Thursday, July 29, 2010

Do Psychiatric Drugs Do More Harm Than Good? A Review of “Anatomy of an Epidemic” by Robert Whitaker

The idea that people with psychiatric disorders should “take their meds”, that these meds control their symptoms, that they’d better off on than off their drugs, is a noncontroversial position today. Decades of advice from doctors, nurses, therapists, academics, and drug company spokesmen have pushed people with disorders such as schizophrenia, bipolar disorder, major depression, and anxiety to take prescribed medications. We think of someone who decides not to take medications as acting in an irrational manner. Patients who are hospitalized don’t have a choice—they must take their medications.

Is this virtually monolithic societal support of the use of psychiatric drugs a group delusion, similar to the delusions that (nonmedicated) schizophrenics experience? Robert Whitaker takes up this question in his book entitled Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America.

Whitaker has two main points in the book. One, is that there has been an epidemic of mental illness in America in the recent past. There is twice the rate of disabled mentally ill in 2007 compared to 1987, and six times the rate compared to 1955. This trend is even more obvious for children, where the number of disabled mentally ill children multiplied thirty-five fold between 1987 and 2007.

Whitaker bases these claims of an epidemic on SSI (Supplementary Security Income) and SSDI (Social Security Disability Insurance) statistics. He compares these figures in 2007 and 1987 to hospitalization figures in 1955 (most disabled mentally ill in the 1950’s were cared for in state and county mental hospitals). These SSI and SSDI figures are not true prevalence figures, of course, since there are people disabled by mental illness not on these programs, and people on these programs who aren’t truly disabled. Since diagnostic criteria for mental illness has changed significantly in the past half century, it’s impossible to arrive at a true prevalence figure. But his general point of a mental illness epidemic is hard to deny, considering that America spent $25 billion in 2007 on antidepressants and antipsychotics. If there was little or no mental illness, why are doctors prescribing so many pills?

Whitaker’s second point is much more controversial. He says that this epidemic of mental illness is, in large part, caused by the very drugs that are being used to treat psychiatric disorders! Whitaker presents evidence in his book that psychiatric drugs do more harm than good when looked at from a long-term perspective. He acknowledges that these drugs make the patient better in the short term, such as the 6 week period in which clinical trials of new drugs occur. But, looked at over the period of years, not weeks, patients do better off drugs than on them.

Whitaker uses several pieces of evidence to craft his argument. One, is that the epidemic of disabling mental illness occurred during the period in which psychiatric drugs were used. During the early phase of psychiatric drugs (mid 1950’s through the mid 1980’s), antipsychotic drugs were used primarily on people with schizophrenia. Anti-anxiety and antidepressant drugs were prescribed for people with anxiety and depression. Lithium was used as a mood stabilizer for people with bipolar disorder. Most of these early drugs (with the exception of the anti-anxiety drugs) had terrible side effects, such as tardive dyskinesia for the typical antipsychotics. These side effects limited the number of people willing to take these drugs. (The anti-anxiety drugs Miltown and Valium were very popular, especially among women, but also very addictive.) Studies showed that those on the drugs, including the anti-anxiety drugs, had worse long-term outcomes than those off the drugs. These studies were never widely publicized, and doctors continued to prescribe the drugs to adults (children rarely were prescribed drugs in this period, with the exception of Ritalin for ADHD).

The second period, beginning with the FDA approval of Prozac for depression in 1987, saw the release and aggressive promotion of “second-generation” psychiatric drugs, which included SSRI antidepressants (e.g. Prozac, Zoloft, and Paxil), and atypical antipsychotics (e.g. Risperdal, Zyprexa, and Seroquel). Drug companies heavily marketed these drugs both to the public and to doctors, with the help of academic leaders in psychiatry. This period also saw a major increase in the diagnosis and drug treatment of pediatric psychiatric disorders.

The second-generation drugs had fewer and less-severe side effects than the older drugs, but weren’t any more effective than these drugs. They still had some serious side effects, however, such as increased risk of suicide for Prozac, and weight gain for Zyprexa. These adverse effects were generally swept under the rug as the pharmaceutical marketing machine (with the aid of drug-money soaked academic psychiatrists) promoted them as miracle drugs.

