Robert Whitaker on history, science and the illusion of psychiatry. Interview for Nowa Debata.
We gladly present our interview with Robert Whitaker, noted journalist, author and science historian, who talks about the history, (bad) science and the illusion of contemporary psychiatry.
Robert Whitaker has won numerous awards as a journalist covering medicine and science, including the George Polk Award for Medical Writing and a National Association for Science Writers’ Award for best magazine article. In 1998, he co-wrote a series on psychiatric research for the Boston Globe that was a finalist for the Pulitzer Prize for Public Service. Anatomy of an Epidemic won the 2010 Investigative Reporters and Editors book award for best investigative journalism.
Robert, you are a science historian, best-selling author and award-winning journalist covering science and medicine. What sparked your interest in psychiatry in particular?
It came about in a very indirect manner. In 1998, I co-wrote a series for the Boston Globe on the abuse of psychiatric patients in research settings. I thought that would be the end of my reporting on psychiatry, but while doing that series, I came upon outcome studies for schizophrenia that belied what I knew to be “true.” I had thought that psychiatry was making good progress in treating schizophrenia, but a study by Harvard researchers found that outcomes today were no better than they had been in the first half of the 20th century, prior o the arrival of antipsychotics. Then I came upon studies by the World Health Organization that found that schizophrenia outcomes were much better in three developing countries (India, Nigeria and Colombia), than in the United States and other developed countries. I wrote my first book, Mad in America, to explore why that might be so.
In your research you have demonstrated that for the past 30 years the American psychiatry has been telling the public a false story trying to convince us that the psychopharmacological revolution in diagnosis and treatment of mental disorders has proven a huge success. In your book Anatomy of an Epidemic you invoke a well-known optical illusion called “the young lady and an old hag”, whereby it is the “young lady” image of the psychopharmacological era that has overwhelmingly prevailed in the public domain. How is this picture of psychiatry false? What is the illusion?
The common wisdom is that the arrival of chlorpromazine in asylum medicine, back in 1954, kicked off a psychopharmacological revolution, this great advance in care in the treatment of mental disorders. Moreover, we have scientific evidence that the drugs work: They may alleviate symptoms over the short term. Together, the historical belief and the scientific evidence combine to create the young lady image in the mind of society.
But in Anatomy of an Epidemic, I looked at this question: How do psychiatric drugs affect the long-term course of major mental disorders? When you ask that question you find overwhelming evidence, compiled across 50 years, of how the medications increase the chronicity of disorders, and worsen functional outcomes (ability to work, etc.) That is the old hag picture.
So, the illusion is that we have made great progress in treating mental disorders. But once you look at how the drugs affect long-term outcomes, you see that no such progress has been made.
In recent years it has been increasingly admitted (even by the members of the psychiatric profession) that the chemical imbalance theory of mental illness, which serves as the foundation of biopsychiatry, is in fact a metaphor or even a myth. No chemical imbalance has ever been scientifically proven to be the cause of any mental disorder. Furthermore, there is a growing disconnect between what research psychiatrists say in professional journals and what the popular media or drug advertisements promote as scientific facts. What are the origins of this theory and what do you think are some of its most fundamental flaws?
The chemical imbalance story arose as a hypothesis, beginning in the 1960s, when researchers began to understand how antipsychotics and antidepressants acted on the brain. They discovered that antipsychotics blocked dopaminergic activity in the brain, and thus hypothesized that schizophrenia was due to too much dopamine. Antidepressants were found to increase levels of serotonin and norepinephrine in the synaptic cleft (the gap between neurons), and thus researchers hypothesized that depression was due to abnormally low levels of these neurotransmitters.
Here we see the founding flaw: The hypothesis arose from an understanding of how the drugs act, and not from findings in schizophrenia patients or in depressed patients.
The chemical imbalance hypothesis began to fall apart in the 1970s and early 1980s, when researchers failed to find that people diagnosed with schizophrenia reliably had overactive dopamine systems, and that people diagnosed with depression had low levels of serotonin. But psychiatry nevertheless continued to peddle this story to the public, and it did so partly to elevate its own status. It was a metaphor that made it seem that psychiatry had its own magic bullets, just like internal medicine doctors did.
In your book Anatomy of an Epidemic you argue that the psychopharmacology revolution, which started in the 1950s with the introduction of Thorazine followed by other classes of psychiatric drugs (antidepressants, antipsychotics, mood stabilizers etc.), has fundamentally changed the way people experience mental disorders and, most importantly, has affected the outcomes of medicated patients. What is this change and is it for the better or for worse?
