To reduce the rising burden of mental disorders around the world, the Lancet Commission on Global Mental Health and Sustainable Development has declared a need to increase psychiatric services globally, which should include an effort to “reduce the cost and improve the supply of effective psychotropic drugs for mental, neurological, and substance use disorders.”

While reducing the burden of mental disorders is certainly a laudable goal, we believe that implementing this plan will increase the global burden of mental disorders rather than decrease it.

Following the American Psychiatric Association’s publication of the third edition of its “Diagnostic and Statistical Manual” (DSM III) in 1980, there has been a remarkable expansion of the psychiatric enterprise in the United States and other developed countries. That expansion, which included dramatically increasing the use of psychiatric drugs, offers a lesson from the past that helps predict the effect of a planned “global” expansion of psychiatric services.

advertisement

After DSM III was published, the main models of depression and other major mental disorders held that they were brain illnesses caused by chemical imbalances, and that psychiatric drugs could help fix these imbalances. The antidepressant Prozac, the first serotonin-specific reuptake inhibitor (SSRI), hit the market in 1988. It was touted as a wonder drug, and our society’s use of antidepressants and other psychiatric drugs soared. Today in the United States, more than one in five adults — and more than one in 20 children and adolescents — take a psychiatric drug on a daily basis.

Yet even as more and more people have been getting medical treatment for psychiatric disorders, the number of adults on government disability due to these disorders has more than tripled since 1987. The number of children so disabled by psychiatric disorders has increased more than 30-fold during this period.

The same correlation is seen in country after country that has adopted widespread use of psychiatric drugs and, in particular, the regular use of antidepressants. These countries have all seen sharp increases in disability due to mental disorders.

While this rise in disability may be due to many factors, there are two ways that increased use of antidepressants can contribute to it. Although antidepressants may provide a small benefit over placebo over the short term, there have now been a number of studies concluding that these drugs increase the risk that a person will become chronically depressed over the long term. Researchers have dubbed this drug-induced worsening “tardive dysphoria,” meaning that SSRIs are causing a biological change that often leads to persistent dysphoria, a state of profound unease or dissatisfaction.

In addition, one of the risks of taking an antidepressant is that it can trigger a manic reaction. When this occurs, the individual may be diagnosed with bipolar disorder, which is seen as a more serious illness than depression. A large study done by Yale investigators found that taking an SSRI antidepressant more than doubles the risk that a depressed person will convert to bipolar disorder.

Much of the Lancet report focuses on expanding psychiatric services in less-developed countries, where the “treatment gap” — the gap between the number of people suffering from a disorder and the number getting treatment for it — is greater than it is in developed countries. However, for the past 20 years, there has there has been an ongoing effort to “globalize” mental health care, which has led to the increased use of psychiatric drugs in these countries. We have already seen the impact of that expansion. As the Lancet report acknowledged, the burden of mental illness has been rising in “all countries.”

In short, there has been an expansion of psychiatric services globally over the past 35 years, which has led to a dramatic increase in the use of antidepressants and other psychiatric drugs. At a public health level, that approach has not worked. The Lancet report, in fact, acknowledges this failure. “A recent analysis of data from 1990 to 2015 from four high-resourced countries (Australia, Canada, England, and the U.S.) show that the observed prevalence of mood and anxiety disorders and symptoms has not decreased, despite substantial increases in the provision of treatment, particularly antidepressants, and no increase in risk factors.”

The changing outcome for schizophrenia in developing countries provides another example of the perils of exporting Western ideas about psychiatric diagnosis and treatments to other parts of the globe. In the decades before 1990, the World Health Organization conducted two studies that compared outcomes for people with schizophrenia in three developing countries (India, Nigeria, and Colombia) with outcomes in the United States and five other developed countries. In each study, the WHO found that outcomes in the developing countries were better — so much so that the investigators concluded that living in a developed country was a strong predictor that a person diagnosed with schizophrenia would not have a good outcome.

