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Cracked – Why Psychiatry is Doing More Harm Than Good
By James Davies, Icon Books (May 2013)
Review by Lorna Kernan
At first sight, little about this book would have enticed this reviewer to pick it up, with its
“tablet blister-sleeve” image dominating the cover as well as its mission-statement title.
But we all know about appearances. Cracked turns out to be a page-turner, addressing serious
issues, including how psychiatry has expanded its jurisdiction over us and, by increasing the
number of “mental disorders” that we can suffer from in the DSM has, thereby, been seduced
into creating a massive market for drug-based psychiatric treatments generating multi-billion
dollar/pound/euro rewards for pharmaceutical multi-nationals. Probably one in four of us are
now diagnosable with some sort of “mental disorder”.
What this book does do well is to package up a world that oozes power, control,
manipulation, lawlessness and dependence, leaving this reviewer wondering, who are the
gatekeepers for those on the receiving end of this chain – the suffering human subject? Davies
does give some space to the critical voice, but he does want to confirm the statement of his
title.
Who is enslaved by whom, we might ask? And perhaps keep this question in mind as the
content of Cracked unfolds.
Cracked was launched to coincide with the publication of the American Psychiatry
Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders – 5th Edition
(DSM-5) in May 2013, and James Davies (medical and social anthropologist, senior lecturer
and psychotherapist) has assembled a damning charge sheet on the world of modern
psychiatry. The book doesn’t focus solely on DSM-5, but rather uses its arrival to examine
the world of psychiatry and the powerful pharmaceutical giants and the financial relationships
– or acute dependence – forged through a common denominator: drugs.
Davies’s potted history of psychiatry runs from the 1900s with Emil Kraepelin’s biological
convictions, what he calls the “talking cure” years of the 1940s, 50s and 60s, before a neoKraepelinian revolution coincides with the DSM-III. Included too is the genesis and turbulent
history of the APA’s money-spinning DSM manual and its various incarnations up to DSM-5,
the birth of “soothing tonics” which morphed into “chemical cures”, as well as the murky
world of “research” with tailored drug trials and, well, money, and more money … but, he
glosses over much on his journey.
Davies uses a mix of methods: he conducts his own research supported by both his
interviews, and others’ interviews, of many of the leaders in the fields of what we could call
“traditional psychiatry” on the one hand, and “critical psychiatry” on the other, and does a
sweep of published books, articles, papers, research studies and analysis.
And, least the litigious heavyweight types might take Davies to task, the arguments and
claims are supported, his many face-to-face interviews in quotes, and the drug trials, articles
and statistics referenced, with back-up from much that is in the public domain through legal
challenges and the use of the Freedom of Information Act.
Why, Davies wonders, is psychiatry so powerful and influential? And why is psychiatry,
originally the backwater of medicine, such a fast-growing medical specialism despite having
the lowest curative rate? How can psychiatry prescribe more psychiatric drugs than are
prescribed in non-psychiatric areas?
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Davies begins with the problem of psychiatric diagnosis, which was in complete disarray and
was variously put to the test, and gives examples, including the now-famous Rosenhan
experiment in the US in the early 1970s1.
He points out that the crucial problem for psychiatry is that both physical examination and
medical tests (bloods, urine, x-rays, etc.) will not reveal any ‘mental disorder’. There are no
objective biological tests – no scientific truths – to support the de rigueur chemical treatments
for human emotional suffering.
Without science, the “matching method”2 (p. 11) necessarily became the tool of choice and a
radical solution was required: tear up the unreliable DSM-II (1968:182 disorders/134 pages
which replaced the DSM-I of 1952: 106 disorders/130 pages) and start again. But make it
more “scientific”.
Robert Spitzer (psychiatrist, Columbia University) headed up the radical overhaul and
produced DSM-III (1980: 265 diagnosis/494 pages; DSM III R in 1987: 292 diagnosis/567
pages). Spitzer removed many disorders, expanded definitions, and created criteria for each
disorder that a patient has to meet for a particular diagnosis. During an interview with
psychiatrist Daniel Carlat (Carlat, 2010, p. 53-4) in 2010, Spitzer explained, for example, that
for depression, five criteria seemed to be “the perfect number of symptoms needed to make a
diagnosis … it would be nice if we had a biological gold standard, but that doesn’t exist,
because we don’t understand the neurobiology of depression” (p. 17). When Davies
interviewed Spitzer, also in 2010, Spitzer said that his ‘Taskforce Team’ included one
psychoanalyst as “a token gesture” (p. 213) because many psychiatrists who worked on DSMI and DSM-II had psychoanalytic training. Spitzer also said, “our team was not typical of the
psychiatric community … we took over because we had the power” (p. 35).
