Book Summary: Cracked by James Davies

A book summary of the key ideas from Cracked: Why Psychiatry is Doing More Harm Than Good by James Davies.

The Book in a Nutshell

In Cracked, James Davies sets out to investigate why psychiatry has become the fastest-growing medical specialism but still has the poorest curative success, why psychiatric drugs are the most prescribed in history despite dubious efficacy, and why psychiatry is expanding the number of mental disorders it believes to exist. His research reveals that modern psychiatry rests on a foundational myth about its links to physical pathology. This is compounded by perverse financial incentives that underpin overdiagnosis and over-prescription, as well as poor clinical trial governance by the pharmaceutical industry and its regulators.

Book Summary: The Key Ideas

#1: The rise of the DSM and psychiatric diagnoses. The number of psychiatric conditions as defined by the DSM has increased significantly over the last half century. With the medical profession applying a matching principle, this has likely driven a notable increase in psychiatric diagnoses and treatments, running the risk of medicalising normal emotions.

#2: The truth about happy pillss. Studies have shown no clinically significant difference between anti-depressants and placebo in treating depression. SSRIs and other antidepressants rely heavily on the chemical imbalance theory, but there is very little evidence to support this, and their prescription can have significant unwanted side effects.

#3: The perverse financial incentives of psychiatric diagnosis and prescription. Nearly all psychiatric drug research is sponsored by major pharmaceutical companies, which have a history of suppressing negative results and manipulating trial data. This financial influence extends to psychiatry, with substantial incentives for overprescription and endorsement of medications, compounded by a lack of transparency regarding financial relationships.

#4: The bio-psychiatric myth and why it’s flawed. One strong argument against the idea that problems like depression and anxiety having a biological cause is the appearance of symptom pools throughout history. This means certain symptoms can become common in a culture at an unconscious level, spreading in a manner that is not at all biological.

#5: How to solve the crisis in psychiatry. To solve the crisis, psychiatry needs to demonstrate humility, transparency and a willingness to train outside the bio-psychiatric box. But ultimately, the most likely solution is education of the general public.

Book Notes: The Key Ideas in Detail

The below are more detailed notes on the key ideas from Cracked by James Davies. These notes do not by any means cover the full breadth of the book. They are instead intended to serve as an introduction to some of the key ideas, from which to decide whether the book is worth further attention.

Key Idea #1: The rise of the DSM and psychiatric diagnoses

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is essentially a dictionary listing all the psychiatric disorders that exist, according to its editors. It was developed with the aim of standardising definitions of different psychiatric disorders. It then used by psychiatrists who apply the ‘matching method’, matching symptoms to the DSM definition to arrive at a diagnosis for their patients.

Unfortunately, psychiatric manuals like the DSM are riddled with a reliability problem, despite numerous reworks of the manuals. Psychiatrists still cannot agree universally on diagnoses. Even if they could, that does not prove they actually exist as diseases.

Indeed, aside from organic disorders like Alzheimer’s and epilepsy, most psychiatric disorders in the DSM do not have an identified biological mechanism. Instead, their inclusion relies on a consensus of psychiatrists agreeing the disorders exist and agreeing dubious symptom thresholds not based on any science.

The difference between these editor-defined disorders and organic diseases is that the latter only receives a name after its pathological root has been identified. The opposite is the case with most of the disorders in the DSM. As Davies suggests, this is not science but editor consensus, which proves nothing:

“If a group of theologians all agree that God exists, this does not prove that God exists. All it proves is that these theologians believe he does.”

The DSM expansion has been accompanied by a staggering rise in diagnoses over the last few decades. Estimates suggest 25% of Americans now suffer from a diagnosable mental disorder annually, as compared to 1% in the 1950s.

Davies suggests there are at least three potential hypotheses used to explain this trend:

  1. Stresses of contemporary life have taken their toll. Whilst difficult to ascertain whether contemporary life is really more stressful than decades ago, studies actually suggest that social stress has reduced, not increased.
  2. Today’s psychiatrists are better at diagnosing. The weakness of this hypothesis is that diagnostic technology has not really improved. One still cannot objectively test the validity of a psychiatric
  3. Psychiatry has lowered the bar of what qualifies as mental illness, driving up the figures. Davies explores this hypothesis in more detail, arguing that we are, in effect, increasing the rate of diagnosis by medicalising normal emotions.

