How Big Pharma And The Dsm Are Shaping Mental Illnesses
July 20th, 2021
By: Mara Rotaru
Are the American Psychiatric Association and the US pharmaceutical industry whipping up mental illnesses and selling potentially dangerous drugs?
Over the past decade, a fraudulent “epidemic” of mental illnesses has been highlighted more strongly. In the past 2 years, the United States of America has witnessed a 5% increase in the number of adults aged 18 or older with any mental illness. Now, 1 in 4 Americans represent the aforementioned “epidemic” of mental illness, which is incredibly prevalent across the globe riddled with grief and the aftermath of the coronavirus pandemic. However, this trend, in particular, has been criticized years before the pandemic erupted on an international scale. Several arguments present on media platforms blamed increased psychiatric treatment for triggering this tendency especially since the period 1981-2004 illustrating the greatest rise in recorded mental health illness prevalence overlapped with that of the noticeably amplified antidepressant use in the US. However, epidemiological studies and the US NSDUH data of 2013 (National Survey on Drug Use and Health) indicate that said epidemic doesn’t exist, and all arguments claiming iatrogenic factors incited this situation are invalid.
Joseph Biederman, Timothy Edwin, and Thomas Spencer were three extremely reputable psychiatric researchers and leading specialists in child psychiatric disorders. They were affiliated with the prestigious Harvard Medical School in the United States until their reputations were damaged in 2008 when their considerable ties of interest with the pharmaceutical industry were revealed. Biederman's case was under particular scrutiny because he had declared only a small fraction of the $1.6 million he had received from several pharmaceutical companies between 2000 and 2007.
The scandal, synonymous with the corruption and cheating that resides in the drug economy, raised several questions. The most pressing one was whether J. Biederman should be held personally accountable for the dramatic increase in the number of bipolar disorders in American children at the turn of the millennium. Could a doctor, by his scientific authority alone, manage to broaden the criteria for the diagnosis of an illness? Even the most influential individual could not deceive the entire scientific community alone. However, J. Biederman’s membership of the DSM-IV revision committee in 1989, reviewing the fourth version of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association, was intriguing. The DSM, as the “bible of psychiatry,” clarifies the specific criteria for each officially recognized mental disorder. By adding or removing a criterion from the diagnosis of a particular illness, or even a single word, the rules of diagnostic inclusion for millions of potential patients are changed. Yet, as psychiatrist Allen Frances, the former leader of the DSM-IV revision process at the time, recognized; a "false" epidemic was built around the label of bipolar disorder in children around the 2000s, for which pharmaceutical companies and some researchers were largely responsible. A 40-fold increase in the number of children with bipolar disorder between 2000 and 2015 can only be explained by the DSM-IV which allowed for children with severe irritability, mood lability, and symptoms of attention-deficit hyperactivity disorder (ADHD), possibly even without delimited manic episodes would be diagnosed with bipolar disorder. These broader diagnostic criteria evidently would increase the number of cases. But did the DSM help to catalyze this phenomenon?
Frances’s confession is wildly fascinating. Whilst acknowledging that the American classification is partly responsible for the increase in cases of autism and Attention Deficit Disorder (ADD) in children during this period (two "false" epidemics to which the DSM-IV may have unwittingly contributed by broadening the criteria for inclusion in the diagnosis), he considers that the DSM has nothing to do with the spectacular increase in the number of bipolar children as the DSM-IV supervisory board at the time was not fooled by the activism of specialists in the field and precautions had been taken to contain diagnostic inflation. For instance, the introduction of a set of specific criteria for bipolar disorder in children was refused. This was not enough, since lobbying practices do not stop at criteria in a large dictionary. They are often more effective when they seek to penetrate mentalities in all dimensions of the care relationship, from parents' concerns at school to the media discourse or the academic training of physicians. There is a wider picture to consider when investigating the epidemic of bipolar disorders among children and adolescents, and the consumption of medication that went with it.
How does Big Pharma fit in the story?