DSM-III sold out immediately (it took six months to catch up on orders), did revolutionise
psychiatry and was used internationally. In a BBC documentary in 2007, Adam Curtis asked
Spitzer did he think that DSM-III had medicalised ordinary experiences of human sadness
and fear? Spitzer said it probably had led to the medicalisation of 20-30 percent of the
population who may not have had any serious mental problems3.
When Spitzer’s DSM-III reached its end, Allen Frances (head of psychiatry at Duke
University; trained in psychoanalysis) led the revamp team working on DMS IV (1994: 297
diagnosis/886 pages; a revision in 2000 produced the DSM IV-TR).
Davies interviewed Frances in May 2012. Did his DSM manual “unleash any unintended
negative consequences that he now regrets?”. Frances said, “we learned pretty tough lessons
… (which) helped promote three false epidemics in psychiatry” (p. 48). He elaborated by
saying that autism is 20 times what it was 15 years ago; adding bipolar II doubled the ratio of
bipolar versus unipolar depression; and rates of ADHD tripled. And there’s no surprise that,
following aggressive marketing, the use of antipsychotic and mood stabiliser drugs soared.
1
Academics, posing as patients, presented at different psychiatric hospitals saying that they were hearing voices.
After this lie, they would all behave and respond normally. All were admitted and diagnosed with mental disorders
and given antipsychotic drugs. The experiment did backfire though, and when the experiment was revealed, some
of the ‘patients’ were unable to convince the institutions of who and why they were there and were hospitalised for
weeks. Other experiments sent the same set of patients to different psychiatrists to test diagnosis. Consensus was
not the result.
2 Davies says, because “psychiatry has yet to identify any clear biological causes for most of the disorders in the
DSM … the only method available to psychiatrists is what we could call the ‘matching method’: match the
symptoms the patient reports to the relevant diagnosis in the book”. Also, Spitzer confirmed that “there are only a
handful of mental disorders in the DSM known to have a clear biological cause. These are known as organic
disorders (epilepsy, Alzheimer’s and Huntington’s disease). These are few and far between” (p. 22).
3 BBC series The Trap.
3
Frances admitted that the way the DSM is being used has triggered the unnecessary
medicalisation of people and, in his critique of the DSM-5, has warned that the expanding
boundary of psychiatry is swallowing up normality by “proposing changes that will
dramatically expand the realm of psychiatry and narrow the realm of normality … (and) the
conversion of millions more patients (and) people, from currently being without mental
disorders to be psychiatrically sick” (p. 52)
DSM-5 had a long gestation, but ultimately had to be given the green light, as the APA
needed the considerable revenue it would generate (it spent $25 million developing it). The
DSM-5 was riven by problems and intrigue, and dissent on its ‘Taskforce’ was dealt with by
mandatory confidential clauses.
The arrival of the DSM-5 has been very controversial (which has been well-aired), with the
lowering of diagnostic thresholds and the medicalising of “normal” emotional states, and 15
new mental illnesses listed (including hoarding, caffeine withdrawal and binge eating). Some
changes are the new single category ASD for autism and Asperger’s, among others; the
expansion of ADHD to include adulthood; the strange ‘bereavement exclusion removal’
striking out the previous period of grace for grieving people, which had ensured that they
couldn’t be diagnosed with a major depressive disorder for a two-month period after the death
of a loved one; and more attention to the behavioural symptoms in PTSD, among others.
