Editorial Note: It’s common to find those behind Global Mental Health say that they might not originally have believed in the reality of mental illness and the efficacy of treatment but they do now. This and two following position pieces don’t come from the same conversion perspective. I have always believed in the reality of mental illness and the efficacy of treatment. Nevertheless the enthusiasm of the converts is worrying.
This piece first appeared as a review of a recent book Pharmaceutical Selves, which has the subtitle, The Global Shaping of Experience in an Age of Psychopharmacology. The review appeared in Transcultural Psychiatry.
‘Pharmaceutical Selves’ has a distinguished authorship line – Ecks, Biehl, Good, Jenkins, Luhrmann, Martin, Metzyl and Saris. The title Pharmaceutical Selves conveys both the fact that the group of drugs under consideration are the psychotropic drugs and that globalization poses a set of paradoxes. The subtitle was almost redundant – except that it points to areas on which there are strains between the authors. Is there a global shaping of experience they ask? Is there a pharmaceutical industry hegemony?
Let’s sort out Indonesia
The tensions come to their clearest focus in Byron Good’s chapter where facing a series of disasters in Indonesia he critiques standard views of the hegemony of Western pharmaceutical companies and bemoans the lack of resources including psychotropic drugs available to Indonesian sufferers from nervous disorders. Should anthropologists be standing in the way of the pharmaceutical juggernaut, he asks, or should they be ensuring it can make its way down the remotest dirt tracks to the farthest flung outpost? Little time here for talk of outposts of Empire.
He cites a series of clinical cases to illustrate his points and summarizes what he has seen in the following terms: “There are few aggressive efforts to try different drugs or different dosages or to find a medication or combination of medications that will lead to real remission of the psychosis… Failures of response to medication then reinforce the view that drugs only treat superficial symptoms and not the essence of the sickness. Why have anthropologists become activists when it comes to detecting and treating HIV-AIDs but take quite the opposite approach to mental illness?”
Indonesian patients will unquestionably want life saving Western medicines just like the average North Korean would probably trade a lot for decent Western food. Indonesian patients would probably also opt for the latest Western psychotropics just as many in the Soviet bloc once coveted Levi jeans – if they had surplus disposable income. But wanting psychotropics and Levi jeans is a very different matter to needing life-saving medicines and food.
It seems that Good has bought whatever it is about the Western superstructure that generates wants of this sort. He seems to endorse company views that the latest drugs – which are demonstrably inferior to and vastly more expensive than older products – are in fact superior and do more than “treat superficial symptoms”. The skeptical attitudes of patients that he bemoans are ones that I offer as the orthodox views about what these drugs do in a series of my publications and have done in public lectures without anyone objecting. The same views could be found in most standard textbooks – until recently.
There are good reasons why the latest psychotropics don’t travel in the way the anti-retrovirals do. Indonesian patients and doctors I would say make the right calls – better calls than American patients and doctors. The question is why there is no hint from Good that this might be the case, and almost no analysis elsewhere in the book from the other authors as to why this should be.
While there is some mention of sponsored medical education and ghostwritten articles, there is nothing on how the market is structured so that even sophisticated academics can end up believing brain toxins are brain tonics, or that drugs such as the antidepressants labeled as causing birth defects nevertheless should be given to pregnant women in ever increasing amounts.
How do industry do it?
How has the pharmaceutical industry been able to recruit the most radical of feminists to do its marketing for it – with even the Boston Women’s Collaborative now among the promoters of antidepressants to women of child-bearing years? Probably exactly how they have been able to hide what they are doing from the authors of Pharmaceutical Selves. Until recently authors like these were precisely the people we depended on to work out what was going on in situations like this. How has this anthropological agnosia been brought about?
The original academic view of antipsychotics is that they were tranquilizers – they treat symptoms. Available over the counter, they would still be viewed that way by patients. It is doubtful if the benefits of any later antipsychotics would have led to their take-up in the West if it was patients doing the choosing. The huge doses of medicines advocated by Byron Good would have been inconceivable if patients bought these “goods” – with overall probably greater benefit to patients.
