Nurse Ratched with Footnotes
A review of Mad in America: Bad Science, Bad Medicine, and the Enduring Mistreatment of the Mentally Ill, by Robert Whitaker

Reviewed by Dr. E. Fuller Torrey

(Review of “Anatomy of an Epidemic by Robert Whitaker follows 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

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.