But there are voices in psychiatry yearning for change. When Davies spoke to Prof. Sue
Bailey (president of the Royal College of Psychiatrists) about the future of psychiatry, he took
the opportunity of asking her to respond to the British Journal of Psychiatry editorial (signed
by 29 senior consultant psychiatrists – all members of the Royal College of Psychiatry – and
including Pat Bracken, Bantry, Co Cork, who is quoted in the book), which stated that, while
they did not deny that brain sciences and drugs have a role in psychiatry, they insisted that the
dominant “medical model” has not only failed the test of science, but is not getting the
clinical results. Therefore, a paradigm shift is needed away from the “medical model” and
towards an approach that prioritises healing relationships with people using other therapies as
the first line of treatment.
Bailey said she’d “prefer not to comment, because I think their vision is quite limited really.
So while I’m very fond of them, I think we have a better vision than the vision they’ve got”
(p. 262). But she did comment further and, after what seemed like a lively discussion between
the pair, Bailey said, “I say I am different from them, because they are zealots in their own
model. And I think any zealot-driven model is a bad thing” (p. 265).
The medical model, Davies continues, promoted by the “chemical imbalance” theory of the
brain by Joseph Schildkraut4, came to dominate the field. Despite the fact that Schildkraut
said it was “at best a reductionist simplification” (p. 119) of data, pharmacology stood up and
listened.
The possible role of the neurotransmitter serotonin in depression was highlighted by Dr Alex
Coopen, the intellectual grandfather of the SSRI antidepressant. Davies interviewed the 90year-old in 2012, reporting that Coopen still championed of the virtues of Lithium despite
adding a caveat to his research paper in 1967 indicating his uncertainty about ‘chemical
imbalances’5 (Coopen, 1967).
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Davies states that Joseph Schildkraut’s 1966 paper “would launch a paradigm shift in psychiatry … (with its idea
that) … fluctuations in our moods may be due to chemical imbalances in our brains … (and his paper) has become
one of the most cited papers in psychiatric history”.
5 Coppen added a caveat to his paper saying, “we are far from the primary disturbance in depression. The changes
(in serotonin) may all be secondary to other abnormalities which have not been taken into account at all … we are
perhaps only in a slightly better position that Sanctorius of Padua … (when he said some 300 years ago): ‘Where
the bond of union is between the mind and the animal fluids, God Almighty alone knows …’”. (Coopen, 1967).
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This biological vision of humanity has seeped into popular consciousness and has probably
altered people’s understanding of the human psyche and striped away any psychological,
spiritual or moral meaning: if emotional suffering is a chemical imbalance and biological,
then it serves no purpose and must be medicated.
Cracked offers a selection of drug-trials, 90 % undertaken with drug-company cash, many in
eminent universities. Davies also charts the skulduggery of major drug companies (criminal
and damaging and, in some cases, life-threatening, for the drug user), and all in the public
domain via prosecutions and hefty fines6. Davies gives the non-scientific of us a whirlwind
teach-in as to brain functioning, what the drugs trials are designed to do – and design is a
mighty thing: it seems it can deliver any result. Dr Richard Smith’s, former editor of the
British Medical Journal, paper addresses these tactics (Smith, 2005). Here is this reviewers
ridiculously short synopsis of a very complicated process: trial your drug against one that is
knowingly inferior; trial your drug to look “superior” by testing it against too low a dose of a
competitor drug (and visa versa to make your drug look less toxic); use trials that are too
small to show differences; use multiple trial endpoints and then select only those that are
favourable; only present results that are likely to impress …
If that wasn’t enough, these methods have a friendly face: “cherry-picking” – publish good
data, kill the bad; “salami slicing” – publish positive data many times over in different forms
and locations; “washed out” for drug versus placebo trials – put all the patients on a placebo
before the trial begins, then any patients who did improve won’t be included on the trial,
justified on the grounds that if the patient has responded to the placebo, then they are not “ill
enough” … (pp. 150-54).
And, let’s not forget the psychoactive effects of drugs, highlighted by many, including an
Oxford University research team, which Davies says “strongly confirms the view that most
psychoactive effects are neither useful nor beneficial” 7 (Price, Cole, & Goodwin, 2009).
Finally, a study comparing the outcomes of drug trials undertaken by both the drug
companies and other sources (Lexchin, Bero, Djulbegovic & Clark, 2003). Result: drug
company results were four times more likely to show favourable results than those funded
elsewhere. Self-regulation is alive and well.
