4 Reviews of Psychiatry Under the Influence, Mad in America and Anatomy of an Epidemic by Robert Whitaker
Mad in America: Nurse Ratched with Footnotes
Reviewed by Dr. E. Fuller Torrey
Reviews of "Anatomy of an Epidemic" and "Psychiatry Under the Influence", both by Robert Whitaker follow this review)
"...given Whitaker's writing skills, it is unfortunate that he did not turn his attention to one of the many real problems in American psychiatry, such as for-profit managed care, Medicaid rip-off, the excess influence and profits of the pharmaceutical industry, or the tragedy of untreated seriously mentally ill individuals on the streets and in jails."
"Histrionic" is perhaps the kindest adjective that can be used to describe Robert Whitaker's new book on American psychiatry. "Deeply disappointing" would also be appropriate, since Whitaker has heretofore been known as a serious medical writer for the Boston Globe. Mad in America, however, rarely ascends to the level of that newspaper; rather, it mostly descends to the level of the tabloid Globe, available at supermarket check-out counters.
The first half of the book recounts the history of psychiatric treatment in America until 1950. This was the era of Benjamin Rush's spinning chair, eugenics, forced sterilization, the removal of teeth, and lobotomies. It is a sad history that has been described in less overwrought tones in books such as Daniel Kevles's In the Name of Eugenics, Sander Gilman's Seeing the Insane, and Gerald Grob's Mental Illness and American Society 1875-1940. Whitaker, by contrast, approaches his subject as did Ken Kesey in One Flew Over the Cuckoo's Nest, and the result is Nurse Ratched with footnotes. Nowhere does Whitaker acknowledge that these approaches to treatment were measures of desperation in desperate times. The nation's overcrowded psychiatric wards were filled with continuously increasing numbers of very psychiatrically ill patients for whom no effective treatments were available.
The second half of the book describes the use of antipsychotic drugs to treat schizophrenia. Whitaker, however, appears unsure whether schizophrenia even exists, describing it as a term "loosely applied to people with widely disparate emotional problems." At some points in the book, he appears to have even bought Thomas Szasz's myth-of-mental-illness nonsense: "American medicine, in essence, had developed a process for minting 'schizophrenics' from a troubled cast of people…" Nowhere does Whitaker include references to the many studies showing structural brain abnormalities, neurological abnormalities, and neuropsychological deficits in individuals with schizophrenia who had never been treated with any medication.
Whitaker has nothing good to say about antipsychotic medications. He calls them "not just therapeutically neutral, but clearly harmful over the long term" and claims that the drugs themselves cause many of the symptoms of schizophrenia. Like Scientologists and other antipsychiatry groups, Whitaker exaggerates the adverse effects of antipsychotic drugs, saying, for example, that tardive dyskinesia occurs "in a high percentage of patients." He also includes statements that are patently erroneous. For example, he claims that "even moderately high doses of haloperidol were linked to violent behavior," when, in fact, studies have shown that haloperidol and other antipsychotics decrease violent behavior in individuals with schizophrenia. Many of Whitaker's errors originate in his liberal footnoting of Dr. Peter Breggin, who has acknowledged having received support from Scientology, as a source.
In place of antipsychotic drugs, Whitaker extols the virtues of "love and food and understanding, not drugs." Like many antipsychiatry advocates, Whitaker romanticizes the early eighteenth-century era of "moral treatment" in which psychiatric patients were humanely treated. At that time, claims were made for impressive cure rates, culminating in 1843, when Dr. William Awl, director of an Ohio asylum, announced that he had achieved 100 percent recoveries; thereafter he was known as "Dr. Cure-Awl." The failure of "moral treatment" alone as a cure for insanity was clearly established in 1876 by Dr. Pliny Earle, who showed that the prior claims had been highly exaggerated. Whitaker highly praises the more recent version of "moral treatment," Soteria House, started by Dr. Loren Mosher. Mosher was a protégé of Dr. Ronald Laing's, and Mosher's experiments, like Laing's along these lines, have all passed into history because they failed.
