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May 24, 2006

Psychiatric drug promotion and the politics of neoliberalism: The British Journal of Psychiatry is wrong to blame neoliberalism for the over-prescription of antidepressants, argues Theodore Dalrymple

Posted by Theodore Dalrymple

Theodore Dalrymple takes issue with a recent editorial in the British Journal of Psychiatry.

The temptation to suppose that there are one or two principles that answer all the questions that life can throw up is no doubt a universal one. Apart from anything else, the discovery of such principles would obviate the need for original, or indeed for any, thought: and, as all of us who have tried it know, thought is extremely painful. Prejudices are much more comforting.

No doubt we lose in consistency what we gain in complexity. For example, while I am a firm believer in the benefits of the marketplace, I do not believe that market relations are the only relations human beings or institutions can rightfully have. I do not believe, for example, that patients or pupils or students are merely customers, and as such always right.

On the other hand, I do not believe either that market mechanisms are behind all undesirable developments either. One meets this prejudice in strange places: what one might call the hidden hand of the hidden hand. For example, in the April 2006 edition of the British Journal of Psychiatry, there was an editorial entitled "Psychiatric drug promotion and the politics of neoliberalism". It was an interesting example of the genre.

The author, a member of the department of Mental Health Sciences at University College, London, argued that pharmaceutical companies had promoted their antidepressant drugs by claiming that depression was caused by an imbalance of chemicals in the brain that could be righted by their products. I think this is indisputably true.

However, the author went on to say that neoliberalism, the economic policy that has promoted a consumerist society at the expense of government control and regulation, creates permanently dissatisfied people, who are in supposed need of antidepressants to get their brain chemicals back in balance, by rendering them permanent seekers after new objects to consume, and by encouraging them to judge themselves by their inadequate levels of consumption (because there are always people around who have and consume more than they). The author believes the retreat of the state has been the advance of private corporations; she believes likewise such corporations exploit their employees ex officio as it were. She claims that with neoliberalism comes increasing authoritarianism, in proof of which she cites the fact that rates of imprisonment have risen.

This is all very crude, two-legs-bad, four-legs-good stuff. France, which is one of the least neo-liberal of western states, has the highest consumption of psychotropic medicines in the world. The level of government expenditure in Britain has been rising quite fast for several years, and to describe Britain as having an unregulated, freewheeling economy would come as a surprise to ordinary citizens, let alone to small businessmen.

Again to take Britain as an example, its rate of imprisonment has fallen dramatically over the last few decades, by comparison with the numbers of recorded crimes (the only sensible way to measure it). In any case, it is not authoritarian to imprison people for burgling houses; a good case could be made for the authoritarianism of not doing so, in as much as such leniency is the product of elite rather than of popular opinion.

It is true, in my opinion, that private interests have been insinuated wholesale into our public services, to such an extent that the term public service has almost no application; but by the same token, public or bureaucratic control has been insinuated into private business. One of the characteristics, at least of modern Britain, is that it has become increasingly difficult to say exactly where the private and public economic spheres begin and end. In other words, our state is not so much a neo-liberal one, in which free-booting entrepreneurs do exactly as they please and ride roughshod over everyone else; rather, our state is increasingly a corporatist one, in which success in business relies as much on connections with people in positions of political and bureaucratic power as on entrepreneurial ability in the stricter sense. No doubt there has always been an element of corporatism - it is difficult to see how the bogey of a neo-liberal state could actually exist - but it has increased enormously in the past few decades.

The author of the editorial is quite right, in my view, in her criticism of the over-prescription of psychotropic drugs, but her singling out of capitalism as the culprit is symptomatic, in my view, of the desire that there should always be an easily identified culprit or scapegoat.

Doctors, after all, do not have to prescribe anything for their patients; they can refuse to do so, though it usually takes time and trouble to explain why they are doing so. Patients, too, are eager to ascribe their dissatisfactions to an illness, because by doing so it obviates the need for painful self-examination. (It is curious how an age of public self-revelation, and of the use of psychological jargon, should also be an age when self-examination is rarely practised.) For example, the realisation that one is unhappy because one has chased all one's life after false gods is a very painful one, which most people would much prefer to avoid, for it requires either an acceptance of unhappiness or a fundamental change of direction. The latter is far from easy.

It is true that the interests of the pharmaceutical companies have coincided with this avoidance by patients of personal responsibility for their own happiness, ably abetted by the moral cowardice of doctors who do not want to tell patients the truth about their complaints, and who find it easier, quicker and less embarrassing just to hand out the pills.

Careful thought about such matters can be avoided when neo-liberalism, which is a figment of the imagination except possibly in China, can be held solely to blame for the preposterous increase in the use of antidepressants. What one sees in the British Journal of Psychiatry's editorial is the hold of political and economic cliché on the minds of much of the intelligentsia.

In the meantime, the corporate state, in which economic privileges are handed out to those who comply with its dictates, grows ever-stronger. By the way, is it true that employees of state-funded universities have no economic and other interests of their own to pursue?

Theodore Dalrymple is a writer and recently retired as an inner city and prison doctor.


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Dr. Dalrymple writes about the "preposterous increase in the use of antidepressants". (Man, that sound BAD!!)
however, over here in the USA, the scholarly studies all report that most people who have depression (as defined by the American Psychiatric Association) do not receive ANY psychiatric treatment, period. I suspect that in America, antidepressants may be underprescribed, even though we always read reports in the press here that they are being overprescribed.
Dr. Dalrymple seems to blame "depression" (as well as addictions, in other essays) on people not taking responsibility for their lives. but all the studies that i have ever seen report strong genetic components in both depression and addictions. and, at least in the USA, most scientists believe that these disorders have a biochemical basis.
Dr. Dalrymple is undoubtedly right in his belief that a sense of individual responsibility is crucial for overcoming these disorders. but to neglect the biochemical component is an ideologically-driven position, not a scientific one.

Posted by: doug hogan at September 2, 2006 11:21 PM
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"at least in the USA, most scientists believe that these disorders have a biochemical basis."

Indeed. Nevertheless, I doubt that the majority would share your seeming faith in strict genetic determinism and psychotropic drugs. God help us if they do...

"all the studies that i have ever seen report strong genetic components in both depression and addictions"

One presumes that you do not attribute the massively increased incidence of "depression and addictions" to some mysterious genetic cataclysm which has taken place over the last fifty or so years. In which case (assuming that what you suggest is true), it must then presumably be due to a change in environment and/or attitude which causes a latent genetic predisposition to be expressed.

...So is the answer to these problems simply to dole out yet more pills, or to ask whether it might instead be better to examine this environmental/attitudinal change, and perhaps (if possible --- or desirable) try to tackle that? Both Dalrymple and the author whom he criticises clearly view the latter as self-evidently the preferable option: they simply disagree on the nature of this change.

"to neglect the biochemical component is an ideologically-driven position, not a scientific one."

...Whereas to neglect the environmental and psychological components isn't?

And Dalrymple's "neglect" doesn't make him an ideologue: omission does not imply repudiation.

Posted by: Paul H. at August 4, 2007 07:24 PM
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