You know you've made it big if, say, an environmental organization or a human rights group is protesting outside of your corporate headquarters. As, for instance, ExxonMobil becomes increasingly synonymous with the word "evil," its business has become increasingly lucrative. If there's one thing the age of hyper-consumerism has taught us, it's that a company's success can often be measured inversely to its popularity. And the same might be said of an industry.
The multibillion-dollar pharmaceutical industry is so successful and so unpopular that, like the oil industry, it has earned the prefix "big." Along with its billions in profits and double-digit growth, "Big Pharma" has incurred civil suits and bad press. And with all this negative attention, it's easy to forget the millions of Americans who choose daily to consume Big Pharma's products.
Charles Barber's Comfortably Numb: How Psychiatry Is Medicating a Nation (Pantheon) seeks to do much more than demonize an already demonized industry. It is a complex analysis of the current state of psychiatry that combines Barber's experience with the homeless mentally ill with research and interviews with medical professionals and patients. Comfortably Numb points as much toward the American mind as the industry that has so successfully exploited it.
So, who is "Big Pharma" and why should we, you know, hate them?
You know, quite frankly I am less interested in beating up Big Pharma than I am in alternative ways of looking at things. Clearly, Big Pharma has sort of created this very simple, almost cartoon- ish message about the relationship between serotonin and depression.... The drug companies have perpetuated [the idea] that there is this simple relationship and you just take antidepressants and you're much better. And part of my message is that mental illness is incredibly complicated. What I want to do is expose people to other treatment choices and also to a different way of thinking about illness.
I'm definitely not talking about major, clinical depression -- which is a serious, malevolent illness -- but milder depression, you know, or the blues: instead of thinking of what's wrong with you, maybe thinking that there's something right with you, and maybe [sadness] is just part of life.
There's been sort of a confusion in the culture between major psychiatric illness like bipolar, schizophrenia, major depression, major personality disorders, which are all biological, horrific conditions, [and], you know, "life problems," and certainly Big Pharma has exploited that gray area. Having worked with people with severe mental illness for a long time, when you see someone with major clinical depression, it has nothing to do with, you know, "It's February, I don't have enough money, it's raining, I'm depressed." [With major depression] people are at risk for hurting themselves; they feel no pleasure whatsoever; the severity of the depression can be such that their risk for suicide is not typically the worst part of the depression, but actually when people start feeling a little bit better
[and] when [they] actually can muster the energy to kill themselves.
[With regard to] the TV advertising of the drugs: there's not a very big market of people with severe and persistent mental illness. According to the National Institute of Mental Health it's 2.6 percent. So, what you've seen with the drugs, and not just psychiatric drugs, but drugs in general, in order to expand the market base, there's been a kind of move to lifestyle drugs: Viagra, Cialis, and arguably Lipitor and things like that. So like 20 percent of people think they have issues in that area as opposed to the 1 percent of people. Certainly Big Pharma has gone along with that blurriness of distinction.
So you could argue that Big Pharma is exploiting a uniquely American market.
Two-thirds of the global market for antidepressants is accounted for by the U.S., and this is largely a very American phenomenon. A lot of the drugs were invented here, a lot of the big companies are American, the U.S. is the only country in the world other than New Zealand that allows TV advertising for drugs. You can find individual countries in Europe with high rates of antidepressant use, but it's largely an American thing that has been exported to Europe and Japan.
It's a very American notion that right around the corner is "The Answer." I think it's been a mixture of cultural things and the marketing of the drugs, but people really think there's a panacea, a quick fix. The critical thing is that there is no panacea.
The things that I offer up as alternatives are worthy, and there's a good research base for a lot of them, but part of the problem is [the notion that] there's something that's going to cure, you know, everything. With major psychiatric illnesses, there are no cures. They're chronic, and it's just not appropriate to talk about cures. It's more a matter of lowering the volume on the symptoms. There are true remissions of symptoms, but [these cases are] in the minority. In my experience, these are chronic illnesses... And actually if you look at medicine in general, cures are pretty rare: Diabetes, HIV, cancer. A lot of these are chronic illnesses, and that's the way medicine is.
