How the Psychiatrist’s Bible, the DSM, was Actually Written, and Why Psychiatry is Such Big Business
The Weekend University, Dr James Davies, PhD
Get early access to our latest psychology lectures: http://bit.ly/new-talks5 You can follow James Davies on Twitter here: @JDaviesPhD (https://bit.ly/JD-twitter) Why, without solid scientific justification, has the number of mental disorders risen from 106 in the 1960s, to around 370 today? Why has the definition of mental disorder expanded to include ever more domains of human experience? In the first part of this lecture, Dr James Davies will take us behind the scenes of how the psychiatrist’s bible, the DSM, was actually written – did science drive the construction of new mental disorder categories like ADHD and major depression or were less scientific and more unexpected processes at play? His exclusive interviews with the creators of the DSM reveal the answer. The second part will address why psychiatry is such big business, and why, on the whole, it may be doing more harm than good. You’ll get insider knowledge on how psychiatry has put riches and medical status above patients’ well-being. The charge sheet is damning; negative drug trials routinely buried; antidepressants that work no better than placebos; research regularly manipulated to produce positive results; doctors, seduced by huge pharmaceutical rewards, creating more disorders and prescribing more pills; and ethical, scientific and treatment flaws unscrupulously concealed by mass-marketing. You’ll learn the true human cost of an industry that, in the name of helping others, has actually been helping itself. Dr James Davies graduated from the University of Oxford in 2006 with a DPhil in Social and Medical Anthropology. He is a Reader in Social Anthropology and Mental Health at the University of Roehampton and a practicing psychotherapist. James has delivered lectures at universities such as Harvard, Yale, Oxford, Oslo, Brown, UCL and Columbia. He has written for The Times, The New Scientist, The Guardian and Salon, and is author of the bestselling book: Cracked: why psychiatry is doing more harm than good. James is the co-founder of the Council for Evidence-based Psychiatry, now secretariat to the All-Party Parliamentary Group for Prescribed Drug Dependence. His latest book: ‘Mental Health in Crisis’ will be published later this year. Links: Get our latest psychology lectures emailed to your inbox: http://bit.ly/new-talks5 Check out our next event: http://theweekenduniversity.com/events/ Dr Davies’ book: https://amzn.to/33OAMuc
Transcript
Introduction
0:05hello good morning could you all hear me yes excellent it’s great to be here
0:12thank you now thank you for organizing this and thanks for the for the introduction well done for those of you
0:17who’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
0:25pun might my dad makes but anyway great that you’re all here and I’m looking
0:30forward to today I hope what I have to present today will
0:36make your trip worth it I know for a fact the other presenters will make your trip
0:42worth it but I hope mine will also be of use and interest to all of you now
0:49before I get on with my presentation I just like to say just a few a few words
0:55about me and who I am and my background and so on and so forth so my name is
1:01James Davis my doctorate was in medical and social anthropology focusing on
1:07mental health and I’ve trained as a psychotherapist and adult psychotherapist and indeed practiced as
1:13a therapist in different organizations such as the NHS and also for the
1:19organisation mind when I work for the NHS I worked in an outpatient
1:24psychotherapy unit receiving referrals from the wards and also from primary
Dr James Davies PhD
1:31care and it was while working in that setting that I started to become quite
1:38concerned with some of the more traditional forms of psychiatric
1:43intervention and practice that I was witness to for example when it came to
1:49psychiatric diagnosis I often found that these diagnoses created the illusion of
1:55understanding among me and my peers I also felt that these diagnoses were
2:01generating stigma in the people I was working with and also leading them to
2:06become confused about the real nature of their distress
2:11when it came to the psychiatric kitchens while it is true and I certainly subscribe to this notion that for some
2:19people the most severely distressed members of our society these medications
2:24can be experienced as very useful certainly when taken in the short-term and I accept that principle for me
2:31working in the NHS it felt that there was a huge amount of unnecessary over prescribing and in addition to that
2:38a lot of prescribing that was going on for far too long prescribing that ultimately in my view
2:43was doing more harm than good so as a consequence of these experiences
2:49which I culminated over a series of years I started to read voraciously
2:55the critical psychiatry literature to find out a little bit more about what
3:00potentially could be going wrong and after a few years of consulting this literature I decided personally to make
3:07my own contribution to this particular Canon and I decided to do that by way of
3:13not writing an academic article for clinicians and for fellow academics but
3:19rather for writing the kind of book I felt the people I was seeing in the room
3:25might benefit from reading so I wanted to write a book for the general reader in order to reach the people who were on
3:32the receiving end of psychiatric drugs and diagnosis because in my view it felt
3:38that many such people were subjecting themselves to psychiatric interventions
3:43without having the satisfactory information in order to make an informed
3:49decision as to whether or not to subject themselves to this form of intervention
3:55and that’s why I decided to write the book I did to provide them with that information I felt they needed in order
4:02to make an informed choice as to whether to subject themselves to these interventions or not
4:08so that book that that project culminated in a book called cracked why
Cracked Why Psychiatry is Doing More Harm Than Good
4:14psychiatry is doing more harm than good and I published that a few years ago and when it was published and I think still
4:21today that book advanced a position is both countercultural and
4:27counterintuitive the position goes like this the Sakaya tree over the last 30
4:33years under the dominance of the biomedical model has started to become
4:39bad for our mental health now there are a number of reasons why I
4:45argue this to be the case I’m just going to focus on two quickly before focusing
4:50on one in particular in the first part of my lecture today the first reason is
4:57that psychiatric drugs do not do what they say they do on the tin they’re more
5:04ineffectual and dangerous than many of us have been led to suppose
5:09the second point is that the links between the pharmaceutical industry and
5:15psychiatry have become far too cozy in recent decades and this is bias
5:21psychiatry towards privileges I close our masu Terkel treatments in the management of emotional distress and
5:27indeed that is the argument I’m going to focus on in particular in the second part of today’s lecture the final point
5:35I 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
5:41wrongly medicalised more and more people in contemporary society
5:47so apparently one in four of us now suffers from a mental health disorder in
5:52any given year and I’m going to argue that this figure is so startlingly high
5:58because psychiatry has simply renamed more and more of our natural and normal
6:06albeit painful human experiences as indicating psychiatric disorders that
6:13often times require some kind of psychiatric drug so in effect by
6:20reclassifying painful normality as psychiatric
6:25abnormality we have created the illusion of a psychiatric epidemic
6:32now I’m not suggesting here I’m not suggesting here that the suffering itself is a no that is absolutely real
6:40it demands attention and it demands care what I’m contesting is the notion that
6:47this suffering is psychiatric in nature okay
6:53so what is at the heart of this illusion well I’m going to argue today that at
6:59the heart of this illusion sits a book called the DSM the Diagnostic and
7:05Statistical Manual of Mental Disorders the book that includes all of the mental disorders that psychiatry believes to
7:12exist now there are many interesting things about this book but one in particular that stands out for me is
7:19that this book has expanded at a faster rate than almost any other medical
7:26manual in history so for example in the early 1960s this book included around a
7:33hundred disorders whereas today it includes around
7:39370 so what is going on
7:45well that’s the question I set out to answer in part of the book I was I was
7:51writing but I encountered an immediate problem and it was this there was very
7:57little documentary evidence chartering the processes that the committee’s who wrote DSM followed when
8:04they put that manual together so I quickly realized if I were to write some
8:10kind of reconstruction of events then I would have to go and speak to the people
8:16who wrote DSM and that’s what I did I started with someone called dr. Robert
8:23Spitzer who’s now generally regarded to be the most influential psychiatrist of
8:29the 20th century because he was chairperson of DSM 3 published in 1980
8:36he headed of a team of around nine people which was called the taskforce
8:42remember that phrase the taskforce who wrote and put that manual together
8:48now the reason I’m going to start with DSM 3 to day and by the way there have
8:54been five editions of DSM over its history that the most recent being dsm-5
8:59published in May 2013 but the reason I’m going to start with DSM three is because by far it is
9:07the most important edition in the manuals history for the following reasons it established the modern
9:15diagnostic system under which we still operate today so it’s what we call it
9:20the checklist system if you experience this number of symptoms for this amount
9:26of time then you warrant this diagnosis right that checklist system was created
9:32in DSM three number two DSM 3 introduced
9:3880 brand new mental disorders many of the household name disorders with which
9:44you may be familiar disorders like attention deficit disorder or
9:49post-traumatic stress disorder or major depression etc and so forth and
9:55finally DSM 3 significantly lowered the bar for what
10:02constitutes having one of these disorders in other words it made it far easier to get diagnosed with a
10:09psychiatric disorder so for these reasons I’m going to focus on DSM 3 first before moving on to DSM 4
Interview Data
10:20but before I get to that I just want to say for a moment in what I’m about to
10:26present to you now this is a composite of the interview data I gathered from speaking to the leading members of the
