Book Reviews

Whitakercover.jpgReview by Daniel Herman*

There is broad agreement among clinicians that while our current medications are not fully effective, their widespread use has enhanced health and quality of life for people with a mental illness. Consensus argues that while negative side effects can be a significant problem, these are generally outweighed by a reduction in disabling symptoms. Therefore, most believe, long-term outcomes for persons with mental illness in the US and other parts of the industrialized world are better now than they have ever been.

In his latest book, Anatomy of an Epidemic, award-winning journalist Robert Whitaker raises a disturbing question: if our psychiatric treatments are truly effective, why aren't people with mental illness doing better? He argues that long-term outcomes are worse than ever, and that this state of affairs can be largely attributed to the widespread and rapidly expanding use of psychiatric medications. He says they create functional disability and severe iatrogenic complications. In short, he turns conventional wisdom upside down.

How it can be, Whitaker wonders, that the proportion of American disabled by mental illness has risen so dramatically during this era of modern psychiatry? He cites as evidence data showing the proportion of Americans receiving SSI and SSDI due to psychiatric disability grew from 1.25 million (1 per 184) in 1987 to 3.97 million (1 in 76) in 2007. Whitaker augments this line of argument with epidemiologic studies of the course of illness in persons with psychosis in the US and in developing countries, where widespread psychopharmacologic treatment is not typical, suggesting that persons in the developing world experience, on the whole, better outcomes than in the United States. The well-known World Health Organization collaborative International Study of Schizophrenia found, for example, that persons in poor countries diagnosed with schizophrenia enjoyed significantly better outcomes in a broad variety of domains including symptoms, disability and social functioning.

Longitudinal studies of persons with schizophrenia in the United States permit comparisons between persons with varying exposure to antipsychotic medications. Here, again, Whitaker aims to demonstrate that more use of medication is associated with poorer outcomes. Although much of the evidence that he presents concerns psychotic disorders, Whitaker also focuses on anxiety, depression and bipolar disorder as well as childhood disorders such as ADHD.

It is this apparent paradox--more treatment and worse outcomes--that is the essence of the problem Whitaker aims to illuminate. He argues that the main driver of these adverse outcomes is the very treatments that the current consensus claims should mitigate these disorders. Noting that antipsychotics, antidepressants and other psychotropic drugs all operate by effecting neurotransmitter functions in the brain, Whitaker agrees with the scientific community that changes resulting from exposure to these agents reduces selected symptoms. It is the long-term exposure to these agents, he argues, that frequently leads to impaired functioning caused by adaptation of the brain to this altered neurochemical environment. Chronic exposure to psychotropic medications makes the brain function "abnormally" he argues, leaving people worse off than they might otherwise have been without the treatment. This claim, even if true for only a minority of persons receiving treatment, clearly would have dramatic implications for patients and professionals alike.

The strong reaction to this book is a story in itself. Controversy has raged all around, from reviews that consider his arguments to be "worryingly sane and consistently based on evidence" to those harshly critical of Whitaker's facts and conclusions. Whitaker's very appearance in professional gatherings has stimulated considerable controversy. At a SAMSHA-sponsored national conference in San Diego last year, he was first invited, then disinvited, then re-invited to deliver the keynote address. In Boston, he was confronted by Andrew Nierenberg, a clinical researcher who refuted his conclusions and who accused Whitaker of "gratuitous and misinformed attacks" on both the pharmaceutical industry and academic psychiatry and suggested that the book should include a warning label, saying "This book contains misinformation." He and Whitaker have tangled before. A somewhat more balanced assessment came from Dr. Dan Carlat, an author and psychiatrist who regularly blogs about ethics, conflicts of interest, and errant psychiatrists. An essay by another practicing psychiatrist was distributed to the assembly of the APA saying it had caused her "professional turmoil and consternation," and forced her to rethink many of the principles with which she was trained about family and community involvement, and to listen to more carefully to patients. To date little has appeared in the professional journals, whether by design or the notorious lag time for disseminating information in psychiatry, especially when the essence of their work is being put under a microscope.

Critics accuse Whitaker of failing to acknowledge other explanations for apparently increasing numbers of persons disabled by mental illness. Changes in federal disability insurance policy, they argue, contribute to this. They also argue that Whitaker confuses association with causation. Specifically, he interprets studies demonstrating poorer outcomes among people with histories of more psychotropic treatment as evidence for the deleterious effect of the treatment when it may simply reflect the fact that persons with more severe and chronic conditions tend to receive more treatment.

