Editorial Note: This is part 2 of a 3 part lecture given on February 22 that began with Tweeting while Psychiatry Burns. The text and slides continue from last week. The slides for this part are Here. The numbering continues from last week.
When his office was ransacked, Delay’s world was turned upside down but psychiatry and doctors are still here – so we won, didn’t we?
We didn’t win. Both psychiatry and anti-psychiatry were swept away and replaced by a new corporate psychiatry. In 1967, the year before Delay was upended, JK Galbraith argued we no longer have free markets with companies making products we need. Instead corporations now shape our needs to meet their products (Slide 12). It works for cars, oil, and everything else, why would it not work for medicine? Prescription only status makes medicine easier than any other market – a comparatively few hearts and minds need to be won.
Within psychiatry, two factors played a part. One was the emergence of Big Science. This graph from 1974 (Slide 13) shows the correlation between affinity for D-2 receptors and the clinical potency of antipsychotics. It was one of the most famous images in modern psychiatry until replaced by fMRI scan images.
The image remains as accurate today as when it was first published. But these binding data introduce something else as well, for which neither Seeman nor Snyder, nor others who developed radiolabeled techniques can be held responsible. They introduced a new language, a language of Big Science. Where previously psychiatrists and antipsychiatrists and patients were using the same language, this no longer applied after 1974. After 1974, to get into the debate you had to have a manifold filter and a scintillation counter.
This as it turned out was not a science that worked in the interests of patients. No longer answerable it seems to how the patients in front of us actually looked, following the science, we moved on to megadose regimes of antipsychotics that may have harmed as many brains as were ever injured with psychosurgery. Science won’t necessarily save us, it must be applied with wisdom. We have moved into an era when we depend on our experts in a new way – we depend on them to be genuine. Conflict of interest began to play as an issue.
Another factor stems from figures like Rene Descartes (Slide 14), Blaise Pascal and others, who were behind the development of statistics and probability theory. This laid the basis for the Enlightenment.
Statistics initially referred to government statistics – a process of mapping peoples rather than just the land. This led on to the notion of the rule of the people by the people, the creation of social science and epidemiology, along with public health and insurance.
The same forces led around 1900 to the first attempts to map the human individual, their attitudes and abilities, personality, or intelligence. Sales such as the IQ scale led to new concepts of norms and deviations from those norms and psychologists emerged to take a place in the educational system, the legal system, and in the government of ourselves – it was this that underpinned the psychodynamic revolution (Slide 15).
This was not just the replacement of theology and philosophy – the qualitative sciences – by a new set of quantitative sciences. The new sciences set up something else. They set up a market in futures. A market in risks. We were on our way to becoming a Risk Society (Slide 16). In the case of the IQ test for instance, deviations from the norm were now something that predicted problems in the future. Parents sought out psychologists in order to improve the futures for their children. This was how we would govern ourselves in the future. Through the marketplace.
Drugs entered this new market in many different ways. The oral contraceptives for instance are clearly not for the treatment of disease. They were a means of managing risks. Where once, the risks of eternal damnation had been those that concerned people, now it was a much more immediate set of risks – we switched one set of future risks for another (Slide 17).
The best selling drugs in modern medicine don’t treat disease. They manage risks. This holds for the antihypertensives, the statins to lower lipids and other drugs (Slide 18). It holds for antidepressants, which have been sold on the back of efforts to reduce risks of suicide (Slide 19).
All the Evidence that’s Fit to Print
The development of probability theory also gave rise to clinical trials. We are now in an “Evidence Based Medicine” era. What can go wrong if we have clinical trial evidence to demonstrate what works and what doesn’t (Slide 20)?
But clinical trials in psychiatry have never shown that anything worked. Penicillin eradicated a major psychiatric disease without any clinical trial to show that it worked. Chlorpromazine and the antidepressants were all discovered without clinical trials. You don’t need a trial to show something works. Haloperidol and other agents worked for delirium and no one ever thought to do a clinical trial to support this. Anesthetics work without trials to show the point. Analgesics work and clinical trials aren’t needed to show this. Clinical trials nearly got in the way of us getting fluoxetine and sertraline.
