Thanks to One Flew Over the Cuckoo's Nest, there's a new love in Louise's life. There's Jerry 'n' John 'n' Andrew . . . now meet the newest addition - OSCAR! Louise's latest film is The Heretic.
No actress in recent months has elicited more critical acclaim than Louise Fletcher, for her role as Nurse Ratched in One Flew Over the Cuckoo's Nest. She won an Oscar for her fine performance in the film.
Yet Louise landed the role only after five famous actresses, including Ellen Burstyn and Faye Dunaway, turned it down.
"It's their misfortune and my luck,' Louise told me, while on a recent trip to Europe to promote the movie. "I'd like to give a party for these ladies to thank them for the break. Suddenly, I've become a celebrity. And I now have more film offers than I can handle."
"Frankly, I can understand their reasons for turning the film down . Cuckoo's Nest is essentially a downbeat picture, since it is set in a male mental institution. Not in our wildest dreams did we expect the movie would have this fantastic box-office success, and get nine Oscar nominations.
"Also, the part of Nurse Ratched does not offer an actress the opportunity for any great dramatic fireworks. It all has to be underplayed. While she is a neurotic character, she is nonetheless in absolute control of her emotions. A lot has to be implied, then, with the eyes or just a slight intonation of the voice."
Louise smiled, her face all alight, then she sighed, and said, "I've waited a long time to make a comeback - at forty-one - and I'm absolutely thrilled!"
On her last few words, thereby hangs a tale.
Louise abandoned her career for eleven years to become a housewife, devoting herself completely to raising her children, Andrew, who is now thirteen, and John, fourteen. Her husband is Jerry Bick, former literary agent, and producer of such films as Robert Altman's The Long Goodbye and Thieves Like Us.
"Living out in Hollywood, as we were at the time, I saw too many marriages break up because the wife was busy with a career and didn't care enough about her husband and family. I was determined that wouldn't happen to me and Jerry. And it hasn't. We're celebrating our seventeenth wedding anniversary this year!"
Louise explained how they met.
"I'm afraid our first encounter wasn't extraordinarily romantic, but quite usual and normal. We were introduced by mutual friends at a dinner party they gave. Eight out of ten women probably meet their future husbands in this way.
"I hadn't gone out with many men before Jerry, because I was a rather reticent person, and I was also too busy trying to get ahead with my career, believe it or not! Anyway, Jerry and I got along famously at the party. He asked me for a date. I said I'd be delighted. We went out, and after that, I never went out with anyone else!"
She sounded like an old-fashioned girl, I said. Was she?
"It's just that I never felt the need to date another man. I guess I was fortunate, since I met the man of my life when I was still comparatively young. Perhaps that's being old-fashioned. I don't know. But at least I've avoided those emotional crises which can occur in women of my age who haven't had a satisfying marriage and the joy of children.
"Fortunately with my mentality, I don't fall in love with my leading men - and they don't get that way about me, either. Men don't perceive me as a sex symbol, that's all. This means I don't get propositioned at auditions, so it has its advantages. And since I don't flaunt myself, I am considered a serious actress. I am disciplined and behave in a professional manner, so men act accordingly.
"The mirror tells me that I'm attractive. As does my husband. So I have no ego problems with which to cope. That's most of the battle, I feel."
A great deal of Louise's upbringing and North Carolina background came out in her manner, as we talked.
"I had a strong religious and moral upbringing, since we were Episcopalians. I was taught, at an early age, to have respect for other people and be considerate of them. I've still found that to be a general rule in life. After all, you get exactly what you give to others.
"I seem to have wanted to become an actress for as long as I can remember. But I promised my father I would finish school. So I graduated from the University of North Carolina.
"I was twenty-one when I finished college. It was a toss-up between the theater in New York, and the movies in California. But I had been influenced more by the movies, since we didn't get to see too much theater in North Carolina. Anyway, I wanted the experience of living on my own, far from my parents. So I headed west.
"I didn t get acting work immediately. So I took a job as a receptionist in a doctor's office, and enrolled in Jeff Corey's acting classes, which I heard were the best on the coast. Oddly enough, Jack Nicholson went to the same school, but after I did.
"Television was very big at the time, since many of the programs had just transferred from New York City. Movies were at the beginning of a decline. The large studios were cutting down on production and dismissing contract actors. My best bet, I figured, was to work for the small screen.
"I did walk-ons and bits on various television shows for a short time, until finally director John Frankenbeimer gave me a break with a major role on one of the Playhouse 90 series. From that, I was able to get an agent - MCA.
"The important thing was, that I now started to make a living from my acting. Warners offered me a seven-year contract, but I turned it down. I'd seen too many actors sitting idly around, collecting their weekly paychecks, with contracts which didn't offer precise roles. Besides, I felt it would be to my advantage to be independent. And eventually it was. I might not have been able to become an ordinary housewife, if I'd been under contract."
There was no trace of the hardness and impermeability of Nurse Ratched on Louise's face or in her manner as she talked. That extraordinary demode upsweep hairdo which Louise wore in the movie was gone too. Now, her reddish brown hair fell softly down around her face, slightly covering her forehead. She wore only a bit of eye shadow and lipstick. And her voice was warm and welcoming, unlike the steel monotone she employed for the character in the movie.
