Anatomy of an Epidemic

Whitaker, Robert. Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America. New York: Broadway Books, 2015.

The controversy over psychiatric drugs is becoming considerably more heated. A January study showed a negligible difference between antidepressants and placebos in treating the most severe cases of depression. The value of psychiatric drugs has even been the subject of debate in the New Yorker. Robert Whitaker’s Anatomy of an Epidemic is a comprehensive and highly readable history of psychiatry in the United States. Whitaker researches fifty years of literature and conducts in-person interviews with patients suffering severe mental illnesses in order to get at his main argument, which can be broken down into the following four points:

Over the past couple of decades, many new and supposedly more effective psychiatric drugs have been introduced on the market.
If these drugs are so effective, you would think that the rate of those on psychiatric disability would have declined over this period, but in fact, the opposite has happened to an alarming degree.
There are some poorly publicized studies that patients with severe mental illnesses actually fare better when they do not take any psychiatric drugs.
Therefore, it is reasonable to conclude that psychiatric drugs are actually bad for many people, especially when taken for long periods of time.

Whitaker’s thesis is that mental illness has become more prevalent since the 1950s biological revolution in psychiatry, and that modern psychiatric drugs are to blame. He argues that from mood disorders and anxiety to schizophrenia, our current psychiatric medications are actually causing patients to develop more severe and chronic forms of their illnesses. He notes that some of these drugs have demonstrated a short term efficacy, but some are no better than placebos. But it is really the long term effects of these medications that concerns him. He believes that over extended time, our brains are irreversibly changed and damaged from psychiatric medications in ways that turn episodic and potentially manageable disorders into severe and chronic disabilities.

The idea at first seems implausible and goes against everything we have learned from the development of medications in psychiatry. Many doctors and patients fiercely defend psychiatric medications and their ability to improve the lives of those dealing with severe mental illness. If we are to believe now that the drugs we are taking are not just ineffective, but physiologically damaging to our brains, then that is a matter of extraordinary importance. So that begs the question, how persuasive is Whitaker’s evidence? It turns out, there are a lot of problems with his argument:

One problem is that many studies accessing drugs versus placebos do not follow patients over periods of years. So right off the bat we are lacking evidence on the long term effects of antidepressants, anti-anxiety medications, and antipsychotics. As a result, Whitaker turns to a variety of observational studies and examines the correlation between medications given to patients and their long term outcomes. However, we might logically assume that the sicker a patient is, the more likely they are to be medicated, so this would reasonably leave us to imagine worse outcomes for those medicated, even if the medication does not cause the outcomes. The lack of strong evidence available on long term effects and Whitaker’s occasional lapses of objectivity in his interpretation of the data, make it impossible to draw firm conclusions.
Furthermore, Whitaker’s narrative is that medications “may” (a reluctant “may”) work short term, but are definitely long term failures and that these medications are responsible for the epidemic of mental illness in the United States. As proof of the epidemic, he suggests that if medications work so magically now, then the incidence of mental illness should be decreasing rather than increasing. But as he documents elsewhere in his book, we are currently diagnosing more and more forms of normalcy as mental illness and lowering the bar needed to get a diagnosis. For example, it is easier to get a diagnosis of an affective mood disorder now than it was back when one most likely needed to be hospitalized first. Therefore, what we are experiencing is most likely an epidemic of over-diagnosing and not an epidemic of mental illness. Additionally, his conclusion that psychiatric medications have caused a rise in disability claims ignores the complexity that accounts for psychiatric disability. To prove the drugs cause disability, multiple factors need to be considered. It is equally possible that sociocultural stressors such as the increased economic disparity between the wealthy and the poor, the reduced stigma of mental illness, and changes in the definition of disability have resulted in the reported increase in psychiatric disability claims.
Whitaker also compares the number of mentally ill individuals hospitalized in the past with the number of mentally ill on Social Security Disability Income (SSDI) today. This is comparing oranges to apples. An apples to apples comparison would be to look at the number of those hospitalized in the past to those who are hospitalized today. There are clearly fewer in hospitals today due to deinstitutionalization. Many of those who belong in hospitals are likely in jails, prisons, or homeless.
Whitaker concludes that psychiatric drugs overall may be doing more harm than good to people. Using studies from prominent medical journals, he cites studies that people who went off their medications often fared better than those who stayed on their medications. Except he does not consider the possibility that those who stayed on their medications may have done so because they were sicker. By Whitaker’s logic, the fact that people on chemotherapy are sicker than those not on chemotherapy is evidence that chemotherapy does not work. He also argues that psychiatric medications permanently change the brain structure of those who are taking them long term and yet he fails to report on research showing brain structure changes also appear in people with severe mental illnesses.

In the beginning, Whitaker seems to dance around the question of whether mental illness exists, but later seems to come down on the “no” side. His anti-medication and anti-psychiatry crusade seems at times to be overzealous and overpowering to the point where he seems to make sweeping generalizations. Most notably, he avoids admitting that psychiatric medications can help people, which is a huge oversight.

As was the case with Mad in America, while this book is quite faulty at times, it also has its points of brilliance. The first of which is demonstrating how we are now in the habit of 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. (p. 10)

His discussion on children forces us to examine how psychiatry has been recklessly over-medicating the very young. The book also powerfully shows the institutional and financial connections between the American Medical Association, the American Psychiatric Association, NAMI, and pharmaceutical companies. He convincingly questions the theory of chemical imbalance that has come to characterize mental illness and does a very detailed and persuasive job of questioning the serotonin and dopamine hypotheses. Most importantly, he draws attention to how little we know about the long term effects of psychiatric medications on people. This in itself should give us pause about our current paradigm of medication-based care for mental illness and whether the medication path is the only right way forward. But I certainly think it is a right way.

As someone who is mentally ill and takes many of the drugs that Whitaker disparaged, I see things very differently. I have schizoaffective disorder (a combination of schizophrenia and bipolar disorder). I was diagnosed with the disease last year, but have probably had it starting in my early 20s. I was beset by mania, depression, and psychosis. I heard loud, terrifying voices that threatened to kill me. They sounded just as real as any voice I had ever heard in my life. They tortured me all day and I was at times completely disabled by them. I was a bright young woman with a great education, a supportive family, yet I could barely leave home. I could not develop meaningful relationships with people. My parents became my caretakers and many of my friends left completely. Despite my family’s support, I felt utterly alone. Last year, I began a course of different antipsychotics and they worked to a degree, but the voices were still with me. Despite my family’s support and love, it did not “heal” me. Geodon, the antipsychotic I am on right now, has been a godsend. The voices I once heard regularly are few and far between now and when I do hear them, they seem less real. I have been on drugs in the past and have reeled from the bad side effects, ranging from akathisia to major sedation to weight gain. But now that I have found a medication that works, I am more productive and functional than I have been in years. The pharmaceutical industry restored my sanity and saved my life. It didn’t work on the first try or even the second, but my doctor and I persevered. I am no longer afraid to leave my house and I am in graduate school and have friends and a social life again. This may not sound exceptional to a normal person, but it means the world to me. I don’t think any of this would be possible without the drugs that I take. I think one of the fundamental differences between Whitaker and myself is what constitutes a “positive outcome” for people like me. For me, a positive outcome is that the voices and the delusions go away. I think this would be a positive outcome for a lot of people suffering from schizophrenia or schizoaffective disorder. I have never heard of this happening without the use of medication.