Robert Whitaker (2010) New York: Crown Publishers. 416 pp.
Every psychiatrist encounters the antipsychiatry movement. It is encountered in the skeptical colleague who wonders why you wasted your medical degree, in the relative who asks if you still perform lobotomies on everyone, and in the patient who insists that they would never take a psychiatric medication but wants alprazolam. The stigma surrounding the mentally ill and those who treat them endures. So why should you consider reading a provocative book whose dust jacket compares psychotropic drugs to a phrenology chart?
After spending a week alternately wanting to throw this book across the room in disgust and excitedly researching the studies it cites, I found three reasons. First, Whitaker reviews decades of studies, explores novel mental health programs, and interviews many people with mental illness. Whitaker raises important questions about the misuse and overuse of psychotropic drugs and introduced me to the thought-provoking longitudinal studies conducted by Ross Baldessarini and Martin Harrow. Second, the book is being compared to Rachel Carson's Silent Spring, and Whitaker hopes to spark an analogous reform movement. Whitaker has spoken at multiple conferences, delivered a grand rounds presentation at the Massachusetts General Hospital Department of Psychiatry, and founded a nonprofit organization called the Foundation for Excellence in Mental Health Care. Whitaker is advancing his argument, and psychiatrists should respond. Finally, his book is an object lesson in the hazards of interpretation.
Whitaker begins by making two observations. He observes a startling rise in the rates of psychiatric disability from 1987, when 1 in every 184 Americans was disabled by mental illness as defined by receiving Supplemental Security Income or Social Security Disability Insurance payments, to 2007, when 1 in every 76 Americans was disabled by mental illness. As Whitaker notes, the rates of disability because of mental illness more than doubled by this measure. He also observes a dramatic increase in the prescriptions of psychiatric drugs over roughly the same period of time.
He then asks an important question-that of how these two observations are related-before settling for a simple answer: the latter causes the former. Whitaker believes that, as psychiatrists prescribed more psychotropic drugs, they caused more Americans to become mentally disabled.
His thesis seems easy to dismiss, but Whitaker is a fluent writer who synthesizes interviews, depositions, case reports, cohort studies, randomized controlled trials, and basic science studies into a single story. As I read the book, recommended to me by a psychiatry intern who was shaken by its claims, I was unsettled. Whitaker criticizes the rigor of key studies, summarizes concerns that the DSM increases psychiatric diagnoses, details the compromising relationships between academic psychiatry and the pharmaceutical industry, and shows how the selective reporting of data skews perceptions of the efficacy and safety of psychotropic drugs.
The trouble is that, while there is merit to many of these criticisms, Whitaker's argument is totalizing. He does not simply criticize the use of alprazolam for anxiety, something many psychiatrists second, but he criticizes the use of every psychotropic drug for every chronic mental illness. Each agent he considers-antipsychotic, antidepressant, benzodiazepine, lithium, and stimulants-are ultimately "pathological agents." In his conclusion, he acknowledges that medications can be used for "some people" but then demands that psychiatry "admit that the drugs, rather than fix chemical imbalances in the brain, perturb the normal functioning of neurotransmitter pathways" (p. 333). In this statement, the expansive sweep of Whitaker's interpretation becomes clear: I know of no serious psychiatrist who believes that psychotropic drugs "fix chemical imbalances in the brains" of their patients.
The problem is, as it so often is in antipsychiatry literature, that the assumption that the critical factor in any bad outcome is the psychiatrist. In this book, Whitaker never seriously considers the changes in government definitions of disability, diagnostic standards, family structures, alcohol and illicit drug use, incarceration rates for the mentally ill, economic inequality, a shift throughout medicine to prescribe, the prescribing of psychotropic drugs by nonpsychiatrists, or any other possible confounder. If I proposed to resolve the fascinating question Whitaker poses-the relationship between psychiatric disability and psychotropic prescriptions-in the manner he does, my study would be summarily rejected for publication for never considering these other possible confounders. The result is a book that is a well-narrated collection of interpretations that advance a singular argument. Whitaker lingers over observational studies but crudely summarizes a complex, well-controlled, government-funded study-like the Clinical Antipsychotic Trials of Intervention Effectiveness study trial-in two sentences, to the effect that none of the drugs worked.
This is a shame because you could write a complex book on the dangers of polypharmacy, on the benefits of stopping and starting psychotropic medications gradually, on trying to decide who needs psychotropic drugs and who does not, on the need for well-designed long-term studies of the consequences of using psychotropic drugs, on whether (and which) psychosocial interventions are more or less helpful than psychotropic drugs, and on the need to reform the relationships between psychiatrists and the pharmaceutical industry. The data gathered by Whitaker would inform that book, a book that acknowledges the limits of psychiatric knowledge and the irreducible complexity of people with mental illness. Instead, Whitaker is just as crass a materialist as the psychiatrists he caricatures, settling for a simple but crude interpretation: those drugs messed you up.
Abraham M. Nussbaum, MD, MTS
and Department of Psychiatry
University of Colorado
School of Medicine