Biopsychiatry Illuminated

THE CANDLELIGHT PROJECT
by Bob Collier

17 November 2003
Issue 68

MEDICATING NORMALITY:
THE PSYCHIATRIC COLONIZATION OF CHILDHOOD
By Antony Black

Part 2

Myths of Efficacy and Safety

No better example of the success of biological psychiatric propaganda can be evinced than in the now widely held belief among the general public that the aetiology of depression is primarily, if not strictly, a biochemical phenomenon. The idea that fundamentally new ontological properties and behavioural laws emerge at higher levels of organizational structure, a fact clearly manifest from atoms to galaxies, is, in this instance (all hedging and tokenism aside), flatly denied to the human mind, the most complex organizational structure of all. Instead, the notion is earnestly advanced that depression involves a point source, or sources, in the brain upon which exquisitely refined anti-depressant drugs act like magic bullets surgically targeting the offending region(s).

The tiny wrinkle in this crisp, scientific scenario is that there is absolutely no evidence to support it. Instead, the overwhelming weight of clinical and physical evidence suggests that the drugs act not by targeting any hypothetical 'depression center', but by blunting affect and emotion generally. Indeed, these drugs have more or less the same effect on everyone, patient and non-patient alike. This is significant because it makes a mash of the argument that such medications are 'targeting' some sort of hypothesized deficit. If one successfully takes aspirin for a headache it's nonsense to then conclude that one was suffering from an aspirin deficiency. But this is precisely the level (i.e. reverse causal reasoning) on which many of the arguments for these drugs have been and are being made. Apart from this, it takes malign dedication to believe that the vast majority of depressions are anything other than higher order, psychological responses to real-life conditions.

If the arguments for the efficacy and mode of action of most psychiatric drugs are deeply suspect, then so too is the claim for their safety. Thus, in 1980, twenty-five years after the introduction of neuroleptic (antipsychotic) medication, an American Psychiatric task force report finally, grudgingly confirmed what a number of previously neglected studies had attempted to call attention to, namely, that roughly 40% of chronic users of these drugs went on to develop tardive dyskinesia, a Parkinsonian-like movement disorder indicative of permanent brain damage. One might have expected from this sobering experience that biological psychiatry would henceforth have exercised the pre-cautionary principle in its future endeavours. Instead, it has simply set about expunging crimes of Christmas past whilst denying the risks of Yuletides to come.

Its proponents continue to claim, for instance, that electro-shock therapy is harmless, this despite overwhelming experimental and clinical evidence to the contrary and despite the vociferous condemnation of a legion of former patients(9). They also continue to ignore the commonsense potential for (and experimental evidence indicating) permanent changes in physiology whenever the brain's dynamic homeostasis is chronically altered or upset(10) - as it often is while taking the 'new, improved' psychiatric medications. Constantly advised against screwing around with our brains when it comes to the casual, intermittent use of recreational drugs, we are yet urged to believe that ingesting legal psychotropic drugs on a continuous, round-the-clock basis, often for years on end, is without peril.

Still, biopsychiatrists will argue, and most people believe, that these medications have undergone rigorous testing under the auspices of the American FDA to insure their efficacy and safety. Nothing could be further from the truth.

First of all, the experimental studies of these drugs are constructed, financed, and supervised entirely by the drug companies themselves. Their vaunted independence is a complete myth(11). Second, the timelines of the trials are so unreasonably short as to fly in the face of the most elementary scientific reasoning. Prozac, for instance, was released onto the market with only six weeks of clinical trials. In essence, anyone now taking the drug for more than six weeks is involved in his or her own study into its long-term effects. Third, the experimental protocol and statistical design of many of these studies are a complete scandal in their own right. In the case of Prozac, among other statistical shenanigans: data were pooled from different sources, then massaged into shape; additional confounding medications were administered simultaneous to the test drug; and the dropout rate of roughly 50% was neither factored into the results nor explained in the final reports(12).

It is pertinent to note here that Prozac and company are increasingly being given to children(13) despite their never having been part of the original experimental protocols, and despite the added risk that accrues from the interference with the developing brain.

The general public, it need hardly be emphasized, would have to root long and hard through the civic archives to unearth even the faintest trace of these controversial matters; the corporate media are hardly disposed to attack one of their own (the pharmaceutical /medical complex). Let off the hook by the press and abetted by the state, biological psychiatry has remained impervious to criticism, electing, instead, to simply expand its frontiers by seeking new markets in which to ply its trade.

