Mental Health News Archive

Jeffrey Longhofer, Ph.D., LCSW
Associate Professor
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Mental Health News Archive

(FYI, Marcia Angell, M.D.,  the author of this essay, is on the
faculty of Harvard Medical School and is the former Editor of the New
England Journal of Medicine.)

The Epidemic of Mental Illness: Why?
New York Review of Books, June 23, 2011
Author: Marcia Angell
(A Review Essay of the Following Books)

The Emperor’s New Drugs: Exploding the Antidepressant Myth
by Irving Kirsch
Basic Books, 226 pp., $15.99 (paper)

Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the
Astonishing Rise of Mental Illness in America
by Robert Whitaker
Crown, 404 pp., $26.00

Unhinged: The Trouble With Psychiatry—A Doctor’s Revelations About a
Profession in Crisis
by Daniel Carlat
Free Press, 256 pp., $25.00


It seems that Americans are in the midst of a raging epidemic of
mental illness, at least as judged by the increase in the numbers
treated for it. The tally of those who are so disabled by mental
disorders that they qualify for Supplemental Security Income (SSI) or
Social Security Disability Insurance (SSDI) increased nearly two and a
half times between 1987 and 2007—from one in 184 Americans to one in
seventy-six. For children, the rise is even more startling—a
thirty-five-fold increase in the same two decades. Mental illness is
now the leading cause of disability in children, well ahead of
physical disabilities like cerebral palsy or Down syndrome, for which
the federal programs were created.

A large survey of randomly selected adults, sponsored by the National
Institute of Mental Health (NIMH) and conducted between 2001 and 2003,
found that an astonishing 46 percent met criteria established by the
American Psychiatric Association (APA) for having had at least one
mental illness within four broad categories at some time in their
lives. The categories were “anxiety disorders,” including, among other
subcategories, phobias and post-traumatic stress disorder (PTSD);
“mood disorders,” including major depression and bipolar disorders;
“impulse-control disorders,” including various behavioral problems and
attention-deficit/hyperactivity disorder (ADHD); and “substance use
disorders,” including alcohol and drug abuse. Most met criteria for
more than one diagnosis. Of a subgroup affected within the previous
year, a third were under treatment—up from a fifth in a similar survey
ten years earlier.

Nowadays treatment by medical doctors nearly always means psychoactive
drugs, that is, drugs that affect the mental state. In fact, most
psychiatrists treat only with drugs, and refer patients to
psychologists or social workers if they believe psychotherapy is also
warranted. The shift from “talk therapy” to drugs as the dominant mode
of treatment coincides with the emergence over the past four decades
of the theory that mental illness is caused primarily by chemical
imbalances in the brain that can be corrected by specific drugs. That
theory became broadly accepted, by the media and the public as well as
by the medical profession, after Prozac came to market in 1987 and was
intensively promoted as a corrective for a deficiency of serotonin in
the brain. The number of people treated for depression tripled in the
following ten years, and about 10 percent of Americans over age six
now take antidepressants. The increased use of drugs to treat
psychosis is even more dramatic. The new generation of antipsychotics,
such as Risperdal, Zyprexa, and Seroquel, has replaced
cholesterol-lowering agents as the top-selling class of drugs in the
US.

What is going on here? Is the prevalence of mental illness really that
high and still climbing? Particularly if these disorders are
biologically determined and not a result of environmental influences,
is it plausible to suppose that such an increase is real? Or are we
learning to recognize and diagnose mental disorders that were always
there? On the other hand, are we simply expanding the criteria for
mental illness so that nearly everyone has one? And what about the
drugs that are now the mainstay of treatment? Do they work? If they
do, shouldn’t we expect the prevalence of mental illness to be
declining, not rising?

These are the questions, among others, that concern the authors of the
three provocative books under review here. They come at the questions
from different backgrounds—Irving Kirsch is a psychologist at the
University of Hull in the UK, Robert Whitaker a journalist and
previously the author of a history of the treatment of mental illness
called Mad in America (2001), and Daniel Carlat a psychiatrist who
practices in a Boston suburb and publishes a newsletter and blog about
his profession.

The authors emphasize different aspects of the epidemic of mental
illness. Kirsch is concerned with whether antidepressants work.
Whitaker, who has written an angrier book, takes on the entire
spectrum of mental illness and asks whether psychoactive drugs create
worse problems than they solve. Carlat, who writes more in sorrow than
in anger, looks mainly at how his profession has allied itself with,
and is manipulated by, the pharmaceutical industry. But despite their
differences, all three are in remarkable agreement on some important
matters, and they have documented their views well.

First, they agree on the disturbing extent to which the companies that
sell psychoactive drugs—through various forms of marketing, both legal
and illegal, and what many people would describe as bribery—have come
to determine what constitutes a mental illness and how the disorders
should be diagnosed and treated. This is a subject to which I’ll
return.

Second, none of the three authors subscribes to the popular theory
that mental illness is caused by a chemical imbalance in the brain. As
Whitaker tells the story, that theory had its genesis shortly after
psychoactive drugs were introduced in the 1950s. The first was
Thorazine (chlorpromazine), which was launched in 1954 as a “major
tranquilizer” and quickly found widespread use in mental hospitals to
calm psychotic patients, mainly those with schizophrenia. Thorazine
was followed the next year by Miltown (meprobamate), sold as a “minor
tranquilizer” to treat anxiety in outpatients. And in 1957, Marsilid
(iproniazid) came on the market as a “psychic energizer” to treat
depression.

In the space of three short years, then, drugs had become available to
treat what at that time were regarded as the three major categories of
mental illness—psychosis, anxiety, and depression—and the face of
psychiatry was totally transformed. These drugs, however, had not
initially been developed to treat mental illness. They had been
derived from drugs meant to treat infections, and were found only
serendipitously to alter the mental state. At first, no one had any
idea how they worked. They simply blunted disturbing mental symptoms.
But over the next decade, researchers found that these drugs, and the
newer psychoactive drugs that quickly followed, affected the levels of
certain chemicals in the brain.

Some brief—and necessarily quite simplified—background: the brain
contains billions of nerve cells, called neurons, arrayed in immensely
complicated networks and communicating with one another constantly.
The typical neuron has multiple filamentous extensions, one called an
axon and the others called dendrites, through which it sends and
receives signals from other neurons. For one neuron to communicate
with another, however, the signal must be transmitted across the tiny
space separating them, called a synapse. To accomplish that, the axon
of the sending neuron releases a chemical, called a neurotransmitter,
into the synapse. The neurotransmitter crosses the synapse and
attaches to receptors on the second neuron, often a dendrite, thereby
activating or inhibiting the receiving cell. Axons have multiple
terminals, so each neuron has multiple synapses. Afterward, the
neurotransmitter is either reabsorbed by the first neuron or
metabolized by enzymes so that the status quo ante is restored. There
are exceptions and variations to this story, but that is the usual way
neurons communicate with one another.

When it was found that psychoactive drugs affect neurotransmitter
levels in the brain, as evidenced mainly by the levels of their
breakdown products in the spinal fluid, the theory arose that the
cause of mental illness is an abnormality in the brain’s concentration
of these chemicals that is specifically countered by the appropriate
drug. For example, because Thorazine was found to lower dopamine
levels in the brain, it was postulated that psychoses like
schizophrenia are caused by too much dopamine. Or later, because
certain antidepressants increase levels of the neurotransmitter
serotonin in the brain, it was postulated that depression is caused by
too little serotonin. (These antidepressants, like Prozac or Celexa,
are called selective serotonin reuptake inhibitors (SSRIs) because
they prevent the reabsorption of serotonin by the neurons that release
it, so that more remains in the synapses to activate other neurons.)
Thus, instead of developing a drug to treat an abnormality, an
abnormality was postulated to fit a drug.

That was a great leap in logic, as all three authors point out. It was
entirely possible that drugs that affected neurotransmitter levels
could relieve symptoms even if neurotransmitters had nothing to do
with the illness in the first place (and even possible that they
relieved symptoms through some other mode of action entirely). As
Carlat puts it, “By this same logic one could argue that the cause of
all pain conditions is a deficiency of opiates, since narcotic pain
medications activate opiate receptors in the brain.” Or similarly, one
could argue that fevers are caused by too little aspirin.

But the main problem with the theory is that after decades of trying
to prove it, researchers have still come up empty-handed. All three
authors document the failure of scientists to find good evidence in
its favor. Neurotransmitter function seems to be normal in people with
mental illness before treatment. In Whitaker’s words:

   Prior to treatment, patients diagnosed with schizophrenia,
depression, and other psychiatric disorders do not suffer from any
known “chemical imbalance.” However, once a person is put on a
psychiatric medication, which, in one manner or another, throws a
wrench into the usual mechanics of a neuronal pathway, his or her
brain begins to function…abnormally.

Carlat refers to the chemical imbalance theory as a “myth” (which he
calls “convenient” because it destigmatizes mental illness), and
Kirsch, whose book focuses on depression, sums up this way: “It now
seems beyond question that the traditional account of depression as a
chemical imbalance in the brain is simply wrong.” Why the theory
persists despite the lack of evidence is a subject I’ll come to.

Do the drugs work? After all, regardless of the theory, that is the
practical question. In his spare, remarkably engrossing book, The
Emperor’s New Drugs, Kirsch describes his fifteen-year scientific
quest to answer that question about antidepressants. When he began his
work in 1995, his main interest was in the effects of placebos. To
study them, he and a colleague reviewed thirty-eight published
clinical trials that compared various treatments for depression with
placebos, or compared psychotherapy with no treatment. Most such
trials last for six to eight weeks, and during that time, patients
tend to improve somewhat even without any treatment. But Kirsch found
that placebos were three times as effective as no treatment. That
didn’t particularly surprise him. What did surprise him was the fact
that antidepressants were only marginally better than placebos. As
judged by scales used to measure depression, placebos were 75 percent
as effective as antidepressants. Kirsch then decided to repeat his
study by examining a more complete and standardized data set.

The data he used were obtained from the US Food and Drug
Administration (FDA) instead of the published literature. When drug
companies seek approval from the FDA to market a new drug, they must
submit to the agency all clinical trials they have sponsored. The
trials are usually double-blind and placebo-controlled, that is, the
participating patients are randomly assigned to either drug or
placebo, and neither they nor their doctors know which they have been
assigned. The patients are told only that they will receive an active
drug or a placebo, and they are also told of any side effects they
might experience. If two trials show that the drug is more effective
than a placebo, the drug is generally approved. But companies may
sponsor as many trials as they like, most of which could be
negative—that is, fail to show effectiveness. All they need is two
positive ones. (The results of trials of the same drug can differ for
many reasons, including the way the trial is designed and conducted,
its size, and the types of patients studied.)

For obvious reasons, drug companies make very sure that their positive
studies are published in medical journals and doctors know about them,
while the negative ones often languish unseen within the FDA, which
regards them as proprietary and therefore confidential. This practice
greatly biases the medical literature, medical education, and
treatment decisions.

Kirsch and his colleagues used the Freedom of Information Act to
obtain FDA reviews of all placebo-controlled clinical trials, whether
positive or negative, submitted for the initial approval of the six
most widely used antidepressant drugs approved between 1987 and
1999—Prozac, Paxil, Zoloft, Celexa, Serzone, and Effexor. This was a
better data set than the one used in his previous study, not only
because it included negative studies but because the FDA sets uniform
quality standards for the trials it reviews and not all of the
published research in Kirsch’s earlier study had been submitted to the
FDA as part of a drug approval application.

Altogether, there were forty-two trials of the six drugs. Most of them
were negative. Overall, placebos were 82 percent as effective as the
drugs, as measured by the Hamilton Depression Scale (HAM-D), a widely
used score of symptoms of depression. The average difference between
drug and placebo was only 1.8 points on the HAM-D, a difference that,
while statistically significant, was clinically meaningless. The
results were much the same for all six drugs: they were all equally
unimpressive. Yet because the positive studies were extensively
publicized, while the negative ones were hidden, the public and the
medical profession came to believe that these drugs were highly
effective antidepressants.

Kirsch was also struck by another unexpected finding. In his earlier
study and in work by others, he observed that even treatments that
were not considered to be antidepressants—such as synthetic thyroid
hormone, opiates, sedatives, stimulants, and some herbal remedies—were
as effective as antidepressants in alleviating the symptoms of
depression. Kirsch writes, “When administered as antidepressants,
drugs that increase, decrease or have no effect on serotonin all
relieve depression to about the same degree.” What all these
“effective” drugs had in common was that they produced side effects,
which participating patients had been told they might experience.

It is important that clinical trials, particularly those dealing with
subjective conditions like depression, remain double-blind, with
neither patients nor doctors knowing whether or not they are getting a
placebo. That prevents both patients and doctors from imagining
improvements that are not there, something that is more likely if they
believe the agent being administered is an active drug instead of a
placebo. Faced with his findings that nearly any pill with side
effects was slightly more effective in treating depression than an
inert placebo, Kirsch speculated that the presence of side effects in
individuals receiving drugs enabled them to guess correctly that they
were getting active treatment—and this was borne out by interviews
with patients and doctors—which made them more likely to report
improvement. He suggests that the reason antidepressants appear to
work better in relieving severe depression than in less severe cases
is that patients with severe symptoms are likely to be on higher doses
and therefore experience more side effects.

To further investigate whether side effects bias responses, Kirsch
looked at some trials that employed “active” placebos instead of inert
ones. An active placebo is one that itself produces side effects, such
as atropine—a drug that selectively blocks the action of certain types
of nerve fibers. Although not an antidepressant, atropine causes,
among other things, a noticeably dry mouth. In trials using atropine
as the placebo, there was no difference between the antidepressant and
the active placebo. Everyone had side effects of one type or another,
and everyone reported the same level of improvement. Kirsch reported a
number of other odd findings in clinical trials of antidepressants,
including the fact that there is no dose-response curve—that is, high
doses worked no better than low ones—which is extremely unlikely for
truly effective drugs. “Putting all this together,” writes Kirsch,

   leads to the conclusion that the relatively small difference
between drugs and placebos might not be a real drug effect at all.
Instead, it might be an enhanced placebo effect, produced by the fact
that some patients have broken [the] blind and have come to realize
whether they were given drug or placebo. If this is the case, then
there is no real antidepressant drug effect at all. Rather than
comparing placebo to drug, we have been comparing “regular” placebos
to “extra-strength” placebos.

That is a startling conclusion that flies in the face of widely
accepted medical opinion, but Kirsch reaches it in a careful, logical
way. Psychiatrists who use antidepressants—and that’s most of them—and
patients who take them might insist that they know from clinical
experience that the drugs work. But anecdotes are known to be a
treacherous way to evaluate medical treatments, since they are so
subject to bias; they can suggest hypotheses to be studied, but they
cannot prove them. That is why the development of the double-blind,
randomized, placebo-controlled clinical trial in the middle of the
past century was such an important advance in medical science.
Anecdotes about leeches or laetrile or megadoses of vitamin C, or any
number of other popular treatments, could not stand up to the scrutiny
of well-designed trials. Kirsch is a faithful proponent of the
scientific method, and his voice therefore brings a welcome
objectivity to a subject often swayed by anecdotes, emotions, or, as
we will see, self-interest.

Whitaker’s book is broader and more polemical. He considers all mental
illness, not just depression. Whereas Kirsch concludes that
antidepressants are probably no more effective than placebos, Whitaker
concludes that they and most of the other psychoactive drugs are not
only ineffective but harmful. He begins by observing that even as drug
treatment for mental illness has skyrocketed, so has the prevalence of
the conditions treated:

   The number of disabled mentally ill has risen dramatically since
1955, and during the past two decades, a period when the prescribing
of psychiatric medications has exploded, the number of adults and
children disabled by mental illness has risen at a mind-boggling rate.
Thus we arrive at an obvious question, even though it is heretical in
kind: Could our drug-based paradigm of care, in some unforeseen way,
be fueling this modern-day plague?

Moreover, Whitaker contends, the natural history of mental illness has
changed. Whereas conditions such as schizophrenia and depression were
once mainly self-limited or episodic, with each episode usually
lasting no more than six months and interspersed with long periods of
normalcy, the conditions are now chronic and lifelong. Whitaker
believes that this might be because drugs, even those that relieve
symptoms in the short term, cause long-term mental harms that continue
after the underlying illness would have naturally resolved.

The evidence he marshals for this theory varies in quality. He doesn’t
sufficiently acknowledge the difficulty of studying the natural
history of any illness over a fifty-some-year time span during which
many circumstances have changed, in addition to drug use. It is even
more difficult to compare long-term outcomes in treated versus
untreated patients, since treatment may be more likely in those with
more severe disease at the outset. Nevertheless, Whitaker’s evidence
is suggestive, if not conclusive.

If psychoactive drugs do cause harm, as Whitaker contends, what is the
mechanism? The answer, he believes, lies in their effects on
neurotransmitters. It is well understood that psychoactive drugs
disturb neurotransmitter function, even if that was not the cause of
the illness in the first place. Whitaker describes a chain of effects.
When, for example, an SSRI antidepressant like Celexa increases
serotonin levels in synapses, it stimulates compensatory changes
through a process called negative feedback. In response to the high
levels of serotonin, the neurons that secrete it (presynaptic neurons)
release less of it, and the postsynaptic neurons become desensitized
to it. In effect, the brain is trying to nullify the drug’s effects.
The same is true for drugs that block neurotransmitters, except in
reverse. For example, most antipsychotic drugs block dopamine, but the
presynaptic neurons compensate by releasing more of it, and the
postsynaptic neurons take it up more avidly. (This explanation is
necessarily oversimplified, since many psychoactive drugs affect more
than one of the many neurotransmitters.)

With long-term use of psychoactive drugs, the result is, in the words
of Steve Hyman, a former director of the NIMH and until recently
provost of Harvard University, “substantial and long-lasting
alterations in neural function.” As quoted by Whitaker, the brain,
Hyman wrote, begins to function in a manner “qualitatively as well as
quantitatively different from the normal state.” After several weeks
on psychoactive drugs, the brain’s compensatory efforts begin to fail,
and side effects emerge that reflect the mechanism of action of the
drugs. For example, the SSRIs may cause episodes of mania, because of
the excess of serotonin. Antipsychotics cause side effects that
resemble Parkinson’s disease, because of the depletion of dopamine
(which is also depleted in Parkinson’s disease). As side effects
emerge, they are often treated by other drugs, and many patients end
up on a cocktail of psychoactive drugs prescribed for a cocktail of
diagnoses. The episodes of mania caused by antidepressants may lead to
a new diagnosis of “bipolar disorder” and treatment with a “mood
stabilizer,” such as Depokote (an anticonvulsant) plus one of the
newer antipsychotic drugs. And so on.

