Friday, October 18, 2013

Psychiatric imperialism: Disease-mongering in Europe, and avoiding the tobacco trap

I’ve discussed Ethan Watters’ book Crazy Like Us: The Globalization of the American Psyche here in the past, and some recent news about psychiatry and drug marketing in Europe has touched on its thesis implicitly and explicitly. These reports offer an opportunity to see psychiatric colonization in action, both in the marketing campaign of an individual drug company and in the international manipulations of US psychiatry.

Reading articles in business publications, like Bloomberg’s “ADHD Pill Faces High Hurdle in Europe as Stigma Persists,” is always interesting. They usually contain little intentional spin on the part of the writers. But this is only because they’re so tightly bound to the corporations from which they live that they just dutifully repeat corporate spin out of obedience or ideology. At the same time, the fact that they are so immersed in the system and not seeking in this context to justify corporations’ claims to outside critics often leads to surprising candor about what the companies are actually doing.

The Bloomberg article, by Trista Kelley, describes how Shire, a company based in Ireland, is attempting to expand the market for its “ADHD” drug Vyvanse, already a big seller in the US. The mindless repetition of corporate PR is evident throughout. ADHD is described as a real brain disorder with serious consequences for children as they grow, and the drug is portrayed as a real treatment for this condition. The people quoted are all sympathetic to Shire’s cause (one, Mary Baker, is president of something called the European Brain Council, described as “a Brussels-based non-profit representing doctors, patients [sic] and companies including Shire that work on neurology and psychiatry issues,” as though it were evident that these groups had identical interests). It’s these individuals who characterize resistance to the diagnosis and the drug as rooted in stigma for parents who give and children who take drugs – as the title of the article suggests - or a tradition of blaming parents.

But as the title also suggests, this isn’t about education but about marketing. While the company’s marketing efforts are depicted as an educational campaign, it’s a business article about their efforts to expand the market for a lucrative product. Shire can’t sell the pill without convincing people that it treats a real medical condition, so in conjunction with “rolling out the pill” in eight European countries it’s been “discussing the prevalence of the illness with doctors at psychiatry conferences around Europe.” “Before gaining sales,” the article reports, “Shire must first face the uphill battle of getting the disorder acknowledged and then diagnosed”:
“The next year to two years is going to be a significant educational effort on our part,” Chief Executive Officer Flemming Ornskov said in an interview in May, referring to Vyvanse in the European market. “The climate in Europe is a bit more negative. It will take us some time."
But the smart money’s on Shire, the article suggests, because the company isn’t alone. Their efforts to have the so-called disorder recognized and their drug prescribed are but a small part of the powerful wave of influence coming from the pharma-psychiatry complex in the US:
The path for Vyvanse may be eased in 2015 when the World Health Organization’s International Classification of Diseases is revised, according to Keyur Parekh, an analyst at Goldman, Sachs & Co. in London. The classification is used as a treatment guideline in Europe, much as the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders is used for psychiatry in the U.S.

The revision probably will align the stricter international guidelines with those in the DSM, which should help Shire’s ADHD business, Parekh said in a report to clients in May.
Although Kelley’s language – “The revision probably will align…” – obscures the people behind the efforts to obtain this alignment, a recent piece in Psychology Today by Christopher Lane (whose Shyness I’ve also mentioned here in the past) – “Crazy Like Us: How the U.S. Exports Its Model of Illness” - describes this process in more detail, drawing on Watters’ insights. Lane reports:
The fears of many European psychiatrists may soon be realized. Earlier this week, Psychiatric News reported that the American Psychiatric Association has begun petitioning the various agencies overseeing changes to the ICD, or International Classification of Diseases, to request that they adopt its most-controversial changes in DSM-5.

According to Psychiatric News, the APA has asked the ICD formally to include seven new disorders listed in DSM-5, though not in ICD-9-CM or ICD-10-CM.

…The APA’s aim is clearly to make the two diagnostic systems converge more successfully, to ensure greater consistency—and avoid an apples and oranges problem—in psychiatric research. But the outcome, if the petition is approved, is likely eventually to export to Europe and other regions a range of disorders still mired in controversy and, according to the results of the APA’s own field trials, still very much in need of further research.
(See here for more information on the relationship between the ICD and the DSM, and here for regular updates on the ICD.* Interestingly enough, the post at the APA’s Psychiatric News that Lane and others link to has now disappeared. Following the link, you’re informed that the page no longer exists, and neither a search of the site nor a Google search turned it up for me.