In a similar vein, Whitaker discusses at length the WHO multi-center schizophrenia study that reported that individuals from developing countries (Nigeria, Colombia, India), "where such medications are less frequently used," had a better outcome than did individuals in developed countries. In fact, the study reported that the percentage of chronically disabled patients was similar in all the countries. What did differ was the percentage of complete cures-40 percent in developing versus 25 percent in developed countries. As has been widely discussed, the fact that more patients in the developing countries had a very acute onset of their illness suggests that many of them probably had a reversible viral encephalitis or other organic cause of their schizophrenia-like symptoms and thus had better outcomes.
Despite its major shortcomings, Mad in America is not without merit. Chapter 11, on the problems in the clinical trials industry, reflects the author's considerable prior expertise in this area. Indeed, he could have profitably written the entire book about this. And given Whitaker's writing skills, it is unfortunate that he did not turn his attention to one of the many real problems in American psychiatry, such as for-profit managed care, Medicaid rip-off, the excess influence and profits of the ''
Book Review: Anatomy of an Epidemic (Robert Whitaker)
by DJ Jaffe
What's amazing about Anatomy of an Epidemic: Magic bullets, psychiatric drugs, and the astonishing rise of mental illness in America (2010, Broadway Paperbacks) is how it can go from sheer brilliance to sheer lunacy within the same page. And it does so repeatedly with a preponderance of brilliance early being replaced by lunacy as one goes further into it. Rather than writing from a scientific perspective--gather facts and follow to a conclusion--Mr. Whitaker wrote like a lawyer: decide conclusion, then ignore facts contrary to conclusion. Among the facts he ignores are people with severe mental illness in jails, in prisons, homeless and psychotic. They don't appear anywhere in his narrative. The people in his narrative--like people everywhere since time immemorial--have "trauma" in their past. The relevancy of that is never explained.
Mr. Whitaker's pre-determined narrative is that medicines 'may' (a reluctant 'may') work short term, but are definitely long term failures and that medicines are the primary cause of the alleged 'epidemic of mental illness'. His book contains numerous slights of numbers.
As proof of an epidemic he suggests that if medicines were so wonderful now, then incidence of mental illness would go down, not up. That would be true, but as he brilliantly documents elsewhere, we are diagnosing more and more forms of normalcy as illness and lowering the bar as to what is needed to get a diagnosis. For example, years ago, you practically had to be hospitalized to get a diagnosis of bipolar. Today, it's available to anyone with insurance. What we are likely experiencing is an epidemic of over-diagnosing, not an epidemic of illness.
To support an 'epidemic' he compares the number of mentally ill hospitalized in past, with number on Social Security Disability Income (SSDI) today. Not exactly apples to apples. If you compare hospitalization rates years ago, to today (apples to apples) there are fewer in hospitals (re: deinstitutionalization). Although more in jails.
He compares numbers of individuals mentally ill in past with numbers today, without adjusting for population increases.
He cites studies that people who went off medicines did better than those who stayed on without ever considering that those who stayed on may have stayed on because they were sicker. To Whitaker, the fact that people on, say chemotherapy are sicker than those not on chemotherapy is a sign that chemotherapy doesn't work.
He does a credible job of questioning the serotonin and dopamine hypothesis but then concludes because those particular theories are still unproven, mental illness is not a brain disease. Is the brain the only organ in the body that can never get diseased or malfunction? Apparently, Whitaker thinks "yes".
He credits an antipsychiatry group for discovering through a hunger strike that mental illness is not biological. Apparently the lack of a diagnostic test bothered them. This is akin to saying colon cancer didn't exist before the invention of the colonoscopy. As further proof of their discovery, he points out that someone didn't answer a letter they wrote.
He finds methodological fault with almost every study that supports the benefits of medication and no faults with those that don't. He properly worships the "double-blind, active placebo" study except when he wants to show talk therapy works and then any study will do.
He fails to highlight the most obvious short-coming of the long-term retroactive studies he quotes: i.e., that individuals who suicide, are incarcerated, hospitalized, homeless or missing are rarely still in a study at the end point and therefore it may be the higher functioning who are really being studied.
He highlights how medications may change brain structure but fails to report on research showing brain structure changes also appear in people with mental illness never medicated. No one knows if the brain changes in people medicated are due to a medications beneficial efficacy or an unwanted side-effect, a fact Whitaker ignores.
