October 22, 2024 • 25 mins
If depression isn't caused by a chemical imbalance, why does everyone think it is?
WITH:
AND INFORMED BY:
Breaking Off My Chemical Romance - The Nation
Many People Taking Antidepressants Discover They Cannot Quit - The New York Times
Emotional Blunting, No Libido, No Life - by P.E. Moskowitz
The Epidemic of Mental Illness: Why? - New York Review of Books
The Illusions of Psychiatry - The New York Review of Books
Mad World: The Politics of Mental Health by Micha Frazer-Carroll
How do new disorders get into the DSM? - Slate
Delusions of Progress: Psychiatry’s Diagnostic Manual - Los Angeles Review of Books
“Scientific Nightmare”: The Backstory of the “DSM” - Los Angeles Review of Books
Anatomy of an Epidemic by Robert Whitaker
With Prozac Nation, Elizabeth Wurtzel blew open the memoir as we know it - BBC
Prozac: Revolution in a Capsule - The New York Times
How Prozac entered the lexicon - BBC News
Renamed Prozac Fuels Women's Health Debate - Washington Post
After the Boom, No Reason to Smile - Barron's
Something Happened to U.S. Drug Costs in the 1990s - The New York Times
Conflicts of interest and DSM-5: the media reaction - Speaking of Medicine and Health
Many authors of psychiatry bible have industry ties - New Scientist
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:00):
Hey, it's okay. Baska Case gets into some heavy topics
about mental health. But keep in mind that I'm not
a mental health professional. So in the description of this
and every episode, I'll leave you a list of relevant
resources and links to the things I'm reading, and while
you're listening, take care. In our last episode, I talked
with Samara, a musician who had been on some kind
(00:23):
of psychoactive drug for most of her life.
Speaker 2 (00:25):
I can't even remember the names of them anymore, but
I was on about six different psychiatric medications at one
time at a certain point, and I just I didn't
recognize my own personality.
Speaker 1 (00:40):
Samora's mental health issues, her depression, her anxiety, her thoughts
of suicide. They existed alongside years of gender dysphoria and
internalized transphobia, religious trauma, being rejected by her parents, and
spending some time un housed, sleeping on the street. But
what she told me was that it felt like her
brain was broken. It felt like she was broken.
Speaker 2 (01:01):
I just felt if I could just get my brain
to act like everybody else's, then I would be respected
and accepted and successful. I guess I'd still have this
rugged individualist mindset and be like oh, I have to
(01:23):
be mentally well. If everything is stripped away from me,
like no level of support, I need to be well.
So the whole big focused was you're broken. So that's it.
Speaker 1 (01:37):
For most of her life, Tomorrow I put her trust
in various psychiatrists to fix her.
Speaker 2 (01:42):
I would tell her like, oh, I stopped this one
because it wasn't really working for me, and she wasn't
asking me if I was like tapering off of it
or anything. She'd be like, Okay, do you want to
try this different one? I'd be like, well, sure, I
trust you, like you're you're a medical professional.
Speaker 1 (01:59):
If someone stop some medication suddenly, I would imagine a
health care professional would be really curious as to why
you stopped. Do you characterize it as aggressive or is
that just the impression I'm getting.
Speaker 2 (02:10):
I felt like there wasn't a lot of thought put
into how these medications were given to me and how
they would affect each other. I felt like she was
a businesswoman, So.
Speaker 1 (02:28):
Of course I started looking into the thing Tomorrow was
telling me about her experiences with psychiatry, and I found
out that seeing herself as broken and then seeing her
doctor her psychiatrists as the ultimate authority figure and then
finally describing her as a businesswoman. That might be attributed
to a process that started in the nineteen seventies. The
(02:51):
messaging that many of us receive about mental illness and
the most effective ways to treat it didn't happen by accident,
And to be honest, I was kind of gagged when
I learned more about where that messaging had come from.
This is Vaska case. I'm NK and this episode is
about what happens when patients become consumers in the marketplace
(03:14):
of mental health.
Speaker 3 (03:16):
Person's gonna want person's gonna want A person's gonna want me,
person's gonna want me. A person's gonna want me, person's
gonna want me.
Speaker 4 (03:26):
When I'm presing an anxiety, I mean so I basically
had what what back in the day they would call
a nervous breakdown. I don't know what that correct terminology
(03:46):
is now, yeah, and like bring back nervous breakdown.
Speaker 1 (03:49):
They're calling it a MENTV now.
Speaker 4 (03:54):
Great, Yeah, I had a men TV.
Speaker 3 (03:57):
This is P. E.
Speaker 1 (03:58):
Moskowitz, a writer andjournalist. They read a newsletter called mental Health.
That's health HLLL health in that subsac One of my faves.
They critique the cultural narrative that mental illness is a
purely biological problem to solve, when the reality of mental
illness is something a little more complicated. As a mental
health reporter, they've had their own journey with being on meds.
Speaker 4 (04:20):
So I had this breakdown and I got on SSRIs
and it was helpful in the sense that it blunted
the anxiety and the depression, but it also blunted everything else.
And when I was in crisis, it was useful for
not feeling like I was going to die at any moment, right,
but it also meant that I couldn't really experience like
the joy of the beautiful summer day, or the joy
(04:43):
of sex, or the joy of whatever. Because everything is blunted.
You end up just not feeling like you can feel
what your true self is. And then that takes a
whole process of rediscovery when you come off of these drugs,
in addition to the very real physical and mental withdrawal
that you go through.