ADD, The Incredibly Expanding Diagnosis

It may be disconcerting for educators to realize that they have been the thin edge of the wedge wherein children have become biopsychiatry's largest population of involuntary patients. But so it is, for much of the driving force behind children's mental health referrals has come from the problems that children - mostly boys - are causing teachers. Chief amongst their complaints, naturally, is manageability for which the medical profession has conveniently supplied a diagnosis, Attention Deficit Disorder or ADD(14).

To be fair, ADD, or at least its associated syndrome, has a long historical pedigree whose narrative suggests that it may not entirely be the biological reification of a normatively defined behavioural set. The story begins in 1902 when the first report on the syndrome was made by the British physician George Still. His suggestions were lent some support when researchers, following an outbreak of encephalitis in 1917, recorded among the other symptoms of affected children: hyperactivity, impulsivity and impaired attention - the very trio of symptoms that later came to characterize the modern diagnosis. By the 1950's the syndrome became subsumed under the term MBD ("minimal brain damage") a term which reflected the presumed organic nature of the disorder. The problem was that no one, try as they might, could identify any such organic damage so the term was later revised to Minimal Brain Dysfunction. When no actual physiological dysfunction could be proven either the term withered away to be replaced in 1980 (in DSM III) by ADD.

Significantly, however, the new diagnosis substantially broadened its net by de-emphasizing impulsivity and concentrating, instead, on distractibility and poor attention. Suddenly the doors were thrown wide open to diagnostic abuse. After all, given a little emotional trauma, say, from strife in the family, poverty, abuse, neglect, hospitalizations or a dozen other such commonly occurring life contexts, what child could or would not present as distractible or poorly attending?

Moreover, not only are the diagnostic criteria vague and open to wide interpretation, but ADD has no definitive medical or psychological marker. A diagnosis is thus often made almost exclusively on the basis of a patient's history, which, as things usually work out, is given by someone likely to be highly biased as to the desired conclusion. Why desired? Because a finding of ADD relieves both parents and society from any complicity in or responsibility for their children's' problems. Indeed, the very presumption of a biological basis for a child's behaviours automatically precludes the notion, or the search for, psycho-social aetiological factors. In addition, not only is there less stigma attached to a neurological as opposed to a psychiatric diagnosis, but being labelled ADD allows entitlements to special education services and (especially in the US) to disability and insurance rights.

A vivid example of these three factors in action is to be found in the United States in the highly influential and messianic group known as CHADD (Children and Adults with Attention Deficit Disorder). Dedicated almost solely to the proving and propagandizing of a purely biological basis for ADD, its lobbying efforts virtually single handedly oversaw the introduction of the Disabilities Education Act in 1991(15). The ensuing stampede to take advantage of the new entitlements afforded by the Act has undoubtedly been the prime driving force in the explosion in the number of ADD diagnoses over the past decade. And, of course, more ADD means more Ritalin.

Anatomy of a Wonder Drug

Ritalin, produced by Novartis (formerly Ciba-Geigy), is the brand name of a drug called methylphenidate and is classified as a stimulant. It is very closely related to amphetamine though, according to biopsychiatrists, devoid of amphetamine's addictive properties. Apparently, no one told this to the DEA (the Drug Enforcement Agency, in the US) which lists it as a Class II drug with a high potential for addiction or abuse(16). Still, proponents like to emphasize that Ritalin has a long history (since the early 1960's) of safe usage. It's physical side effects, which include tics, spasms and chronically elevated heart rates and blood pressure, are acknowledged, but said to be more or less insignificant or inconsistently found at the dosages (5mg - 20mg) usually dispensed. It is said to have no long term risks(17). This may indeed be the case - or it may not. The problem with taking the word of biopsychiatrists on this matter is simply that they have such a dismal track record when it comes to both unearthing and admitting the damaging nature of their magic potions and pills(18). Much of the exculpating research is, of course, conducted or financed by the very companies making the drugs. And, unfortunately, the time honoured adage of 'buyer beware' suffers in translation when the drugs primary consumers are neither the buyers, nor aware. They are children.

