“It was not surprising that medical students accepted
the dogma of biomedical reductionism in psychiatry
uncritically; they had no time to read and analyze the
original literature. What took me a while to understand,
as I moved through my residency, was that psychiatrists
rarely do the critical reading either.”
—COLIN ROSS, CLINICAL ASSOCIATE PROFESSOR OF
PSYCHIATRY AT SOUTHWEST MEDICAL CENTER IN
DALLAS, TEXAS (1995)1
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.
Psychiatry’s Season of Discontent
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
Avoiding the Obvious
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.”
This was a topic that psychiatry did not like to talk about or acknowledge. Yet, at the same time, everyone understood what gave psychiatrists a competitive advantage in the therapy marketplace. New Jersey psychiatrist Arthur Platt was at a professional meeting in the late 1970s when a keynote speaker laid it out for them: “He said, ‘What is going to save us is that we’re physicians,’” Platt recalls.14 They could write prescriptions and the psychologists and social workers couldn’t, and that was an economic landscape that presented the field with an obvious solution. If the image of psychotropic drugs could be rehabilitated, psychiatry would thrive.
Putting on the White Coat
The process that led to the rehabilitation of psychiatric drugs in the public’s mind got under way in the 1970s. Threatened by Szasz’s criticism that psychiatrists did not really function as “doctors,” the APA argued that psychiatrists needed to more explicitly embrace this role. “A vigorous effort to remedicalize psychiatry should be strongly supported,” said the APA’s Sabshin in 1977.15 Numerous articles appeared in the American Journal of Psychiatry and other journals explaining what this meant. “The medical model,” wrote University of Kentucky psychiatrist Arnold Ludwig, is based on the “premise that the primary identity of the psychiatrist is as a physician.”16 Mental disorders, said Paul Blaney, from the University of Texas, were to be seen as “organic diseases.”17 The psychiatrist’s focus should be on making the proper diagnosis, which arose from a cataloguing of the “symptoms and signs of illness,” said Samuel Guze, from Washington University. It was only psychiatrists, he added, that had the “medical training necessary for the optimal application of the most effective treatments available today for psychiatric patients: psychoactive drugs and ECT [electroshock].”18
Theirs was a model of care straight out of internal medicine. The doctor in that setting took a patient’s temperature, or tested blood glucose levels, or did some other diagnostic test, and then once the illness was identified, prescribed the appropriate drug. “Remedicalization” of psychiatry meant that the Freudian couch was to be trotted off to the Dumpster, and once that happened, psychiatry could expect to see its public image restored. “The medical model is most strongly linked in the popular mind to scientific truth,” explained Tufts University psychiatrist David Adler.19
In 1974, the APA picked Robert Spitzer from Columbia University to head up the task force that would, through a revision of the APA’s Diagnostic and Statistical Manual, prompt psychiatrists to treat patients in this way. DSM-II, which had been published in 1967, reflected Freudian notions of “neurosis,” and Spitzer and others argued that such diagnostic categories were notoriously “unreliable.” He was joined by four other biologically oriented psychiatrists on the task force, including Samuel Guze at Washington University. DSM-III, Spitzer promised, would serve as “a defense of the medical model as applied to psychiatric problems.”20 The manual, said APA president Jack Weinberg in 1977, would “clarify to anyone who may be in doubt that we regard psychiatry as a specialty of medicine.”21
Three years later, Spitzer and his colleagues published their handiwork. DSM-III identified 265 disorders, all of which were said to be distinct in kind. More than one hundred psychiatrists had contributed to the five-hundred-page tome, authorship that indicated it represented the collective wisdom of American psychiatry. To make a DSM-III diagnosis, a psychiatrist would determine if a patient had the requisite number of symptoms said to be characteristic of the disease. For instance, there were nine symptoms common to “major depressive episode,” and if five were present, then a diagnosis of this illness could be made. The new manual, Spitzer boasted, had been “field tested,” and those trials had proven that clinicians in different facilities, when faced with the same patient, were likely to arrive at the same diagnosis, proof that diagnosis would no longer be as subjective as before. “These [reliability] results were so much better than we had expected” they would be, he said.22