Other books, most notably, The Invisible Plague by Dr. E. Fuller Torrey and Judy Miller have done a much better job at documenting the increase in mental illness. That particular book focuses on schizophrenia and posits that the increase is due to viruses; a cause Mr. Whitaker ignores altogether. And while Whitaker does a good job of showing institutional connections between Big Pharma and psychiatry, Dr. Torrey did this in 2002.
In the beginning, Whitaker dances around the subject of whether mental illness exists, but later seems to come down on the 'no' side. He engages in creative semantics to avoid admitting medications can help people. He claims medicines 'perturb' normality. By the logic of the book, if someone is born missing a leg, and a medication can restore the leg, that medication 'perturbs normality' rather than cures a missing leg. Contrary evidence is usually ignored or at best, footnoted.
It is easy to go page by page and find fault with this book. Especially after it gets to the "Scientology to the rescue" section. And yet the book also has moments of sheer brilliance. It is a shame that those were subsumed ("perturbed") by the quackery.
The book does a brilliant job at showing how we are medicalizing normalcy. As Whitaker wrote:
Not too long ago, goof-offs, cutups, bullies, nerds, shy kids, teachers pets, and any number of recognizable types filled the schoolyard, and all were considered more or less normal...But today, children diagnosed with mental disorders--most notably, ADHD, depression and bipolar illness,--help populate the school yard.
He painstakingly documents how one had to be highly symptomatic to be diagnosed with certain conditions in the past and be barely symptomatic to get the same diagnosis today. It's powerful stuff. It also begs a question: If we are diagnosing normalcy as illness and then treating it with medications, could that account for the medications being less effective than expected? If you "treat" someone who wasn't ill, the "treatment" won't work because nothing had to be fixed to begin with. Wouldn't those 'failures' would lower the overall efficacy of medications.
The book does brilliant job of showing how we permanently medicate episodic illnesses As Dr. E. Fuller Torrey pointed out in Surviving Schizophrenia not everyone affected by schizophrenia is permanently affected. Some have a single episode and are never affected again. Some are episodically affected and some are permanently ill. This is true for many other illnesses as well. Yet standard procedure for mentally ill seems to be "once medicated, always medicated'. This book highlights the issues with that.
The book shows the institutional connections between American Psychiatric Association, NAMI, and PharmCos. While many (self included) have documented isolated discrete incidents of this alliance impeding good care, Whitaker does a better job at showing the institutional connections between the organizations, not just the single company or single doctor or single illness connections.
Anatomy of an Epidemic could have been one of the great books because many these points he makes are important and haven't been documented with such clarity before. Unfortunately they are too obscured by the anti-medication crusade make this a worthwhile read for the uninformed.
Anatomy of an Epidemic is further proof, the mental illness narrative in America falls into two main storylines, psychiatry and antipsychiatry.
Antipsychiatry groups deny mental illness exists. And whatever does exist, is not medical in nature. Psychiatry groups represent the other extreme: they believe almost everything is a mental illness and up to 50% of people had a "diagnosable" mental disorder during their life.
What's needed is a middle ground that accepts the antipsychiatry mantra that we have medicalized everything, and their devotion to confronting abuse, but rejects their position that mental illness does not exist. A philosophy that embraces holding a microscope to the medical/pharmacological/mental health complex; but is grounded in science.
A philosophy that accepts pro-psychiatry philosophy that mental illness exists, and medications can work, but rejects their philosophy that everything is a mental illness and deserves equal funding.
Mr. Whitaker comes close to delivering that, but can't bring himself to the table.
Mad in America: Bad Science, Bad Medicine, and the Enduring Mistreatment of the Mentally Ill
Reviewed by Zebulon Taintor, M.D.
Psychiatric Services 2003; doi: 10.1176/appi.ps.54.1.112-a
View Author and Article Information
by Robert Whitaker; Cambridge, Massachusetts, Perseus Publishing, 2002, 334 pages, $27
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Editor's Note: Two different perspectives on a controversial book, Mad in America: Bad Science, Bad Medicine, and the Enduring Mistreatment of the Mentally Ill, are included among this month's book reviews.