Speaker 1 (05:00):
In twenty twenty two, reporting for The Nation, PE wrote
about the chemical imbalanced theory of depression. That's the idea
that depression is caused by a lack of the neurotransmitter serotonin,
a problem that antidepressants can fix.
Speaker 4 (05:13):
The prevalence of these disorders has been skyrocketing in the
last twenty years, as has the prescription of medication to
quote unquote treat those disorders. You would think if we
had come up with the solution to these individual and
discrete problems and found the chemicals that work to treat them,
that depression, suicide, anxiety, etc. Would all be going down.
Speaker 1 (05:33):
When I read PE's article earlier this year, I was
familiar with the chemical imbalanced theory of depression because most
people are. That idea was first hypothesized by a psychiatrist
named Joseph Schildkraut in nineteen sixty five, and it's widely
accepted as fact. What was new to me is that
scientists have spent half a century trying to prove that
(05:54):
this is why antidepressants work, but they haven't. There's no
solid evidence that has a neurobiological cause. No study has
ever proven that a lack of serotonin is what causes it.
In fact, one researcher spent fifteen years trying to prove
that SSRIs are effective, and ultimately he found that while
they do seem to help people with depression. In blind trials,
(06:18):
placebos worked almost as well, and Pe isn't the first
to point this out.
Speaker 4 (06:23):
It's interesting because until essentially the nineteen eighties, our way
of thinking about mental health was very, very, very very different.
It was more based in psychological factors like trauma and
family dynamics and life circumstances. And this was before the
quote unquote prescription drug revolution.
Speaker 1 (06:43):
Anytime they've written something critical of psychiatry in a forum
other than their own self, stack there's always a big response.
Sometimes there have even been death threats.
Speaker 4 (06:53):
It's like crazy. But people, i think are very passionately
committed to this idea that whatever is going on in
their brain and has nothing to do with their lives
or their histories, or their families or how bad they
feel in general in this world. And what happened is
not that any of all that was disproven. It was
(07:13):
that a lot more money was poured into the biochemical
model of mental health.
Speaker 1 (07:20):
And this dominant understanding of mental health started in a
time when the very nature of psychiatry was in crisis.
That's coming up after the break. So there is a
reason that no one says nervous breakdown anymore. What I
(07:41):
mean is it's a throwback to a different pharmaceutical age,
the era of benzo addiction value and popping and Mommy's
Little Helpers. By the nineteen seventies, psychiatry as an industry
had a reputation problem, and by then popular culture reflected
the backlash.
Speaker 4 (07:56):
Is this the way they end for me?
Speaker 1 (07:58):
Here in this place? And mental health hospittally cool it. Basically,
psychiatrists were seen as quacks, not legitimate doctors, and being
a psychiatric patient was incredibly stigmatized.
Speaker 2 (08:10):
Mom a quack is a quack all he's interested and
is taking money from people.
Speaker 3 (08:14):
While go see doctor Evans.
Speaker 2 (08:16):
He's a licensed MD.
Speaker 3 (08:17):
You can trust him.
Speaker 2 (08:18):
The fellow that told you this stuff sounds like a phone.
Speaker 1 (08:21):
But at the end of the nineteen seventies, the profession's
biggest players decided to change that, and they did it
by rewriting the story about mental distress.
Speaker 5 (08:35):
Some patients are disturbed, unable to care for themselves in
normal life situations.
Speaker 1 (08:39):
In the old story based on Freud, mental illness was
seen as abstract and psychological and influenced by personal circumstances.
Periods of distress were often seen as temporary, but the
new approach it was called the biomedical model, and it
meant that emotional experiences would be seen the same way
as medical conditions like diabautes or cancer, and that mental
(09:02):
illnesses would be most effectively treated with medication instead of therapy.
And that made psychiatrists the only medical professionals with the
authority to diagnose and prescribe the right treatment. And with
this important shift, psychiatrists became less interested in their patient's
life stories.
Speaker 5 (09:19):
So the biomedical approach takes place in silos, like completely
divorced from our social settings. If there were an approach
where doctors, for example, came into our homes, there might
be things that were immediately evident about the causes of
what we call illness mische.
Speaker 1 (09:36):
Fraser Carrol is the author of Mad World, The Politics
of Mental Health, a book about the ways mental illness
has been defined by systemic and structural forces. Even though
we often think of mental illness as an individual issue.
Speaker 5 (09:48):
And so I think we obscure the social causes when
we take a biomedical approach, and we also don't question
things like, well, actually, why are certain things categorized as
illness and the ones categorized as health, and would that
always be the case in the different world.
Speaker 1 (10:06):
In mad World. Fraser Carroll explains that in order for
psychiatry to enforce its rebrand, it relied on a book
that would eventually be known as Psychiatry's Bible, The Diagnostic
The Diagnostic and Statistical Manual. The Diagnostic and Statistical Manual.
Speaker 3 (10:25):
Nailed It.
Speaker 1 (10:26):
Usually it's just referred to as the DSM.
Speaker 5 (10:28):
This manual has been overhauled. It's been changed many times
across the course of less than a century, so many
diagnostic categories have shifted and changed across time.
Speaker 1 (10:40):
The DSM is a thick catalog of mental illnesses and disorders,
revised every six or seven years by the American Psychiatric Association.