When I mentioned this to her, she laughed. When she laughs, there is a quality about her which reminds one of Ellen Burstyn or Shirley MacLaine.
"I didn't research the role, or expressly study for it. Rather, I tried to look for the hard core within me, bring it to the surface and expand upon it. I also attempted to take refuge in fact, people who I had met or whom I'd known that possessed similar characteristics. They hadn't necessarily been nurses. I myself have never had anything to do with a hospital, least of all a mental institution. But using my information, it was all a matter of trial and error."
New role, new home. Louise and Jerry, with their sons, just moved into a new apartment in Westwood.
"So much has happened so quickly; my head is still spinning. Our former quarters were too cramped. When we saw this place, we decided to take it. We felt we just had to get out of the old place. It was robbed last year, and we were nervous living there. I didn't have time to assist in the actual moving, because I was involved in publicity for the film. We put everything in crates and labeled them before I went away. It was all moved in during this trip to Europe.
Before 1973, we lived in London for seven years, on Old Church Street in Chelsea. We had a house there. Jerry's mother gave us a lot of her things, which we shipped to England to furnish the place. We left them in London when we came back to the States, because it would have meant the added expense of shipping them back at a time when we were watching our pennies. Now we may bring some of the furniture over.
"For me, who had never been abroad, London was a wonderful experience. Its pace is slower than America, but being southern anyway, that tempo suited me fine. We made a lot of nice friends there, both in and out of the entertainment world, so we might possibly move back one day. But not for the moment. The kids are settled in school in Los Angeles, and they don't want to budge. My career has started to move, and Jerry is in the midst of production.
"Jerry's work is what originally brought us to England. He came to produce a movie, but it never got off the ground. That's the business. His first major project abroad was a picture called Michael Kalhaus, with David Warner, which was directed by Volker Schoendorf."
The resumption of Louise's own career came about unexpectedly.
"Jerry and I were over at Bob Altman's house one evening for a script reading of Thieves Like Us. Keith Carradine, Shelley Duvall, and most of the principal actors were there. They needed someone to read the part of Maddy, which hadn't been cast, and I was asked. The following day Bob said to Jerry, that since I was going to be in Louisiana anyway, with Jerry, who was producing the film, it made good sense for me to take the role. Until then, I hadn't thought about acting for years.
"I felt that it was the right moment to resume my career. I didn't believe I could wait much longer if I wanted to do something worthwhile, since there aren't that many interesting parts around for grandmothers."
Louise laughed at her last remark.
"It's not as bad a time for my age range of actress as some women would have one believe. For example, there seems to be an abundance of good parts about for Ellen Burstyn and Glenda Jackson, who are my age. I think producers have now become conscious of the fact that there is this talent pool, which is commercial, so they are hunting up properties for them. I have had so many offers since Cuckoo, I can't quite make up my mind.
"It all broke at the good moment for my family too. The kids have reached a point in their lives when they are fairly self-sufficient. During the day, they are away at school, so there is no problem. Even when they are at home, they are independent. They have their own friends and activities.
"Andrew, the younger of the two, is more competitive and outgoing than John. He's athletic and loves sports. John is more into books and art. He likes to spend his spare time reading or going to the galleries. To me, they are as different as day from night. John is, in some ways, a reflection of his father, whereas Andrew has many of my characteristics.
"When I was younger, I was very much into athletics. At one time, I even thought I wanted to become a classical ballet dancer. I had the slim figure for it - I still do, mind you. And I'm the right height - five foot eleven. But that was back in North Carolina, years ago.
"These days, I'm not much into exercise. I'm more into cooking. Jerry loves to eat, and the boys certainly have a hearty appetite. I can do the whole Julia Child bit. In fact, I follow her cookbook closely, and I must say, it does work! My speciality is boeuf bourguignon, but I also do a wonderful chicken kiev.
"When we were living in London, we used to go out regularly to all the best restaurants because they were, so to speak, in our backyard. But in Los Angeles we tend to stay at home. We sure could use that tabby cat we had in London, who'd polish off the waste scraps in no time!
"We're very much home people. We don't belong to any Hollywood set, and we lead a relatively quiet life together. That's why I'm always amazed when I hear all those stories about people sleeping around in Hollywood, and about wife and husband swapping. They don't occur to our friends!"
Would Louise like more children? She smiled when I asked her.
"Two is a nice number, without furthering the population explosion. I don't think it's good for a woman over forty to have children. Abnormalities are more common in the infant after that age. And, let's face it, I spent almost a decade, enjoyable as it was, devoting myself to my sons. Now is my time.
"Even though my career is taking off, I don't intend to allow it to usurp more than a reasonable amount of my life. Two films a year will be the maximum. I've built up a very strong relationship with my family, and I won't sacrifice it for anything, not even my work.
"This is very characteristic of Cancer. Cancer people are homemakers. But I am also aggressive, when necessary, and somewhat of a loner, like Leo. This is because I was born on July 22, which is just between the two signs. I inherited qualities from them both."
Louise said she had an appointment, and stood up to go. I noticed she was wearing a trouser suit, and I remarked upon how lovely it looked.