This book is an antineuroleptic and generally an antipsychiatry polemic, with some bright spots. I should have been a good reviewer for Mad in America, given that I haven't accepted an honorarium from a drug company since 1995, I promote psychiatric rehabilitation, and I regret that more money is spent marketing medications than on research. However, the title of the book implies a broad perspective that is sorely lacking. Instead, the author moves along a narrow focus on treatments that psychiatry has long since discarded to argue that neuroleptics are the logical endpoint of "bad science, bad medicine, and the enduring mistreatment of the mentally ill."
The treatments from 1750 to 1950 are described as asylum care evolving into eugenics and segregation of people with mental illness, as efforts to reduce patients' intelligence, and as causing brain damage. Only moral treatment is described positively, for its humanity and humility. The books I use in teaching a historical perspectiveâ€"The Discovery of the Asylum (1) and Madness and Government (2)â€"are not mentioned, and describe this era quite differently. The era since 1950, where I use Madness in the Streets (3), is headed "Back to Bedlam" in Mad in America.
Whitaker argues that evidence shows that people with schizophrenia do better without taking neuroleptics. This assertion rests on data from the World Health Organization, Courteney Harding's studies, and Soteria. Much is made of the WHO international pilot study of schizophrenia without consideration of the follow-up studies that have concluded that the outcome of schizophrenia is not better in developing countries. Despite cultures that often are more supportive than those of developed countries, poverty of individuals and poverty of service systems combine to produce results that are documented in the background reports produced for World Health Day in 2001 and published as the World Health Report 2001: Mental Health: New Understanding, New Hope (4).
Whitaker omits literature that shows positive effects of neurolepticsâ€"only lithium and venlafaxine are mentioned anecdotally. He uses quotes out of context to make psychopharmacologists sound opposed to medication. He argues, in effect, that had the Food and Drug Administration paid attention to the data submitted, it would never have approved neuroleptics: "Evidence that neuroleptics were making people chronically ill showed up fairly early." A reader comes away with the idea that neuroleptics are prescribed only because drug companies market them well.
The book's best chapter is on the excesses of recent psychopharmacologic researchâ€"for example, the case of Richard Borisonâ€"and the hyping of the more recently developed antipsychotics.
Dr. Taintor is affiliated with the department of psychiatry of New York University Medical School in New York City.
Rothman DJ: The Discovery of the Asylum: Social Order and Disorder in the New Republic. Boston, Little, Brown, and Company, 1971
Foley HA, Sharfstein SS: Madness and Government: Who Cares for the Mentally Ill? Washington, DC, American Psychiatric Press, 1983
Isaac R, Armatt E: Madness in the Streets: How Psychiatry and the Law Abandoned the Mentally Ill. New York, Free Press, 1989
World Health Report 2001: Mental Health: New Understanding, New Hope. Geneva, World Health Organization, 2001
Review of Psychiatry Under the Influence: Institutional Corruption, Social Injury, and Prescriptions
by Robert Whitaker and Lisa Cosgrove. Review by DJ Jaffe
Psychiatry Under the Influence: Institutional Corruption, Social Injury, and Prescriptions for Reform by Robert Whitaker and Lisa Cosgrove aspires to be an important book, but is a misleading one that covers little new ground. The authors repeat the oft-told story of the American Psychiatric Association (APA) claiming it knows the cause of mental illness, creating a Diagnostic and Statistical Manual (DSM) that sometimes defines essentially normal people as being ill, medicines not working for those normal people and wraps it in a narrative that claims the APA does this to create jobs for members and because it is under the influence of pharmaceutical company money. The practice of pharmaceutical companies paying psychiatrists for bad research and then leveraging it in marketing campaigns designed to get normal people to buy their medications is an important story that the authors do try to tell. But because they include any snippet of a fact to support their case, exclude so many other interpretations and facts, and largely ignore serious mental illness, Psychiatry Under the Influence misses its mark.
The story of the DSM defining some normal people as having an illness was previously well told by Dr. Allan Frances in Saving Normal. In DSM 5, some barely symptomatic normal people, especially children, now qualify for a psychiatric diagnosis--often minor depression, anxiety, or ADHD. Cosgrove and Whitaker repeat this. They also go further. Because two doctors can look at the same patient and not agree on the diagnosis, they seem to suggest all mental illness, including serious mental illness does not exist. Nonsense. DSM is clearly an inadequate tool to differentiate two similar illnesses, but serious mental illnesses do exist, psychiatrists can treat them, and the medications--side effects not withstanding, do help. They hurt their arguments by their failure to explicitly recognize the existence of serious mental illness and its devastating impact on those who have it.
