Pseudoscience in Psych

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Disclaimer:

Critics of psychiatry are often accused of being Scientologists.  So, just for the record, I'll state that I am not now, nor have I ever been, a Scientologist.  Scientology is an evil cult.

Overview

The history of psychiatry is characterized by the repeated rise (and fall) of various fads, gimmicks, and borderline-superstitions.  Hydrotherapy, lobotomies, Freudian psychoanalysis, insulin comas — these were all viewed as “The Next Big Thing”, only to be discredited later as being useless (or worse).  To put it another way, every so often the psychiatric establishment grabs its collective head, looks back in horror at the preceding era, and exclaims, “Mein Gott, what were we thinking?”

Some optimists claim, though, that mental healthcare has finally emerged from the dark ages, and that new scientific discoveries – particularly in the field of psychopharmacology – have ushered in a sort of psychiatric Renaissance period.  It would be nice if this were true, but it's not.

The mental-health industry continues to be replete with pseudoscientific theories and dubious treatments, as well as outright fraud.  In this essay, I'm going to focus on three problem areas:  antidepressant drugs, antipsychotic drugs, and 12-step-based addiction-treatment programs.

Mental illness and “chemical imbalance” theories

Psychiatrists used to blame mental illnesses largely on early-childhood experiences.  In the last few decades, though, the mental-health industry has moved from blaming mother to blaming the brain.  So, is mental illness caused by chemical imbalances in the brain?  Maybe, but it's not that simple.

Contrary to popular belief, scientists have never been able to find a consistent biochemical, genetic, anatomical, or other functional marker that can reliably distinguish healthy people from the mentally ill.  Many studies have provided tantalizing clues, but no overall, clear picture has emerged from the data.  Often, findings made in one laboratory have been hard to replicate in another lab.  Even in studies reporting some abnormality associated with schizophrenia, for example, many schizophrenics do not show that particular abnormality.

“But what about serotonin?”, you say.  Isn't depression caused by a lack of the neurotransmitter serotonin?  Again, the actual data is complex, partly contradictory, and generally less than convincing.  The brain contains literally hundreds of different neurotransmitters and neuromodulators that are all functionally interconnected in a highly complex (and poorly understood) system.  To focus mainly on serotonin is to grossly oversimplify the physiology of negative mood states.  Also, it's interesting to note that the antidepressant Wellbutrin (generic name: bupropion) has very little effect on serotonin, and yet clinical studies claim that Wellbutrin is no less effective than any other antidepressants on the market.

It's not hard to imagine, though, why serotonin is “the usual suspect” in depression – after all, Prozac (fluoxetine), Zoloft (sertraline), Paxil (paroxetine), Luvox (fluvoxamine), Celexa (citalopram), and Lexapro (escitalopram) all inhibit serotonin re-uptake in synaptic terminals.  The companies that make these drugs obviously have a vested interest in promoting the serotonin hypothesis.

No reasonable person can deny that all of our mental states, including our emotions, can – in principle – be reduced to the physical, chemical, and electrical properties of the brain.  The mind does not exist independently of the nervous system.  The evidence is overwhelming for such a reductionist or materialist view.  This fact alone, however, doesn't necessarily imply that mental illnesses are explained by currently fashionable though simplistic “chemical imbalance” theories.  After all, these theories don't incorporate outside elements – things like conflicts with relatives, poor sleeping habits, difficulties with romantic relationships, problems on the job – and other such factors that can all contribute to emotional troubles.

The best source for skeptical information on “chemical imbalance” theories is a book called, Blaming the Brain:  The Truth About Drugs and Mental Health, by Elliot Valenstein, PhD.  Much of the information from the preceding five paragraphs comes from the book.  Unlike some critics of psychiatry, Elliot Valenstein is hardly a fringe figure – he's a respected neuroscientist based at the University of Michigan.  I reviewed Blaming the Brain in my “Favorite books” section.

Antidepressants: Glorified Placebos

The first antidepressant drug (iproniazid) was introduced in the mid-1950s, but the real hype didn't start until the Eli Lilly Company launched Prozac in 1987.  Although the drug quickly became a blockbuster, even appearing on magazine covers, neither Prozac nor its less-famous cousins have lived-up to the propaganda.  In reality, these drugs are far from being “miracle cures”.  Antidepressants often have nasty side-effects, they can be expensive, and worst of all, they are hardly more effective than placebos at treating depression.

The Antidepressant Reading List

  • “Is it Prozac? Or Placebo?”  This excellent article from Mother Jones magazine provides a good overview of the argument that antidepressants are nothing more than glorified placebos.  If you only read one selection from this group of articles, make it this one.

