Anatomy of an Epidemic
Encyclopedia
Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America is book by Robert Whitaker
published in 2010 by Crown
. Whitaker asks why the number of Americans who receive government disability
for mental illness
approximately doubled since 1987. He tries to answer that question and examines the long-term outcomes for the mentally ill in the U.S. In April 2011 IRE
announced that the book had won its award as the best investigative journalism book of 2010 stating, "this book provides an in-depth exploration of medical studies and science and
intersperses compelling anecdotal examples. In the end, Whitaker punches holes in the
conventional wisdom of treatment of mental illness with drugs."
), gram negative antibiotics (specifically mephenesin
) and the anti-tuberculosis agents isoniazid
and iproniazid
respectively. The psychiatric mechanisms of action of these drugs were not known at the time and these were initially called major tranquilizers (now typical antipsychotics) due to their induction of "euphoric quietiude," minor tranquilizers (now benzodiazepines) and psychic energizers (now antidepressants) due to patients "dancing in the wards." These compounds were developed during a period of growth for the pharmaceutical industry bolstered by the 1951 Durham-Humphrey Amendment
giving physicians monopolistic prescribing rights thus aligning the interests of physicians and pharmaceutical companies. This also followed the industry's development of "magic bullets" that treat people with, for example, diabetes, which provided an analogy to sell the idea of these drugs to the public. It was not until many years later, after the mechanisms of these drugs were determined that the serotonergic hypothesis of depression and dopaminergic hypothesis of schizophrenia were developed to fall in line with the drug's mechanisms. According to Whitaker's analysis of the primary literature lower levels of serotonin and higher levels of dopmine have proved to be true in patients WITH prior exposure to antidepressants or antipsychotics (ie as homeostatic mechanisms) but NOT in patients without prior exposure.
Another means by which he undermines the magic bullet theory is that he shows that the historical notion that the "invention of the antipsychotic Thorazine
" having emptied the asylums is a myth. His case begins by showing that during the late 1940s and 1950s ~75% of cases admitted for first episode schizophrenia recovered to the community by approximately 3 years (Thorazine was not released until 1955). He then notes that the arrival of Thorazine did not improve discharge rates in the 1950s for people newly diagnosed with schizophrenia. In fact, based on the only large scale first episode schizophrenia study of this era, 88% of those who were not treated were discharged within eighteen months compared to 74% of neuroleptic treated. This is additionally evidenced by the fact that when Thorazine was introduced in 1955 there were 267k schizophrenia patients in state and county mental hospitals, and eight years later, there were 253k thus indicating that the advent of neuroleptics barely budged the number of hospitalized patients. What he argues actually cleared the asylums was the beginning of Medicare
and Medicaid
in 1965. These programs provided federal subsidies for nursing home care but no such subsidy for care in state mental hospitals, and so the states, seeking to save money, naturally began shipping their chronic patients to nursing homes.
He traces the effects of what looks like an iatrogenic
epidemic—unfortunately, the drugs that patients receive can perturb their normal brain function.
Whitaker suggests that the "wonder drug" glow around the second generation psychotropics has long since disappeared. He views the "hyping" of the top-selling atypical antipsychotic
s as "one of the more embarrassing episodes in psychiatry's history, as one government study after another failed to find that they were any better than the first-generation anti-psychotics".
One of Whitaker's solutions is the style of care documented by professor Jaakko Seikkula at Keropudas Hospital in Tornio
in Lapland where drugs are given to patients only on a limited basis—with good outcomes. According to Whitaker, the district has the lowest per capita spending on mental health of all health districts in Finland
. He also advocates that those with depression engage in exercise. Exercise for depression is so successful that in the UK the doctor may write a prescription for exercise. In fact, studies have shown that exercise produces a "substantial improvement" within six weeks, that its effect size is "large," and that 70% of all depressed patients respond to an exercise program. "These success rates are quite remarkable," German investigators wrote in 2008.
, did interviews with Salon
and The Boston Globe
during the release of this book. He also did a book tour, and he spoke for an hour and a half on C-SPAN
where there is an archived video. Still, in his book he explains that this story was never told in mainstream newspapers. For example, Whitaker says a study of long-term outcomes for people with schizophrenia done by Martin Harrow in 2007 (which Whitaker thinks is the best work ever done on the subject in the U.S.) was never in a National Institute of Mental Health
press release and thus never reached reporters at U.S. newspapers.
As of October 2010, the only negative review of the book, written by sleep researcher Dennis Rosen for The Boston Globe, asks for a review of data, and devotes a paragraph to Thabo Mbeki
and AIDS denialism. Other reviews were in New Scientist
, The Record, Time
magazine, and Salon
.