Some patients take as many as six psychoactive drugs daily. One well-
respected researcher, Nancy Andreasen, and her colleagues published
evidence that the use of antipsychotic drugs is associated with
shrinkage of the brain, and that the effect is directly related to the
dose and duration of treatment. As Andreasen explained to The New York
Times, “The prefrontal cortex doesn’t get the input it needs and is
being shut down by drugs. That reduces the psychotic symptoms. It also
causes the prefrontal cortex to slowly atrophy.”*

Getting off the drugs is exceedingly difficult, according to Whitaker,
because when they are withdrawn the compensatory mechanisms are left
unopposed. When Celexa is withdrawn, serotonin levels fall
precipitously because the presynaptic neurons are not releasing normal
amounts and the postsynaptic neurons no longer have enough receptors
for it. Similarly, when an antipsychotic is withdrawn, dopamine levels
may skyrocket. The symptoms produced by withdrawing psychoactive drugs
are often confused with relapses of the original disorder, which can
lead psychiatrists to resume drug treatment, perhaps at higher doses.

Unlike the cool Kirsch, Whitaker is outraged by what he sees as an
iatrogenic (i.e., inadvertent and medically introduced) epidemic of
brain dysfunction, particularly that caused by the widespread use of
the newer (“atypical”) antipsychotics, such as Zyprexa, which cause
serious side effects. Here is what he calls his “quick thought
experiment”:

   Imagine that a virus suddenly appears in our society that makes
people sleep twelve, fourteen hours a day. Those infected with it move
about somewhat slowly and seem emotionally disengaged. Many gain huge
amounts of weight—twenty, forty, sixty, and even one hundred pounds.
Often their blood sugar levels soar, and so do their cholesterol
levels. A number of those struck by the mysterious illness—including
young children and teenagers—become diabetic in fairly short order….
The federal government gives hundreds of millions of dollars to
scientists at the best universities to decipher the inner workings of
this virus, and they report that the reason it causes such global
dysfunction is that it blocks a multitude of neurotransmitter
receptors in the brain—dopaminergic, serotonergic, muscarinic,
adrenergic, and histaminergic. All of those neuronal pathways in the
brain are compromised. Meanwhile, MRI studies find that over a period
of several years, the virus shrinks the cerebral cortex, and this
shrinkage is tied to cognitive decline. A terrified public clamors for
a cure.

   Now such an illness has in fact hit millions of American children
and adults. We have just described the effects of Eli Lilly’s
best-selling antipsychotic, Zyprexa.

If psychoactive drugs are useless, as Kirsch believes about
antidepressants, or worse than useless, as Whitaker believes, why are
they so widely prescribed by psychiatrists and regarded by the public
and the profession as something akin to wonder drugs? Why is the
current against which Kirsch and Whitaker and, as we will see, Carlat
are swimming so powerful? I discuss these questions in Part II of this
review.

—This is the first part of a two-part article.

(FYI, Marcia Angell, M.D.,  the author of this essay, is on the
faculty of Harvard Medical School and is the former Editor of the New
England Journal of Medicine.)

The Epidemic of Mental Illness: Why?
New York Review of Books, June 23, 2011
Author: Marcia Angell
(A Review Essay of the Following Books)

The Emperor’s New Drugs: Exploding the Antidepressant Myth
by Irving Kirsch
Basic Books, 226 pp., $15.99 (paper)

Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the
Astonishing Rise of Mental Illness in America
by Robert Whitaker
Crown, 404 pp., $26.00

Unhinged: The Trouble With Psychiatry—A Doctor’s Revelations About a
Profession in Crisis
by Daniel Carlat
Free Press, 256 pp., $25.00


It seems that Americans are in the midst of a raging epidemic of
mental illness, at least as judged by the increase in the numbers
treated for it. The tally of those who are so disabled by mental
disorders that they qualify for Supplemental Security Income (SSI) or
Social Security Disability Insurance (SSDI) increased nearly two and a
half times between 1987 and 2007—from one in 184 Americans to one in
seventy-six. For children, the rise is even more startling—a
thirty-five-fold increase in the same two decades. Mental illness is
now the leading cause of disability in children, well ahead of
physical disabilities like cerebral palsy or Down syndrome, for which
the federal programs were created.

A large survey of randomly selected adults, sponsored by the National
Institute of Mental Health (NIMH) and conducted between 2001 and 2003,
found that an astonishing 46 percent met criteria established by the
American Psychiatric Association (APA) for having had at least one
mental illness within four broad categories at some time in their
lives. The categories were “anxiety disorders,” including, among other
subcategories, phobias and post-traumatic stress disorder (PTSD);
“mood disorders,” including major depression and bipolar disorders;
“impulse-control disorders,” including various behavioral problems and
attention-deficit/hyperactivity disorder (ADHD); and “substance use
disorders,” including alcohol and drug abuse. Most met criteria for
more than one diagnosis. Of a subgroup affected within the previous
year, a third were under treatment—up from a fifth in a similar survey
ten years earlier.

Nowadays treatment by medical doctors nearly always means psychoactive
drugs, that is, drugs that affect the mental state. In fact, most
psychiatrists treat only with drugs, and refer patients to
psychologists or social workers if they believe psychotherapy is also
warranted. The shift from “talk therapy” to drugs as the dominant mode
of treatment coincides with the emergence over the past four decades
of the theory that mental illness is caused primarily by chemical
imbalances in the brain that can be corrected by specific drugs. That
theory became broadly accepted, by the media and the public as well as
by the medical profession, after Prozac came to market in 1987 and was
intensively promoted as a corrective for a deficiency of serotonin in
the brain. The number of people treated for depression tripled in the
following ten years, and about 10 percent of Americans over age six
now take antidepressants. The increased use of drugs to treat
psychosis is even more dramatic. The new generation of antipsychotics,
such as Risperdal, Zyprexa, and Seroquel, has replaced
cholesterol-lowering agents as the top-selling class of drugs in the
US.

What is going on here? Is the prevalence of mental illness really that
high and still climbing? Particularly if these disorders are
biologically determined and not a result of environmental influences,
is it plausible to suppose that such an increase is real? Or are we
learning to recognize and diagnose mental disorders that were always
there? On the other hand, are we simply expanding the criteria for
mental illness so that nearly everyone has one? And what about the
drugs that are now the mainstay of treatment? Do they work? If they
do, shouldn’t we expect the prevalence of mental illness to be
declining, not rising?

These are the questions, among others, that concern the authors of the
three provocative books under review here. They come at the questions
from different backgrounds—Irving Kirsch is a psychologist at the
University of Hull in the UK, Robert Whitaker a journalist and
previously the author of a history of the treatment of mental illness
called Mad in America (2001), and Daniel Carlat a psychiatrist who
practices in a Boston suburb and publishes a newsletter and blog about
his profession.

The authors emphasize different aspects of the epidemic of mental
illness. Kirsch is concerned with whether antidepressants work.
Whitaker, who has written an angrier book, takes on the entire
spectrum of mental illness and asks whether psychoactive drugs create
worse problems than they solve. Carlat, who writes more in sorrow than
in anger, looks mainly at how his profession has allied itself with,
and is manipulated by, the pharmaceutical industry. But despite their
differences, all three are in remarkable agreement on some important
matters, and they have documented their views well.

First, they agree on the disturbing extent to which the companies that
sell psychoactive drugs—through various forms of marketing, both legal
and illegal, and what many people would describe as bribery—have come
to determine what constitutes a mental illness and how the disorders
should be diagnosed and treated. This is a subject to which I’ll
return.

Second, none of the three authors subscribes to the popular theory
that mental illness is caused by a chemical imbalance in the brain. As
Whitaker tells the story, that theory had its genesis shortly after
psychoactive drugs were introduced in the 1950s. The first was
Thorazine (chlorpromazine), which was launched in 1954 as a “major
tranquilizer” and quickly found widespread use in mental hospitals to
calm psychotic patients, mainly those with schizophrenia. Thorazine
was followed the next year by Miltown (meprobamate), sold as a “minor
tranquilizer” to treat anxiety in outpatients. And in 1957, Marsilid
(iproniazid) came on the market as a “psychic energizer” to treat
depression.

In the space of three short years, then, drugs had become available to
treat what at that time were regarded as the three major categories of
mental illness—psychosis, anxiety, and depression—and the face of
psychiatry was totally transformed. These drugs, however, had not
initially been developed to treat mental illness. They had been
derived from drugs meant to treat infections, and were found only
serendipitously to alter the mental state. At first, no one had any
idea how they worked. They simply blunted disturbing mental symptoms.
But over the next decade, researchers found that these drugs, and the
newer psychoactive drugs that quickly followed, affected the levels of
certain chemicals in the brain.

Some brief—and necessarily quite simplified—background: the brain
contains billions of nerve cells, called neurons, arrayed in immensely
complicated networks and communicating with one another constantly.
The typical neuron has multiple filamentous extensions, one called an
axon and the others called dendrites, through which it sends and
receives signals from other neurons. For one neuron to communicate
with another, however, the signal must be transmitted across the tiny
space separating them, called a synapse. To accomplish that, the axon
of the sending neuron releases a chemical, called a neurotransmitter,
into the synapse. The neurotransmitter crosses the synapse and
attaches to receptors on the second neuron, often a dendrite, thereby
activating or inhibiting the receiving cell. Axons have multiple
terminals, so each neuron has multiple synapses. Afterward, the
neurotransmitter is either reabsorbed by the first neuron or
metabolized by enzymes so that the status quo ante is restored. There
are exceptions and variations to this story, but that is the usual way
neurons communicate with one another.

When it was found that psychoactive drugs affect neurotransmitter
levels in the brain, as evidenced mainly by the levels of their
breakdown products in the spinal fluid, the theory arose that the
cause of mental illness is an abnormality in the brain’s concentration
of these chemicals that is specifically countered by the appropriate
drug. For example, because Thorazine was found to lower dopamine
levels in the brain, it was postulated that psychoses like
schizophrenia are caused by too much dopamine. Or later, because
certain antidepressants increase levels of the neurotransmitter
serotonin in the brain, it was postulated that depression is caused by
too little serotonin. (These antidepressants, like Prozac or Celexa,
are called selective serotonin reuptake inhibitors (SSRIs) because
they prevent the reabsorption of serotonin by the neurons that release
it, so that more remains in the synapses to activate other neurons.)
Thus, instead of developing a drug to treat an abnormality, an
abnormality was postulated to fit a drug.

That was a great leap in logic, as all three authors point out. It was
entirely possible that drugs that affected neurotransmitter levels
could relieve symptoms even if neurotransmitters had nothing to do
with the illness in the first place (and even possible that they
relieved symptoms through some other mode of action entirely). As
Carlat puts it, “By this same logic one could argue that the cause of
all pain conditions is a deficiency of opiates, since narcotic pain
medications activate opiate receptors in the brain.” Or similarly, one
could argue that fevers are caused by too little aspirin.

But the main problem with the theory is that after decades of trying
to prove it, researchers have still come up empty-handed. All three
authors document the failure of scientists to find good evidence in
its favor. Neurotransmitter function seems to be normal in people with
mental illness before treatment. In Whitaker’s words:

   Prior to treatment, patients diagnosed with schizophrenia,
depression, and other psychiatric disorders do not suffer from any
known “chemical imbalance.” However, once a person is put on a
psychiatric medication, which, in one manner or another, throws a
wrench into the usual mechanics of a neuronal pathway, his or her
brain begins to function…abnormally.

Carlat refers to the chemical imbalance theory as a “myth” (which he
calls “convenient” because it destigmatizes mental illness), and
Kirsch, whose book focuses on depression, sums up this way: “It now
seems beyond question that the traditional account of depression as a
chemical imbalance in the brain is simply wrong.” Why the theory
persists despite the lack of evidence is a subject I’ll come to.

Do the drugs work? After all, regardless of the theory, that is the
practical question. In his spare, remarkably engrossing book, The
Emperor’s New Drugs, Kirsch describes his fifteen-year scientific
quest to answer that question about antidepressants. When he began his
work in 1995, his main interest was in the effects of placebos. To
study them, he and a colleague reviewed thirty-eight published
clinical trials that compared various treatments for depression with
placebos, or compared psychotherapy with no treatment. Most such
trials last for six to eight weeks, and during that time, patients
tend to improve somewhat even without any treatment. But Kirsch found
that placebos were three times as effective as no treatment. That
didn’t particularly surprise him. What did surprise him was the fact
that antidepressants were only marginally better than placebos. As
judged by scales used to measure depression, placebos were 75 percent
as effective as antidepressants. Kirsch then decided to repeat his
study by examining a more complete and standardized data set.

The data he used were obtained from the US Food and Drug
Administration (FDA) instead of the published literature. When drug
companies seek approval from the FDA to market a new drug, they must
submit to the agency all clinical trials they have sponsored. The
trials are usually double-blind and placebo-controlled, that is, the
participating patients are randomly assigned to either drug or
placebo, and neither they nor their doctors know which they have been
assigned. The patients are told only that they will receive an active
drug or a placebo, and they are also told of any side effects they
might experience. If two trials show that the drug is more effective
than a placebo, the drug is generally approved. But companies may
sponsor as many trials as they like, most of which could be
negative—that is, fail to show effectiveness. All they need is two
positive ones. (The results of trials of the same drug can differ for
many reasons, including the way the trial is designed and conducted,
its size, and the types of patients studied.)

For obvious reasons, drug companies make very sure that their positive
studies are published in medical journals and doctors know about them,
while the negative ones often languish unseen within the FDA, which
regards them as proprietary and therefore confidential. This practice
greatly biases the medical literature, medical education, and
treatment decisions.

Kirsch and his colleagues used the Freedom of Information Act to
obtain FDA reviews of all placebo-controlled clinical trials, whether
positive or negative, submitted for the initial approval of the six
most widely used antidepressant drugs approved between 1987 and
1999—Prozac, Paxil, Zoloft, Celexa, Serzone, and Effexor. This was a
better data set than the one used in his previous study, not only
because it included negative studies but because the FDA sets uniform
quality standards for the trials it reviews and not all of the
published research in Kirsch’s earlier study had been submitted to the
FDA as part of a drug approval application.

Altogether, there were forty-two trials of the six drugs. Most of them
were negative. Overall, placebos were 82 percent as effective as the
drugs, as measured by the Hamilton Depression Scale (HAM-D), a widely
used score of symptoms of depression. The average difference between
drug and placebo was only 1.8 points on the HAM-D, a difference that,
while statistically significant, was clinically meaningless. The
results were much the same for all six drugs: they were all equally
unimpressive. Yet because the positive studies were extensively
publicized, while the negative ones were hidden, the public and the
medical profession came to believe that these drugs were highly
effective antidepressants.

Kirsch was also struck by another unexpected finding. In his earlier
study and in work by others, he observed that even treatments that
were not considered to be antidepressants—such as synthetic thyroid
hormone, opiates, sedatives, stimulants, and some herbal remedies—were
as effective as antidepressants in alleviating the symptoms of
depression. Kirsch writes, “When administered as antidepressants,
drugs that increase, decrease or have no effect on serotonin all
relieve depression to about the same degree.” What all these
“effective” drugs had in common was that they produced side effects,
which participating patients had been told they might experience.

It is important that clinical trials, particularly those dealing with
subjective conditions like depression, remain double-blind, with
neither patients nor doctors knowing whether or not they are getting a
placebo. That prevents both patients and doctors from imagining
improvements that are not there, something that is more likely if they
believe the agent being administered is an active drug instead of a
placebo. Faced with his findings that nearly any pill with side
effects was slightly more effective in treating depression than an
inert placebo, Kirsch speculated that the presence of side effects in
individuals receiving drugs enabled them to guess correctly that they
were getting active treatment—and this was borne out by interviews
with patients and doctors—which made them more likely to report
improvement. He suggests that the reason antidepressants appear to
work better in relieving severe depression than in less severe cases
is that patients with severe symptoms are likely to be on higher doses
and therefore experience more side effects.

To further investigate whether side effects bias responses, Kirsch
looked at some trials that employed “active” placebos instead of inert
ones. An active placebo is one that itself produces side effects, such
as atropine—a drug that selectively blocks the action of certain types
of nerve fibers. Although not an antidepressant, atropine causes,
among other things, a noticeably dry mouth. In trials using atropine
as the placebo, there was no difference between the antidepressant and
the active placebo. Everyone had side effects of one type or another,
and everyone reported the same level of improvement. Kirsch reported a
number of other odd findings in clinical trials of antidepressants,
including the fact that there is no dose-response curve—that is, high
doses worked no better than low ones—which is extremely unlikely for
truly effective drugs. “Putting all this together,” writes Kirsch,

   leads to the conclusion that the relatively small difference
between drugs and placebos might not be a real drug effect at all.
Instead, it might be an enhanced placebo effect, produced by the fact
that some patients have broken [the] blind and have come to realize
whether they were given drug or placebo. If this is the case, then
there is no real antidepressant drug effect at all. Rather than
comparing placebo to drug, we have been comparing “regular” placebos
to “extra-strength” placebos.

That is a startling conclusion that flies in the face of widely
accepted medical opinion, but Kirsch reaches it in a careful, logical
way. Psychiatrists who use antidepressants—and that’s most of them—and
patients who take them might insist that they know from clinical
experience that the drugs work. But anecdotes are known to be a
treacherous way to evaluate medical treatments, since they are so
subject to bias; they can suggest hypotheses to be studied, but they
cannot prove them. That is why the development of the double-blind,
randomized, placebo-controlled clinical trial in the middle of the
past century was such an important advance in medical science.
Anecdotes about leeches or laetrile or megadoses of vitamin C, or any
number of other popular treatments, could not stand up to the scrutiny
of well-designed trials. Kirsch is a faithful proponent of the
scientific method, and his voice therefore brings a welcome
objectivity to a subject often swayed by anecdotes, emotions, or, as
we will see, self-interest.