Psychiatry now had its medical-model “bible,” and the APA and others in the field rushed to extol it. DSM-III is an “amazing document … a brilliant tour de force,” Sabshin said.23 “The development of DSM-III,” said Gerald Klerman, “represents a fateful point in the history of the American psychiatric profession … [and] its use represents a reaffirmation on the part of American psychiatry to its medical identity and its commitment to scientific medicine.”24 Thanks to DSM-III, wrote Columbia University psychiatrist Jerrold Maxmen, “the ascendance of scientific psychiatry became official … the old [psychoanalytical] psychiatry derives from theory, the new psychiatry from fact.”25
But as critics at the time noted, it was difficult to understand why this manual should be regarded as a great scientific achievement. No scientific discoveries had led to this reconfiguring of psychiatric diagnoses. The biology of mental disorders remained unknown, and the authors of DSM-III even confessed that this was so. Most of the diagnoses, they said, “have not yet been fully validated by data about such important correlates as clinical course, outcome, family history, and treatment response.”26 It was also evident that the boundary lines between disease and no disease had been arbitrarily drawn. Why did it require the presence of five of nine symptoms said to be characteristic of depression for a diagnosis of the illness to be made? Why not six such symptoms? Or four? DSM-III, wrote Theodore Blau, president of the American Psychological Association, was more of “a political position paper for the American Psychiatric Association than a scientifically-based classification system.”27
None of that mattered, however. With the publication of DSM-III, psychiatry had publicly donned a white coat. The Freudians had been vanquished, the concept of neurosis basically tossed into the trash bin, and everyone in the profession was now expected to embrace the medical model. “It is time to state forcefully that the identity crisis is over,” Sabshin said.28 Indeed, the American Journal of Psychiatry urged its members to “speak with a united voice, not only to secure support, but to buttress [psychiatry’s] position against the numerous other mental health professionals seeking patients and prestige.”29 The medical model and DSM-III, observed University of Tennessee psychiatrist Ben Bursten in 1981, had been used to “rally the troops … to thwart the attackers [and] to rout the enemy within.”30
Indeed, it wasn’t only the Freudians who had been vanquished. Loren Mosher and his band of social psychiatrists also had been roundly defeated and sent packing.
When Mosher started his Soteria Project in 1971, everyone understood that it threatened the “medical model” theory of psychiatric disorders. Newly diagnosed schizophrenia patients were being treated in an ordinary home, staffed by nonprofessionals, without drugs. Their outcomes were to be compared with patients treated with drugs in a hospital setting. If the Soteria patients fared better, what would that say about psychiatry and its therapies? From the minute that Mosher proposed it, the leaders of American psychiatry had tried to make sure it would fail. Although Mosher headed up the Center for Schizophrenia Studies at the NIMH, he’d still needed to obtain funding for Soteria from the grants committee that oversaw NIMH’s extramural research program, which was composed of psychiatrists from leading medical schools, and that committee slashed his initial request of $700,000 for five years to $150,000 for two years. This ensured that the project would struggle with finances from the outset, and then, in the mid-1970s, when Mosher began reporting good results for his Soteria patients, the committee struck back. The study had “serious flaws” in its design, it said. Evidence that Soteria patients had superior outcomes was “not compelling.”31 Mosher must be biased, the academic psychiatrists concluded, and they demanded that Mosher be removed as the primary investigator. “The message was clear,” Mosher said, in an interview twenty-five years later. “If we were getting outcomes this good, then I must not be an honest scientist.”32 Soon after that, the grants committee shut off funding for the experiment altogether, and Mosher was pushed from his job at the NIMH, even though the committee had grudgingly concluded, in its final review of the project, that “this project has probably demonstrated that a flexible, community based, non-drug residential psychosocial program manned by non-professional staff can do as well as a more conventional community mental health program.”
The NIMH never funded an experiment of this type again. Furthermore, Mosher’s ouster provided everyone in the field with a clear message: Those who did not get behind the biomedical model would not have much of a future.