UPDATE 10-26: Suzy Chapman has helpfully informed me in the comments that the URL for the Psychiatric News post has changed and has been updated on her and Lane's sites. It can be found here.)

To put the APA’s current efforts in context, Lane links to a guest post by Patrick Landman at Psychology Today from early this year. In it, Landman, a psychiatrist working in France, explained the scientific and social concerns behind European opposition to the importation of the US disease-and-drug model. Some highlights**:
DSM-5 will be published on May 20, 2013. Should Europeans be concerned about the publication of a classificatory system that has no legal currency there—especially since not all of Europe’s different social security systems require a diagnosis as a precondition for the reimbursement of the costs of psychiatric care?

I will try to explain succinctly why Europeans should be—indeed are—concerned about the DSM and its effects.

First, the DSM has lost its bet: there are no hard-and-fast biological markers that would allow establishing a psychiatric diagnosis.

… We’ve seen a lot of hope that science could finally unlock the key to mental illnesses. But this firm belief in the scientific psychiatry of the future, held by DSM advocates, has so far proven unfounded: thirty years after its publication, there’s still no confirmed scientific explanation, genetic or biological, for mental disease. Despite the hundreds of millions of dollars that have been invested in this branch of research, we're still waiting for the “salvation” biological markers were supposed to bring. As the research progresses, the task is turning out to be ever-more complex, while the scientific elucidation of mental illness is pushed further and further into the future.

Even after the United States declared the 1990s “the decade of the brain,” biological psychiatry has so completely failed in its effort to give psychiatry a rock-solid scientific basis that we must at last ask questions about its methodology and epistemological foundations. At the same time, the pharmaceutical industry has continued to produce new psychotropic drugs at ever-increasing speed.

…Psychiatry has entered the new era of the DSM, yet none of the many evaluations carried out in its name in the U.S. and Europe has shown significant or lasting improvement in the mental health of their citizens.
Despite the scientific and practical failure of the model, its influence continues to expand, propelled by corporate marketing and the associated power of US psychiatry. Landman’s post explains why this isn’t about any single company trying to shape cultural beliefs to hawk its pills or the introduction of a handful of dubious diagnoses in the ICD:
…New medication leads to the creation of new diagnoses, or the modification of existing ones. Consequently, it matters little whether the DSM is clinically binding for European psychiatrists, because in our liberal and globalized world both the spirit of the DSM and the pharmaco-induced model of clinical psychiatry are fast becoming universal. [my emphasis]
It’s about psychiatric imperialism, which has profound economic, political, and social effects. We in the US have to contest the hold of the model and call attention to the harms it causes here. But we shouldn’t fall into what I call the tobacco trap. Allan Brandt calls the tobacco industry’s lies about the harms of tobacco the “crime of the century” due to “the powerful impact on health and disease that Big Tobacco had through its acts of fraud and deception” which has resulted in the deaths of tens of millions of people and untold suffering. In this context, Brandt relates:
The tobacco industry remains quite strong despite losing lawsuits and enhanced public regulation. As a result, more people across the globe are smokers today than perhaps at any time in human history. As rates of smoking have declined in Western developed nations, the industry has aggressively sought new smokers in developing and poorer nations. It is now expected that in the coming century there will be one billion tobacco-related deaths. This despite the fact that we know such a great deal about the health effects of cigarette use. [my emphasis]
I frequently read articles that draw inspiration from the “success story” of the US campaign against the manipulations of the cigarette industry. And the effort to bring the scientific reality to light and reduce the rates of smoking is largely a success story…in the US. But as Brandt and others show, setbacks here have led cigarette companies to step up their colonization of other – mainly poor – countries. (This of course enhances their economic and political power within the US as well.)

The US is biopsychiatry’s home and base of operations. So much harm has been done, and continues to be done, in this country, and the struggles for science and human rights in the US are more important than ever. At the same time, sales revenues for “antidepressants” in the US are declining,*** the neuroleptic glut can’t go on forever, and public awareness of the scientific vacuum at the center of the model is growing.