10:33DSM task force the interviews I conducted with them and also the archival research I undertook at the
10:40American Psychiatric Association in Washington DC where they house all of the DSM documents the documents
10:46pertaining to the construction of DSM and I’ve made two separate trips to
10:53those archives in order to familiarize myself with those documents
10:58but let me just before I get to that data first set the scene so I’ll just tell you a brief story
11:05years ago I’m in my office at the University of Roehampton and I
11:10you know it really strikes me I really need to speak to this guy called dr. Robert Spitzer so I think well let me go
11:17online let me find his let me find his telephone number so I searched online and I find this number and I think well
11:23I’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
11:29assumed 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
11:36calling from London I’d love to be able to book an appointment to speak to Professor Robert Spitzer at some point
11:42would that be possible and then she’s she she respond by saying hold on hold on rather
11:50one you’re one what this is this is not what I expected
11:56actually 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
12:06back just about that one that’s it and it’s Robert Spitzer and I say oh hi
12:13I’m James Davis oh I’d like to interview you and it so he says well what do you want
12:18to 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
12:24it and we have a conversation for an hour off-the-cuff at the end of that conversation I say to him listen Rob but
12:31this has been absolutely fascinating do you mind if we carry on this conversation I’ll come to the US why
12:37don’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
12:43we’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
12:48trip and they say fine we’ll fund the trip so I I head off to the United States six months later so six months
12:55later I get on a train from New York City take the train out through New Jersey to Princeton
13:03University and Robert Spitzer’s now lives in in one of those lovely New
13:09England homes just northeast of the University so I get it I get a cab and I
13:14head out there and the cab pulls up outside and it’s just beautiful or home and it clear they’ve chosen a lovely
13:19place to live I walk up to the to the front door I knock on the door and
13:24Robert Spitzer opens the door and he’s standing there and he’s got this loose sports top on he’s wearing shorts and
13:30he’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
13:35stay for lunch and now I just had all those mountainous American breakfast you know
13:42so I say yes that would be nice and he said to my great relief look before
13:47before we have lunch why don’t we sit down so I can tell you what you want to
13:52know so I go into his living room we sit down I set up my computer I press record
13:59and off we go now one of the first questions I had for
DSM Expansion
14:06Robert Spitzer was this what was the rationale for this huge expansion of the
14:12DSM that happened under your watch remember 80 brand new mental disorders went into that manual what was the
14:18rationale for that and this is how he responded the disorders we included work really
14:26new to the field they were mainly diagnoses that clinicians used in practice but which weren’t recognized by
14:32the DSM so by including them in the DSM we gave them professional recognition so
14:38presumably these disorders have been discovered in a biological sense that’s why they were included right
14:44no not at all there are only a handful of mental disorders in the DSM known to
14:50have a clear biological cause these are known as the organic disorders these are
14:56few and far between so let me get this clear there are no discovered biological causes for many of
15:03the remaining mental disorders in the DSM it’s not for many it’s for any no
15:09biological markers have been identified and let me just say something here for a
15:16moment now the reason why this may sound strange to many people maybe not
15:21necessarily people in this room but people out there in wider society it’s because people expect psychiatry to
15:28work much like the rest of modern mainstream medicine in modern mainstream
15:33medicine and of course there are exceptions to this but broadly speaking a name will only be ratified as
15:39indicating the existence of a disorder after some kind of pathological roots
15:44have been discovered in the body in the cells in the tissues in the organs etc
15:50but the surprising thing about psychiatry is that it works in
15:55completely the opposite way psychiatry first names a disorder before
16:03any pathological roots have been discovered in the body so in effect a
16:08new mental disorder can make it into the DSM and become part of our wider culture
16:14even though there is no biological evidence whatsoever to support its
16:20inclusion so I continued so if there are known known biological
16:28causes on what grounds do mental disorders make it into the DSM what
16:34other evidence supports their inclusion well psychiatry has to look for other
16:40things behavioral psychological we have other procedures I then asked him what
16:48these procedures were I guess our general principle was that if
16:55a large enough number of clinicians felt that a diagnostic concept was important
17:00in their work then we were likely to add it as a new category that was essentially it it became the question of
17:07how much consensus there was to recognize and include a particular disorder
17:13so it was agreement that determined what went into the DSM that was essentially
17:19how it went right another point to make here
17:25agreement does not constitute scientific proof right if a group of theologians
17:33all get together and agree that God exists this doesn’t prove that God
17:40exists all it proves is that this group of theologians believe it does so in
17:47what sense is dsm committee agreement different why when a group of
17:52psychiatrists comes together and agrees upon something should the rest of us accept they have got it right
18:00well the obvious answer to that question would be well surely there are other forms of research that are guiding the
18:06committee in the agreements they reach and that would be fair enough so let me deal with that point now and let me deal
18:14with it by drawing into the conversation a professor of psychology at Harvard
18:19Kennedy School someone called Paula J Kaplan now Paul is very interesting
18:25because she was a consultant to DSM 3 but more importantly because she lobbied
18:33Robert Spitzer not to include a new disorder that was proposed for inclusion
18:40this disorder was called self-defeating personality disorder
SDPD
18:46or SDPD for short now she argued that this
18:51diagnosis was very dangerous because the characteristics of SDPD were very
18:58similar to the characteristics that women displayed when they had been
19:03victims of violence so in other words she argued that this diagnosis could be
19:08used to pathologize female victims of violence they were suffering because they had a self-defeating personality
19:14disorder not because they’ve just been abused but also it could let the
19:20perpetrators of such violence off the hook because presumably they were just doing what these women wanted the women
19:27had a self-defeating personality disorder than the men or whomever the abusers were was simply obliging
19:34so for this reason she argued it was a dangerous diagnosis and it shouldn’t be
19:39included but Spitzer remained adamant he did not want to get rid of the diagnosis
19:46and when when I was at the DSM archives in Washington DC
19:55by the way there are nine lineal feet of documents there I’m sifting through a
20:01box and I find this little tag which reads SDPD and I go down and I pull out
20:07this document am I find the very meeting in which Robert Spitzer and his team are
20:14discussing Paula J Kaplan’s argument and I’m just going to show you a transcript
20:20of that minuted meeting here verbatim because I think it’s quite interesting it says the following they the women
20:28percent are narrow gauged but persuasive argument their powerful argument is that
20:33it is a political hot potato the feminist issue is a false one that this
20:39diagnosis could pathologize female victims of violence think women’s
20:45arguments seem irrelevant to questions on the table they are obscuring their own good arguments the good arguments
20:51being that SDPD is a controversial diagnosis the irrelevant arguments being those posed by kaplan benedek no
20:58empirical basis for category but you’re right arguments aren’t responsive to questions rose we do great disservice by
21:06backing off and not acknowledging that this pattern is pathological
21:13so 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
Research
21:20last-ditch attempt to try and influence them against doing this Paula J Kaplan
21:27launches on the final strategy I decide to scrutinize thoroughly the very
21:33research used to justify including SDPD in the DSM let’s have a look now of what
21:40she found firstly she found only two pieces of research which is a remarkably small
21:47amount by anyone’s standards but now let’s have a look at what that research
21:52constitutes in the first piece of research which was conducted by Robert
21:58Spitzer a group of psychiatrists at only one University who all accepted that
22:04SDPD existed were shown some old clinical case these Kaplan pointed out
22:11that just become some psychiatrists at one Hospital all diagnosed their
22:16patients with SDPD was not proof that the disorder actually exists all it
22:23proves as Kaplan said is that a group of psychiatrists working at the same
22:28institution gave the same label rightly or wrongly to a given set of behaviors
22:35it proves nothing more than that but if you think that first piece of
22:41research is weak then just consider the second piece a questionnaire was sent to a selected
22:48number of members of the American Psychiatric Association this asked them whether the diagnosis SDPD should be
22:56included in the DSM an official report later conducted by the psychologists
23:02cutcenes and Kirk show that only eleven percent voted yes which is surely not a
23:08representative sample of the psychiatric community so that is the research basis for
23:16including SDPD in the DSM now you could say to me look James fair enough but
23:23look surely this is an outlier you’re cherry-picking the most extreme example
23:28in order to rubbish the whole process that’s what you’re doing the research basis for the others disorders was far
23:35more 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
23:43I’m gonna deal with it by inviting into the discussion somebody called dr. Theodore Miller and by the way dr.