Whitaker’s book is broader and more polemical. He considers all mental
illness, not just depression. Whereas Kirsch concludes that
antidepressants are probably no more effective than placebos, Whitaker
concludes that they and most of the other psychoactive drugs are not
only ineffective but harmful. He begins by observing that even as drug
treatment for mental illness has skyrocketed, so has the prevalence of
the conditions treated:

   The number of disabled mentally ill has risen dramatically since
1955, and during the past two decades, a period when the prescribing
of psychiatric medications has exploded, the number of adults and
children disabled by mental illness has risen at a mind-boggling rate.
Thus we arrive at an obvious question, even though it is heretical in
kind: Could our drug-based paradigm of care, in some unforeseen way,
be fueling this modern-day plague?

Moreover, Whitaker contends, the natural history of mental illness has
changed. Whereas conditions such as schizophrenia and depression were
once mainly self-limited or episodic, with each episode usually
lasting no more than six months and interspersed with long periods of
normalcy, the conditions are now chronic and lifelong. Whitaker
believes that this might be because drugs, even those that relieve
symptoms in the short term, cause long-term mental harms that continue
after the underlying illness would have naturally resolved.

The evidence he marshals for this theory varies in quality. He doesn’t
sufficiently acknowledge the difficulty of studying the natural
history of any illness over a fifty-some-year time span during which
many circumstances have changed, in addition to drug use. It is even
more difficult to compare long-term outcomes in treated versus
untreated patients, since treatment may be more likely in those with
more severe disease at the outset. Nevertheless, Whitaker’s evidence
is suggestive, if not conclusive.

If psychoactive drugs do cause harm, as Whitaker contends, what is the
mechanism? The answer, he believes, lies in their effects on
neurotransmitters. It is well understood that psychoactive drugs
disturb neurotransmitter function, even if that was not the cause of
the illness in the first place. Whitaker describes a chain of effects.
When, for example, an SSRI antidepressant like Celexa increases
serotonin levels in synapses, it stimulates compensatory changes
through a process called negative feedback. In response to the high
levels of serotonin, the neurons that secrete it (presynaptic neurons)
release less of it, and the postsynaptic neurons become desensitized
to it. In effect, the brain is trying to nullify the drug’s effects.
The same is true for drugs that block neurotransmitters, except in
reverse. For example, most antipsychotic drugs block dopamine, but the
presynaptic neurons compensate by releasing more of it, and the
postsynaptic neurons take it up more avidly. (This explanation is
necessarily oversimplified, since many psychoactive drugs affect more
than one of the many neurotransmitters.)

With long-term use of psychoactive drugs, the result is, in the words
of Steve Hyman, a former director of the NIMH and until recently
provost of Harvard University, “substantial and long-lasting
alterations in neural function.” As quoted by Whitaker, the brain,
Hyman wrote, begins to function in a manner “qualitatively as well as
quantitatively different from the normal state.” After several weeks
on psychoactive drugs, the brain’s compensatory efforts begin to fail,
and side effects emerge that reflect the mechanism of action of the
drugs. For example, the SSRIs may cause episodes of mania, because of
the excess of serotonin. Antipsychotics cause side effects that
resemble Parkinson’s disease, because of the depletion of dopamine
(which is also depleted in Parkinson’s disease). As side effects
emerge, they are often treated by other drugs, and many patients end
up on a cocktail of psychoactive drugs prescribed for a cocktail of
diagnoses. The episodes of mania caused by antidepressants may lead to
a new diagnosis of “bipolar disorder” and treatment with a “mood
stabilizer,” such as Depokote (an anticonvulsant) plus one of the
newer antipsychotic drugs. And so on.

Some patients take as many as six psychoactive drugs daily. One well-
respected researcher, Nancy Andreasen, and her colleagues published
evidence that the use of antipsychotic drugs is associated with
shrinkage of the brain, and that the effect is directly related to the
dose and duration of treatment. As Andreasen explained to The New York
Times, “The prefrontal cortex doesn’t get the input it needs and is
being shut down by drugs. That reduces the psychotic symptoms. It also
causes the prefrontal cortex to slowly atrophy.”*

Getting off the drugs is exceedingly difficult, according to Whitaker,
because when they are withdrawn the compensatory mechanisms are left
unopposed. When Celexa is withdrawn, serotonin levels fall
precipitously because the presynaptic neurons are not releasing normal
amounts and the postsynaptic neurons no longer have enough receptors
for it. Similarly, when an antipsychotic is withdrawn, dopamine levels
may skyrocket. The symptoms produced by withdrawing psychoactive drugs
are often confused with relapses of the original disorder, which can
lead psychiatrists to resume drug treatment, perhaps at higher doses.

Unlike the cool Kirsch, Whitaker is outraged by what he sees as an
iatrogenic (i.e., inadvertent and medically introduced) epidemic of
brain dysfunction, particularly that caused by the widespread use of
the newer (“atypical”) antipsychotics, such as Zyprexa, which cause
serious side effects. Here is what he calls his “quick thought
experiment”:

   Imagine that a virus suddenly appears in our society that makes
people sleep twelve, fourteen hours a day. Those infected with it move
about somewhat slowly and seem emotionally disengaged. Many gain huge
amounts of weight—twenty, forty, sixty, and even one hundred pounds.
Often their blood sugar levels soar, and so do their cholesterol
levels. A number of those struck by the mysterious illness—including
young children and teenagers—become diabetic in fairly short order….
The federal government gives hundreds of millions of dollars to
scientists at the best universities to decipher the inner workings of
this virus, and they report that the reason it causes such global
dysfunction is that it blocks a multitude of neurotransmitter
receptors in the brain—dopaminergic, serotonergic, muscarinic,
adrenergic, and histaminergic. All of those neuronal pathways in the
brain are compromised. Meanwhile, MRI studies find that over a period
of several years, the virus shrinks the cerebral cortex, and this
shrinkage is tied to cognitive decline. A terrified public clamors for
a cure.

   Now such an illness has in fact hit millions of American children
and adults. We have just described the effects of Eli Lilly’s
best-selling antipsychotic, Zyprexa.

If psychoactive drugs are useless, as Kirsch believes about
antidepressants, or worse than useless, as Whitaker believes, why are
they so widely prescribed by psychiatrists and regarded by the public
and the profession as something akin to wonder drugs? Why is the
current against which Kirsch and Whitaker and, as we will see, Carlat
are swimming so powerful? I discuss these questions in Part II of this
review.

—This is the first part of a two-part article.

(FYI, Marcia Angell, M.D.,  the author of this essay, is on the
faculty of Harvard Medical School and is the former Editor of the New
England Journal of Medicine.)

The Epidemic of Mental Illness: Why?
New York Review of Books, June 23, 2011
Author: Marcia Angell
(A Review Essay of the Following Books)

The Emperor’s New Drugs: Exploding the Antidepressant Myth
by Irving Kirsch
Basic Books, 226 pp., $15.99 (paper)

Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the
Astonishing Rise of Mental Illness in America
by Robert Whitaker
Crown, 404 pp., $26.00

Unhinged: The Trouble With Psychiatry—A Doctor’s Revelations About a
Profession in Crisis
by Daniel Carlat
Free Press, 256 pp., $25.00


It seems that Americans are in the midst of a raging epidemic of
mental illness, at least as judged by the increase in the numbers
treated for it. The tally of those who are so disabled by mental
disorders that they qualify for Supplemental Security Income (SSI) or
Social Security Disability Insurance (SSDI) increased nearly two and a
half times between 1987 and 2007—from one in 184 Americans to one in
seventy-six. For children, the rise is even more startling—a
thirty-five-fold increase in the same two decades. Mental illness is
now the leading cause of disability in children, well ahead of
physical disabilities like cerebral palsy or Down syndrome, for which
the federal programs were created.

A large survey of randomly selected adults, sponsored by the National
Institute of Mental Health (NIMH) and conducted between 2001 and 2003,
found that an astonishing 46 percent met criteria established by the
American Psychiatric Association (APA) for having had at least one
mental illness within four broad categories at some time in their
lives. The categories were “anxiety disorders,” including, among other
subcategories, phobias and post-traumatic stress disorder (PTSD);
“mood disorders,” including major depression and bipolar disorders;
“impulse-control disorders,” including various behavioral problems and
attention-deficit/hyperactivity disorder (ADHD); and “substance use
disorders,” including alcohol and drug abuse. Most met criteria for
more than one diagnosis. Of a subgroup affected within the previous
year, a third were under treatment—up from a fifth in a similar survey
ten years earlier.

Nowadays treatment by medical doctors nearly always means psychoactive
drugs, that is, drugs that affect the mental state. In fact, most
psychiatrists treat only with drugs, and refer patients to
psychologists or social workers if they believe psychotherapy is also
warranted. The shift from “talk therapy” to drugs as the dominant mode
of treatment coincides with the emergence over the past four decades
of the theory that mental illness is caused primarily by chemical
imbalances in the brain that can be corrected by specific drugs. That
theory became broadly accepted, by the media and the public as well as
by the medical profession, after Prozac came to market in 1987 and was
intensively promoted as a corrective for a deficiency of serotonin in
the brain. The number of people treated for depression tripled in the
following ten years, and about 10 percent of Americans over age six
now take antidepressants. The increased use of drugs to treat
psychosis is even more dramatic. The new generation of antipsychotics,
such as Risperdal, Zyprexa, and Seroquel, has replaced
cholesterol-lowering agents as the top-selling class of drugs in the
US.

What is going on here? Is the prevalence of mental illness really that
high and still climbing? Particularly if these disorders are
biologically determined and not a result of environmental influences,
is it plausible to suppose that such an increase is real? Or are we
learning to recognize and diagnose mental disorders that were always
there? On the other hand, are we simply expanding the criteria for
mental illness so that nearly everyone has one? And what about the
drugs that are now the mainstay of treatment? Do they work? If they
do, shouldn’t we expect the prevalence of mental illness to be
declining, not rising?

These are the questions, among others, that concern the authors of the
three provocative books under review here. They come at the questions
from different backgrounds—Irving Kirsch is a psychologist at the
University of Hull in the UK, Robert Whitaker a journalist and
previously the author of a history of the treatment of mental illness
called Mad in America (2001), and Daniel Carlat a psychiatrist who
practices in a Boston suburb and publishes a newsletter and blog about
his profession.

The authors emphasize different aspects of the epidemic of mental
illness. Kirsch is concerned with whether antidepressants work.
Whitaker, who has written an angrier book, takes on the entire
spectrum of mental illness and asks whether psychoactive drugs create
worse problems than they solve. Carlat, who writes more in sorrow than
in anger, looks mainly at how his profession has allied itself with,
and is manipulated by, the pharmaceutical industry. But despite their
differences, all three are in remarkable agreement on some important
matters, and they have documented their views well.

First, they agree on the disturbing extent to which the companies that
sell psychoactive drugs—through various forms of marketing, both legal
and illegal, and what many people would describe as bribery—have come
to determine what constitutes a mental illness and how the disorders
should be diagnosed and treated. This is a subject to which I’ll
return.

Second, none of the three authors subscribes to the popular theory
that mental illness is caused by a chemical imbalance in the brain. As
Whitaker tells the story, that theory had its genesis shortly after
psychoactive drugs were introduced in the 1950s. The first was
Thorazine (chlorpromazine), which was launched in 1954 as a “major
tranquilizer” and quickly found widespread use in mental hospitals to
calm psychotic patients, mainly those with schizophrenia. Thorazine
was followed the next year by Miltown (meprobamate), sold as a “minor
tranquilizer” to treat anxiety in outpatients. And in 1957, Marsilid
(iproniazid) came on the market as a “psychic energizer” to treat
depression.

In the space of three short years, then, drugs had become available to
treat what at that time were regarded as the three major categories of
mental illness—psychosis, anxiety, and depression—and the face of
psychiatry was totally transformed. These drugs, however, had not
initially been developed to treat mental illness. They had been
derived from drugs meant to treat infections, and were found only
serendipitously to alter the mental state. At first, no one had any
idea how they worked. They simply blunted disturbing mental symptoms.
But over the next decade, researchers found that these drugs, and the
newer psychoactive drugs that quickly followed, affected the levels of
certain chemicals in the brain.

Some brief—and necessarily quite simplified—background: the brain
contains billions of nerve cells, called neurons, arrayed in immensely
complicated networks and communicating with one another constantly.
The typical neuron has multiple filamentous extensions, one called an
axon and the others called dendrites, through which it sends and
receives signals from other neurons. For one neuron to communicate
with another, however, the signal must be transmitted across the tiny
space separating them, called a synapse. To accomplish that, the axon
of the sending neuron releases a chemical, called a neurotransmitter,
into the synapse. The neurotransmitter crosses the synapse and
attaches to receptors on the second neuron, often a dendrite, thereby
activating or inhibiting the receiving cell. Axons have multiple
terminals, so each neuron has multiple synapses. Afterward, the
neurotransmitter is either reabsorbed by the first neuron or
metabolized by enzymes so that the status quo ante is restored. There
are exceptions and variations to this story, but that is the usual way
neurons communicate with one another.

When it was found that psychoactive drugs affect neurotransmitter
levels in the brain, as evidenced mainly by the levels of their
breakdown products in the spinal fluid, the theory arose that the
cause of mental illness is an abnormality in the brain’s concentration
of these chemicals that is specifically countered by the appropriate
drug. For example, because Thorazine was found to lower dopamine
levels in the brain, it was postulated that psychoses like
schizophrenia are caused by too much dopamine. Or later, because
certain antidepressants increase levels of the neurotransmitter
serotonin in the brain, it was postulated that depression is caused by
too little serotonin. (These antidepressants, like Prozac or Celexa,
are called selective serotonin reuptake inhibitors (SSRIs) because
they prevent the reabsorption of serotonin by the neurons that release
it, so that more remains in the synapses to activate other neurons.)
Thus, instead of developing a drug to treat an abnormality, an
abnormality was postulated to fit a drug.

That was a great leap in logic, as all three authors point out. It was
entirely possible that drugs that affected neurotransmitter levels
could relieve symptoms even if neurotransmitters had nothing to do
with the illness in the first place (and even possible that they
relieved symptoms through some other mode of action entirely). As
Carlat puts it, “By this same logic one could argue that the cause of
all pain conditions is a deficiency of opiates, since narcotic pain
medications activate opiate receptors in the brain.” Or similarly, one
could argue that fevers are caused by too little aspirin.

But the main problem with the theory is that after decades of trying
to prove it, researchers have still come up empty-handed. All three
authors document the failure of scientists to find good evidence in
its favor. Neurotransmitter function seems to be normal in people with
mental illness before treatment. In Whitaker’s words:

   Prior to treatment, patients diagnosed with schizophrenia,
depression, and other psychiatric disorders do not suffer from any
known “chemical imbalance.” However, once a person is put on a
psychiatric medication, which, in one manner or another, throws a
wrench into the usual mechanics of a neuronal pathway, his or her
brain begins to function…abnormally.

Carlat refers to the chemical imbalance theory as a “myth” (which he
calls “convenient” because it destigmatizes mental illness), and
Kirsch, whose book focuses on depression, sums up this way: “It now
seems beyond question that the traditional account of depression as a
chemical imbalance in the brain is simply wrong.” Why the theory
persists despite the lack of evidence is a subject I’ll come to.

Do the drugs work? After all, regardless of the theory, that is the
practical question. In his spare, remarkably engrossing book, The
Emperor’s New Drugs, Kirsch describes his fifteen-year scientific
quest to answer that question about antidepressants. When he began his
work in 1995, his main interest was in the effects of placebos. To
study them, he and a colleague reviewed thirty-eight published
clinical trials that compared various treatments for depression with
placebos, or compared psychotherapy with no treatment. Most such
trials last for six to eight weeks, and during that time, patients
tend to improve somewhat even without any treatment. But Kirsch found
that placebos were three times as effective as no treatment. That
didn’t particularly surprise him. What did surprise him was the fact
that antidepressants were only marginally better than placebos. As
judged by scales used to measure depression, placebos were 75 percent
as effective as antidepressants. Kirsch then decided to repeat his
study by examining a more complete and standardized data set.

The data he used were obtained from the US Food and Drug
Administration (FDA) instead of the published literature. When drug
companies seek approval from the FDA to market a new drug, they must
submit to the agency all clinical trials they have sponsored. The
trials are usually double-blind and placebo-controlled, that is, the
participating patients are randomly assigned to either drug or
placebo, and neither they nor their doctors know which they have been
assigned. The patients are told only that they will receive an active
drug or a placebo, and they are also told of any side effects they
might experience. If two trials show that the drug is more effective
than a placebo, the drug is generally approved. But companies may
sponsor as many trials as they like, most of which could be
negative—that is, fail to show effectiveness. All they need is two
positive ones. (The results of trials of the same drug can differ for
many reasons, including the way the trial is designed and conducted,
its size, and the types of patients studied.)

For obvious reasons, drug companies make very sure that their positive
studies are published in medical journals and doctors know about them,
while the negative ones often languish unseen within the FDA, which
regards them as proprietary and therefore confidential. This practice
greatly biases the medical literature, medical education, and
treatment decisions.

Kirsch and his colleagues used the Freedom of Information Act to
obtain FDA reviews of all placebo-controlled clinical trials, whether
positive or negative, submitted for the initial approval of the six
most widely used antidepressant drugs approved between 1987 and
1999—Prozac, Paxil, Zoloft, Celexa, Serzone, and Effexor. This was a
better data set than the one used in his previous study, not only
because it included negative studies but because the FDA sets uniform
quality standards for the trials it reviews and not all of the
published research in Kirsch’s earlier study had been submitted to the
FDA as part of a drug approval application.

Altogether, there were forty-two trials of the six drugs. Most of them
were negative. Overall, placebos were 82 percent as effective as the
drugs, as measured by the Hamilton Depression Scale (HAM-D), a widely
used score of symptoms of depression. The average difference between
drug and placebo was only 1.8 points on the HAM-D, a difference that,
while statistically significant, was clinically meaningless. The
results were much the same for all six drugs: they were all equally
unimpressive. Yet because the positive studies were extensively
publicized, while the negative ones were hidden, the public and the
medical profession came to believe that these drugs were highly
effective antidepressants.

