The patient

  Psychiatric diagnoses arise in a dialogue between patient and doctor. The patient offers his concerns and the psychiatrist tests these against the range of illnesses he or she knows. Both parties in this exchange can influence the threshold for what is ‘psychiatric’. How do we as individuals interpret our experiences? What do we just accept (even if unpleasant and difficult) and what do we consider unacceptable, worthy of reporting and needing help? We seek help much more readily now and seek it from professionals where previously we might have put up with it or turned to friends and relatives. Anxieties over child-rearing, disappointments in relationships, bereavement, and distress after trauma – all are now considered legitimate territory for psychiatric assessment and possible intervention.

  Society has rejected the stiff upper lip and embraced psychology and psychotherapy. It has become immeasurably more tolerant and decent as a result. Our emotions and inner life are taken seriously, we are expected to share them and ‘understand our feelings’. Consequently we seek help with understanding them and relief from them if they become unbearable.

  These changes have led to an enormous rise in demand for counselling and psychotherapy and also for antidepressants and medications to reduce anxiety. Of the antidepressants prescribed in the UK 96 per cent are prescribed by family doctors. Most of these are for individuals who will never see a psychiatrist and many who would hardly have been considered unwell a generation earlier. This is not all a bad thing – many patients benefit from these treatments. But there are risks. As treatment thresholds get lower there is less risk that patients who need treatment will be neglected but an increased risk that others who won’t benefit do get treatments. Relying on medicines for relief may also inhibit us exploring alternative strategies. Persisting with an unhappy marriage and hoping that the pills will make it better is not a sensible long-term strategy. Similarly our expectations change imperceptibly and personal resilience may be eroded.

  Treatments we seek from psychiatrists may even make us worse. Excessive prescription of valium and other sedatives led to an epidemic of dependence which proved enormously difficult to reverse. Some studies indicate that routine counselling after severe road traffic accidents or after stillbirths may slow down recovery, not just not help. Perhaps some experiences are best simply put behind one and forgotten. In natural disasters, providing counselling may distract energy and resources from the promotion of self-help and social cohesion.

‘Big Pharma’

  There is a growing unease about the relationship of the medical profession with the companies which research, manufacture and sell the drugs we use. The cost of developing a prescription drug in the US is estimated at $800,000,000. So the pharmaceutical industry is increasingly concentrated in a small group of immensely powerful multinational businesses. The statistics are staggering. It takes on average up to 10 years from isolating and patenting a molecule, through tests and trials to its first routine prescriptions to patients. Only 1 per cent of new molecules make it from test tube to prescription. The research and development budget is consequently enormous. That of Pfizer (the largest pharmaceutical company in 2005) is greater than the whole national research budget of some European states.

  Not surprising then that the marketing of these drugs is ruthless. The financial relationships between doctors and these companies are murky. Over half of all educational meetings for psychiatrists in the US are funded by pharmaceutical companies and luxurious hospitality and travel are routinely offered to doctors as barely concealed inducement for them to prescribe. Until recently psychiatry was immune from this as our drugs cost so little. However the new generation antipsychotics and antidepressants are vastly more expensive (newer ‘atypical’ antipsychotics cost $2000–$3,000 a year per patient in the US compared to $100–$200 or less for the older drugs; newer antidepressants also cost several hundred dollars a year as opposed to ‘pennies’ for the old antidepressants such as tofranil and amitryptiline). The patent on a new drug is strictly time limited and the companies have to recoup all their development costs usually within 10–15 years from launch. With the financial muscle of the pharmaceutical companies brought to bear on the profession it is hardly surprising that social and psychological interventions (which have no such financial backing) have a lower profile.

  ‘Big Pharma’ has been accused of stretching the boundaries of what are treatable psychiatric disorders to increase the sales of its drugs. It has been accused of creating a need for its drugs rather than developing drugs for existing needs. The enormous success of prozac has lead to an expansion of the concept of clinical depression. Milder and milder cases get treated. Prozac’s iconic status has helped reduce stigma against depression but has made it a ‘lifestyle’ drug. Most university students will know class-mates on antidepressants – inconceivable only a generation ago. Diagnostic patterns have changed in response to the marketing of these drugs. There has been a striking increase in the diagnosis of disorders such as PTSD (post-traumatic stress disorder) and social phobia (a disorder which some would consider just extreme shyness) since drugs have been licensed to treat them.

  Even more worrying is the massive growth in psychiatric prescribing for children. Once a rarity, child psychiatrists now regularly prescribe psychotropic drugs for children. The most dramatic increase has been in the diagnosis and treatment of ADHD (attention deficit hyperactivity disorder): 7 per cent of US schoolchildren are diagnosed with ADHD (one in ten boys as they are three times more likely to be diagnosed), with half of these on stimulant drugs.

  The prescribing of ritalin (methylphenidate) increased sixfold in the 1990s in the US and accounts for 85 per cent of world prescriptions but Europe is rapidly catching up (150,000 prescriptions in the UK in 2002). Child psychiatrists insist that the diagnosis is made carefully and that drugs are used only after psychological treatments have been tried but the figures simply don’t stack up. Irrespective of the controversy about the legitimacy of the diagnosis, there can be little doubt that this is an example of psychiatric practice being rushed by commercial agendas.

  Before leaving the pharmaceutical industry we need to acknowledge its very positive contribution to human health and welfare. It would be naïve to ignore the financial imperatives that flow from such staggering R&D costs and to profess surprise at the marketing practices. The dramatic increase in both its scale and power, however, raises ethical problems which are not restricted to psychiatry. They include the exploitation of poorer countries for research where ethical standards may be less strict and where the patients in their trials may never have the resources to benefit from the drugs developed. The temptation to create spurious health needs to sell products is particularly potent in the psychological sphere as almost everyone would like to ‘feel a bit better’. Honest debate and tighter guidelines are needed.