As we accepted the medical model, we were taught to believe that people who suffer a psychiatric episode have a “broken brain,” or an “illness,” much like diabetes. Thus, rather than seeing such episodes as arising, at least in part, from environmental stresses and setbacks (and hence possibly episodic problems,) we are taught that they are chronic problems. This model is a very pessimistic one, and disempowering one too. It discourages the sense that people can, in one resilient manner or another, get through the crisis and regain a more normal sense of self. Instead, the message is that the person has a broken brain, and needs to take medication for the rest of his or her life.
As for the outcomes, the scientific literature is quite clear. The medications increase the long-term chronicity of major mental disorders (schizophrenia, depression, anxiety, manic depressive illness), and worsen functional outcomes too. Some people may do okay on the medications long-term, but on the whole, the drugs worsen long-term outcomes.
What has been the role of media and public institutions, including governmental agencies, health organizations and universities, in the promotion of the biological model of mental illness. How do you assess their involvement?
Various commercial, academic, and governmental agencies in the United States were the leaders in promoting the medical model of mental illness. It is easy to identify these storytelling forces.
First, the American Psychiatric Association, with the publication of the third version of its „Diagnostic and Statistical Manual” in 1980, adopted the medical model and promoted it to the public. Second, the pharmaceutical companies naturally liked this model, for it promoted the use of psychiatric drugs.
Third, a parent group, the National Alliance for the Mentally Ill (NAMI) sprung up in the 1980s, led by families who had adult children diagnosed with schizophrenia, and they wanted to promote this model too, for it told of a “no fault” cause of schizophrenia. It wasn’t due to trauma, environmental stresses, or bad mothering, but rather was a simple chemical problem. NAMI turned into a powerful lobbying force, and a powerful public relations force too.
Fourth, here in the United States, psychiatrists at medical schools who believed in the medical model gained control of the National Institute of Mental Health (NIMH), our federal agency that funds research, and so the NIMH began selling the medical model to the American public too.
That is a powerful quartet of storytelling voices lined up together. But they were telling a story forged by ideology and commercial interests, rather than by good science. Eventually, the United States successfully exported this biological model to Europe and other parts of the world.
In your books you argue that psychiatric drugs, instead of fixing mental problems, may in fact exacerbate them. In other words, not only are psychiatric drugs ineffective, but also they fuel the epidemic of mental illness that we are witnessing today. Also, you claim that patients who go on medications run a serious risk of falling into a “drug trap”. What is the basis for your conclusions? What is this “drug trap” that you mention in your writings? Is your criticism limited to old-generation drugs, for instance first neuroleptics, or is it also valid for the latest classes of psychiatric medications?
When you follow the science re long-term outcomes, you see quite clearly the evidence that the medications increase the chronicity of the disorders, and this is particularly true for the affective disorders (depression and manic-depressive illness.) Long-term SSRI use also increases the risk that a person diagnosed with an affective disorder will go on to long-term disability.
Speaking of psychiatric drugs fueling the epidemic of disabling mental illness, it is quite clear that a significant percentage of people who begin taking an SSRI antidepressant for a mild bout of depression worsen on the drug, and develop new and more severe psychiatric symptoms (such as drug-induced mania.) Thus, we see, in the scientific literature, that SSRIs increase the risk that a person who suffers a depressive episode will then have a manic episode, which usually leads to a diagnosis of bipolar disorder. Science is telling us that use of the medications can, in fact, create chronic patients.
The drug trap described in my books is quite simple, and it holds for both the first generation drugs and the second-generation drugs. Say you begin taking an antipsychotic medication, which works by blocking dopamine receptors in the brain. In response, your brain increases the number of dopamine receptors in the brain. It does so to try to maintain normal functioning of its dopaminergic systems. Now it may be that this process helps curb psychotic symptoms over the short term. But once these compensatory changes happen, the brain is said to be “supersensitive” to dopamine. This increases the risk of relapse should a person try to go off the medication, and yet, at the same time, if people stay on an antipsychotics, the long-term functioning of dopaminergic systems are impaired.
So, initial drug use, which may be helpful over the short term, can lead to changes in the brain that make it difficult to withdraw from the drug, and yet also lead to long-term use which is associated with outcomes. The initial use, which may be helpful, leads to a long-term trap: it’s hard to get off the drug, but staying on the drug may lead to a bad outcome too.
In your work you seem disturbed by the fact that the modern epidemic of mental illness is increasingly affecting children and that this shift goes hand in hand with medicating ever younger patients (even two-year olds are put on drugs as treatment of bipolar disorders). Some observers argue that mental disorders in children are not genuine medical conditions but ‘phony’ diseases created to broaden the market for psychiatric drugs after the adult market was ‘saturated’? What is your take on this issue? Do you think we will achieve a healthier and saner society medicating our children at an increasingly younger age?
