Reviewed by Clancy Sigal
Sunday, March 2, 2008; BW03
How Psychiatry Is Medicating a Nation
By Charles Barber
Pantheon. 280 pp. $26
Tony Soprano takes the antidepressants Prozac, lithium and Xanax. His mother is on Prozac, and his son takes Lexapro. Lorraine Bracco, who plays Tony's psychiatrist, in real life suffers from depression and has "partnered" with the pharmaceutical giant Pfizer to help sell Zoloft.
Take your pick of 30 such antidepressants with soothing names and M&M-like colors -- Wellbutrin, Paxil, Celexa, BuSpar, Elavil, Vivactil, etc. -- and you're liable to see, in direct-to-consumer TV and newspaper ads, a Superbowl champ or film actress flacking for Big Pharma.
According to Charles Barber, since the early 1990s mental illness has gone from shameful to shameless, from unspoken and unspeakable to "a newfound faddishnes s." This profit-driven popularization deliberately blurs the line between true psychosis -- which Barber, who worked for 10 years in New York City homeless shelters, knows a lot about -- and simply feeling lousy. "In its improbable odyssey from the back wards of asylums to the boardrooms of corporations," Barber contends, "psychiatry has gone from invisible to visible" and is losing its soul in the process.
The most headline-catching part of Barber's jeremiad is his statistics-laden case that drug companies such as Glaxo, Merck and Lilly have not merely filled a legitimate need but have aggressively created a vast market for chemical mood lifters. According to Barber, spending on antidepressants and antipsychotic pills totaled $25 billion in 2006 -- with Zoloft's sales alone exceeding those of Tide detergent -- and the pharmaceutical industry's bloated profits increasingly depend on targeting the "cash-carrying worried well" rather than the truly mentally ill, who are often impoverished. The "worried well," meaning "the wealthy, prosperous denizens of suburban America," is a phrase that appears a lot in Barber's text, with just the faintest hint of a sneer. I suspect he means people like you and me with run-of-the-mill emotional problems. (Truth in reviewing: I take Lexapro.)
I strongly sympathize with Barber's worldview, which derives from his work with homeless psychotics on the street, in shelters and at Manhattan's Bellevue Hospital. I can't think of a civilian job, perhaps aside from being a firefighter, that's harder to do or more heroic in aim. He's not against pills per se -- after all, Prozac helped drag him back from his own pit of despair as a young man. He just wants the drug companies, so many of them under criminal indictments for fraud, to come clean and publish their negative as well as upbeat drug trial results; and for primary care physicians to think twice about dispensing pills that have unmentioned side effects; and for patients who are merely unhappy to "just say no" to antidepressants.
Barber, a lecturer in psychiatry at Yale medical school, previously wrote a poignant memoir, Songs from the Black Chair, about how a school friend's suicide plunged him into a depression that he eventually rechanneled into a vocation of helping rough-living, often delusional "crazies."
In Comfortably Numb, he reminds readers that the whole corporate-driven, take-a-pill "revolution" in mental health over the past 20 years is a result of "the discovery of drugs that actually work, at least for some people," and of brain imaging by MRI and PET scans. These technological advances, he argues, have had the unfortunate effect of "physicalizing" behavior and securing for drug-oriented psychiatry a "smashing victory" over old-fashioned talk therapies with their slower, hard-to-quantify results. The triumph of mechanistic neurology was accomplished by convincing influential doctors and the media "that behavior is genetic, hardwired, strictly biological" and that mental illness is caused by "chemical changes in the brain," as former Surgeon General David Satcher once put it.
But Barber is uncertain or confused -- I'm not sure which -- about whether antidepressants help very many people. He cites two massive government studies released in 2006 that showed that most patients do not get better taking antidepressants or antipsychotic drugs, and he reports that his own clients in New York shelters "remained essentially unchanged" by the newfangled meds that became common in the 1990s. Yet he also states that "antidepressants can be truly life saving for people with severe and disabling mental illness." It's not the only place where Barber appears to undermine his strong belief in non-chemical, "human touch" psychotherapy.
In the final section of his book, he propagandizes for the talking approach known as Cognitive-Behavioral Therapy (CBT) and for even woollier treatments called Motivational Interviewing and Stages of Change (complete with the usual indecipherable diagram). He unblushingly calls CBT "carpentry of the soul." No wonder that some of his sub-villains, the drug-dispensing doctors, recoil at this vaporous stuff.
Ultimately, Barber seems to be ambivalent about the neurology-versus-psychology debate. Maybe it's because of his own positive Prozac experience. Or maybe he feels it necessary to wrap his rather modest and humane approach to getting through life in the techno-speak of neurology. In any case, he makes extravagant claims for listening-and-talking therapy in puzzling language. "The positive outcomes of these various approaches in alleviating some of the most intractable of human problems . . . have been proven repeatedly and spectacularly," he writes. Proven? By whom, where, using what methods -- and what does "proof" in such an inherently untestable area mean?
Barber enthusiastically quotes a researcher who says that "when a therapist speaks to a patient . . . the action of neuronal machinery in the therapist's brain is having an indirect and, one hopes, long-lasting effect on the neuronal machinery in the patient's brain." And he devotes several pages to studies showing that "psychotherapy results in detectable changes in the brain." These passages put Barber, whose clinical practice comes across as decent and commonsensical, in the tricky position of using questionable neurological arguments to push his non-, or even anti-, chemical therapy.
Again, I sympathize. He's up against a psychiatric profession that, in his words, has "long been a house divided against itself, plagued by false dichotomies: Mind versus Brain, Genes versus Environment, Medication versus Psychotherapy." It could be that Barber also is divided against himself, which is not a bad place for a healer to be. *
Clancy Sigal, a novelist and screenwriter, is the author of "Zone of the Interior," about working with schizophrenics at two hospitals in England.