Assessing the overall responsibility of the DSM for the inflation of psychiatric diagnoses and the overconsumption of medication is in itself a prowess. The financial manna represented by the drug industry in the world today is comparable with that of the largest oil companies. Their revenues are astronomical: the profits of the 20 largest pharmaceutical companies, easily exceed 100 billion dollars per year. The term "big pharma", coined in the 1990s after "big oil" or "big tobacco" industries, refers to the pivotal multinational companies that dominate the world drug market. However, this expression demonizes an industry whose image has already deteriorated over the past two decades. The gradient of criticism ranges from informed denunciation to the so-called “Big Pharma Conspiracy Plot”. According to this belief, Big Pharma incarnates a secret entity governed by shared interests that wish to alienate consumers, even if it means inventing new diseases… Psychiatry is all the more exposed to conspiracy theories because mental illnesses are complex diseases that remain largely mysterious, and for which there is currently no curative treatment.
Experts’ opinions and public distrust match
Under constant scrutiny and the suspicious eyes of the public, the DSM has been accused of complying with pharmaceutical companies’ interests, hence extending suspicion to other medical practices. The discovery of neuroleptics, as strong sedatives, in the early 1950s initiated a therapeutic revolution. However, the mechanisms of action of psychotropic molecules, in charge of affecting behavior, mood, thoughts, or perception are not well known, despite the constant progress in psychopharmacology. Above all, the efficiency of neuroleptics is debated even within the circle of experts: do they act only on the surface of the disease, or in-depth? Do they help relieve symptoms or simply mask them? The psychiatric community itself remains very divided on the use of neuroleptics in the consulting room. While there is a broad consensus on prescribing antipsychotics for the most serious mental illnesses, there is a great deal of skepticism about prescribing them for milder disorders (such as transient anxiety) or for children and adolescents in particular, and often outright opposition from health professionals. For once, the word of the experts is relaying popular distrust to denounce the pernicious influence of pharmaceutical lobbying. There are countless scholarly books and damning testimonies from experts on the subject (such as those of the English psychiatrist David Healy: one of the most virulent critics on the international scene of the harmful influence of the pharmaceutical industry on modern psychiatry). Hence, suspicion surrounding the impact of medication is understandable, to a certain extent.
The DSM, responsible but not guilty?
To put things in perspective, we have to go back to the 1960s, the golden age of the development of the American pharmaceutical industry. As the philosopher Rachel Cooper has shown, the first editions of the DSM (DSM-I in 1952 and DSM-II in 1968) can hardly be accused of having promoted the pharmaceutical industry. At the time, the DSM was only an administrative tool that was seldom used by researchers and wasn’t likely to interest the first psychopharmacological researchers. This began to change with the publication of the DSM-III in 1980, whilst big pharma began to emerge. Certainly, many of the specialists who participated in the writing of the DSM-III were optimistic supporters of the neuroleptic revolution. This enthusiasm was shared by the architects of the DSM and the pioneers of psychopharmacology. Nevertheless, no trace of the proven or suspected influence of the pharmaceutical industry has been found to date in the archives of the American classification. One might even say that it was the DSM that influenced the pharmaceutical industry (rather than the other way round), in the sense that the success of the DSM-III helped impose new scientific standards, such as inter-rater reliability - the scientific assurance that two independent experts can make the same diagnosis on the same patient. In the hope of demonstrating robust results, all therapeutic trials will now have to apply the DSM criteria.
Contextually, three elements will gradually make the DSM a privileged target for pharmaceutical lobbying. The first was the sharp increase in the share of private funding from the pharmaceutical industry in psychiatric research (in extremely diverse forms, ranging from research funding to payment of expert fees, from gifts in the form of vacation stays to the funding of student symposia). The case of J. Biederman, who combined his university salary with private salaries, was never considered reprehensible in itself (what was reprehensible in his case was the fact that he did not declare income from the pharmaceutical industry, the importance of which could only cast doubt on the neutrality of his judgment as an expert).