Over a year after the book was published, Marcia Angell
, former editor of The New England Journal of Medicine, published a two-part review of Whitaker's and other books in The New York Review of Books
which received a great deal of publicity. Dr. Angell was seeking and not finding any evidence after 50 years of use that psychiatric drugs have given patients any benefit. Among those who read Dr. Angell's review was John Horgan who then wrote a positive review for The Chronicle of Higher Education
. Horgan says the book has been ignored by the major media.
. MindFreedom International
started an online campaign and many people wrote to President Obama
. Whitaker was reinvited and delivered his address. However a psychiatrist, Dr. Mark Ragins, was added to the program to rebut Whitaker.
Robert Whitaker (author)
Robert Whitaker is an American journalist and author, writing primarily about medicine, science, and history.- Early career :He was a medical writer at the Albany Times Union newspaper, in Albany, N.Y., from 1989 to 1994. In 1992, he was a Knight Science Journalism fellow at MIT. Following that...
published in 2010 by Crown
Crown Publishing Group
-External links:*...
. Whitaker asks why the number of Americans who receive government disability
Social Security Disability Insurance
Social Security Disability Insurance is a payroll tax-funded, federal insurance program of the United States government. It is managed by the Social Security Administration and is designed to provide income supplements to people who are physically restricted in their ability to be employed...
for mental illness
Mental illness
A mental disorder or mental illness is a psychological or behavioral pattern generally associated with subjective distress or disability that occurs in an individual, and which is not a part of normal development or culture. Such a disorder may consist of a combination of affective, behavioural,...
approximately doubled since 1987. He tries to answer that question and examines the long-term outcomes for the mentally ill in the U.S. In April 2011 IRE
Investigative Reporters and Editors
Investigative Reporters and Editors, Inc. is a nonprofit organization that focuses on the quality of investigative reporting. Formed in 1975, it presents the IRE Awards and holds conferences and training classes for journalists. Its headquarters is in Columbia, Missouri, at the University of...
announced that the book had won its award as the best investigative journalism book of 2010 stating, "this book provides an in-depth exploration of medical studies and science and
intersperses compelling anecdotal examples. In the end, Whitaker punches holes in the
conventional wisdom of treatment of mental illness with drugs."
Magic bullets
Whitaker begins by showing that the antipsychotics, benzodiazepines and antidepressants were discovered as side effects during research for antihistamines (specifically promethazinePromethazine
Promethazine is a first-generation antihistamine of the phenothiazine family. The drug has anti-motion sickness, antiemetic, and anticholinergic effects, as well as a strong sedative effect and in some countries is prescribed for insomnia when benzodiazepines are contraindicated...
), gram negative antibiotics (specifically mephenesin
Mephenesin
Mephenesin is a centrally acting muscle relaxant. It can be used as an antidote for strychnine poisoning....
) and the anti-tuberculosis agents isoniazid
Isoniazid
Isoniazid , also known as isonicotinylhydrazine , is an organic compound that is the first-line antituberculosis medication in prevention and treatment. It was first discovered in 1912, and later in 1951 it was found to be effective against tuberculosis by inhibiting its mycolic acid...
and iproniazid
Iproniazid
Iproniazid is a hydrazine drug used as an antidepressant. It acts as an irreversible and nonselective monoamine oxidase inhibitor . Though it has been widely discontinued in most of the world, it is still used in France.- History :Iproniazid was the first antidepressant ever marketed...
respectively. The psychiatric mechanisms of action of these drugs were not known at the time and these were initially called major tranquilizers (now typical antipsychotics) due to their induction of "euphoric quietiude," minor tranquilizers (now benzodiazepines) and psychic energizers (now antidepressants) due to patients "dancing in the wards." These compounds were developed during a period of growth for the pharmaceutical industry bolstered by the 1951 Durham-Humphrey Amendment
Durham-Humphrey Amendment
The Durham-Humphrey Amendment explicitly defined two specific categories for medications, legend and over-the-counter . This amendment was co-sponsored by former vice president and senator Hubert H. Humphrey Jr., who was a pharmacist in South Dakota before beginning his political career...
giving physicians monopolistic prescribing rights thus aligning the interests of physicians and pharmaceutical companies. This also followed the industry's development of "magic bullets" that treat people with, for example, diabetes, which provided an analogy to sell the idea of these drugs to the public. It was not until many years later, after the mechanisms of these drugs were determined that the serotonergic hypothesis of depression and dopaminergic hypothesis of schizophrenia were developed to fall in line with the drug's mechanisms. According to Whitaker's analysis of the primary literature lower levels of serotonin and higher levels of dopmine have proved to be true in patients WITH prior exposure to antidepressants or antipsychotics (ie as homeostatic mechanisms) but NOT in patients without prior exposure.
