On March 4, 2020, the very eminent Allen Frances, MD, published an article in Aeon, which according to its About page is “a digital magazine, publishing some of the most profound and provocative thinking on the web. We ask the big questions and find the freshest, most original answers, provided by leading thinkers on science, philosophy, society and the arts.”
The article is called The lure of ‘cool’ brain research is stifling psychotherapy. The central theme is that prior to 1990, the National Institute of Mental Health (NIMH) “appreciated the need for a well-rounded approach [to mental health] and maintained a balanced research budget that covered an extraordinarily wide range of topics and techniques.” However, since 1990, the opening year of the Decade of the Brain, the NIMH has “increasingly narrowed its focus almost exclusively to brain biology – leaving out everything else that makes us human, both in sickness and in health.”
It’s an interesting article, but the basic premise is similar to most of Dr. Frances’s recent material – that there are problems in the psychiatric field, but none of these problems can be blamed on psychiatry.
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Here are some quotes interspersed with my thoughts and observations.
“Having largely lost interest in the plight of real people, the NIMH could now more accurately be renamed the ‘National Institute of Brain Research’.”
“This misplaced reductionism arose from the availability of spectacular research tools (eg, the Human Genome Project, functional magnetic resonance imaging, molecular biology and machine learning) combined with the naive belief that brain biology could eventually explain all aspects of mental functioning. The results have been a grand intellectual adventure, but a colossal clinical flop. We have acquired a fantastic window into gene and brain functioning, but little to help clinical practice.”
So, the bio-bio-bio perspective that characterizes psychiatry today is the fault of the NIMH. But let’s take a look at the NIMH leadership from its inception in 1949 to the present. Here’s a list of the institute’s directors during that period. (Source: Wikipedia)
So, whatever else may be said of the NIMH, apart from the two brief periods when psychologists were named as acting directors, it has always been firmly under the control of psychiatrists.
And psychiatrists have been promoting the brain illness theories at least since the time of Emil Kraepelin (1856-1926). This promotion was interrupted by the psychoanalytic period, but was solidly re-established in both theory and practice by the late sixties. Perhaps the most tangible indicator of this return to a biological perspective was the removal in DSM-II (1968) of the term “reaction” from the names of the various “psychiatric disorders”. “Schizophrenic reaction” of DSM-I became “schizophrenia”. “Depressive reaction” became “major depression”, etc. The significance of this was that in DSM-I, the various disorders were conceptualized as reactions on the part of the individual to various stressors. In DSM-II, these disorders had become fully-fledged illnesses, which was precisely what psychiatrists needed to profit from the newly-emerging psychiatric drugs. The shift in the 50’s and 60’s back to the bio-bio-bio perspective was a deliberate and calculated tactic on the part of the psychiatric leadership and the rank and file, to enable them to cash in on the emerging drug bonanza and to enhance their perceived prestige. Treating “real illnesses” with “real medicines” enabled them to believe that they were real doctors. It is also noteworthy that in the late 90’s, Dr. Frances and his co-author Michael B. First, MD, were active cheerleaders for neuroscience. Here’s a quote from their book Am I OK? A Layman’s Guide to the Psychiatrist’s Bible, 1998:
“The tremendous advances in neuroscience, brain imaging, and genetics are almost every day giving us a clearer picture of how the brain works to produce behavior – in both illness and health. It is a source of wonder that we live at a time when it will be possible to have answers to questions that puzzled physicians and philosophers for at least the last five millennia. The practical return from the neuroscience revolution will lead to more specific and effective treatments and hopefully also improved methods of prevention.” (p 415)
Dr. First, incidentally, was the Text and Criteria Editor for DSM-IV.
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Back to the Aeon article:
“Unfortunately, we don’t live in a rational world. Drug companies spend hundreds of millions of dollars every year influencing politicians, marketing misleadingly to doctors, and pushing pharmaceutical treatments on the public. They successfully sold the fake marketing jingle that all emotional symptoms are due to a ‘chemical imbalance’ in the brain and therefore all require a pill solution. The result: 20 per cent of US citizens use psychotropic drugs, most of which are no more than expensive placebos, all of which can produce harmful side-effects.”