One of the big differences between developing and developed countries was that patients in the developing countries used antipsychotic medications only for short periods, while those in developed countries used them long term. Only 16 percent of patients in the developing countries took antipsychotics long term.

About 20 years ago, however, pharmaceutical companies began marketing atypical antipsychotics around the world. The results of that effort are now becoming clear. In a recent study funded by Eli Lilly, in which patients with schizophrenia in 37 countries were maintained on antipsychotics for three years, the better outcomes in the developing countries disappeared. They were now as poor as in the developed countries.

Any call for improving global mental health needs to recognize two facts: First, there are commercial forces at work in this enterprise, which urge more access to psychiatric drugs. Second, as the globalization of mental health has unfolded over the past several decades, the burden of mental disorders has increased in tandem. Without such recognition, proposals for closing the global treatment gap risks further exporting a failed paradigm of care.

The fatal flaws in the report could have been avoided if it had been created by a more diverse group that included international leaders with lived experience, including people from Asia, South America, and Africa. It should have included academics and researchers who have critically examined the scientific evidence regarding the merits and long-term effects of psychiatric drugs. And it should have included leaders of international recovery movements, such as the Hearing Voices Network, in order to incorporate their thoughts on what has been most helpful.

While the Lancet report is to be commended for acknowledging the importance of social and economic factors on mental health, the fact that it doesn’t investigate the public health failure of the past 30 years, which has unfolded even as the global market for the use of psychiatric drugs has expanded, puts it into the category of a potentially harmful document. It promotes more psychiatric treatment on a global scale without making the case that this will lower the burden of mental disorders worldwide. Indeed, it is easy to make the case, as we have sought to quickly do here, that “closing the treatment gap,” when treatment includes increased use of psychiatric drugs, will likely make things worse.

Robert Nikkel is director of Mad in America Continuing Education and a former state mental health commissioner. Robert Whitaker is a journalist, author of three books about the history of psychiatry, and publisher of the Mad in America webzine.

Leave a Comment

Please enter your name.
Please enter a comment.

  • Even though I was a physician I had a 50 year career as a psychotherapist because I found great success in psychiatry by talking to patients, getting to know them, and helping them to see the connection between past trauma and present symptoms. This approach virtually obviated the need to use psychiatric drugs. With my psychoanalytic training I found that it was possible to do the same with psychotic patients: there we found that the trauma began in infancy, before the left brain developed its linguistic ability.
    It is wonderful to find authors such as Robert Whitaker, Eliott Valenstein, and Peter Breggin helping to publicize the negative effects of these drugs and the flawed science that has been used to sell them.

  • It is notoriously difficult to establish causation at the epidemiological level, viz. “antidepressants cause long-term psychiatric harm”. What the cited studies have demonstrated is a correlation, in some cases, between antidepressant usage and poorer long-term outcomes. The authors of one of the studies admit that confounding variables are not thoroughly controlled and that further studies are required. Their clinical recommendation is measured and cautious:

    “Until mechanisms of benefits and harms are better understood, these findings argue for using antidepressant medication only if short-term benefits (e.g., reducing active suicide risk) are likely to outweigh delayed consequences.”

    To really test the hypothesis that anti-depressant usage causes long-term harm, post-hoc epidemiological studies are insufficient. Until there is more direct evidence, statements such as “SSRIs are causing a biological change that often leads to persistent dysphoria, a state of profound unease or dissatisfaction” are premature and irresponsible.

    • We have over 50 years of data, proving that there are increasing rates of suicide, and so called mental illness. Pharma made sure that this data would not be collected and the adverse events would be attributed elsewhere.

      https://www.statnews.com/2018/09/17/thousands-of-foster-children-may-be-getting-psychiatric-drugs-without-safeguards-watchdog-agency-says/

      There are plenty of dead or incarcerated young people to prove causality. The pharma industry only funds research that helps them sell their products.