23:50Theodore Mullen was a member of the original task force so he was privy to everything that went on in the following
23:57quote this is what he says about the research not only supporting the
24:03inclusion of dear SDPD but all of the other disorders that went in to DSM this
24:09is what he says there was very little systematic research and much of the research that
Robert Spitzer
24:17existed was really a hodgepodge scattered inconsistent and ambiguous I
24:23think the majority of us recognize that the amount of good solid science upon
24:29which we were making our decisions was pretty modest
24:35so let me now go back to sitting in robert’s pizzas front room back in
24:42Princeton I decide to read to Robert this quote to see what he made of it and
24:48after a short and a slightly uncomfortable silence Robert Spitzer responded in a way I
24:55simply had not expected he said the following well it is certainly true that for many
25:03of the disorders that were added there wasn’t a tremendous amount of research and certainly there wasn’t research on
25:10the particular way we define these disorders in the case of millons quote I think he’s mainly referring to the
25:16personality disorders but again it is certainly true that the amount of research validating data on most
25:24psychiatric disorders is very limited indeed so you’re saying that there was little
25:31research not only supporting your inclusion of new disorders but also supporting how these disorders should be
25:37defined there are very few disorders whose definition was a result of specific research data
25:48so I was so surprised by this admission that when I returned to the UK some days
Donald Klein
25:55later I decided to check it out with other members of his task force so on as
26:01a rainy english morning I decided to call at his office in New York City
26:07someone called professor Donald climb now professor Donald Klein is a really
26:13important figure in the history of DSM he was second-in-command to Robert Spitzer but actually from the archives
26:20it turns out he probably had in many areas almost more influence than Robert Spitzer so a key player in the history
26:27of DSM I called him and I read to him what Spitzer had said to me to see what
26:34he made of it and this is how he responded sure we had very little in the way of
26:40data so we were forced to rely on clinical consensus which admittedly is a
26:46very poor way to do things but it was better than anything else we had
26:51so without data to guide you how was this consensus reached I asked for an
26:58example we thrashed it out basically we had a three-hour argument there would be about
27:0412 people sitting down at a table usually there was a chairperson and there was somebody taking notes and at
27:11the end of each meeting there would be a distribution of events and at the next meeting some would agree with the
27:16inclusion and others will continue arguing if people were still divided the matter would be eventually decided by a
27:24vote a vote really sure that is how it went
Henry Pinsker
27:32right so they’re voting here I’m interested so the next person I
27:41speak to dr. Henry Pinsker again a member of the original nine I decide to
27:47raise the issue of voting with him and this is what he said some things were discussed over a number
27:54of different meetings which would sometimes be followed by an exchange of memoranda about it and then there would
28:00simply be a vote vote people would raise hands there weren’t that many people
28:09regarding the legitimacy of this method Pinsker continued we never had any
28:14question that that was how we should proceed I had no reservations at all about working that way
28:22and just to confirm this was the case
28:27when I was in the archives I managed to source with the archivist 12 minute task
28:34force meetings and we could only source 12 because that’s all we could find and out of those 12 minute a task force
28:41meetings there is evidence clear evidence of votes taking place in 10 of
28:47them and we’re not talking about one or two votes here lots and lots of votes on
28:53a whole host of different topics in one of the documents was about twenty four votes unloaded evidence how to define
28:58the disorders where to set symptom thresholds whether or not to include the disorders in other words the archival
29:06evidence absolutely supports what the oral history is saying Oh
29:12what one point I just want to make about all of this voting isn’t scientific
29:18activity its it what is it it’s a cultural
29:25activity when anything is voted into existence whatever it may be whether it’s a new President of the United
29:31States whether it’s a new union leader whether or not it’s a new mental
29:37disorder the likelihood we’ve got it wrong is never far away
Rennie Garfinkel
29:45okay so let me give you aa yes could I just introduced you to
29:51Rennie Garfinkel for a moment very interesting woman she
29:58during the construction of DSM 3 she’d just finished her training as a
30:03psychologist so she was very young very green very naive and innocent as we all
30:09are before we go out there into the big wide world and she got a kind of internship at the APA and she turned up
30:14at 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
30:20DSM could you go up there and just help out make coffee photocopy usual sorts of
30:25things fine so she goes like they shouldn’t know what she’s part of and she’s sitting in the task force meetings
30:31and that’s things well and she starts to realize she’s actually part of something quite important here and she’s pretty
30:37took some quite fascinating dynamics so 30 or so years later I decide to
30:44interview her what was going on what was happening what did you observe
30:50this is what she said you must understand what I saw happening
30:56on these committees wasn’t scientific it more resembled a group of friends trying to decide where they want to go for
31:02dinner one person says I feel like Chinese food another person says no no
31:07no 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
31:14Italian she then gave me an example of how far
31:21down the scale of intellectual respectability she felt these meetings
31:27could sometimes fall on one occasion I was sitting in on a task force meeting
Task force meetings
31:33and there was a discussion about whether a particular behavior should be classed as a symptom of a particular disorder
31:38and as the conversation went on to my great astonishment one task force member suddenly piped up oh no no no we can’t
31:45include that behavior as a symptom because I do that
31:51and so it was decided that that behavior wouldn’t be included cause presumably if
31:56someone on the task force does it it must be perfectly normal
32:02all right so let me just give you some more impressions of these these these
32:09meetings gathered by way of my interviews and other people other
32:14sources I consulted according to other members of the task force these meetings will often haphazard Affairs suddenly
32:21these things would happen and there didn’t seem to be much basis for it except someone just decided all of a
32:26sudden to run with it said one participant it seemed another member admitted that the loudest voice is
32:32usually won out with no extensive data one could turn to the outcome of
32:37taskforce decisions often depended on who in the room had the strongest personality but the problem with relying
32:44on consensus reiterated Garfinkel is that in the discussion some voices will
32:50just get quieter either because they don’t want to fight or because they see
32:55they’re in the minority and snap that’s when the decision is made
33:02admittedly when the task force lacked expertise on a particular disorder Spitzer would consult the relevant
33:08leaders in the field and the archives are full of these letters he was writing back and forth to
33:13you the experts but this also led to chaotic meetings that members often
33:19found difficult to participate in one of the only British members of the task force a psychiatrist called David
33:24Schaffer recalled how such meetings often unfolded in these meetings of the
33:29so-called experts or advisors people be standing and sitting and moving around people would talk on top of each other
33:35but Bob Robert Spitzer would be too busy typing notes to chair the meeting in an
33:40orderly way now in
33:472005 a very interesting article was published in The New Yorker magazine and
33:53the title of that article was a dictionary of disorder and it was a
33:59biographical study of Robert Spitzer’s influence on global psychiatry and
34:05midway through that article there’s a section on the construction of DSM 3
34:11which I just want to read to you very briefly Roger Peale and Paul asada
Construction of DSM 3
34:18psychiatrist and since Elizabeth Hospital in Washington DC wrote a paper in which they used the term hysterical
34:25psychosis to describe the behavior of two kinds of patients they had observed Spitzer read the paper and asked Peale
34:33masada if he could come to Washington to meet them during a 40-minute conversation the three decided that
34:40hysterical psychosis should really be divided into two disorders brief
34:45reactive psychosis and factitious disorder then Bob asked for a typewriter Peale
34:53says to peel surprise Spitzer drafted the definitions on-the-spot he banged
34:59out criteria sets for factitious disorder and for brief reactive psychosis and it struck me that this was
35:06a productive fella he comes in to talk about an issue and walks away with diagnostic criteria for two different
35:14mental disorders and by the way both of those disorders went into the DSM with
35:21only very minor modification from the original criteria written up there and then in that room
The impact of DSM 3
35:30let me just read you two paragraphs before we move on as Spitzer’s dsm 3 was
35:39published in 1980 it became a sensation overnight the almost 500 page long
35:45manual sold out immediately the manuals purchase not only by
35:51psychiatrists but by nurses social workers lawyers psychologists
35:56psychotherapists etc and the enthusiasm quickly spread far beyond the United States in Britain for example the manual
36:04had such impact that by the end of the 1980s most British psychiatrists were
36:10being trained to use DSM furthermore Spitzer’s DSM categories quickly became
36:15those that guided all research into psychiatric disorders internationally
36:21this meant that the disorders that were studied by researchers in Germany Australia Canada Britain Scandinavia and
36:28so on and so forth with those defined and listed in Spitzer’s DSM in short the
36:35book ultimately changed the fundamental nature of research and practice within the field not to mention the lives of
36:42tens or countless millions diagnosed with the psychiatric disorders listed
36:47there in and yet as the influence of the manual
36:53spread the truth about its construction remained obscure most professionals
37:01using the manual simply did not know and I would say still do not know today
37:08the extent to which biological evidence or solid research failed to guide the
37:15choices the taskforce made they did not know that the definitions of the disorders contrived the validity of the
37:22disorders included and the symptom thresholds people must meet in order to receive the diagnosis were not decided
37:29on the basis of rigorous research but with a product of committee decisions which at best reflected the well-meaning
