MANY BOOKS in recent years have taken on psychiatry and the pharmaceutical industry (Prozac Nation and The Emperor’s New Drugs are two examples). Robert Whitaker’s Anatomy of an Epidemic falls within this genre. However, he makes a sweeping claim beyond the usual accusations of profiteering and over-prescription—namely, that the overprescription of psychiatric medications is in fact one of the major causes of the sharp rise in psychiatric disorders over the past three decades. The book’s detective-story style, eminent readability, and indictment of the pharmaceutical industry and psychiatry have made this book very popular, reaching best-seller status.
While some of Whitaker’s arguments are clearly sound (perhaps even understated) and others are provocative and cry out for further investigation, the central argument of the book is flawed, as we shall see.
It is indisputable that many people are misdiagnosed and/or overmedicated. No doubt this is largely the fault of the pharmaceutical industry and the many psychiatrists who are deep in their pockets. Whitaker does a good job of reminding us that the pharmaceutical industry distorts and conceals data from trials of their “miracle” products in order to maintain their industry’s unsurpassed profit margins, that many “breakthrough” medications turn out to be no better than, or even more dangerous than, their less-profitable predecessors; and that many widely-prescribed and vastly-profitable psychiatric medications provide questionable efficacy and unquestionable harm.
Whitaker sets out to dismantle the “facts” as fed to us by the American Psychological Association (APA) and the pharmaceutical industry: That mental illness has been underdiagnosed and undertreated in the past, and that science has now established that mental illness is a product of “chemical imbalance,” which can be treated with appropriate medications in the same way that a diabetic can be treated with insulin. Through presentation of buried data, Whitaker correctly argues that there is no evidence that we have an understanding of the roots of mental illness, biological or otherwise, and further, that psychiatric meds in no way constitute the “magic bullet” to “treat” these illnesses.
It is not just the scientific status of these arguments that Whitaker challenges, however; he also questions the entire methodology. 1) Randomized controlled trials for new drugs are generally conducted only for short periods of time, so that even if short-term efficacy is demonstrated, we are left with no knowledge of their long-term efficacy or side effects. 2) Data comparing people with the same diagnosis, some of whom are on psych meds and some of whom aren’t, are biased, in that those who choose not to take meds are likely to be less symptomatic and/or to have more internal and external resources. 3) Before-and-after historical comparisons, or cross-cultural comparisons, are limited by differences in the way diagnoses are made, the kinds of nonpharmacological treatment available to the test subjects, and perhaps most importantly, the economic and social conditions under which they developed and are experiencing mental illness.
The author tells a compelling and hair-raising tale of how the drug industry’s constant search for new markets has resulted in the invention of new diagnoses and the “uncovering” of heretofore “hidden” epidemics in new populations (e.g., bipolar disorder in children). Again, this is not news to many of us. The novel argument he puts forth is that long-term, and sometimes even short-term, use of psychoactive medications (such as Prozac, Zoloft, Abilify, Paxil, and Xanax) may in fact cause the very neurochemical and brain abnormalities that studies cite as “evidence” of the biological basis of mental illness.
Some of the most compelling studies he reviews show that, prior to the advent of psychiatric meds in the 1950s, the course of most psychiatric disorders was much shorter and less debilitating, with more people returning to optimal functioning and complete recovery. But, as E. Fuller Torrey, a psychiatrist who has devoted his career to understanding the root causes of schizophrenia, points out in his critical review of Whitaker’s book, it has been known for centuries that about a third of people diagnosed with schizophrenia resume normal functioning without treatment. Moreover, the pre-medication “natural course” studies Whitaker cites included many people who were not in fact schizophrenic, but had less serious illnesses which are not necessarily chronic: hence the false appearance of better premedication outcomes.
Other arguments made by Whitaker are credible; the possibility that overprescribing Ritalin to children (disproportionately poor and non-white) may be fueling an epidemic of child bipolar disorder certainly warrants further study. Yet Whitaker’s observations do not address the root causes of the current very real (and not “iatrogenic,” or caused by physicians or therapists, as he misleadingly claims) plague of mental illness, and without this understanding of root causes he is unable to point a way toward how we could ameliorate this vast suffering either in the short- or the long-term.
Not to let the drug companies off the hook for their shameless profiteering, but they are more parasitic than causal when evaluating the course of mental illness since the 1950s. The rise in mental illness dates back to the onset of capitalism and industrialization; the rise we see in the past thirty years likely has more to do with social causes such as high unemployment, the decline in living wages, cuts to social services, and many other stressful phenomena.
Whitaker accurately points out the hypocrisy with which big pharma purports to take the stigma out of mental illness by deploying a biological model that purports to “blame the disease, not its victim,” thereby creating multibillion-dollar markets for themselves. The new stigma then becomes that of refusing to take medication. But the psycho-pharmaceutical industry is far from unique in creating markets for its products or in profiting from people’s misery. This is the nature of our for-profit system.
There is no doubt that psychiatric medications are overused. It is crucial to note, as Whitaker does, that all the studies including psychotherapy or exercise show that for mild to moderate anxiety and depression, therapy and/or exercise are just as or more effective than medication. However, the reality is that many people may have access only to medication, and these data are not a reason to eschew the only viable option for relief. Moreover, there is a big difference between saying that the drug companies and psychiatrists, for reasons of financial gain, overprescribe, and sometimes mis-prescribe medications, and arguing that the medications themselves are the cause of mental illness.
Many of us can point to patients, friends, family members, or our own positive experience with psychiatric medications. Some of this may be a placebo effect; some may be the result of poorly understood, but nonetheless real, medical benefits. Moreover, for every overmedicated person, there is another unmedicated one who has been denied access to treatment, or who refuses treatment due to distrust (often warranted) of psychiatric medications. While psych meds are no “magic bullet,” they may indeed, in spite of their profitability, be reasonable “damage control.”
Anatomy of an Epidemic can be thought-provoking reading for those with some knowledge of the history of mental illness and of the data on effectiveness of psychiatric medication. The book could be misleading or even dangerous if used on its own to make a personal determination about whether to take psych meds or not. And even more dangerous in the hands of the managed-care moguls who I can imagine cravenly using Whitaker’s arguments to withhold needed medication from even more people.