The second contextual element to be taken into account, covering the same period, is the imperative set by the Food and Drug Administration - the American federal agency in charge, among other things, of issuing marketing authorizations for drugs - to justify for any drug a specific efficacy for a given disorder. A drug is only allowed to be marketed for one or more clearly defined indications (and not, as was the case with the first barbiturates, for very vague and general indications such as "tranquilizer"). Therefore, it is easy to understand why the fine categories of the DSM will become the "core target" of research and pharmaceutical marketing.
The third historical element to take into account, finally, is the possibility in the United States for pharmaceutical companies to carry out advertising campaigns aimed directly at the consumer even for drugs that are not over-the-counter but require a prescription. For example, one can listen to the radio or watch television commercials urging individuals to take antidepressants or anti-anxiety drugs. The commercials will be keen to popularize the DSM criteria, in a very deleterious way, blurring the boundary between public prevention and consumerist incitement. Hence, these three contextual elements explain why the DSM-IV, published in 1994 is subject to a "credibility crisis". If pharmaceutical lobbying ever had any influence on the DSM, it is in these two editions that the most harmful effects can be found.
DSM-5: an ethical turning point?
In a lengthy article, psychology professor Lisa Cosgrove and her colleagues at Boston University, revealed in 2006 the extent of the links of interest that existed between the DSM-IV experts and the pharmaceutical industry: more than half of the 170 experts on the DSM revision committee had received substantial funding from pharmaceutical companies, either directly for their research or for consultancy. However, while the names of the experts did appear in the DSM, their links with the pharmaceutical industry were surprisingly nowhere to be found. Amid the preparation of the next edition of the DSM, DSM-5, the affair was bound to be embarrassing. The American Psychiatric Association (APA) had to take strong measures, such as instituting (something unheard of in the making of a psychiatric classification) a compulsory declaration of links of interest with the pharmaceutical industry for each member participating in the writing of DSM-5. It was thus decided that experts involved in the DSM process should not have an income of more than $10,000 per year from the pharmaceutical industry, and no more than $50,000 in shares in a pharmaceutical company. Of course, critics were quick to point out the relatively generous level of these thresholds, as well as the lack of specific information required in the declaration of interest forms. Nevertheless, this decision attests to a salutary awareness on the part of the architects of the DSM - they have everything to gain, both scientifically and financially, by demonstrating their independence from pharmaceutical companies. Along with that, since transparency alone never guarantees the absence of bias or indirect influence, it was also necessary to work on reinforcing the scientific credibility of the DSM's general project. This was achieved by setting up a Scientific Oversight Committee to ensure neutral and objective control of the scientific relevance of each proposed change in the classification.
The publication of the DSM-5, in 2013, thus revealed a change of attitude, fragile but without ambivalence, in the way of confronting questions of conflicts of interest. Undoubtedly, the extent of a problem of influence cannot be measured only by the control of pecuniary interests. It is also necessary to take into account the whole culture linked to the prescription of drugs, their symbolic inscription in society, and how they are used to relieve psychological suffering. Let's take the case of Portugal: the DSM has never had the scientific or administrative authority that it has in the United States; pharmaceutical companies are very powerful there, but their research activities and commercial practices are much more regulated. Nevertheless, the consumption of psychotropic drugs in Portugal has also increased by 6.74%, partly due to economic recessions, indicating that this paradox can’t be accounted simply by referring to the distant and anonymous entities of big pharma or the DSM.
Paediatric bipolar disorder: international comparisons of hospital discharge rates 2000–2010
Saving normal: An insider's revolt against out-of-control psychiatric diagnosis, DSM-5, Big Pharma, and the medicalization of ordinary life.
Conflicts of Interest and Disclosure in the American Psychiatric Association's Clinical Practice Guidelines | Request PDF
DSM History - psychiatry.org
How did the use of psychotropic drugs change during the Great Recession in Portugal? A follow-up to the National Mental Health Survey
Allen Frances on the DSM, Mental Illness and Humane Treatment
John Hopkins Medicine, Mental Health Disorder Statistics
The Bogus “Epidemic” of Mental Illness in the US