Kirsch was also struck by another unexpected finding. In his earlier
study and in work by others, he observed that even treatments that
were not considered to be antidepressants—such as synthetic thyroid
hormone, opiates, sedatives, stimulants, and some herbal remedies—were
as effective as antidepressants in alleviating the symptoms of
depression. Kirsch writes, “When administered as antidepressants,
drugs that increase, decrease or have no effect on serotonin all
relieve depression to about the same degree.” What all these
“effective” drugs had in common was that they produced side effects,
which participating patients had been told they might experience.

It is important that clinical trials, particularly those dealing with
subjective conditions like depression, remain double-blind, with
neither patients nor doctors knowing whether or not they are getting a
placebo. That prevents both patients and doctors from imagining
improvements that are not there, something that is more likely if they
believe the agent being administered is an active drug instead of a
placebo. Faced with his findings that nearly any pill with side
effects was slightly more effective in treating depression than an
inert placebo, Kirsch speculated that the presence of side effects in
individuals receiving drugs enabled them to guess correctly that they
were getting active treatment—and this was borne out by interviews
with patients and doctors—which made them more likely to report
improvement. He suggests that the reason antidepressants appear to
work better in relieving severe depression than in less severe cases
is that patients with severe symptoms are likely to be on higher doses
and therefore experience more side effects.

To further investigate whether side effects bias responses, Kirsch
looked at some trials that employed “active” placebos instead of inert
ones. An active placebo is one that itself produces side effects, such
as atropine—a drug that selectively blocks the action of certain types
of nerve fibers. Although not an antidepressant, atropine causes,
among other things, a noticeably dry mouth. In trials using atropine
as the placebo, there was no difference between the antidepressant and
the active placebo. Everyone had side effects of one type or another,
and everyone reported the same level of improvement. Kirsch reported a
number of other odd findings in clinical trials of antidepressants,
including the fact that there is no dose-response curve—that is, high
doses worked no better than low ones—which is extremely unlikely for
truly effective drugs. “Putting all this together,” writes Kirsch,

   leads to the conclusion that the relatively small difference
between drugs and placebos might not be a real drug effect at all.
Instead, it might be an enhanced placebo effect, produced by the fact
that some patients have broken [the] blind and have come to realize
whether they were given drug or placebo. If this is the case, then
there is no real antidepressant drug effect at all. Rather than
comparing placebo to drug, we have been comparing “regular” placebos
to “extra-strength” placebos.

That is a startling conclusion that flies in the face of widely
accepted medical opinion, but Kirsch reaches it in a careful, logical
way. Psychiatrists who use antidepressants—and that’s most of them—and
patients who take them might insist that they know from clinical
experience that the drugs work. But anecdotes are known to be a
treacherous way to evaluate medical treatments, since they are so
subject to bias; they can suggest hypotheses to be studied, but they
cannot prove them. That is why the development of the double-blind,
randomized, placebo-controlled clinical trial in the middle of the
past century was such an important advance in medical science.
Anecdotes about leeches or laetrile or megadoses of vitamin C, or any
number of other popular treatments, could not stand up to the scrutiny
of well-designed trials. Kirsch is a faithful proponent of the
scientific method, and his voice therefore brings a welcome
objectivity to a subject often swayed by anecdotes, emotions, or, as
we will see, self-interest.

Whitaker’s book is broader and more polemical. He considers all mental
illness, not just depression. Whereas Kirsch concludes that
antidepressants are probably no more effective than placebos, Whitaker
concludes that they and most of the other psychoactive drugs are not
only ineffective but harmful. He begins by observing that even as drug
treatment for mental illness has skyrocketed, so has the prevalence of
the conditions treated:

   The number of disabled mentally ill has risen dramatically since
1955, and during the past two decades, a period when the prescribing
of psychiatric medications has exploded, the number of adults and
children disabled by mental illness has risen at a mind-boggling rate.
Thus we arrive at an obvious question, even though it is heretical in
kind: Could our drug-based paradigm of care, in some unforeseen way,
be fueling this modern-day plague?

Moreover, Whitaker contends, the natural history of mental illness has
changed. Whereas conditions such as schizophrenia and depression were
once mainly self-limited or episodic, with each episode usually
lasting no more than six months and interspersed with long periods of
normalcy, the conditions are now chronic and lifelong. Whitaker
believes that this might be because drugs, even those that relieve
symptoms in the short term, cause long-term mental harms that continue
after the underlying illness would have naturally resolved.

The evidence he marshals for this theory varies in quality. He doesn’t
sufficiently acknowledge the difficulty of studying the natural
history of any illness over a fifty-some-year time span during which
many circumstances have changed, in addition to drug use. It is even
more difficult to compare long-term outcomes in treated versus
untreated patients, since treatment may be more likely in those with
more severe disease at the outset. Nevertheless, Whitaker’s evidence
is suggestive, if not conclusive.

If psychoactive drugs do cause harm, as Whitaker contends, what is the
mechanism? The answer, he believes, lies in their effects on
neurotransmitters. It is well understood that psychoactive drugs
disturb neurotransmitter function, even if that was not the cause of
the illness in the first place. Whitaker describes a chain of effects.
When, for example, an SSRI antidepressant like Celexa increases
serotonin levels in synapses, it stimulates compensatory changes
through a process called negative feedback. In response to the high
levels of serotonin, the neurons that secrete it (presynaptic neurons)
release less of it, and the postsynaptic neurons become desensitized
to it. In effect, the brain is trying to nullify the drug’s effects.
The same is true for drugs that block neurotransmitters, except in
reverse. For example, most antipsychotic drugs block dopamine, but the
presynaptic neurons compensate by releasing more of it, and the
postsynaptic neurons take it up more avidly. (This explanation is
necessarily oversimplified, since many psychoactive drugs affect more
than one of the many neurotransmitters.)

With long-term use of psychoactive drugs, the result is, in the words
of Steve Hyman, a former director of the NIMH and until recently
provost of Harvard University, “substantial and long-lasting
alterations in neural function.” As quoted by Whitaker, the brain,
Hyman wrote, begins to function in a manner “qualitatively as well as
quantitatively different from the normal state.” After several weeks
on psychoactive drugs, the brain’s compensatory efforts begin to fail,
and side effects emerge that reflect the mechanism of action of the
drugs. For example, the SSRIs may cause episodes of mania, because of
the excess of serotonin. Antipsychotics cause side effects that
resemble Parkinson’s disease, because of the depletion of dopamine
(which is also depleted in Parkinson’s disease). As side effects
emerge, they are often treated by other drugs, and many patients end
up on a cocktail of psychoactive drugs prescribed for a cocktail of
diagnoses. The episodes of mania caused by antidepressants may lead to
a new diagnosis of “bipolar disorder” and treatment with a “mood
stabilizer,” such as Depokote (an anticonvulsant) plus one of the
newer antipsychotic drugs. And so on.

Some patients take as many as six psychoactive drugs daily. One well-
respected researcher, Nancy Andreasen, and her colleagues published
evidence that the use of antipsychotic drugs is associated with
shrinkage of the brain, and that the effect is directly related to the
dose and duration of treatment. As Andreasen explained to The New York
Times, “The prefrontal cortex doesn’t get the input it needs and is
being shut down by drugs. That reduces the psychotic symptoms. It also
causes the prefrontal cortex to slowly atrophy.”*

Getting off the drugs is exceedingly difficult, according to Whitaker,
because when they are withdrawn the compensatory mechanisms are left
unopposed. When Celexa is withdrawn, serotonin levels fall
precipitously because the presynaptic neurons are not releasing normal
amounts and the postsynaptic neurons no longer have enough receptors
for it. Similarly, when an antipsychotic is withdrawn, dopamine levels
may skyrocket. The symptoms produced by withdrawing psychoactive drugs
are often confused with relapses of the original disorder, which can
lead psychiatrists to resume drug treatment, perhaps at higher doses.

Unlike the cool Kirsch, Whitaker is outraged by what he sees as an
iatrogenic (i.e., inadvertent and medically introduced) epidemic of
brain dysfunction, particularly that caused by the widespread use of
the newer (“atypical”) antipsychotics, such as Zyprexa, which cause
serious side effects. Here is what he calls his “quick thought
experiment”:

   Imagine that a virus suddenly appears in our society that makes
people sleep twelve, fourteen hours a day. Those infected with it move
about somewhat slowly and seem emotionally disengaged. Many gain huge
amounts of weight—twenty, forty, sixty, and even one hundred pounds.
Often their blood sugar levels soar, and so do their cholesterol
levels. A number of those struck by the mysterious illness—including
young children and teenagers—become diabetic in fairly short order….
The federal government gives hundreds of millions of dollars to
scientists at the best universities to decipher the inner workings of
this virus, and they report that the reason it causes such global
dysfunction is that it blocks a multitude of neurotransmitter
receptors in the brain—dopaminergic, serotonergic, muscarinic,
adrenergic, and histaminergic. All of those neuronal pathways in the
brain are compromised. Meanwhile, MRI studies find that over a period
of several years, the virus shrinks the cerebral cortex, and this
shrinkage is tied to cognitive decline. A terrified public clamors for
a cure.

   Now such an illness has in fact hit millions of American children
and adults. We have just described the effects of Eli Lilly’s
best-selling antipsychotic, Zyprexa.

If psychoactive drugs are useless, as Kirsch believes about
antidepressants, or worse than useless, as Whitaker believes, why are
they so widely prescribed by psychiatrists and regarded by the public
and the profession as something akin to wonder drugs? Why is the
current against which Kirsch and Whitaker and, as we will see, Carlat
are swimming so powerful? I discuss these questions in Part II of this
review.

—This is the first part of a two-part article.




Stumbling Into Bad Behavior
By MAX H. BAZERMAN and ANN E. TENBRUNSEL
New York Times, April 20, 2011

IT’S easy to look at big names like Warren E. Buffett, and big companies like Ernst and Young, and be judgmental. Of course they overlooked ethical lapses. Why wouldn’t they? That’s business.
Regulators, prosecutors and journalists tend to focus on corruption caused by willful actions or ignorance. But in our research, and in the work of other scholars who study the psychology of behavioral ethics, we have found that much unethical conduct that goes on, whether in social life or work life, happens because people are unconsciously fooling themselves. They overlook transgressions — bending a rule to help a colleague, overlooking information that might damage the reputation of a client — because it is in their interest to do so.
When we are busy focused on common organizational goals, like quarterly earnings or sales quotas, the ethical implications of important decisions can fade from our minds. Through this ethical fading, we end up engaging in or condoning behavior that we would condemn if we were consciously aware of it.
The underlying psychology helps explain why ethical lapses in the corporate world seem so pervasive and intractable. It also explains why sanctions, like fines and penalties, can have the perverse effect of increasing the undesirable behaviors they are designed to discourage.
In one study, published in 1999, participants were asked to play the role of a manufacturer in an industry known for emitting toxic gas. The participants were told that their industry was under pressure from environmentalists. To ward off potential legislation, the manufacturers had reached a voluntary but costly agreement to run equipment that would limit the toxic emissions. Some participants were told they would face modest financial sanctions if they broke the agreement; others were told they would face no sanctions if they did.
An economic analysis would predict that the threat of sanctions would increase compliance with the agreement. Instead, participants who faced a potential fine cheated more, not less, than those who faced no sanctions. With no penalty, the situation was construed as an ethical dilemma; the penalty caused individuals to view the decision as a financial one.
When we fail to notice that a decision has an ethical component, we are able to behave unethically while maintaining a positive self-image. No wonder, then, that our research shows that people consistently believe themselves to be more ethical than they are.
In addition to preventing us from noticing our own unethical conduct, ethical fading causes us to overlook the unethical behavior of others. In the run-up to the financial crisis, corporate boards, auditing firms, credit-rating agencies and other parties had easy access to damning data that they should have noticed and reported. Yet they didn’t do so, at least in part because of “motivated blindness” — the tendency to overlook information that works against one’s best interest. Ample research shows that people who have a vested self-interest, even the most honest among us, have difficulty being objective. Worse yet, they fail to recognize their lack of objectivity.
In one experiment for a study published last year, student participants were asked to estimate a fictitious company’s value. They were assigned one of four roles: buyer, seller, buyer’s auditor or seller’s auditor. All participants read the same information, including an array of data to help them estimate the firm’s worth. Not surprisingly, sellers provided higher estimates of the company’s worth than buyers did. More interestingly, the auditors, who were advising either a buyer or a seller, were also strongly biased toward the interests of their clients.
Rather than making a conscious decision to favor their clients, the auditors incorporated information about the company in a biased way — with the sellers’ auditors providing estimates that were 30 percent higher, on average, than the estimates of auditors who served buyers. The study was replicated, with actual auditors from one of the “Big Four” accounting firms, and with similar results.
A solution often advocated for this lack of objectivity is to increase transparency through disclosure of conflicts of interest. But a 2005 study by Daylian M. Cain, George Loewenstein and Don A. Moore found that disclosure can exacerbate such conflicts by causing people to feel absolved of their duty to be objective. Moreover, such disclosure causes its “victims” to be even more trusting, to their detriment.
Our legal system often focuses on whether unethical behavior represents “willful misconduct” or “gross negligence.” Typically people are only held accountable if their unethical decisions appear to have been intentional — and of course, if they consciously make such decisions, they should be. But unintentional influences on unethical behavior can have equally damaging outcomes.
Our confidence in our own integrity is frequently overrated. Good people unknowingly contribute to unethical actions, so reforms need to address the often hidden influences on our behavior. Auditors should only audit; they should not be allowed to sell other services or profit from pleasing their customers. Similarly, if we want credit-rating agencies to be objective, they need to keep an appropriate distance from the issuers of the securities they assess. True reform needs to go beyond fines and disclosures; if we are to truly eliminate conflicts of interest we must understand the psychology behind them.
Max H. Bazerman, a professor of business administration at Harvard, and Ann E. Tenbrunsel, a professor of management at the University of Notre Dame, are the authors of “Blind Spots: Why We Fail to Do What’s Right and What to Do About It.”


Radical jihadism is not a mental disorder
By Stephen N.Xenakis Washington Post, Sunday, December 5, 2010;
The case of Omar Khadr was the first war crimes prosecution of the Obama administration, and it could set a dangerous precedent for how mental health professionals are used in terrorism trials.

I attended the proceedings in October - the first American tribunal for a child soldier since World War II - because I had been working with Khadr's defense team for two years. I am a child and adolescent psychiatrist and a retired Army brigadier general; the defense had asked me to evaluate Khadr's physical and mental health, as well as adviser on military procedure.

As I listened to the prosecution's expert testimony depicting Khadr's state of mind, I was reminded of psychiatry and the politicization of mental health under the Soviet regime. Those were the years when political dissidents were accused of insanity simply because they had the audacity to challenge the Soviet system. The medical profession, especially psychiatry, was a political instrument of control and repression.

Prosecutors from the military and the Justice Department built their case against Khadr largely on testimony from their expert witness, forensic psychiatrist Michael Welner, whom they called upon to offer a medical opinion on Khadr's mental condition. Welner, a physician in private practice in New York and a professor at New York University, is developing the Depravity Scale, a tool that is intended to help juries judge the heinous or evil nature of a crime.

Painting a broad picture of the defendant, prosecutors portrayed Khadr as an unrepentant and dangerous warrior who threw a grenade that killed a special forces medic during a firefight in Afghanistan in 2002. Khadr was 15 years old at the time. Army medics saved his life after he was shot in the back twice and the compound where he lived was bombed to rubble.

During the trial, according to my notes and observations, Welner depicted Khadr as a continuing risk to society. "In my professional opinion, Omar Khadr is at a high risk of dangerousness as a radical jihadist," Welner said. Based on hundreds of hours of reviewing records and interviewing witnesses, and 7 to 8 hours of examining the prisoner, the doctor said he concluded that Khadr was a radical jihadist who was at risk of inspiring others to violent acts in the future.

But radical jihadism is not a clinical condition, and diagnosing it is not within the domain of psychiatric experts. Radical jihadism is an ideology - and can be embraced by the psychiatrically sane and insane alike.

Beyond being simply unscientific, however, the testimony had another troubling aspect. Welner relied, in part, on the research of a particularly egregious source: Danish educational psychologist Nicolai Sennels.

Welner noted that there are few academic or medical sources on the "future dangerousness" of "radical jihadists who have been apprehended and detained." Sennels, he said, is an exception. Welner described the lengthy conversation the two men had held and said his perspective was informed in part by Sennels's research on Muslim youth whom he treated as a prison psychologist. But Welner wasn't familiar with all of Sennels's written work. As the defense explained during cross-examination, Sennels is also known for inflammatory views on Islam, having claimed that "massive inbreeding within the Muslim culture during the last 1,400 years may have done catastrophic damage to their gene pool." Sennels has described the Koran as "a criminal book that forces people to do criminal things." Welner specifically repudiated these views in court.

In making its case against Khadr, the government relied on Welner's professional status as a forensic psychiatrist to put a scientific sheen on what were essentially lay opinions. The prosecutors depicted Khadr as a probably violent and radical charismatic leader. He had pleaded guilty to murder (albeit in a firefight when he was 15), was a devout Muslim and was well-liked by both detainees and guards, so he had to be dangerous. Through testimony disguised as expert psychiatric opinion, the prosecution portrayed Khadr as having "marinated" in jihadi thinking before and during his long internment at Guantanamo, and described him as a "rock star" who, as the son of a close lieutenant of Osama bin Laden's, enjoyed the adulation of other detainees.

How should Khadr be treated, then, according to the prosecution? He was a candidate for what they called "deradicalization," much like Saudi Arabia has carried out with other detainees who have returned from Guantanamo. Unfortunately, they noted, such programs are not available in the United States or Canada.

Khadr's attorneys, who were concerned that the trial could degenerate into a battle between experts, chose not to call the defense mental health experts who know him well. That means I didn't get to take the stand. If I had, I would have said - without violating the confidentiality of my work for more than two years with Khadr, and after spending more than 200 clinical hours with him - that he does not need "deradicalization" and does not show any proclivity toward committing terrorist acts. What he needs and deserves is physical and mental health treatment. He suffered extensive wounds, had multiple surgeries, is blind in his left eye and lives with the aftereffects of his injuries and interrogations.

