by Alison Bateman-House*
Charles Barber's latest book, Comfortably Numb: How Psychiatry is Medicating a Nation (Pantheon Books), is a passionate, multi-pronged critique of the state of psychiatry in the United States. Barber takes as his starting point his fourteen years working with the mentally ill homeless in New York City. In positions ranging from a counselor to a senior social services administrator, he worked on the streets, in shelters, and in supportive residential programs with clients who were dealing with severe and persistent mental illness, homelessness, addiction, and frequently chronic health problems.
Entering the field in 1988, Barber was perfectly positioned to witness the introduction and uptake of such new psychiatric medications as Prozac, Paxil, and Zoloft. Over time, he "became oddly enthralled by the ongoing parade of medications that entered [his] clients' mouths (and sometimes their arms, via injection)." (xii) Interested in everything from the drugs' marketing campaigns to their costs to their effects on those taking them, Barber became an astute observer of all aspects of the pharmaceutical regimes of his clients.
During those same years, Barber believed that he was witnessing a sea change in the attitude of "ordinary" Americans to psychotropic medications and mental illness. In the late 1980s, Barber felt that those outside of the field typically believed that the mentally ill homeless suffered primarily from moral weaknesses or character deficits. Barber characterized the suburban, upper-middle-class professionals he socialized with as compassionate yet nonetheless convinced that Barber's clients were themselves the primary cause of their problems. Within a decade, however, those same privileged professionals were routinely divulging their mental health problems, or those of family members or friends, in casual conversation. In Barber's memorable line recalling cocktail party banter, "Words like Prozac and Paxil and lithium were tossed around along with the salted peanuts and the shrimp."(xiii) How, he wondered, had mental illness and the drugs used to treat it become so hip, so integrated into popular culture and daily life?
Barber has a way with words, and he makes his points clearly and concisely. The tone of Comfortably Numb, however, is not that of a debater making a case. Barber is an evangelist, and he hits his message early, repeatedly, and without coyness. His thesis is that while pharmaceutical treatments can be, and often are, therapeutic for those with severe psychiatric conditions, most Americans are not seriously mentally ill and they are not appropriate candidates for these drugs. Barber argues that psychiatric drugs' "efficacy with very specific populations has been overgeneralized and misapplied to treat the troubles of the masses generally and upper-middle-class angst specifically."(21) With his usual knack for a concise phrase devoid of sugarcoating, he concludes, "the wrong people are taking the medications."(114)
Barber's evidence for this thesis is, unfortunately, uneven. He convincingly documents the increased visibility and acceptability of mental illness in American popular culture over the last two decades through such means as listing celebrities who have disclosed either having a mental illness or taking psychiatric medication. Cinema and theater are singled out for particular attention; Barber even compiles a list of actors who were nominated for Oscars for their portrayal of a mentally-ill character.
Barber pays less attention to supporting his contention that most Americans are not seriously mentally ill and thus not appropriate consumers of psychotropic medication. While he compiles statistic after statistic about the quantity of psychiatric drugs prescribed to and consumed by Americans, to Barber such data is not proof of widespread mental health needs. Rather, he views these numbers of evidence of the success of marketing campaigns that not only seek to persuade health care providers to prescribe certain drugs but also to convince potential consumers that they suffer from conditions that can be treated pharmaceutically.
In the chapter "American Misery," Barber describes the "Medicated American." In his portrayal, she (twice as many psychiatric drugs are prescribed for women than men) does not have a psychiatric diagnosis, but her family doctor wrote her a prescription after she, prompted by advertising, asked for an antidepressant. Her insurance company paid for the drug, but she was not well counseled about its side effect profile. She takes the drug because she hopes that it will liberate her from her unhappiness. Barber understands her desire for relief but argues that it is inappropriate to treat her misery with drugs meant to treat serious psychiatric illness. To confuse depression with Depression, he argues, "is to compare a gentle spring rain to an unrelenting and vengeful typhoon."(107)
Barber is sharply critical of the way psychiatric drugs are marketed and prescribed in the United States, and, in his view, there is blame aplenty. He condemns pharmaceutical companies and managed-care organizations for valuing profits over patient (and public) health. He accuses the Food and Drug Administration of abdicating its responsibilities to objectively and scientifically evaluate drug safety, and claims that the agency "under the Bush administration appears to have perceived itself as being a client of Big Pharma rather than serving the American public." (31) His harshest condemnation is reserved for doctors and universities and their adherence to what Barber calls biological psychiatry, i.e. the mindset that mental illness - indeed, any type of mental or emotional distress - should be treated pharmaceutically, even when effective non-drug treatment modalities exist.
Barber charges psychiatry with forfeiting its special expertise in mental illness in its quest to be everything to everyone, and he argues that defining psychiatric problems as "issues" or "conditions" rather than "diseases" sets too low a bar for determining the appropriate purview of psychiatry. Among his most thought-provoking - and upsetting - points is that the majority of those who need psychotropic drugs do not have access to them while those who are prescribed the drugs often do not have a clinically diagnosable mental illness.
In the second part of the book Barber looks at a variety of alternate approaches - ranging from cognitive-behavioral therapy to dietary interventions to exercise - and takes a brief foray into the importance of social inclusion for mental health. While interesting, I found this section less compelling than the first part of the book, largely because it offers less of the indignation and passion that permeates the earlier section. Nonetheless, Barber is to be applauded for attempting to offer solutions rather than just enumerating problems.
While Barber is strongly critical of what he sees as the medicalization of unhappiness, he is fair-minded and acknowledges the importance of psychiatric drugs when used appropriately. In Comfortably Numb, Barber makes a compelling case both that the status quo is deeply problematic and that there are alternatives. The only time he oversteps is in his effort to paint the desire for a quick fix for misery as essentially American. While it may seem quintessentially American to feel that unhappiness is a problem for which there must be a solution, it seems a bit much to link the overuse of psychiatric drugs in modern America with the closing of the American frontier, as Barber does. To successfully argue that there is something fundamentally American about our society's embrace of psychiatric drugs would necessitate a robust international comparison, which is lacking. Aside from this quibble, however, Comfortably Numb is an enlightening, provocative book that is worth reading.
*Alison Bateman-House, MA, MPH, is a student in the joint socio-medical sciences/history doctoral program at Columbia University in New York City, where she works at the interface of bioethics and the history of medicine and public health.