"I don't think I have any actual dresses in the closet. I love trousers, and especially jump suits. I can't resist a really snazzy outfit, and I think I've over-bought on this trip. Aside from the honor, the wonderful thing about this success of mine, is that we'll no longer have to watch the budget.
"We're not big spenders, but we've had a let of expenses these past years. Like the kids' private school, and the furniture for the apartment."
I walked her to the hotel door.
"I'm glad I didn't become a doctor."
Was she seriously contemplating it, I asked her.
"If I hadn't become an actress, that was my ambition."
Louise has certainly made it to the hospital, and received an Oscar for it, in the bargain.
Tuesday, 1 December 2015
Louise Fletcher
Estelle Louise Fletcher (born 22 July 1934; age 81) is the Academy Award-winning, Emmy Award-nominated American actress who played the Bajoran spiritual leader Vedek (laterKai) Winn Adami in fourteen episodes of Star Trek: Deep Space Nine.
A screen legend in her own right, Fletcher is best known for her performance as the loathsome Nurse Mildred Ratched in the classic film One Flew over the Cuckoo's Nest, which earned her the 1975 Academy Award for Best Actress in a Leading Role. Star Trek: Voyager guest star Brad Dourif was nominated for an Oscar for his performance in the film, whileMichael Berryman, Peter Brocco, Christopher Lloyd, andVincent Schiavelli also had roles. The film featured makeups by Fred Phillips.
Fletcher is one of only four Star Trek performers to have been nominated for a Best Leading Actress Academy Award (the others being Samantha Eggar, Whoopi Goldberg and Jean Simmons) and the only one to have won the award.
Fletcher was born in Birmingham, Alabama. Both of her parents were deaf, and as a result, she learned sign language at a very early age. Her aunt, who taught her how to speak, also introduced her to acting.
Fletcher attended the University of North Carolina at Chapel Hill, where in 1956 she acted in the Institute of Outdoor Drama. After graduation, she traveled to Los Angeles, working as a receptionist by day and taking acting classes at night. By the end of 1958, she was working regularly in television, and continued to do so for several years.
Fletcher made guest appearances on dozens of popular television series, including Maverick, Wagon Train, and Perry Mason. She also appeared in the second episode of the CBS action drama series The Untouchables, which, like the original Star Trek, was produced by Desilu Studios. She made her film debut with an uncredited role in the 1963 war drama A Gathering of Eagles, which featured Robert Lansing in a supporting role.
Following her marriage to producer Jerry Bick in 1960 and subsequent motherhood, Fletcher went on a long hiatus to raise her family, returning in the 70s. Fletcher divorced Bick in 1978 after 18 years of marriage; they have two grown sons.
Fletcher returned to the silver screen when she was cast by legendary director Robert Altman in the 1974 filmThieves Like Us. Her co-stars in this film included Keith Carradine, John Schuck and Bert Remsen.
In January of 1975, Fletcher won the role of Nurse Ratched in One Flew Over the Cuckoo's Nest. Five other actresses had turned down the role, and Fletcher was cast only a week before filming began. Not only did Fletcher win the Academy Award for Best Actress for her performance (which was presented to her by Jill Ireland and her husband Charles Bronson), but the film also won Best Picture, as well as three other Oscars. Her portrayal of a cruel, sadistic nurse in a 1950s mental ward, stifling patients' individuality (as well as their recovery), was ranked the fifth greatest screen villain by the American Film Institute. [1]
Since winning her Academy Award, Fletcher has starred in numerous other film projects, the majority of which feature fellow Star Trek alumni. In 1978, she had a memorable supporting role in the comedic thriller The Cheap Detective, co-starring James Cromwell, David Ogden Stiers, Vic Tayback, and Jonathan Banks. The following year, she appeared with her Cuckoo's Nest co-star Christopher Lloyd (Kruge in Star Trek III: The Search for Spock) in the comedy The Lady in Red (also featuring Dick Miller).
In 1983, Star Trek: The Motion Picture special effects director-turned-feature film director and producerDouglas Trumbull cast her in the science fiction film Brainstorm. That same year, she co-starred with fellow recurring DS9 performer Wallace Shawn in Strange Invaders, along with Kenneth Tobey, Dey Young andThomas Kopache. Fletcher was also cast in the 1984 thriller Firestarter based upon the novel by Stephen King and also costarred Leon Rippy. Fletcher won a Saturn Award as Best Actress from the Academy of Science Fiction, Fantasy & Horror Films for her role in Brainstorm, and was also nominated for a Saturn Award for her performance in the 1987 horror film Flowers in the Attic. In 1989, she was seen in the martial arts film Best of the Best, which was edited by William Hoy.
1990-present
Fletcher had a role in the 1990 film Blue Steel, co-starring Clancy Brown, Mike Starr, and William Marshall. She then appeared in the Emmy Award-nominated mini-series In a Child's Name with Jeff Allin, Timothy Carhart,Dennis Cockrum, David Huddleston, Caroline Kava, and Mitch Ryan. In 1992, she was a regular on the short-lived CBS series The Boys of Twilight, along with Amanda McBroom. In 1994, Fletcher co-starred with David Warner in the thriller Tryst, with Seymour Cassel in Tollbooth, and with Bruce Davison in the TV movieSomeone Else's Child.