The association-causation conundrum is also relevant to Whitaker's claims that the significant brain differences observed between healthy people and those with severe mental illnesses (such as reduced gray and white matter volume in persons with schizophrenia, for example) are evidence, not for the impact of the disease process, but rather for the adverse impact of the medications used to treat the illness. This has proved to be a difficult question to study. A new paper by a prominent research psychiatrist, Nancy Andreasen and colleagues lends some credibility to the argument as do the conclusions of a recent comprehensive research synthesis on this question. However, it is also important to note that even if future research were to confirm the association between exposure to antipsychotic medication and reduced brain volume, it is not clear that these modest reductions necessarily correlate directly with impaired functioning in persons with schizophrenia.

Ethical concerns have largely constrained contemporary researchers from carrying out studies that would provide the most compelling evidence on questions critical to Whitaker's assertions. The design of the NIMH-sponsored RAISE study, in which I am a member of a team currently examining treatment for first episode psychosis, does not permit a systematic test of the impact of a no medication or delayed medication treatment strategy. However, there may be signs of movement in the way in which the psychiatric research establishment views this issue. A newly-launched Australian trial will vary treatment regimens to determine the impact of delaying the introduction of medication in some cases of psychosis.

It is important to note that while Whitaker aims to raise the alarm about the potential adverse effects of psychiatric medications, he's no Scientologist. He does not reject the entire psychiatric enterprise nor does he advocate that persons with mental illness should necessarily stop using medications. Whitaker acknowledges that medications may indeed alleviate symptoms and, for many, are indispensable elements in the process of long-term recovery. He argues for more judicious use of medications and close monitoring of adverse outcomes as well greater emphasis on the provision of empirically supported psychosocial interventions. In fact, this aligns well with current best-practice guidelines promoted by psychiatric experts.

Whitaker's unsettling thesis is certainly worthy of careful consideration and serious debate. The history of medicine and psychiatry in particular is replete with broadly accepted and applied treatments that were later found to be ineffective or harmful. Cynicism is apt to continue to grow as a result of ongoing revelations showing close ties between powerful commercial interests that develop and promote drugs used to treat psychiatric disorders and many of the investigators who evaluate them, making it critical that claims like Whitaker's are seriously considered. The need for well-designed research to provide solid evidence refuting or supporting his claims is clear.

*Daniel Herman, DSW, MS, is the Director of the ACT Institute for Recovery-Based Practice in the Center for Practice Innovations at New York State Psychiatric Institute where he is also an investigator in the Division of Mental Heath Services and Policy Research. He is an Associate Professor in the Department of Psychiatry at Columbia University.

email: dbh14 [at} columbia.edu

Comments (5)
Tim Shannon, ND:

Of the reviews I've seen about this book, this is perhaps one of the most evenhanded. The review is also interesting in that it reviews some of the controversy while offering no opinion on Whitaker's work.

Personally, I think at the very least, Whitaker's book helps to underline a very disturbing fact: Psychiatry is making serious mistakes. Even if many of Whitaker's assertions and research are incorrect, SOME of it most certainly is. in addition, whether or not it's true that the drugs are a primary cause of our current mental health epidemic, there's ample evidence to show it has SOMETHING to do with it.

In addition, psychiatry has done little to substantiate any of it's central tenets - with science. They are guilty of marketing themselves into this corner. It is their responsibility - to all of us - to come clean and show integrity.

Posted by Tim Shannon, ND | June 3, 2011 5:27 PM
Tony Foster:

I've been privy to one of Whitakers' seminars. You had mentioned in your review about the association/causal problem in Whitaker's research; that poor outcomes could be due to the fact that the particular group studied had more severe psychiatric symptoms and chronicity. Therefore, long term medication was utilized. This fleshes out the fact that, perhaps, it wasn't the medication that caused poor outcomes, but chronicity and severity of symptoms. What confuses me here is that if the studies that he quoted were random samples of people with mental illness, one arm being those who did not receive meds and those who did receive conventional treatment, what are the odds, statistically, that the group who received medication were all chronic and more severe than the other group??? If selected randomly, both experimental conditions had a reasonable chance of receiving a variety of people with varying levels of mental illness. If the former hypothesis is correct, what caused the medication group to have more chronic and severe cases than the group who did not receive any medication? Random sampling should have eliminated that. How often was this design replicated I wonder. He spoke of three or four studies of which I will further read.