The pharmaceutical industry, says Davies, makes over $12.5 billion each year from
antidepressants with another $18 billion from annual antipsychotic sales and the message that
echoes from manufacturer to doctor to patient is that drugs work. Would it be “obtuse” to
suggest, says Davies, that all this money and overwhelming zeal is the product of a
misleading myth? Well, that’s what he is suggesting and that “solid scientific research now
shows clearly that antidepressants don’t actually work, or at least not in the way that people
think” (p. 59).
Probably one of the best-known is the Kirsch and Sapirstein meta-analysis (Kirsch &
Sapirstein, 1998) which addressed this question: if depressed patients could feel better on a
“sugar pill” because they believed it to be an antidepressant, to what extent did
antidepressants themselves work through the placebo effect because of the same belief? Did
the expectation of recovery actually aid their recovery? The research had surprising results:
four groups, each treated differently (results in brackets): drug (1.5), psychotherapy (1.6),
6
One example of many: the US government fined GlaxcoSmithKline $3 billion (yes, billion) in 2012 for many
offences, including withholding negative data about its best-selling diabetes drug, Avandia. Because of this, and
no doubt to save face, GlaxcoSmithKline supports the alltrials.net.campaign.
7
Research published by the Oxford group in the British Journal of Psychiatry are at odds with the modern myth of
the ‘happy pill’ and Davies gives over several pages to the findings.
5
placebo (1.1) and no treatment (0.5). All the groups improved, even those who had no
treatment. But improvement between drug and placebo was strikingly small at about 0.4.
The published paper unsurprisingly was, said Kirsch, “controversial … the most significant
critique was that we had left out many important trials from our meta-analysis … (which)
would lead to a different conclusion” (p. 63).
Kirsch and Sapirstein had only used published trials as they weren’t aware of the unpublished
trials (40 per cent) or that suppressing negative trials was standard practice.
Regulatory agencies require that, for a drug to get the green light for public use, two clinical
trials must confirm the drug is more effective than a placebo. The negative results are not
considered and remain unpublished – no matter how many negative trials exist.
After invoking the Freedom of Information Act, Kirsch and Sapirstein reanalysed all the data.
The final results revealed that antidepressants didn’t work moderately better than placebos –
they worked almost no better at all (and further elaborated on in Kirsch, 2008 & 2009).
The second published findings were front-page news around the world, eliciting much debate.
This caused further criticisms, interesting, but too detailed to go into here. Despite this, and
others’ findings confirming the Kirsch and Sapirstein results, prescription rates are soaring8.
So what about antipsychotics? Davies stresses that there is no research confirming that
antipsychotics (or antidepressants) fix any known brain abnormality or “rebalance” brain
chemistry to some optimal level. The benefits of short-term use of antipsychotics has been
supported by research (along with other interventions), especially in Finland,9 and Davies
cites some revealing statistics. But long-term users of drugs it seems have no glimmer of
hope, the side-effects sometimes unbearable, and the brain damage confirmed: when drugs
were withdrawn (in controlled settings, of course), patients can be left with ‘tardive
dyskineaia’ (TD), which includes squirming and twisting, and sudden, uncontrollable
movements of the mouth, tongue, jaw and cheeks. Chemicals cause damage, but we all know
this from our legal friends: alcohol and cigarettes.
Davies has plenty to digest visiting US Senator Chuck Grassley10 in Washington to hear the
sordid details of corruption and whistle-blowers, the murky scandals, litigation, unbelievable
conflict of interests and names “names” and reveals cash rewards (far too many to cite here,
but here are just two11).
Many psychiatrists do acknowledge the dangers and others shrug and said that the drug
industry is their primary sponsor. Davies interviewed Dr Ian Anderson (UK’s Chair of
NICE12) because Anderson had altered a clause in NICE guidelines, which Davies believes
allows “pharmaceutical companies to claim that antidepressants have ‘statistically significant’
8
In 2011, prescriptions of antidepressants: UK: 746 per 1,000 people; US: 843 per 1,000 people.
Davies quotes from Robert Whitaker’s book (Whitaker, 2010), which includes “a model of care pioneered by a
Finnish group … who began using antipsychotics in a selective, cautious manner”. The study itself cannot be
referenced here, but interesting Finnish research was cited in Lacunae Vol 2, Issue (1) 2012, p 83, in Alan
Rowan’s ‘Psychoanalytically Working with Psychosis: Some Reflections on Practice’ (Seikkula, 2006 & 2008).