In 1995, Fletcher portrayed Elzabeth Deane in the science fiction film Virtuosity, which involved virtual reality. She then portrayed Nora Bloom on the similarly-themed, short-lived television series VR.5. Fletcher then guest-starred in two 1996 episodes of the CBS series Picket Fences, earning an Emmy Award nomination for her performance in her second episode.
Fletcher was one of several Trek alumni to star in the 1997 film Breast Men, her performance in which earned her a Golden Satellite Award nomination. Among her co-stars in Breast Men were Matt Frewer, Terry O'Quinn,Raphael Sbarge, Frank Novak, and Heidi Swedberg. In 2000, Fletcher co-starred with Whoopi Goldberg inMore Dogs Than Bones, and in 2005, she co-starred with Erick Avari in Dancing in Twilight.
Fletcher earned her second Emmy Award nomination for her performance in an episode of CBS' Joan of Arcadia, on which Michael Welch was a regular. Fletcher then appeared on 7th Heaven (which starred Stephen Collins and Catherine Hicks) and had a recurring role on NBC's long-running medical drama, ER. More recently, she portrayed Mrs. Wilson in the direct-to-video release, a Dennis the Menace Christmas.
In 2009, Fletcher guest-starred in two episodes of the popular NBC series Heroes. Her first episode, "Ink," was directed by former Star Trek: Voyager regular Roxann Dawson and also guest-starred Robert Knepper andRick Worthy. Her second episode, "Hysterical Blindness," featured series regulars Greg Grunberg, Zachary Quinto, and Cristine Rose.
In 1993, Fletcher accepted the role of Vedek Winn in the first season of Star Trek: Deep Space Nine. Her portrayal of the inflexible, wry character gave it the condescending edge the part required. After two seasons, her character advanced to the status of Kai, which made her an even more integral part of the DS9 saga. Her recurring character on the series continued until the series finale in 1999.
Louise Fletcher
És sobretot coneguda per al seu paper de la infermera en cap a l'hospital psiquiàtric d'Algú va volar sobre el niu del cucut(1975), paper que li va valer un Oscar l'any següent.
Després d'anar a la Universitat de Carolina del Nord es va traslladar a Los Angeles, Califòrnia, on treballava com a secretària de dia i feia classes d'actuació per la nit.
Va començar a actuar en diverses produccions per la televisió, però després de casar-se el 1960 amb Jerry Bick, es va retirar per educar els seus dos fills; el 1978 es va divorciar del seu marit, que va morir el 2004.
El 1974 va tornar al cinema, participant en la pel·lícula Thieves Like Us. Miloš Forman va veure aquesta interpretació, i la va cridar per interpretar el paper de la infermera Mildred Ratched a la pel·lícula Algú va volar sobre el niu del cucut'' (1975), pel qual va guanyar l'Oscar a la millor actriu. També ha aparegut en altres pel·lícules com Exorcist II: The Heretic (1977), The Cheap Detective (1978), Brainstorm (1983), Firestarter (1984), Flowers in the Attic (1987) o Intencions perverses (1999).
Fletcher va ser candidata als Emmy pel seu paper en la sèrie de televisió Picket Fences. També va tenir un paper en la sèrieStar trek: Espai Profund Nou.
The Illusions of Psychiatry
In my article in the last issue, I focused mainly on the recent books by psychologist Irving Kirsch and journalist Robert Whitaker, and what they tell us about the epidemic of mental illness and the drugs used to treat it.1 Here I discuss the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM)—often referred to as the bible of psychiatry, and now heading for its fifth edition—and its extraordinary influence within American society. I also examine Unhinged, the recent book by Daniel Carlat, a psychiatrist, who provides a disillusioned insider’s view of the psychiatric profession. And I discuss the widespread use of psychoactive drugs in children, and the baleful influence of the pharmaceutical industry on the practice of psychiatry.
One of the leaders of modern psychiatry, Leon Eisenberg, a professor at Johns Hopkins and then Harvard Medical School, who was among the first to study the effects of stimulants on attention deficit disorder in children, wrote that American psychiatry in the late twentieth century moved from a state of “brainlessness” to one of “mindlessness.”2 By that he meant that before psychoactive drugs (drugs that affect the mental state) were introduced, the profession had little interest in neurotransmitters or any other aspect of the physical brain. Instead, it subscribed to the Freudian view that mental illness had its roots in unconscious conflicts, usually originating in childhood, that affected the mind as though it were separate from the brain.
But with the introduction of psychoactive drugs in the 1950s, and sharply accelerating in the 1980s, the focus shifted to the brain. Psychiatrists began to refer to themselves as psychopharmacologists, and they had less and less interest in exploring the life stories of their patients. Their main concern was to eliminate or reduce symptoms by treating sufferers with drugs that would alter brain function. An early advocate of this biological model of mental illness, Eisenberg in his later years became an outspoken critic of what he saw as the indiscriminate use of psychoactive drugs, driven largely by the machinations of the pharmaceutical industry.