    • And yet the scientific method assumes the “null hypothesis” until proven otherwise. Since there is no scientific data proving that antidepressants DO result in long-term improvements over time (and when I say none, I mean essentially ZERO), it is proper to assume that they do not. So the recommendation for short-term use only as a second-line intervention is very appropriate. And there is enough data suggesting long-term harm that the dictum “first do no harm” suggests even more caution. Claims that “antidepressants save lives” are just as premature and irresponsible as claiming that SSRIs cause persistent dysphoria, and probably even more irresponsible given the potential damage that could be caused and the lack of proof of long-term efficacy.

    • @Mavis Johnson
      Concurrently increasing rates of X and Y doesn’t prove that Y caused X. So no, there isn’t enough evidence to prove antidepressants directly cause increased mental illness down the line.

      @Stephen T. McCrea
      You are right that the flip side of the coin is just as valid. In my understanding too, there is inconsistent evidence supporting the claim of long-term benefits. This kind of science is maddeningly difficult to do. Not only are epidemiological studies of any kind difficult, but there is also the fact that neurological factors involved in behavioral disorders and their treatment are very poorly understood. Then there’s the enormous spectre of the placebo effect which plagues all psychiatric studies…… so yeah, caution and intellectual humility are a must if we’re going to come to reliable conclusions.

  • I was on 1 mg of risperidone for 25 years until I was 73. I’ll be 74 soon and have all sorts of medical problems, some Serious. Current situation’s forced me to go on 40 mg of citalopram recently and I am scared to death.

  • The “Anti Med” moniker comes straight from Pharma Propaganda. In many cases Trolls paid by Pharma Interests monitor these sites, in order to sway public opinion and mislead us. The comment sections on sites like this along with the opinion sections of our newspapers are fertile ground for this Psi Ops campaign. Years ago we believed the Internet would have brought sensible, fact based discussion, and the sharing of information. Instead the opposite has happened.
    Most of the research on these topics is Pharma Funded, and even the advocacy groups are in the pocket of the industry. Pharma has been influencing academia for over 2 decades, so we have no exception of any objectivity there either. It can be quite informative to look at any piece of research, and then track the funding.
    Pharma has paid off our policy makers, bribed politicians, and undermines objective science, because it is profitable. At the same time mass media will not cover the adverse events, and physicians are not even allowed to write them down. They were told by Pharma groups that could lead to liability.

    It is a Fact that certain people with certain serious disorders do better on Medication. Pharma used this fact to expand their market. Through devious ad campaigns for off label drugs, to dumping “Samples’ on low income clinics, they expanded their market. As we speak they are using nefarious advertising schemes infiltrating patient groups online, targeting vulnerable desperate people. This country used to have Laws regarding deceptive marketing, but the Pharma industry did away with them.
    Pharma lobbied state legislatures to allow any Tom, Dick or Harriet, to prescribe psychiatric medications, even to children in foster care, and at our Border. The APA has been silent, just as they re wrote the DSMV to improve prescribing opportunities for Pharma.

    Our media in the service of Pharma turned horrors like Mass Shootings into advertisements for Pharma. There are two distinct versions of “Mental Health” the one they show on TV, where a person sees a professional and talks about it, and the one where even children are forced into a medicated stupor. The children just have to be distressed, from abuse or poverty, they don’t even need a diagnosis, thanks to pharma. Typically they are surrounded by large muscular security guards with a high school education, and forcefully injected with drugs that terrify them into submission. Nothing has changed in 50 years, except that more and more children need medication. No research was done on the the long term effects of the increased suicides. Pharma even got the prescribing physicians to claim any question of these tactics was “Anti Med.” A famous Nazi once said, “If it is repeated enough times, it becomes fact.”

  • Thought of sharing the following new study published in JAMA psychiatry:

    Nicol, G. E., et al. (2018). Metabolic effects of antipsychotics on adiposity and insulin sensitivity in youths: a randomized clinical trial. JAMA psychiatry.