Psychiatry’s Mad Men
Once DSM-III was published, the APA set out to market its “medical model” to the public. Although professional medical organizations have always sought to advance the economic interests of their members, this was the first time that a professional organization so thoroughly adopted the marketing practices familiar to any commercial trade association. In 1981, the APA established a “division of publications and marketing” to “deepen the medical identification of psychiatrists,” and in very short order, the APA transformed itself into a very effective marketing machine.33 “It is the task of the APA to protect the earning power of psychiatrists,” said APA vice president Paul Fink in 1986.34
As a first step, the APA established its own press in 1981, which was expected to bring “psychiatry’s best talent and current knowledge before the reading public.”35 The press was soon publishing more than thirty books a year, with Sabshin happily noting in 1983 that the books “will provide much positive public education about the profession.”36 The APA also set up committees to review the textbooks it published, intent on making sure that authors stayed on message. Indeed, in 1986, as it readied publication of Treatment of Psychiatric Disorders, the APA’s Roger Peele—one of the organization’s elected officials—worried anew about this concern. “How do we organize 32,000 members for advocacy?” he asked. “Who should be allowed to speak to the issue of the treatment of psychiatric illness? Only researchers? Only the academic elite? … Only members appointed by APA presidents?”37
Very early on, the APA realized that it would be valuable to develop a nationwide roster of “experts” that could promote the medical-model story to the media. It established a “public affairs institute” to oversee this effort, which involved training members “in techniques for dealing with radio and television.” In 1985 alone, the APA ran nine “How to Survive a Television Interview” workshops.38 Meanwhile, every district branch in the country identified “public affairs representatives” who could be called on to speak to the press. “We now have an experienced network of trained leaders who can effectively cope with all varieties of media,” Sabshin said.39
Much like any commercial organization selling a product, the APA regularly courted the press and exulted when it received positive coverage. In December 1980, it held a daylong media conference on “new advances in psychiatry” that “was attended by representatives of some of the nation’s most prestigious and widely circulated newspapers,” Sabshin crowed.40 Next, it placed “public service spots” on television to tell its story, an effort that included sponsoring a two-hour program on cable television titled Your Mental Health. It also developed “fact sheets” for distribution to the media that told of the prevalence of mental disorders and the effectiveness of psychiatric drugs. Harvey Rubin, chair of the APA’s public affairs committee, taped a popular radio program that carried the medical-model message to listeners around the country.41 The APA had launched an all-out media blitz—it handed out awards to journalists whose stories it liked—and every year Sabshin detailed the good publicity this effort was generating. In 1983, he noted that “with the help and urging of the Division of Public Affairs, U.S. News and World Report published a major cover story on depression, which included substantial quotes from prominent psychiatrists.”42 Two years later, Sabshin announced that “APA spokespersons were placed on the Phil Donahue program, Nightline and other network programs.” That same year, it “helped develop a Reader’s Digest book chapter on mental health.”43
All of this paid big dividends. Newspaper and magazine headlines now regularly told of a “revolution” under way in psychiatry. Readers of the New York Times learned that “human depression is linked to genes” and that scientists were uncovering the “biology of fear and anxiety.” Researchers, the paper reported, had discovered “a chemical key to depression.”44 Societal belief in biological psychiatry was clearly taking hold, just as the APA hoped, and in 1984, Jon Franklin of the Baltimore Evening Sun wrote a seven-part series titled “The Mind-Fixers” on the astonishing advances that were being made in the field.45 He put this revolution into a historical context:
Since the days of Sigmund Freud the practice of psychiatry has been more art than science. Surrounded by an aura of witchcraft, proceeding on impression and hunch, often ineffective, it was the bumbling and sometimes humorous stepchild of modern science. But for a decade and more, research psychiatrists have been working quietly in laboratories, dissecting the brains of mice and men and teasing out the chemical formulas that unlock the secrets of the mind. Now, in the 1980s, their work is paying off. They are rapidly identifying the interlocking molecules that produce human thought and emotion…. As a result, psychiatry today stands on the threshold of becoming an exact science, as precise and quantifiable as molecular genetics. Ahead lies an era of psychic engineering, and the development of specialized drugs and therapies to heal sick minds.
Franklin, who interviewed more than fifty leading psychiatrists for his series, called this new science “molecular psychiatry,” which was “capable of curing the mental diseases that afflict perhaps 20 percent of the population.” He was awarded the Pulitzer Prize for expository journalism for this work.