37:37profession opinions of a small subset of psychiatrists in short most people did
37:46not know that the fundamental changes Spitzer brought to global psychiatry
37:51only required the consensus of an extremely small group of people nine
37:58people and indeed as Robert Spitzer openly confirmed to me in our interview
Most people did not know
38:06and actually I think this is this is my this is my favorite quote of all he said
38:12the following our team was certainly not typical of the psychiatric community and that was
38:19one of the major arguments against DSM 3 it allowed a small group with a particular viewpoint to take over
38:26psychiatry and change it in a fundamental way what did you make of that criticism what
38:35did I make of that chart well it was absolutely true it was a revolution
38:41that’s what it was we took over because we had the power
Who has the power
38:50quite a striking confession I actually I actually got that quote the
38:58day after I was leaving and I was at the hotel and I was having breakfast the day
39:04after 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
39:11thought you know what just call him this guy usually answers the phone so just call him so I called him back and and I
39:19said 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
39:26the criticisms of DSM and this is what he said and I recorded this on a fountain outside of one of those you
39:33know best inns or something you know sitting and I recorded it there and this
39:38is what he said to me that morning and I think it’s really really quite a powerful statement because it’s true
39:44it’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
39:52do with who has the power it is absolutely to do with who has their
39:58power and don’t let anyone tell you otherwise shocking the extent to which this
40:04happens not just on death but on all the committee’s that define how we are meant
40:10to understand and respond to emotional difficulties okay alright I’ve got ten minutes left of
40:18this section is that okay before we have a quick break because I want to move forward now into dsm-4 so not that much
40:24more to go but but stay with me please so in
40:301994 dsm-4 reaches the end of its shelf
40:36life and it’s replaced dsm 3 story and is replaced by DSM 4 which remains the
40:42DSM in use for 20 years right up until May 2013 when it’s replaced by
40:50dsm-5 yeah ok so in
40:552013 I had the opportunity to talk to interview the new chairperson of DSM for
41:01dr. Alan Francis who took over from Robert Spitzer on two separate occasions and
41:06so I the first one of the first questions I had to him was with the benefit of hindsight
41:12was there anything you did when constructing DSM for that you now regret
41:18and this is what he had to say well the first thing I have to say about
41:23that is that DSM 4 was a remarkably unambitious and modest effort to
41:29stabilize psychiatric diagnosis not to create new problems this meant keeping
41:34the introduction of new disorders to an absolute minimum what did he mean by that well his team
41:42only introduced eight new mental disorders into the main manual which is
41:47a modest amount compared to the 80 introduced by Spitzer however from another standpoint this
41:55claim to modesty is very shaky because it excludes the following his team
42:02actually created 30 new mental disorder but put them in the appendix and
42:09subdivided many existing conditions in effect creating new ones so if you count
42:15the appendix inclusions and the subdivisions all of which people can and
42:21are diagnosed with then his team expanded the DSM from around 270
42:27disorders to around 370 disorders which is the very opposite
42:33of modesty and conservativism so we carried on
Tough Lessons
42:40yet despite that conservativism francis said and i let the comment slip we
42:46learned some pretty tough lessons we learnt overall that even if you make minimal changes to the DSM the way the
42:53world uses the manual is not always the way you intended it to be used can I
42:58just 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
43:05who’s at fault right if they’re any men mental health professionals here in the room who in good faith use these manuals
43:11and you do in good faith it’s your fault it’s not their fault it’s your fault by
43:16the way okay so the way the world uses the manual is not always the way
43:21intended it to be used for instance we added bipolar to Asperger’s disorder and
43:28finally we added ADHD and well these decisions help promote three false
43:34epidemics in psychiatry I asked him what he meant by that
43:40well we now have a rate of autism that is twenty times what it was fifteen years ago by adding bipolar to a milder
43:48version of bipolar we also doubled the ratio of bipolar versus unipolar depression resulting in lots more use of
43:55antipsychotic and mood stabilizer drugs rates of ADHD also tripled partly
44:01because new drug treatments were released that were aggressively marketed so every decision you make has a
44:07trade-off and you can’t assume the way you write the DSM will be the way it will be used there he goes again
44:14so the way the DSM is being used has led to the zatia of a number of people who
44:21really don’t warrant their diagnosis exactly can you put a figure on how many people
44:28have been wrongly medicalized there is no right answer to who should be
44:33diagnosed there is no gold standard for psychiatric diagnosis so it’s impossible to know for sure but when the diagnosis
44:42rates triple over the course of 15 years my assumption is that medicalization is
44:48going on powerful statement for him to make he
44:54was the chairperson of DSM 4 but could the situation be even worse than this I
45:00would argue absolutely it could be and it is because he’s only talking about the eight disorders he put into the main
45:06manual he’s not talking about the subdivisions and the appendix inclusions all of which medicalised more and more
45:12painful normality he’s also not talking about the existing problem of over
45:17medicalization he allowed to live on created by DSM 3 allowed to live on into
45:23DSM for right he allowed DSM 3 to carry on he’s not talking about that either
45:29think of some of the disorders he allowed to live on we had disorders like female orgasmic disorder
45:38yeah caffeine related disorders
45:44stammering stuttering transsexualism or positional defiant
45:53disorder which is something i evidently acutely suffer from
46:01look nobody is suggesting that these things aren’t experienced as problems by
46:07certain people I’m sure they are but whether or not they constitute psychiatric illnesses it’s another
46:14matter entirely so my final question for Alan Francis
46:20was this with the benefit of hindsight why isn’t it you just simply scrapped a
46:26lot of what went on before on the basis of number one it enjoyed woeful scientific support and on the number
46:33basis number two that it was many of this stuff much of this stuff was frankly eccentric and this is how he
46:40responded if we were going to either add new diagnoses or eliminate existing ones
Reducing the system
46:47there had to be substantial scientific evidence to support that decision and there simply wasn’t so by following
46:56our own conservative rules we couldn’t reduce the system any more than we could increase it now you could argue that
47:03that is a questionable approach but we felt it was important to stabilize the
47:08system and not make arbitrary decisions in either direction but
47:13one of the problems with proceeding in that way I said is that it assumes the DSM system you inherited from Spitzer
47:20was fit for purpose for example it assumes that the disorders Spitzer included and the diagnostic threshold
47:27splits his team set were themselves scientifically established
47:32we did not assume that at all we knew that everything that came before was arbitrary francis quickly corrects
47:39himself we knew that most decisions that came before were arbitrary I had been
47:46involved in DSM 3 I understood its limitations probably more than most people did but the most important value
47:52at that time was to stabilize a system not change it arbitrarily
47:58so you are essentially saying that you set out to stabilize the arbitrary
48:04decisions that were made during the construction of DSM 3 in other words corrected Frances it felt better to
48:10stabilize the existing or decisions than to create a whole new assortment of new ones
48:18and I thought that was a very good place to bring the interview to a close
48:23all right so let me one final paragraph
48:30before we have a very short break
48:35so during this part of the lecture to a close what I have discussed today I
48:41believe poses a serious challenge to those who embrace the conventional view
48:46that mental disorders are discrete patterns of biologically rooted
48:52pathological feeling and behavior identified by way of objective research
48:58processes what an inspection of the construction of DSM rather reveals is
49:04that the separate disorders into which DSM organized diverse behavioral and
49:10mental phenomena were largely the outcome of vote based judgments settled
49:16by a small culturally homogeneous subset of mental health professionals
49:23who were socially positioned at a given time to have their judgments ratified by
49:30the institutional apparatus of the American Psychiatric Association
49:35now while such judgments may indicate that a group of professionals sharing
49:42similar socio cultural beliefs biases persuasions and interests may see some
49:49things in the same way at a given point in time they do not confirm that what they see
49:56is either objectively true Universal or indeed stable in air at any verifiable
50:04sense we’re going to move on to a slightly different territory now in the
50:10second part so in the first part we looked at the construction of DSM and the argument was essentially that we’ve
50:17expanded the definition of mental disorder to encompass more and more
50:22domains of human experience now what are the consequences of that of
50:28course is that we’ve created a larger and larger market for psycho
50:34pharmaceutical medications right because the more people out there in society who are disordered the more people out there
50:41who are going to need treatments now this has happened in an era when
50:47there has been a dearth of psycho-social alternative provision so
50:54the inevitable consequence of that has been more and more prescribing as a consequence of more and more over
51:00medicalization let me just give you a sense of scale last year in the NHS
51:08500,000 people were given psychological therapy as an intervention
51:14last year in the NHS 7.4 million people were prescribed an
51:20antidepressant so you can see the imbalance in provision here this is made all the more
51:28concerning given that the research shows that when people go to see their GP
51:35because they’re suffering from emotional problems or acute emotional distress the
51:40vast majority of those people actually want some kind of psychological or
51:46social intervention not an antidepressant but what they invariably
51:51get is an antidepressant because provision for the alternatives are at an all-time well they’re actually better
51:57than it was but it’s still comparatively speaking very low
52:02and this can partly explain why and I
Statistics
