In my letter to Prospect Magazine I write the following response to Andrew Solomon’s critical review of Cracked.
“I knew Cracked would be controversial. I was proven right. Some reviews were lauding, some mixed, a couple censorious. But by far the most damning was Andrew Solomon’s in The Prospect. Not damning in the sense it was analytically incisive (he misrepresents the book at many points – see my website), but in that its tone was unnecessarily unkind. He called my position arrogant, smug, ill-informed and stated that by writing this book I now have ‘blood on my hands’, presumably because Cracked may dissuade people from problematic psychiatric treatments like ECT or antidepressants.
After researching Solomon’s biography I discovered his father is CEO of Forest Laboratories, which manufactures the third most popular antidepressant – citalopram. As I pointed out in Cracked, Forest was charged by the U.S. Justice Department for defrauding the government of millions of dollars, because top executives had hidden a clinical study showing that their antidepressants were not effective in children and might pose dangerous risks to them, including causing some children to become suicidal. For being at the helm during this and other misdemeanors Solomon’s father in 2011 was considered for exclusion from the health-care industry by the U.S. Office of Inspector General, which handles the fight against fraud in government health programs.
Could my criticism of the father’s company explain the tone of the son’s review? I really don’t know. Nor could I ever know. But given the uncertainty, Solomon should have stated his potential domestic conflict of interest. Being upfront would not have obviated his opinion, nor made him unfit to comment on these issues, nor impugned his character. But it would have told the reader something they ought to know when assessing the independence of his review”.
In the above letter I state that Andrew Solomon misrepresents Cracked at many points, and that I will show where on my website. So let me honour that now:
1. Solomon states in his review that I claim, “most people with schizophrenia are better off not taking antipsychotics”.
This is just not true. All I say is what the research tells us, that short-term use of these pills can help stabalise patients, but long-term use can start to unleash counter-therapeutic effects, debilitating side effects, and damning neurological effects that we still do not understand.
2. Further misrepresenting me Solomon claims I say: ‘that lithium is bad for people with bipolar disorder’.
Nowhere do I make that claim. All I reiterate is what the research shows, that this drug can be fatal in high doses.
3. Solomon states that I take, “particular umbrage at the chemical imbalance theory [which] has been out of circulation for a decade”.
I agree that the theory is now dead in the water. But my point was a different one: that despite this many patients are still availed of this theory to help explain why they should take antidepressants. Many of the patients I have treated in the NHS for depression who take anti-depressants fall into this category. But Solomon is not a practitioner, and so can be forgiven for not knowing what actually happens on the ground.
4. Solomon then takes issue with my discussion of Irving Kirsch’s meta-analysis, which shows that antidepressants work no better than placebos for the majority of people taking them. Solomon says I ignore studies that contradict Kirsch’s (e.g. Erick Turner’s study that placebos are highly effective but that antidepressants are slightly effective).
Here Solomon’s understanding of Turner’s work is superficial. Turner’s analysis actually reached broadly the same conclusions as Kirsch’s – the difference is that, Turner’s lowered the bar for what constitutes a ‘clinically significant’ difference between placebos and antidepressants, thus creating the artificial impression that antidepressants are moderately better than placebos when in fact for the majority of patients their difference is clinically insignificant. If you stretch the goalposts you get a different result, and that’s what Turner does.
5. Once again, Solomon critiques Kirsch’s work. He writes: ‘Konstantinos Fontoulakis has shown that Kirsch miscalculated the mean drug-placebo difference’.
To be correct, Fontoulakis has not ‘shown’ this, he simply uses different analytical measures to reach a different conclusion. But even if, for the sake of argument, we accept Fontoulakis’s conclusions, they still do not show that antidepressants have ‘clinically significant’ benefits over placebos for the majority of people taking them. This is because the difference Fontoulakis finds does not go beyond the 3.0 points threshold on the Hamilton scale for clinical significance. So even if Fontoulakis’ conclusions stand, his work does not undermine Kirsch’s.
6. Solomon complains about my critiquing the dubious ties between many psychiatrists and drug companies. He quotes my saying: “[W]henever someone ostensibly benefits from a psychiatric prescription, the pharmaceutical industry and many within psychiatry benefit too,” Solomon then goes on to state: “Davies writes accusingly. But when a doctor performs a heart transplant, he gets paid, and so does the hospital, and pharmaceutical companies profit from the immunosuppressant drugs that are used by transplant recipients. The fact that there’s money to be made in the exchange of commodities and services does not invalidate the source of profit”.
Solomon again misrepresents my point. I do not resent psychiatrists getting paid for their work, I merely show that many are receiving money from the pharmaceutical industry for a variety of reasons, and that many of these payments are not transparent. This is problematic given that research shows that doctors who receive these payments are more likely to be biased in their clinical activities and beliefs than doctors who don’t. We need greater transparency and accountability – that is my point – not that doctors should work for free…..