Books written by psychiatrists for the lay press at this time told a similar story. In The Good News About Depression, Yale University psychiatrist Mark Gold informed readers that “we who work in this new field call our science biopsychiatry, the new medicine of the mind…. It returns psychiatry to the medical model, incorporating all the latest advances in scientific research, and for the first time in history, providing a systematic method of diagnosis, treatment, cure and even prevention of mental suffering.” In the past few years, Gold added, psychiatry had conducted “some of the most incredible medical research ever done…. We have probed the frontiers of science and human understanding wherein lie the ultimate comprehension and cure of all mental illnesses.”46
If there was one book that cemented this belief in the public’s mind, it was The Broken Brain. Published in 1984 and written by Nancy Andreasen, future editor of the American Journal of Psychiatry, it was touted as “the first comprehensive account of the biomedical revolution in the diagnosis and treatment of mental illness.” In it, Andreasen concisely set forth the tenets of biological psychiatry: “The major psychiatric illnesses are diseases. They should be considered medical illnesses just as diabetes, heart disease, and cancer are. The emphasis in this model is on carefully diagnosing each specific illness from which the patient suffers, just as an internist or neurologist would.”47
The broken brain—hers was a book with a brilliant title, one that conveyed a bottom-line message that the public could easily grasp and remember. However, what most readers failed to notice was that Andreasen, in several places in her book, confessed that researchers had not yet actually found that people diagnosed with psychiatric disorders have broken brains. Researchers had new tools for investigating brain function, and they hoped this knowledge would come. “Nevertheless, the spirit of a revolution—the sense that we are going to change things dramatically, even if the process requires a number of years—is very much present,” Andreasen explained.48
Twenty-five years later, that breakthrough moment still lies in the future. The biological underpinnings of schizophrenia, depression, and bipolar disorder remain unknown. But the public has long since been convinced otherwise, and we can see now the marketing process that got this delusion under way. At the start of the 1980s, psychiatry was worried about its future. Sales of psychiatric drugs had notably declined in the past seven years, and few medical school graduates wanted to go into the field. In response, the APA mounted a sophisticated marketing campaign to sell its medical model to the public, and a few years later the public could only gasp in awe at the apparent advances that were being made. A revolution was under way, psychiatrists were now “mind-fixers,” and as a Johns Hopkins “brain chemist,” Michael Kuhar, told Jon Franklin, this “explosion of new knowledge” was going to lead to new drugs and broad changes in society that would be “fantastic!”49
Psychiatrists were not the only ones in American society who were eager to tell of a biomedical revolution in psychiatry. During the 1980s, a powerful coalition of voices came together to tell this story, and this was a group with financial clout, intellectual prestige, and moral authority. Together they enjoyed all the resources and social status necessary to convince the public of almost anything, and this storytelling coalition has stayed intact ever since.
As we saw earlier, the financial interests of pharmaceutical companies and physicians became closely aligned in 1951, when Congress gave doctors their monopolistic prescribing privileges. But in the 1980s, the APA and the industry took this relationship one step further and essentially entered into a drug marketing “partnership.” The APA and psychiatrists at academic medical centers served as the front men in this arrangement, the public thereby seeing “men of science” on stage, while the pharmaceutical companies quietly provided the funds for this capitalistic enterprise.
The seed for this partnership was planted in 1974 when the APA formed a task force to assess the importance of pharmaceutical support for its future. The answer was “very,” and in 1980 that led the APA to institute a policy change of transformative importance. Up to that time, pharmaceutical companies had regularly put up fancy exhibits at the APA’s annual meeting and paid for social events, but they hadn’t been allowed to put on “scientific” talks. However, in 1980, the APA’s board of directors voted to allow pharmaceutical companies to start sponsoring scientific symposiums at its annual meeting. The drug firms paid the APA a fee for this privilege, and soon the most well-attended events at its annual meeting were the industry-funded symposiums, which provided the attendees a sumptuous meal and featured presentations by a “panel of experts.” The speakers were paid handsomely to give the talks, and the drug companies made certain that their presentations went off without a hitch. “These symposia are meticulously prepared with rehearsals before the meeting, and they have excellent audio-visual content,” Sabshin explained.50
The door to a full-fledged “partnership” had been flung open, one that would sell the medical model and the benefits of psychiatric medications to the public, and the APA now began to regularly rely on pharmaceutical money to fund many of its activities. The drug companies began “endowing” continuing education programs and psychiatric grand rounds at hospitals, and, as one psychiatrist observed, the companies were “happy to cap them with free food and booze to sweeten the love of learning.”51 When the APA launched a political action committee in 1982 to lobby Congress, this effort was funded by pharma. The industry helped pay for the APA’s media-training workshops. In 1985, APA secretary Fred Gottlieb observed that the APA was now receiving “millions of dollars of drug house money” each year.52 Two years later, an issue of the APA’s newsletter, Psychiatric News, featured a photo of Smith, Kline and French handing a check to APA president Robert Pasnau, which led one reader to quip that the APA had become the “American Psychopharmaceutical Association.”53 The APA was prospering financially now, with its revenues jumping from $10.5 million in 1980 to $21.4 million in 1987, and it settled into a fancy new building in Washington, D.C. It openly talked about “our partners in industry.”54