  • An anti med article like this is very dangerous to those of us with severe mental illness. It can encourage people to go off their meds which can lead to suicide or violence. The article didn’t offer solutions either. And why are the studies so old? Medication has improved a great deal since the studies were done. I tried suicide several times before I discovered the miracle of meds.

    • I am tired of folks like you calling articles like this “anti-med.” It is not. It is pro-truth, sharing actual facts that are not disclosed or actively hidden by doctors and the pharmaceutical industry.

      Reporting on the facts does not need to be interpreted as an invalidation of your individual experience. The article fully acknowledges that many people find these drugs helpful and does not argue against their use. It argues that people should be told the truth about the drugs they are taking. Are you arguing that doctors should lie to their patients about the risks and benefits of a drug because they’re worried the patient might not take the drug? Don’t you believe that patients have the right to make their own decisions about what works for them?

      I really hope you can take the perspective that your own experience is not automatically the experience of others. There are many people who describe positive results or even having their lives saved from taking psychiatric drugs. There are many others who report highly destructive experiences and even having their lives destroyed by the very same drugs. They don’t automatically make everyone else better, and every person has to make their own decision about what works for them, and we all deserve all the information available so we can make the most informed decisions possible. It’s not a “pro-drug” vs. “anti-drug” issue. It’s an issue of self-determination and informed decision making.

  • Fascists don’t use Antibiotics for torture and thought control, or to make traumatized children easier to handle, like they do in American Foster Homes, and at our Border.

  • KU:

    My eighteen year old daughter, and avid bicyclist, skiier, mountain climber, and ballroom dancer, NEVER had diabetes or obesity before being involuntarily treated for years and years with multiple antipsychotics. Despite no family history of diabetes she definitely is pre-diabetic at the age of 28, she has gall bladder problems, chronic GERDS, recurring boils and other infections, sleeping problems, obesity, fibromyalgia, I could go on and on. She is sendentary, sleeps 16-18 hours a day, etc. etc. Her health risks have ballooned since being put on meds and you say that many BUT we also know that people with schizophrenia have metabolic changes even before they take any meds. people with mental illness are way more likely to engage in behavior such as tobacco use, shitty diet and no exercise, and alcohol use. these are the top 3 preventable causes of death in the US. If you weren’t so indoctrinated you may even get out and actually speak to psychiatric survivors who will tell you the number one reason they smoke tobacco is to counter the sedative effects of the meds which ruin your life and make it impossible to do any activities of daily living, let alone go back to school, hold down a job. And we are only talking physical side effects like sedation and obesity. Don’t get me going on the cognitive impairment caused by the meds. You are one ignorant person. I hope to God you aren’t a medical provider. Because if you are, I can only pray for your patients/clients

    • That is a common story which the pharmaceutical industry effectively censored. Physicians are reluctant or resistant to acknowledging these adverse events. They have been brainwashed by years of pharma propaganda that states that these medications are better than death, and that acknowledging the adverse events could lead to liability. In Post Fact America, these drugs were approved for serious mental disorders, but clever marketers along with the APA, expanded those definitions. Now they are regularly used on Children, traumatized Veterans, and anyone experiencing distress. The Profit Driven system is marketing these dangerous drugs for nearly everything. They even got journalists to repeat their marketing propaganda after every tragedy. When they say “Mental Health” what they really mean is drugging people with these drugs. The Pharma Industry did not long term studies, because they could cut in profitability.

      Some of the people who survive this ‘treatment” have lost all of their teeth, are unable to talk correctly and have Tardive Disconesia. Our media re-framed all of this, blaming “Drugs’ and even poke fun at the victims. They made it appear that these Side Effects were due to illegal drugs, not Psychopharmacology. A large number of people who are on the streets and homeless, have all been “treated” this way.

