Another major pharmaceutical company recently had a setback. On June 6, 2001, GlaxoSmithKline was ordered by a Wyoming jury to pay millions of dollars in compensation to the family of a man who killed his wife, daughter and daughter, as well as himself, when taking Paxil (called Seroxat in Britain). The jury attributed 80 percent of the blame for the manís behavior to the influence of the medication.
Eli Lilly was also in the news this year in connection with the decision by the Centre for Addiction and Mental Health at the University of Toronto not to hire the prominent researcher David Healy, who is currently at the University of Wales College of Medicine. Healy is author of The Antidepressant Era (Harvard University Press, 1998) and he has been an outspoken critic of Prozac and other antidepressants. He has claimed that Prozac has contributed to the suicides of between 40,000 to 200,000 people worldwide. In the Wyoming case against GlaxoSmithKline, he testified expressing his concerns about the effects of SSRI antidepressants. He said that studies showed that one in four people on Paxil became agitated, and some become so agitated as to become murderous or suicidal. He also has claimed that studies show that about half of people experience withdrawal effects when coming off Zoloft (Lustral in Britain), which suggests that, contrary to the claims of pharmaceutical companies, taking antidepressants may be habit forming and even addictive. Healy alleged in April 2001, because of his views about antidepressants, Eli Lilly exerted influence over the University of Toronto about the decision to not hire him. Lilly is a major contributor to the hospital, and gave money to fund the Eli Lilly Education Centre at their hospital. Eli Lilly and the University of Toronto deny Healyís allegations, but many of the faculty at the university are upset by the very suggestion of infringements on academic freedom.
These events are noteworthy on their own, but it is especially striking how little press coverage these stories get, or to be more accurate, how little these stories seem to affect the popular perception of these medications in the general public and even among health care professionals. The events are covered in national and local newspapers, and in short reports on the TV news; more alarmist writers such as Peter Breggin (author of Toxic Psychiatry, Talking Back to Prozac, Talking Back to Ritalin, and other books in a similar vein) get exposure on national TV. There are of course psychiatric patient survivors groups, and there is an interesting web site called ďThe Prozac Survivors Support Group.Ē Yet I have seen no suggestion that the rates of prescription of antidepressants are significantly declining. Glenmullenís book Prozac Backlash generated some controversy last year, but it was far from being a bestseller, and it is still outsold by Peter Kramerís decade old Listening to Prozac.
The lack of effect of these negative views on the public perception of antidepressants could have several explanations. One might ascribe it to the financial power of the multinational pharmaceutical companies. It certainly must make some difference that Prozac, Zoloft, Paxil and other antidepressants are marketed through costly campaigns on TV and in national magazines. These corporations also spend millions marketing their products to psychiatrists, providing education and not-so-subtle incentives for the prescription of their drugs. However, other mighty medications have fallen out of favor with the public: when the anti-anxiety drugs such as Valium got a reputation for being potentially addictive in the 1980s, they became prescribed far less. It is doubtful that Prozac and its cousins are invincible, and marketing can only help protect a product from a backlash to a certain extent. Indeed, sometimes too much marketing can make the public suspicious.
Another possible explanation for the lack of public alarm about antidepressants is that public opinion and psychiatric practice are rational and are so they are not to be swayed by misinformation and emotional rhetoric. While there may be very rare cases where psychotropic medication has unfortunate side effects, it is as safe as its manufacturers claim it is. Presumably this is what defenders of pharmaceutical corporations and mainstream psychiatry would claim. Although I am a skeptic (and even a cynic) by nature, itís a view to be taken seriously. The suggestions that antidepressants can be dangerous are highly controversial: these drugs are available in most countries around the world, and it would be quite a conspiracy that managed to hide the truth from every regulatory body overseeing medications in the western world.
Although both these
perspectives have some truth in them, they canít simply be combined to
give us the whole truth. There are many factors that go to create
public opinion; the media helps to form public opinion, but it also aims
to reflect what people think. I suspect that thereís also an element
of randomness concerning whether and when the media start to turn against
a phenomenon such as the ďwonderdrugĒ Prozac. However, if the court
cases in wrongful death suits continue to go against Prozac and its kin,
it is likely that the tide will turn sooner rather than later.
Strangely enough, it seems that most of the innovative philosophy web sites created on the Internet are done by just a few people. Of course, maintaining those sites takes a great deal of work, since a good web site is dynamic and constantly evolving. I can think of a number of examples of people running out of the time and energy to maintain their sites as much as they wish they could. The case that leaps to mind first is The Philosophy News Service, run by Richard Jones. His site maintained a daily update of philosophy related news, together with regular columns on the latest events in different areas of philosophy, including one on philosophy of psychiatry written by myself. But the most recent date his site was updated was April 22, 2000. Since then there has been no word as to what has happened to the site or whether it will return to normal functioning. If the editor of philosophy print journal were unable to work on it for a couple of months, its readers might never notice. But if a web site editor leaves his or her site unchanged for a few weeks, its regular visitors notice.