Trials demonstrate treatment effects. In some cases, these effects are minimal. The majority of trials for sertraline and for fluoxetine failed to detect any treatment effect. In clinical practice many of us are under no doubt that these drugs do work. But if our drugs really worked, we shouldn’t have 3 times the number of patients detained now compared with before, 15 times the number of admissions and lengthier service bed stays for mood and other disorders that we have now. This isn’t what happened in the case of a treatment that works, such as penicillin for GPI.
Aside from this, professors of psychiatry have been jailed for inventing patients, much of the scientific literature is now ghost written, many trials are not reported if the results don’t suit the companies sponsoring the study, while other trials are multiply reported making it difficult to work out how many trials there have been. Within the studies that are reported, data such as quality of life scales on antidepressants have been almost uniformly suppressed. More generally there is no access to the data. To call this science is misleading.
But these are not the most important consequences for medicine of clinical trials. The critical development is contained in the following quote from Max Hamilton in 1972 about his rating scale:
“it may be that we are witnessing a change as revolutionary as was the introduction of standardization and mass production in manufacture. Both have their positive and negative sides” (Slide 21).
Anyone who has used the Hamilton Rating Scale for Depression will wonder what is this man talking about when he talks about a revolutionary aspect to using a checklist like this. Maybe as a communist, he was sensitive to things that we are not sensitive to now.
Rating Scales have been such feature of psychiatric trials so long now that it is perhaps difficult to see that there are revolutionary aspects to what happened. We use these checklists in all walks of life from sexual behavior, to children’s behavior. Where once there was life’s rich variety, now our children fall outside all sorts of norms when checked against these lists. And when they do parents desperately want to bring their children back inside appropriate norms. We bring them to psychologists and to doctors.
The figures on treatment effects from rating scales used in our clinical trials have set up a new market. When you consider that as far back as 2000 we were treating children from the ages of 1 to 4 with “Prozac” and “Ritalin”, you realize that we are not treating diseases here (Slide 22). Pharma makes markets but until recently they have not sold psychotropic drugs to children. The explosion of drug use in children is a manifestation of the force that fills the sails of pharma marketing. It comes from us. What parent could not want to minimize future risks for their child?
Anorexia offers an analogy for what is involved (Slide 23). Clearly people have starved themselves for millennia for all kinds of reasons. But Anorexia nervosa emerged in 1873 a few years after the first weighing scales. Eating disorders increased in frequency in the 1920s when weighing scales migrated into drug stores complete with a plate featuring norms for ideal weight. In the 1960s, the frequency increased yet again with new variants mushrooming – as we all bought portable scales for our bathrooms.
Competing theories have focused on the possible psychodynamics of the problem, the biology of the problem, or socio-political aspects of the problems. None of these recognize the role of scales and norms for weight and deviations from the norm and an awareness that deviations in the direction of what had formerly been thought to be healthy and beautiful carried risks.
This problem applies to any situation in which we have a datastream frm one area of our life but not others. It applies to figures for GDP which run the risk of seriously distorting society in general. The problems seem likely to get worse with the proliferation of Health Apps.
But there is another consequence for medicine itself. Figures like scores on a Hamilton Scale set up algorithms – If X, then do Y. The figures drive the prescription of drugs. But the use of checklists like this looks scientific to managers who run health systems. They want staff to stick to checklist questions in clinical encounters rather than have doctors or nurses talk to patients. Its scientific after all in a way that conversations are not. And doing things this way means doctors can be replaced by nurses and pharmacists and everyone in the near future will be replaceable by robots.
Harold Shipman (Slide 24) was one of the greatest serial killers ever. He killed over 200 people with opioids. Shipman’s case illustrates that situations where trust is important can provide the conditions for extraordinary abuses.