The DSM, by ignoring contextual factors, has led to a dramatic increase in diagnosis. Davies uses the example of age being ignored in diagnosis of ADHD. This is shown in differences in ADHD diagnosis driven by school year cut-off age, where younger pupils have a higher probability of diagnosis. The latest broadening of the DSM will further exacerbate this diagnostic inflation, allocating more medication and resources to normal emotions and therefore reducing resources allocated to serious problems.

Key Idea #2: The truth about happy pills

Research initiated by Irving Kirsch and followed by others has confirmed that there is a clinically insignificant difference between antidepressants and placebo. Davies argues that antidepressants continue to be approved because approval authorities ignore negative trial results. They instead simply require a threshold number of positive studies, despite the number of negative clinical trials.

The placebo effect that plays out in many of these clinical trials relies heavily on expectations. Studies show that the magnitude of placebo effects can be dramatically impacted by things like the colour of pills, branding and who prescribes the medication. Pharmaceutical companies seem very much aware of this reality, with a striking correlation between what the placebo research tells us and their chosen colour of pills.

An increasing pool of studies and anecdotes also reveal that antidepressants can affect the brain and personalities in unusual ways. The most commonly described effect is a numbing of emotions, reducing one’s experience of the regular spectrum of emotions. Other stranger changes can take place in people, even presenting a risk of suicidal ideation.

The so-called “drug-centred view” of antidepressants therefore takes a stance at odds with the mainstream pharmaceutical view. That is, that antidepressants are merely soothing tonics like other recreational drugs, and not curative.

The use of SSRI antidepressants centres heavily on the idea that they can correct a chemical imbalance. But the role of serotonin in mood regulation remains unsubstantiated. Davies highlights three core issues:

  1. There is no substantial evidence that antidepressants actually work. As shown in the aforementioned discussion of placebo effects.
  2. Even if they did work, the deductive argument is flawed. To paraphrase Davies, just because a headache gets better after taking aspirin, it doesn’t mean we were suffering from aspirin deficiency.
  3. There simply isn’t evidence of serotonin deficiency causing depression based on thousands of studies.

Key Idea #3: The perverse financial incentives of psychiatric diagnosis and prescription

Nearly all research into psychiatric drugs is sponsored by major pharmaceutical companies. These companies have suppressed negative results in the past, and have a record of poorly designed clinical trials. Many companies have deliberately manipulated drug-trial data by using techniques such as comparing to a known inferior drug, using multiple end points, and discarding unfavourable results. Reputable journals also know that pharmaceutical companies will purchase thousands of copies, which lessens incentives to expose dubious research.

One study compared the outcomes of studies funded by the pharmaceutical industry with studies funded from other sources. Those funded by the pharmaceutical industry were four times more likely to show favourable outcomes.

The circle of incentives is distorted further by the psychiatry’s broad financial incentivisation from the pharmaceutical industry. In addition, some 95% of DSM committee members had financial associations with the pharmaceutical industry.

The evidence shows that this creates a large psychological incentive to overprescribe or endorse medications. This is supported by research that showed that psychiatrists who received over a certain threshold of income from pharmaceutical companies wrote three times the number of prescriptions for children than those who didn’t receive any funding. Transparency rules are unfortunately not sufficient to draw conclusions about how much psychiatrists have received and from whom, making it even harder to assess this circle of incentives.

The overdiagnosis and overprescription problem in psychiatry is further exacerbated by the marketing structure of pharmaceutical companies. Key Opinion Leaders (KOLs) are paid to promote their drugs to peers. Sales reps often exert enormous pressure on these paid KOLs to convert them from doctors into marketeers.

Key Idea #4: The bio-psychiatric myth and why it’s flawed

In the early 1900s, Emil Kraepelin popularised the idea that psychiatric conditions have clear neurological or biological pathology. This gave rise to a barrage of new medical interventions during the first half of the 20th century. Early treatment included removing parts of the body, injecting horse serum, and deliberately giving patients hypothermia and malaria.