Note the unambiguous assignment of blame to pharma: the result of their marketing is that 20% of US citizens use psychotropic drugs. And the psychiatrists were simply the victims of misleading marketing. The poor lambs. Eight years of college plus three years of supervised residency, and they fall for a hoax like that! Oh my!
In reality, psychiatrists promoted the chemical imbalance hoax with just as much vigor as pharma – perhaps even more so. I have provided numerous examples of this – each more shameless than the next – in an earlier post.
The reality is that the blame for the chemical imbalance hoax lies fairly and squarely on the psychiatrists who pushed this drivel on their customers. Their motivation in this regard was clear, unambiguous, and self-serving: to induce people, who otherwise might not have done so, to take the pills. In the 50’s and 60’s, there was a great deal of judicious skepticism among the general public concerning the use of quick-fix pills as “treatments” for problems of living, and there was a clear understanding among psychiatrists that this skepticism had to be neutralized. Pharma certainly provided much of the funding, but it was psychiatrists who pushed the false and dehumanizing message. Here’s a quote from Terry Lynch’s classic exposé Depression Delusion (2015):
“The public acceptance of the depression brain chemical imbalance notion as a fact has also been enormously helpful to psychiatry on several levels. By promoting this concept as a fact or a likely reality for half a century, many psychiatrists have persuaded themselves and the public that they are real doctors treating real diseases. The brain chemical imbalance fallacy being publicly accepted as truth has elevated the status of psychiatry, perhaps more than any other idea over the past fifty years.” (p 236)
And despite the vague self-conscious back-pedaling that we are seeing today, there has never been anything even remotely like an apology from organized psychiatry to the millions of people who were hurt and permanently damaged by this hoax. In this regard, it is particularly interesting to note that in 2015 the APA abandoned their various earlier logos and adopted a stylized outline of a human brain as their official logo for all purposes. I wrote about this matter here.
It also needs to be stressed that Dr. Frances played a personal role in the promotion of the chemical imbalance hoax.
DR. FRANCES AND THE PROMOTION OF THE CHEMICAL IMBALANCE HOAX
Here’s another quote from Am I OK?:
“Depression is really no different than hypertension. Medicines that treat high blood pressure are taken to reestablish the body’s ability to maintain a normal blood pressure. Antidepressants work in the same way—restoring brain neurochemistry to its original natural state.” (p 49) [Emphasis added]
So, according to Drs. Frances and First, antidepressants restore “brain neurochemistry to its original natural state.” This is a perfect example of the chemical imbalance hoax written specifically to convince a lay audience.
In addition, there is an endorsement of the chemical imbalance theory in Dr. Frances’s own DSM-IV (1994):
“Neurotransmitters implicated in the pathophysiology of a Major Depressive Episode include norepinephrine, serotonin, acetylcholine, dopamine, and gamma-aminobutyric acid.” (p 324)
The assertion that the neurotransmitters listed are “implicated in the pathophysiology of a Major Depressive Episode” is synonymous with the chemical imbalance theory as it is generally promoted and understood.
PSYCHIATRISTS ABANDONED PSYCHOTHERAPY BY CHOICE
Back to Dr. Frances’s current article:
“Drug companies are a commercial Goliath with enormous political and economic power. Psychotherapy is a tiny David with no marketing budget; no salespeople mobbing doctors’ offices; no TV ads; no internet pop-ups; no influence with politicians or insurance companies. No surprise then that the NIMH’s neglect of psychotherapy research has been accompanied by its neglect in clinical practice. And the NIMH’s embrace of biological reductionism provides an unintended and unwarranted legitimisation of the drug-company promotion that there is a pill for every problem.”
The notion that the NIMH killed off psychotherapy is fanciful. Psychiatrists stopped doing talk therapy once it became clear that they could double, or even triple, their income and enhance their prestige doing 15-minute med checks, which has now become their only stock-in-trade. They could resume psychotherapy at any time. Psychiatrists – leaders and rank and file – could also speak out against any facet of the NIMH’s agenda at any time, but I haven’t seen much of that. They could also decline pharma’s generous invitations to become “thought leaders”, but I haven’t seen much of that, either.