At the time of recording, the latest revision was published
in twenty twenty two. But in the late nineteen seventies
the APA was working on the DSM three, and it
would be a major shift from the first two versions,
(11:01):
because that addition aimed to solidify psychiatry's new medical authority
by categorizing mental distress into clear objective symptoms much like
other medical conditions, and the DSM three captured more behaviors
and experiences in the widening net of mental illness than
had ever been captured before with two hundred and sixty
five discrete diagnoses. A growing number of diagnoses meant that
(11:24):
more people could see themselves in the official codified definitions
of mental illness, and it also meant more people would
be eligible for psychoactive medication. The APA president at the
time was adamant that the DSM three would prove psychiatry
was a legitimate medical field, and it succeeded. Once the
biomedical model of mental illness had been enshrined across the
(11:45):
five hundred pages of psychiatry's Bible, the stage was set
for a comeback. Then came the prescription drug revolution of
the nineteen nineties, thinks in part to a green and
white pill that to this day is a household name.
Prozac is the brand name of a drug called fluoxetine,
(12:06):
an antidepressant. Pharmaceutical company Eli Lilly began manufacturing it in
the late nineteen eighties, and by the end of the
nineteen nineties, Prozac was the moment the subject of a
best selling memoir, the star of a movie which also
included Christina Ricci. Prozac was on the cover of New
York magazine and Newsweek that were headlines calling Prozac a
(12:29):
wonder drug and a breakthrough. It was thanks to Prozac
that the neurochemical theory of depression went mainstream. It's a
big part of why many people still believe that depression
is caused by a chemical imbalance, and the mainstreaming of
that theory did reduce the stigma associated with both mental
(12:49):
illness and psychiatric treatments by doubling down on the idea
that depression was something biological, simply a matter of brain
chemistry and genetics. And that mattered because having a mental
illness then and now is sometimes seen as a moral
or personal failure. Reducing that stigma meant that more people
came out of the depression closet in order to seek support,
(13:10):
and that matters too. But Prozac was not really a
wonder drug because that neurochemical theory about depression was still
a theory. As pe pointed out earlier, what it was
for the pharmaceutical companies was a lesson, a lesson and
very effective marketing because before the nineteen nineties, psychoactive drugs
(13:35):
had mostly been advertised to healthcare providers, but Eli Lilly
marketed prozac directly to consumers and TV commercials and popular magazines,
And after Eli Lilly's huge success with Prozac, other drug
manufacturers followed suit, marketing a variety of problems and their
corresponding pharmaceutical solutions, problems like inadequate eyelashes or being too
(13:59):
moody on your period, and that is a whole other episode,
and I can't even get into it. In the nineties,
depression grew into an eleven billion dollar industry, the drug
industry's biggest money maker of the decade. One financial magazine
declared the nineties the Decade of Depression, and thanks at
least in part to Prozac's success. Today, nearly one in
(14:22):
six Americans take a psychiatric drug on a regular basis.
But even though the biomedical model still deeply informs the
way we think about mental illness today, treating depression and
anxiety in the same way we treat other diseases isn't
so straightforward. For one, there isn't a way to test
(14:44):
for mental disorder, like you can't see depression on an ultrasound,
So the psychiatric diagnostic process is subjective, which isn't the
case in extremely objective fields like cardiology and the subjective
nature of psychiatry also makes it easy to change the
definitions and criteria for different disorders, which is why the
number of diagnoses in the DSM are constantly in flux.
(15:07):
And all of this is great for drug companies because
more disorders means more chances to sell existing drugs for
new purposes and more opportunities to develop new ones. But
it wasn't just drug manufacturers that benefited from this shift.
I'll tell you who else benefited after this break so
(15:38):
the nineties. In the nineteen nineties, medical doctors of all
kinds were relying more and more on prescribing medication to
treat emotional distress, and at the same time, the relationship
between drug prescribers and drug manufacturers was flourishing. Many kinds
of doctors have relationships with specific pharmaceutical company and sometimes
(16:01):
prescribe accordingly, but psychiatrists collectively receive more financial perks from
drug companies than any other medical specialty. Psychiatrists are paid consultants,
They serve on advisory boards, and get their trips to
conferences paid for. Some become drug influencers known in the
industry as kol's or key opinion leaders, and drug manufacturers
(16:23):
subsidize their educational materials and give them personal gifts and
invite them to speak at conferences and in exchange. Psychiatrists
speak to the press and to other medical doctors on
behalf of drug manufacturers. When the DSM four came out
in the mid nineties, over half of its contributors had
connections to the drug industry, and the group working on
mood disorders like bipolar disorder everyone had ties to drug companies,
(16:49):
and it's pretty common that the people defining the disorders
that are most often treated with drugs rather than therapy
tend to be the same groups of people with the
highest rates of fin financial ties to drug manufacturers. When
the most recent version of the DSM was published, eighty
percent of its authors had financial conflicts of interest. But
(17:11):
what I find most meaningful about all of this is
that when mental illness is treated only as something biological,
it also means we have a personal, individual responsibility to
treat it. That's how Samara felt. Here's pe Moskowitz again.
Speaker 4 (17:28):
I think the thing is that the entire system is
set up for the easiest and cheapest way to solve
these problems, and something like going through intensive psychoanalysis or
somatic therapy, or you having to change the actual circumstances
of one's life, which could involve like changing jobs or
somehow getting out of poverty, which the government doesn't help
(17:51):
anyone do. All of those things are very hard to address,
and those all contribute to depression and other forms of
mental illness. And it it's much easier to just say, oh, well,
it's actually just your brain and not the circumstances surrounding
your life and your past and your traumas and all
of that.