The defense opted instead to allow Khadr to make the statement that he wanted to make, believing that his words would be more powerful than anything a mental health expert could say. Khadr apologized to the medic's widow and gave a moving repudiation of hate and violence.

In the end, considerations about Khadr's mental health might not have mattered to the jury as they determined his sentence: 40 years in prison, though, per a plea bargain, he will serve no more than eight additional years at Guantanamo or in a Canadian prison.

The military panel also heard testimony from the medic's widow. She read a letter from her 11-year-old daughter, only four years younger than Khadr was when he threw the grenade, condemning him as a murderer. Her voice may have had more of an impact on Khadr's fate than Welner's testimony.

But a doctor's words, and the pseudoscience of radicalism, could have a particularly insidious effect. In totalitarian regimes, the government often exploited psychiatrists to label citizens as "enemies of the state" without substantive clinical data. I don't believe that happened here. Radical jihadism is a serious threat, and we must use every resource available to combat it. But we should be cautious that if we misuse the science of mental health in the process, we are slipping closer to those totalitarian states. And that could be a greater threat to our national security than Omar Khadr ever was.

Stephen N. Xenakis is a child and adolescent psychiatrist and a retired Army brigadier general.

The Myth of Charter Schools
New York Review of Books, November 11, 2010
Diane Ravitch

A Review Essay on the documentary "Waiting for ‘Superman"

Ordinarily, documentaries about education attract little attention,
and seldom, if ever, reach neighborhood movie theaters. Davis
Guggenheim’s Waiting for “Superman” is different. It arrived in late
September with the biggest publicity splash I have ever seen for a
documentary. Not only was it the subject of major stories in Time and
New York, but it was featured twice on The Oprah Winfrey Show and was
the centerpiece of several days of programming by NBC, including an
interview with President Obama.

Two other films expounding the same arguments—The Lottery and The
Cartel—were released in the late spring, but they received far less
attention than Guggenheim’s film. His reputation as the director of
the Academy Award–winning An Inconvenient Truth, about global warming, contributed to the anticipation surrounding Waiting for “Superman,”but the media frenzy suggested something more. Guggenheim presents the popularized version of an account of American public education that is promoted by some of the nation’s most powerful figures and institutions.

The message of these films has become alarmingly familiar: American
public education is a failed enterprise. The problem is not money.
Public schools already spend too much. Test scores are low because
there are so many bad teachers, whose jobs are protected by powerful
unions. Students drop out because the schools fail them, but they
could accomplish practically anything if they were saved from bad
teachers. They would get higher test scores if schools could fire more
bad teachers and pay more to good ones. The only hope for the future
of our society, especially for poor black and Hispanic children, is
escape from public schools, especially to charter schools, which are
mostly funded by the government but controlled by private
organizations, many of them operating to make a profit.

The Cartel maintains that we must not only create more charter
schools, but provide vouchers so that children can flee incompetent
public schools and attend private schools. There, we are led to
believe, teachers will be caring and highly skilled (unlike the lazy
dullards in public schools); the schools will have high expectations
and test scores will soar; and all children will succeed academically,
regardless of their circumstances. The Lottery echoes the main story
line of Waiting for “Superman”: it is about children who are desperate
to avoid the New York City public schools and eager to win a spot in a
shiny new charter school in Harlem.

For many people, these arguments require a willing suspension of
disbelief. Most Americans graduated from public schools, and most went
from school to college or the workplace without thinking that their
school had limited their life chances. There was a time—which now
seems distant—when most people assumed that students’ performance in
school was largely determined by their own efforts and by the
circumstances and support of their family, not by their teachers.
There were good teachers and mediocre teachers, even bad teachers, but
in the end, most public schools offered ample opportunity for
education to those willing to pursue it. The annual Gallup poll about
education shows that Americans are overwhelmingly dissatisfied with
the quality of the nation’s schools, but 77 percent of public school
parents award their own child’s public school a grade of A or B, the
highest level of approval since the question was first asked in 1985.

Waiting for “Superman” and the other films appeal to a broad
apprehension that the nation is falling behind in global competition.
If the economy is a shambles, if poverty persists for significant
segments of the population, if American kids are not as serious about
their studies as their peers in other nations, the schools must be to
blame. At last we have the culprit on which we can pin our anger, our
palpable sense that something is very wrong with our society, that we
are on the wrong track, and that America is losing the race for global
dominance. It is not globalization or deindustrialization or poverty
or our coarse popular culture or predatory financial practices that
bear responsibility: it’s the public schools, their teachers, and
their unions.

The inspiration for Waiting for “Superman” began, Guggenheim explains,
as he drove his own children to a private school, past the
neighborhood schools with low test scores. He wondered about the fate
of the children whose families did not have the choice of schools
available to his own children. What was the quality of their
education? He was sure it must be terrible. The press release for the
film says that he wondered, “How heartsick and worried did their
parents feel as they dropped their kids off this morning?” Guggenheim
is a graduate of Sidwell Friends, the elite private school in
Washington, D.C., where President Obama’s daughters are enrolled. The
public schools that he passed by each morning must have seemed as
hopeless and dreadful to him as the public schools in Washington that
his own parents had shunned.

Waiting for “Superman” tells the story of five children who enter a
lottery to win a coveted place in a charter school. Four of them seek
to escape the public schools; one was asked to leave a Catholic school
because her mother couldn’t afford the tuition. Four of the children
are black or Hispanic and live in gritty neighborhoods, while the one
white child lives in a leafy suburb. We come to know each of these
children and their families; we learn about their dreams for the
future; we see that they are lovable; and we identify with them. By
the end of the film, we are rooting for them as the day of the lottery
approaches.

In each of the schools to which they have applied, the odds against
them are large. Anthony, a fifth-grader in Washington, D.C., applies
to the SEED charter boarding school, where there are sixty-one
applicants for twenty-four places. Francisco is a first-grade student
in the Bronx whose mother (a social worker with a graduate degree) is
desperate to get him out of the New York City public schools and into
a charter school; she applies to Harlem Success Academy where he is
one of 792 applicants for forty places. Bianca is the kindergarten
student in Harlem whose mother cannot afford Catholic school tuition;
she enters the lottery at another Harlem Success Academy, as one of
767 students competing for thirty-five openings. Daisy is a
fifth-grade student in East Los Angeles whose parents hope she can win
a spot at KIPP LA PREP, where 135 students have applied for ten
places. Emily is an eighth-grade student in Silicon Valley, where the
local high school has gorgeous facilities, high graduation rates, and
impressive test scores, but her family worries that she will be
assigned to a slow track because of her low test scores; so they enter
the lottery for Summit Preparatory Charter High School, where she is
one of 455 students competing for 110 places.

The stars of the film are Geoffrey Canada, the CEO of the Harlem
Children’s Zone, which provides a broad variety of social services to
families and children and runs two charter schools; Michelle Rhee,
chancellor of the Washington, D.C., public school system, who closed
schools, fired teachers and principals, and gained a national
reputation for her tough policies; David Levin and Michael Feinberg,
who have built a network of nearly one hundred high-performing KIPP
charter schools over the past sixteen years; and Randi Weingarten,
president of the American Federation of Teachers, who is cast in the
role of chief villain. Other charter school leaders, like Steve Barr
of the Green Dot chain in Los Angeles, do star turns, as does Bill
Gates of Microsoft, whose foundation has invested many millions of
dollars in expanding the number of charter schools. No successful
public school teacher or principal or superintendent appears in the
film; indeed there is no mention of any successful public school, only
the incessant drumbeat on the theme of public school failure.

The situation is dire, the film warns us. We must act. But what must
we do? The message of the film is clear. Public schools are bad,
privately managed charter schools are good. Parents clamor to get
their children out of the public schools in New York City (despite the
claims by Mayor Michael Bloomberg that the city’s schools are better
than ever) and into the charters (the mayor also plans to double the
number of charters, to help more families escape from the public
schools that he controls). If we could fire the bottom 5 to 10 percent
of the lowest-performing teachers every year, says Hoover Institution
economist Eric Hanushek in the film, our national test scores would
soon approach the top of international rankings in mathematics and
science.

Some fact-checking is in order, and the place to start is with the
film’s quiet acknowledgment that only one in five charter schools is
able to get the “amazing results” that it celebrates. Nothing more is
said about this astonishing statistic. It is drawn from a national
study of charter schools by Stanford economist Margaret Raymond (the
wife of Hanushek). Known as the CREDO study, it evaluated student
progress on math tests in half the nation’s five thousand charter
schools and concluded that 17 percent were superior to a matched
traditional public school; 37 percent were worse than the public
school; and the remaining 46 percent had academic gains no different
from that of a similar public school. The proportion of charters that
get amazing results is far smaller than 17 percent.Why did Davis
Guggenheim pay no attention to the charter schools that are run by
incompetent leaders or corporations mainly concerned to make money?
Why propound to an unknowing public the myth that charter schools are
the answer to our educational woes, when the filmmaker knows that
there are twice as many failing charters as there are successful ones?
Why not give an honest accounting?

The propagandistic nature of Waiting for “Superman” is revealed by
Guggenheim’s complete indifference to the wide variation among charter
schools. There are excellent charter schools, just as there are
excellent public schools. Why did he not also inquire into the charter
chains that are mired in unsavory real estate deals, or take his
camera to the charters where most students are getting lower scores
than those in the neighborhood public schools? Why did he not report
on the charter principals who have been indicted for embezzlement, or
the charters that blur the line between church and state? Why did he
not look into the charter schools whose leaders are paid
$300,000–$400,000 a year to oversee small numbers of schools and
students?

Guggenheim seems to believe that teachers alone can overcome the
effects of student poverty, even though there are countless studies
that demonstrate the link between income and test scores. He shows us
footage of the pilot Chuck Yeager breaking the sound barrier, to the
amazement of people who said it couldn’t be done. Since Yeager broke
the sound barrier, we should be prepared to believe that able teachers
are all it takes to overcome the disadvantages of poverty,
homelessness, joblessness, poor nutrition, absent parents, etc.

The movie asserts a central thesis in today’s school reform
discussion: the idea that teachers are the most important factor
determining student achievement. But this proposition is false.
Hanushek has released studies showing that teacher quality accounts
for about 7.5–10 percent of student test score gains. Several other
high-quality analyses echo this finding, and while estimates vary a
bit, there is a relative consensus: teachers statistically account for
around 10–20 percent of achievement outcomes. Teachers are the most
important factor within schools.

But the same body of research shows that nonschool factors matter even
more than teachers. According to University of Washington economist
Dan Goldhaber, about 60 percent of achievement is explained by
nonschool factors, such as family income. So while teachers are the
most important factor within schools, their effects pale in comparison
with those of students’ backgrounds, families, and other factors
beyond the control of schools and teachers. Teachers can have a
profound effect on students, but it would be foolish to believe that
teachers alone can undo the damage caused by poverty and its
associated burdens.

Guggenheim skirts the issue of poverty by showing only families that
are intact and dedicated to helping their children succeed. One of the
children he follows is raised by a doting grandmother; two have single
mothers who are relentless in seeking better education for them; two
of them live with a mother and father. Nothing is said about children
whose families are not available, for whatever reason, to support
them, or about children who are homeless, or children with special
needs. Nor is there any reference to the many charter schools that
enroll disproportionately small numbers of children who are
English-language learners or have disabilities.

The film never acknowledges that charter schools were created mainly
at the instigation of Albert Shanker, the president of the American
Federation of Teachers from 1974 to 1997. Shanker had the idea in 1988
that a group of public school teachers would ask their colleagues for
permission to create a small school that would focus on the neediest
students, those who had dropped out and those who were disengaged from school and likely to drop out. He sold the idea as a way to open
schools that would collaborate with public schools and help motivate
disengaged students. In 1993, Shanker turned against the charter
school idea when he realized that for-profit organizations saw it as a
business opportunity and were advancing an agenda of school
privatization. Michelle Rhee gained her teaching experience in
Baltimore as an employee of Education Alternatives, Inc., one of the
first of the for-profit operations.

Today, charter schools are promoted not as ways to collaborate with
public schools but as competitors that will force them to get better
or go out of business. In fact, they have become the force for
privatization that Shanker feared. Because of the high-stakes testing
regime created by President George W. Bush’s No Child Left Behind
(NCLB) legislation, charter schools compete to get higher test scores
than regular public schools and thus have an incentive to avoid
students who might pull down their scores. Under NCLB, low-performing
schools may be closed, while high-performing ones may get bonuses.
Some charter schools “counsel out” or expel students just before state
testing day. Some have high attrition rates, especially among
lower-performing students.

Perhaps the greatest distortion in this film is its misrepresentation
of data about student academic performance. The film claims that 70
percent of eighth-grade students cannot read at grade level. This is
flatly wrong. Guggenheim here relies on numbers drawn from the
federally sponsored National Assessment of Educational Progress
(NAEP). I served as a member of the governing board for the national
tests for seven years, and I know how misleading Guggenheim’s figures
are. NAEP doesn’t measure performance in terms of grade-level
achievement. The highest level of performance, “advanced,” is
equivalent to an A+, representing the highest possible academic
performance. The next level, “proficient,” is equivalent to an A or a
very strong B. The next level is “basic,” which probably translates
into a C grade. The film assumes that any student below proficient is
“below grade level.” But it would be far more fitting to worry about
students who are “below basic,” who are 25 percent of the national
sample, not 70 percent.

Guggenheim didn’t bother to take a close look at the heroes of his
documentary. Geoffrey Canada is justly celebrated for the creation of
the Harlem Children’s Zone, which not only runs two charter schools
but surrounds children and their families with a broad array of social
and medical services. Canada has a board of wealthy philanthropists
and a very successful fund-raising apparatus. With assets of more than
$200 million, his organization has no shortage of funds. Canada
himself is currently paid $400,000 annually. For Guggenheim to praise
Canada while also claiming that public schools don’t need any more
money is bizarre. Canada’s charter schools get better results than
nearby public schools serving impoverished students. If all inner-city
schools had the same resources as his, they might get the same good
results.

But contrary to the myth that Guggenheim propounds about “amazing
results,” even Geoffrey Canada’s schools have many students who are
not proficient. On the 2010 state tests, 60 percent of the
fourth-grade students in one of his charter schools were not
proficient in reading, nor were 50 percent in the other. It should be
noted—and Guggenheim didn’t note it—that Canada kicked out his entire
first class of middle school students when they didn’t get good enough
test scores to satisfy his board of trustees. This sad event was
documented by Paul Tough in his laudatory account of Canada’s Harlem
Children’s Zone, Whatever It Takes (2009). Contrary to Guggenheim’s
mythology, even the best-funded charters, with the finest services,
can’t completely negate the effects of poverty.

Guggenheim ignored other clues that might have gotten in the way of a
good story. While blasting the teachers’ unions, he points to Finland
as a nation whose educational system the US should emulate, not
bothering to explain that it has a completely unionized teaching
force. His documentary showers praise on testing and accountability,
yet he does not acknowledge that Finland seldom tests its students.
Any Finnish educator will say that Finland improved its public
education system not by privatizing its schools or constantly testing
its students, but by investing in the preparation, support, and
retention of excellent teachers. It achieved its present eminence not
by systematically firing 5–10 percent of its teachers, but by
patiently building for the future. Finland has a national curriculum,
which is not restricted to the basic skills of reading and math, but
includes the arts, sciences, history, foreign languages, and other
subjects that are essential to a good, rounded education. Finland also
strengthened its social welfare programs for children and families.
Guggenheim simply ignores the realities of the Finnish system.

In any school reform proposal, the question of “scalability” always
arises. Can reforms be reproduced on a broad scale? The fact that one
school produces amazing results is not in itself a demonstration that
every other school can do the same. For example, Guggenheim holds up
Locke High School in Los Angeles, part of the Green Dot charter chain,
as a success story but does not tell the whole story. With an infusion
of $15 million of mostly private funding, Green Dot produced a safer,
cleaner campus, but no more than tiny improvements in its students’
abysmal test scores. According to the Los Angeles Times, the
percentage of its students proficient in English rose from 13.7
percent in 2009 to 14.9 percent in 2010, while in math the proportion
of proficient students grew from 4 percent to 6.7 percent. What can be
learned from this small progress? Becoming a charter is no guarantee
that a school serving a tough neighborhood will produce educational
miracles.

Another highly praised school that is featured in the film is the SEED
charter boarding school in Washington, D.C. SEED seems to deserve all
the praise that it receives from Guggenheim, CBS’s 60 Minutes, and
elsewhere. It has remarkable rates of graduation and college
acceptance. But SEED spends $35,000 per student, as compared to
average current spending for public schools of about one third that
amount. Is our society prepared to open boarding schools for tens of
thousands of inner-city students and pay what it costs to copy the
SEED model? Those who claim that better education for the neediest
students won’t require more money cannot use SEED to support their
argument.

Guggenheim seems to demand that public schools start firing “bad”
teachers so they can get the great results that one of every five
charter schools gets. But he never explains how difficult it is to
identify “bad” teachers. If one looks only at test scores, teachers in
affluent suburbs get higher ones. If one uses student gains or losses
as a general measure, then those who teach the neediest
children—English-language learners, troubled students, autistic
students—will see the smallest gains, and teachers will have an
incentive to avoid districts and classes with large numbers of the
neediest students.

Ultimately the job of hiring teachers, evaluating them, and deciding
who should stay and who should go falls to administrators. We should
be taking a close look at those who award due process rights (the
accurate term for “tenure”) to too many incompetent teachers. The best
way to ensure that there are no bad or ineffective teachers in our
public schools is to insist that we have principals and supervisors
who are knowledgeable and experienced educators. Yet there is
currently a vogue to recruit and train principals who have little or
no education experience. (The George W. Bush Institute just announced
its intention to train 50,000 new principals in the next decade and to
recruit noneducators for this sensitive post.)

Waiting for “Superman” is the most important public-relations coup
that the critics of public education have made so far. Their power is
not to be underestimated. For years, right-wing critics demanded
vouchers and got nowhere. Now, many of them are watching in amazement as their ineffectual attacks on “government schools” and their
advocacy of privately managed schools with public funding have become
the received wisdom among liberal elites. Despite their uneven record,
charter schools have the enthusiastic endorsement of the Obama
administration, the Gates Foundation, the Broad Foundation, and the
Dell Foundation. In recent months, The New York Times has published
three stories about how charter schools have become the favorite cause
of hedge fund executives. According to the Times, when Andrew Cuomo
wanted to tap into Wall Street money for his gubernatorial campaign,
he had to meet with the executive director of Democrats for Education
Reform (DFER), a pro-charter group.