When psychoactive drugs were first introduced, there was a brief period of optimism in the psychiatric profession, but by the 1970s, optimism gave way to a sense of threat. Serious side effects of the drugs were becoming apparent, and an antipsychiatry movement had taken root, as exemplified by the writings of Thomas Szasz and the movie One Flew Over the Cuckoo’s Nest. There was also growing competition for patients from psychologists and social workers. In addition, psychiatrists were plagued by internal divisions: some embraced the new biological model, some still clung to the Freudian model, and a few saw mental illness as an essentially sane response to an insane world. Moreover, within the larger medical profession, psychiatrists were regarded as something like poor relations; even with their new drugs, they were seen as less scientific than other specialists, and their income was generally lower.
In the late 1970s, the psychiatric profession struck back—hard. As Robert Whitaker tells it in Anatomy of an Epidemic, the medical director of the American Psychiatric Association (APA), Melvin Sabshin, declared in 1977 that “a vigorous effort to remedicalize psychiatry should be strongly supported,” and he launched an all-out media and public relations campaign to do exactly that. Psychiatry had a powerful weapon that its competitors lacked. Since psychiatrists must qualify as MDs, they have the legal authority to write prescriptions. By fully embracing the biological model of mental illness and the use of psychoactive drugs to treat it, psychiatry was able to relegate other mental health care providers to ancillary positions and also to identify itself as a scientific discipline along with the rest of the medical profession. Most important, by emphasizing drug treatment, psychiatry became the darling of the pharmaceutical industry, which soon made its gratitude tangible.
These efforts to enhance the status of psychiatry were undertaken deliberately. The APA was then working on the third edition of the DSM, which provides diagnostic criteria for all mental disorders. The president of the APA had appointed Robert Spitzer, a much-admired professor of psychiatry at Columbia University, to head the task force overseeing the project. The first two editions, published in 1952 and 1968, reflected the Freudian view of mental illness and were little known outside the profession. Spitzer set out to make the DSM-III something quite different. He promised that it would be “a defense of the medical model as applied to psychiatric problems,” and the president of the APA in 1977, Jack Weinberg, said it would “clarify to anyone who may be in doubt that we regard psychiatry as a specialty of medicine.”
When Spitzer’s DSM-III was published in 1980, it contained 265 diagnoses (up from 182 in the previous edition), and it came into nearly universal use, not only by psychiatrists, but by insurance companies, hospitals, courts, prisons, schools, researchers, government agencies, and the rest of the medical profession. Its main goal was to bring consistency (usually referred to as “reliability”) to psychiatric diagnosis, that is, to ensure that psychiatrists who saw the same patient would agree on the diagnosis. To do that, each diagnosis was defined by a list of symptoms, with numerical thresholds. For example, having at least five of nine particular symptoms got you a full-fledged diagnosis of a major depressive episode within the broad category of “mood disorders.” But there was another goal—to justify the use of psychoactive drugs. The president of the APA last year, Carol Bernstein, in effect acknowledged that. “It became necessary in the 1970s,” she wrote, “to facilitate diagnostic agreement among clinicians, scientists, and regulatory authorities given the need to match patients with newly emerging pharmacologic treatments.”3
The DSM-III was almost certainly more “reliable” than the earlier versions, but reliability is not the same thing as validity. Reliability, as I have noted, is used to mean consistency; validity refers to correctness or soundness. If nearly all physicians agreed that freckles were a sign of cancer, the diagnosis would be “reliable,” but not valid. The problem with the DSM is that in all of its editions, it has simply reflected the opinions of its writers, and in the case of the DSM-III mainly of Spitzer himself, who has been justly called one of the most influential psychiatrists of the twentieth century.4 In his words, he “picked everybody that [he] was comfortable with” to serve with him on the fifteen-member task force, and there were complaints that he called too few meetings and generally ran the process in a haphazard but high-handed manner. Spitzer said in a 1989 interview, “I could just get my way by sweet talking and whatnot.” In a 1984 article entitled “The Disadvantages of DSM-III Outweigh Its Advantages,” George Vaillant, a professor of psychiatry at Harvard Medical School, wrote that the DSM-IIIrepresented “a bold series of choices based on guess, taste, prejudice, and hope,” which seems to be a fair description.
Not only did the DSM become the bible of psychiatry, but like the real Bible, it depended a lot on something akin to revelation. There are no citations of scientific studies to support its decisions. That is an astonishing omission, because in all medical publications, whether journal articles or textbooks, statements of fact are supposed to be supported by citations of published scientific studies. (There are four separate “sourcebooks” for the current edition of the DSM that present the rationale for some decisions, along with references, but that is not the same thing as specific references.) It may be of much interest for a group of experts to get together and offer their opinions, but unless these opinions can be buttressed by evidence, they do not warrant the extraordinary deference shown to the DSM. The DSM-III was supplanted by the DSM-III-R in 1987, the DSM-IV in 1994, and the current version, the DSM-IV-TR (text revised) in 2000, which contains 365 diagnoses. “With each subsequent edition,” writes Daniel Carlat in his absorbing book, “the number of diagnostic categories multiplied, and the books became larger and more expensive. Each became a best seller for the APA, and DSM is now one of the major sources of income for the organization.” TheDSM-IV sold over a million copies.