It would have been relatively easy for single universities or hospitals on their own to run controlled trials of the antipsychotics or SSRIs to explore their immediate tranquilizing properties – trials that would have differentiated them unequivocally from placebos – something that multi-centered company trials of these drugs as antipsychotics or antidepressants has failed to do.
Allied to issues like this are the status of these drugs on prescription only. This has put some of the most naïve consumers on earth – doctors – in the sights of the most sophisticated marketing machinery ever seen. Mixing Lord of the Rings metaphors with The Iliad, these same doctors, under siege from industry, faced with a horse left outside the gates of the citadel have happily hauled it inside – oblivious to the fact that the most enthusiastic advocates of evidence based medicine these days are pharmaceutical companies. It’s one thing for Trojans under siege to be fooled, but why are anthropologists, bio-ethicists and others taken in?
Where are the anthropologists & social scientists gone when we need them?
There is no analysis here of structural factors like the prescription only status of drugs, the role of controlled trials as a marketing tool, or the patent status of drugs that makes Indonesia a potential market for Western pharmaceutical companies. The drugs are treated like simple facts, stripped of the social matrix that makes them drugs. It seems assumed they are born in the laboratory as drugs rather than chemicals.
There is much that is excellent about this book. A lot that is downright alarming. But also a big hole. Someone has to get to grips with how pharma do it. This was once the domain of medical anthropology and social science. But even the critics now seem to be defanged and are likely to be found endorsing the feeding of psychotropic drugs to pregnant women, infants, and Indonesians.
As the first murder of teacher by a pupil in UK school, Daily Mail, today, says “he used to be on anti-depressants”.
Doesn’t our heart sink at these words.
Why, after all these years of hinting does the media still not see the elephant in the room.
This boy was fifteen. He came from professional parents. He had never exhibited behaviour life this before.
Am I alone in thinking what sort of doctor gives a boy of 15 anti-depressants?
I hope, for the doctor’s sake, it was Prozac. The only anti-depressant licensed for children.
If it wasn’t Prozac, then, am I alone in thinking that it wasn’t the child who was guilty of cold-blooded murder, it was the doctor.
Can someone please advise the press that it is no use hinting at medication, they need to come clean and state which medication.
This is vital information and David Cameron, said “everything that can be done to get to the bottom of this will be done”.
We need people like David Healy and Peter Gotzche and, new kid on the block., Dr. James Davies, CEP. to tell it how it is.
And, another lovely blog from DH; Jakarta does not deserve this.
One big stumbling block to the idea that Western drug-centric psychiatry will free the world from mental illness is this:
The World Health Organization has repeatedly found that people with schizophrenia fare BETTER in “underdeveloped” nations like India or Nigeria than in the US and Western Europe. “Anti-psychotic” drugs were not unheard of in most of the locations studied – and they were prescribed by doctors, not purchased over-the-counter, just as in the West. Nevertheless, they were used far more sparingly and usually only short-term for flare-ups of agitation, distress or delusional thinking. Doctors relied far more on family counseling and on strengthening the social connections of their patients, trying to help them find work, get married, and otherwise live as part of their communities.
The findings were stubbornly persuasive … but most Western psychiatrists simply refused to believe it, for not very mysterious reasons:. “Pharmaceutical companies, which control the scientific production of research at universities, are not interested in saying, ‘Social factors are more important than my drug,’ ” said Jose Bertolote, a WHO psychiatrist. “I’m not against the use of medication, but it’s a question of imbalance.” .
That’s a quote from Shankar Vedantam’s excellent article for the Washington Post on this topic. Full article here:
http://www.washingtonpost.com/wp-dyn/content/article/2005/06/26/AR2005062601091.html
It will be a terrible loss if pharmaceutical companies and their “enlightened” experts succeed in overthrowing this paradigm of care in favor of the far bleaker and more damaging one that rules the “advanced” countries.
I would imagine that in ‘less developed’ countries people recognise what distress amounts to, and do not see it in medical terms. The medical terms suggest ‘complicated syndromes’ and are ‘developed’ country terms. I would imagine in countries like Nigeria people recognise that most of the time an outburst comes to an end of its own accord, anyway.