52:08want you this statistic to stay with you over 20% of the adult population in
52:14England was prescribed a psychiatric drug last year alone over 20% of the
52:23adult population of England was prescribed a psychiatric drug
52:2916 percent were prescribed antidepressants the rest antipsychotics
52:36stimulants anxiolytics etc and so forth and this figure has doubled in the last
52:4315 years in addition to that not only are we
52:50prescribing double the amount of drugs we did to 15 years ago but the average
52:55duration of time as person spends for example and an antidepressant has also
53:01doubled 10 years ago it was about a year today it is around two years in fact
53:07half of all antidepressant users in England have been taking antidepressants
53:12for at least two years so not only is prescribing going up but we’re staying
53:17on the drugs for longer and longer and this is particularly concerning given
53:24the following facts that long-term use is not associated with good stuff okay
53:32increase severe side effects the impairment of autonomy and resilience increased weight gain worsening outcomes
53:40for some people poor long-term outcomes for major depressive disorder greater relapse race increase mortality and an
53:48increased risk of developing neuro degenerative diseases such as dementia
Mechanisms of Influence
53:56so we should be concerned about these current trends this epidemic of over
54:01prescribing so how then does the relationship between over medicalization which
54:09manuals like DSM have encouraged and rising drug consumption actually
54:14operates what mechanisms of influence does industry exert to expand
54:22psychiatric drug consumption via over medicalization putting it in the least
54:28varnished terms how do pharmaceutical companies influence processes of
54:34medicalization to aid wider consumption of their products and in order to
54:40address this question head-on I want to distinguish momentarily between two
54:45different forms of pharmaceutical industry influence which we will call direct influence and in
54:53act influence so focusing firstly on direct influence here’s a definition of
54:59what that would mean the undertaking of activities explicitly designed to
55:05increase psychiatric prescribing such as direct marketing and advertising
55:10initiatives to both the public and the medical establishment
55:16fortunately in the UK it’s illegal to market drugs to the general public it’s
55:23not illegal in the US it’s not illegal in New Zealand but here it is but pharma companies nevertheless invest heavily in
55:30marketing campaigns targeting professionals psychiatrists and medical professionals
55:37and that goes on very widely but allow me for a moment just to give you an
55:42illustration of direct marketing to the consumer and this concerns a new
55:49diagnosis that was introduced into the dsm-4 in the year 2000 and this
55:57diagnosis was called premenstrual dysphoric disorder
56:04apparently up to 8% of women were said to suffer from the condition and its
56:11main symptoms occurred two weeks before menstruation and the symptoms included
56:18things such as feelings fatigue anxiety emotional instability distress in daily
56:24activities and difficulty in concentrating in short premenstrual dysphoric disorder was a slightly
56:30mitigated version of PMT premenstrual tension
56:36now by the early 2000s the number of women being diagnosed with premenstrual
56:44dysphoric disorder went up exponentially and one of the key reasons for this was
56:50that the pharmaceutical company Eli Lilly had begun investing tens of
56:56millions of dollars promoting this so-called disorder and its so-called corrective something they called
57:03Seraphim and what I want to show you now is one of the commercials with which Eli
57:10Lilly 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
57:16popular one let me just play it to you
57:31[Music]
58:01[Music]
58:11[Music]
58:23okay hands up the woman in this room that don’t have premenstrual dysphoric disorder I
58:30mean really we were talking about the over
58:36medicalization of normality I mean this is astonishing is it not and this is just one of four commercials that were
58:42going around the United States at that time promoting Sarah fat as a drug for a
58:48presume that the presumed mental disorder now I just want to stay with
58:54this 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
59:02interesting is it not it’s a Hebrew play on the word Seraphim a word with female
59:08associations attached also think of the packaging used this particular pill
59:14Seraphim was encased in a very pretty pink and lavender pill and so was the
59:20packaging in these sort of traditionally female symbolism
59:26this is all standard fare of marketing but what about to tell you now actually
59:31gets far more interesting what Eli Lilly initially
59:37concealed from the hundreds of thousands of women who started to take Seraphim
59:42was that Seraphim is actually prozac
59:50prozac and Seraphim are both made by Eli Lilly and chemically they are exactly
59:57the same hundreds of thousands of women were taking Prozac and they didn’t know it
1:00:05they just repackaged the pill now I’ve given you that example because
1:00:13I don’t want you to go away thinking that direct marketing is good and pure because it’s direct because it’s obvious
1:00:20everything’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
1:00:26did you and nor did the women who were taking seraphim no they were taking Prozac so direct marketing is
1:00:33problematic but I don’t want to focus too much on direct marketing today because I want to actually focus on
1:00:39something that is even more problematic and that’s it’s more clandestine alternative what we will call in direct
1:00:47marketing and here’s a definition of what it means a
1:00:52form of financial influence that invariably operates by proxy and/or purposeful dis fault via the financial
1:01:00sponsoring of persons institutions or apparatuses deemed sympathetic and/or potentially advantageous to the
1:01:07expansion of psycho pharmaceutical markets so what I want to do now is give you
1:01:13three examples just three out of plethora of how indirect influence
1:01:20actually works the first example I want to give you is
1:01:26perhaps the most obvious example and this occurs by way of industry
1:01:32financially sponsoring what are called key opinion leaders these are senior
1:01:37members of the medical or psychiatric profession who get paid and will do and
1:01:43say things consistent with industry interests and to get a sense of how
1:01:48common these financial conflicts of interests are a couple of years ago a
1:01:55respected at watchdog charity in the United States in fact one of the most respected in the u.s. called Pro Publica
1:02:03looked at all of the payments that were made from the whole of the pharmaceutical industry to the whole of
1:02:09medicine and what they found was that half of the highest payments made by the
1:02:16whole of farmer to the whole of US medicine were made to doctors in a
1:02:21single speciality and that was psychiatry
1:02:28Sassicaia tree was taking more of the higher payments than any other area of medicine
1:02:34another example when researchers at the University of Massachusetts inspected
1:02:39the financial interests of the people who sat in and helped construct the DSM
1:02:45at DSM for this is what they found and this is the piece of research I’m I’m
1:02:51alluding to here by cosgrove what they found was that 56% of the people who
1:02:57were involved on the advisory panels and the consultancy groups for the construction of DSM for 56% of them had
1:03:04one or more financial tie to the pharmaceutical industry and then get
1:03:10this on the panels that considered the disorders for which drugs or the first
1:03:16line of treatment a hundred percent had financial ties to the pharmaceutical
1:03:23industry now this form of influence is so
1:03:30powerful due to how typical and routine it has become within the psychiatric profession a typicality that has
1:03:37seemingly inoculated many to the depths of the biasing effects an example of
1:03:43this was was dramatically illustrated to me a few years ago in the houses of parliament there was a debate around at
1:03:49DSM and Alan Francis had been invited to it and during that I decided to point
1:03:55out to him how many people on his dsm-4 had financial conflicts of interest with
1:04:01respect to the pharmaceutical industry and his response was this well you know
1:04:07I know what you’re saying James but ultimately we were all real good guys that was the phrase used we were good
1:04:13guys we were just trying to do what we thought was best but I have to admit it
1:04:19was remiss of dsm-4 not to have a conflict of interest policy at that
1:04:26time well following DSM for dsm-5 did have a
1:04:35conflict of interest policy and the reason for that was post DSM for medicine became more and more concerned
1:04:43about financial ties to industry and there was a lot more pressure for them to be transparent and there was
1:04:50certainly a lot of pressure on dsm-5 to be more transparent regarding its triad ties so it was more transparent so let’s
1:04:57have a look at what we can find of the 29 members of the
1:05:03dsm-5 task force the people who wrote and put it the manual together 21 it turns out had financial ties to
1:05:11the pharmaceutical industry including the chair of the DSM task force David
1:05:17Kaufer and the vice chair Dowell Reagan
1:05:23now while of course those possessing financial ties to
1:05:28industry often dismiss or downplay their biasing effects and I should know this
1:05:34because I’ve interviewed so many of them the research is very clear that they
1:05:40bias those receiving them both individuals and institutions towards
1:05:45favoring psychopharmaceuticals in their clinical educational and research activities in other words such payments
1:05:53biased clinicians researchers and institutions in industry friendly
1:05:58directions now given that DSM medical eyes huge waves of pork painful
1:06:05normality driving up drug prescriptions as a consequence it’s concerning that those responsible for the creation of
1:06:12DSM were at the same time receiving money from industry they’re going to be
1:06:17less concerned about one of the major consequences of over medicalization than somebody like me who wouldn’t ever take
1:06:25money from industry so that’s the first and most obvious
1:06:30example of how indirect influence works but let me now give you another example
1:06:36by bringing things slightly closer to home and I’m going to do that now by
1:06:41referring to and by the way here’s the research some of the research is an awful lot out
1:06:47there but some of the research into the biasing effects of such conflicts of interest
1:06:54I want to now refer you to these two documents used in the NHS now these are
1:07:00two of the most powerful documents in mental health and the reason for that is
1:07:06because these two documents have been used for the last 15 years throughout primary care to help doctors determine
1:07:15whether or not the people sitting in front of them have either anxiety or
1:07:20depression it’s depression as phq-9 anxiety is GAD 7 so you give these to
1:07:27your patient they tick some boxes and depending on the score they get determines the intervention you
1:07:34you offer now one of the very interesting things
1:07:39about these documents and one of the most powerful arguments against them is that they set the bar very low for what