It is quite clear that the medicating of children in the United States, and increasingly in Europe and other countries as well, has been driven by a desire by drug companies to expand the market for their new antipsychotics and other psychiatric drugs. For instance, researchers had concluded in the 1960s and 1970s that juvenile bipolar disorder basically didn’t exist, but then the new atypical antipsychotics came to market, and suddenly U.S. psychiatrists, led by Joseph Biederman at Massachusetts General Hospital in Boston, were announcing that they had “discovered” it existed in children after all, and that the new antipsychotics should be prescribed to such children.
This practice—of medicating children at a young age—is an extraordinary medical disaster in the making. The children so medicated suffer psychiatric, physical, emotional and cognitive side effects, and there is no evidence that the drugs provide a long-term benefit on any important domain of functioning. In a very real sense, this practice robs the children of their “right to be,” and grow up in a normal fashion, with their brains and souls developing without the intrusion of the drugs.
This is a horrible wrong. As a society, I believe we will look back on this one day and wonder how we could ever have done such a thing.
The notion that the current epidemic of mental illnesses is iatrogenic in nature begs the question about the quality and reliability of medical research. Shouldn’t all the institutions, procedures and trials guarantee that the treatments we are getting are both safe and efficacious? What problems do you see in this respect?
There are many problems with drug research. The first is that in order to get a drug approved in the U.S., a company only needs to show that the drug is effective over the short term on a target symptom. This is true in most other countries as well. Thus, there is no regular governmental method for assessing the safety and efficacy of a drug over the long-term, and the cost-benefit ratio of a drug over the long term may be very different than over the short term.
The second problem we have is that it is quite evident now that when drug companies fund the trials of their psychiatric drugs, that process is not a scientifically honest one. The trials may be biased by design, the results spun, and negative trials unpublished. Thus, much of the research on the short-term safety and efficacy of psychiatric drugs isn’t honest in kind.
We just don’t have good science informing us about the true effects of these drugs, both short-term and long-term. Instead, we have dishonest science masquerading as honest science, and that dishonest science is then touted as providing an “evidence base” for their use.
In Anatomy of an Epidemic you describe the “commercial beauty” of the partnership between psychiatry and the pharmaceutical industry which developed in the 1980s. How and why did this happen? What, in your opinion, are the key consequences of this partnership?
In the late 1970s, American psychiatry felt that it was in a fight for its survival. There were any number of groups offering psychological therapies—talk therapy, mind therapies, etc.—and psychiatry ultimately saw itself in competition with these groups. The American Psychiatric Association adopted the medical model in the 1980s partly to emphasize that psychiatrists were doctors, which is an elevated status in society, particularly in comparison to the other groups offering talk therapies.
The medical model naturally leads to the widespread use of psychiatric medications. Of course, the pharmaceutical industry welcomed this, and these two institutions -organized psychiatry and the drug industry—now saw their financial interests merge.
Once this happened, the money that flowed from the pharmaceutical industry to the APA, through various channels, increased. In addition, pharmaceutical companies began hiring psychiatrists at academic medical centers to act as speakers, advisors, consultants.
As a result of this new partnership, organized psychiatry and the experts at academic medical centers became unreliable providers of information. The stories they told to the American public about mental disorders and psychiatric medications became skewed. We – the public – could no longer trust psychiatrists at American medical schools to provide an accurate accounting of the risks and benefits of the medications.
In your writings you’ve mentioned that in the 1970s the psychiatric profession started silencing all the dissenting voices coming from psychiatrists and researchers critical of the biological model of psychiatry. What was the reason for this internal censorship? How was it achieved and is it still ongoing?
The most visible example of this occurred when Loren Mosher, who was head of schizophrenia studies at the NIMH in the 1970s, ran a study called the Soteria Project. In this experiment, newly diagnosed schizophrenia patients who were treated in a non-medical way– in a house and with minimal use of antipsychotic medications–had better two-year outcomes than those treated conventionally with antipsychotics in a hospital setting. This result threatened societal belief in antipsychotics, and those medications can be seen as a “product” touted by organized psychiatry to society. Mosher was ousted from his position at the NIMH, and his ouster served as a warning signal to others: Publishing research that fundamentally challenged the merits of psychiatric medications could prove hazardous to one’s career.
In my opinion, this is the real reason for the internal censorship: The APA and organized psychiatry have a guild interest to protect, which is societal belief in the medications, and psychiatrists who threaten this guild interest cannot expect to prosper in this field.
