The Myth of the Chemical Cure: A Critique of Psychiatric Drug Treatment (Anglais) Broché – 4 décembre 2007
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She wrote in the first chapter of this 2009 book, "Since the 1960s we have lived in an age characterized by the idea that drugs can cure the problems that are now referred to as 'mental illness'... By 'cure' I mean the idea that drugs can improve symptoms by helping to rectify the underlying pathological mechanism that is presumed to give rise to the symptoms in the first place... The story by which drugs first came to be seen in this way, as specific treatments for specific mental disorders ... and whether or not this way of thinking about drugs and their actions is justified, are the subjects of this book." (Pg. 1) She adds, "Over the following pages I hope to convince readers that the modern understanding of what drugs do in psychiatry ... is fatally flawed; that most knowledge about psychiatric drugs is, at best, only a partial acount. This is because it ... has been inspired and promoted by professional, commercial and political interests. This misconception has led to the misdirection of research, the misinterpretation of available evidence and the obstruction of a fuller and more accurate understanding of what psychiatric drugs do." (Pg. 2)
She argues, "The disease-centered model has been imported from general medicine, where... most drug action can be appropriately understood in this way." (Pg. 7) She says, "This book concerns the creation of a myth, the myth of the disease-centered model of drug action, and how that myth could be accepted as a real description of the world." (Pg. 11) She adds, "I will... attempt to uncover the interests that led to the development and success of the disease-centered model of drug action and its accompanying model of psychic distress... I will outline an alternative 'drug-centered' approach that is consistent with a wide range of evidence, yields more information about what effects drugs have in different situations and forms a better basis from which to weigh the pros and cons of drug treatment." (Pg. 13)
She points out, "A further problem with modern clinical drug trials is that people are usually dropped from the study once they relapse or if they stop the study drug for any reason. Therefore, there is no information about the ultimate outcome of these participants... In addition, we know that positive studies are more likely to be published than negative ones... and within published studies measures that show positive effects are reported and negative ones sometimes ignored ... Therefore, published data is likely to be inaccurately skewed towards showing beneficial effects of treatment." (Pg. 20-21)
She concludes, "The data surveyed in this book suggest that psychiatric drug treatment is currently administered on the basis of a huge collective myth; the myth that psychiatric drugs act by correcting the biological basis of psychiatric symptoms or diseases... the evidence suggests that these drugs induce characteristic abnormal states that can account for their so-called therapeutic effects." (Pg. 237) She adds, "this book demonstrates the eagerness of the psychiatric profession to embrace the myth of disease-specific treatments. This is understandable, given the profession's long-standing battle to align itself squarely as a branch of the medical profession... From the beginning of the 20th century psychiatry sought to relocate its practice in general hospitals and outpatient departments. Drug treatments, if they could be presented as acting on a disease process, were well suited to this new environment... The psychiatric profession was supported in its aims by a State that was seeking technical solutions for various social problems. Psychiatry offered the possibility of transforming the complex political problem of how to manage psychiatric disturbance into a medical and technical issue... the ability to remove difficult issues of social control from the political arena was appealing... The new drugs... helped justify both the turn towards community care and the development of more medicalized legislation." (Pg. 243)
This critique will be "must reading" for anyone studying the modern role of psychopharmacology---whether or not one always agrees with Moncrieff.
In this book, currently in its second edition, Moncrieff takes serious objection to contemporary psychiatric treatment as it involves the use of medication. This level of antagonism is only natural given that she sees the standard framework of understanding drug treatment as off base. The typical disease-centered (her term) account of drug action borrows unjustifiably from medicine: just as cephalexin assaults a particular problem-causing agent like streptococcal bacteria, Prozac assaults a particular problem-causing agent too--a chemical imbalance.
But this is too much a stretch for the author, who proposes that we are on much stronger ground in looking at psychoactive medication through the lens of a drug-centered model (again, her term): just as ethyl alcohol consumption beyond a threshold produces brain-wide effects often adverse (decreased cognitive ability) and sometimes--in certain contexts and settings--desirable (social disinhibition), Prozac places the user under an altered brain state that may be theoretically desirable (increased mood; diminished anxiety) though with significant adverse effects (decreased libido; suicidal ideation).
Just about everywhere Moncrieff directs our attention, the story looks pretty much the same. There are reports that the drugs seem to help a certain proportion of the population who takes them, amidst a torrent of unenviable side effects upon all who do. Antidepressants, neuroleptics, and stimulants are leaving in their wake a host of drug-dependent, libido-less, emotionally detached zombie-patients. Even where there appears to be some effectiveness, it is hard to shake the specter of placebo.
Moncrieff is no mere contrarian pundit, and her report is not new. Rather she joins those who have already been questioning psychopharmacology for a few years now. A group represented by the voices of Irving Kirsch and Robert Whitaker. Certainly, with the poor results the aforementioned researchers have produced concerning antidepressants and antipsychotics, along with what Moncrieff herself brings to the table, her case for skepticism today is sound.
I am not so ready, however, to abandon the psychopharmacological ship so completely. For one, nothing that might be said about drugs today implies anything about the drugs of tomorrow. And even if every new generation of drugs has come with the recognition that the prior generation was not the final answer as was thought or hoped, why must this require a deeply negative assessment of the motives behind all (or even most) who created and prescribed them to patients? Progress is the natural course of all science; and we can expect this to be the case with psychiatric medication as it is with non-psychiatric medication.
Furthermore, I find Moncrieff--with her binary drug-centered versus disease-centered constructs--more framework-driven than those who make up the psychiatric establishment. Whatever their script-writing inclinations, I don't believe I've met a single psychiatrist or doctor who looks at psychiatric medication as the seamless shoring up of a faulty neurological disorder such that treatment ever comes without side effects. Moreover, the implication that real drugs made to combat real diseases meet such a standard is simply not true. The most novel of cancer and HIV/AIDS drugs are notorious for the side effects they can impart when taken. But this doesn't signify the illegitimacy of the disease concept or the drugs, does it? It's not even completely true that Moncrieff's own paradigm case for a "disease-centered" model of drug action--insulin for diabetes--comes without side effects, since those receiving insulin treatment occasionally report fatigue, tremors, hunger, and anxiety. Suffice it to say, the criticisms at times seem based on straw men.
Still, if one can get past the framework mentality of Moncrieff's book, it makes for an informative read. At the very least, it contains considerations that any potential or current psychiatric medication patient will want to consider as they evaluate or re-evaluate their own treatment.
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