CRACKED

Aptly described on the cover as 'chilling reading' and 'a potent polemic', this book makes a good case to back up its subtitle of why psychiatry is doing more harm than good. In the US and the UK, an incredible one in four people will be diagnosed with a mental disorder in any given year, and more than 50 million antidepressant prescriptions will be given in England alone. The author is a psychotherapist with a Ph.D. in medical and social anthropology from Oxford. He interviews many of the key people in the field in the course of his investigations, beginning with the DSM - the Bible of psychiatry (Diagnostic and Statistical Manual of Mental Disorders) now in its fifth edition.

The number of mental disorders has risen from 106 from the first edition in 1952 to 374 in the current edition, which is a story in itself. The process of arriving at a classification has been based on clinical consensus and professional recognition, naming and defining a condition without it necessarily having a biological basis or being the result of scientific research. It was decided that five symptoms would be adequate to make a diagnosis, without any real intellectual justification for this figure. Disorders are like constellations in the sky, the discernment of a pattern. One of the reasons for the rise in the number of mental disorders is what the author calls medicalisation of misery, which fails to distinguish between the normal challenges of life and actual mental disorder. For instance, there was a huge outcry when grief was medicalised in the latest edition. In other cases such as ADHD, self-harm and anorexia, the condition, once classified, becomes very common with a corresponding drug developed to treat it. In the view of the experts interviewed, this can lead to serious overdiagnosis and false epidemics.

Antidepressants have gross sales of £12.5 billion a year, but detailed research by Irving Kirsch (who discovered that 40% of trials were unpublished - needless to say the less favourable ones) showed that they were hardly any more effective than placebos and the context of the trial itself encouraged a placebo effect through the expectation inherent in the experiment. Eli Lilly even marketed Prozac under the name Sarafem to treat premenstrual dysphoric disorder, so women were taking Prozac without knowing it. It is also clear that antidepressants do not actually cure people but rather induce an overall numbing effect that is not a return to normality. Some of these treatments are given in the name of chemical imbalance, which Davies shows to be a convenient myth hinting at a biological basis for the condition when there is none. The condition is effectively biologised and medicalised, which suits a chemical approach. This brings up another interesting question, namely the idea of mental disease as opposed to dis-ease, with the implicit assumption of a brain or biological basis to the condition. This approach is encouraged in medical schools and of course by the pharmaceutical industry but is seriously one-sided, as Davies point out later in the book.

As also indicated out in books I reviewed in April, leading psychiatrists and universities have extensive ties with the industry, as does the FDA, the regulatory body in the US. Key opinion formers are induced to support industry research and promote new drugs to their colleagues with their implicit intellectual authority. Many of these fees are undeclared by the professors to their universities, and Davies also gives an interesting example of Daniel Carlat, who was wooed by the industry to support the marketing of Effexor, having heard it promoted by a doctor he respected. Towards the end of the conference he received an envelope with $750 and a note to go out and enjoy the city. When he returned to his practice, there were already two messages on his answering machine and he began giving presentations at £400 an hour. Eventually, on one occasion he mentioned the fact that the trials for this drug might have been too short, a point that was immediately picked up by the sales rep in the audience, who called the next day to ask if he had been ill. It was at this point that he realised that, from the point of view of the company, he was just a marketer for the drug.

Sometimes it can be important to understand the culture in order to market a drug effectively. The author gives an interesting example from Japan about how culture shapes the experience of illness. GSK held a conference on this topic, which enabled them to understand the Japanese mentality better and therefore to find the right words to promote their antidepressant drugs. This was hugely successful and resulted in a great increase in sales. Towards the end of the book, the author interviews the President of the Royal College of Psychiatrists about the state of the profession, arguing that the non-medical approach is in fact the real work of psychiatry. He recommends that psychiatry needs to develop a greater humility about what it can achieve, that there should be much more thorough regulation and transparency about financial ties the pharmaceutical industry, that future psychiatrists should gain a greater critical awareness of the lack of a scientific basis for many psychiatric diagnoses, and finally that the public should become better informed about the current crisis in psychiatry.

This is where Davies' informed, incisive and highly readable book comes in. I would encourage everyone to read it (and I note that the author recently spoke to the London group). I also agree with his conclusion that the solution is not yet more medicalisation but rather 'an overhaul of our cultural beliefs, a really confusing of life with spiritual, religious or humanistic meaning with emphasis on the essential involvement of community, and with whatever helps bring us greater direction, understanding, courage and purpose.'