The Trouble with Spikol

Congress gives the pharm team a boost.

By Liz Spikol
Add Comment Add Comment | Comments: 0 | Posted Mar. 12, 2008

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Illustration by Alex Fine

Last week the House of Representatives passed the Paul Wellstone Mental Health and Addiction Equity Act, a parity bill that would require insurance companies to cover mental illness and addiction the same way they cover physical conditions.

Sounds good, right? But it's not all pinwheels and lollipops.

The bill, sponsored by Patrick Kennedy, faces competition from a Senate parity bill passed last fall. That bill--sponsored by Patrick's dad, Sen. Edward Kennedy--was far less expansive (read: popular with insurance companies and more Republicans). Now there's going to have to be some compromise, and I'm guessing it won't come on the part of Eli Lilly or Aetna.

Should a mental health parity bill actually become law, it'll be a bittersweet victory. By equating mental illnesses with physical illnesses--apparently a necessity in order to get access to healthcare--we run the risk of furthering the so-called "medical model" of psychiatry, which tells us that mental illnesses are biological illnesses whose primary remedy lies in medication.

Don't misunderstand me. I love my meds. And for many years I used the "chemical imbalance" tag as a sort of talisman to protect me from people who might believe my psychosis and depression were a result of a character weakness.

I didn't want it to be my fault. I wanted it to be my brain.

But over the years I've become frustrated by the system's reliance on the medical model. Its dominance eliminates so many possibilities--not only for diagnosis but for treatment. For those of us in recovery from mental illness--those of us living fulfilling lives despite the struggle--the primacy of biological psychiatry feels restrictive.

I don't need to tell you that pharmaceutical companies have a serious investment in the medical model. And they make a persuasive case to the public.

The FDA gave pharmaceutical companies the go-ahead to do TV advertisements in 1997, and since then we've become accustomed to the ridiculously self-parodic prime-time ads--those featuring an unshowered person who's suddenly romping through fields like a Bollywood star after taking a pill that just happens to have an unbelievable list of side effects. Such ads are allowed only here and in New Zealand.

The claims made on these highly influential ads are often misleading or flat-out false. An important study released a couple weeks ago in the journal PLoS Medicine evaluated the effectiveness of four antidepressants--Prozac, Effexor, Serzone and Paxil--in more than 5,000 people. The study's authors found these drugs were no more effective than placebos for treating mild to moderate depression. Yet antidepressants are the most prescribed drugs in the U.S. There were 118 million prescriptions written for them in 2005.

Studies like this one tell us we must find other ways to feel better. And lucky for us, there are plenty of options, which is perhaps the best reason of all to shift away from the exclusivity of the medical model. In his fascinating new book Comfortably Numb: How Psychiatry Is Medicating a Nation, Yale psychiatry lecturer Charles Barber, who worked for many years as a public health provider, quotes the American Family Physician, the Archives of General Psychiatry and the American Journal of Psychiatry to support his claim that cognitive behavior therapy can be just as effective as antidepressants in treating depression.

Barber also points to progressive approaches in other countries. In 2004 the U.K.'s National Institute for Health and Clinical Excellence (NICE) issued "Clinical Guidelines for Depression," which Barber cites in his book. They are: 1) sleep and anxiety management, 2) watchful waiting, 3) exercise, 4) guided self-help and 5) cognitive behavioral therapy.

As for antidepressants, NICE suggests them only as a last resort, "not recommended for initial treatment of mild depression because the risk-benefit ratio is poor."

Those risks are often minimized. Side effects aren't just irritations to be endured briefly and then surmounted. They can be intense and debilitating, and there can be long-term impact. For severe mental illnesses--like schizophrenia, bipolar disorder and major depression--it's fair to say medications are generally a necessity. But I've only recently come to understand that the greatest tragedy of these illnesses can be their cure.

And meds can't work alone. I asked Barber about that in an email. He wrote: "What we've overlooked, in our simple-minded impatient-for-the-quick-fix fashion, is that recovery--even when it involves medication--occurs over time and in a social context. Relationships matter. Families matter. Doctor-patient relationships matter. Recovering patients will tell you that they get better (and get worse) under the influence of and in connection to other people."

If that's so--and I believe it is--the notion of what mental illness is must not be hogtied by an equation with biology.

Just a few days before the parity bill passed the House, another decision was made in the halls of power: The FDA gave Wyeth approval to make a new antidepressant that's a variant of Effexor. Wyeth loses its patent on Effexor in two years, so it created a chemical mix, Pristiq, that's almost indistinguishable from the original product. The New York Times quoted psychiatrist Daniel Carlat as saying, "Is there a compelling public health reason for Wyeth to be releasing another antidepressant into the market, with no clear advantages over others? Not that I can see."

By the time Pristiq hits the shelves, we may have a parity bill to pay for it. I'm just not sure we'll want to buy it.

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