Monday, May 3, 2010

"Anatomy of an Epidemic" or The Same Story Told Over and Over Again

On Salon.com, there is an interview with Robert Whitaker, the author of Mad in America, about his new book titled "Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America."

The article/interview at Salon is devoid of any context:
"In the past few months, the perennial controversy over psychiatric drug use has been growing considerably more heated. A January study showed a negligible difference between antidepressants and placebos in treating all but the severest cases of depression. The study became the subject of a Newsweek cover story, and the value of psychiatric drugs has recently been debated in the pages of the New Yorker, the New York Times and Salon...The timing of Robert Whitaker’s "Anatomy of an Epidemic," a comprehensive and highly readable history of psychiatry in the United States, couldn’t be better."
That study in JAMA is hardly a first (1, 2, 3), nor is Mr. Whitaker's book a first (4, 5, 6, and anything written by Peter Breggin). Timing couldn't be better? Sure, if by timing you mean, when can one cash in on anti-psychiatry sentiment.

I have not read this book. I did read his previous book, Mad in America, which surveyed the history of the treatment of mental illness in American and the rise of psychiatric drugs. Based on that book, which was sensationalistic and misrepresented research, I think I know what to expect in his new book. My focus, instead, will be on his interview. Comments in red.
"Psychiatric drug use is a notoriously tough subject for writers, because of all the contradictory research. Why wade into it? In 1998, I was writing a series for the Boston Globe on abuse of psychiatric patients in research settings. I came across the World Health Organization’s outcomes study for schizophrenia patients, and found that outcomes were better for poor countries of the world -- like India, Colombia, Nigeria -- than for the rich countries. And I was startled to find that only a small percentage of patients in those countries were medicated. I also discovered that the number of people on disability for mental illness in this country has tripled over the last 20 years..."
 He doesn't provide an actual number for "only a small percentage of patients." However, according to the Worldwide-Schizophrenia Outpatient Health Outcomes (W-SOHO;7), which surveyed Europe, Asia, Africa, and Latin America, it revealed that a not so small 40% of patients where on antipsychotic medications. The real differences between rich and poor counties is that patients in developing countries were primarily on first generation antipsychotics (60%) and on monotherapy (75%). The reasons for outcome differences are many.
"...If our psychiatric drugs are effective at preventing mental illness, I thought, why are we getting so many people unable to work?"
I don't think anyone of real importance claimed that psychiatric drugs were aimed at "preventing mental illness." Again, there is no context. For example, one explanation for the increase of those on disability is that entitlement programs have increased their coverage over the years to include those with mental illnesses.
"What's so risky about Ritalin? For one, a significant percentage -- between 10 and 25 percent -- of kids prescribed medication for ADHD will have a manic episode or psychotic episode and deteriorate in such a way that they’re diagnosed with bipolar disorder..."
He is misrepresenting the data. That study (8), examined the comorbidity of ADHD and mania, not the association of stimulant medication use and risk of mania. It's quite possible that those who eventually develop bipolar disorder have an ADHD appearance during childhood.
"But if these studies are so groundbreaking, why have they gone unreported in the media? Because the NIMH didn’t announce it. Just as they didn’t announce the 2007 outcome study for schizophrenia patients. In that study, the recovery rate was 40 percent for those off meds, but only 5 percent for those on meds. I checked all the NIMH press releases for 2007, and found no release on this study. I found no announcement of it in any American Psychiatric Association publication or textbook. Not a single newspaper published an account of the study. And that’s because the psychiatric establishment -- the NIMH, the APA, even the National Alliance on Mental Illness, an advocacy organization -- did not put out any press release about it or try to alert the media in any way."
Either he's lying or had a lobotomy. I have reviewed that study as well as it's follow-up (9). Here is what the researchers actually discovered :
"Looking at it from a different viewpoint, the data suggests that schizophrenia patients with good prognostic features, with better premorbid developmental achievements and with more favorable personality characteristics are the subgroup more likely to stay off antipsychotics for a prolonged period"
That's why the NIMH, APA, and NAMI didn't sound the alarm about that supposed discovery. Here's another way to highlight the absurdity of his conclusion: Two women have been diagnosed with breast cancer. One has a strong family history of breast cancer and tested positive for the BRCA gene (i.e., she has a poor prognosis). The other woman has no family history nor the BRCA gene. Both were treated with chemo. One recovered quickly stopped treatment. The other woman, while still being treated, died. The chemotherapy killed her, right?