We’re likely to see more successes in the US in the coming years – particularly in reducing the drugging of children - but it’s important to avoid becoming complacent. These successes are likely to be more than matched by biopsychiatry’s gains in other countries. As psychiatric imperialism is driven by the need to cultivate new markets for drugs, there’s every reason to expect a global intensification. So US activists need to continue to call attention to imperialistic efforts around the globe, to local resistance movements, and to alternative understandings of and approaches to psychological issues.

* The person who runs that site, Suzy Chapman, was bullied by the American Psychiatric Association into changing its name last year.

** I don’t agree with everything Landman says in that article or elsewhere.

***From that summary at Research and Markets:
Branded pharmaceutical companies are increasingly pulling out the antidepressant market, despite widespread use of the medication, as patent expiry and new drug development failures make it unprofitable to remain in the market.

However, according to The Pharmaceutical Strategist, the market still holds promise for that innovative player that would manage to exact value out of the current dissatisfaction of treatment outcome experienced by both patients and physicians alike.

With its naturally fluctuating course, depression is a highly placebo-responsive condition. Mean placebo response rates in antidepressant clinical trials hover around the 35% level. Physician-patient relationship, socio-cultural background, the treatment situation set and setting and even the color and shape of the placebo pill are contributing factors to the placebo response.

A dependable brand name also evokes an inherent response in the depressed patient. With billions of dollars already invested in developing antidepressant brands over the past two decades, finding a way to measure such response and to reliably measure its true effect can offer some of those valuable brands a new lease on life.


  1. The URL for the APA News alert article has been changed and has been updated on my site and in Chris Lane's blog:

  2. Salty,

    The deadline for public comment on all diagnosis and procedure proposals submitted via the September 18–19 ICD-9-CM Coordination and Maintenance Committee meeting is November 15, 2013.

    Details of proposed code changes and rationales for the APA's proposals can be found from Page 32 of the Diagnosis Agenda:

    The email address for sending public comment on diagnosis proposals can be found on Page 8.

    On Pages 45-46 are a number of other proposals for changes/additions to ICD-10-CM Chapter 5 codes, including the proposal to add two additional DSM-5 disorders to ICD-10-CM: Illness anxiety disorder and Somatic symptom disorder (see screenshot: )

    These are not currently proposed to eliminate or subsume any existing ICD-10-CM codes but are proposed as inclusion terms to existing ICD-10-CM categories.

    If proposed additions to ICD-10-CM do not meet the criteria for inclusion during a partial code freeze, their consideration would be deferred to 2015.

    The following DSM-5 disorders that are proposed for addition to ICD-10-CM are already proposed for inclusion in the public version of the ICD-11 Beta drafting platform:

    Binge eating disorder (BED
    Hoarding disorder
    Excoriation (skin picking) disorder
    Illness anxiety disorder
    Premenstrual dysphoric disorder (PMDD)
    (In the public version of the ICD-11 Beta draft, Premenstrual dysphoric disorder (PMDD) is currently proposed to be coded with a discrete code to dual parents under Chapter 15 Diseases of the genitourinary system section, Premenstrual tension syndrome, and also under Chapter 5 Depressive disorders.)

    Somatic symptom disorder is not currently proposed for the ICD-11 Beta draft, but a controversial new ICD construct called "Bodily distress disorder" (as yet undefined in the public version of the ICD-11 Beta draft), which may accommodate DSM-5's SSD, is being proposed and will be subject to ICD-11 field trials and evaluation. BDD is proposed to subsume several existing ICD-10 categories.

    So, comments and objections in to NCHS by November 15.

  3. Amendment to my comment above: The screenshot for the September 2013 ICD-9-CM C & M meeting Diagnosis Agenda proposal for inserting DSM-5's new 'Somatic symptom disorder' and 'Illness anxiety disorder' categories into ICD-10-CM is:

  4. Thanks again, especially for the deadline information and the URL for the Diagnosis Agenda. I've been watching the video of Regier that you provide at your post

    and reading the Diagnosis Agenda and the 2010 Leibenluft DMDD article. I'm...let's say having some trouble regulating my disruptive mood. :)