Another means by which he undermines the magic bullet theory is that he shows that the historical notion that the "invention of the antipsychotic Thorazine
Chlorpromazine
Chlorpromazine is a typical antipsychotic...
" having emptied the asylums is a myth. His case begins by showing that during the late 1940s and 1950s ~75% of cases admitted for first episode schizophrenia recovered to the community by approximately 3 years (Thorazine was not released until 1955). He then notes that the arrival of Thorazine did not improve discharge rates in the 1950s for people newly diagnosed with schizophrenia. In fact, based on the only large scale first episode schizophrenia study of this era, 88% of those who were not treated were discharged within eighteen months compared to 74% of neuroleptic treated. This is additionally evidenced by the fact that when Thorazine was introduced in 1955 there were 267k schizophrenia patients in state and county mental hospitals, and eight years later, there were 253k thus indicating that the advent of neuroleptics barely budged the number of hospitalized patients. What he argues actually cleared the asylums was the beginning of Medicare
Medicare (United States)
Medicare is a social insurance program administered by the United States government, providing health insurance coverage to people who are aged 65 and over; to those who are under 65 and are permanently physically disabled or who have a congenital physical disability; or to those who meet other...
and Medicaid
Medicaid
Medicaid is the United States health program for certain people and families with low incomes and resources. It is a means-tested program that is jointly funded by the state and federal governments, and is managed by the states. People served by Medicaid are U.S. citizens or legal permanent...
in 1965. These programs provided federal subsidies for nursing home care but no such subsidy for care in state mental hospitals, and so the states, seeking to save money, naturally began shipping their chronic patients to nursing homes.
Psychiatric drugs
While Whitaker is pro-drug, he believes that medication must be used in a "selective, cautious manner. It should be understood that they’re not fixing any chemical imbalances. And honestly, they should be used on a short-term basis."He traces the effects of what looks like an iatrogenic
Iatrogenesis
Iatrogenesis, or an iatrogenic artifact is an inadvertent adverse effect or complication resulting from medical treatment or advice, including that of psychologists, therapists, pharmacists, nurses, physicians and dentists...
epidemic—unfortunately, the drugs that patients receive can perturb their normal brain function.
Whitaker suggests that the "wonder drug" glow around the second generation psychotropics has long since disappeared. He views the "hyping" of the top-selling atypical antipsychotic
Atypical antipsychotic
The atypical antipsychotics are a group of antipsychotic tranquilizing drugs used to treat psychiatric conditions. Some atypical antipsychotics are FDA approved for use in the treatment of schizophrenia...
s as "one of the more embarrassing episodes in psychiatry's history, as one government study after another failed to find that they were any better than the first-generation anti-psychotics".
One of Whitaker's solutions is the style of care documented by professor Jaakko Seikkula at Keropudas Hospital in Tornio
Tornio
Tornio is a town and municipality in Lapland, Finland. The municipality covers an area of of which is water. The population density is , with a total population of . It borders to the Swedish municipality of Haparanda...
in Lapland where drugs are given to patients only on a limited basis—with good outcomes. According to Whitaker, the district has the lowest per capita spending on mental health of all health districts in Finland
Finland
Finland , officially the Republic of Finland, is a Nordic country situated in the Fennoscandian region of Northern Europe. It is bordered by Sweden in the west, Norway in the north and Russia in the east, while Estonia lies to its south across the Gulf of Finland.Around 5.4 million people reside...
. He also advocates that those with depression engage in exercise. Exercise for depression is so successful that in the UK the doctor may write a prescription for exercise. In fact, studies have shown that exercise produces a "substantial improvement" within six weeks, that its effect size is "large," and that 70% of all depressed patients respond to an exercise program. "These success rates are quite remarkable," German investigators wrote in 2008.
Children
Whitaker sees that children are vulnerable to being prescribed a lifetime of drugs. As the author says, a psychiatrist and parents may give a child a "cocktail" to force him or her to behave. Then when this child grows up to eighteen, Whitaker says he or she becomes a disabled adult.Review of data and statistics
Over the year and a half he spent researching this book, Whitaker thoroughly reviewed U.S. government statistics and evidence in the scientific literature. He maintains a website where the scientific studies are linked.Reception and media coverage
Whitaker, who was a finalist for the 1998 Pulitzer Prize for Public Service and is an award-winning author and a former director of publications for the Harvard Medical SchoolHarvard Medical School
Harvard Medical School is the graduate medical school of Harvard University. It is located in the Longwood Medical Area of the Mission Hill neighborhood of Boston, Massachusetts....