How the Light Gets In sounds like a festival to blow all minds with intellectual discussion and ‘fun’. Wish I could go.
Not just for ‘our debate’, but to grab some ‘intelligent’ thinking for a change.
Minor league psychiatrists and minor league doctors really have no business practicing medicine, but, real thoughts, about real things, isn’t that just so refreshing.
Is it my imagination or how did I miss the invitation to listen to Professor Peter Gotzche talking at Westminster.
Why wasn’t I invited to listen to someone who could actually save millions of lives.
I am a supporter of CEP, just recently, but how were we left off the mailing list to listen at Westminster. I might have done some more weeding, to save up……
Thank you David, if I could attend Hay, I would, just might, and thanks for telling us you will be there……………….talking about us.
When you went to Westminster, I don’t suppose it was a lot of fun.
Daunting, in fact. Hay sounds quite the opposite and much more interesting than Westminster. Hope it hits the spot, what you say………………but, never mind, hay, you are so lucky being able to put across your points without any acrimony…coming your way…….Hay, hey, the Institute for Arts and Ideas seems a good way to go.
Loads of brilliant company…..you are so lucky……………..please wear your Rxisk.org T-shirt……………:)
And I have asked before, where do I get one to wear at Inveraray Highland Games and Best of the West and Loch Fyne Seafood Fair and all the places I visit where I could, make a difference, you know……………….Duke of Argyll is my landlord. I really would like to help administer, the PR.
Moving swiftly along………
They have some nerve our politicians.
Re The Boy who stabbed the teacher.
1. Michael Gove, Education, writes a two-page article in the Daily Mail, mostly, about himself and, naturally, about the splendid teacher (s).
2. Question Time with David Dimbleby, has five senior figureheads in our society, on his panel, discussing not wanting ‘Heathrow Airport Security’ in our schools.
And, reading and watching all this, did we hear one word about The Boy, we did not.
Isn’t it All About The Boy?
The boy, whose splendid teacher got killed as the boy had a huge surge of adrenalin.
The boy, who other children, said was ‘detached’ and ‘withdrawn’, and, they mentioned, a-ds…
Second day of the press story and no mention of, hush, a-ds.
Are the press of the notion that an injunction might be put on the table forbidding any use of Brand Names in their reporting?
My child was bullied relentlessly, at school, a la Seroxat, and it was up to me to turn this frightful situation around and take her out of main-stream education and home-educate.
With me, she received an outstanding education, this A+ student.
I would, also, say this charming little girl, was lost and thought my alarming behaviour might somehow have been her fault. This, was not lost on me.
What was the Chairman of The National Trust doing on Question Time discussing murder. Is this his chosen field of expertise?
Who are the heretics and who are the hypocrites?
Hyping up teachers is admirable when it is the right time to do so……..her body is hardly cold…………the boy has a murder charge….reminds me of Christopher Pittman……languishing in a jail somewhere in the US…….
Deja-vu or just another mixed up kid?
Seroxat and Effexor or just another mixed up chemical?
http://www.nytimes.com/2004/08/23/us/drug-trial-justice-science-boy-s-murder-case-entangled-fight-over.html
http://en.wikipedia.org/wiki/Christopher_Pittman
http://www.christopherpittman.org/
Do us UK citizens look forward to a possible take- over of AstraZeneca by Pfizer.
GSK and Pfizer – that is something to get in a frenzy about……eh, Andrew?
Peter Hitchins, a fast learner journalist, got it in one.
I quote:
Can we please now have a simple rule for all coroners, magistrates and judges.
ONE SIMPLE QUESTION WILL TELL US ALL WE NEED TO KNOW ABOUT DRUGS.
THE POLICE, DOCTORS AND PATHOLOGISTS SHOULD BE REQUIRED TO DISCOVER WHETHER THAT PERSON HAS EVER BEEN A USER OF MIND-ALTERING DRUGS
It will become plain.
Then, at last, we can do something.,
Mail on Sunday May 4 2014
And, moving swiftly along…..oh, no, it’s Captcha…..sense of humour failure. 🙁
Surely, kids might want to read a bit about all this…………… :./
I bought a ltle bk of txt msgs to keep up..me, age 62.