As psychiatry became a drug-intensive specialty, the pharmaceutical industry was quick to see the advantages of forming an alliance with the psychiatric profession. Drug companies began to lavish attention and largesse on psychiatrists, both individually and collectively, directly and indirectly. They showered gifts and free samples on practicing psychiatrists, hired them as consultants and speakers, bought them meals, helped pay for them to attend conferences, and supplied them with “educational” materials. When Minnesota and Vermont implemented “sunshine laws” that require drug companies to report all payments to doctors, psychiatrists were found to receive more money than physicians in any other specialty. The pharmaceutical industry also subsidizes meetings of the APA and other psychiatric conferences. About a fifth of APA funding now comes from drug companies.
Drug companies are particularly eager to win over faculty psychiatrists at prestigious academic medical centers. Called “key opinion leaders” (KOLs) by the industry, these are the people who through their writing and teaching influence how mental illness will be diagnosed and treated. They also publish much of the clinical research on drugs and, most importantly, largely determine the content of the DSM. In a sense, they are the best sales force the industry could have, and are worth every cent spent on them. Of the 170 contributors to the current version of the DSM (the DSM-IV-TR), almost all of whom would be described as KOLs, ninety-five had financial ties to drug companies, including all of the contributors to the sections on mood disorders and schizophrenia.5
The drug industry, of course, supports other specialists and professional societies, too, but Carlat asks, “Why do psychiatrists consistently lead the pack of specialties when it comes to taking money from drug companies?” His answer: “Our diagnoses are subjective and expandable, and we have few rational reasons for choosing one treatment over another.” Unlike the conditions treated in most other branches of medicine, there are no objective signs or tests for mental illness—no lab data or MRI findings—and the boundaries between normal and abnormal are often unclear. That makes it possible to expand diagnostic boundaries or even create new diagnoses, in ways that would be impossible, say, in a field like cardiology. And drug companies have every interest in inducing psychiatrists to do just that.
In addition to the money spent on the psychiatric profession directly, drug companies heavily support many related patient advocacy groups and educational organizations. Whitaker writes that in the first quarter of 2009 alone,
Eli Lilly gave $551,000 to NAMI [National Alliance on Mental Illness] and its local chapters, $465,000 to the National Mental Health Association, $130,000 to CHADD (an ADHD [attention deficit/hyperactivity disorder] patient-advocacy group), and $69,250 to the American Foundation for Suicide Prevention.
And that’s just one company in three months; one can imagine what the yearly total would be from all companies that make psychoactive drugs. These groups ostensibly exist to raise public awareness of psychiatric disorders, but they also have the effect of promoting the use of psychoactive drugs and influencing insurers to cover them. Whitaker summarizes the growth of industry influence after the publication of theDSM-III as follows:
In short, a powerful quartet of voices came together during the 1980’s eager to inform the public that mental disorders were brain diseases. Pharmaceutical companies provided the financial muscle. The APA and psychiatrists at top medical schools conferred intellectual legitimacy upon the enterprise. The NIMH [National Institute of Mental Health] put the government’s stamp of approval on the story. NAMI provided a moral authority.
Like most other psychiatrists, Carlat treats his patients only with drugs, not talk therapy, and he is candid about the advantages of doing so. If he sees three patients an hour for psychopharmacology, he calculates, he earns about $180 per hour from insurers. In contrast, he would be able to see only one patient an hour for talk therapy, for which insurers would pay him less than $100. Carlat does not believe that psychopharmacology is particularly complicated, let alone precise, although the public is led to believe that it is:
Patients often view psychiatrists as wizards of neurotransmitters, who can choose just the right medication for whatever chemical imbalance is at play. This exaggerated conception of our capabilities has been encouraged by drug companies, by psychiatrists ourselves, and by our patients’ understandable hopes for cures.
His work consists of asking patients a series of questions about their symptoms to see whether they match up with any of the disorders in the DSM. This matching exercise, he writes, provides “the illusion that we understand our patients when all we are doing is assigning them labels.” Often patients meet criteria for more than one diagnosis, because there is overlap in symptoms. For example, difficulty concentrating is a criterion for more than one disorder. One of Carlat’s patients ended up with seven separate diagnoses. “We target discrete symptoms with treatments, and other drugs are piled on top to treat side effects.” A typical patient, he says, might be taking Celexa for depression, Ativan for anxiety, Ambien for insomnia, Provigil for fatigue (a side effect of Celexa), and Viagra for impotence (another side effect of Celexa).
As for the medications themselves, Carlat writes that “there are only a handful of umbrella categories of psychotropic drugs,” within which the drugs are not very different from one another. He doesn’t believe there is much basis for choosing among them. “To a remarkable degree, our choice of medications is subjective, even random. Perhaps your psychiatrist is in a Lexapro mood this morning, because he was just visited by an attractive Lexapro drug rep.” And he sums up:
Such is modern psychopharmacology. Guided purely by symptoms, we try different drugs, with no real conception of what we are trying to fix, or of how the drugs are working. I am perpetually astonished that we are so effective for so many patients.