The release of the psychiatry reference manual DSM-III in 1980 led to a major change in diagnostic criteria, leading to more reliable diagnoses based on symptoms. The DSM-III (followed by the DSM-IV in 1994) made psychiatry appear more scientific and objective, since it dispensed with vague Freudian notions like “neurosis.” But the problem was that it wasn’t accompanied by any breakthroughs in the understanding of the biology of mental illness. The “chemical imbalance” theory, i.e. that schizophrenia was a result of too much dopamine, and depression a result of too little serotonin, was demolished by research findings. But drug companies and psychiatrists continued to tell people that this imbalance theory was true. Whitaker makes a good argument that the drugs actually cause chemical imbalances, not treat them. These iatrogenic (drug-caused) imbalances force people on the drugs to continue taking them, as they get terrible withdrawal symptoms if they try to stop. Getting children addicted to these drugs was a pharmaceutical marketing home run, as the kids would be hooked for life, a reliable long-term source of income.

It was during these last 25 years of widespread prescription of psychiatric drugs that the disability numbers soared. These drugs didn’t seem to be helping people over the long term, or else why would they be forced to go on disability? Large numbers of children started becoming disabled. According to Whitaker, the second-generation drugs had as dismal a long-term effect on patients as the first-generation drugs. The problem for society was that many times more people were taking them than took the earlier drugs. The few academic psychiatrists who questioned the efficacy of drugs were stripped of their positions and funding, and marginalized. Millions of dollars in drug money flowed to virtually all the academic leaders in psychiatry.

Whitaker weaves in anecdotes along with his research findings, enhancing the readability of his book. Some of the stories are haunting, such as the case of “Jasmine,” a girl prescribed an antidepressant for bed wetting in fifth grade. The agitation she got from this drug led psychiatrists to put her on a drug cocktail that included Zyprexa. She was hospitalized in high school, and the drug merry-go-round to which she was subjected fried her brain, leaving her perpetually psychotic and mute. Of course, Jasmine is an exception, and most children and adults on drugs have much more positive outcomes, but the reader is left to wonder, “what would have happened if she never got on drugs the first place?”

Whitaker provides examples of how drugs used to treat one condition (e.g. Ritalin for ADHD) lead to some children developing manic symptoms, which led them to be diagnosed with bipolar disorder, which led them to receive drug “cocktails” including powerful and harmful antipsychotics. They end up on a long-term trajectory of serious physical and mental problems, an outcome which probably would have been much more benign if they hadn’t been prescribed any drugs in the first place.

My own experience with psychiatric drugs was generally a positive one. I didn’t start on drugs until I was 27. I had many years of dysfunctional behavior, of cognitive and emotional problems. Virtually any intellectual activity at all (e.g. reading or writing) would trigger horrible “states” that would last for days. These “states” would include severe obsessions, difficulty concentrating, emotional suppression, and tics. Although I had a job, I was working well below my ability, and had little social life. It was under these conditions that I decided to try Anafranil, a drug used to treat OCD, and it did help improve my functioning for a while. I tried combining Anafranil with many other drugs that were less helpful, although I usually never took more than two at a time. Being very sensitive to side effects, I stuck to low or moderate dosages. After ten years of Anafranil, I felt that it was no longer needed, and convinced my psychiatrist to allow me to stop taking it. I followed up with 3 years of low doses of Xanax, then got off medication completely. I’ve been basically medication-free for 3 years. I think the late onset of starting with drugs, the small number and doses of drugs, and the eventual getting off drugs made me one of the few long-term medication success stories.

Whitaker is not anti-drug, and acknowledges that “there is a place for the drugs in psychiatry’s toolbox” (p. 333). But he wants psychiatrists to “think about the medications in a scientifically honest way and to speak honestly about them to the public” (p. 333). Certainly the vast majority of drug prescriptions are unnecessary and possibly harmful. After reading this book, (although Whitaker doesn’t suggest this) I think that a strong case can be made to outlaw prescribing psychiatric drugs for children. If they cause more harm than good in the long run, then it is children who have the most to lose by taking these drugs. Exceptions can be made for children already on drugs, and for the few children who are completely out of control, and whose behavior cannot be managed by any other means. Psychiatrists would howl about any such legislation, but let them (and their drug company masters) put forward studies that show children benefit long-term from drugs. If Whitaker is right, and there are no such studies, then let’s ban the prescribing of drugs for children.

I found this book to be one of the most powerful and thought-provoking books I’ve read in years. I recommend it to anyone concerned with the mental illness epidemic that plagues our country.