DR. FRANCES WAS AN ACTIVE AND PAID PARTICIPANT IN THE PROMOTION OF PSYCHIATRIC DRUGS.
In 1996, Dr. Frances, along with his then partners John Docherty, MD, and David Kahn, MD, produced “Schizophrenia Practice Guidelines”. [The Journal of Clinical Psychiatry, 1996, Vol. 57, Supplement 12B]. These guidelines were essentially a marketing tool for the neuroleptic drug risperidone (Risperdal). Dr. Frances, Dr. Docherty, and Dr. Kahn were paid $515,000 by Johnson & Johnson for this work, and it was stated by an expert witness in a subsequent court hearing (the State of Texas v. Janssen Pharmaceutica, a subsidiary of Johnson & Johnson 2004), that on July 3, 1996, Dr. Frances sent the following in an email to Janssen Pharmaceutica:
“We are also committed to helping Janssen succeed in its effort to increase its market share and visibility in the payor, provider, and consumer communities.”
Note the comprehensive nature of the commitment. Drs. Frances, Docherty, and Kahn are confirming their commitment to promote Risperdal to consumers, medical prescribers, and payers. It is particularly significant that sales of Risperdal increased dramatically from $172 million in 1994 to $1.726 billion in 2005. Most of the sales during this period of growth came from off-label use, particularly dementia and related problems (Forbes, November 12, 2013, J&J’s $2.2 Billion Settlement Won’t Stop Big Pharma’s Addiction To Off-Label Sales by Michael Bobelian). In this context, the following quote from Am I OK? is particularly significant:
“The ‘antipsychotics’ work well for anxiety and agitation in many patients who are not psychotic.” (p 421)
So when we read the horror stories of elderly nursing home residents being brain-coshed with neuroleptic drugs, let’s remember that Dr. Frances played his part in this heroic saga, and honored the commitment that he had made to Janssen back in 1996.
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I have written more on Dr. Frances’s ties to Janssen here. In addition, Paula Caplan, PhD, has written a comprehensive and compelling account of this entire sordid business. Her article, which appeared in Aporia in January 2015, is titled Diagnosisgate: Conflict of Interest at the Top of the Psychiatric Apparatus.
AM I OK? SOME INTERESTING ADDITIONAL QUOTES
Am I OK? has particular interest in the present context in that it is essentially a marketing document, selling psychiatric “illnesses” and “cures” to a lay audience. Here are some interesting quotes:
“DSM-IV has achieved a central role in mental health circles because accurate diagnosis is now more important than ever. For the first time, we have a science not just an art, of psychiatry. The field has come a long way from the shaman’s rattle or the doctor’s folk remedies or the alchemist’s mercury concoctions. Using powerful imaging devices, we can actually visualize just how the brain works in sickness and in health. We now have very effective tools for treating mental disorders, and the future looks even brighter. Getting the right treatment almost always depends on having the right diagnosis.” (p 10)
There is no science in psychiatric diagnosis. Apart from those diagnoses that are clearly due to a general medical condition (e.g. Alzheimer’s disease), the loose clusters of poorly-defined thoughts, feelings, and behaviors collated in successive editions of the DSM were not discovered in nature. Rather, they reflect decisions made by the various APA committees and work groups, and faithfully embody the prejudices and vested interests of these groups. There is, for instance, not a shred of evidence that people who meet five or more of the nine criteria for “major depressive disorder” constitute an etiologically coherent group, or even that they have any sickness whatsoever. This is what Thomas Insel, MD, then Director of NIMH, meant when he wrote:
“While DSM has been described as a ‘Bible’ for the field, it is, at best, a dictionary, creating a set of labels and defining each. The strength of each of the editions of DSM has been ‘reliability’ – each edition has ensured that clinicians use the same terms in the same ways. The weakness is its lack of validity. Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever. Indeed, symptom-based diagnosis, once common in other areas of medicine, has been largely replaced in the past half century as we have understood that symptoms alone rarely indicate the best choice of treatment.” April 29 2013 (here)
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BACK TO AM I OK?