The story of psychiatry getting the cause of mental illness wrong was recently well documented by former APA President Dr. Jeffrey Lieberman in Shrinks: The Untold Story. Lieberman focused on the failure of Freudian theories to explain illness, while Cosgrove and Whitaker focus on the failure of the serotonin theory to explain depression. The serotonin theory--and it was always a theory--may not have withstood the test of additional research, but the neural connective pathways that serotonin effects are still thought to be involved in depression, as are genetics. We simply don't know enough yet. Brain imaging is still in its infancy and we can't remove live brains to analyze them. Psychiatry Under the Influence uses the fact that the exact causes of mental illnesses are not yet known to position mental illnesses as being neither chemical imbalances, diseases, disorders, illnesses, or medical. It's a claim that few who have met people with serious mental illness, or suffer from serious mental illness would make.
One part of the book does deserve wider attention. It is the authors' documentation on how pharmaceutical company-funded medication studies and abstracts play up the positive findings and minimize the negative. They provide good examples of pharmaceutical companies, aided and abetted by psychiatrists, mining the data: reexamining it after it is in to find some obscure positive result to report--a process the authors describe as being akin to throwing a dart at the wall and drawing a bulls eye around it after it has landed. "Torture the data enough and it will confess to anything." It's good stuff. But to make the point, the authors do the exact same thing they criticize: reanalyze studies to come to the conclusion they want. For example, the authors spend multiple pages examining the efficacy of a particular class of depression medicines, SSRIs, and find them wanting. But buried in the text is the line it "was only for severely depressed patients...that the SSRIs had provided a benefit." And elsewhere, they report "True drug benefits were nonexistent to negligible among depressed patients with mild, moderate and even severe baseline symptoms, whereas they were large for patients with very severe symptoms."
That's the honest narrative the authors should have followed: antidepressants don't work in people who do not have major depression, but do work in those who do. And while minor mental illness may be invented, serious mental illness is not.
When Psychiatry Under the Influence turns to serious mental illness, it does a good job of showing how pharmaceutical companies mismarketed new generation atypical antipsychotics as being superior to haloperidol (Haldol). But the efficacy of haloperidol itself in helping people with schizophrenia, or lithium in helping people with bipolar, is not highlighted, presumably because it would destroy the narrative that mental illnesses are made up and medicines don't work. Likewise, the authors largely ignore the fact that atypicals are less likely to cause tardive dyskinesia, which makes them a worthy alternative for some, even if their efficacy is not superior to other medications and they have side effects of their own. They tell how antipsychotics "shrink" brain tissue, but people with schizophrenia who have never been medicated also experience this change. They also fail to state that changes in brain structure may be why medicines work, not a sign of a problem.
The section on solutions suggests reducing the influence of pharmaceutical companies by pooling research dollars and blinding researchers as to who is funding their research. That's a neat idea. But the authors also argue psychiatry should "share authority over 'psychiatric problems' with other parties, such that its voice becomes one among many, rather than the ruling one." That would compound the problem not fix it. Other groups that want to "share authority" over psychiatry define mental illness far more expansively than the APA, and their proposed treatments are even more dubious. One major group believes anyone who has a "lived-experience" is worthy of support from public mental health dollars. Their suggested fix for "lived-experience" is "Emotional CPR," a pop-psychology educational program the organization describes as a "Tool of Peacekeeping and Bringing Healing to Communities" based on the idea that "inner peace creates global peace." Is that what we want the purview of psychiatry to become? Creating inner peace for all rather than helping people with schizophrenia? As the Director of the National Institute of Mental Health, Dr. Tom Insel, told a recent conference, there is no oversight of psychotherapies, so anyone can claim they have one that works. These groups should definitely not be given authority over psychiatry.
DJ Jaffe is Executive Director of Mental Illness Policy Org and author of the upcoming book, How the Mental Health Industry Kills the Seriously Mentally Ill: A Handbook for Change.