 I could continue, but what's the point. His book has one intended audience: People who already hate psychiatry. If one cares to fully fact check the entire interview, you'll find one misleading statement after another. Whitaker is biased and has no scruples about misrepresenting facts and data to suit his narrative.

He is no different than the very industry that he is attacking.  

19 comments:

Anonymous said...

Great article. Thank you for writing this!

Anonymous said...

OK, I see your point. And I am not anti-psychiatry. Hell, I work in this field. But I think the Whitakers of the world are a necessary corrective to the countervailing bullshit spewed by the pro-psychiatry crowd that has has bamboozled the populace as to the so-called superior efficacy of drugs in treating mental illness. You know, the crowd that pimped the the second generation antipsychotics as better than the first generation agents, all with the benefits of no side effects? LOL. Yeah,like obesity and diabetes are no big deal. And lets not even mention the marketing crap about antidepressants, which have been revealed to be mostly placebo, in studies published, not in Scientology journals, but the flagship journals of medicine, including JAMA, NEJM, and Lancet!

NeuroPsych said...

I have to respectively disagree. One reason for the negative/angry feelings toward the field is because people/patients feel like they have been mislead/deceived. Using the same tactics against the field will only appeal to those who feel deceived. It is polarizing and causes those on the other side to become defensive. These tactics shut down rational thinking. This accomplishes nothing except for propagating the problem.

Anonymous said...

Oh OK. So we should just let the Big Pharma and medical device companies continue to trample the truth without any push back? By the way, patients FEEL like they have been deceived? Shouldn't it be, patients HAVE been deceived?

Anonymous said...

Neuropsych, why is the term anti psychiatry always used when there is a questioning of the statistics of mainstream psychiatry? Why is this type of demonizing necessary?

If someone wrote a book criticizing cardiology, you wouldn't say, this will appeal to the anti cardiology crowd.

Regarding what you said regarding the study of ADHD and bipolar disorder, bipolar reactions are a side effect of stimulants. Whitaker was suggesting that the researchers were overlooking that,

A diagnosis can't be made on the basis of a drug reaction but yet it seems that many of your colleagues are willing to do that.

Regarding people recovering from schizophrenia without meds, even if Whitaker's statistics are off, you agree that there are people who can succeed without meds. But yet again, most of your colleagues seems to think that people with schizophrenia need to be medicated come heck or high water. With the horrific side effects and peoples statistically dying 25 years earlier because of these meds (there are admittedly other reasons), that is criminal not to explore that.

You also said,

"I don't think anyone of real importance claimed that psychiatric drugs were aimed at "preventing mental illness." Again, there is no context. For example, one explanation for the increase of those on disability is that entitlement programs have increased their coverage over the years to include those with mental illnesses."

Well, not directly but when your colleagues are claiming that mental illness is due to chemical imbalances that is exactly the claim you are making about mental illness.

Yes, causation doesn't equal correlation but if psych meds are such wonderful healing agents, it is a valid question to ask why the disability rolls have increased so much, especially with kids.

I am puzzled by your claim that this book is devoid of rational thinking. Of course, you haven't read it so I am not sure on what basis you can make that claim.

If you had, you would have read that mainstream psychiatrists like Gustava Fava, expressed concern that the long term use of antidepressants worsens depression.

Like you said, I could go on but I will stop here.

AA

NeuroPsych said...

Anon - The reason I used the term "anti-psychiatry" is due to the fact that there is an anti-psychiatry movement in this country. I know of no anti-cardiology movement. There are many books, published each year, that are highly critical of biological psychiatry.

Based on the author's interview and my experience reading his previous book, I find that his arguments are not persuasive. I think they appeal to a group of people who have already made their mind up about psychiatry.

I agree with the point you make about making a diagnosis based on a drug reaction. I have criticized this before in my blog. What I was reacting to was him referencing a study to make a point, but in doing so, he misrepresented the actual aim of the study. He did the same thing with the schizophrenia study...it's not that "his statistics were off," he completely misreported the findings of the study.

No where in my post did I say the book is "devoid of rational thinking." I freely admitted to not reading it. I read his previous book, which I said was "sensationalistic and misrepresented research."

In one of my comments to another reader I said that his tactics, which are also used by psychiatry itself, only serve to "shut down rational thinking."