In light of the poor success rate of these treatments, the 1940s saw a new procedure’s development: the lobotomy. This surgical technique involved the removal of specific brain regions believed to be associated with the patient’s mental illness. The procedure’s inventor was even honored with the Nobel Prize in 1949. By the time the practice was discontinued in the 1970s due to devastating effects, nearly 40,000 individuals had undergone lobotomies.

Electroconvulsive therapy (ECT) also rose to prominence during the 1940s, and is still in use. This despite fake ECT treatment (where there is no electric shock without patient’s knowledge) scoring equally favourably in treatment outcomes (and in one study, better!).

Like our pharmaceutical industry, all of these interventions gained impetus due to the assignment of psychiatric conditions to physical pathology.

Davies argues that there is another problem with this view, too. Our assignment of suffering to biology devalues its purpose. Positive cultural associations with suffering have lost their hold, which raises important questions, like whether we are replacing the religious and philosophical value of suffering and stress with a technological view.

One of the strongest arguments against the bio-psychiatric myth is that “growing cultural awareness of a condition can lead to its proliferation”. Davies uses the examples of anorexia and self-harm, which have both increased significantly in prevalence as awareness and culturalisation has spread through media coverage, films and television programmes.

As the medical historian Edward Shorter found, such psychosomatic conditions come in waves throughout history and do not behave like physical diseases such as cancer and heart disease, which express themselves in the same way across time and space. Instead, they seem heavily influenced by historical and cultural factors.

While it might be true to an extent that this is driven by awareness of what to look for among doctors, Shorter was convinced that higher diagnosis was increased markedly just by them being on the cultural map. Shorter illustrated this argument through a concept known as a “symptom pool”. The idea being that each culture possessed a metaphorical pool of culturally legitimate symptoms. This explained, he argued, why some symptoms were prevalent in one culture but not another.

This idea is important because it suggests some disorders are influenced more by cultural than biological factors. In an unconscious process (like contagious yawning), people start showing symptoms found in the cultural symptom pool. As our symptom pool changes, we find new ways to express our distress.

“If enough people begin to talk about a symptom as though it exists, and if this symptom is given legitimacy by an accepted authority, then, sure enough, more and more people will begin to manifest that symptom.”

Companies have realized they can influence symptom perceptions directly. Culturally sensitive marketing leverages country differences. Drug companies spend large sums to learn how to persuade cultures to see emotional states as biologically treatable. Davies cites examples from Japan, Argentina, and Latvia.

Key Idea #5: How to solve the crisis in psychiatry

Davies calls for a more holistic and humanistic approach to mental health care. He emphasises the need for understanding patients’ life experiences and contexts rather than relying solely on diagnostic labels and medication. Such non-diagnostic approaches have shown promise vs. diagnostic approaches, demonstrating significantly better patient outcomes and reduced rates of hospitalisation. If we don’t change course, we run the risk of continuing to embed mental illness through the medical model. This can turn conditions from treatable to chronic, and spur a cycle of pharmacological dependency.

Davies points to four main propositions to change things:

  1. Psychiatry needs to develop humility in its aspirations. Davies argues that psychiatry needs to get away from trying to put all emotions into a box of physical cause. In other words, it needs to demonstrate some modesty. It should embrace the potential purpose of suffering rather than always turning to medicalisation.
  2. Greater transparency and regulation around financial ties. Davies believes there should be a national register of what psychiatrists, researchers and mental health organisations are getting paid and by whom. “You have a right to know whether the psychiatrist who has just prescribed you or your child a powerful drug is being paid by the company that makes the drug.”
  3. Training of psychiatrists should include awareness of psychiatry’s scientific failings and of the options outside medical model. But Davies is again not optimistic: “Until a new, critically reflective generation of psychiatrists emerges, nothing will change.”
  4. The public needs to become more informed about the crisis in psychiatry. Given his lack of optimism on Points 1-3, Davies believes this is most important option.

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