1:07:48constitutes having a form of depression or anxiety for which a drug should be
1:07:53prescribed and by the way 90% of people who fill in these
1:07:59questionnaires get prescribed medications as a consequence
1:08:05now what the tens of millions of people who have filled in these questionnaires
1:08:10in the NHS and I’ve got prescribe drugs as a consequence almost certainly did
1:08:15not know was that these documents were developed by their distribution
1:08:22throughout the NHS was paid for by and their copyright was owned by
1:08:30Pfizer Pharmaceuticals which incidentally makes two of the most
1:08:37prescribed anti anxiety and antidepressant drugs in the NHS so
1:08:45here you have a company setting the bar very low for what constitutes needing a
1:08:51drug what at the same time as manufacturing and profiting from those
1:08:57drugs and this as we’re going on within the NHS for 15 years in fact if you go
1:09:03onto Google if any of you online now and you type in sort of depression
1:09:08NHS etc nine times out of ten you’re going to
1:09:13you’re going to find the phq-9 coming up first and that’s the document you have
1:09:19to fill in to assess whether or not you have depression and if so how severely okay so another example of how industry
1:09:29indirectly is promoting over medicalization and as a consequence over
1:09:35prescribing can I give you the third and final example now
1:09:41this concerns a personal anecdote so
1:09:47twelve months after dsm-5 was published in May
1:09:542013 actually wasn’t twelve months it was six months excuse me six months after I was in New York City and I was
1:10:02in one of those Airbnb apartments I was up on the upper end of near Columbia
1:10:08University in in one of these apartments one evening and I’m checking my emails and I decided to go online and actually
1:10:15look up you know what’s going on in the publishing market what books are selling well in the United States at the moment
1:10:20so I go to Amazon and I open the page and I stop and
1:10:27I look and I can’t believe what I’m seeing at that point six months after dsm-5 was
1:10:36published the highest selling book in the whole of the United States was
1:10:42dsm-5 that just to give you a sense of scale
1:10:47Harry Potter yeah very popular I have two little kids and they’re really into
1:10:54it at the moment very and this was the time when Harry Potter was really big Harry Potter was at number seven
1:11:00fifty shades of gray some of you may know that one number nine again very popular
1:11:08dsm-5 was number one but in addition to that guess how much a paperback version
1:11:15of dsm-5 cost the cheapest version eighty eight dollars a copy
1:11:22so who was buying this book right who’s buying it
1:11:31so the next day I’m interviewing a prominent medical anthropologist at New
1:11:36York University we do our interview and at the very end and she works in mental health so she knows the system very well
1:11:42I asked her what was going on I said I’ve been online last night I found out this
1:11:49information 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
1:11:55and she said from my experience in the New York state area where I work in primary care what’s happening is the
1:12:02pharmaceutical industry is buying DSM in bulk and then distributing it for free
1:12:09to clinicians up and down the country and that is why the sales are so high
1:12:15why would industry do that it just makes complete business sense
1:12:21they’re more people who are being medicalized the greater the market you have for your own products
1:12:28now I try to verify this so I contacted Amazon they would not declare who was
1:12:35buying the books they’re not legally obliged to do so so when I went to the American Psychiatric Association I tried
1:12:42so optically to discover what had been going on and I got confirmation that the vast majority of DSM sales were bought
1:12:49in bulk when I asked who was buying them in bulk the door immediately shut and I
1:12:56couldn’t find it so I haven’t been able to get definitive proof of this but given everything else we know I’ll leave
1:13:04it for you to make up for yourselves your own minds the extent to which this is going on and indeed it is absolutely
1:13:11consistent with what industry has been doing in relation to psychiatry over
1:13:16over the last 20 years or so and I just want to read very quickly this this paragraph to summarize a lot of points
1:13:22and the research relating to the points being made pharmaceutical industry has been a major financial sponsor of UK and US academic
1:13:30Sakaya tree significantly influencing psychiatric research training and practice this this influence has been
1:13:35exerted through many heads of psychiatry departments receiving departmental income from drug companies but at the
1:13:41same time as receiving personal income through nearly all clinical trials into psychiatric drugs antidepressants
1:13:47neuroleptics tranquilizers being pharmaceutically financed or commissioned through most academic drug
1:13:54researchers receiving research funding consultants fees speakers fees or other honoraria from industry and through
1:14:00leading psychiatric organizations such as the American Psychiatric Association the publisher of DSM receiving most of
1:14:06its operational costs from industry eg with such report the AP A’s annual revenues rose from 10.5 million in 1980
1:14:14to 50 point 2 million by 2000
1:14:24to bring this closer to home in 2012 I did a Freedom of Information request to
1:14:32our eight leading psychiatry departments universities departments in the UK to
1:14:37see how much money they were receiving from industry one of the department
1:14:43simply failed to respond to the quest and two of the departments had simply
1:14:50not gathered any data at all so I only got information regarding four of our
1:14:56leading psychiatry departments and this is how much money they received for research funding alone only research
1:15:01funding from industry between 2009 2012 5.5 million from the University of
1:15:07Newcastle 1.5 nine million from University of Edinburgh 687 thousand from Oxford and Institute
1:15:14of Psychiatry 1.87 million this doesn’t sound like a lot of money actually to many people it may not but it is for
1:15:20academics this is a lot of money you can pay for salaries you can pay for PhD students pay for seminars etc and so
1:15:25forth for an academic department this is a lot of money but by the way this only relates to the research funding being
1:15:33received private industry income received by faculty isn’t gathered by the University
1:15:39so money for consultancy work speakers fees and other honoraria as British universities are simply not obliged to
1:15:46gather this information this is what Liverpool University stated psychiatrists are not required to report
1:15:52individual payments to the University so we don’t hold any information which could be provided in response to this
1:15:58part of the request but even if universities commit to
1:16:04gathering this information I identified irregular reporting one prominent and
1:16:09psychiatry Department stated their faculty had received no payments at all
1:16:14despite a clear obligation to do so if they had received such payments and
1:16:19despite three of its senior psychiatrists having reported receiving payments so I went on to their published
1:16:27research it was clear they reported their payments they hadn’t reported those to their University even though
1:16:34they were obliged to do so the important point I’m trying to make here is that
1:16:39through the era of psycho pharmaceutical expansion neither universities nor any
1:16:46other private or public body in the United Kingdom has been legally obliged to declare the names of individual
1:16:53psychiatrists and the precise levels of Industry income they receive each year and this is concerning given such
1:17:00payments have demonstrably biasing effects on both clinical research and practice they foster professional
1:17:08industrial dependencies and allegiances and in the case of speakers fees and
1:17:13consultancy fees and other honoraria these payments are seen by pharmaceutical companies as
1:17:20investments from which immeasurable return is expected they don’t just give
1:17:26this money out for nothing they give it out for an effect and if an individual doctor isn’t delivering
1:17:34then the money will be taken away and it will be given to a doctor who is and there’s lots of documentary evidence
1:17:40supporting this these are investments from which a return is expected and yet
1:17:46doctors do not have to report their financial conflicts of interest to any agency or any authority in the UK is
1:17:53absolutely in my view unacceptable
1:18:01that pharmaceutical companies have actively used these extensive financial ties to shape practice and ideology
1:18:08within the mental health field driving up prescription rates as a consequence this should surprise no one but the
1:18:15extent to which such companies have promoted increased prescribing by corrupt means is still not fully
1:18:21appreciated so I’d like to focus very briefly on this issue now by drawing
1:18:28upon 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
1:18:35I just want to focus on a case study because I think it’s quite illustrative of some of the problems we encounter in
1:18:40this area in May 2000 dr. Charles Schultz a psychiatrist at the very
1:18:47height of his powers walks up to a podium at the annual meeting of the
1:18:52American Psychiatric Association and announces a breakthrough in
1:18:58anti-psychotic drug research the breakthrough amounts to the development of a new drug that has quote dramatic
1:19:07benefits over its competitors it’s name is seroquel and because of its
1:19:13superiority quote patients must receive these medications first
1:19:19two months before this commanding announcement was made at the APA and to
1:19:26the national media the pharmaceutical company that manufactures seroquel Astra
1:19:32Zeneca was in disarray they had just discovered that further
1:19:38research into seroquel had revealed that the drug was far less effective than its
1:19:45arch rival drug a drug called Haldol the document containing this finding was
1:19:52being circulated among senior staff at the company who were now not quite sure
1:19:58what to do an internal email written at the time and later released by the
1:20:04company during litigation captures the mood very well so this is the email
1:20:10going around Jeff and Mike here’s the analyses I got from Emma I’ve also attached a message I
1:20:17sent to her yesterday asking for clarification the data don’t look good in fact I don’t know how we can get a
1:20:23paper out of this my guess is that we all including Schulz saw the good stuff and then thought further analyses would
1:20:30be supportive and that the paper was in order but what seems to submit was to be the cases that we were highlighting only
1:20:37the good stuff and that our own analysis now supports the view out there that we are less effective than Haldol and our
1:20:43competitors once you’ve had chance to digest this let’s get together or teleconference and discuss where to go
1:20:49from here we need to do this quickly because Schulz needs to get a draft ready for the APA and he needs any
1:20:55additional analyses we can give him well before then so this is the company
