Anatomy of an Epidemic
Read Anatomy of an Epidemic Online
Authors: Robert Whitaker
Also by Robert Whitaker
Mad in America
The Mapmaker’s Wife
On the Laps of Gods
To Lindsay
May you sing “Seasons of Love” again
and be filled with joy
Part One:
The Epidemic
Part Two:
The Science of Psychiatric Drugs
5.
The Hunt for Chemical Imbalances
Part Three:
Outcomes
8.
An Episodic Illness Turns Chronic
11.
The Epidemic Spreads to Children
Part Four:
Explication of a Delusion
14.
The Story That Was … and Wasn’t Told
Part Five:
Solutions
The history of psychiatry and its treatments can be a contentious issue in our society, so much so that when you write about it, as I did in an earlier book,
Mad in America
, people regularly ask about how you became interested in the subject. The assumption is that you must have a personal reason for being curious about this topic, as otherwise you would want to stay away from what can be such a political minefield. In addition, the person asking the question is often trying to determine if you have any personal bias that colors your writing.
In my case, I had no personal attachment to the subject at all. I came to it in a very back-door manner.
In 1994, after having worked a number of years as a newspaper reporter, I left daily journalism to cofound a publishing company, CenterWatch, that reported on the business aspects of the clinical testing of new drugs. Our readers came from pharmaceutical companies, medical schools, private medical practices, and Wall Street, and for the most part, we wrote about this enterprise in an industry-friendly way. We viewed clinical trials as part of a process that brought improved medical treatments to market, and we reported on the financial aspects of that growing industry. Then, in early 1998, I stumbled upon a story that told of the abuse of psychiatric
patients in research settings. Even while I co-owned CenterWatch, I occasionally wrote freelance articles for magazines and newspapers, and that fall I cowrote a series on this problem for the
Boston Globe
.
There were several types of “abuses” that Dolores Kong and I focused on. We looked at studies funded by the National Institute of Mental Health (NIMH) that involved giving schizophrenia patients a drug designed to exacerbate their symptoms (the studies were probing the biology of psychosis). We investigated the deaths that had occurred during the testing of the new atypical antipsychotics. Finally, we reported on studies that involved withdrawing schizophrenia patients from their antipsychotic medications, which we figured was an unethical thing to do. In fact, we thought it was outrageous.
Our reasoning was easy to understand. These drugs were said to be like “insulin for diabetes.” I had known that to be “true” for some time, ever since I had covered the medical beat at the
Albany Times Union
. Clearly, then, it was abusive for psychiatric researchers to have run dozens of withdrawal studies in which they carefully tallied up the percentage of schizophrenia patients who became sick again and had to be rehospitalized. Would anyone ever conduct a study that involved withdrawing insulin from diabetics to see how fast they became sick again?
That’s how we framed the withdrawal studies in our series, and that would have been the end of my writing on psychiatry except for the fact that I was left with an unresolved question, one that nagged at me. While reporting that series, I had come upon two research findings that just didn’t make sense. The first was by Harvard Medical School investigators, who in 1994 announced that outcomes for schizophrenia patients in the United States had
worsened
during the past two decades and were now no better than they had been a century earlier. The second was by the World Health Organization, which had twice found that schizophrenia outcomes were much better in poor countries, like India and Nigeria, than in the United States and other rich countries. I interviewed various experts about the WHO findings, and they suggested that the poor outcomes in the United States were due to social policies and cultural
values. In the poor countries, families were more supportive of those with schizophrenia, they said. Although this seemed plausible, it wasn’t an altogether satisfactory explanation, and after the series ran in the
Boston Globe
, I went back and read all of the scientific articles related to the WHO study on schizophrenia outcomes. It was then that I learned of this startling fact: In the poor countries, only 16 percent of patients were regularly maintained on antipsychotic medications.
That is the story of my entry into the psychiatry “minefield.” I had just cowritten a series that had focused, in one of its parts, on how unethical it was to withdraw schizophrenia patients from their medications, and yet here was a study by the World Health Organization that seemingly had found an association between good outcomes and
not
staying continuously on the drugs. I wrote
Mad in America
, which turned into a history of our country’s treatment of the severely mentally ill, to try to understand how that could be.
I confess all this for a simple reason. Since psychiatry is such a controversial topic, I think it is important that readers understand that I began this long intellectual journey as a believer in the conventional wisdom. I believed that psychiatric researchers were discovering the biological causes of mental illnesses and that this knowledge had led to the development of a new generation of psychiatric drugs that helped “balance” brain chemistry. These medications were like “insulin for diabetes.” I believed that to be true because that is what I had been told by psychiatrists while writing for newspapers. But then I stumbled upon the Harvard study and the WHO findings, and that set me off on an intellectual quest that ultimately grew into this book,
Anatomy of an Epidemic
.
A Modern Plague
“That is the essence of science: ask an impertinent
question, and you are on the way to
a pertinent answer.”
—
JACOB BRONOWSKI (1973)
1
This is the story of a medical puzzle. The puzzle is of a most curious sort, and yet one that we as a society desperately need to solve, for it tells of a hidden epidemic that is diminishing the lives of millions of Americans, including a rapidly increasing number of children. The epidemic has grown in size and scope over the past five decades, and now disables 850 adults and 250 children
every day
. And those startling numbers only hint at the true scope of this modern plague, for they are only a count of those who have become so ill that their families or caregivers are newly eligible to receive a disability check from the federal government.
Now, here is the puzzle.
As a society, we have come to understand that psychiatry has made great progress in treating mental illness over the past fifty years. Scientists are uncovering the biological causes of mental disorders, and pharmaceutical companies have developed a number of effective medications for these conditions. This story has been told in newspapers, magazines, and books, and evidence of our societal belief in it can be found in our spending habits. In 2007, we spent $25 billion on antidepressants and antipsychotics, and to put that figure in perspective, that was more than the gross domestic product of Cameroon, a nation of 18 million people.
2
In 1999, U.S. surgeon general David Satcher neatly summed up this story of scientific progress in a 458-page report titled
Mental Health
. The modern era of psychiatry, he explained, could be said to have begun in 1954. Prior to that time, psychiatry lacked treatments that could “prevent patients from becoming chronically ill.” But then Thorazine was introduced. This was the first drug that was a specific antidote to a mental disorder—it was an
antipsychotic
medication—and it kicked off a psychopharmacological revolution. Soon
antidepressants
and
antianxiety
agents were discovered, and as a result, today we enjoy “a variety of treatments of well-documented efficacy for the array of clearly defined mental and behavioral disorders that occur across the life span,” Satcher wrote. The introduction of Prozac and other “second-generation” psychiatric drugs, the surgeon general added, was “stoked by advances in both neurosciences and molecular biology” and represented yet another leap forward in the treatment of mental disorders.
3
Medical students training to be psychiatrists read about this history in their textbooks, and the public reads about it in popular accounts of the field. Thorazine, wrote University of Toronto professor Edward Shorter, in his 1997 book,
A History of Psychiatry
, “initiated a revolution in psychiatry, comparable to the introduction of penicillin in general medicine.”
4
That was the start of the “psychopharmacology era,” and today we can rest assured that science has proved that the drugs in psychiatry’s medicine cabinet are beneficial. “We have very effective and safe treatments for a broad array of psychiatric disorders,” Richard Friedman, director of the psychopharmacology clinic at Weill Cornell Medical College, informed readers of the
New York Times
on June 19, 2007.
5
Three days later, the
Boston Globe
, in an editorial titled “When Kids Need Meds,” echoed this sentiment: “The development of powerful drugs has revolutionized the treatment of mental illness.”
6