All this said, it must be admitted that Ritalin and company (Dexedrine, Cylert and Clonidine) are, in their own way, effective - at least in the short run. Stimulants have always been effective. At the turn of the 20th century cocaine was (for a while) hailed by Sigmund Freud as a miracle drug; a panacea for all psychic ills. From the 1930's on amphetamines were extensively studied and were found to improve vigilance, accuracy, endurance, speed - and these improvements occurred across the board on everyone who tried them. And so it is with Ritalin. It has the same effect on all individuals regardless of their psychiatric status. Once again, this belies the claim that it is correcting some sort of biochemical imbalance. Moreover, there is considerable doubt as to its mode of action, for among its principal emotional side effects are flattening of affect, depression, loss of energy and diminution of creative thought. Given that no chemical imbalance has ever been demonstrated for ADD, nor is even likely to exist in the vast majority of those so labelled, it is highly probable that these *subduing 'side' effects* are, in fact, the drug's primary agency. Far from treating a medical problem, it is very likely we are simply medicating a problem child.

But what of long term prognoses? All of the long term studies to date have consistently demonstrated there to be no benefits whatsoever when medication is employed *alone* as a treatment of ADD. There is no improvement in outcome as measured by rates of school failure, juvenile delinquency, drug abuse or later success in holding down jobs or maintaining relationships. Improvement has been demonstrated only when medication was allied with intensive individual and family counselling in conjunction with the provision of special educational services. The further disentangling of these 'curative' factors is, at present, an ongoing project(19).

The foregoing discussion has focused almost solely on Ritalin and company. But, of course, children are subject to the full range of the biopsychiatric arsenal. As mentioned earlier, the new spectrum anti-depressants (the SSRI's)(20) are now widely given to children. In institutional settings (i.e. youth correctional facilities) the anti-depressants and amphetamine-like prescriptions are dispensed in epidemic proportions, and these are liberally supplemented with anti- anxiety medications, often including the infamous neuroleptics. That these kids often present as depressed, irritable or anxious is hardly surprising. One straight look at their circumstances and life history is enough to suggest a reason. Still, there are many who would challenge this - and coolly reverse the causal arrow.

Nature vs. Nurture

The question of whether constitutional or contextual factors are central to the defining of human personality is, it hardly bears repeating, as old as the hills. In this sense the debate between biological psychiatry and its critics is yet another chapter in a very long and probably unending story. Nevertheless, let me brazenly offer, at this point, a preliminary solution to the riddle of nature vs. nurture.

It is clear that genes and biochemistry have *something* to do with moods and behaviour, just as it is clear that the psyche is based in a physical substrate and that constitutional factors manifestly influence everything from temperament to potential intellectual limits. But where biopsychiatry sees these as *determining* factors, holistic philosophers mark them as merely *bracketing* ones. The rather large difference is that to see biological parameters as framing human potential is a far cry from believing that we have uncovered - or that there even exist - specific, localized chemical substrates of complex emotional and psychological states. It is, furthermore, naive to suppose that the drugs in question could ever act in a functionally specific (i.e. fine tuned) way. In addition, the notion of conceiving of ourselves primarily as biochemical mechanisms is, I would posit, a profoundly - and dangerously - dehumanizing one(21).

Still, it is arguable that this is all of little moment and even less comfort to a family or parent caught in the vice of turmoil and stress attendant upon a child's slow descent into a vortex of oppositional behaviour and academic failure. And it is true that it would be cruel to withhold a treatment - however spuriously conceived - that might save the day in the short run when other interventions hold promise, perhaps, only in the longer run. Interventions which, moreover, might entail efforts that the principal protagonists are unwilling or incapable of fulfilling.

The problem with this saving (if ideally exaggerated) scenario is that, for the most part, the principal protagonists - the doctors, the parents, the teachers, and for that matter, the media, the courts etc. - actually *believe* that what they're doing is other than an emergency tactical manipulation of a decidedly non-medical phenomenon. And this incongruence between ideation and action is not just some philosophical quibble. It has very tangible and far reaching social consequences.

It means that all problem behaviour is now in danger of being swept up in a pathologically defined net. Seen through such a biological determinist lens, what modern-day Tom Sawyer or Huckleberry Finn is likely to roam unhindered, free from the paternalistic embrace of medical science?