1:21:00thinking 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
1:21:06an APA academic conference look at the relationship between him and the company here
1:21:12so in this email the publications manager at AstraZeneca casts about for a
1:21:18solution he knows the research into seroquel doesn’t look good yet he also realizes that Schulz has to present a
1:21:25paper on seroquel at the American Psychiatric Association’s meeting in two months time if Schulz reports the
1:21:32negative data the drug is presumably doomed a way out is needed and fast
1:21:40so what does the company do how in just two months does it move from privately
1:21:47despairing over the failings of Seroquel to making a public declaration about its
1:21:53exceptional advantages does the company rapidly undertake a new
1:21:58study that finally secures seroquel superiority does it we analyzed the old
1:22:04data only to discover that its previous negative interpretation was wrong the
1:22:10company does neither there is no time and even if there were time the existing
1:22:16data is definitive the drug is weaker than its competitors in many areas that
1:22:22it seems is plain for all to see at this point you’d probably expect the
1:22:29company to cut its losses and with regret to publish the whole truth but
1:22:35the company does not take that route presumably there’s too much money at stake and anyway perhaps there’s another
1:22:42way out sure it’s not an ideal route to take or even an honest one but given the
1:22:50money that could be lost it has to be worth a go the company therefore opts for a strategy known in drug research as
1:22:57cherry-picking in other words it picks and publishes the data that makes the
1:23:03drug look effective while leaving aside the data that does not and this was the
1:23:10solution that Astra Zeneca opted for in early 2000 rather than admitting that
1:23:16after a year on seroquel patients suffered more relapses and worse ratings
1:23:22on various symptoms scales than patients on Haldol not to mention gaining an
1:23:27average of 5 kilograms in weight which put them at an increased risk of
1:23:32diabetes the company rather honed in on one shred of positive data about the drug faring
1:23:40slightly better on some measures of cognitive functioning and it was on the basis of these data that public claims
1:23:48were made that seroquel has quote greater efficacy than Haldol a fact
1:23:53hopefully leading physicians to quote better understand the dramatic benefits
1:23:59of newer medications like seroquel the company had favoured the practice of
1:24:06cherry-picking for some time indeed in the following email again internal again released during litigation we hear how
1:24:13cherry-picking had been used in the previously berry trial called trial 15
1:24:19again going among the senior echelons of the company please allow me to join into
1:24:24the fray there has been a precedent set regarding cherry-picking of data this would be the recent vela grim presentations of cognitive functioning
1:24:31data from trial 15 one of the berry trials thus far I’m not aware of any
1:24:36repercussions regarding interest in the reported data that does not mean that we
1:24:41should continue to advocate this practice there was growing pressure from outside the industry to provide all data
1:24:47resulting from clinical trials conducted by the industry thus far we have buried
1:24:52trials 1530 156 and now considering Koster the largest issue is how do we
1:25:01face the outside world when they begin to criticize us for suppressing data one
1:25:06could say that our competitors indulge in this practice however until now I believe we have been looked upon by the
1:25:14outside world favorably with regard to ethical behavior we must decide if we
1:25:19wish to continue to enjoy this distinction
1:25:25obviously AstraZeneca decides not to plunge for the ethical option rather it
1:25:31continues to risk its reputation and the health of patients by cherry-picking the positive data and burying the negative
1:25:38data to sell the advantages of Seroquel over Haldol this finally backfired in
1:25:442010 when so many people taking seroquel were suffering from such awful side
1:25:50effects that about 18,000 of them were officially claiming that the company had lied about the risks of the drug these
1:25:57claims were finally vindicated in 2010 when Astra Zeneca paid out 125 million
1:26:03to settle a class-action out-of-court for de fording the public
1:26:09but 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
1:26:16just to let you know before we finish I’m running out of time Glaxo SmithKline it’s drug Paxil and Ciroc sac did three
1:26:24trials one trial showed mixed results another trial showed that it was no more
1:26:29effective than a placebo and trial 3 suggested the placebo was actually more effective with certain children
1:26:36but this is children by the way let’s just so the company published only the
1:26:41most positive study publicly declaring that the drug is effective for major depression in children company officials
1:26:48actively suppressed negative results from one study because as they said it
1:26:53would be commercially unacceptable to include a statement that the efficacy had not been demonstrated as this would
1:27:00undermine the profile of paroxetine there was a lawsuit filed against
1:27:05GlaxoSmithKline in 2004 jeep SK settled out of court two months later when the
1:27:11company paid 2.5 million for charges of consumer fraud a meager sum considering that GlaxoSmithKline made four point
1:27:18nine seven billion in worldwide sales from the drug in 2003 alone by the way
1:27:26this is a drug for children forest laboratories charged by the US Justice Department for defaulting the
1:27:31government of millions of dollars for hiding a clinical study showing that their antidepressants celexa and lexapro
1:27:37were not effective in children and might even pose dangerous risks to them at worst these risk included causing some
1:27:43children to become suicidal process has said that by failing to disclose the negative results which they
1:27:50buried forests have kept crucial information hidden from physicians and from the wider public preventing them
1:27:56from having all the information they require to make right treatment decisions for young children
1:28:03Pfizer robach certain marketed as atronics by the drug giant our friend Pfizer again is no more effective at
1:28:11countering major depression than a placebo sugar pill Pfizer withheld negative trials from publication on 74%
1:28:16of the patients the article surveyed were actually left unpublished authors concluded in the BMJ that if the
1:28:25excluded data had been included the evidence would have showed that the risks of taking the drug far exceeded the benefits yet reboxetine has been
1:28:32approved for marketing in many European countries since 1997 and is still being taken by thousands of patients in the UK
1:28:39today finally New England Journal of Medicine 2008 this article reviewed 70 of the
1:28:47major clinical trials into antidepressant and it and it asked how many of these trials had been published
1:28:52the answer 38 showed positive results for antidepressants slightly better
1:28:58outcomes compared to placebos and nearly every one of these positive studies have
1:29:03been published by the companies that undertook them 36 studies actually showed negative
1:29:10results out of these a full 22 had been buried that is never published 11 had
1:29:15been published in a way to convey a positive outcome and only three have been published accurately conclusion a
1:29:22total of 33 negative studies had either been buried or manipulated to convey a
1:29:28positive outcome so to bring things to a conclusion one
1:29:34final paragraph of course where psychopharmaceuticals genuinely helped
1:29:39people they may have some currency however research has also shown that the
1:29:45safety and efficacy of psychiatric drugs in particular has been exaggerated by
1:29:50both industry and those professionals whom industry funds and that growing
1:29:55consumption of such drugs has been less driven by their clinical success than by
1:30:01good marketing concealing bad science the manipulation and burying of nigut
1:30:07negative clinical trials data lacks medicines regulation and I’ve said
1:30:12nothing about that today but that’s a whole other story the manipulation for non drug alternatives strong financial
1:30:20allegiances between industry and psychiatry and the aggressive medicalization of everyday human
1:30:27distress in short the argument that psycho pharmaceutical promotion has placed sufferers needs before those of
1:30:35its shareholders is very very difficult to substantiate and I will leave the
1:30:41presentation there and I’m happy to take any questions you may have thank you [Applause]
1:31:08yeah okay well we’ll just ought ism is an interesting Catholic is
1:31:14that the research basis for for the neurobiology of autism is
1:31:20probably stronger than for any other area and it’s a very involved literature and you know to be honest with you to go
1:31:27into all of that now would be rather difficult I suppose all I’d say is that Alan Francis who created DSM 4 and who
1:31:35included the diagnosis of Asperger’s which is essentially a mitigated form of
1:31:41autism argued that by including that mitigated form of autism more and more people got
1:31:49medicated unnecessarily so his conclusion was by expanding the definition of autism to capture these
1:31:56these you know very mild versions of certain characteristics that certain people have labeled as characteristic
1:32:03autism we expanded the drug epidemic so that would be his argument and I
1:32:09think he’s probably in that respect by the way autism no longer exists it was abolished by dsm-5 so people who have
1:32:18autism don’t really have it anymore
1:32:23that was interesting to remember remember also homosexuality right you know that was a psychiatric disorder
1:32:30until 1974 and then post 1974 it seems to be one and you know that you know if
1:32:38you 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
1:32:44I think it’s quite illustrative the cultural processes behind decisions as to whether or not to keep things in or
1:32:49out yeah oh
1:32:57well no no this is this is a highly contested area I mean one of the the
1:33:02most common arguments that we heard and then early 22,000 s was the chemical imbalance theory of depression you know
1:33:08it wasn’t championed as a theory it was champion as a clinical truth of fact the biological facts the fact of the matter
1:33:15is it’s been disproven and no credible neurobiologists would subscribe to the
1:33:20notion that depression is caused by a deficiency in serotonin it’s just gone the Royal College of Psychiatrists last
1:33:26year publicly disavow the theory after after much lobbying so we’ve moved on
1:33:33from that there’s not to say there’s a biological element in in depression of course there
1:33:38is there’s a biological accompaniment to any state of mind the question is is
1:33:43whether or not there’s a dysfunction that can be traced as the cause of something called depression and thus far
1:33:50there is no evidence for that
1:33:56yep yep okay there’s a gentleman at the back
1:34:07and just trying to reconcile our seroquel is not effective but also
1:34:14antipsychotics don’t do what they say on the tin so is that that is the
1:34:19tranquilizer or sedative or stimulant whatever it is it’s not as strong or the side effects are just less