For the drug companies, the best part of this new partnership was that it enabled them to turn psychiatrists at top medical schools into “speakers,” even while those doctors considered themselves “independent.” The paid-for symposiums at the annual meetings greased this new relationship. The symposiums were said to be “educational” presentations, with the drug companies promising not to “control” what the experts said. Yet their presentations were rehearsed, and every speaker knew that if he broke from that script and started talking about the drawbacks of psychiatric medications, he would not be invited back.* There would be no industry-sponsored symposiums on “supersensitivity psychosis,” or the addictive effects of benzodiazepines, or how antidepressants were no more effective than active placebo. These speakers came to be known as “thought leaders,” their presence on the symposium panels elevating them to the status of “stars” in the field, and by the early 2000s, they were getting paid $2,000 to $10,000 per speech. “Some of us,” confessed E. Fuller Torrey, “believe that the present system is approaching a high-class form of prostitution.”55
These “thought leaders” also became the experts regularly quoted by the media, and they wrote the textbooks published by the APA. Psychiatry’s thought leaders shaped our society’s understanding of mental disorders, and once they began serving as paid speakers, the pharmaceutical companies sent money their way through multiple channels. As the New England Journal of Medicine observed in 2000, thought leaders “serve as consultants to companies whose products they are studying, join advisory boards and speakers’ bureaus, enter into patent and royalty arrangements, agree to be the listed authors of articles ghostwritten by interested companies, promote drugs and devices at company-sponsored symposiums, and allow themselves to be plied with expensive gifts and trips to luxurious settings.”56 Nor was it just a few psychiatrists from academia that pharma courted with its dollars. The drug industry understood this was a very effective way to market their drugs, and collectively the companies began paying money to virtually every well-known figure in the field. In 2000, when the New England Journal of Medicine tried to find an expert to write an editorial on depression, it “found very few who did not have financial ties to drug companies that make antidepressants.”
The NIMH also joined this storytelling coalition. The biological psychiatrists knew that they had successfully captured the NIMH when the Soteria Project was closed and Mosher was ousted, and during the 1980s the NIMH actively promoted the biological psychiatry story to the public, an effort that took wing under the leadership of Shervert Frazier. Prior to being picked to head the NIMH in 1984, Frazier directed the APA’s Commission on Public Affairs, which had run the media-training workshops underwritten by pharmaceutical firms, and soon Frazier was announcing that the NIMH, for the first time in its forty-year history, would launch a major educational campaign called the Depression Awareness, Recognition and Treatment (DART) program. This educational effort would inform the public that depressive disorders are “common, serious and treatable,” the NIMH said. Pharmaceutical companies would “contribute resources, knowledge and other forms of assistance to the project,” which the NIMH promised would run for at least a decade.57 As it helped expand the market for psychiatric medications, the NIMH even assured the public that the broken-brain story was true. “Two decades of research have shown that [psychiatric disorders] are diseases and illnesses like any other diseases and illnesses,” said NIMH director Lewis Judd in 1990, even though nobody had ever been able to explain the nature of the pathology.58
The final group to participate in this storytelling campaign was the National Alliance for the Mentally Ill. Founded in 1979 by two Wisconsin women, Beverly Young and Harriet Shelter, it arose as a grassroots protest to Freudian theories that blamed schizophrenia on “aloof, uncaring mothers and preoccupied mothers who were unable to bond with their infants,” a NAMI historian observed.59 NAMI was eager to embrace an ideology of a different kind, and the message it sought to spread, said former NAMI president Agnes Hatfield in 1991, was that “mental illness is not a mental health problem; it is a biological illness. There is considerable clarity on the part of families that they are focusing on a physical disease.”60
For the APA and pharma companies, the emergence of NAMI could not have come at a more opportune moment. This was a parents’ group eager to embrace biological psychiatry, and both the APA and pharmaceutical firms pounced. In 1983, the APA “entered into an agreement with NAMI” to write a pamphlet on neuroleptic drugs, and soon the APA was encouraging its branches across the country “to foster collaborations with local chapters of the National Alliance for the Mentally Ill.”61 The APA and NAMI joined together to lobby Congress to increase funding for biomedical research, and the beneficiary of that effort, the NIMH—which saw its research budget soar 84 percent during the 1980s—thanked the parents for it. “The NIMH in a very meaningful sense is NAMI’s institute,” Judd told NAMI president Laurie Flynn in a 1990 letter.62 By that time, NAMI had more than 125,000 members, most of whom were middle-class, and it was busily seeking to “educate the media, public officials, healthcare providers, educators, the business community, and the general public about the true nature of brain disorders,” said one NAMI leader.63 NAMI brought a powerful moral authority to the telling of the broken-brain story, and naturally pharmaceutical companies were eager to fund its educational programs, with eighteen firms giving NAMI $11.72 million from 1996 to 1999.64
In short, a powerful quartet of voices came together during the 1980s eager to inform the public that mental disorders were brain diseases. Pharmaceutical companies provided the financial muscle. The APA and psychiatrists at top medical schools conferred intellectual legitimacy upon the enterprise. The NIMH put the government’s stamp of approval on the story. NAMI provided a moral authority. This was a coalition that could convince American society of almost anything, and even better for the coalition, there was one other voice on the scene that, in its own way, helped make the story bulletproof in society’s eyes.