Dominated by hedge fund managers who control billions of dollars, DFER
has contributed heavily to political candidates for local and state
offices who pledge to promote charter schools. (Its efforts to unseat
incumbents in three predominantly black State Senate districts in New
York City came to nothing; none of its hand-picked candidates received
as much as 30 percent of the vote in the primary elections, even with
the full-throated endorsement of the city’s tabloids.) Despite the
loss of local elections and the defeat of Washington, D.C. Mayor
Adrian Fenty (who had appointed the controversial schools chancellor
Michelle Rhee), the combined clout of these groups, plus the enormous
power of the federal government and the uncritical support of the
major media, presents a serious challenge to the viability and future
of public education.

It bears mentioning that nations with high-performing school
systems—whether Korea, Singapore, Finland, or Japan—have succeeded not by privatizing their schools or closing those with low scores, but by
strengthening the education profession. They also have less poverty
than we do. Fewer than 5 percent of children in Finland live in
poverty, as compared to 20 percent in the United States. Those who
insist that poverty doesn’t matter, that only teachers matter, prefer
to ignore such contrasts.

If we are serious about improving our schools, we will take steps to
improve our teacher force, as Finland and other nations have done.
That would mean better screening to select the best candidates, higher
salaries, better support and mentoring systems, and better working
conditions. Guggenheim complains that only one in 2,500 teachers loses
his or her teaching certificate, but fails to mention that 50 percent
of those who enter teaching leave within five years, mostly because of
poor working conditions, lack of adequate resources, and the stress of
dealing with difficult children and disrespectful parents. Some who
leave “fire themselves”; others were fired before they got tenure. We
should also insist that only highly experienced teachers become
principals (the “head teacher” in the school), not retired businessmen
and military personnel. Every school should have a curriculum that
includes a full range of studies, not just basic skills. And if we
really are intent on school improvement, we must reduce the appalling
rates of child poverty that impede success in school and in life.

There is a clash of ideas occurring in education right now between
those who believe that public education is not only a fundamental
right but a vital public service, akin to the public provision of
police, fire protection, parks, and public libraries, and those who
believe that the private sector is always superior to the public
sector. Waiting for “Superman” is a powerful weapon on behalf of those
championing the “free market” and privatization. It raises important
questions, but all of the answers it offers require a transfer of
public funds to the private sector. The stock market crash of 2008
should suffice to remind us that the managers of the private sector do
not have a monopoly on success.

Public education is one of the cornerstones of American democracy. The
public schools must accept everyone who appears at their doors, no
matter their race, language, economic status, or disability. Like the
huddled masses who arrived from Europe in years gone by, immigrants
from across the world today turn to the public schools to learn what
they need to know to become part of this society. The schools should
be far better than they are now, but privatizing them is no solution.

In the final moments of Waiting for “Superman,” the children and their
parents assemble in auditoriums in New York City, Washington, D.C.,
Los Angeles, and Silicon Valley, waiting nervously to see if they will
win the lottery. As the camera pans the room, you see tears rolling
down the cheeks of children and adults alike, all their hopes focused
on a listing of numbers or names. Many people react to the scene with
their own tears, sad for the children who lose. I had a different
reaction. First, I thought to myself that the charter operators were
cynically using children as political pawns in their own campaign to
promote their cause. (Gail Collins in The New York Times had a similar
reaction and wondered why they couldn’t just send the families a
letter in the mail instead of subjecting them to public rejection.)
Second, I felt an immense sense of gratitude to the much-maligned
American public education system, where no one has to win a lottery to
gain admission.


Fate That Narcissists Will Hate: Being Ignored New York Times, November 29, 2010 By CHARLES ZANOR
Narcissists, much to the surprise of many experts, are in the process of becoming an endangered species. Not that they face imminent extinction — it's a fate much worse than that. They will still be around, but they will be ignored. The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (due out in 2013, and known as DSM-5) has eliminated five of the 10 personality disorders that are listed in the current edition. Narcissistic personality disorder is the most well-known of the five, and its absence has caused the most stir in professional circles. Most nonprofessionals have a pretty good sense of what narcissism means, but the formal definition is more precise than the dictionary meaning of the term. Our everyday picture of a narcissist is that of someone who is very self-involved — the conversation is always about them. While this characterization does apply to people with narcissistic personality disorder, it is too broad. There are many people who are completely self-absorbed who would not qualify for a diagnosis of N.P.D. The central requirement for N.P.D. is a special kind of self-absorption: a grandiose sense of self, a serious miscalculation of one's abilities and potential that is often accompanied by fantasies of greatness. It is the difference between two high school baseball players of moderate ability: one is absolutely convinced he'll be a major-league player, the other is hoping for a college scholarship. Of course, it would be premature to call the major-league hopeful a narcissist at such an early age, but imagine that same kind of unstoppable, unrealistic attitude 10 or 20 years later. The second requirement for N.P.D.: since the narcissist is so convinced of his high station (most are men), he automatically expects that others will recognize his superior qualities and will tell him so. This is often referred to as "mirroring." It's not enough that he knows he's great. Others must confirm it as well, and they must do so in the spirit of "vote early, and vote often." Finally, the narcissist, who longs for the approval and admiration of others, is often clueless about how things look from someone else's perspective. Narcissists are very sensitive to being overlooked or slighted in the smallest fashion, but they often fail to recognize when they are doing it to others. Most of us would agree that this is an easily recognizable profile, and it is a puzzle why the manual's committee on personality disorders has decided to throw N.P.D. off the bus. Many experts in the field are not happy about it. Actually, they aren't happy about the elimination of the other four disorders either, and they're not shy about saying so. One of the sharpest critics of the DSM committee on personality disorders is a Harvard psychiatrist, Dr. John Gunderson, an old lion in the field of personality disorders and the person who led the personality disorders committee for the current manual. Asked what he thought about the elimination of narcissistic personality disorder, he said it showed how "unenlightened" the personality disorders committee is. "They have little appreciation for the damage they could be doing." He said the diagnosis is important in terms of organizing and planning treatment. "It's draconian," he said of the decision, "and the first of its kind, I think, that half of a group of disorders are eliminated by committee." He also blamed a so-called dimensional approach, which is a method of diagnosing personality disorders that is new to the DSM. It consists of making an overall, general diagnosis of personality disorder for a given patient, and then selecting particular traits from a long list in order to best describe that specific patient. This is in contrast to the prototype approach that has been used for the past 30 years: the narcissistic syndrome is defined by a cluster of related traits, and the clinician matches patients to that profile. The dimensional approach has the appeal of ordering à la carte — you get what you want, no more and no less. But it is precisely because of this narrow focus that it has never gained much traction with clinicians. It is one thing to call someone a neat and careful dresser. It is another to call that person a dandy, or a clotheshorse, or a boulevardier. Each of these terms has slightly different meanings and conjures up a type. And clinicians like types. The idea of replacing the prototypic diagnosis of narcissistic personality disorder with a dimensional diagnosis like "personality disorder with narcissistic and manipulative traits" just doesn't cut it. Jonathan Shedler, a psychologist at the University of Colorado Medical School, said: "Clinicians are accustomed to thinking in terms of syndromes, not deconstructed trait ratings. Researchers think in terms of variables, and there's just a huge schism." He said the committee was stacked "with a lot of academic researchers who really don't do a lot of clinical work. We're seeing yet another manifestation of what's called in psychology the science-practice schism." Schism is probably not an overstatement. For 30 years the DSM has been the undisputed standard that clinicians consult when diagnosing mental disorders. When a new diagnosis is introduced, or an established diagnosis is substantially modified or deleted, it is not a small deal. As Dr. Gunderson said, it will affect the way professionals think about and treat patients. Given the stakes, the blow-back from experts in personality disorders should come as no surprise. Dr. Gunderson has written a letter co-signed by other clinical and research leaders to the trustees of the American Psychiatric Association and the task force that governs DSM-5. And Dr. Shedler and seven colleagues published an editorial in the September issue of The American Journal of Psychiatry. In the relatively small world of mental health diagnostics, this is most certainly a battle worth watching. Right now, this much seems clear: It is way too early for the narcissists to give up their seat on the bus. Charles Zanor is a psychologist in West Springfield, Mass.