It's interesting that we're seeking this "cure," because Americans haven't always embraced the mental health "model." Could you talk about that?
There's both a good and a bad part to this sort of biological understanding of mental illness. One of the good parts of it is that stigma has decreased. I argue that there's overuse of the drugs by people who don't really need them, but people who actually have severe conditions have gotten treated. To some degree, the stigma of mental illness has been reduced.
There's sort of a superficiality to that, though: it's sort of OK if you have lots of money or if you're a celebrity to say you're depressed, or it's okay to be casually dropping that you take antidepressants.... It doesn't translate to the severe mental illnesses, though, like schizophrenia. It's not too chic to say that you're hearing voices, but at cocktail parties it's okay to say you're depressed and taking Lexipro. So Britney Spears -- who has bipolar disorder or post-partum or some combination of the two -- is no longer chic. She used to be sort of okay, now she's sort of in trouble....
One of the points in my book is that for the homeless mentally ill, the rates of treatment and retention are still, depending on which study you look at, around 50 percent. [In Comfortably Numb] I quote a medical historian who says that the likelihood of your treatment goes up as the severity of your condition goes down. So, the homeless mentally ill, people with schizophrenia, you know, half of them are on the streets.... If you have sort of moderate depression and if you're middle-class or upper-middle-class, it's highly likely you're in some kind of treatment.
You know, there are the "worried well": they are easier to treat, they show up more, they're not likely to be having voices telling them to hurt themselves, and they pay cash. If [people with severe mental illness] are in any reimbursable system, it's in the public system, and that doesn't pay very well. It's a hell of a lot easier for mental health professionals to treat these "worried well." It used to be that psychiatry dealt with the severe cases. It seems to me that medicine should concentrate on the most severe cases, should sort of triage. If you're a cardiologist, you deal with severe heart disease, you don't necessarily move toward mild heart issues...
What was your sense of how well the field of neuroscience actually understands the brain?
We don't have any clue. We're starting to figure out a few things, but the understanding of the brain is where the understanding of the heart was a hundred years ago, and anybody who tells you we really know how things work is delusional.
The first drugs of the early '50s and '60s acted on four chemicals that were thought to have some relevance to thought and mood regulation. All the other drugs that have followed since are basically copycats of these four. But there are potentially 100 other neurotransmitters out there. They could potentially have just as profound an impact on brain function... but we just haven't gotten there.
The science is going to be amazing. But right now [psychopharmacology] is incredibly crude... A brain scan is a "picture" of your brain, but most neuroscientists will tell you that these are very blurry pictures and we have some idea but we're not sure of what's really going on... [Brain scans] are actually sending secondary images of blood flow, it's not like they're x-rays of the brain. The attributions that are made to those things are very uber-popular right now, so I was just struck by how crude our understanding really is.
If you're severely schizophrenic, what's going to work?
So, then, say someone is very, very shy. Why shouldn't they just take a pill?
Social anxiety disorder was one of the newer diagnoses in the expansion of the DSM [Diagnostic and Statistical
Manual of Mental Disorders], and I think it's like any diagnosis: there are absolutely people that have a pathological
shyness or social anxiety. In a severe case, medications -- I don't know the research but I would imagine -- could be very effective.
You know, there are the "worried well": they are easier to treat, they show up more, they're not likely to be having voices telling them to hurt themselves, and they pay cash... It's a hell of a lot easier for mental health professionals to treat these "worried well." It used to be that psychiatry dealt with the severe cases.
What happens, though, is that there is something called "shyness" that isn't a medical condition. And so it's like depression: there are severe cases in which a medical model works, but then you get farther and farther away from that. Rather than looking at how I might overcome this, or should I take a public speaking class or whatever, the first choice would be to go to medication.
I would argue that unless it's a really pathological condition you go to other things first, and then if those things aren't working then you can go to medication.