Speaker 1 (18:09):
And that might mean we overlook other factors that could
also be contributing to mental distress. But the idea that
mental illness is caused by the interplay of many factors biological, genetic, psychological,
and environmental is far harder to conceptualize and a lot
less convenient.
Speaker 4 (18:26):
I think we're very attracted to the idea of individual
solutions to systemic problems, and we see that with mental
health too, where I use the analogy of like, let's
say we all live next to like a toxic, polluting factory, right,
and the factory gives person a cancer and person B
some kind of weird bone disease, and persons see lung issues,
(18:48):
And then what we're all doing is essentially saying, well,
what are the cures to these three different diseases, But
no one is saying, Hey, what's going on with that
factory down the road that's making this all sick?
Speaker 3 (18:59):
Right?
Speaker 4 (19:00):
And so I feel like I see that a lot
with mental health, where people are convinced that these supposedly
discrete disorders like depression, anxiety, ADHD, whatever, all of these
things are somehow not related to each other and are
somehow not related to the society in which we live,
which statistically just doesn't make sense. So to me, it's
(19:23):
obvious like we're not actually addressing the root cause of
the problem.
Speaker 1 (19:26):
This personal responsibility approach is especially seductive when changing the
conditions that also contribute to our mental distress feels impossible,
or when the incentive to address the conditions doesn't exist.
But expanding what counts as mental illness, along with the
mainstreaming of the drug to treat it, has had a
huge impact on society and culture. The influence of that
(19:48):
pivotal DSM three can still be seen today and how
we talk about, understand and treat mental health.
Speaker 4 (19:54):
I think one of the biggest consequences of our reliance
on this via medical biochemical model of mental illness is
that we don't really understand the long term consequences of
how any of this stuff works because there's a lot
of funding for short term studies to get things through
(20:16):
the FDA, but then there's no funding for things like
how do people get off of these drugs or what
happens if you take these drugs for ten or twenty years.
And I think there is a growing movement within psychiatry
to see these drugs as both good and bad, and
not just good. I've talked to psychiatrists who are like,
I will prescribe an SSRI, but I will only do
(20:41):
it if it feels like that's the best option and
it's not the first line of defense. And it doesn't
mean that prescription drug medications can't be useful. But I
think the problem is that it's not on an equal
playing field to other explanations and ways of dealing with
mental health.
Speaker 1 (21:00):
It's not that psychiatric medicine is all bad or all good.
For a lot of people. Drugs like antidepressants are a
source of relief and support, and for that reason, they
do belong in the psychiatric toolbox. It's just there may
also be other equally effective ways to treatmental distress, but
there are far fewer resources funneled into researching those alternatives.
Speaker 4 (21:28):
They don't have billions upon billions of dollars of funding
to push out a kind of research machine and fund universities.
There's not like the Freud Department of Studies at University
of whatever. Instead there's like the Pfiser Department of this.
So there's just not an economic incentive to have these
theories on cool footing, Which doesn't mean that the biochemical
(21:49):
model has done nothing good.
Speaker 1 (21:51):
But we need more research into studying alternatives to psychoactive
drugs and more interventions directed at environmental conditions Mesua Phraser
Carol Again.
Speaker 5 (22:02):
So in the book, I talk about, for example, getting
a diagnosis of vitamin D deficiency. The doctor's solution to
that is vitamin D supplements, which is one way of
getting at the problem. But also if you look at
my living conditions, I don't have a garden, I don't
have a space where I can privately go and sit
outside and gain access to funlight. My working conditions mean
(22:24):
that I have to be inside a lot of the
time as well, in the office. There are so many
different reasons why such a simple diagnosis could actually be
remedied in the social world.
Speaker 1 (22:34):
If mental health crises could be seen not only as
individual problems, but symptoms of deeper systemic issues, then paying
attention to our mental distress could actually lead to real change.
Change it helps everyone.
Speaker 5 (22:46):
One thing that people in crisis often say is like
they just want someone to be with them rather than
try to forcibly make the quote problem go away, because
I think that so many of the medical approaches we
see which can be really punished and really cascer or
sometimes they try to say, well, this is the problem,
let's quickly find the solution and lets you adicate the distress. Actually,
(23:10):
I think in some context, for example, when I think
that my mental distress has been associated with like white supremacy,
I think that rather than trying to shut down the
symptom and kind of silence the symptom, it's kind of
more useful sometimes to be with it and hear it
and say, Okay, this is a signal like I'm living
in a really really messed up society, and actually, maybe
(23:31):
I can listen to that signal rather than trying to
suppress it. These ideas, they're not going to make sense
for everyone. Sometimes we do just want to get rid
of our distress. But I think that idea that we
could just be with it or could listen to it
is also like a potentially useful tool.
Speaker 1 (23:48):
And sometimes when it comes to the ways we experience
mental distress, you can't solve the problem with the magic pill.
Basket Case is a production of molten Heart and iHeart Podcasts.
This series was created and is executive produced by Jasmine J. T.
(24:08):
Green and it is hosted, produced, and sound designed by
me NK Nicole Kelly. Special thanks to p E. Moskowitz
and Misha Fraser Carrol and thanks to Robert Whittaker, Marcia Angel,
Andrew Skull, and Rachel Levive whose work guided my thinking
about this topic. Production support by Siona Petros and Ammani Leonard.