Another fine philosophy site is Thomas Ryan Stone's Episteme Links, one of the most exhaustive listings of philosophy sites on the net. This year Dr. Stone planned to expand the site with a number of topic areas, each with its own editor. This would mean that links for particular subject areas could be maintained by the editor without Stone having to do anything, and so it would save him time. I was to edit the page of philosophy of psychiatry links . But the project has been put on the shelf for the time being, because he has not had the time to develop the necessary software for the editors to do their work.
For a long time the AAPP has had its own web site, but it gets updated infrequently. I know that the AAPP would like to expand it, putting up this Bulletin on the web, creating message boards for AAPP members, and advertising all sorts of events relevant to philosophy of psychiatry. But nobody has the time to put it together.
I myself maintain the Philosophy of Psychiatry Bibliography, which lists books and book reviews relevant to the philosophical understanding of mental illness and its role in society. I started it in about 1997, and it grew to several thousand entries and many different sections, but I haven't had the time to update it significantly in the last year. Ideally I'd like to expand the bibliography to include not just books, but also journal articles. Unfortunately the chances of my finding the time to do that are extremely slim.
That's not to say I have abandoned work on creating Internet web sites. For instance, I run the Philosophy of Psychiatry Announcements e-mail list, on which any list member can post announcements which go to all the other list members, of which there are currently 110. I run it through a free e-mail list web service, eGroups. With every e-mail that goes out, a small advertisement appears along with the message. Blatant commercialism starts to enter into the academic space. But I know that using eGroups means I get a better service than I would if I used the Internet services provided by the college at which I teach. The commercial service provides more services, more reliably, more control, and they have greater user-friendliness than my college provides.
One of the main projects I run on the Internet is Metapsychology Online Review, which is part of Mental Health Net, a commercial information provider. Mental Health Net is sponsored by CMHC Systems, who describe themselves as, "the industry leader in providing management information systems for mental health, substance abuse, MR/DD, and children and family agencies in the United States." I edit and publish about twenty book reviews each month, aiming to create one of the only sites on the web which includes a substantial number of reviews relevant to philosophy of psychiatry. Of course, putting this together takes time. As any editor knows, it takes work to get the review copies, solicit the reviews, chase late reviewers, edit reviews and post them on the web site. Personally, I would probably not do it if there were not a financial incentive: all the books reviews are linked to the giant Internet store Amazon.com, and I get some revenue from the sales of books through those hyperlinks from Metapsychology. Of course, currently the site hardly breaks even, if one includes the expenses of sending out books, but I have hopes that Metapsychology will eventually become profitable. On the home page of Metapsychology is a banner advertisement, and when visitors click on it, CMHC Systems makes a little money. Being a commercial web site, ultimately if it is not profitable, CMHC would not continue to sponsor Mental Health Net.
Other institutions profit from web sites on philosophy of psychiatry. Most obviously, the Johns Hopkins University Press makes the journal Philosophy, Psychiatry and Psychology available on the Internet, but only to people who subscribe to Project Muse, which is a commercial enterprise run by the Press. Of course, even print journals, where most serious books get reviewed, while often subsidized, also carry advertising. Often those book reviews appear years after the publication of the books, and Internet web sites can publish reviews much faster -- for example, Metapsychology generally publishes reviews within a day or two of receiving them. Speed, low costs, and the lack of space restrictions are what make Internet publishing so attractive.
But it is not as yet clear who will do the work to create Internet services such as book reviews and information sites for many academic fields, including philosophy of psychiatry. Most academic and medical professionals currently don't have career incentives to devote energy to creating such web sites, because they need to devote their energy to more traditional forms of publication in order to get tenure or promotion.
At this stage in the development of the Internet, different kinds of web sites proliferate, but there's not a great deal of quality control, and it takes a good deal of experience to know which kinds of web sites to trust. One might think that sites designed to make money are untrustworthy, but in fact commercial web sites can produce high quality products, and non-commercial web sites are often not much good. Furthermore there's a large grey area between commercial and non-commercial sites with all the various forms of sponsoring and advertising. Philosophy of psychiatry is a field which can greatly benefit from greater public exposure, and in many ways the Internet could be an excellent medium to advance the discussion. But if the Internet is to be used to its full potential for our area of study, there is still a great deal of work to be done in finding ways to nurture the growth of useful and credible sources of information and discussion.
[Note added June 2001:
Richard Jones' site, the Philosophy News Service, has now completely disappeared.
Jones has not, to my knowledge, made any statements about the demise of
his excellent site. It is sorely missed.][
Western psychological discourse does of course evolve over time. New words, or new uses of old words, enter the language. For example, psychoanalysis has given us "anal" and "repression." Behaviorism has given us "positive reinforcement." I don't know when the noun "disrespect" was revived as a verb denoting not just a psychological attitude but a moral action, but it is a usage that is here to stay. These are perfectly normal developments of our language. Nevertheless, when it comes to reporting one's own feelings, I tend to think that "pain" is a more natural, less theory-laden term than "C-fibers firing." It is hard to me to imagine that people could become comfortable using the language of neuropsychology when talking with each other about how they feel.