The Critics Believe in Aliens
The story of a “psychopharmacology revolution” had first been told in the 1950s and 1960s, and then, as we’ve seen in this chapter, it was revived in the 1980s. However, the storytellers in the 1980s were more vulnerable to criticism than the storytellers of the earlier decades simply because there was now twenty years of research that undermined their narrative. None of the drugs had proven to help people function well over the long term, and the chemical-imbalance theory of mental disorders was in the process of flaming out. As NIMH researchers had concluded in 1984, “elevations or decrements in the functioning of serotonergic systems per se are not likely to be associated with depression.” Close readers of The Broken Brain could also see that, in fact, no great new discoveries had been made. There was a Grand Canyon–sized gap between what the broken-brain storytellers were intimating was true and what was actually known, and that same gap would appear in their stories when Prozac and the other second-generation drugs came to market. But fortunately for the proponents of biological psychiatry, criticism of the medical model and of psychiatric drugs became associated, in the public mind, with Scientology.
L. Ron Hubbard, a science-fiction writer, founded the Church of Scientology in 1952. One of the church’s core tenets is that the earth is populated by souls that previously lived on other planets, an “extraterrestrial” creation myth that could have been lifted directly from a sci-fi novel. In addition, Hubbard had his own ideas about how to heal the mind. Prior to founding Scientology, he had published Dianetics: The Modern Science of Mental Health, which outlined the use of an “auditing” process to eliminate painful past experiences from the mind. The scientific and medical community ridiculed dianetics as quackery and dismissed Hubbard as a huckster, and he in turn developed an intense hatred for psychiatry. In 1969, Scientology and Thomas Szasz cofounded the Citizens Commission on Human Rights, and this group began waging campaigns against lobotomy, electroshock, and psychiatric drugs.
This proved to be very fortuitous for the APA and its storytelling partners as they raised the flag of biological psychiatry. Indeed, it is easy to imagine the drug companies deciding to secretly fund Scientology’s protests, eager as they were to shove money to any organization that would—wittingly or unwittingly—advance their cause. For not only did Scientologists believe in extraterrestrials, they also had gained a reputation for being a secretive, litigious, and even malevolent cult. Scientology, Time wrote in 1991, is a “hugely profitable global racket that survives by intimidating members and critics in a Mafia-like manner.”65 Thanks to Scientology, the powers that be in psychiatry had the perfect storytelling foil, for they could now publicly dismiss criticism of the medical model and psychiatric drugs with a wave of the hand, deriding it as nonsense that arose from people who were members of a deeply unpopular cult, rather than criticism that arose from their own research. As such, the presence of Scientology in the storytelling mix served to taint all criticism of the medical model and psychiatric drugs, no matter what its source.
Those were the storytelling forces that formed in the 1980s. When Prozac arrived on the market, they were lined up perfectly for the creation—and maintenance—of a tale about psychiatry’s great new leap.
* The academic psychiatrists also began to regularly give dinner talks to local psychiatric groups, and in 2000, University of Mississippi psychiatrist John Norton confessed in a letter to the New England Journal of Medicine that after he wrote about the side effects of the sponsor’s drug, “my invitations to speak suddenly dropped from four to six times per month to essentially none.” Prior to that experience, he said, “I deluded myself into thinking I was educating physicians, and not being swayed by the sponsors.”