January 10, 2010

The Americanization of Mental Illness
By ETHAN WATTERS
AMERICANS, particularly if they are of a certain leftward-leaning, college-educated type, worry about our country’s blunders into other cultures. In some circles, it is easy to make friends with a rousing rant about the McDonald’s near Tiananmen Square, the Nike factory in Malaysia or the latest blowback from our political or military interventions abroad. For all our self-recrimination, however, we may have yet to face one of the most remarkable effects of American-led globalization. We have for many years been busily engaged in a grand project of Americanizing the world’s understanding of mental health and illness. We may indeed be far along in homogenizing the way the world goes mad.
This unnerving possibility springs from recent research by a loose group of anthropologists and cross-cultural psychiatrists. Swimming against the biomedical currents of the time, they have argued that mental illnesses are not discrete entities like the polio virus with their own natural histories. These researchers have amassed an impressive body of evidence suggesting that mental illnesses have never been the same the world over (either in prevalence or in form) but are inevitably sparked and shaped by the ethos of particular times and places. In some Southeast Asian cultures, men have been known to experience what is called amok, an episode of murderous rage followed by amnesia; men in the region also suffer from koro, which is characterized by the debilitating certainty that their genitals are retracting into their bodies. Across the fertile crescent of the Middle East there is zar, a condition related to spirit-possession beliefs that brings forth dissociative episodes of laughing, shouting and singing.
The diversity that can be found across cultures can be seen across time as well. In his book “Mad Travelers,” the philosopher Ian Hacking documents the fleeting appearance in the 1890s of a fugue state in which European men would walk in a trance for hundreds of miles with no knowledge of their identities. The hysterical-leg paralysis that afflicted thousands of middle-class women in the late 19th century not only gives us a visceral understanding of the restrictions set on women’s social roles at the time but can also be seen from this distance as a social role itself — the troubled unconscious minds of a certain class of women speaking the idiom of distress of their time.
“We might think of the culture as possessing a ‘symptom repertoire’ — a range of physical symptoms available to the unconscious mind for the physical expression of psychological conflict,” Edward Shorter, a medical historian at the University of Toronto, wrote in his book “Paralysis: The Rise and Fall of a ‘Hysterical’ Symptom.” “In some epochs, convulsions, the sudden inability to speak or terrible leg pain may loom prominently in the repertoire. In other epochs patients may draw chiefly upon such symptoms as abdominal pain, false estimates of body weight and enervating weakness as metaphors for conveying psychic stress.”
In any given era, those who minister to the mentally ill — doctors or shamans or priests — inadvertently help to select which symptoms will be recognized as legitimate. Because the troubled mind has been influenced by healers of diverse religious and scientific persuasions, the forms of madness from one place and time often look remarkably different from the forms of madness in another.
That is until recently.
For more than a generation now, we in the West have aggressively spread our modern knowledge of mental illness around the world. We have done this in the name of science, believing that our approaches reveal the biological basis of psychic suffering and dispel prescientific myths and harmful stigma. There is now good evidence to suggest that in the process of teaching the rest of the world to think like us, we’ve been exporting our Western “symptom repertoire” as well. That is, we’ve been changing not only the treatments but also the expression of mental illness in other cultures. Indeed, a handful of mental-health disorders — depression, post-traumatic stress disorder and anorexia among them — now appear to be spreading across cultures with the speed of contagious diseases. These symptom clusters are becoming the lingua franca of human suffering, replacing indigenous forms of mental illness.
DR. SING LEE, a psychiatrist and researcher at the Chinese University of Hong Kong, watched the Westernization of a mental illness firsthand. In the late 1980s and early 1990s, he was busy documenting a rare and culturally specific form of anorexia nervosa in Hong Kong. Unlike American anorexics, most of his patients did not intentionally diet nor did they express a fear of becoming fat. The complaints of Lee’s patients were typically somatic — they complained most frequently of having bloated stomachs. Lee was trying to understand this indigenous form of anorexia and, at the same time, figure out why the disease remained so rare.
As he was in the midst of publishing his finding that food refusal had a particular expression and meaning in Hong Kong, the public’s understanding of anorexia suddenly shifted. On Nov. 24, 1994, a teenage anorexic girl named Charlene Hsu Chi-Ying collapsed and died on a busy downtown street in Hong Kong. The death caught the attention of the media and was featured prominently in local papers. “Anorexia Made Her All Skin and Bones: Schoolgirl Falls on Ground Dead,” read one headline in a Chinese-language newspaper. “Thinner Than a Yellow Flower, Weight-Loss Book Found in School Bag, Schoolgirl Falls Dead on Street,” reported another Chinese-language paper.
In trying to explain what happened to Charlene, local reporters often simply copied out of American diagnostic manuals. The mental-health experts quoted in the Hong Kong papers and magazines confidently reported that anorexia in Hong Kong was the same disorder that appeared in the United States and Europe. In the wake of Charlene’s death, the transfer of knowledge about the nature of anorexia (including how and why it was manifested and who was at risk) went only one way: from West to East.
Western ideas did not simply obscure the understanding of anorexia in Hong Kong; they also may have changed the expression of the illness itself. As the general public and the region’s mental-health professionals came to understand the American diagnosis of anorexia, the presentation of the illness in Lee’s patient population appeared to transform into the more virulent American standard. Lee once saw two or three anorexic patients a year; by the end of the 1990s he was seeing that many new cases each month. That increase sparked another series of media reports. “Children as Young as 10 Starving Themselves as Eating Ailments Rise,” announced a headline in one daily newspaper. By the late 1990s, Lee’s studies reported that between 3 and 10 percent of young women in Hong Kong showed disordered eating behavior. In contrast to Lee’s earlier patients, these women most often cited fat phobia as the single most important reason for their self-starvation. By 2007 about 90 percent of the anorexics Lee treated reported fat phobia. New patients appeared to be increasingly conforming their experience of anorexia to the Western version of the disease.
What is being missed, Lee and others have suggested, is a deep understanding of how the expectations and beliefs of the sufferer shape their suffering. “Culture shapes the way general psychopathology is going to be translated partially or completely into specific psychopathology,” Lee says. “When there is a cultural atmosphere in which professionals, the media, schools, doctors, psychologists all recognize and endorse and talk about and publicize eating disorders, then people can be triggered to consciously or unconsciously pick eating-disorder pathology as a way to express that conflict.”
The problem becomes especially worrisome in a time of globalization, when symptom repertoires can cross borders with ease. Having been trained in England and the United States, Lee knows better than most the locomotive force behind Western ideas about mental health and illness. Mental-health professionals in the West, and in the United States in particular, create official categories of mental diseases and promote them in a diagnostic manual that has become the worldwide standard. American researchers and institutions run most of the premier scholarly journals and host top conferences in the fields of psychology and psychiatry. Western drug companies dole out large sums for research and spend billions marketing medications for mental illnesses. In addition, Western-trained traumatologists often rush in where war or natural disasters strike to deliver “psychological first aid,” bringing with them their assumptions about how the mind becomes broken by horrible events and how it is best healed. Taken together this is a juggernaut that Lee sees little chance of stopping.
“As Western categories for diseases have gained dominance, micro-cultures that shape the illness experiences of individual patients are being discarded,” Lee says. “The current has become too strong.”
Would anorexia have so quickly become part of Hong Kong’s symptom repertoire without the importation of the Western template for the disease? It seems unlikely. Beginning with scattered European cases in the early 19th century, it took more than 50 years for Western mental-health professionals to name, codify and popularize anorexia as a manifestation of hysteria. By contrast, after Charlene fell onto the sidewalk on Wan Chai Road on that late November day in 1994, it was just a matter of hours before the Hong Kong population learned the name of the disease, who was at risk and what it meant.
THE IDEA THAT our Western conception of mental health and illness might be shaping the expression of illnesses in other cultures is rarely discussed in the professional literature. Many modern mental-health practitioners and researchers believe that the scientific standing of our drugs, our illness categories and our theories of the mind have put the field beyond the influence of endlessly shifting cultural trends and beliefs. After all, we now have machines that can literally watch the mind at work. We can change the chemistry of the brain in a variety of interesting ways and we can examine DNA sequences for abnormalities. The assumption is that these remarkable scientific advances have allowed modern-day practitioners to avoid the blind spots and cultural biases of their predecessors.
Modern-day mental-health practitioners often look back at previous generations of psychiatrists and psychologists with a thinly veiled pity, wondering how they could have been so swept away by the cultural currents of their time. The confident pronouncements of Victorian-era doctors regarding the epidemic of hysterical women are now dismissed as cultural artifacts. Similarly, illnesses found only in other cultures are often treated like carnival sideshows. Koro, amok and the like can be found far back in the American diagnostic manual (DSM-IV, Pages 845-849) under the heading “culture-bound syndromes.” Given the attention they get, they might as well be labeled “Psychiatric Exotica: Two Bits a Gander.”
Western mental-health practitioners often prefer to believe that the 844 pages of the DSM-IV prior to the inclusion of culture-bound syndromes describe real disorders of the mind, illnesses with symptomatology and outcomes relatively unaffected by shifting cultural beliefs. And, it logically follows, if these disorders are unaffected by culture, then they are surely universal to humans everywhere. In this view, the DSM is a field guide to the world’s psyche, and applying it around the world represents simply the brave march of scientific knowledge.
Of course, we can become psychologically unhinged for many reasons that are common to all, like personal traumas, social upheavals or biochemical imbalances in our brains. Modern science has begun to reveal these causes. Whatever the trigger, however, the ill individual and those around him invariably rely on cultural beliefs and stories to understand what is happening. Those stories, whether they tell of spirit possession, semen loss or serotonin depletion, predict and shape the course of the illness in dramatic and often counterintuitive ways. In the end, what cross-cultural psychiatrists and anthropologists have to tell us is that all mental illnesses, including depression, P.T.S.D. and even schizophrenia, can be every bit as influenced by cultural beliefs and expectations today as hysterical-leg paralysis or the vapors or zar or any other mental illness ever experienced in the history of human madness. This does not mean that these illnesses and the pain associated with them are not real, or that sufferers deliberately shape their symptoms to fit a certain cultural niche. It means that a mental illness is an illness of the mind and cannot be understood without understanding the ideas, habits and predispositions — the idiosyncratic cultural trappings — of the mind that is its host.
EVEN WHEN THE underlying science is sound and the intentions altruistic, the export of Western biomedical ideas can have frustrating and unexpected consequences. For the last 50-odd years, Western mental-health professionals have been pushing what they call “mental-health literacy” on the rest of the world. Cultures became more “literate” as they adopted Western biomedical conceptions of diseases like depression and schizophrenia. One study published in The International Journal of Mental Health, for instance, portrayed those who endorsed the statement that “mental illness is an illness like any other” as having a “knowledgeable, benevolent, supportive orientation toward the mentally ill.”
Mental illnesses, it was suggested, should be treated like “brain diseases” over which the patient has little choice or responsibility. This was promoted both as a scientific fact and as a social narrative that would reap great benefits. The logic seemed unassailable: Once people believed that the onset of mental illnesses did not spring from supernatural forces, character flaws, semen loss or some other prescientific notion, the sufferer would be protected from blame and stigma. This idea has been promoted by mental-health providers, drug companies and patient-advocacy groups like the National Alliance on Mental Illness in the United States and SANE in Britain. In a sometimes fractious field, everyone seemed to agree that this modern way of thinking about mental illness would reduce the social isolation and stigma often experienced by those with mental illness. Trampling on indigenous prescientific superstitions about the cause of mental illness seemed a small price to pay to relieve some of the social suffering of the mentally ill.
But does the “brain disease” belief actually reduce stigma?
In 1997, Prof. Sheila Mehta from Auburn University Montgomery in Alabama decided to find out if the “brain disease” narrative had the intended effect. She suspected that the biomedical explanation for mental illness might be influencing our attitudes toward the mentally ill in ways we weren’t conscious of, so she thought up a clever experiment.
In her study, test subjects were led to believe that they were participating in a simple learning task with a partner who was, unbeknownst to them, a confederate in the study. Before the experiment started, the partners exchanged some biographical data, and the confederate informed the test subject that he suffered from a mental illness.
The confederate then stated either that the illness occurred because of “the kind of things that happened to me when I was a kid” or that he had “a disease just like any other, which affected my biochemistry.” (These were termed the “psychosocial” explanation and the “disease” explanation respectively.) The experiment then called for the test subject to teach the confederate a pattern of button presses. When the confederate pushed the wrong button, the only feedback the test subject could give was a “barely discernible” to “somewhat painful” electrical shock.
Analyzing the data, Mehta found a difference between the group of subjects given the psychosocial explanation for their partner’s mental-illness history and those given the brain-disease explanation. Those who believed that their partner suffered a biochemical “disease like any other” increased the severity of the shocks at a faster rate than those who believed they were paired with someone who had a mental disorder caused by an event in the past.
“The results of the current study suggest that we may actually treat people more harshly when their problem is described in disease terms,” Mehta wrote. “We say we are being kind, but our actions suggest otherwise.” The problem, it appears, is that the biomedical narrative about an illness like schizophrenia carries with it the subtle assumption that a brain made ill through biomedical or genetic abnormalities is more thoroughly broken and permanently abnormal than one made ill though life events. “Viewing those with mental disorders as diseased sets them apart and may lead to our perceiving them as physically distinct. Biochemical aberrations make them almost a different species.”
In other words, the belief that was assumed to decrease stigma actually increased it. Was the same true outside the lab in the real world?
The question is important because the Western push for “mental-health literacy” has gained ground. Studies show that much of the world has steadily adopted this medical model of mental illness. Although these changes are most extensive in the United States and Europe, similar shifts have been documented elsewhere. When asked to name the sources of mental illness, people from a variety of cultures are increasingly likely to mention “chemical imbalance” or “brain disease” or “genetic/inherited” factors.
Unfortunately, at the same time that Western mental-health professionals have been convincing the world to think and talk about mental illnesses in biomedical terms, we have been simultaneously losing the war against stigma at home and abroad. Studies of attitudes in the United States from 1950 to 1996 have shown that the perception of dangerousness surrounding people with schizophrenia has steadily increased over this time. Similarly, a study in Germany found that the public’s desire to maintain distance from those with a diagnosis of schizophrenia increased from 1990 to 2001.
Researchers hoping to learn what was causing this rise in stigma found the same surprising connection that Mehta discovered in her lab. It turns out that those who adopted biomedical/genetic beliefs about mental disorders were the same people who wanted less contact with the mentally ill and thought of them as more dangerous and unpredictable. This unfortunate relationship has popped up in numerous studies around the world. In a study conducted in Turkey, for example, those who labeled schizophrenic behavior as akil hastaligi (illness of the brain or reasoning abilities) were more inclined to assert that schizophrenics were aggressive and should not live freely in the community than those who saw the disorder as ruhsal hastagi (a disorder of the spiritual or inner self). Another study, which looked at populations in Germany, Russia and Mongolia, found that “irrespective of place . . . endorsing biological factors as the cause of schizophrenia was associated with a greater desire for social distance.”
Even as we have congratulated ourselves for becoming more “benevolent and supportive” of the mentally ill, we have steadily backed away from the sufferers themselves. It appears, in short, that the impact of our worldwide antistigma campaign may have been the exact opposite of what we intended.
NOWHERE ARE THE limitations of Western ideas and treatments more evident than in the case of schizophrenia. Researchers have long sought to understand what may be the most perplexing finding in the cross-cultural study of mental illness: people with schizophrenia in developing countries appear to fare better over time than those living in industrialized nations.
This was the startling result of three large international studies carried out by the World Health Organization over the course of 30 years, starting in the early 1970s. The research showed that patients outside the United States and Europe had significantly lower relapse rates — as much as two-thirds lower in one follow-up study. These findings have been widely discussed and debated in part because of their obvious incongruity: the regions of the world with the most resources to devote to the illness — the best technology, the cutting-edge medicines and the best-financed academic and private-research institutions — had the most troubled and socially marginalized patients.
Trying to unravel this mystery, the anthropologist Juli McGruder from the University of Puget Sound spent years in Zanzibar studying families of schizophrenics. Though the population is predominantly Muslim, Swahili spirit-possession beliefs are still prevalent in the archipelago and commonly evoked to explain the actions of anyone violating social norms — from a sister lashing out at her brother to someone beset by psychotic delusions.
McGruder found that far from being stigmatizing, these beliefs served certain useful functions. The beliefs prescribed a variety of socially accepted interventions and ministrations that kept the ill person bound to the family and kinship group. “Muslim and Swahili spirits are not exorcised in the Christian sense of casting out demons,” McGruder determined. “Rather they are coaxed with food and goods, feted with song and dance. They are placated, settled, reduced in malfeasance.” McGruder saw this approach in many small acts of kindness. She watched family members use saffron paste to write phrases from the Koran on the rims of drinking bowls so the ill person could literally imbibe the holy words. The spirit-possession beliefs had other unexpected benefits. Critically, the story allowed the person with schizophrenia a cleaner bill of health when the illness went into remission. An ill individual enjoying a time of relative mental health could, at least temporarily, retake his or her responsibilities in the kinship group. Since the illness was seen as the work of outside forces, it was understood as an affliction for the sufferer but not as an identity.
For McGruder, the point was not that these practices or beliefs were effective in curing schizophrenia. Rather, she said she believed that they indirectly helped control the course of the illness. Besides keeping the sick individual in the social group, the religious beliefs in Zanzibar also allowed for a type of calmness and acquiescence in the face of the illness that she had rarely witnessed in the West.
The course of a metastasizing cancer is unlikely to be changed by how we talk about it. With schizophrenia, however, symptoms are inevitably entangled in a person’s complex interactions with those around him or her. In fact, researchers have long documented how certain emotional reactions from family members correlate with higher relapse rates for people who have a diagnosis of schizophrenia. Collectively referred to as “high expressed emotion,” these reactions include criticism, hostility and emotional overinvolvement (like overprotectiveness or constant intrusiveness in the patient’s life). In one study, 67 percent of white American families with a schizophrenic family member were rated as “high EE.” (Among British families, 48 percent were high EE; among Mexican families the figure was 41 percent and for Indian families 23 percent.)
Does this high level of “expressed emotion” in the United States mean that we lack sympathy or the desire to care for our mentally ill? Quite the opposite. Relatives who were “high EE” were simply expressing a particularly American view of the self. They tended to believe that individuals are the captains of their own destiny and should be able to overcome their problems by force of personal will. Their critical comments to the mentally ill person didn’t mean that these family members were cruel or uncaring; they were simply applying the same assumptions about human nature that they applied to themselves. They were reflecting an “approach to the world that is active, resourceful and that emphasizes personal accountability,” Prof. Jill M. Hooley of Harvard University concluded. “Far from high criticism reflecting something negative about the family members of patients with schizophrenia, high criticism (and hence high EE) was associated with a characteristic that is widely regarded as positive.”
Widely regarded as positive, that is, in the United States. Many traditional cultures regard the self in different terms — as inseparable from your role in your kinship group, intertwined with the story of your ancestry and permeable to the spirit world. What McGruder found in Zanzibar was that families often drew strength from this more connected and less isolating idea of human nature. Their ability to maintain a low level of expressed emotion relied on these beliefs. And that level of expressed emotion in turn may be key to improving the fortunes of the schizophrenia sufferer.
Of course, to the extent that our modern psychopharmacological drugs can relieve suffering, they should not be denied to the rest of the world. The problem is that our biomedical advances are hard to separate from our particular cultural beliefs. It is difficult to distinguish, for example, the biomedical conception of schizophrenia — the idea that the disease exists within the biochemistry of the brain — from the more inchoate Western assumption that the self resides there as well. “Mental illness is feared and has such a stigma because it represents a reversal of what Western humans . . . have come to value as the essence of human nature,” McGruder concludes. “Because our culture so highly values . . . an illusion of self-control and control of circumstance, we become abject when contemplating mentation that seems more changeable, less restrained and less controllable, more open to outside influence, than we imagine our own to be.”
CROSS-CULTURAL psychiatrists have pointed out that the mental-health ideas we export to the world are rarely unadulterated scientific facts and never culturally neutral. “Western mental-health discourse introduces core components of Western culture, including a theory of human nature, a definition of personhood, a sense of time and memory and a source of moral authority. None of this is universal,” Derek Summerfield of the Institute of Psychiatry in London observes. He has also written: “The problem is the overall thrust that comes from being at the heart of the one globalizing culture. It is as if one version of human nature is being presented as definitive, and one set of ideas about pain and suffering. . . . There is no one definitive psychology.”
Behind the promotion of Western ideas of mental health and healing lie a variety of cultural assumptions about human nature. Westerners share, for instance, evolving beliefs about what type of life event is likely to make one psychologically traumatized, and we agree that venting emotions by talking is more healthy than stoic silence. We’ve come to agree that the human mind is rather fragile and that it is best to consider many emotional experiences and mental states as illnesses that require professional intervention. (The National Institute of Mental Health reports that a quarter of Americans have diagnosable mental illnesses each year.) The ideas we export often have at their heart a particularly American brand of hyperintrospection — a penchant for “psychologizing” daily existence. These ideas remain deeply influenced by the Cartesian split between the mind and the body, the Freudian duality between the conscious and unconscious, as well as the many self-help philosophies and schools of therapy that have encouraged Americans to separate the health of the individual from the health of the group. These Western ideas of the mind are proving as seductive to the rest of the world as fast food and rap music, and we are spreading them with speed and vigor.
No one would suggest that we withhold our medical advances from other countries, but it’s perhaps past time to admit that even our most remarkable scientific leaps in understanding the brain haven’t yet created the sorts of cultural stories from which humans take comfort and meaning. When these scientific advances are translated into popular belief and cultural stories, they are often stripped of the complexity of the science and become comically insubstantial narratives. Take for instance this Web site text advertising the antidepressant Paxil: “Just as a cake recipe requires you to use flour, sugar and baking powder in the right amounts, your brain needs a fine chemical balance in order to perform at its best.” The Western mind, endlessly analyzed by generations of theorists and researchers, has now been reduced to a batter of chemicals we carry around in the mixing bowl of our skulls.
All cultures struggle with intractable mental illnesses with varying degrees of compassion and cruelty, equanimity and fear. Looking at ourselves through the eyes of those living in places where madness and psychological trauma are still embedded in complex religious and cultural narratives, however, we get a glimpse of ourselves as an increasingly insecure and fearful people. Some philosophers and psychiatrists have suggested that we are investing our great wealth in researching and treating mental illness — medicalizing ever larger swaths of human experience — because we have rather suddenly lost older belief systems that once gave meaning and context to mental suffering.
If our rising need for mental-health services does indeed spring from a breakdown of meaning, our insistence that the rest of the world think like us may be all the more problematic. Offering the latest Western mental-health theories, treatments and categories in an attempt to ameliorate the psychological stress sparked by modernization and globalization is not a solution; it may be part of the problem. When we undermine local conceptions of the self and modes of healing, we may be speeding along the disorienting changes that are at the very heart of much of the world’s mental distress.
Ethan Watters lives in San Francisco. This essay is adapted from his book “Crazy Like Us: The Globalization of the American Psyche,” which will be published later this month by Free Press.
This article has been revised to reflect the following correction:
Correction: January 24, 2010 A biographical note for the author of an article on Jan. 10 about the influence of American ideas on the treatment of mental illness abroad misidentified the publisher of his new book. Ethan Watters’s ‘‘Crazy Like Us: The Globalization of the American Psyche’’ was just published by Free Press, not Basic Books. The article also gave an outdated name for a patient advocacy organization that has supported a biomedical view of mental illness. It is the National Alliance on Mental Illness, no longer the National Alliance for the Mentally Ill.

By New York Times, March 24, 2010
Social Networks a Lifeline for the Chronically Ill
By CLAIRE CAIN MILLER
A former model who is now chronically ill and struggles just to shower says the people she has met online have become her family. A quadriplegic man uses the Web to share tips on which places have the best wheelchair access, and a woman with multiple sclerosis says her regular Friday night online chats are her lifeline.
For many people, social networks are a place for idle chatter about what they made for dinner or sharing cute pictures of their pets. But for people living with chronic diseases or disabilities, they play a more vital role.
“It’s really literally saved my life, just to be able to connect with other people,” said Sean Fogerty, 50, who has multiple sclerosis, is recovering from brain cancer and spends an hour and a half each night talking with other patients online.
People fighting chronic illnesses are less likely than others to have Internet access, but once online they are more likely to blog or participate in online discussions about health problems, according to a report released Wednesday by the Pew Internet and American Life Project and the California HealthCare Foundation.
“If they can break free from the anchors holding them down, people living with chronic disease who go online are finding resources that are more useful than the rest of the population,” said Susannah Fox, associate director of digital strategy at Pew and author of the report.
They are gathering on big patient networking sites like PatientsLikeMe, HealthCentral, Inspire, CureTogether and Alliance Health Networks, and on small sites started by patients on networks like Ning and Wetpaint.
Sherri Connell, 46, modeled and performed in musicals until, at age 27, she learned she had multiple sclerosis and Lyme disease. She began posting her journal entries online for friends and family to read. Soon, people from all over the world were reading her Web site and telling her they had similar health problems.
In 2008, she and her husband started a social network using Ning called My Invisible Disabilities Community. It now has 2,300 members who write about living with lupus, forthcoming operations or medical bills, for example.
“People have good and bad days, and they don’t know a good day’s going to come Wednesday at 5 o’clock when a live support group is meeting,” Ms. Connell said. “The Internet is a great outlet for people to be honest.”
Not surprisingly, according to Pew, Internet users with chronic illnesses are more likely than healthy people to use the Web to look for information on specific diseases, drugs, health insurance, alternative or experimental treatments and depression, anxiety or stress.
But for them, the social aspects of the Web take on heightened importance. Particularly if they are homebound, they also look to the Web for their social lives, discussing topics unrelated to their illnesses. Some schedule times to eat dinner or watch a movie while chatting online.
John Linna, a pastor in Neenah, Wis., did not know what a blog was when his son suggested he start one after discovering he needed to stay home on a ventilator.
“That day my little world began to expand,” he wrote in a post last year about blogging. “Soon I had a little neighborhood. It was like stopping in for coffee every day just to see how things were going.”
When Mr. Linna died earlier this year, people all over the Web who had never met him in person mourned the loss.
Others use the Web to find practical tips about living with their disease or disability that doctors and family members, having not lived with it themselves, cannot provide.
On Diabetic Connect, a diabetes social network with 140,000 members, people share recipes like low-sugar banana pudding, review products like an insulin pump belt and have discussions like a recent one started by a patient with a new diagnosis. “I don’t like to talk to my family and friends about this,” she wrote. “Honestly I feel helpless. I really just need some advice and people to talk to who might have been experiencing the same things.”
Amy Tenderich is the community manager for Diabetic Connect and writes a blog called Diabetes Mine. “There’s no doctor in the world, unless they’ve actually lived with this thing, that can get into that nitty-gritty,” she said. “I’ve walked away from dinner parties with tears in my eyes because people just don’t understand.”
Patients often use social networks to interact with people without worrying about the stigma of physical disabilities, said Susan Smedema, an assistant professor of rehabilitation counseling at Florida State University who studies the psychosocial aspects of disability.
From her home in Maine, Susan Fultz plays online games at Pogo.com and commiserates with people who are frustrated that they do not have a diagnosis for their symptoms.
“There’s no worry of being judged or criticized, and that is something that I know a lot of us don’t get in our daily lives,” said Ms. Fultz, who has Lyme disease and psoriatic arthritis.
Those with chronic diseases or disabilities, like all Internet users, have to be wary about sharing private health information online, particularly with anonymous users.
Research has also shown that emotions can be contagious, said Paul Albert, digital services librarian at Weill Cornell Medical Library in New York who has researched how social networks meet the needs of patients with chronic diseases.
“If you hang out on a message board where people are very negative, you can easily adopt a negative attitude about your disease,” he said. “On the other hand, if people are hopeful, you might be better off.”
Some people also worry that patients might exchange erroneous medical information on the Web, he said. Yet most patient social networks make clear that the information on the site should not substitute for medical advice, and the Pew study found that just 2 percent of adults living with chronic diseases report being harmed by following medical advice found on the Internet.
Instead, the sites are used to share information from the front lines, said Lily Vadakin, 45, who has multiple sclerosis and works as a site administrator for Disaboom, a social network for people with disabilities. For instance, she has discussed with other patients how to combat fatigue by working at home and taking vitamin supplements.
“That’s what the community can give you — a real-life perspective,” she said.