This internal censorship continues today. Any academic psychiatrist who fundamentally challenges the merits of psychiatric medications cannot expect to prosper. He or she will find it difficult to get research grants, and certainly cannot expect to take up a leadership position within the American Psychiatric Association.
I don’t know the European scene that well, but if you asked Irish psychiatrist David Healy this question, he would certainly say that this internal censorship exists in European circles too, and that it can be hazardous to one’s career interests—as he personally found out—to fundamentally challenge the merits of psychiatric drugs.
In your books you’ve presented multiple cases of psychiatric patients who get a psychiatric diagnosis, often at an early age, and then go on drugs. Do you see any similarities in these stories? What is the experience that all medicated patients share?
I think there is a core experience that is often experienced by people put on psychiatric medications. People may find initial relief from the medication. But so often, after a time, that relief begins to fade, and once that happens, the person begins a search for a new drug, or a new combination of drugs, that will work. Once again, the new drug or combination may work for a time. But then this efficacy may begin to fade, and there are new side effects to cope with, and the search for the right drug or drugs is renewed. So it goes for years, and suddenly 10 years have gone by, and the person wonders why he or she is still struggling with symptoms and side effects from the drugs.
In short, the initial drug prescription serves as a gateway to a longer time on psychiatric drugs, and once this happens, there is no ready exit door from a lifetime of drug use and all the problems that can come with such long-term use.
In Anatomy of an Epidemic you say that the way Prozac was brought to market in late 80s by Eli Lilly became a model of conduct followed by other manufacturers in the pharmaceutical industry. Could you describe some of the most characteristic aspects of the “Prozac scenario”.
You see in the Prozac story a commercial model for using “science” to create a marketing success. The model is this: Bias your clinical trials by design to favor your drug; hide adverse effects; spin the published data; and then, once your drug is approved for market, have the academic doctors you pay to be your “thought leaders” extol the merits of your new product. In this way, a pharmaceutical company can present its new drug to the public as having been scientifically proven to be better and safer than older drugs of a similar type. Bad science leads to big profits.
But it is now pretty well known that pharmaceutical companies used this model to sell their new psychiatric drugs during the past 20 years, and many have had to pay big fines in the United States for their improper practices. The U.S. public no longer trusts the drug companies that make psychiatric drugs, and thus it might not be so easy for drug companies in the future to follow this “model” to success.
Every now and then the media reports of homicides or suicides committed by people under the influence of psychiatric medications. Conventional wisdom has it that it’s either the illness alone or its interaction with alcohol and/or illegal drugs that is to blame. However some observers, most notably Peter Breggin, argue that psychiatric drugs may have a role in inducing suicidal thoughts and violent behavior. Also, when a celebrity suddenly dies, their psychiatric medications very often seem to be part of the story. The tragic death of Whitney Houston, who had been taking Xanax, is a most recent example. What is your take on this problem?
I don’t think there is any question about it. Can SSRIs stir suicidal and or homicidal thoughts. Yes. Can antipsychotics cause a side effect known as akathisia (an extreme inner agitation), which is known to increase the risk of agitated and violent behavior? Yes. Can benzodiazepines be taken in a fatal overdose? Yes. The drugs can clearly cause such tragic side effects.
Every so often we learn of groundbreaking discoveries in psychiatry or brand-new psychiatric medications. What is your opinion on these alleged successes? Do these reports reflect the genuine advancement of psychiatry or are they simply a tool to mask the actual failure of biopsychiatry?
The history of psychiatry is filled with pronouncements of groundbreaking discoveries, either in the form of new treatments or new discoveries made about the nature of mental disorders. In the 1940s, people read in the media about such miracle cures as metrazole convulsive therapy, insulin coma therapy, electroshock, and frontal lobotomy. Those treatments fell out of favor in the 1950s, when psychiatry announced the discovery of new miracle drugs for psychosis, depression, and anxiety. In the 1970s, society began to realize those first-generation psychiatry drugs weren’t the miracle they were touted to be, and then, with Prozac’s arrival in 1987, the public was told of a second-generation of drugs much safer and more effective than the first generation. Prozac was said to make people “better than well.” But now, twenty years later, we know that those new drugs weren’t any better than the first generation.
And so it goes with biopsychiatry. Groundbreaking discoveries may be announced, but they do not last. And here we are in 2012, knowing very little about the biology of major mental disorders, and with treatments that may worsen long-term outcomes.
