January 7, 2012

Anatomy of an Epidemic

“This is the most alarming book I’ve read in years,” wrote Carl Elliot, MD, PhD (professor, Center for Bioethics, University of Minnesota), reviewing Anatomy of an Epidemic by Robert Whitaker.  I agree wholeheartedly.  Not disturbing like clowns, but more like the truth-behind-the-collapse-of-the-economy kind of disturbing.  This is one of those books that gets under your skin and profoundly changes the way that you look at the world, or at least my world, the world of modern psychiatry. You cannot come away from this book unchanged.   Anatomy of an Epidemic is an essential read for anyone in mental health- on both ends of the continuum from prescribers to consumers.  Actually, given the vast reach and breadth of psychopharmocology’s influence, I would venture to say that this book is essential reading for everyone, since everyone is bound to know someone under the influence, as it were, and the deceptions revealed in this book are likely not limited to the psycho/pharmaceutical industry.

Robert Whitaker is a journalist and founder of CenterWatch, a publishing company that reports on the business aspects of clinical testing for new drugs.  With this book he set out to examine why, in the presence of the greatest drugs in the history of mental health care, are there more people disabled by mental illness than ever before.  His quest began when he uncovered two studies that were anathema to his former view that antipsychotics for treating schizophrenia were like insulin for diabetics: one was a 1994 based Harvard study indicating that schizophrenia outcomes had worsened over the previous 2 decades and were no better than a century before; the other was from the World Health Organization indicating how schizophrenia outcomes were better in poorer countries, where it turns out only 16% o patients remain on antipsychotic medications.

Unfortunately, what he unearths is a widespread deception on the part of psychiatric institutions, like the American Psychiatric Association, and the pharmaceutical industry to perpetuate the myth of mental illness as a “chemical imbalance” and modern mental health care, i.e. psychiatric medications, as the magic bullet to restore balance.   What he finds in exhaustively combing through the literature is that there is no real basis for the “chemical imbalance” theory and, ergo, the justification for psychotropics to bring the balance back.   In fact, time and again, the prolonged use of psychotropics has been associated with illness exacerbation and chronicity.  By and large, medications are the root of disease chronicity, not the underlying disease itself.  The epidemic is almost entirely iatrogenic.  Benzodiezepines for anxiety, antidepressants for depression, mood stabilizers for bipolar, neuroleptics for schizophrenia, psychostimulants for ADHD- they all help ameliorate symptoms acutely, but worsen the course of the illness in the long run through compensatory neuro-adaptation in the brain. In other words, medications end up causing the “imbalance” for which they are initially prescribed, making the brain function “qualitatively as well as quantitatively different from the normal state,” as Steve Hyman, provost of Harvard University and former NIMH director, put it  (p.83).  Short-term studies, which are the ones used to clear a drug by the FDA, are HEAVILY biased in favor of the medications.  Study counter-measures to bias against placebo and treatment cessation- such as rapid discontinuation from a medication and the subsequent rebound effect- i.e. symptom resurgence- (think of driving with your foot on the brake and the gas at the same time and then abruptly releasing the breaks), and even negative study suppression,  are then used to argue that illnesses are chronic and the medications are needed for the rest of the patient’s life.  Illnesses that were formerly mostly self-limited– which actually include depression, bipolar and schizophrenia- are now deemed chronic conditions in need of continuous psychopharmacological care. When long-term follow-up studies were actually completed, the groups that faired the best were those not exposed to psychiatric medications.

Fortunately, he concludes the book with some hope in the form of solutions beyond medications, like a hospital in Turku, Finland with their “need-adapted” treatment of psychotic patients via group-family therapy and “psychosis team” interventions- highlighting some intrepid explorers on the frontiers of mental health care willing to think outside of the (sub)standards of care to provide hope and healing.   Although he did not touch on orthomolecular psychiatry and the use of micronutrients for mental health care, his solutions beyond medications merit consideration, especially when one consider the Hippocratic creed to do no harm.

As I said, this book is disturbing and you cannot come away unchanged.  Whitaker makes a well researched, cogent argument linking psychiatric medications to disease chronicity.  This topic is obviously highly complex and highly contentious. And certainly, some people function better on medications and need them to survive.  However, I do think that his hypothesis merits serious consideration.  If Whitaker’s premise is true, we students of modern psychiatry have been duped and our educational institutions have been co-opted, the standard of care models which outline our treatment paradigms must be jettisoned, and we must see again with new eyes just what we are doing to treat mental illness and what it means to care.