  • “Antidepressants Versus Placebos: Meaningful Advantages Are Lacking” is an article by Irving Kirsch, Ph.D. and David Antonuccio, Ph.D.  I guess the title says it all.

  • Although this article first appeared back in 1995, the arguments and the data have withstood the test of time.  Psychologists Seymour Fisher and Roger Greenberg have long taken a skeptical stance with regard to the effectiveness of antidepressants and other psychotropic drugs.  “Prescriptions for Happiness?” is really quite a good overview of research in this area.

  • “Hard to Swallow” is a well-written description of the problems surrounding antidepressant drugs.  Perhaps the most interesting revelation concerns the underhanded methods used by pharmaceutical companies to get their antidepressant drugs approved by the FDA.

  • “It's What's in Your Head” is a follow-up piece to “Hard to Swallow” (see article cited above).

  • “No Prescription for Happiness”:  This Boston Globe piece from 1999 is a bit dated now, but it still provides a good summary of why we should be very skeptical of antidepressants as “wonder drugs”.

  • “The Emperor's New Drugs” argues that antidepressants are, at best, marginally better than placebos.  This is a peer-reviewed paper written for a professional audience, so it's a bit dense and dry.  (USA Today ran a surprisingly good, more-accessible article about this study).

  • “Against Depression, a Sugar Pill Is Hard to Beat” – somewhat skeptical article about antidepressants, but the journalist ultimately waffles on their effectiveness.

  • In “Placebo Nation”, science writer John Horgan argues that newer antidepressants are no more effective than older ones (contrary to what many people believe), and that, in any case, they're all over-rated.  Although the page referenced above doesn't contain a citation, Horgan's article appeared in the New York Times on March 21, 1999.

  • “You keep hoping that the next [antidepressant] is going to solve all of the problems”, says a psychiatrist quoted in this Wall Street Journal article.

  • British psychiatrist Joanna Moncrieff has written a review of antidepressant studies, and concluded that the studies are generally flawed:  “Are antidepressants overrated?  A review of methodological problems in antidepressant trials.”  Journal of Nervous and Mental Disease, May 2001.

  • David Antonuccio, Ph.D. and colleagues managed to get a skeptical article published in Psychiatric Times – not an outlet that's normally known for being critical of psychotropic drugs.  The article is called, “Rumble in Reno:  The Psychosocial Perspective on Depression”.

  • The media tend to run human-interest pieces that highlight people who are happy with the antidepressant drugs they've taken.  But how typical are these stories?  When the National Depressive and Manic-Depressive Association (NDMDA) conducted a survey on antidepressant satisfaction, the results were telling.  See this article from 1999:  “Most Patients Report Troublesome Side Effects, Modest Improvement Using Current Antidepression Treatments”.

  • Psychiatrist Arif Khan and his colleagues showed that pharmaceutical companies typically need to run five clinical trials in order to obtain two successful ones (i.e., trials in which the putative antidepressant shows a statistically significant superiority over placebo).  One wonders just how “significant” those results really are.

An admission from the medical establishment

Goodman and Gilman's The Pharmacological Basis of Therapeutics is the standard medical textbook for pharmacology and is widely considered to be the “bible” of the field.  Thus, the following passage has particular significance:

A somewhat surprising fact is that clinically employed antidepressants, as a group, have outperformed inactive placeboes in only about 2/3 to 3/4 of controlled comparisons, with a similar proportion of depressed adult subjects rated as showing clinically significant responses.  Moreover, assessment-based changes in clinical rating of depressive symptoms, rather than categorization as "treatment-responsive," often yield surprisingly small average differences between active antidepressants and placebo in contemporary outpatient trials involving patients with depressive illness of only moderate severity.  With pediatric and geriatric depression, results are typically even less clear.  Pediatric studies often have failed to show superiority of drug over a placebo...  Another major problem with antidepressant agents is that because placebo response rates tend to be as high as 30% to 40% in research subjects diagnosed with major depression and possibly even higher in some anxiety disorders, statistical and clinical distinctions between active drug and placebo are difficult to prove...  Moreover, evidence concerning clinical dose-response and dose-risk relationships is especially limited with this class of drugs.  [10th edition, page 470]

This passage isn't exactly a full-scale condemnation of antidepressant effectiveness, but it's about as close as you'll get from the medical establishment.  (Also, keep in mind that the statistics cited in the first sentence are most likely inflated by the file drawer effect.)