  • kdn – I did not comment about psychotherapy and do not see how that is related. I believe that all psychosocial interventions including therapy can change the brain and improve psychiatric illness and patients’ lives.

    We do not fully understand most psychiatric conditions and do not have good ways to study medication effects. We make diagnoses based on clusters of symptoms rather than on objective findings. For all we know 10 depressed patients can have 10 different illnesses that present in the same way. It’s like saying that a person with a fever, weakness, and lightheartedness must have pneumonia and should be on antibiotic X. That person may actually have a different infection, although antibiotic X may still work. This makes it extremely difficult to research psychiatric illness and treatment. We do the best with what we have right now.

    • Thank you for your reply. However, we need to understand that the use of psychiatric drugs cannot be compared AT ALL to the use of antibiotics. In the case of antibiotics, we understand completely their ‘mechanisms of action.’ This is not at all the case for psychiatric drugs. When considering that the brain is very complex organ with billions of neurons and trillions of synapses (that connect and interact in complex ways) it is naïve to think that some drug would somehow take care of various mental issues that people have (in any case the ‘mental issues’ that people have are always connected to psychosocial factors, except in extremely rare cases where genetics are involved). Additionally, as we know, these drugs appear to simply result in ’emotional blunting’ with nasty long-term effects.

    • I don’t think we’re doing the best we can. The research is biased by the desire for power and money. We’re not doing honest science, or else all of these issues would already be well publicized and we’d be doing a lot less genetic research and a lot more research on trauma and its effects. We can and must do a LOT better, but it won’t happen until we stop allowing billions in profits for selling people drugs that don’t really solve the problem at hand and pretending they are the solution.

    • The thing is that we do not fully understand antibiotics. Antibiotics are sometimes inappropriately used for viral conditions for which they are ineffective. Antibiotic use and overuse leads to illnesses such as C. diff colitis where there is bacterial overgrowth and the development of drug resistant bacteria. BUT people are not vilifying infectious disease and primary care physicians as they are psychiatric providers. If we are to do better, we should work as a team, not dismiss an entire specialty. Most of the time doctors are doing what they are doing as attempts to relieve suffering. Yes, if every patient who was mentally ill could be prescribed a psychosocial intervention that he/she would then adhere to, that would be wonderful, wouldn’t it?

    • KU: Even though we do not understand antibiotics, we clearly know what they are used for: to get rid of harmful bacteria. In other words, in the case of treating an infectious disease, caused by bacteria, then one can try giving different antibiotics. This is NOT AT ALL the case for psychiatric drugs – psychiatric drugs are trial and error ‘inventions’ and nobody knows what they do in the brain. However, doctors have blind “faith” in them because they are actively promoted by profit driven pharma.
      Yes, there are psychosocial interventions that would suit different patients – for example, check out the “open dialogue” method. These methods are definitely better than prescribing psychiatric drugs using blind faith, which as we know often results in considerable long term harm.

    • There is a BIG difference you are ignoring. We can say FOR SURE that antibiotics treat an actual infection which can be observed under a microscope, and we can judge if they are working by looking to see if said infection is reducing or no longer evident. There is NO similarity here to psychiatric conditions – there is not one DSM “diagnosis” that can be reliably identified by any measure, and as such, there is no ability to judge objectively whether or not a particular intervention “works.” You are right, that’s not a reason to stop looking, but it IS a reason to stop pretending that these “disorders” are anything but a set of socially-created lists of behaviors we find troubling or inconvenient. How is it possible to take a manual seriously when it has disorders like “Oppositional Defiant Disorder” or “Intermittent Explosive Disorder” or “Disorder of Written Expression?” Ever notice that there is no “hypoactivity disorder” or “overly-compliant disorder?” These disorders are social constructs that have no relationship to any physiological problem that has ever been identified.