Just because I hold the opinion that this author or this book is not worth reading, that does not mean I hold the opposite opinion that psychiatry is great. The majority of my posts are highly critical of psychiatric research and the biological model of mental illness.

Then again, that fact does not mean I am in agreement with the anti-psychiatry movement either.

altostrata said...

Wow, if you want to see "context" for Whitaker's book, take a look at paxilprogress.org. This is a non-commercial patient support site for withdrawal from all kinds of psychiatric drugs, not just Paxil.

There are thousands of patient-reported case histories on this site. Read a few. You'll find patients support each other because they get absolutely no support from the medical establishment.

Psychiatrists are not better informed about the side effects and adverse events associated with these drugs than any other type of doctor.

Although the drugs they purvey are almost all either addictive or cause physical dependency, psychiatrists take no responsibility for safely getting their patients off these drugs. Then they misdiagnose withdrawal syndrome as relapse (or "bipolar syndrome") and put the patient on a merry-go-round of psych drugs -- which causes further autonomic damage.

This alone contributes to the putative rise in mental illness.

Furthermore, doctors fail to advise of common side effects such as sexual dysfunction (affecting as much as 50% of those taking SSRIs) and withdrawal difficulty (20% or more incidence, and misrepresent these drugs as correcting fictive "hormonal imbalances," telling many patients they will have to be medicated for life. This makes a mockery of both informed consent and evidence-based medicine. It's as though they were in denial of any drawbacks of these drugs.

There's no fad of anti-psychiatry. The self-serving lies and manipulations in the service of the pharmaceutical industry are coming home to roost. Criticism of psychiatry is a natural and very well-justified trend. I sure won't weep for any of those pompous, overpaid pharma shills when their game is finally called.

altostrata said...

Neuropsych, you should know better than to publish a review of a book without reading it! I would like to see your book criticizing psychiatry without getting outraged.

In support of Whitaker's thesis, this new study out of Harvard:

http://www.ncbi.nlm.nih.gov/pubmed/20478876?dopt=Abstract

Am J Psychiatry. 2010 May 17. [Epub ahead of print]
Illness Risk Following Rapid Versus Gradual Discontinuation of Antidepressants.

Baldessarini RJ, Tondo L, Ghiani C, Lepri B.

Abstract

Objective Rapid discontinuation of some psychotropic medications is followed by discontinuation symptoms as well as an increased risk of early illness recurrence. Recurrence occurs earlier after rapid than after gradual discontinuation with lithium and antipsychotics. The authors compared illness recurrence after rapid versus gradual discontinuation of antidepressants.

Method The authors compared 398 patients with a DSM-IV diagnosis of recurrent major depressive disorder (N=224), panic disorder (N=75), bipolar II disorder (N=62), or bipolar I disorder (N=37). Two-thirds were women, the mean age was 42 years, and patients were treated with antidepressants for a mean of 8.5 months. Antidepressants were discontinued clinically, either rapidly (over 1-7 days; N=188) or gradually (over 14 days or more; N=210), with a mean follow-up duration of 2.8 years; patients who were ill at discontinuation were excluded from the analysis. The authors compared latency to first new illness episodes using survival analysis and Cox multivariate modeling.

Results The latency to first illness with rapid discontinuation was 0.4 times that with gradual discontinuation, and the latency after rapid discontinuation was one-fourth the estimated average previous interepisode interval in the same patients. The effect was similar across antidepressant classes and across years; the pace of discontinuation had less effect with drugs of prolonged half-life. The effect also varied by diagnosis (bipolar I >/= panic > bipolar II >/= major depressive disorder) but not by episodes per year, duration of index illness, use of concomitant treatment, or antidepressant dose or duration.

Conclusions The recurrence risk for depression or panic was much shorter after rapid than after gradual discontinuation of antidepressants. These findings have implications for both clinical management and the design and interpretation of clinical trials.


My note: Neither the short nor the so-called "gradual" taper of 14 days was sufficient to minimize what the study's authors called "relapse," but was probably withdrawal syndrome. Most people who have stopped taking antidepressants do not even have this amount of guidance from their doctors. We can assume there is a large number of people who are at greater risk of "relapse" after taking antidepressants.

NeuroPsych said...

Alto,

1) This post is NOT a book review. It's a review of his interview. A reader wanted me to give my impression of the interview.