The Placebo Effect and the “Rule of Thirds”:

When evaluating medical treatments, how can you tell real effects from non-specific (i.e., placebo) effects?  A quick first approximation is to test for what I call the “rule of thirds”:

“The data from our sample of 6,931 patients, who underwent five noneffective treatments, clusters around one-third excellent results, one-third good results, and one-third poor results...”
— From a research article about the characteristics of the placebo effect:  Roberts AH, Kewman DG, Mercier L, and Hovell M. (1993).  “The power of nonspecific effects in healing:  Implications for psychosocial and biological treatments”. Clinical Psychology Review, 13, pages 375-391.

“The priest said that about a third of the people he ministers to are healed, another third are ‘noticeably improved’, and the other third are unchanged.”
— From an article about faith-healing:  “Finding power in the Holy Spirit”, by Willmar Thorkelson (religion editor), The Minneapolis Star, page 1B.  May 21, 1975.

“Put 100 patients on any antidepressant, and about a third will respond beautifully.  Another third will have a partial response and the last third will not respond at all.”
— Dr. Pierre Blier, as quoted in The Gainesville Sun: “A speedier remedy for depression” by Diane Chun.  January 12, 2002.  From the article, it's clear that Dr. Blier firmly believes in the overall usefulness of antidepressants.

Schizophrenia and antipsychotic drugs

Investigative reporter Robert Whitaker has written a disturbing exposé of the way that society, including the medical establishment, has historically abused (and continues to abuse) people who suffer from schizophrenia.  If you think that modern psychiatry is based on rational, scientific principles, you should read Whitaker's book, Mad in America: Bad Science, Bad Medicine, and the Enduring Mistreatment of the Mentally Ill.  A significant portion of the book is devoted to debunking the belief that antipsychotic drugs (e.g., Thorazine, Haldol, Risperdal, Zyprexa) are safe and effective.  The author has a website dedicated to the book.  (My “Favorite Books” page has more information about Mad in America – see the link on the left).

Can (or should) schizophrenics be treated without the use of antipsychotic drugs?  The idea might sound radical, but psychiatrist Loren Mosher has done some intriguing research on this question.  Recall also that mathematician John Nash recovered without the use of any medications, though the movie, A Beautiful Mind, was inaccurate in this respect.  Robert Whitaker wrote a scathing opinion piece (“Mind drugs may hinder recovery”) about the mis-information perpetuated by the movie.

Another good article about treating schizophrenia without drugs: “New hope for people with schizophrenia”.

Let me be clear, here:  I'm not opposed to antipsychotic drugs in principle – I'm opposed to the current crop of drugs only because they don't work very well, because they have very nasty side-effects (i.e., tardive dyskinesia), and because they hinder long-term recovery.  Maybe someday researchers will discover antipsychotic drugs that work well and are safe.  But we're not there yet.

Alcoholism and Addiction: Introduction

Of all the sub-specialties within the field of mental health, addiction treatment is by far the most pseudoscientific.  As writer Maia Szalavitz put it, “In any other area of medicine, if a physician told you the only cure for your condition was to join a support group that involves ‘turning your will and your life’ over to God (AA's third step), you'd seek a second opinion.”  In general, addiction counselors consist largely of well-intentioned but scientifically-naïve people who vainly seek simple solutions to complex problems  – a “one size fits all” approach.

Does Alcoholics Anonymous work?

Alcoholics Anonymous originated in the 1930s as a sort-of “spin-off” group from a Depression-era religious order called the Oxford Group.  Because AA doesn't even aspire to being scientific, we can't exactly call it pseudo-scientific.  Nevertheless, we can ask whether AA is based on rational principles and whether it works.

Alcoholics Anonymous clearly helps some people.  Go to any meeting and you can find members who swear that the group literally saved their lives.  There's no reason to doubt there isn't some truth to these claims.  However, there are a number of problems with AA:

  1. Although it's difficult to make accurate assessments of the group's success rate, a number of studies show that AA doesn't work nearly as well as commonly believed.  There is a high turn-over rate, and relapses are common.  You'd never know this, though, based on the popular image of Alcoholics Anonymous.  AA's reputation certainly exceeds the group's actual effectiveness.

  2. AA is resistant to change.  The group has a quasi-religious basis which makes it largely immune to criticism, either from outside the group or from within.

  3. Although there is wide variability from meeting to meeting (and, of course, from member to member), AA has an overall cult-like quality to it.  At some meetings, there's the feeling that people's responses are not spontaneous, but rather are almost scripted.  Essayist Paul Roasberry has written an article about the cultish aspects of AA, and Charles Bufe has a whole book called, Alcoholics Anonymous:  Cult or Cure?

