go-round of diagnoses du jour, while swallowing pricey pills by the handful. Many of us have shared the consternation of parents who have been told they ought to drug their young children. If you have had such experiences, you will find Whitaker and Cosgrove’s exposé both enraging and heart wrenching.
Psychiatry Under the Influence recounts many means of “growing the market” for psychiatrists’ services and drug companies’ products. Free market economies are fueled by consumer demand. How could a large swathe of the populace be convinced that they needed the services of a psychiatrist and costly psychoactive drugs? Whitaker and Cosgrove detail many practices that have served this end. Psychological difficulties—with their inherently subjective criteria, diffuse definitions, and fuzzy boundaries—constitute a fertile ground for disease mongering. From 1980 onward, each time that the Diagnostic and Statistical Manual of Mental Disorders (DSM, which is compiled by and published by the APA) was revised, the sheer number of conditions that purportedly demanded professional attention increased, sometimes dramatically. Moreover, the boundary conditions for many disorders expanded, with the result that more and more individuals met the criteria for a diagnosis. Furthermore, the APA, with ample financial backing from the drug industry, targeted potential consumers directly via public education and awareness programs, broad-based “screening” programs, and public service announcements offering rosy promises of successful new treatments. In the US and New Zealand, direct-to-consumer advertising in the form of TV commercials, print media advertisements, and social media sidebars rounded out the picture.
Psychiatry Under the Influence also describes the industry practice of hiring notable academic psychiatrists—often from prestigious academic institutions—to serve as “Key Opinion Leaders” (KOLs). KOLs conduct sessions for workaday medical practitioners and psychiatrists ostensibly to provide continuing medical education. But, of course, the actual work of KOLs—for which an individual KOL might earn half a million US dollars or more—is to lead attendees to opinions regarding diagnoses and pharmacological treatments that enhance corporate profits.
Having detailed a range of ethically dubious practices, Whitaker and Cosgrove then reflect on the social injury that has flowed from them. This includes harm done to individuals who have been badly served by the diagnoses and treatments they have received. But, as Whitaker and Cosgrove point out, there are broader societal harms as well. These include cultivating a widespread sense of vulnerability and psychic fragility and promulgating a narrow and reductionist narrative of personhood. Moreover, while institutional psychiatry has devoted considerable effort to expanding its customer base among affluent members of society, the needs of impoverished individuals have been set aside. In the US, mental health services in the public sector have dwindled. Today, many thousands of severely disturbed individuals live on the streets of US cities; for thousands of others, jails and prisons serve as ersatz mental hospitals. Psychiatry’s guild interests, it would seem, have superseded its duty of care.
Psychiatry Under the Influence is of special interest for feminist psychologists. Many of its arguments dovetail with arguments that feminists in psychology have long advanced. For example, since at least the day of Charlotte Perkins Gilman in the late 1800s, feminists have registered concerns about over-diagnosing and over-treating women. Over 100 years later, women still remain the major consumers of mental health services; they are also the major consumers of certain types of psychoactive drugs. In the US, for example, one woman in four between the ages of 40 and 50 takes SSRIs (which are now prescribed for a diffuse array of conditions) (Rabin, 2013). Furthermore, feminists have long contested certain specific diagnostic categories. (A few examples: hysteria, dependent personality disorder, masochistic personality disorder, premenstrual dysphonic disorder, paraphilic rapism, and hypoactive sexual desire disorder.) Stepping back from specific diagnoses, feminists have often been skeptical of US psychiatry’s exclusively biomedical model (which some have labeled the bio-bio-bio model). Psychiatry Under the Influence echoes this skepticism, and it underscores feminists’ insistence that oppressive social and political contexts play a pivotal role in psychological suffering. Whitaker and Cosgrove’s historical account of how institutional psychiatry came to embrace the biomedical model will thus be of considerable interest.
Psychiatry Under the Influence ought to be read by all psychologists. Like it or not, the knowledge base of psychology is entangled with that of psychiatry. Undergraduate and graduate textbooks, the training of therapists and counselors, and mandatory continuing education programs for practitioners typically promulgate whatever diagnostic categories the latest revision of the DSM has on offer, presenting them as if they were foundational truths. How often do instructors raise the crucial issues of low reliability and lack of validity of those categories? How do instructors present the continual inflation in the number of diagnoses to students and trainees? Do instructors raise the possibility that the profligate deployment of diagnostic labels engenders societal harm? How often do they raise larger epistemological and moral questions about how best to frame suffering? Furthermore, the day-to-day activities of clinical psychologists are also entangled in psychiatry. In the US, most clinical psychologists—at least if they wish to be paid—must frame their work in terms of the DSM’s diagnostic categories.
Whitaker and Cosgrove’s exploration of guild interests and institutional corruption in psychiatry ought to capture psychologists’ interest for another reason. Institutional corruption is hardly unique to psychiatry. Indeed, US-based psychologists who read the phrases institutional corruption and guild interests will probably think about the secret long-running collusion between the leaders of the American Psychological Association and the US military regarding psychologists’ participation in so-called enhanced interrogation techniques. But the framework of institutional corruption that Whitaker and Cosgrove introduce might be used to investigate whether guild ethics have supplanted professional ethics in other arenas of institutional psychology (cf. Pope, 2016).
The run-up to the latest revision of the DSM (DSM-5, released in 2013) was accompanied by an onslaught of criticism in the popular press, online, and in professional venues. The criticisms came from individuals and organizations in many fields and from many parts of the world. Psychiatry Under the Influence helps us to place those criticisms in longer historical perspective and in a broader institutional context, and within a larger theoretical framework. Seen in historical perspective, the crisis that erupted around the DSM-5 was long in the making; it will certainly not be the last such crisis. Could institutional psychiatry reform? Could psychiatry in the US extricate itself from the stranglehold of corrupting influences? Could prestigious psychiatrists be induced to forgo the blandishments of the drug industry? Is it possible to obtain honest clinical trials data? The reform efforts undertaken thus far by institutional psychiatry seem to range between mendacious (e.g. denials; ad hominem attacks on critics) and ineffective (e.g. calling for “transparency” regarding financial relationships with drug companies). It is not surprising that Whitaker and Cosgrove seem to doubt whether psychiatry can reform itself from within. Instead they call for a “paradigm shift” to a “post-psychiatry” society (p. 206) that no longer allows institutional psychiatry to exert hegemony over the domain of psychological suffering. Psychiatry Under the Influence is an important first step toward such a shift.