MHOTY
got mine in Oxfam
Dear David
I think drug companies are successful at promoting tranquillizers as medicine because doctors support a medication and longterm mental illness approach, and people believe what doctors tell them. Psychotropic drugs damage people, but cancer drugs damage people as well. I think the problem is that there’s no acknowledgement of the success of non drug recovery, even though these methods can bring about complete recovery. Sucessful recovery is medically denied.
As far as exporting western psychiatric drugs to eastern countries goes, psychotropics are disabling and this is bound to feature. Am I right in saying that in India ‘Schizophrenia’ as a longterm illness exists mainly in the upper classes that can afford the western long term drug treatments and the longterm disability that results from their use.
This morning, I mentally composed a letter to Andrew.
Dear Andrew
I hope your children are brave; they will have to be when they see what is going to happen to you. I hope their private education is going well.
We went to visit the school to sign a form regarding home-education.
I was frantic, my daughter disappeared. One minute she was there. The next she was gone.
She was found sobbing in the labyrinth of tunnels underneath the school.
Despite my reluctance, she wanted to find every teacher in every classroom who had taught her. We trawled the school and she went in to every classroom, on her own, to thank the teachers and to say goodbye.
We drove home in silence.
Not home, but to a dilapidated building in a quaint fishing village, where she spent three years sleeping on a sofa, surrounded by books which I acquired for home-education.
She was so quiet it was disabling. My bubbly girl who was always singing, had stopped singing. She was so withdrawn.
She wasn’t bothered about leaving her designer bedroom, her friends, her life, her school. She sat in a kayak, which might as well have been the size of the Pacific she was so far away from me, for hours, and was so listless she had not the energy to paddle back to me.
At the point of the Standard Grade examinations, the bombshell letter from the school arrived. My application to have her sit her exams at the school was rejected.
A telephone call to the Education Department resulted in a visit and the examination request was back on track.
I had sat in the school with the Headmaster and quietly explained the story of Seroxat and an educational psychologist was brought in. They sat in hypnotised disbelief.
And, then sent me the letter. We were not welcome.
We were not welcome in schools, Andrew, we were not welcome in our village surgery and we had almost been turned into social pariahs.
She did well, but we were both fairly disgusted by now and at sixteen she left our new home, a caravan, and moved in next door, to the riding school.
She took equestrian examinations and became a Ride Leader.
She was so clever she was invited to be Yard Manager and go on for another four years to take the highest equestrian qualification.
But, too much had happened. She was a brilliantly observant child and she had seen too much. She wanted off. Not a small life with small doctors and small teachers and small thoughts.
At eighteen, she got herself a job on the internet and flew off to Ontario and slogged it out on a stud farm. A year later she got herself another job on the internet on a small ranch on Vancouver Island, owned by retired teachers, of a different breed, breeding puppies and ponies.
She came to visit me last month.
We still can’t speak about Seroxat and doctors and teachers. We can talk about just about everything else worth talking about.
Is this what you intended, Andrew?
Did you ever think your infamous drug would be capable of this?
And, her daddy, who was abandoned during the drug fiasco, is once more part of her life and these things have to be slowly orchestrated.
There is too much pain and regret.
I really hope, for you, it was worth it.
Sometimes, the story is so long, so convoluted, so immensely unfair, that I wish I was off, too.
But, I will wait a little longer to live out the final quarter of my life.
I am hopeful it will become the way it should have been before you entered my life.
My child has more spunk in her little finger than the skunk you repeatedly deny is sitting in a Seroxat tablet.
And, as my friend, my doctor, said, Annie is an attractive, articulate, intelligent woman, but……..
And, as the psychiatrist, said, Paroxetine comes with ‘abrupt discontinuation symptoms’ but……
He said it.
I keep thinking I will wake up one morning and listen to my family life.
Mum, where is my PE kit? Annie, where are my car keys, I am going to be late for the Air Ambulance?
But, it is all gone now. The miracle of happy families and babies struck out with a fatal blow from Seroxat.
BUT…..seems to be in everyone’s vocabulary…what have you done?
Sincerely,
Annie