“One in five people has a psychiatric problem at any given moment, and half will have one in a lifetime.” (p 10)
This is a classic piece of psychiatric disease-mongering. Psychiatrists invent psychiatric “illnesses” and then “discover” that lots of people have them. Consider this: they could actually increase the spot prevalence to 90%, and there would be no piece of data that could contradict this. There is no definition of a mental disorder other than that provided by the APA. There is no objective etiological reality against which their criteria can be compared. This is analogous to glaziers going around at night breaking windows, then fixing them the next day, and rejoicing in the fact that they have a lot of business!
By the same token, of course, psychiatrists could reduce the total prevalence to 1% by tightening the criteria. But don’t hold your breath.
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“Know the following symptoms so well that you can spot emerging episodes before they get out of hand. You can’t control the weather, but you can control depression.” (p 33)
Dr. Frances and Dr. First are actually encouraging people to memorize the “symptoms” of “major depressive disorder” so that they can avail of psychiatric help before emerging episodes “get out of hand”!` This is grade A disease-mongering.
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“ECT [electro-convulsive therapy] is a terrifically effective treatment that is also relatively safe considering the great benefits that can often be gained. ECT is especially useful for psychotic mood disorders, people who need a really fast response, medication nonresponders, and for those who cannot tolerate antidepressant medication. Electroconvulsive therapy has a higher response rate (80 to 90 percent versus the 65 to 70 percent achieved by medication combinations) and also works more rapidly. However, it has the disadvantage of providing fewer clues as to what type of medication is likely to work to prevent recurrence in the maintenance phase. Due to misguided fears, ECT has been most typically considered a treatment of last resort when nothing else works. It probably deserves to be used earlier and more often.” (pp 51-52)
One can only wonder how many hapless customers were drawn in by this kind of hyperbole: “terrifically effective”; “really fast”; “80%-90%”; but note – only “relatively safe considering the great benefits.” Also note: no mention of cognitive damage. [Emphasis added]
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“Antipsychotic medications [neuroleptic drugs] commonly have side effects. These include feeling terrible, being slowed down or stiff, getting restless or being unable to sit still, developing tremors in the hands or feet, gaining weight, and having sexual problems. Unfortunately, many patients deal with such problems by stopping their medication, usually without telling the doctor. This is always a bad idea. Most side effects can be reversed either by lowering the dose, switching to a different medication, or adding an “antidote” (like Cogentin or Artane). Fortunately, a whole new class of “atypical” antipsychotics (Risperdal, Zyprexa, Seroquel, Zeldoc, and Clozapine) has recently become available. These have much fewer side effects than the older medicines and may be more effective for many patients. The new medicines are often a godsend and may help you feel ‘awakened’.” (p 324)
Note the profound understatement in describing akathisia as “getting restless” and “unable to sit still”, and tardive dyskinesia as “developing tremors in the hands or feet”. Note also that Risperdal is listed first in the names of the new neuroleptics.
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“Scientific research is now hot on the trail tracking down which specific genes are involved in which psychiatric disorders and determining how they exert their influence. Within a decade we may well unlock at least some of the basic secrets of Schizophrenia, Bipolar Disorder, and Obsessive-Compulsive Disorder. It won’t be a simple story. Many genes are probably involved in producing each disorder and the precise patterns of causation will undoubtedly differ in different people. The environmental factors that promote illness are remarkably varied and include complications related to childbirth, infections, physical trauma, family stressors, and all the other difficulties that must be faced in a long lifetime. In contrast, a strongly supportive environment may help to protect against illness, particularly if the genetic loading is not all that strong to start with.” (p 415)
This was 22 years ago. Presumably “scientific research” is still “hot on the trail”.
FINALLY
Dr. Frances continues to write on the flaws and ills of psychiatric practice, but never acknowledges the role that psychiatrists, including himself, played in the creation and maintenance of these problems. The spurious promotion of psychiatric “diagnoses” as real illnesses, and the routine prescribing of chemical and electrical “cures” were, and still are, psychiatric inventions that continue to destroy individuals and undermine our cultural and personal resilience.