NY Times, March 20, 2010
Rethinking Sex Offender Laws for Youth Texting
By TAMAR LEWIN
In Iowa, Jorge Canal is on the sex offenders registry because, at age 18, he was convicted of distributing obscene materials to a minor after he sent a picture of his penis by cellphone to a 14-year-old female friend who had requested it.
In Florida, Phillip Alpert, then 18, was charged with distributing child pornography and put on the sex offenders registry because after a fight, he sent a photograph of his nude 16-year-old girlfriend by e-mail to dozens of people, including her parents.
In most states, teenagers who send or receive sexually explicit photographs by cellphone or computer — known as “sexting” — have risked felony child pornography charges and being listed on a sex offender registry for decades to come.
But there is growing consensus among lawyers and legislators that the child pornography laws are too blunt an instrument to deal with an adolescent cyberculture in which all kinds of sexual pictures circulate on sites like MySpace and Facebook.
Last year, Nebraska, Utah and Vermont changed their laws to reduce penalties for teenagers who engage in such activities, and this year, according to the National Council on State Legislatures, 14 more states are considering legislation that would treat young people who engage in sexting differently from adult pornographers and sexual predators.
And on Wednesday, the first federal appellate opinion in a sexting case recognized that a prosecutor had gone too far in trying to enforce adult moral standards.
The opinion upheld a block on a district attorney who threatened to bring child pornography charges against girls whose pictures showing themselves scantily dressed appeared on classmates’ cellphones.
“There’s a lot of confusion about how to regulate cellphones and sex and 16-year-olds,” said Amy Adler, a law professor at New York University. “We’re at this cultural shift, not only because of the technology, but because of what’s happening in terms of the representation of teen sexuality as you can see on ‘Gossip Girl.’ ”
There are real risks that sexually explicit pictures, meant to be shared only with a friend or partner, will make their way into wide publication on the Internet and into the hands of sexual predators.
Last year, a 14-year-old New Jersey girl was arrested and charged with possession and distribution of child pornography after posting dozens of sexually explicit photographs of herself on MySpace.
Such cases, lawyers say, are far afield from what the child pornography laws were intended for. So, too, was the case of Mr. Canal, which was upheld last year by the Iowa Supreme Court.
Mr. Canal was 18 when he sent the picture of his erect penis to a 14-year-old schoolmate, along with another picture of his face, with the text “I love you” on it. The girl, identified only by her initials, thought she erased the image, but her parents found it and passed it to the police.
“The child pornography law was about protecting children from pedophiles,” Professor Adler said. “While sexting is bad judgment, it’s simply not what the Supreme Court had in mind when it crafted the child pornography law. It just doesn’t make sense that in a lot of the sexting situations, the pornographer and the victim are one and the same person.”
As a practical matter, young people are rarely, if ever, jailed under the child pornography laws for the practice.
Some of the 14 states considering legislation would make sexting a misdemeanor, while others would treat it like juvenile offenses like truancy or running away.
“Many jurisdictions are creating a separate offense for these situations,” said Mary Leary, a law professor at Catholic University. “They’re moving it to family or juvenile court. The more choices available to a prosecutor, including diverting the case entirely from the juvenile justice system, the better.”
She and many others believe that some criminal penalties should remain on the books.
Jesse Weins, chairman of the criminal justice department at Dakota Wesleyan University, said that because the legal code functioned as a guide to acceptable behavior, “there should be something there, even if oftentimes it doesn’t make sense to prosecute.”
But there are those who favor decriminalization.
“Generally this should be an education issue,” said Witold Walczak, legal director of the Pennsylvania American Civil Liberties Union. “No one disputes that sexting can have very bad consequences, and no parent wants kids sending out naked images. But if you’ve got thousands of kids engaging in this, are you going to criminalize all of them?”
One recent survey found that about one in five teenagers reported having engaged in sexting. Another found that almost half the boys in coed high schools had seen a picture depicting a female classmate nude.
There are two basic scenarios. In one, a teenager shares a nude picture, usually with a romantic partner. In the other, a partner, or more commonly an ex-partner, distributes the image.
The new Nebraska law makes that distinction, giving a pass to children under 18 who send out their own photograph to a willing recipient who is at least 15. On the other hand, a teenager who passes the photograph on to friends could face a felony child pornography charge and five years in prison.
The Tunkhannock, Pa., case that produced Wednesday’s court ruling illustrates how complicated such cases can be. Those pictures were discovered by the school authorities, who confiscated the students’ cellphones and turned them over to the district attorney.
Mr. Walczak, the girls’ lawyer, said that he planned to file a separate lawsuit charging that the school search of material on confiscated phones breached students’ privacy.
The district attorney told parents of the students involved — both those in the images and those whose phones contained the images — that their children could be prosecuted for child pornography unless they took part in an after-school program.
The program, divided by gender, involved random drug tests, probation and classes in which the girls would “gain an understanding of what it means to be a girl in today’s society,” by, among other things, writing essays on why their actions were wrong.
Only three of more than a dozen families refused to join the program — those of two girls, ages 12 and 13, who were pictured wearing bras at a slumber party, and of a third girl who was shown emerging from the shower with a towel wrapped under her breasts. The parents say the photographs were not pornographic, a question no court has yet considered. And there has been no evidence that any of the three girls played a part in circulating the photographs.
The parents went to court, claiming that prosecution would amount to retaliation for refusal to join the program.
“We need laws that deal with sexting more holistically, based on the facts of a particular situation,” said Professor Weins, who has written a law review article on the subject. “And that’s not how the child pornography laws work.”



Google and Facebook raise new issues for therapists and their clients
By Dana Scarton   The Washington Post Tuesday, March 30, 2010; HE01

As his patient lay unconscious in an emergency room from an overdose of sedatives, psychiatrist Damir Huremovic was faced with a moral dilemma: A friend of the patient had forwarded to Huremovic a suicidal e-mail from the patient that included a link to a Web site and blog he wrote. Should Huremovic go online and check it out, even without his patient's consent?
Huremovic decided yes; after all, the Web site was in the public domain and it might contain some potentially important information for treatment. When Huremovic clicked on the blog, he found quotations such as this: "Death makes angels of us all and gives us wings." A final blog post read: "I wish I didn't wake up." Yet as Huremovic continued scanning the patient's personal photographs and writings, he began to feel uncomfortable, that perhaps he'd crossed some line he shouldn't have.
Across the country, therapists are facing similar situations and conflicted feelings. When Huremovic, director of psychosomatic medicine services at Nassau University Medical Center in New York, recounted his vignette last year at an American Psychiatric Association meeting and asked whether others would have read the suicidal man's blog, his audience responded with resounding calls -- of both "yes!" and "no!" One thing was clear: How and when a therapist should use the Internet -- and even whether he or she should -- are questions subject to vigorous debate.
"We are just beginning to understand what ethical issues the Internet is raising," says Stephen Behnke, ethics director for the American Psychological Association. "To write rules that allow our field to grow and develop and yet prevent [patient] harm at the same time: That's the challenge."
In fact, the tremendous availability online of personal information threatens to alter what has been an almost sacred relationship between therapist and patient. Traditionally, therapists obtained information about a patient through face-to-face dialogue. If outside information was needed, the therapist would obtain the patient's consent to speak with family members or a previous mental-health practitioner. At the same time, patients traditionally knew little about their therapists outside the consulting room. Now, with the click of a mouse, tech-savvy therapists and patients are challenging the old rules and raising serious questions about how much each should know about the other and where lines should be drawn.
Among the questions under debate:
Should a therapist review the Web site of a patient or conduct an online search without that patient's consent?
Is it appropriate for a therapist to put personal details about himself on a blog or Web site or to join Facebook or other social networks?
What are the risks of having patients and therapists interact online?
Neither the American Psychiatric Association nor the American Psychological Association has rules specifically governing therapists' online behavior, but ethics advisers with the psychiatric association maintain that online searches are not wrong -- as long as they're done in the patient's interest and not out of therapist curiosity.
Many therapists contend it's more important to discuss such questions than it is to dictate behavior. "It's not whether a particular application is right or not," says Sheldon Benjamin, director of neuropsychiatry at the University of Massachusetts Medical School in Worcester. "It's whether you do it mindfully -- whether you understand how it changes the doctor-patient relationship."
To Google or not
Benjamin, 53, swears by his iPhone and enthusiastically tells of sampling the Internet in its infancy. At the same time, Benjamin, who directs psychiatric training at UMass, advocates caution when it comes to mixing the Internet with therapy.
He says he has never searched a patient's name online and worries that doing so could dilute the therapeutic process by bringing in information from outside the patient-therapist discussion. When patients have asked Benjamin to read their blogs, he has agreed, with one caveat: that he do so during a regular counseling session. "Even if you brought me a disability form, I'd fill it out in the room with you," says Benjamin. "I was taught to make the time with the patient the time when the work is done."
Suena Massey takes a different approach. Massey, 35, an assistant professor of psychiatry at George Washington University Medical Center, considers Googling a patient a valuable professional tool. "One of the duties of a psychiatrist is to corroborate what patients say," Massey explains. To that end, online searches can be helpful when traditional approaches -- obtaining the patient's consent to contact his previous psychiatrist or family members -- are not available.
One such case involved a patient who presented with symptoms of mania, a component of bipolar disorder. The man claimed to be well connected in Washington. After their meeting, Massey typed the patient's name into a search engine. Up popped postings suggesting that the man's claims were accurate. In a subsequent session Massey told her patient she had Googled him, and he was okay with it. She ended up treating him for bipolar disorder; had his claims been false, she says, she would have considered his condition to be more severe.
Massey says she will warn a patient about her possible use of Google searches if she thinks the patient might have a problem with it. "You could almost make the argument that it's negligent not to search online when there is public information available" and it might help treat a patient, she says. "If you're just looking things up out of personal interest, I think most doctors would feel uncomfortable with that."
Public vs. private
But what happens when the circumstances are reversed? What happens when a patient seeks information about his therapist online or pursues a relationship with his therapist on Facebook, MySpace or via another social network?
Most therapists are not alarmed by the idea of a Google search. "I know my patients Google me," Massey says. "I think it's their right as consumers." Some providers anticipate such searches by maintaining Web sites detailing their professional qualifications.
However, there can be problems when personal details are available. Take the case of a man who, after developing romantic and erotic feelings toward his therapist, typed her name into a search engine and found a Web site featuring personal photographs of the therapist, including a bathing-suit shot.
The man quit treatment and reported the discovery to Behnke's office. "He knew the image of his therapist in her bathing suit was going to be so present to him that he wouldn't be able to concentrate on his psychotherapy," Behnke explained in a telephone interview. "There was material on the Internet that had an impact on this psychologist's clinical work."
Behnke cautions therapists to assume that most clients will conduct online searches, and he urges them to make sure they remain vigilant about what gets posted.
Although most therapists say it's inappropriate to have relationships with patients via social networks, there is little agreement on whether it's okay for therapists to join such sites, and, if they do, just how private their information should remain.
For Huremovic, 39, social network abstinence is safest. "I have an understanding that if you choose to be a psychiatrist and a psychotherapist that you have to be very private in other parts of your social being," he says.
But some therapists, especially younger ones for whom using the Internet is a way of life, don't share this view.
For instance, psychologist Stephanie Smith, 35, has a Web site, and she has a presence on Twitter. Smith tweets to market her Colorado practice and to allow colleagues and other interested parties to monitor happenings in psychology. Typical posts provide tips for managing stress, announce a recent study's findings or refer followers to psychology blogs. Smith, who says Twitter has increased traffic to her professional Web site, admits to the rare tweet about her children or celebrity news.
"It's my style, but I know some people would not be comfortable" with her disclosure of nonprofessional information, she says.
Smith also has a Facebook account for her personal life. After teenage patients discovered that account and sent her "friend" requests, Smith enacted a policy forbidding past or current clients from engaging her online. She informs new clients of the policy and obligates them to comply.
This is the type of problem that UMass's Benjamin wants to avoid. "To me, it's a much bigger issue than bumping into a patient in a restaurant," he says. "You're putting out there, 'Hey, these are my contacts.' And someone then wants to enter your social circle. It puts you in a position where you must take a stand."
Keely Kolmes, a California psychologist who writes and lectures on Internet ethics, recommends that therapists make clear distinctions between their professional and personal lives online. "Younger clinicians get the Net but don't completely understand ethical and boundary issues that can come up," she says.
A former computer consultant, Kolmes, who is in her early 40s, goes to great lengths to keep her lives separate. On her personal Facebook account, for instance, she does not use a photo of herself on her profile page and she doesn't make reference to her professional name. She also restricts her public tweets and blogs to news of a professional nature. Still, she recognizes that any online sighting of one's therapist changes the dynamic for a patient.
"A lot of patients really want to think about you as existing in just that one space [of the therapy room,] and suddenly they're seeing you on Twitter and blogging," she says. "They can see that you're online at night posting things. I realize my choice to do that suddenly shifts my relationship with them."

Scarton is a Washington-based freelance writer specializing in health and medical matters.




June 4, 2010

Gay? Whatever, Dude
By CHARLES M. BLOW
Last week, while many of us were distracted by the oil belching forth from the gulf floor and the president’s ham-handed attempts to demonstrate that he was sufficiently engaged and enraged, Gallup released a stunning, and little noticed, report on Americans’ evolving views of homosexuality. Allow me to enlighten:
1. For the first time, the percentage of Americans who perceive “gay and lesbian relations” as morally acceptable has crossed the 50 percent mark. (You have to love the fact that they still use the word “relations.” So quaint.)
2. Also for the first time, the percentage of men who hold that view is greater than the percentage of women who do.
3. This new alignment is being led by a dramatic change in attitudes among younger men, but older men’s perceptions also have eclipsed older women’s. While women’s views have stayed about the same over the past four years, the percentage of men ages 18 to 49 who perceived these “relations” as morally acceptable rose by 48 percent, and among men over 50, it rose by 26 percent.
I warned you: stunning.
There is no way to know for sure what’s driving such a radical change in men’s views on this issue because Gallup didn’t ask, but that doesn’t mean that we can’t speculate. To help me do so, I called Dr. Michael Kimmel, a professor of sociology at the State University of New York at Stony Brook and the author or editor of more than 20 books on men and masculinity, and Professor Ritch Savin-Williams, the chairman of human development at Cornell University and the author of seven books, most of which deal with adolescent development and same-sex attraction.
Here are three theories:
1. The contact hypothesis. As more men openly acknowledge that they are gay, it becomes harder for men who are not gay to discriminate against them. And as that group of openly gay men becomes more varied — including athletes, celebrities and soldiers — many of the old, derisive stereotypes lose their purchase. To that point, a Gallup poll released last May found that people who said they personally knew someone who was gay or lesbian were more likely to be accepting of gay men and lesbians in general and more supportive of their issues.
2. Men may be becoming more egalitarian in general. As Dr. Kimmel put it: “Men have gotten increasingly comfortable with the presence of, and relative equality of, ‘the other,’ and we’re becoming more accustomed to it. And most men are finding that it has not been a disaster.” The expanding sense of acceptance likely began with the feminist and civil rights movements and is now being extended to the gay rights movement. Dr. Kimmel continued, “The dire predictions for diversity have not only not come true, but, in fact, they’ve been proved the other way.”
3. Virulent homophobes are increasingly being exposed for engaging in homosexuality. Think Ted Haggard, the once fervent antigay preacher and former leader of the National Association of Evangelicals, and his male prostitute. (This week, Haggard announced that he was starting a new “inclusive” church open to “gay, straight, bi, tall, short,” but no same-sex marriages. Not “God’s ideal.” Sorry.) Or George Rekers, the founding member of the Family Research Council, and his rent boy/luggage handler. Last week, the council claimed that repealing “don’t ask, don’t tell” would lead to an explosion of “homosexual assaults” in which sleeping soldiers would be the victims of fondling and fellatio by gay predators. In fact, there is a growing body of research that supports the notion that homophobia in some men could be a reaction to their own homosexual impulses. Many heterosexual men see this, and they don’t want to be associated with it. It’s like being antigay is becoming the old gay. Not cool.
These sound plausible, but why aren’t women seeing the same enlightening effects as men? Professor Savin-Williams suggests that there may be a “ceiling effect,” that men are simply catching up to women, and there may be a level at which views top out. Interesting.
All of this is great news, but it doesn’t mean that all measures relating to acceptance of gay men and lesbians have changed to the same degree. People’s comfort with the “gay and lesbian” part of the equation is still greater than their comfort with the “relations” part — the idea versus the act — particularly when it comes to pairings of men.
As Professor Savin-Williams told me, there is still a higher aversive reaction to same-sex sexuality among men than among women.
For instance, in a February New York Times/CBS News poll, half of the respondents were asked if they favored letting “gay men and lesbians” serve in the military (which is still more than 85 percent male), and the other half were asked if they favored letting “homosexuals” serve. Those who got the “homosexual” question favored it at a rate that was 11 percentage points lower than those who got the “gay men and lesbians” question.
Part of the difference may be that “homosexual” is a bigger, more clinical word freighted with a lot of historical baggage. But just as likely is that the inclusion of the root word “sex” still raises an aversive response to the idea of, how shall I say, the architectural issues between two men. It is the point at which support for basic human rights cleaves from endorsement of behavior.
As for the aversion among men, it may be softening a bit. Professor Savin-Williams says that his current research reveals that the fastest-growing group along the sexuality continuum are men who self-identify as “mostly straight” as opposed to labels like “straight,” “gay” or “bisexual.” They acknowledge some level of attraction to other men even as they say that they probably wouldn’t act on it, but ... the right guy, the right day, a few beers and who knows. As the professor points out, you would never have heard that in years past.
All together now: stunning.

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