While Carlat believes that psychoactive drugs are sometimes effective, his evidence is anecdotal. What he objects to is their overuse and what he calls the “frenzy of psychiatric diagnoses.” As he puts it, “if you ask any psychiatrist in clinical practice, including me, whether antidepressants work for their patients, you will hear an unambiguous ‘yes.’ We see people getting better all the time.” But then he goes on to speculate, like Irving Kirsch in The Emperor’s New Drugs, that what they are really responding to could be an activated placebo effect. If psychoactive drugs are not all they’re cracked up to be—and the evidence is that they’re not—what about the diagnoses themselves? As they multiply with each edition of the DSM, what are we to make of them?
In 1999, the APA began work on its fifth revision of the DSM, which is scheduled to be published in 2013. The twenty-seven-member task force is headed by David Kupfer, a professor of psychiatry at the University of Pittsburgh, assisted by Darrel Regier of the APA’s American Psychiatric Institute for Research and Education. As with the earlier editions, the task force is advised by multiple work groups, which now total some 140 members, corresponding to the major diagnostic categories. Ongoing deliberations and proposals have been extensively reported on the APA website (www.DSM5.org) and in the media, and it appears that the already very large constellation of mental disorders will grow still larger.
In particular, diagnostic boundaries will be broadened to include precursors of disorders, such as “psychosis risk syndrome” and “mild cognitive impairment” (possible early Alzheimer’s disease). The term “spectrum” is used to widen categories, for example, “obsessive-compulsive disorder spectrum,” “schizophrenia spectrum disorder,” and “autism spectrum disorder.” And there are proposals for entirely new entries, such as “hypersexual disorder,” “restless legs syndrome,” and “binge eating.”
Even Allen Frances, chairman of the DSM-IV task force, is highly critical of the expansion of diagnoses in the DSM-V. In the June 26, 2009, issue of Psychiatric Times, he wrote that the DSM-V will be a “bonanza for the pharmaceutical industry but at a huge cost to the new false positive patients caught in the excessively wide DSM-V net.” As if to underscore that judgment, Kupfer and Regier wrote in a recent article in theJournal of the American Medical Association (JAMA), entitled “Why All of Medicine Should Care About DSM-5,” that “in primary care settings, approximately 30 percent to 50 percent of patients have prominent mental health symptoms or identifiable mental disorders, which have significant adverse consequences if left untreated.”6 It looks as though it will be harder and harder to be normal.
At the end of the article by Kupfer and Regier is a small-print “financial disclosure” that reads in part:
Prior to being appointed as chair, DSM-5 Task Force, Dr. Kupfer reports having served on advisory boards for Eli Lilly & Co, Forest Pharmaceuticals Inc, Solvay/Wyeth Pharmaceuticals, and Johnson & Johnson; and consulting for Servier and Lundbeck.
Regier oversees all industry-sponsored research grants for the APA. The DSM-V (used interchangeably with DSM-5) is the first edition to establish rules to limit financial conflicts of interest in members of the task force and work groups. According to these rules, once members were appointed, which occurred in 2006–2008, they could receive no more than $10,000 per year in aggregate from drug companies or own more than $50,000 in company stock. The website shows their company ties for three years before their appointments, and that is what Kupfer disclosed in the JAMA article and what is shown on the APA website, where 56 percent of members of the work groups disclosed significant industry interests.
The pharmaceutical industry influences psychiatrists to prescribe psychoactive drugs even for categories of patients in whom the drugs have not been found safe and effective. What should be of greatest concern for Americans is the astonishing rise in the diagnosis and treatment of mental illness in children, sometimes as young as two years old. These children are often treated with drugs that were never approved by the FDA for use in this age group and have serious side effects. The apparent prevalence of “juvenile bipolar disorder” jumped forty-fold between 1993 and 2004, and that of “autism” increased from one in five hundred children to one in ninety over the same decade. Ten percent of ten-year-old boys now take daily stimulants for ADHD—“attention deficit/hyperactivity disorder”—and 500,000 children take antipsychotic drugs.
There seem to be fashions in childhood psychiatric diagnoses, with one disorder giving way to the next. At first, ADHD, manifested by hyperactivity, inattentiveness, and impulsivity usually in school-age children, was the fastest-growing diagnosis. But in the mid-1990s, two highly influential psychiatrists at the Massachusetts General Hospital proposed that many children with ADHD really had bipolar disorder that could sometimes be diagnosed as early as infancy. They proposed that the manic episodes characteristic of bipolar disorder in adults might be manifested in children as irritability. That gave rise to a flood of diagnoses of juvenile bipolar disorder. Eventually this created something of a backlash, and the DSM-V now proposes partly to replace the diagnosis with a brand-new one, called “temper dysregulation disorder with dysphoria,” or TDD, which Allen Frances calls “a new monster.”7
One would be hard pressed to find a two-year-old who is not sometimes irritable, a boy in fifth grade who is not sometimes inattentive, or a girl in middle school who is not anxious. (Imagine what taking a drug that causes obesity would do to such a girl.) Whether such children are labeled as having a mental disorder and treated with prescription drugs depends a lot on who they are and the pressures their parents face.8As low-income families experience growing economic hardship, many are finding that applying for Supplemental Security Income (SSI) payments on the basis of mental disability is the only way to survive. It is more generous than welfare, and it virtually ensures that the family will also qualify for Medicaid. According to MIT economics professor David Autor, “This has become the new welfare.” Hospitals and state welfare agencies also have incentives to encourage uninsured families to apply for SSI payments, since hospitals will get paid and states will save money by shifting welfare costs to the federal government.