7. Solomon then writes “Davies’s most vigorous criticism is that psychiatry, ‘by progressively lowering the bar for what counts as mental disorder, has recast many natural responses to the problems of living as mental disorders requiring psychiatric treatment.’ I’d argue almost the opposite: that a century ago, you would have accomplished very little by seeking a diagnosis for your mental woes; all that could be said was that such pain was part of the human condition. Nowadays, acknowledging your inner turmoil gives you access to technologies that may allay it. Because diagnosis is now useful, there is more of it.”
Solomon here plays down that psychiatric diagnostic manuals have expanded at a faster rate than any other medical manuals in history, pathologising more and more human experience. This process has happened without solid scientific justification. This is not to say there aren’t some diagnostic categories that are useful, it is just to say that many, if not most, aren’t. By endorsing the harmful epidemic of over-diagnosis, Solomon seems blind to the damage caused by this epidemic. The more people who are diagnosed unnecessarily the more will suffer from the stigma of being diagnosed mentally ill, the more will be prescribed often ineffectual and dangerous medications (with powerful side and withdrawal effects), and the fewer, in my experience, will be offered non-medical alternatives, as is the case right now in the NHS. All Solomon seems to be saying is that the increase in diagnoses is a good thing because it has lead to more prescriptions. He does not provide any evidence as to why we should accept he is right.
8. Solomon writes: “One of the most powerful myths embraced by the psychiatric establishment,” according to Davies, is that ‘psychiatric drugs are capable of ‘curing’ us and are therefore distinct from recreational drugs that merely alter our state of mind.’ This is another one of Davies’s straw men. No one has claimed that such pills “cure” mental illness; they only treat its symptoms. But neither does ibuprofen cure arthritis, nor tamoxifen cure breast cancer”.
Solomon is taking this statement out of context, omitting the arguments of the chapter where I explain this statement. In short, the ‘curing model’ of antidepressants is implied by what patients are regularly told: that their depression is due to a chemical imbalance that drugs rebalance. Of course there are those who do not accept this view, but when taking a broader historical perspective it is true to say the ‘curing model’ has had great traction in psychiatry over the last 30 years, largely as an implication of the resurgence of biological model of emotional distress.
9. Solomon writes the following: “Davies’s most dubious choice is to impose moral language on the conversation. When he argues that ‘experiences of sadness, anxiety or unhappiness were often listed as symptoms of underlying disorders, rather than seen as natural and normal human reactions to certain life conditions that needed to be changed,’ he seems to be on a moral quest to lionise what is ‘natural’—and therefore should not be changed.”
As is clear from a cursory reading of my book, what I mean by a ‘natural’ reaction is an ‘understandable’ and ‘appropriate’ reaction to a life situation that requires changing. ‘Depression’ therefore may be a ‘natural’ reaction to being subject to harmful social injustice. In this case, rather than trying to medicate this natural reaction away (which can result in leaving the injustice intact), we should rather respect what the depression is trying to communicate and do something about changing our social predicament. Solomon seems to want you to change your biochemistry rather than your circumstances (at least this is what the above argument seems to imply). This, in my view, betrays a damaging social conservatism where pathology is relocated from society to persons.
10. Solomon then writes: “I’d like to wish upon Davies a month of acute psychosis or major depression and then see how he feels about lessons learned, and check whether this pompous psychic Marxism continues to appeal to him. His smug view of human suffering conflates the fact that suffering can be ennobling with the supposition that people should do more of it.”
I am a psychotherapist and so have worked clinically with many people suffering from major depression and psychotic experiences. Thus Solomon’s intimation that I am out of touch with clinical reality is a strange one for a non-practitioner to make. Stranger still is Solomon’s statement that I believe people, with respect to suffering, ‘should do more of it’. This is another example of Solomon misrepresenting my position: in my clinical experience many forms of suffering that are currently dismissed as medical disease are not disease at all. Rather are they often a call to change; the organism’s protest against inhospitable social or psychological conditions. Therefore, rather than turning to anesthetics as a first response there is often value in working through our suffering productively – trying to discern what it is seeking to communicate so that we can work to put things right. There is nothing in this view that either glamourizes or masochistically encourages suffering. I merely argue what my clinical experience has taught me; that it is oftentimes better to face ones suffering and work through it productively than have recourse to anesthetics.
11. Solomon then goes on to criticising me for saying: “It was hubris for medicine to try to manage realms of life it was never designed to treat”.
Solomon again gets it wrong. I did not say this. Rather, Thomas Szasz said this to me in our interview. I make it clear in the book that this sentence, and the whole paragraph from which it is taken, is paraphrased from that interview.
12. Solomon then concludes: “Davies’s book will likely influence at least a few people away from treatment that could save them. Some of those people may commit suicide and others will live in dire pain. His arrogant, ill-informed attempt to discredit psychiatry leaves him with blood on his hands.”
People are better off without psychiatric interventions that do harm. I argue that many psychiatric inventions do such harm. Of course Solomon believes something else – obviously quite strongly…. But there is a core difference between us: I have set out the evidence to justify my position, but as far as I am aware, beyond the anecdotal, Solomon has not done the same. Until he does, there is little of substance sitting behind his opinions. Without substance there is no possibility for a grounded debate. All the calumny and strong feeling in the world will no more change the existing facts than conjure out of thin air new ones to support him.