4. Behind The Medical Model: interest groups and human rights
Constant movement in the fashion of ideas is a central feature of the psychiatric view of schizophrenia. Without these changing fashions it would be far more difficult to maintain high confidence levels amongst supporters of the medical model. Most of the psychiatric ideas about the cause and the treatment of schizophrenia are simply guesswork—sometimes wild guesswork—and a consistent strategy has evolved to cover up the doubtful nature of these ideas by first cheering loudly as new theories are conceived, predicting imminent breakthroughs, and then quickly disposing of them and moving on to new ones before failure becomes apparent. This strategy encourages supporters to focus their gaze optimistically on the near future. By anticipating imminent breakthroughs[1] supporters are able to tolerate current anomalies and human rights problems as being temporary aberrations that will soon be corrected. Anticipating breakthroughs also distracts supporters from the wreckage of past psychiatric theories and practices.
A powerful coalition of interest groups support the medical model. These include other mental health professionals such as psychologists and social workers, consumers of mental health services—that is, voluntary patients and patients’ relatives—the pharmaceutical industry, and the State.
People who manifest schizophrenic symptoms are often viewed as being socially disruptive and potentially dangerous, both to themselves and other people.[2] In past times and in other cultures there have been a variety of ways by which the State has attempted to control such people, usually through banishment or some form of incarceration. The current method is for the State to provide mental health services, and for mad people who are thought to be potentially disruptive or dangerous to be controlled by applying psychiatric treatments. To facilitate this form of control, the State enacts and enforces mental health legislation which empowers medical practitioners to identify such people and, if they are unwilling to cooperate, to incarcerate them involuntarily in mental hospitals and impose forced treatment on them.
These arrangements have one major advantage and one major disadvantage for the State. The advantage is that human rights complaints, which inevitably arise from a situation in which a large number of non-criminal citizens are stripped of their civil liberties, can be deflected by assertions that the control is actually only care and treatment for a medical condition. The disadvantage is that the State has to underwrite the cost of most mental health expenses.[3]
The costs of schizophrenia are substantial. In the United States researchers working for the National Institute of Mental Health have estimated the total annual cost of schizophrenia at $65 billion. This estimate was based on an assumption that the lifetime prevalence of schizophrenia for adult Americans was 1.5 per cent. The costs were broken down into direct and indirect components. Direct costs were related to expenditures on treatment for both inpatients and outpatients as well as costs incurred by the criminal justice system. These were estimated at $19 billion. Indirect costs were based on estimates of lost productivity and were broken down into $24 billion for wage earners, about $4 billion for homemakers, about $4 billion for individuals in institutions, $7 billion for people who commit suicide and $7 billion for people who could not work because they were required to take care of schizophrenic family members.[4]
The cost of research and training in relation to schizophrenia is also substantial. In 1991 it was estimated at $71 million in the United States. This figure was composed of $51,302,000 in direct grants from the National Institute of Mental Health and approximately $20 million from state governments, private institutions and pharmaceutical companies.[5] The size of this schizophrenia research industry has allowed psychiatric researchers to become an influential interest group supporting the medical model.
Psychiatrists are trained in medicine before they begin to specialise. Although the training of psychiatrists produces two branches of treatment—the talking therapies and the biomedical treatments—all students of psychiatry are taught, as a matter of course, that the symptoms of schizophrenia have a pathological cause; and most psychiatrists find that their professional interests give them little cause to question this teaching. Psychiatry continues to hold a dominant position within an increasingly competitive mental health industry. However, the medical training of psychiatrists will only continue to provide them with a competitive edge over rival professionals such as psychologists as long as medical explanations for abnormal psychology prevail.
Like the psychiatric profession, the pharmaceutical industry has strong commercial interests in ensuring the continued dominance of the medical model for schizophrenia. The medical model provides the rationale for drug therapy and, in turn, the pharmaceutical industry provides an extensive range of neuroleptic drugs from which prescribing psychiatrists can choose. In the United States the pharmaceutical industry openly funds the main psychiatric professional organisation, the American Psychiatric Association, which receives ‘30% of its total budget from drug company advertising in its many publications’.[6]
"Pharmaceutical companies pay through the nose to get their message across to psychiatrists across the country. They finance major symposia at the two predominant annual psychiatric conventions, offer yummy treats and music to conventioneers, and pay $1,000–$2,000 per speaker to hock their wares. It is estimated that, in total, drug companies spend an average of $10,000 per physician, per year, on education."[7]
The pharmaceutical industry also selectively funds scientific research into the side-effects of neuroleptic drugs as well as research and development of new products. Drug company sponsorship of clinical trials is a major source of revenue for many psychiatric researchers. This flow of money provides strong incentives for further promotion of the medical model but it also casts doubt on the quality of the findings:
"This spring, the New York Post revealed that Columbia University has been cashing in. Its Office of Clinical Trials generates about $10 million a year testing new medications—much of which is granted to the Columbia Psychiatric Institute for implementing these tests. The director of the institute was being paid $140,000 a year by various drug companies to tour the country promoting their drugs."[8]
Pharmaceutical companies advertise their products in psychiatric journals, often alongside scientific research reports in the same areas of treatment for which their own drugs are being recommended. Because these drug companies are driven by the normal market concerns for the promotion of product sales, there is often a certain amount of confusion concerning the difference between scientific findings and sales promotion.
This point can be illustrated by a recent report of research undertaken into the efficacy of an atypical neuroleptic called risperidone, which was approved for use in the US in 1994. The pre-approval research used a sample of 388 people who were undergoing treatment for schizophrenia with conventional neuroleptics, but who were failing to respond to the drugs. Some were given an increased dosage of a conventional neuroleptic, some were given a placebo, and some were given risperidone. After eight weeks the researchers found that the patients given risperidone were more improved than those in the other two groups.[9]
However, there were two problems with this research. The first was that the criterion for judging ‘improvement’ was simply a matter of awarding the patients daily points on the basis of their observed willingness to cooperate and interact socially. This is an unsound method. Not only is the system of awarding points wholly subjective and open to abuse, but the symptoms to be evaluated were not even definitively linked with schizophrenia. ‘Unwillingness to cooperate’, for instance, is not normally used as an indicator for diagnosing schizophrenia. Improvement in this ‘symptom’ should be considered irrelevant as a measure of successful treatment. Various drugs and substances might demonstrably affect schizophrenics in different ways but, unless there is amelioration of the specific symptoms of schizophrenia, no valid claims can be made for the efficacy of a particular drug as a treatment.
The second problem with the research was that one of the authors, Richard Meibach, was identified in a subsequent article as being an employee of Janssen Pharmaceutical Research Foundation, the research arm of the manufacturer of risperidone.[10] This type of conflict of interest is a constant feature of pharmaceutical-industry involvement in discussions about schizophrenia.
Next: Consumer Support Groups
[1] Anne Brown and Rebecca Weaver, 'Promising New Medications in Development'.
[2] M. S. Humphreys et al., ‘Dangerous Behaviour Preceding First Admission for Schizophrenia’, pp. 501–5.
[3] T. G. McGuire, ‘Measuring the Economic Costs of Schizophrenia’, pp. 375–88.
[4] Richard Jed Wyatt et al., An Economic Evaluation of Schizophrenia—1991.
[5] Ibid.
[6] Loren R. Mosher, ‘Are Psychiatrists Betraying Their Patients?’, p. 40.
[7] Ibid.
[8] Ibid.
[9] Stephen R. Marder and Richard C. Meibach, ‘Risperidone in the treatment of schizophrenia’, p. 825.
[10] Editorial, Science News, Vol. 145, No. 25, 18 June 1994, p. 398.