(24:32):
Adrian Lilly is our mix engineer. Our theme is blue
and orange by Command Jasmine. Our show art was created
by Sinney Rolson. Fact checking by Serena Solenn. Legal services
provided by Rowan Marron and File. Our executive producer from
iHeart Podcasts is Lindsay Hoffman.
Speaker 3 (24:58):
Elsskin Is. It's Gonnath's gonna Walk's gonna Walkerson's gonna looks,
is gonna want, is gonna want?
Speaker 6 (25:10):
Depression and anxiety mean when I have depression and anxiety.
When I have depression and anxiety, When I have depression
and anxiety.
Speaker 5 (25:24):
My god, Oh my god, oh my god. I don't
Hey, it's okay. Baska Case gets into some heavy topics
about mental health. But keep in mind that I'm not
a mental health professional. So in the description of this
and every episode, I'll leave you a list of relevant
resources and links to the things I'm reading, and while
you're listening, take care. In our last episode, I talked
with Samara, a musician who had been on some kind
(00:23):
of psychoactive drug for most of her life.
Speaker 2 (00:25):
I can't even remember the names of them anymore, but
I was on about six different psychiatric medications at one
time at a certain point, and I just I didn't
recognize my own personality.
Speaker 1 (00:40):
Samora's mental health issues, her depression, her anxiety, her thoughts
of suicide. They existed alongside years of gender dysphoria and
internalized transphobia, religious trauma, being rejected by her parents, and
spending some time un housed, sleeping on the street. But
what she told me was that it felt like her
brain was broken. It felt like she was broken.
Speaker 2 (01:01):
I just felt if I could just get my brain
to act like everybody else's, then I would be respected
and accepted and successful. I guess I'd still have this
rugged individualist mindset and be like oh, I have to
(01:23):
be mentally well. If everything is stripped away from me,
like no level of support, I need to be well.
So the whole big focused was you're broken. So that's it.
Speaker 1 (01:37):
For most of her life, Tomorrow I put her trust
in various psychiatrists to fix her.
Speaker 2 (01:42):
I would tell her like, oh, I stopped this one
because it wasn't really working for me, and she wasn't
asking me if I was like tapering off of it
or anything. She'd be like, Okay, do you want to
try this different one? I'd be like, well, sure, I
trust you, like you're you're a medical professional.
Speaker 1 (01:59):
If someone stop some medication suddenly, I would imagine a
health care professional would be really curious as to why
you stopped. Do you characterize it as aggressive or is
that just the impression I'm getting.
Speaker 2 (02:10):
I felt like there wasn't a lot of thought put
into how these medications were given to me and how
they would affect each other. I felt like she was
a businesswoman, So.
Speaker 1 (02:28):
Of course I started looking into the thing Tomorrow was
telling me about her experiences with psychiatry, and I found
out that seeing herself as broken and then seeing her
doctor her psychiatrists as the ultimate authority figure and then
finally describing her as a businesswoman. That might be attributed
to a process that started in the nineteen seventies. The
(02:51):
messaging that many of us receive about mental illness and
the most effective ways to treat it didn't happen by accident,
And to be honest, I was kind of gagged when
I learned more about where that messaging had come from.
This is Vaska case. I'm NK and this episode is
about what happens when patients become consumers in the marketplace
(03:14):
of mental health.
Speaker 3 (03:16):
Person's gonna want person's gonna want A person's gonna want me,
person's gonna want me. A person's gonna want me, person's
gonna want me.
Speaker 4 (03:26):
When I'm presing an anxiety, I mean so I basically
had what what back in the day they would call
a nervous breakdown. I don't know what that correct terminology
(03:46):
is now, yeah, and like bring back nervous breakdown.
Speaker 1 (03:49):
They're calling it a MENTV now.
Speaker 4 (03:54):
Great, Yeah, I had a men TV.
Speaker 3 (03:57):
This is P. E.
Speaker 1 (03:58):
Moskowitz, a writer andjournalist. They read a newsletter called mental Health.
That's health HLLL health in that subsac One of my faves.
They critique the cultural narrative that mental illness is a
purely biological problem to solve, when the reality of mental
illness is something a little more complicated. As a mental
health reporter, they've had their own journey with being on meds.
Speaker 4 (04:20):
So I had this breakdown and I got on SSRIs
and it was helpful in the sense that it blunted
the anxiety and the depression, but it also blunted everything else.
And when I was in crisis, it was useful for
not feeling like I was going to die at any moment, right,
but it also meant that I couldn't really experience like
the joy of the beautiful summer day, or the joy
(04:43):
of sex, or the joy of whatever. Because everything is blunted.
You end up just not feeling like you can feel
what your true self is. And then that takes a
whole process of rediscovery when you come off of these drugs,
in addition to the very real physical and mental withdrawal
that you go through.
Speaker 1 (05:00):
In twenty twenty two, reporting for The Nation, PE wrote
about the chemical imbalanced theory of depression. That's the idea
that depression is caused by a lack of the neurotransmitter serotonin,
a problem that antidepressants can fix.
Speaker 4 (05:13):
The prevalence of these disorders has been skyrocketing in the
last twenty years, as has the prescription of medication to
quote unquote treat those disorders. You would think if we
had come up with the solution to these individual and
discrete problems and found the chemicals that work to treat them,
that depression, suicide, anxiety, etc. Would all be going down.
