Psychiatry: A Case Study of Institutional Corruption

Five years ago, I spent time as a fellow in a lab at the Safra Center for Ethics at Harvard that was devoted to studying “institutional corruption,” and what I particularly appreciated about the lab was that it provided a clear method to investigate and conceptualize the problem. The framework was this: Identify “economies of influence” that may corrupt the behavior of individuals within the institution, document the corruption, and explore the resulting social injury.

Lisa Cosgrove and I joined together in studying the “institution” of psychiatry through this lens, and we focused on its institutional behavior since 1980, when the American Psychiatric Association published the third edition of its Diagnostic and Statistical Manual. This was when the APA adopted its disease model for categorizing mental disorders, with the profession then taking up the task of selling this new model to the public. This was the particular guild interest that arose in 1980, and has shaped its behavior ever since. We’re all familiar with the second “economy of influence” that has exerted a corrupting influence on psychiatry—pharmaceutical money—but I believe the guild influence is really the bigger problem.

In our book Psychiatry Under the Influence, we then documented the corrupt behavior, which could be found in every corner of psychiatry: the false story told to the public about drugs that fixed chemical imbalances in the brain; the biasing of clinical trials by design; the spinning of results; the hiding of poor long-term results; the expansion of diagnostic categories for commercial purposes; and the publishing of clinical trial guidelines that inevitably promoted the use of psychiatric drugs.

At the end of our investigation, I had a new way of conceptualizing the social injury that was caused by this corruption: our society had organized itself around a false narrative, one that was presented to us as a narrative of science, but was belied by a close examination of the actual evidence.

Now, with the publication of a new study in the American Journal of Psychiatry titled “The Long-term Effects of Antipsychotic Medication on Clinical Course in Schizophrenia,” we have a new opportunity to observe this “institutional mind” of psychiatry at work. The article, authored by former APA president Jeffrey Lieberman and seven other psychiatrists, is meant to serve as an evidence-based review that defends the profession’s current protocols for prescribing antipsychotics, which includes their regular long-term use. By closely examining this review, we can assess, once more, whether this is a profession that can be trusted to honestly evaluate its evidence base and use that evidence to guide its care.

The Context

In 2010, I published Anatomy of an Epidemic, and in that book, I wrote about the long-term effects of antipsychotics, and concluded that there is a history of science that leads to this conclusion: on the whole, antipsychotics worsen the long-term outcomes of people diagnosed with schizophrenia and other psychotic disorders. Joanna Moncrieff has similarly written about the hazards of antipsychotics in her book The Bitterest Pills and in published papers. So too has Peter Gøtzsche in his book Deadly Psychiatry and Organized Denial and various journals.

All of this criticism helped to promote further inquiry into this concern, which put psychiatry on the hot seat: did it prescribe these drugs in a way that caused more harm than good? Did their protocols for the drugs—immediate use for all first-episode psychotic patients and then “maintenance” use of the drugs—need to be rethought?

In their newly published study, Lieberman and colleagues perform what they describe as an “evidence-based” review of these questions. They conclude that there is no compelling evidence that supports this concern. In a subsequent press release and a video for a Medscape commentary, Lieberman has touted it as proving that antipsychotics provide a great benefit, psychiatry’s protocols are just fine, and that the critics are “nefarious” individuals intent on doing harm.

Joanna Moncrieff has already published a blog on Mad in America that is critical of the study, and, in particular, of the authors’ dismissal of studies related to the effect of antipsychotics on brain volumes. Miriam Larsen-Barr, who has done research on user attitudes toward antipsychotics, also wrote a blogcriticizing the study and press release, focusing on how the authors ignore user accounts about how the drugs affect their lives.

In this MIA report, I simply want to look closely at how Lieberman and his collaborators reviewed the literature and individual studies. We can then see whether they have done so in a way that reveals the mind of a group interested in truly investigating the question of the long-term effects of antipsychotics, with the patients’ well-being uppermost in their thoughts, or whether it reveals the “mind” of a group interested in protecting guild interests.

Then, at the end of this exercise, we can ask this essential question: If we can’t trust the profession to develop “evidence-based” treatments that put the interests of patients first, as opposed to their own guild interests, what should our society do? …

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