Posted by Tony Foster | January 18, 2012 3:31 PM
Dan Herman:

Tony: your question is a good one and your logic is correct that in a randomized trial, variation in individual characteristics of participants in both arms of the study should be, on average, roughly comparable. The problem is that many studies in this area do employ random assignment. Specifically, one of the questions that Whitaker is most interested in: does long-term use of antipsychotic medications lead to less favorable outcomes, is one for which there are few if any randomized designs. Rather, most research has employed 'naturalistic' designs in which the outcomes of people with more limited antipsychotic use are compared to those with longterm use.

Posted by Dan Herman | March 15, 2012 10:57 AM
JC:

I get appalled by how many people believe that it's a valid argument to say that the reason the drug treated group is doing worse is because they were sicker to begin with and the reason why people on more drugs are even worse off than people on less drugs is because they are also sicker and therefore need more drugs.

There is no excuse for people working in the field of mental health not to know that illness severity has almost nothing to do with forced, coerced or encouraged treatment compliance. I worked as a mental health tech for 11 years and one of the things we had to teach family members in didactic groups is how the medications prevented relapse, how each relapse would cause their illness to become worse and more treatment resistant and how the overwhelming majority of mental patients who wind up in the hospital get there by feeling better and then deciding that they didn't need the drugs and so they stop taking them (which is true, but I knew nothing of psychiatric drug withdrawal at the time).

We encouraged family members to "tip furniture" (make up an incidence) whenever their ill family member decided to go off their drugs and it was actually in our training to do so. "Just call the police, say your daughter has stopped taking her medication and has threatened to kill herself and then go down there and write the petition."

Considering this, there are a lot of people trapped in the mental health system regardless of the severity of their illness. That 40% in Harrows study who got better off drugs had to not only stop taking the drugs but evade petitions and family members who would force them to take them. Let's also not forget that it's practically impossible to receive social services without taking the drugs.

People who argue that illness severity dictates long term treatment either don't work in the mental health field or are trying to deceive people. The aim is to put everybody on drugs and keep them on drugs no matter what, especially if they are doing perfectly fine at some point because they are expected to rapidly deteriorate without the drugs.

Lastly, Whitaker cites studies that address this problem. Harrows study did address prognosis and found that the better prognosis patients on meds were still doing worse than the bad prognosis off meds. Bipolar on meds was also doing worse than schizophrenia off meds and bipolar disorder is of course not supposed to be nearly as devastating as schizophrenia, especially not when disability is concerned.

The first studies done by the NIMH were randomized studies as well. Those put in the drug and placebo groups were completely random and yet those on drugs had a lower discharge rate and higher relapse rate.

Anybody who read Whitaker's book would know this. I am shocked at how frequently I keep hearing arguments toward Whitaker that are already defeated by the information in his book and the studies he references. It's frustrating.

Posted by JC | September 25, 2012 2:38 PM
JC:

Besides that, there is so much evidence on Whitaker's side that all hangs together so well even though it's coming from so many different angles. So many different types of studies from so many different generations from so many different parts of the world. Does anybody ever stop to think about just how ridiculously small the odds are that the conclusions from these studies could be wrong? If it were just one study or even just 10 of the same types of studies or even 20 studies done at the same hospital then I could understand the skepticism. But these are dozens of studies from all over the world spanning at least two generations. The odds that so many different studies could all come to the same conclusion (40+% of schizophrenia patients get better without somatic treatment) despite being ran by different people in different times with different biases for different reasons and still be wrong is just lower than low. Scientifically, I don't think it would even be considered much of a possibility let alone a probability. Yet as Whitaker has uncovered in his research, Psychiatry is not an honest science.

As Carl Sagan used to say, "extraordinary claims require extraordinary evidence" and now psychiatry has made some incredibly extraordinary claims. That they understand mental illness enough to justify changing the functioning of the bodies most important organ in order to treat it. Yet where is their evidence? Whitaker has made a very simple claim, one that many common sense lay people have been making for many years and he's got lots of evidence from within psychiatry's own research to back it up and yet psychiatrists, bought and paid for by big pharma while fighting for a pseudo scientific ideology, choose to be skeptical at best and sometimes even hostile toward his work.

Put it this way, psychiatry gets a brain scan showing that boys with ADHD who are on average two years younger than boys without ADHD have smaller brains, they issue press releases and make the study famous all while failing to inform the public that the ADHD boys were younger so of course their brains would be smaller. That's all that anybody needs to know about psychiatry. That actually happened.

Posted by JC | September 25, 2012 2:58 PM
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