  4. AA emphasizes a “one size fits all” approach to sobriety.  Members tend to feel that they have discovered the Truth with a capital “T”, and that reliance on any other approach will inevitably lead the alcoholic to the infamous fate of “jails, institutions, or death”.  This dogmatic insistence on a single approach turns off many potential members who might otherwise benefit from regular meetings with other recovering alcoholics.

  5. AA probably hurts some people.  It's not hard to imagine a case where an active alcoholic goes to his or her first AA meeting and emerges with the feeling that, “If this is what it means to be sober, then I might as well keep on drinking.”  If the group were less rigid and if it encouraged people to find their own path toward sobriety, then more people would benefit.  If you truly believe that AA is the only way (as many members claim), and you also know that you can't accept their approach, then you could be creating a self-fulfilling prophesy.  Another way to put it is this:  “Many see AA as their last hope – when they fail to find answers in the program which really work, some give up, drink fatally and die.”

  6. The legal system often forces people to attend AA meetings – a tactic that is unlikely to help alcoholics and also amounts to illegal, state-sponsored religion.  Courts have repeatedly ruled that Alcoholics Anonymous is a religious organization.

Alternative information about addiction

Lots of people don't like AA, or otherwise disagree with conventional views on substance abuse.  However, you don't often hear about dissenters, because the mass-media tends not to run negative stories about the recovery movement.  Here are some sources that present non-traditional, or skeptical views about addiction.  (Note:  I don't necessarily agree with all the information from these sources, but I think it's important for the public to be exposed to diverse viewpoints – even radical ones – about the recovery industry):

Does alcoholism/addiction treatment work?

Many careful studies show that treatment is no more effective than letting the addiction run its natural course.  Or, as alcoholism researcher George Vaillant put it, “Perhaps the best that can be said for our exciting treatment effort at Cambridge Hospital is that we were certainly not interfering with the normal recovery process.“

One of the best-designed studies took place in England in the mid-1970s.  Researchers compared two groups of male alcoholics.  The first group underwent a conventional, year-long program that included AA meetings and other standard features of addiction treatment.  For subjects in the second group, the only treatment was a single counseling session between the alcoholic, his wife, and a psychiatrist.  After one year, follow-up studies showed no significant differences between the two groups.  See Jim Orford and Griffith Edwards (1977). Alcoholism:  A comparison of treatment and advice, with a study of the influence of marriage.  Oxford: Oxford University Press.

(For a slightly longer discussion of treatment and its effectiveness, see this excerpt from a book written by psychologist Stanton Peele.  See also this excellent article written by journalist Heather Ogilvie:  “A different approach to treating alcoholism”.)

Addiction: Lack of public discussion

When it comes to the specific aspects of addiction-treatment, there is a serious lack of debate or skepticism in the popular press and among the general public.  People just assume that alcoholics/addicts need conventional treatment at a rehab facility, followed by life-long attendance at AA or NA.  But is this approach grounded in science?  Does it work?  These questions rarely get raised in the media.

By contrast, it's not hard to find magazine articles that outline the pros and cons of mammograms, or the value of low-carbohydrate weight-loss diets, or the usefulness of various other medical treatments.  Case in point: not long ago, the medical establishment did an about-face with regard to the benefits of hormone-replacement therapy, and this news got a lot of play in the popular press.  But when was the last time you read an article that questioned the usefulness of rehabilitation clinics, such as the Betty Ford Center?

Robert Downey, Jr. can surely afford the best treatment that money can buy.  Then why does he keep relapsing?  And when he does relapse, why aren't there any investigative reporters who try to see whether rehab facilities and 12-step groups actually do any good?

Partly, I think, the reason is this: the recovery movement is steeped in religion or spirituality, and is thus largely untouchable.  Critics do exist, but they rarely get much mainstream attention.

For additional information, see my “Favorite books” section for reviews of The Diseasing of America, by psychologist Stanton Peele, and Heavy Drinking: The Myth of Alcoholism as a Disease, by Herbert Fingarette.  See also Stanton Peele's website.

Alcoholism and addiction: Alternative groups

Alcoholics Anonymous isn't the only game in town (though they like to think so).  Here are some other support groups and programs – ones that aren't based on the 12-step model:

Also, journalist Anne Fletcher has written an excellent book about the wide variety of ways that people have overcome their substance-abuse problems.  Fletcher interviewed 222 people who had been sober for at least five years.  Then, she compiled the results into a book called, Sober for Good: New Solutions for Drinking Problems.  The New York Times ran a very favorable review of the book.

Sources of news about the mental health industry:



    © 2004 Alex Chernavsky   alexc@aya.yale.edu