Despite the fact that biopsychiatry continues to dominate both the medical and popular view of mental problems, the mainstream media are clearly becoming more and more critical of this approach. One example is the New York Times, wherein your book , as well as Irving Kirsch’s and Daniel Carlat’s, received a considerable amount of praise in a two-part essay by Marcia Angell (“The Epidemic of Mental Illness: Why?” and “The Illusions of Psychiatry”). Also, Peter Breggin is a frequent contributor to the Huffington Post and the recent „60 minutes” show suggested that antidepressants are hardly more effective than the placebo effect. Given all this coverage, is it fair to say that the tide is turning and biopsychiatry is gradualy losing ground, or is too far-fetched an observation?
I think there is a bit of a societal rebellion happening against biopsychiatry today. Psychiatry has been touting its medical model since 1980, but it hasn’t proven to lessen the amount of psychiatric distress in any society. Instead, as societies adopt such beliefs, the burden of mental illness in those societies increases. This is why the tide is turning: After 30 years, societies are seeing that biopsychiatry isn’t really “working” for them, and so they want to explore other possibilities.
If the biological model of diagnosing and treating mental illness is in fact a failure, what, do you think, is the alternative? Should we stop using psychiatric drugs altogether, or can they be beneficial for some categories of patients?
I think we need to embrace an alternative form of care that is formed by these principles:
One, psychiatry needs to be humble and admit that we don’t really know much about the “biology” of mental disorders. Thus, we shouldn’t expect to develop “magic bullets” for those disorders.
Two, we should adopt a vision of psychiatric distress that is non-stigmatizing. We should remember that to be human is to have the capacity to experience psychiatric distress, and thus psychiatric symptoms—anxiety, depression, mania and even psychosis—should not be seen necessarily as an illness, but within the extraordinary range of moods, emotions, and mental states that humans experience.
Three, we should focus more on providing psychosocial care. What do we know helps most people stay well? Food, shelter, friends, meaning in life, a job—these are things that people need to be well in mind, and so treatment should focus on providing such support to those who are suffering psychiatric difficulties.
I don’t think psychiatric drugs need to be abandoned altogether. They can helpful over the short term, and there are some people who do well on them long-term, and so psychiatry should develop protocols for using the medications in a limited, cautious manner. But the use of the drugs in this manner should be as an adjunct to psychosocial care, rather than the centerpiece of care.
What, in your view, does the future hold for biopsychiatry? Can psychiatry even exist outside the biological model?
As for whether psychiatry could exist outside the biological model, sure. Psychiatry could be a medical field that developed comprehensive, nuanced, holistic programs for treating mental disorders. But if psychiatry keeps embracing a reductionist medical model, then I don’t think its future is very bright. Medical school graduates in the U.S. are mostly avoiding psychiatry these days, choosing to specialize in other disciplines, and this is a sign that they don’t see a bright future for psychiatry.
Your work challenges nearly everything that most psychiatrists, public health institutions and universities say about psychiatry. How is your research received in those circles? What are you trying to achieve through your work?
As you can imagine, many in those circles have reacted angrily to my book. But here is what I wish they would remember: I am just the messenger. In Anatomy of an Epidemic, I looked at what mainstream psychiatric research had to say about the long-term effects of psychiatric medications. If you do that thoroughly, you find that this mainstream research tells of a failed paradigm of care, in terms of the effects of drugs on long-term outcomes. It’s their research, so to speak.
And more and more, at least some people in those circles who have read Anatomy of an Epidemic have come to realized that, and inviting me to speak about the book. For instance, in the past year, I have been invited to give grand rounds at medical schools and to give talks at professional conferences, including a talk at a national meeting of the American Psychiatric Association. So, at least in some circles, the initial anger has given way to some inquiry about my book, and even discussion of its implications for treatment protocols.
My hope was that my book would provide readers with a clear look at what science has to say about the long-term effects of psychiatric medications, and that this would stir a societal discussion, both in the U.S. and in other countries, about whether our current medication-based model of care needs to be fundamentally rethought. The book, at least in some circles in the U.S., seems to be stirring such a discussion.
I have spent much of the past two years on the road, giving talks about this subject. In addition, I turned my website, madinamerica.com, into a web magazine for discussing these issues, a project that is still evolving. I also was a fellow this past year at Harvard University’s Safra Center for Ethics, and I used that fellowship to do some further research on the American Psychiatric Association, and its promotion of the medical model for the past 30 years. I may write more about that soon.
Beyond that, I have a new book in mind, one related to the raising of healthy children, which we are doing so poorly in the U.S. today, that I hope to begin working on soon.
Bob, thank you for taking the time.
Interview by Mateusz Rolik and Tomasz Gabiś