10 Full breakdown and coverage of all exposures on Senator’s Grassley’s US government website:
http://www.grassley.senate.gov/about/Disclosure-of-Drug-Company-Payments-to-Doctors.cfm
11 (1) Dr Alan Schatzbert, Chair of Psychiatry Standford University and President of APA 2009-2010: $4.8m in
stock Corcept Therapeutics (he co-founded), which was testing mifepristone, while being principal investigator on
a National Institute of Mental Health grant that included research on mifepristone. (2) Prof Charles Nemeroff,
Chair of Psychiatry Elmory University, known as the “Boss of Bosses” because of his voluminous drug research
and public profile; 2000-2007 earned $2.8m from drug companies (incl $1m from GlaxoSmithKline), while being
on a US Government grant $3.9m to study GlaxoSmithKline drugs.
12 NICE: National Institute for Health and Care Excellence.
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benefits over placebos even though the ‘significant’ difference could be as low as a single
point on the Hamilton Scale” (p. 176). Davies also asked Anderson if he had “ever received
money for consultancy research, grants, conferences, honoraria, etc.”, and Anderson said,
“Yes, yes I have” (p. 176).
It is no surprise then, that the US has introduced the Sunshine Act (2013), where doctors must
declare their pharmaceutical ties and that the EU has formed the “Ethical Life Science Group”
to track industry payments to institutions and doctors.
Then we’re struck dumb with strange cases of déjà vu: the rebranding of drugs under different
names: Eli Lilly rebranded Prozac for depression as Sarafem, a “premenstrual corrective”,
and GlaxoSmithKline rebranded Wellbutrin for depression as Zyban for nicotine addiction.
Elsewhere, Cracked has been criticised as being a bit “smug” and “chippy” and that Davies’s
“cherry picking” from what is already in the public domain cleverly props up his position. But
that does not mean that what he does garner is not of value and authentic. Much of what
Davies does draw together is, of course, available elsewhere – so some criticisms are
probably fair enough. But the information exists in diverse places, with the many papers,
articles and research studies published for the academic market in various jurisdictions.
Davies does revisit some of the main protagonists (in the main, for one-to-one interviews),
which affords them an up-to-date voice. What Cracked does well is to bring the diverse to
one place and addresses it to a more general readership in an affordable paperback. It is
essential reading and a springboard for further research.
So, leaving Cracked aside now, we ask again: who is enslaved by whom? Is it money? Is it
power? Is it greed? What is it about the human condition that allows the suffering and
wounded to be preyed upon with chemical myths and the symbols of capitalism: $ £ €?
Increasingly, capitalist society seduces the subject into tempering the real of the body with
what it promises will “fix” it, allay suffering and fulfil desire with nirvana-like solutions:
objects, gadgets, alcohol, drugs … bring on the jouissance13.
Rik Loose’s question, posed in his introduction to the ICLO-NLS / NCAD Conference,14 is
germane: what can be done “when not just our desire has been tamed but our drives have
been at best domesticated and at worst kidnapped by the toxic mix of science and
capitalism?” Perhaps we need only reflect on the ancient Latin saying, of which the father of
psychoanalysis reminds us: homo homini lupus: man is a wolf to man (Freud, 1930a, p. 111).
Lorna Kernan is a practitioner in Dublin, working as psychotherapist in private
practice and as a group facilitator in Shine.
lornakernan@rcsi.ie
Briefly, this complex term “jouissance” (not translated from the French), used by psychoanalyst and psychiatrist
Jacques Lacan, is “painful pleasure … jouissance is suffering” (1959-60, p 184), and thus expresses the
paradoxical satisfaction that the subject derives from his/her symptom – the suffering derived from his/her own
satisfaction.
14 Contemporary Art & Lacanian Psychoanalysis: The Limit of the Object, organised by ICLO-NLS (Irish Circle
of the Lacanian Orientation-New Lacanian School) and NCAD (National College of Art & Design), in NCAD,
Dublin 8, on March 9, 2013.
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