26 October 2012, 6.29am AEST

Depression, drugs and the DSM: a tale of self-interest and public outrage

MATTERS OF THE MIND – a series which examines the clinician’s bible for diagnosing mental disorders, the DSM, and the controversy surrounding the forthcoming fifth edition. In Australia, antidepressant medications account for 61% (13.7 million) of all mental health-related subsidised prescriptions…

Authors

1. 

   Andrew Kemp

   NHMRC Career Development Fellow at University of Sydney
2. 

   Andre Brunoni

   Psychiatrist and researcher at University of São Paulo

Disclosure Statement

Andrew Kemp receives funding from the National Health & Medical Research Council and the Australian Research Council.
Andre Brunoni does not work for, consult to, own shares in or receive funding from any company or organisation that would benefit from this article, and has no relevant affiliations.

The Conversation provides independent analysis and commentary from academics and researchers.
We are funded by CSIRO, Melbourne, Monash, RMIT, UTS, UWA, Canberra, CDU, Deakin, Flinders, Griffith, La Trobe, Murdoch, QUT, Swinburne, UniSA, UTAS, UWS and VU.

The cosy relationship between the psychiatry and Big Pharma has come under increasing scrutiny. Hannah Nicole Aspire

MATTERS OF THE MIND – a series which examines the clinician’s bible for diagnosing mental disorders, the DSM, and the controversy surrounding the forthcoming fifth edition.

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In Australia, antidepressant medications account for 61% (13.7 million) of all mental health-related subsidised prescriptions, followed by anxiety-reducing medicines. One in five Australians aged 16 to 85 are afflicted by either a mood, anxiety or substance-use disorder.
We now know that depression is not just a disorder of the mind; it also increases risk for a host of conditions and diseases, and mortality. Hence the need for effective treatments.
The Diagnostic and Statistical Manual of Mental Disorders (DSM) is the manual clinicians use to determine mental health diagnoses and whether medication should be prescribed. The preparation for and development of the latest edition, the DSM-5, has generated an extraordinary amount of public and media debate.
Criticism of the DSM-5 is also coming from within the profession of psychiatry itself. An outspoken critic of the DSM-V is Allen Francis, a psychiatrist and chair of the task force that produced the DSM-IV in 1994. He has warned that if the DSM is published unamended, it will lead to medicalisation of normal human emotions. Francis argues that the DSM-5 changes will raise the prevalence of mood and anxiety disorders.
Specific concerns over the proposed changes to the DSM-5 criteria of these disorders relate to removing the bereavement exclusion to major depressive disorder and lowering thresholds for generalised anxiety disorder.
The idea that depression is a disease has already opened up huge opportunities for the pharmaceutical industry, argues Gary Greenberg, psychotherapist and author of Manufacturing Depression. People are now asking themselves whether their unhappiness is a disease that can be treated by medication. Given the ease with which antidepressants are prescribed, this is a problem. Further lowering the criteria by which we are diagnosed with these disorders may serve to further perpetuate this problem.
Daniel Carlat, psychiatrist and author of Unhinged, however, has criticised the discipline for embracing medication-based treatment when there is no evidence to support the idea that depression is caused by a “neurochemical imbalance”.
But our understanding of the biological basis of depression has come a long way since the “neurochemical imbalance” was first proposed in 1965. While the immediate effects of antidepressants are to increase the availability of serotonin and norepinephrine in the brain’s synapse, the patent’s symptoms may not improve until three to four weeks of treatment. Clearly, then, depression is a little more complicated than a “neurochemical imbalance”.
The biological basis of depression is now understood to be underpinned by a complex interplay between life stress, genetics and brain function.
Unfortunately, the unfounded belief that depression is caused by too little of a certain neurotransmitter is alive and well. Direct-to-consumer campaigns have largely revolved around the claim that the selective serotonin reuptake inhibitors (antidepressants known as SSRIs) correct a chemical imbalance caused by a lack of serotonin.
In this regard, psychiatrist, psychopharmacologist, scientist and author David Healy argues in The Antidepressant Era that pharmaceutical companies are as much in the business of selling the “depression” diagnosis as they are in selling antidepressants.

Depression isn’t just a disorder of the mind, it also increases risk for a host of other conditions. Kalexanderson

So what are some of the possible consequences of treating the “worried well” with antidepressants?
While some have labelled antidepressant medications as “placebos with side effects”, the possibility that pharmacological treatments may have adverse long-term consequences has attracted increasing attention.
Take the disturbing documentary, Numb. This doco features a successful suburban dad who comes to the conclusion that his emotions have become blunted over the years. He decides to stop taking his medication after long-term use… with rather disturbing consequences. (He is alive today, but remains on antidepressants.)
But doesn’t this just indicate that some depressions require long-term treatment with antidepressant medication?
This is certainly the consensus amongst clinicians. However, Robert Whitaker – a journalist and author of Anatomy of an Epidemic – claims that long-term use of psychiatric drugs may actually contribute to the very conditions they are prescribed to treat.
An important counter-point to this rather heretical claim is that correlation does not imply causation. Just because certain events – such as increasing prescription of SSRI antidepressants and the increase in psychiatric disability – appear to be related in time, one event does not necessarily cause the other.
Indeed, Carlat attributes increased psychiatric disability to three major factors:

Our understanding of the biological basis of depression has come a long way since the ‘neurochemical’ imbalance was first proposed. Carlos Smith

1. The number of official DSM diagnoses has increased from 130 (in the first version of the DSM) to 886 (in the DSM-IV-TR, the current version).
2. There are more treatments available to clinicians, motivating them to look for newly treatable diseases.
3. Expansion of social security schemes to include psychiatric disorders such as ADHD and PTSD that are difficult to diagnose and easily faked.

But the road to DSM-5 has been a little murkier than simply concerns over the boundary between normal sadness and clinical depression. It involves tales of scandal and conflicts of interest.
The cosy relationship between the psychiatry and Big Pharma has come under increasing scrutiny, as have undisclosed financial dealings, commercialisation of “science” and ghostwriting.
David Healy argues in his recent book, Pharmageddon, that far from making drugs safer, clinical trials actually conceal risk; a consequence of private companies running clinical trials and the publication of ghost-written articles in leading peer-reviewed journals.
Here lies our primary reason for writing the present article: the research community is crying out for increased government funding allowing us to carry out unbiased research. Let’s not throw the baby out with the bath water – we need the pharmaceutical industry – but we also urgently need more government support for high-quality research to better understand depression and its treatment.