1:34:27do you see what I’m getting at yeah I mean I suppose what I remember that phrase is that though there was an
1:34:33argument made that psychiatric drugs cure or remedy biological malfunctions
1:34:39or varying sorts so that the the medical model was recruited to explain the drug
1:34:45action of psychopharmaceuticals and it turns out that that particular model is incorrect and Joanna Moncrief a
1:34:52psychiatrist at UCL has proposed an alternative which is called the drug centered model psychiatric medications
1:34:58alter people’s states of mind absolutely true no one’s going to dispute that which may or may not be experienced by
1:35:06those individuals in question as positive some people experience them as positive and we have to honor that and
1:35:13respect that but a lot of people don’t experience them that way a lot of people experience them as harmful and we need
1:35:18to pay more attention to that group of the patient population so it was really
1:35:23to contest the traditional understanding of drug action as something correcting
1:35:29an imbalance that is not the case I think we should follow Joanna Moncrief
1:35:35personally in in her particular perspective on this topic seroquel just had not as good outcomes for the people
1:35:42who took it and they just didn’t like it as much yeah well well in this case it was side
1:35:48effects it was the the adverse drug effects that people were experiencing
1:35:54which they weren’t warned they were going to experience because the necessary data had been buried by the
1:36:00company that was the problem in that case yeah
1:36:13yeah well there was I mean that’s a good question
1:36:19it’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
1:36:27actually because it’s a pragmatist question and that’s what matters in this area the DSM there’s an element to the
1:36:34DSM I’m quite sympathetic towards I mean I think it’s fundamentally human to want to categorize
1:36:40experience you have classified experience since time immemorial anthropologists have documented that the
1:36:48various ways in which different societies across the globe partition different features of the natural world
1:36:55different species of bird and animal etc classifying phenomena is a fundamentally human experience and I think you know
1:37:01doing that with respect to different species of emotional suffering makes sense
1:37:06however that’s not what the DSM only does the
1:37:11DSM does something more than that what it does it then pronounces upon the meaning of the experience it classifies
1:37:18calling it dysfunction disorder disease in other words it brings to these
1:37:25classifications the medical philosophy it claims to derive from them it assumes
1:37:30to be the case what it should rather demonstrate to be the case that these different patterns of suffering indicate
1:37:38disorder and disease there is no evidence to support that that is a cultural move that is an interpretive
1:37:44move which is hugely problematic in my view a lot of the spirit experience is captured by DSM or just natural and
1:37:51normal again painful reactions to living in a difficult world
1:37:56and that’s not to undermine the severity of these experiences you know you can suffer deeply acutely as a consequence
1:38:03of the traumatic things you’ve been subject to that isn’t a disordered reaction that’s a fundamentally human
1:38:10natural reaction I don’t think it’s doing anyone any favors by calling it illness
1:38:15dysfunction I think it’s very stigmatizing actually I think the medical model is more responsible for
1:38:22stigma in society than anything else we’ve been led to believe the origins of stigma reside in ABBA knighted public
1:38:28who are prejudiced against people who suffer I think that prejudice if there is any to the extent exists has been
1:38:35exacerbated by the models of distress that have been foisted upon us over the last thirty years
1:38:41so yes to some kind of classification system but Adi medicalized
1:38:47classification system that also recognizes the extent to which patterns of suffering are culturally situated
1:38:54they change over time an excellent example of this is self harming behavior
1:38:59back in the 1970s clinically speaking this was very rarely encountered because
1:39:05self harming behavior wasn’t the kind of style of suffering that people unconsciously selected to communicate
1:39:12their distress it wasn’t around but from the 1990s onwards suddenly people start to select
1:39:19this behavior unconsciously as a communicative mechanism think of hysteria back in the early 20th century
1:39:25very similar it was the epidemic problem and it disappears think of anorexia
1:39:31nervosa in the early 90s in Japan in Hong Kong excuse me there were very few
1:39:36cases 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
1:39:43socialized to think about their distress and socialized to communicate it so a category system that that is non-medical
1:39:50that recognizes cultural specifics the specificity and that patterns of suffering change something like that
1:39:56yeah I’d go for but I think that’s going to happen anytime soon that’s just with DSM and I could talk
1:40:03about that farmer as well but maybe you have said enough for now
1:40:10who should I go for huh
1:40:38yeah it’s a very good question I I was astonished the extent to which they were
1:40:43honest and I member calling my wife and saying you wouldn’t believe what Rob Robert Spitz has just said I
1:40:51was really surprised and I think what I quickly learned was that there’s a huge
1:40:58disjunct between what the people who sat on these committees thought about the process and how this process was
1:41:05represented by the private corporation the American Psychiatric Association which incidentally
1:41:11makes a lot of its operational costs funds a lot of its operational costs from publication of DSM DSM makes the
1:41:18APA about six million dollars a year in publication revenue and the APA had a vested
1:41:26interest in representing this as a piece of science whereas the people on the committees were quite clear that it was
1:41:32a hugely problematic endeavor and important endeavor as they believed an endeavor that would improve the state of
1:41:37psychiatric diagnosis improve its reliability etc and so forth but not to
1:41:43the extent that it was being represented by the APA so I think what I encountered was what the APA had sort of covered
1:41:50over and led people to believe didn’t exist and could I give you another example of
1:41:57how the APA does this I wanted to speak to the people who wrote dsm-5 so I come to the a contacted the
1:42:05APA and said could I do so I want to understand the processes that went on behind the scenes as I did with DSM 3
1:42:12and DSM 4 and it turns out that I wasn’t allowed to speak to anyone involved in dsm-5 because all of them were
1:42:20asked to sign confidentiality agreements prohibiting them from speaking to
1:42:25anybody any academic any journalists about what went on behind the scenes in the construction of dsm-5 so I said well
1:42:32can 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
1:42:37said well why not because they’ve all been embargoed for twenty years post-publication
1:42:43so we cannot work out what went on behind the scenes and so the APA has a
1:42:49vested interest in keeping this hidden and I think what I discovered was that when you get behind the scenes things
1:42:54look a little different – have they been represented oh
1:43:00there’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
1:43:05yeah
1:43:18so sorry I’m sorry I to do with antidepressants and then
1:43:24connected with blood pressure which often goes together then thing of having high potassium –
1:43:33high potassium as a result of long-term taking an antidepressant and blood
1:43:40pressure pill so you know then you get high potassium
1:43:46yeah which is pretty frightening yeah that’s what the these things yeah I I
1:43:52think the long-term the effects are taking the medications long term we’re finally now beginning to discover
1:43:59and the situation doesn’t look good let us remember that these drugs were
1:44:05approved for public use on the basis of clinical trials that only followed
1:44:10people on the medication for around eight weeks yeah all the clinical trials
1:44:15that Haley yeah yeah demonstrate efficacy were trials between eight to
1:44:22twelve weeks okay so Jennifer remember the cipriani meta-analysis published in
1:44:272018 there was lots of coverage saying antidepressants work this all this sort
1:44:32of stuff well actually what that analysis showed was that they work almost hardly better than placebos for
1:44:40the most severely distressed members of societies and actually you could explain away that difference in terms of the
1:44:46drug effects producing side effects that boost the placebo effect etc but also
1:44:51what that headlining didn’t report was that the studies surveyed in that
1:44:56meta-analysis were between eight and twelve weeks long so they told us nothing about the vast majority of
1:45:03people taking antidepressants in the UK today who hadn’t taken them for eight or twelve weeks you prescribed them for at
1:45:08least six months so we’re a situation where engaging in a vast public experiment with more and more people
1:45:15taking these drugs for longer and longer and we really still don’t know the extent to which that this kind of
1:45:20prescribing is harming people but the evidence we’re getting in already is indicating it is it is problematic very
1:45:27problematic so what can the public do about that
1:45:32it’s another well just finally and I’ve been told
1:45:39this 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
1:45:47need brave journalists don’t we we need brave journalists covering this kind of thing we need
1:45:53brave clinicians and academics speaking up about it we need greater regulation of links
1:46:00between farmer and psychiatry and we’ve outlined in fact we’ve found an
1:46:05organization by the way we don’t make any money from this organization its operating costs we pay for out of our
1:46:12own pocket so I’m promoting this organization now because it’s an organization that disseminates
1:46:17information 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
1:46:23of 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
1:46:29evidence-based psychiatry Council for evidence-based psychiatry oh sorry can you hear me
1:46:40the count it’s called the Council for evidence-based psychiatry I
1:46:45get to plug it four or five times now the Council for evidence-based psychiatry
1:46:51yeah and we we’ve put on a website we put lots of information online for
1:46:57people we have a Twitter accounts and we regularly tweet things we think are important around issues of mental health
1:47:03we’re a very critical organization we comprise academics psychiatrists
1:47:11pharmacologists except for what all united in the belief that we are
1:47:16dramatically over prescribing these medications and under estimating the extent to which they can cause people
1:47:22people 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
1:47:27I refer you to the website and there’ll be information on there and and follow us on our Twitter feed we actually don’t
1:47:33have 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
1:47:39other people want that questions address please come and come and see me now thank you very much
1:47:51thank you [Applause]