It also means that potential social policies and research that might bear on these matters are rendered null and void before they even reach the drawing board. How many studies, for instance, have brought the bright beam of science to bear on the relationship between, say, class size and ADD? None to my knowledge. And yet the experience of myself and many of my colleagues suggests the relationship is a profound one.

Or what researcher has given earnest lucubration as to just how destructive to a child's self-image, and sense of identity (and, indeed, efficacy and responsibility), are the stigmatizing effects of taking a medication over the long term. Again, none that I am aware of, though common sense and experience suggest these effects are substantial.

That in a better world a mature *bio-psycho-social* model of human nature could find wise and judicious employment within a culture of non-reductionist social relations, is so much hypothetical grist for the speculative mill. The plain fact of the matter is that the widespread drugging of children is now being played out against an Orwellian background of pseudo-scientific claims, evidential suppression, corporate/medical entwinement, and crudely simplistic social and scientific philosophies. Perhaps, then, it is time to start talking less about the 'pathology' of children, and more about the pathology of our medical values.

Antony Black

Notes

(9) The original animal studies on ECT in the 1940's and 50's were damning, as were many studies carried out in former Soviet Russia. Memory loss from shock therapy is widely attested by former patients. It's actually quite easy to confound a proponent on this matter. Just ask them to demonstrate once and for all the procedure's eminent safety - by having it done (just once) on themselves. I've never had any takers.

(10) Experimental evidence in animal studies indicates that chronic down-regulation results in the permanent loss of serotonin receptors.

(11) Only last year a number of leading medical journals publicly announced that they were suspending acceptance until further notice of studies associated with the major pharmaceutical companies.

(12) For a full discussion of this fascinating topic see, 'Talking Back to Prozac', by Peter R. Breggin (1994).

(13) It takes a strong kid to go against the pressure exercised by a prison psychiatrist to take one of these drugs. Nevertheless, many are savvy enough to recognize that something is askew - and that it isn't them. The daily rounds for dispensing pills, in some of these places, reminds one, in all honesty, of scenes from One Flew Over the Cuckoo's Nest.

(14) Actually, ADD was changed to ADHD (the "H" for hyperactivity) in DSM IV. But most everyone still refers to it as ADD.

(15) CHADD and Ciba-Geigy were actually involved in an open scandal in 1995 when it was revealed that the latter had contributed $900,000 to the former over 5 years without having disclosed this to either the public or to the CHADD membership. It is also worthy of note here that ADD is not the only disorder to have been given a boost from a parent's organization. The LD (Learning Disorder) syndrome was largely driven by such an organization. Indeed, there is little evidence to support this syndrome as neurological phenomena either.

(16) CHADD lobbied heavily, though unsuccessfully, to have Ritalin moved to Schedule III which would have made it much easier to obtain.

(17) Indeed, a 1986 study by Henry Nasrallah et al. published in Psychiatric Research suggested possible cortical atrophy in subjects all of whom had been subject to long term treatment with stimulants. To my knowledge this research has not been followed up.

(18) This relates directly to the preceding note. Not starting up, not following up, and not admitting when something *is* up, is one of the key threads running through biopsychiatric history over the past fifty years.

(19) A study sponsored by the National Institute of Mental Health in the US to determine which of, or which combination of, treatment modalities *were* effective in helping those diagnosed as ADD has been ongoing for a number of years now. At the time of writing I had not been able access to its results.

(20) SSRI's - Selective Serotonin Reuptake Inhibitors.

(21) I have used the term 'reductionist' and 'reductionism' throughout, assuming the reader to understand the term. But just for the record, 'reductionism' as here used refers to the notion that in studying any higher organizational entity the properties of the whole can be deduced from the parts, the complex explained by the simple, the higher derived solely from the lower. Though much of modern science has, in its practice, employed reductionist methodology, it is now widely conceded that science is, in some areas, now reaching the workable limits of reductionist ideation. Evolutionary theory is a prime example. Human psychology, many would assert, is another.

Copyright © Antony Black

Antony Black is a freelance writer concentrating, for the most part, on international issues from a 'radical' left perspective. Having incubated first in an intellectual context of psychology and psychiatric theory, then veered into the sciences, thence to writing and teaching, he has yet retained an abiding interest in his first 'career'.

Read other articles by Antony Black at The Academy for the Study of the Psychoanalytic Arts:
http://www.academyanalyticarts.org/

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