, did interviews with Salon
Salon.com
Salon.com, part of Salon Media Group , often just called Salon, is an online liberal magazine, with content updated each weekday. Salon was founded by David Talbot and launched on November 20, 1995. It was the internet's first online-only commercial publication. The magazine focuses on U.S...
and The Boston Globe
The Boston Globe
The Boston Globe is an American daily newspaper based in Boston, Massachusetts. The Boston Globe has been owned by The New York Times Company since 1993...
during the release of this book. He also did a book tour, and he spoke for an hour and a half on C-SPAN
C-SPAN
C-SPAN , an acronym for Cable-Satellite Public Affairs Network, is an American cable television network that offers coverage of federal government proceedings and other public affairs programming via its three television channels , one radio station and a group of websites that provide streaming...
where there is an archived video. Still, in his book he explains that this story was never told in mainstream newspapers. For example, Whitaker says a study of long-term outcomes for people with schizophrenia done by Martin Harrow in 2007 (which Whitaker thinks is the best work ever done on the subject in the U.S.) was never in a National Institute of Mental Health
National Institute of Mental Health
The National Institute of Mental Health is one of 27 institutes and centers that make up the National Institutes of Health...
press release and thus never reached reporters at U.S. newspapers.
As of October 2010, the only negative review of the book, written by sleep researcher Dennis Rosen for The Boston Globe, asks for a review of data, and devotes a paragraph to Thabo Mbeki
Thabo Mbeki
Thabo Mvuyelwa Mbeki is a South African politician who served two terms as the second post-apartheid President of South Africa from 14 June 1999 to 24 September 2008. He is also the brother of Moeletsi Mbeki...
and AIDS denialism. Other reviews were in New Scientist
New Scientist
New Scientist is a weekly non-peer-reviewed English-language international science magazine, which since 1996 has also run a website, covering recent developments in science and technology for a general audience. Founded in 1956, it is published by Reed Business Information Ltd, a subsidiary of...
, The Record, Time
Time (magazine)
Time is an American news magazine. A European edition is published from London. Time Europe covers the Middle East, Africa and, since 2003, Latin America. An Asian edition is based in Hong Kong...
magazine, and Salon
Salon.com
Salon.com, part of Salon Media Group , often just called Salon, is an online liberal magazine, with content updated each weekday. Salon was founded by David Talbot and launched on November 20, 1995. It was the internet's first online-only commercial publication. The magazine focuses on U.S...
.
Over a year after the book was published, Marcia Angell
Marcia Angell
Marcia Angell, M.D. is an American physician, author, and the first woman to serve as editor-in-chief of the New England Journal of Medicine...
, former editor of The New England Journal of Medicine, published a two-part review of Whitaker's and other books in The New York Review of Books
The New York Review of Books
The New York Review of Books is a fortnightly magazine with articles on literature, culture and current affairs. Published in New York City, it takes as its point of departure that the discussion of important books is itself an indispensable literary activity...
which received a great deal of publicity. Dr. Angell was seeking and not finding any evidence after 50 years of use that psychiatric drugs have given patients any benefit. Among those who read Dr. Angell's review was John Horgan who then wrote a positive review for The Chronicle of Higher Education
The Chronicle of Higher Education
The Chronicle of Higher Education is a newspaper and website that presents news, information, and jobs for college and university faculty, staff members and administrators....
. Horgan says the book has been ignored by the major media.
Controversy
Whitaker, who had been an invited keynote speaker, was "uninvited" from the Alternatives 2010 conference. The event has been funded since 1985 by the Substance Abuse & Mental Health Services Administration of the United States Department of Health and Human ServicesUnited States Department of Health and Human Services
The United States Department of Health and Human Services is a Cabinet department of the United States government with the goal of protecting the health of all Americans and providing essential human services. Its motto is "Improving the health, safety, and well-being of America"...
. MindFreedom International
MindFreedom International
MindFreedom International is an international coalition of over one hundred grassroots groups and thousands of individual members from fourteen nations. It was founded in 1990 to advocate against forced medication, medical restraints, and involuntary electroconvulsive therapy. Its stated mission is...
started an online campaign and many people wrote to President Obama
Barack Obama
Barack Hussein Obama II is the 44th and current President of the United States. He is the first African American to hold the office. Obama previously served as a United States Senator from Illinois, from January 2005 until he resigned following his victory in the 2008 presidential election.Born in...
. Whitaker was reinvited and delivered his address. However a psychiatrist, Dr. Mark Ragins, was added to the program to rebut Whitaker.
External links
- Book home page at author's site, Mad in America
- Author keynote at Alternatives 2010 (funded by the Substance Abuse & Mental Health Services Administration of the U.S. Department of Health and Human Services)
- Part One
- Part Two
- Part Three
- Part Four