Anatomy of an Epidemic (39 page)

Before I left, Nathan came down from his room, and he shyly showed me a few of his favorite possessions, including a
Star Wars
helmet. He told me that Zachariah was his best friend (the one classmate who didn’t tease him), and then he taught me how to fold a piece of paper into an airplane, which he sent flying around the room. “I like to make movies” with a video recorder, he says, and eventually I quizzed him on a couple of subjects he loves. “The
Titanic
sank in 1912,” he informs me, and after that he proudly identified various bones in the human body—he is fascinated with drawings of skeletons. “His teachers all love him,” his mother says, and at that moment, it was very easy to see why.

We have investigated the epidemic of mental illness that has erupted in the United States during the past fifty years in a step-by-step fashion, and having reviewed the outcomes literature for each of the major disorders, there is an obvious next question to address. Why does our society believe that a “psychopharmacological revolution” has taken place during the past fifty years, when the scientific literature so clearly shows that the revolution failed to materialize? Or, to put it another way, what is the source of our remarkable societal delusion?

To answer that, we need to trace the rise of “biological psychiatry” and then look at the stories that psychiatry—once it embraced that belief system—came to tell.

During the heady days of the 1950s, when it seemed that a new breakthrough drug was being discovered every year, psychiatry had reason to be optimistic about its future. It now had magic pills like
the rest of medicine, and once NIMH researchers and others advanced the chemical imbalance theory of mental disorders, it seemed that these pills might indeed be antidotes to physical diseases. “American psychiatry,” exclaimed former NIMH director Gerald Klerman, “accepted psychopharmacology as its domain.”
²
But two decades later, those heady days were long gone, and psychiatry was mired in a deep crisis, beleaguered on so many fronts that it worried about its survival. There was a sense, said American Psychiatric Association (APA) director Melvin Sabshin in 1980, that the “profession is under severe siege and is cut off from allies.”
³

The first problem that had arisen for psychiatry was an intellectual challenge to its legitimacy, an attack launched in 1961 by Thomas Szasz, a psychiatrist at the State University of New York in Syracuse. In his book
The Myth of Mental Illness
, he argued that psychiatric disorders weren’t medical in kind, but rather labels applied to people who struggled with “problems in living” or simply behaved in socially deviant ways. Psychiatrists, he said, had more in common with ministers and police than they did with physicians. Szasz’s criticism rattled the field, since even mainstream publications like the
Atlantic
and
Science
found his argument to be both cogent and important, the latter concluding that his treatise was “enormously courageous and highly informative … bold and often brilliant.”
⁴
As Szasz later told the
New York Times
, “In smoke-filled rooms, time and time again, I’ve heard the view that Szasz has killed psychiatry. I hope so.”
⁵

His book helped launch an “antipsychiatry” movement, and other academics in the United States and Europe—Michel Foucault, R. D. Laing, David Cooper, and Erving Goffman, just to name a few—joined the fray. All questioned the “medical model” of mental disorders and suggested that madness could be a “sane” reaction to an oppressive society. Mental hospitals might better be described as facilities for social control, rather than for healing, a viewpoint crystallized and popularized in
One Flew Over the Cuckoo’s Nest
, which swept the Oscars for 1975. Nurse Ratched was the malevolent cop in that movie, which ended with Randle McMurphy (played by Jack Nicholson) being lobotomized for failing to stay in line.

The second problem that psychiatry faced was a growing competition for patients. In the 1960s and 1970s, a therapy industry blossomed in the United States. Thousands of psychologists and counselors began offering services to the “neurotic” patients that psychiatry had laid claim to ever since Freud had brought his couch to America. By 1975, the nonphysician therapists outnumbered the shrinks in the United States, and with benzodiazepines falling out of favor, the neurotic patients who had been content to pop “happy pills” in the 1960s were embracing primal scream therapy, Esalen retreats, and any number of other “alternative” therapies said to help heal the wounded soul. Partly as a result of this competition, the median earnings of a U.S. psychiatrist in the late 1970s were only $70,600, and while this was a good wage at the time, it still put psychiatry near the bottom of the medical profession. “Non-psychiatric mental health professionals are laying claim to some, or even all, of psychiatry’s task domains,” wrote Tufts University psychiatrist David Adler. There was reason, he said, to worry about the “death of psychiatry.”
⁶