One of the conditions where trust applies is in prescription only arrangements. This arrangement was introduced to restrict bad drugs but now applies exclusively to the good drugs. Since 1951, the idea is physicians would quarry information out of pharmaceutical companies on behalf of their patients and would provide the counter-balancing wisdom to market forces.
Since 1951, pharmaceutical companies have grown to be the most profitable on the planet. There has been a change from companies run by physicians and chemists to companies run by business managers who rotate in from Big Oil or Big Tobacco, advised by the same lawyers who advise Big Oil and Big Tobacco.
In the case of tobacco industry, it now seems clear the advice was not to research the hazards of smoking, as to do so would increase the legal liabilities of the corporations involved (Slide 25). Similar advice given to the managers of our pharmaceutical corporations would be completely incompatible with prescription-only arrangements. Advice like this converts prescription-only arrangements into a vehicle to deliver adverse medical consequences with legal impunity.
Prescription only opioids are now linked to 30,000 deaths per year in the USA. This happens because clinical trials have been cleverly built into guidelines to mandate the use of opioids for minor pains where wisdom would say this was a bad idea. These trap doctors because their managers will now sack them if they don’t keep to guidelines. We have institutionalized Shipman.
I happen to believe that Prozac and other SSRIs can lead to suicide. These drugs may have been responsible for 1 death for every day that “Prozac” has been on the market in North America. Many of you will probably not agree with me on this – but you haven’t seen the information that I have seen. However we can all agree that there has been a controversy and since the controversy blew up, there has not been a single trial carried out to answer the questions of whether “Prozac” does cause suicide or not. Designed yes, carried out – no.
With the mapping of the human genome, we have the possibilities of creating new markets (Slide 26). We need this data and the data from clinical trials to govern ourselves. The genetic data will tell us about some of the underpinnings to our beliefs – why we believe some of the things we do in the religious and political domains. But the products of this research along with trial data will belong almost exclusively to pharmaceutical corporations, and at present this democratically important data is being deployed against the interests of democracy.
It is also increasingly been managed through organizations like Sense about Science who run Science Media Centers to ensure we are all fed the interpretation of the latest science that best suits corporate interests.
In Slide 27 you see another image of the future. In the course of the last 70 years, plastic surgery evolved into cosmetic surgery. Plastic surgery began as a set of reconstruction procedures aimed at restoring a person to their place in the social order. It evolved into cosmetic surgery when the reliability with which certain procedures could be carried out passed a certain quality threshold.
The word “quality” is pervasive in healthcare today. Quality in modern healthcare however does not refer to genunine interactions between two people as it did in the 1960s. Quality nowadays is used in an industrial sense to refer to the reproducibility of certain outcomes. Big Mac hamburgers are quality hamburgers in this sense — they are the same every time.
Viagra gives good indication of what will happen when we get to this stage. Viagra is a drug that produces quality outcomes – reproducible outcomes. When this happens, it becomes possible to abandon the disease concept. Pharma talks openly instead about lifestyle agents. This is the world that lies in store for us. It is not the world of traditional medicine, where drugs treat diseases to restore the social order. It is a world in which medical interventions will potentially change that order.
But cosmetic also suggests fake – that behind the appearances things might be rotting. The boxes that proliferate in healthcare today are being ticked ever more faithfully but behind the appearances our services are disintegrating.
1952 – 2000
This returns us to the picture of Delay and his colleagues (Slide 28). If some relatively minor person from the UK or US – a white man visited Delay with a research proposal – Pichot and Deniker would be summoned and might be left standing behind Delay for an hour while he discussed matters with the visitor – Pichot on the right and Deniker on the left.
This was not an experience that Deniker or Pichot experienced as some exquisite form of torture or as a humiliation. It was a different time. Honor and loyalty counted for more then than the search for individual authenticity we now have. The hierarchy and the collective was something these men believed in.
What this shows is that there are forces at play that can change not only the kinds of drugs we give, not only the conditions we think we are treating, but our very selves who are doing the giving. These forces can change us just as profoundly as we can be changed by a handful of LSD containing dust.
to be continued..