Growing numbers of for-profit firms specialize in helping poor families apply for SSI benefits. But to qualify nearly always requires that applicants, including children, be taking psychoactive drugs. According to a New York Times story, a Rutgers University study found that children from low-income families are four times as likely as privately insured children to receive antipsychotic medicines.
In December 2006 a four-year-old child named Rebecca Riley died in a small town near Boston from a combination of Clonidine and Depakote, which she had been prescribed, along with Seroquel, to treat “ADHD” and “bipolar disorder”—diagnoses she received when she was two years old. Clonidine was approved by the FDA for treating high blood pressure. Depakote was approved for treating epilepsy and acute mania in bipolar disorder. Seroquel was approved for treating schizophrenia and acute mania. None of the three was approved to treat ADHD or for long-term use in bipolar disorder, and none was approved for children Rebecca’s age. Rebecca’s two older siblings had been given the same diagnoses and were each taking three psychoactive drugs. The parents had obtained SSI benefits for the siblings and for themselves, and were applying for benefits for Rebecca when she died. The family’s total income from SSI was about $30,000 per year.9
Whether these drugs should ever have been prescribed for Rebecca in the first place is the crucial question. The FDA approves drugs only for specified uses, and it is illegal for companies to market them for any other purpose—that is, “off-label.” Nevertheless, physicians are permitted to prescribe drugs for any reason they choose, and one of the most lucrative things drug companies can do is persuade physicians to prescribe drugs off-label, despite the law against it. In just the past four years, five firms have admitted to federal charges of illegally marketing psychoactive drugs. AstraZeneca marketed Seroquel off-label for children and the elderly (another vulnerable population, often administered antipsychotics in nursing homes); Pfizer faced similar charges for Geodon (an antipsychotic); Eli Lilly for Zyprexa (an antipsychotic); Bristol-Myers Squibb for Abilify (another antipsychotic); and Forest Labs for Celexa (an antidepressant).
Despite having to pay hundreds of millions of dollars to settle the charges, the companies have probably come out well ahead. The original purpose of permitting doctors to prescribe drugs off-label was to enable them to treat patients on the basis of early scientific reports, without having to wait for FDA approval. But that sensible rationale has become a marketing tool. Because of the subjective nature of psychiatric diagnosis, the ease with which diagnostic boundaries can be expanded, the seriousness of the side effects of psychoactive drugs, and the pervasive influence of their manufacturers, I believe doctors should be prohibited from prescribing psychoactive drugs off-label, just as companies are prohibited from marketing them off-label.
The books by Irving Kirsch, Robert Whitaker, and Daniel Carlat are powerful indictments of the way psychiatry is now practiced. They document the “frenzy” of diagnosis, the overuse of drugs with sometimes devastating side effects, and widespread conflicts of interest. Critics of these books might argue, as Nancy Andreasen implied in her paper on the loss of brain tissue with long-term antipsychotic treatment, that the side effects are the price that must be paid to relieve the suffering caused by mental illness. If we knew that the benefits of psychoactive drugs outweighed their harms, that would be a strong argument, since there is no doubt that many people suffer grievously from mental illness. But as Kirsch, Whitaker, and Carlat argue convincingly, that expectation may be wrong.
At the very least, we need to stop thinking of psychoactive drugs as the best, and often the only, treatment for mental illness or emotional distress. Both psychotherapy and exercise have been shown to be as effective as drugs for depression, and their effects are longer-lasting, but unfortunately, there is no industry to push these alternatives and Americans have come to believe that pills must be more potent. More research is needed to study alternatives to psychoactive drugs, and the results should be included in medical education.
In particular, we need to rethink the care of troubled children. Here the problem is often troubled families in troubled circumstances. Treatment directed at these environmental conditions—such as one-on-one tutoring to help parents cope or after-school centers for the children—should be studied and compared with drug treatment. In the long run, such alternatives would probably be less expensive. Our reliance on psychoactive drugs, seemingly for all of life’s discontents, tends to close off other options. In view of the risks and questionable long-term effectiveness of drugs, we need to do better.
Louise Fletcher American actress
Academy Awards
1975: Best Actress
Other Nominees
- Isabelle Adjani as Adele Hugo in The Story of Adele H.
- Ann-Margret as Nora Walker Hobbs in Tommy
- Glenda Jackson as Hedda Gabler in Hedda
- Carol Kane as Gitl in Hester Street
![Fletcher, Louise; One Flew over the Cuckoo’s Nest [Credit: Courtesy of United Artists Corporation]](https://lh3.googleusercontent.com/blogger_img_proxy/AEn0k_v7etYTapansaI1Wwgpk7DTHRjST5_MeIflXNx3OkwN9o7gNel1uOcV-cqJ_khxnF5pmITAu3YS6rFXoDjX8Mk-rYd_ZCA3M1vsQhvEcaty1mzMH4lNUf1bC3rmJTk_LnGvRzPQGLbW=s0-d)
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