Comfortably Numb: How Psychiatry is Medicating a Nation

  • Charles Barber
Pantheon, 2008 304 pp., hardcover, $26.00 0375423990 | ISBN: 0-375-42399-0

The art and science of healing mind and body are confronted with limits and uncertainties. All practitioners face the challenges of diagnosis, identifying appropriate treatment options and weighing the treatments' benefits against costs and risks. This process is dynamic, and the boundaries of medicine and therapy are where this dynamism and its uncertainties are acute.

In his book, Comfortably Numb, Charles Barber is an observer of what have been remarkable changes in mental health treatment and in social perceptions of mental illness. The prevalence and presentation of illness have changed. Treatment options have expanded, while evidence about efficacy has grown exponentially and eroded in places, too. The markets in which treatments are developed and sold have grown dramatically. And the systems financing health care have been continually changing.

Barber's book takes on these changes in a style that is broad and ambitious but also quite personal. The result is an engaging and provocative read. He raises few points that are new but makes plain the issues that should concern anyone interested in effective and appropriate treatment of mental illness. In doing so, Barber weaves a story of greed, indolence and perhaps even conspiracy that involves the pharmaceutical industry, regulators, physicians and patients.

A recurring theme and impetus for Barber's work is his experience working with the mentally ill beginning in the late 1980s. His career coincided with a period of both the declining stigma of mental illness (which led to the passage of the US Mental Health Parity Act) and the advent of new classes of drugs. Barber seems discomforted by the declining stigma, primarily because he believes this decline focuses too much attention on those whom he considers the “worried well,” at the expense of the severely mentally ill. But it is the advent of new pharmacotherapies that occupies the center of Barber's plot.

Barber's book is at its best in the recounting of the evolution of mental health therapy, psychiatry and medicine. His history of the asylum movement is informative, despite its brevity. Barber is clear about both the benefits of confinement of the mentally ill in nineteenth century society and the terrible treatment and conditions in some institutions. He then describes the antecedents of the community-based model of treatment—including the advent of psychotherapy and the introduction of lithium as a mood stabilizer—and the subsequent deinstitutionalization of mental health care. His description of the development of biological psychiatry is informative, with highly readable discussions of the promise and limitations of the science of neurology and brain imaging.

But it is at this stage where 'big pharma' joins the story. Barber sees the biological approach to mental health treatment as largely driven by pharmaceutical manufacturers. He places much of the blame for this on medical research and practice for allowing standards to slip. Furthermore, he characterizes Americans as quick to look for simple solutions, which drug therapy provides more readily compared to psychotherapy, behavior modification or other forms of treatment. Added to this mix are insurers, whose objective to lower treatment costs has fueled the move to treatments that rely less on human care and more on pharmacotherapy.

Although Barber provides a reasonable accounting of the marked increase in treatment with newer drugs, he is quick to ascribe bad intent to many and a lack of fortitude to the treated. In doing so, he fails to take on a fundamental question of how treatment margins expand—that is, how therapies diffuse. New treatments that more broadly or effectively treat illness, that come with fewer side effects or that can be provided with fewer costs are sure to result in an increase in treatment. A case in point is selective serotonin reuptake inhibitors (SSRIs), which have led to more treatment for longer periods of time for some individuals and expanded treatment to persons with less severe depression who previously might have gone untreated. Barber gives no real consideration to the notion that new drug therapies have expanded as physicians and patients judge their relative benefits.

His discussion of the late arrival and then quick diffusion of SSRIs in Japan illustrates where a fuller consideration might lead to different conclusions. Barber suggests that SSRIs weren't sold in Japan until 1999 because the Japanese had, until then, accepted mild depression as a normal condition; only marketers convinced them otherwise. Japan's late adoption was influenced by culture, and a reticent regulatory body that didn't approve SSRIs until 1999. This followed a wrenching economic malaise and a rapidly growing suicide rate. Therefore, the patterns leading up to the adoption and then diffusion of antidepressant therapy are more complex and less nefarious than Barber considers.

In addition to his consideration of how mental health treatment has evolved, Barber devotes the second part of his book to his view of how the landscape of mental health treatment should change. This includes expansions of the use of cognitive behavioral therapy, fish oil, exercise and a call for Americans to 'buck up'. As with the charges laid in the first part of the book, the arguments for change in the second are insightful but more polemic than analytic.

But this book is not intended as a scholarly analysis of the basis and effects of new therapies. Rather, it is meant to be a provocative read, which it clearly is. At the boundaries of medical treatment, uncertainty is inherent, and Barber raises questions about those boundaries. Regardless of whether his case is compelling, everyone with a stake in mental health care needs to be demanding of evidence, clear about conflicts of interest and objective in considering treatment options.