Speaker 1 (05:33):
When I read PE's article earlier this year, I was
familiar with the chemical imbalanced theory of depression because most
people are. That idea was first hypothesized by a psychiatrist
named Joseph Schildkraut in nineteen sixty five, and it's widely
accepted as fact. What was new to me is that
scientists have spent half a century trying to prove that
(05:54):
this is why antidepressants work, but they haven't. There's no
solid evidence that has a neurobiological cause. No study has
ever proven that a lack of serotonin is what causes it.
In fact, one researcher spent fifteen years trying to prove
that SSRIs are effective, and ultimately he found that while
they do seem to help people with depression. In blind trials,
(06:18):
placebos worked almost as well, and Pe isn't the first
to point this out.
Speaker 4 (06:23):
It's interesting because until essentially the nineteen eighties, our way
of thinking about mental health was very, very, very very different.
It was more based in psychological factors like trauma and
family dynamics and life circumstances. And this was before the
quote unquote prescription drug revolution.
Speaker 1 (06:43):
Anytime they've written something critical of psychiatry in a forum
other than their own self, stack there's always a big response.
Sometimes there have even been death threats.
Speaker 4 (06:53):
It's like crazy. But people, i think are very passionately
committed to this idea that whatever is going on in
their brain and has nothing to do with their lives
or their histories, or their families or how bad they
feel in general in this world. And what happened is
not that any of all that was disproven. It was
(07:13):
that a lot more money was poured into the biochemical
model of mental health.
Speaker 1 (07:20):
And this dominant understanding of mental health started in a
time when the very nature of psychiatry was in crisis.
That's coming up after the break. So there is a
reason that no one says nervous breakdown anymore. What I
(07:41):
mean is it's a throwback to a different pharmaceutical age,
the era of benzo addiction value and popping and Mommy's
Little Helpers. By the nineteen seventies, psychiatry as an industry
had a reputation problem, and by then popular culture reflected
the backlash.
Speaker 4 (07:56):
Is this the way they end for me?
Speaker 1 (07:58):
Here in this place? And mental health hospittally cool it. Basically,
psychiatrists were seen as quacks, not legitimate doctors, and being
a psychiatric patient was incredibly stigmatized.
Speaker 2 (08:10):
Mom a quack is a quack all he's interested and
is taking money from people.
Speaker 3 (08:14):
While go see doctor Evans.
Speaker 2 (08:16):
He's a licensed MD.
Speaker 3 (08:17):
You can trust him.
Speaker 2 (08:18):
The fellow that told you this stuff sounds like a phone.
Speaker 1 (08:21):
But at the end of the nineteen seventies, the profession's
biggest players decided to change that, and they did it
by rewriting the story about mental distress.
Speaker 5 (08:35):
Some patients are disturbed, unable to care for themselves in
normal life situations.
Speaker 1 (08:39):
In the old story based on Freud, mental illness was
seen as abstract and psychological and influenced by personal circumstances.
Periods of distress were often seen as temporary, but the
new approach it was called the biomedical model, and it
meant that emotional experiences would be seen the same way
as medical conditions like diabautes or cancer, and that mental
(09:02):
illnesses would be most effectively treated with medication instead of therapy.
And that made psychiatrists the only medical professionals with the
authority to diagnose and prescribe the right treatment. And with
this important shift, psychiatrists became less interested in their patient's
life stories.
Speaker 5 (09:19):
So the biomedical approach takes place in silos, like completely
divorced from our social settings. If there were an approach
where doctors, for example, came into our homes, there might
be things that were immediately evident about the causes of
what we call illness mische.
Speaker 1 (09:36):
Fraser Carrol is the author of Mad World, The Politics
of Mental Health, a book about the ways mental illness
has been defined by systemic and structural forces. Even though
we often think of mental illness as an individual issue.
Speaker 5 (09:48):
And so I think we obscure the social causes when
we take a biomedical approach, and we also don't question
things like, well, actually, why are certain things categorized as
illness and the ones categorized as health, and would that
always be the case in the different world.
Speaker 1 (10:06):
In mad World. Fraser Carroll explains that in order for
psychiatry to enforce its rebrand, it relied on a book
that would eventually be known as Psychiatry's Bible, The Diagnostic
The Diagnostic and Statistical Manual. The Diagnostic and Statistical Manual.
Speaker 3 (10:25):
Nailed It.
Speaker 1 (10:26):
Usually it's just referred to as the DSM.
Speaker 5 (10:28):
This manual has been overhauled. It's been changed many times
across the course of less than a century, so many
diagnostic categories have shifted and changed across time.
Speaker 1 (10:40):
The DSM is a thick catalog of mental illnesses and disorders,
revised every six or seven years by the American Psychiatric Association.
At the time of recording, the latest revision was published
in twenty twenty two. But in the late nineteen seventies
the APA was working on the DSM three, and it
would be a major shift from the first two versions,
(11:01):
because that addition aimed to solidify psychiatry's new medical authority
by categorizing mental distress into clear objective symptoms much like
other medical conditions, and the DSM three captured more behaviors
and experiences in the widening net of mental illness than
had ever been captured before with two hundred and sixty
five discrete diagnoses. A growing number of diagnoses meant that
(11:24):
more people could see themselves in the official codified definitions
of mental illness, and it also meant more people would
be eligible for psychoactive medication. The APA president at the
time was adamant that the DSM three would prove psychiatry
was a legitimate medical field, and it succeeded. Once the
biomedical model of mental illness had been enshrined across the
(11:45):
five hundred pages of psychiatry's Bible, the stage was set
for a comeback. Then came the prescription drug revolution of
the nineteen nineties, thinks in part to a green and
white pill that to this day is a household name.