      Moreover, whatever the errors in the use of antibiotics, which are of course driven by arrogance, laziness and the profit motive just as psych drugs are, the use of antibiotic has saved lives and increased life expectancy on the average. Whereas for psychiatric “treatment,” the more “treatment” is received, the shorter the lifespan of the recipient on the average. Those receiving heavy psychiatric treatment are dying 25 YEARS younger than the general population, and that lifespan has DECREASED in the years since drug “treatment” became common. There is no other branch of medicine where increasing levels of treatment lead to shorter life spans, and in any other branch, such data would be considered an emergency situation and something would be done about it. In psychiatry, nobody apparently cares that their treatment is killing off their patients decades early.

      No, the analogy with antibiotics doesn’t even begin to work.

    • Psychiatry is a pseudoscience, a drugs racket, and a means of social control. It’s 21st Century Phrenology, with potent neuro-toxins. Psychiatry has done, and continues to do, far more harm than good. The DSM-5 is a catalog of billing codes. ALL of the bogus “diagnoses” in it were invented, not discovered. The difference is vital. So-called “mental illnesses” are exactly as “real” as presents from Santa Claus, but not more real. Real people have real problems, but inventing imaginary “mental illnesses” to $ELL DRUG$ should not be part of that. “KU”, above, judging only from the comment, seems well-educated, indoctrinated, and propagandized. If psych drugs really “worked”, then why are many different types drugs given for the same “diagnosis”, and any given type of drug is given for a large variety of so-called “diagnoses”. A psychiatrist’s prescription pad may as well be a blindfold and a dartboard. PhRMA and psychiatry are the 2 greatest preventable existential threats to humanity….
      I’m living proof of that fact.

    • kdn – i am aware of many wonderful nonpharmacologic interventions, however many patients are not interested in this, can’t afford it, won’t stick with it, etc.

      stephen – if you ever get a chance to speak with clinicians who work in mental health you would find that most psychiatrists do not use the dsm as a guide. it is true that master’s level folks tend to follow it more closely. but primarily the dsm is used by insurance companies in order to approve or deny treatment for patients. it is also unfortunately used for research and i agree this is not a good thing. there are efforts such as the rdoc to get away from that.

      your comments about reduced lifespan are ridiculous. yes, some psychiatric medications cause terrible metabolic side effects and can lead to significant morbidity and mortality. BUT we also know that people with schizophrenia have metabolic changes even before they take any meds. people with mental illness are way more likely to engage in behavior such as tobacco use, shitty diet and no exercise, and alcohol use. these are the top 3 preventable causes of death in the US.

      this is not a good place to continue the conversation.
      you are entitled to your criticism of psychotropic medications, but i do not think you are as well informed as you think.

    • “This review does not explain the increased mortality, but it does support the longstanding view that people with mental disorders do not die of their condition; they die from the same chronic health conditions as the rest of the population, especially cardiovascular and pulmonary diseases.”

      “https://www.nimh.nih.gov/about/directors/thomas-insel/blog/2015/mortality-and-mental-disorders.shtml”

      It should be noted that psychiatric drugs, especially the antipsychotics, create weight gain, diabetes, metabolic issues, and heart disease as side effects NOTED ON THE PRODUCT INFORMATION.

      And the gap is widening despite (or because of) ever-increasing levels of treatment, widening the gap for the “seriously mentally ill” to 25 years: “http://www.treatmentadvocacycenter.org/fixing-the-system/features-and-news/3915-research-weekly-mortality-gap-for-serious-mental-illness-widens-”

      There is nothing ridiculous about the assertion that treatment is shortening lives – it is strongly supported by the data. Perhaps it is not I who needs to become more informed.

    • KU: If patients are not interested, they need to be educated about the science behind biological processes like epigenetics and neuroplasticity (as well as the dangers of psychiatric drugs). The reason some patients may not be interested would be because they too believe that they have “chemical imbalances” in their brains that need to be somehow “corrected” through the use of psychiatric drugs.

Sign up for our Daily Recap newsletter

A roundup of STAT’s top stories of the day in science and medicine

Privacy Policy