Internal divisions also ran deep. Although the field had turned toward biological psychiatry after the arrival of Thorazine, with most psychiatrists eager to speak well of the drugs, the Freudians who dominated many medical schools in the 1950s had never completely climbed on that bandwagon. While they found some use for the drugs, they still conceived of most disorders as psychological in kind. As such, during the 1970s, there was a deep philosophical split between the Freudians and those who embraced a “medical model” of psychiatric disorders. In addition, there was a third faction in the field, composed of “social psychiatrists.” This group thought that psychosis and emotional distress often arose from an individual’s conflict with his or her environment. If that was so, altering that environment or creating a supportive new one—as Loren Mosher had done with his Soteria Project—would be a good way to help a person heal. Like the Freudians, the social psychiatrists did not see drugs as the centerpiece of care, but rather as agents that were sometimes helpful and sometimes not. With these three approaches in conflict, the field was suffering from an “identity crisis,” Sabshin said.
⁷

By the end of the 1970s, the leaders of the APA regularly spoke of how their field was in a fight for “survival.” In the 1950s, psychiatry had become the fastest growing specialty in medicine, but during the 1970s, the percentage of medical school graduates choosing to go into it dropped from 11 percent to less than 4 percent. This lack of interest in the field, the
New York Times
reported in an article titled “Psychiatry’s Anxious Years,” was “seen as a particularly painful indictment.”
⁸

Such was psychiatry’s self-assessment in the 1970s. It looked into the mirror and saw the field under attack by an “antipsychiatry” movement, threatened economically by nonphysician therapists, and split by internal disagreements. But, in fact, it was turning a blind eye to the root problem, which was that its medications were failing in the marketplace. This was what had allowed the crisis to take hold and spread.

If the first generation of psychotropics had truly worked, the public would have been pounding on psychiatrists’ doors seeking prescriptions for these medicines. Szasz’s argument that mental illness was a “myth” might have been seen by some as intellectually interesting, worthy of debate in academic circles, but it wouldn’t have curtailed the public’s appetite for drugs that made them feel and function better. Similarly, psychiatry could have brushed off the competition from psychologists and counselors as a harmless nuisance. Depressed and anxious people might have indulged in screaming therapies and mud baths, and sought out talk therapy from psychologists, but the prescription bottles would have remained in their medicine cabinets. Nor would the internal divisions have persisted. If the pills had proved to provide long-term relief, then all of psychiatry would have embraced the medical model, for the other proffered forms of care—psychoanalysis and nurturing environments—would have been perceived as too labor-intensive
and unnecessary. Psychiatry fell into a crisis during the 1970s because the “miracle pill” aura around its drugs had disappeared.

From the moment that Thorazine and the neuroleptics were introduced into asylum medicine, many hospitalized patients had found them objectionable, so much so that many “tongued” the pills. This practice was so pervasive that Smith, Kline and French, in the early 1960s, developed a liquid Thorazine, which the patients could be made to swallow. Other manufacturers developed injectable forms of their neuroleptics so that hospitalized patients could be forcibly medicated. “Warning!” an ad for liquid Thorazine screamed. “Mental Patients Are Notorious DRUG EVADERS.”
⁹
In the early 1970s, patients who had experienced such forced treatment began forming groups with names such as the “Insane Liberation Front” and the “Network Against Psychiatric Assault.” At their rallies, many carried signs that read
HUGS
,
NOT DRUGS
!

One Flew Over the Cuckoo’s Nest
helped legitimatize that protest in the public’s mind, and that movie appeared shortly after psychiatry suffered the embarrassment of news reports that the Soviet Union was using neuroleptics to torture dissidents. These drugs apparently inflicted such physical pain that quite sane people would recant their criticisms of a Communist government rather than endure repeated doses of Haldol. Dissident writings told of psychiatric drugs that turned people into “vegetables,” the
New York Times
concluding that this practice could be seen as “spiritual murder.”
¹⁰
Then, in 1975, when Indiana senator Birch Bayh launched an investigation of the use of neuroleptics in juvenile institutions, ex–mental patients hijacked the public hearing to testify that the drugs caused “excruciating pain” and had turned them into emotional “zombies.” Antipsychotics, said one ex-patient, “are used not to heal or help, but to torture and control. It is that simple.”
¹¹

These drugs were no longer being presented to the public as agents that made a raving madman “sit up and talk sense,” as
Time
had reported in 1954, and even as this new view of antipsychotics was sinking into the public mind, the benzodiazepines fell into disrepute. The federal government classified them as schedule IV drugs, and soon Edward Kennedy was announcing that benzos
had “produced a nightmare of dependence and addiction.”
¹²
Antipsychotics and the benzodiazepines were the two classes of drugs that had launched the psychopharmacology revolution, and with both now seen by the public in a negative light, sales of psychiatric drugs plunged in the 1970s, from 223 million drugstore prescriptions in 1973 to 153 million in 1980.
¹³
In its article on psychiatry’s “anxious years,” the
New York Times
explained that a primary reason that medical school graduates were avoiding the field was because its treatments were perceived to be “low in efficacy.”