Prozac is the brand name of a drug called fluoxetine,
(12:06):
an antidepressant. Pharmaceutical company Eli Lilly began manufacturing it in
the late nineteen eighties, and by the end of the
nineteen nineties, Prozac was the moment the subject of a
best selling memoir, the star of a movie which also
included Christina Ricci. Prozac was on the cover of New
York magazine and Newsweek that were headlines calling Prozac a
(12:29):
wonder drug and a breakthrough. It was thanks to Prozac
that the neurochemical theory of depression went mainstream. It's a
big part of why many people still believe that depression
is caused by a chemical imbalance, and the mainstreaming of
that theory did reduce the stigma associated with both mental
(12:49):
illness and psychiatric treatments by doubling down on the idea
that depression was something biological, simply a matter of brain
chemistry and genetics. And that mattered because having a mental
illness then and now is sometimes seen as a moral
or personal failure. Reducing that stigma meant that more people
came out of the depression closet in order to seek support,
(13:10):
and that matters too. But Prozac was not really a
wonder drug because that neurochemical theory about depression was still
a theory. As pe pointed out earlier, what it was
for the pharmaceutical companies was a lesson, a lesson and
very effective marketing because before the nineteen nineties, psychoactive drugs
(13:35):
had mostly been advertised to healthcare providers, but Eli Lilly
marketed prozac directly to consumers and TV commercials and popular magazines,
And after Eli Lilly's huge success with Prozac, other drug
manufacturers followed suit, marketing a variety of problems and their
corresponding pharmaceutical solutions, problems like inadequate eyelashes or being too
(13:59):
moody on your period, and that is a whole other episode,
and I can't even get into it. In the nineties,
depression grew into an eleven billion dollar industry, the drug
industry's biggest money maker of the decade. One financial magazine
declared the nineties the Decade of Depression, and thanks at
least in part to Prozac's success. Today, nearly one in
(14:22):
six Americans take a psychiatric drug on a regular basis.
But even though the biomedical model still deeply informs the
way we think about mental illness today, treating depression and
anxiety in the same way we treat other diseases isn't
so straightforward. For one, there isn't a way to test
(14:44):
for mental disorder, like you can't see depression on an ultrasound,
So the psychiatric diagnostic process is subjective, which isn't the
case in extremely objective fields like cardiology and the subjective
nature of psychiatry also makes it easy to change the
definitions and criteria for different disorders, which is why the
number of diagnoses in the DSM are constantly in flux.
(15:07):
And all of this is great for drug companies because
more disorders means more chances to sell existing drugs for
new purposes and more opportunities to develop new ones. But
it wasn't just drug manufacturers that benefited from this shift.
I'll tell you who else benefited after this break so
(15:38):
the nineties. In the nineteen nineties, medical doctors of all
kinds were relying more and more on prescribing medication to
treat emotional distress, and at the same time, the relationship
between drug prescribers and drug manufacturers was flourishing. Many kinds
of doctors have relationships with specific pharmaceutical company and sometimes
(16:01):
prescribe accordingly, but psychiatrists collectively receive more financial perks from
drug companies than any other medical specialty. Psychiatrists are paid consultants,
They serve on advisory boards, and get their trips to
conferences paid for. Some become drug influencers known in the
industry as kol's or key opinion leaders, and drug manufacturers
(16:23):
subsidize their educational materials and give them personal gifts and
invite them to speak at conferences and in exchange. Psychiatrists
speak to the press and to other medical doctors on
behalf of drug manufacturers. When the DSM four came out
in the mid nineties, over half of its contributors had
connections to the drug industry, and the group working on
mood disorders like bipolar disorder everyone had ties to drug companies,
(16:49):
and it's pretty common that the people defining the disorders
that are most often treated with drugs rather than therapy
tend to be the same groups of people with the
highest rates of fin financial ties to drug manufacturers. When
the most recent version of the DSM was published, eighty
percent of its authors had financial conflicts of interest. But
(17:11):
what I find most meaningful about all of this is
that when mental illness is treated only as something biological,
it also means we have a personal, individual responsibility to
treat it. That's how Samara felt. Here's pe Moskowitz again.
Speaker 4 (17:28):
I think the thing is that the entire system is
set up for the easiest and cheapest way to solve
these problems, and something like going through intensive psychoanalysis or
somatic therapy, or you having to change the actual circumstances
of one's life, which could involve like changing jobs or
somehow getting out of poverty, which the government doesn't help
(17:51):
anyone do. All of those things are very hard to address,
and those all contribute to depression and other forms of
mental illness. And it it's much easier to just say, oh, well,
it's actually just your brain and not the circumstances surrounding
your life and your past and your traumas and all
of that.
Speaker 1 (18:09):
And that might mean we overlook other factors that could
also be contributing to mental distress. But the idea that
mental illness is caused by the interplay of many factors biological, genetic, psychological,
and environmental is far harder to conceptualize and a lot
less convenient.
Speaker 4 (18:26):
I think we're very attracted to the idea of individual
solutions to systemic problems, and we see that with mental
health too, where I use the analogy of like, let's
say we all live next to like a toxic, polluting factory, right,
and the factory gives person a cancer and person B
some kind of weird bone disease, and persons see lung issues,
(18:48):
And then what we're all doing is essentially saying, well,
what are the cures to these three different diseases, But
no one is saying, Hey, what's going on with that
factory down the road that's making this all sick?