It turns out, though, that the Decade of the Brain and the massive rise of psychopharmacology are already having their effect on the way people talk about themselves. People increasingly describe emotional disorders as chemical imbalances in their brains. I notice this with some students. For instance, in a class on suicide, in a course on death and dying, a man in his twenties explained that he suffered from depression, but that he didn't see his condition so much as a mental illness, but rather as a physical problem with his brain, caused by a combination of his experiences of a less-than-ideal childhood and his inherited predispositions. Another dramatic example came at the last AAPP conference, when one of the speakers reported that patients sometimes tell him that they feel that their neurotransmitters are out of balance. Does these signs suggest that we are headed towards a wholesale revolution in popular thinking about the mind, and that we can expect our ordinary language of emotional problems to fade away?
The National Alliance for the Mentally Ill is insistent on the idea that all mental illness is a disorder of the brain. For instance, on their web page "What is Mental Illness?" they claim, "Mental illnesses are not the result of personal weakness, lack of character, or poor upbringing." Of course, this statement, as a universal claim, doesn't stand careful scrutiny. It is motivated far more by the need to take the pressure and stigma of mental illness away rather than medical science or ethical reflection. Poor parenting can cause mental illness, and unless we medicalize the whole notion of personal weakness out of existence, it's clear that it is part of many mental illnesses. But I digress. What is striking is that NAMI is actually rather atypical in its definition of mental illness.
Looking around at other sources of information aimed at the general public, I'm pleasantly surprised to find that in fact there is less emphasis on mental illness as a chemical imbalance than I expected. For instance, there are many popular books and web sites devoted to depression and anxiety, but most of them emphasize how these conditions are often reactions to what has happened in one's life. They recommend a variety of different treatments, and they generally explain how different treatments work for different people. There's increasing emphasis on alternative herbal treatments and dietary supplements such as St. John's Wort, 5-HTP, and most recently, SAM-e. Several books, such as Potatoes, Not Prozac, suggest ways to boost one's serotonin level simply through altering one's diet. These alternatives are put forward by mainstream sources of information. For instance, Depression.com is a web site sponsored by Planet Rx and Bristol-Meyers Squibb, so as we might expect, it gives plenty of information about the standard antidepressant medications. However, it also gives information about thirteen other modes of treatment, including psychotherapy, music, ECT, and aromatherapy.
So it would be rash to suppose that ordinary thinking about psychopathology has become entirely focused on reductionist medical models. It is true that scientific models of mental disorder affect how we talk about ourselves, but it does not follow that people who use that language are committed to the theories that underlie their words. If I come home feeling bleak after another interminable faculty meeting, I might plead, "My serotonin level is crashing, I need some mashed potatoes!" without committing myself to eliminative materialism. The way we talk about emotional problems is influenced by popular trends and the desire to avoid the stigma of madness, but it does not follow that our underlying understanding of mental disorder has changed.
For instance, this year is the last in the "Decade of the Brain": George Bush proclaimed it so on July 17, 1990. Has public thinking about mental illness changed significantly in the last ten years, and if so, can George Bush take any credit for that? Or was Eli Lilly, the manufacturer of the antidepressant Prozac, more influential than Bush in this respect? If the public does now have a greater inclination to think of mental illness as a disorder of the brain than it previously did, how has this affected popular opinion about the responsibility of the mentally ill for their actions? Will drug addicts, now excluded from coverage under the Americans with Disabilities Act, eventually be included? On a tangentially related issue, do people really think that Bill Clinton is a "sex addict"? If so, does this mean they think he cannot control his sexual behavior? There are opinion polls for some of these issues of course, but I donít put a lot of faith in them: they seem to depend so much on the day of the week and how the questions are phrased.
What we can study is the representation of mental illness in the media. This tells us something, but we should be careful not to overestimate the credulity of the public, nor their readiness to listen to reason. Studying discussions of psychiatry on TV, in newspapers and magazines often tells us more about the way that journalists think rather than the ideas of the general public. It is sometimes informative to see which self-help books become best sellers, because they may reflect a mood of the public. Who would have predicted that Peter Kramerís Listening to Prozac would be on the bestseller lists for so many months? The Internet is also a forum for the discussion of philosophical issues in psychiatry, and some of the self-help pages give more clue about popular ways of thinking. Finally, thereís the feedback that students give teachers like myself in classes devoted to ethical and social issues in mental health.
This is all by way of introducing this new column to AAPP Newsletter readers. I will devote future columns to more specific analysis of public and political discussions of psychiatry and mental illness. Iíll be looking at all forms of media, (keeping a special eye on the Internet), as a way of trying to read the publicís mind. This will all be in the service of my main thesis for this column: public debates about mental health involve a myriad of philosophical and ethical issues, which regularly get ignored. My aim will be to show that philosophers of psychiatry have both the opportunity and responsibility to make those debates better informed and more sophisticated.
You can send your comments to my e-mail address at email@example.com