2) I'm was not defending psychiatry or discrediting the author by suggesting that psychiatry's behaviors are defensible. I was critiquing his METHOD of criticism. He was misinterpreting research (either intentionally or unintentionally) to fit his bias, which is what psychiatry does.

Like I said, "He is no different than the very industry that he is attacking."

Just because he is on the opposite side, does not make his tactics any better.

Martin said...

Ultimately it is almost impossible to verify the integrity of the various studies data. Unless you track down and interrogate every last participant.

More and more doubt swirls over psychiatry and big pharmaceutical companies. The sales and revenue from antidepressants etc are enormous.

We have seen how America behaves when big money is at stake. Only a complete fool would not suspect there is something rotten. Whitaker has something of great importance to say.

Anonymous said...

I'm a doctor and the book was very persuasive in my mind. Thanks Whitaker!

rolodexter said...

Another public health title by a journalist, with a bit more credibility
He's doing the rounds, selling his book, telling the same sob story over and over again. "I didn't want to write this book. I started out as a proponent of big pharma," etc. etc. (on NPR and the like). It's a little alarming actually. He does come packed with credentials. I guess my only grip with his grip about the state of the "epidemic" is that, along with his disclaimers about where he came from, how he came to start writing this book as a "rogue," he should've also anticipated the fact that many readers may blanket big pharma as a whole with this condemnation of mental health meds. His stats, of course, are a bit construed, and it begs to be dug into a bit. The Kindle version translates well, with the graphs coming out just as one would expect to find in the hardcover.

Anonymous said...

Just because Upton Sinclair used polemic and emotion doesn't mean his descriptions in "the Jungle" had no basis. He is trying to have an effect with this book, so forgive the inherent weaknesses of a journalistic account. If you want a muckraking account by someone within the discipline, read David Healy: Mania: a history of bipolar disorder and his other works. of course you probably see him as an inconvenient gadfly as well.
Again, there is a difference between postmodern conspiracism a-la Foucault or Foucault fans who misinterpret Madness and Civilization, and calculated muckraking, which is absoolutely necessary in our society when groups of people can become so self-deluded.

altostrata said...

Neuropsych, I look forward to your book on this subject. It will be dispassionate, objective, and not interpret studies to support your point.

(Although doesn't every work citing studies interpret the studies to support a point? Isn't that what citations are for?)

I suggest there's a note of outrage in Whitaker's book and interviews because his findings inspire it. And nothing can be more painful than to see life after life ruined by the bad doctoring coming out of psychiatry.

Take a look at paxilprogress.org and see the reality.

Anonymous said...

Whitaker has saved lives with his writing. What have you done? denounce books without even reading them? give me a break.

Anonymous said...

Instead of criticizing Whitaker for lacking context you should be reading his book. How can you provide full context in an interview?

Anonymous said...

I don't think that you can compare Whitaker to people like Breggin. Breggin tends to cite sources that cant be verified, act as his own source and cite discredible sources and make laughable claims (Paxil is more dangerous than meth, Ativan is more addictive than herion, ect)

Whitaker, on the other hand, is probably the best science journalist there is. He gets deep into the data, misses nothing of significance and comes out with works that have not so much as been dented. The little rebut you gave his interview was childish and silly, you haven't even read the book or researched the studies that he refers to.

Not only that but Whitaker is the major driving force behind the new war with Big Pharma. Whitaker was the first to expose many of the tactics Big Pharma has used, such as the dissection of how they marketed the atypicals. Having been the cofounder of centerwatch, it's no surprise that he had so much insider information. Because of him now psychiatrists have to disclose their ties to drug companies. Even the CCHR latched onto his works. Before 'Mad in America' all the CCHR was - their website especially - revolved around L.Ron Hubbard quotes. In fact go to alexis and use their 'way back' machine and look at it. They based much of their approach toward their fight against psychiatry on his works. Including 'and industry of death', where they got such information as how neuroleptics were discovered (chemical dyes > Pesticides > Phenothiazines) and psychiatry during slavery and eugenics and then ultimately psychiatry as Big Pharma puppets. All that was Whitaker.

Definitely far from a Peter Breggin copycat.

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Anonymous said...

Dear Neuropsych. It is oxymoron and irresponsible to write anything about anything, if you even did not take your time to read the book, reflect on it, take a look at the research mentioned ( at least some). You cannot interview someone about the book you did not read.
People like you are in my opinion have no right to blog on issues. You luck responsibility and objectivity.