Speaker 3 (18:59):
Right?
Speaker 4 (19:00):
And so I feel like I see that a lot
with mental health, where people are convinced that these supposedly
discrete disorders like depression, anxiety, ADHD, whatever, all of these
things are somehow not related to each other and are
somehow not related to the society in which we live,
which statistically just doesn't make sense. So to me, it's
(19:23):
obvious like we're not actually addressing the root cause of
the problem.
Speaker 1 (19:26):
This personal responsibility approach is especially seductive when changing the
conditions that also contribute to our mental distress feels impossible,
or when the incentive to address the conditions doesn't exist.
But expanding what counts as mental illness, along with the
mainstreaming of the drug to treat it, has had a
huge impact on society and culture. The influence of that
(19:48):
pivotal DSM three can still be seen today and how
we talk about, understand and treat mental health.
Speaker 4 (19:54):
I think one of the biggest consequences of our reliance
on this via medical biochemical model of mental illness is
that we don't really understand the long term consequences of
how any of this stuff works because there's a lot
of funding for short term studies to get things through
(20:16):
the FDA, but then there's no funding for things like
how do people get off of these drugs or what
happens if you take these drugs for ten or twenty years.
And I think there is a growing movement within psychiatry
to see these drugs as both good and bad, and
not just good. I've talked to psychiatrists who are like,
I will prescribe an SSRI, but I will only do
(20:41):
it if it feels like that's the best option and
it's not the first line of defense. And it doesn't
mean that prescription drug medications can't be useful. But I
think the problem is that it's not on an equal
playing field to other explanations and ways of dealing with
mental health.
Speaker 1 (21:00):
It's not that psychiatric medicine is all bad or all good.
For a lot of people. Drugs like antidepressants are a
source of relief and support, and for that reason, they
do belong in the psychiatric toolbox. It's just there may
also be other equally effective ways to treatmental distress, but
there are far fewer resources funneled into researching those alternatives.
Speaker 4 (21:28):
They don't have billions upon billions of dollars of funding
to push out a kind of research machine and fund universities.
There's not like the Freud Department of Studies at University
of whatever. Instead there's like the Pfiser Department of this.
So there's just not an economic incentive to have these
theories on cool footing, Which doesn't mean that the biochemical
(21:49):
model has done nothing good.
Speaker 1 (21:51):
But we need more research into studying alternatives to psychoactive
drugs and more interventions directed at environmental conditions Mesua Phraser
Carol Again.
Speaker 5 (22:02):
So in the book, I talk about, for example, getting
a diagnosis of vitamin D deficiency. The doctor's solution to
that is vitamin D supplements, which is one way of
getting at the problem. But also if you look at
my living conditions, I don't have a garden, I don't
have a space where I can privately go and sit
outside and gain access to funlight. My working conditions mean
(22:24):
that I have to be inside a lot of the
time as well, in the office. There are so many
different reasons why such a simple diagnosis could actually be
remedied in the social world.
Speaker 1 (22:34):
If mental health crises could be seen not only as
individual problems, but symptoms of deeper systemic issues, then paying
attention to our mental distress could actually lead to real change.
Change it helps everyone.
Speaker 5 (22:46):
One thing that people in crisis often say is like
they just want someone to be with them rather than
try to forcibly make the quote problem go away, because
I think that so many of the medical approaches we
see which can be really punished and really cascer or
sometimes they try to say, well, this is the problem,
let's quickly find the solution and lets you adicate the distress. Actually,
(23:10):
I think in some context, for example, when I think
that my mental distress has been associated with like white supremacy,
I think that rather than trying to shut down the
symptom and kind of silence the symptom, it's kind of
more useful sometimes to be with it and hear it
and say, Okay, this is a signal like I'm living
in a really really messed up society, and actually, maybe
(23:31):
I can listen to that signal rather than trying to
suppress it. These ideas, they're not going to make sense
for everyone. Sometimes we do just want to get rid
of our distress. But I think that idea that we
could just be with it or could listen to it
is also like a potentially useful tool.
Speaker 1 (23:48):
And sometimes when it comes to the ways we experience
mental distress, you can't solve the problem with the magic pill.
Basket Case is a production of molten Heart and iHeart Podcasts.
This series was created and is executive produced by Jasmine J. T.
(24:08):
Green and it is hosted, produced, and sound designed by
me NK Nicole Kelly. Special thanks to p E. Moskowitz
and Misha Fraser Carrol and thanks to Robert Whittaker, Marcia Angel,
Andrew Skull, and Rachel Levive whose work guided my thinking
about this topic. Production support by Siona Petros and Ammani Leonard.
(24:32):
Adrian Lilly is our mix engineer. Our theme is blue
and orange by Command Jasmine. Our show art was created
by Sinney Rolson. Fact checking by Serena Solenn. Legal services
provided by Rowan Marron and File. Our executive producer from
iHeart Podcasts is Lindsay Hoffman.
Speaker 3 (24:58):
Elsskin Is. It's Gonnath's gonna Walk's gonna Walkerson's gonna looks,
is gonna want, is gonna want?
Speaker 6 (25:10):
Depression and anxiety mean when I have depression and anxiety.
When I have depression and anxiety, When I have depression
and anxiety.
Speaker 5 (25:24):
My god, Oh my god, oh my god. I don't
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