A cure worse than the illness?


Could psychiatric drugs be fuelling an epidemic of mental illness? Robert Whitaker, the award-winning author of a new book on the subject, raises disturbing questions for psychiatry. CARL O’BRIENreports

WHEN ROBERT Whitaker, an award-winning medical reporter, came upon a study by the World Health Organisation on outcomes for patients with schizophrenia a few years ago, he was puzzled.

It said the best outcomes were for people from some of the poorest countries in the world – India, Colombia, Nigeria – rather than the richest countries. It didn’t make sense. How could the outcomes be so poor for well-off nations with access to specialist drugs?

“I was startled to find that just a small percentage of patients in those poor countries were on medication for their condition,” says Whitaker.

“At the same time, I discovered that the number of disabled mentally ill in the US had tripled over the past 20 years.”

It prompted a flurry of queries, but they all boiled down to a single, central question: why has the number of people plagued with mental illness problems been skyrocketing at a time when we have access to medicine that is supposed to be more effective than ever before?

The result of Whitaker’s investigation is Anatomy of an Epidemic, the first major book to investigate the long-term outcomes of patients treated with psychiatric drugs. Through thorough research and personal testimonies, he draws a chilling overall conclusion: that the drugs we so widely use may be doing more harm than good.

The book, published last year, is causing a stir in the US and prompting fiery responses from some members of the psychiatric profession. But it is also causing significant numbers of professionals to rethink their approach to prescribing drugs.

“It’s been a slowly, gathering impact. In the US, this is a very sensitive subject and immediately brings up all sorts of tensions,” he says.

Ironically, for an issue which is fast becoming a burning question in psychiatry, the question of how effective psychiatric drugs are over the longer term isn’t a new one.

Whitaker points to a paper by Jonathan Cole – regarded as the father of American psycho-pharmacology – in the 1970s entitled Is the Cure Worse Than the Disease? This indicated that anti-psychotic medication wasn’t the magic bullet that many hoped it was.

Cole reviewed all of the long-term effects the drugs could cause and observed that studies had shown that at least 50 per cent of all schizophrenia patients could fare well without the medication.

“Every schizophrenic outpatient maintained on anti-psychotic medication should have the benefit of an adequate trial without drugs,” Cole wrote at the time.

Whitaker maintains that psychiatry, in effect, shut off further public discussion of this sort. In the 1970s, he says, psychiatry was fighting for survival. The two main classes of drugs – anti-psychotics and benzodiazepines such as Valium – were increasingly regarded as harmful and sales declined.

At the same time, there was a dramatic increase in the number of counsellors and psychologists offering talk therapy and other non-drug based approaches.

“Psychiatry saw itself in competition for patients with these other therapists, and in the late 1970s, the field realised that its advantage in the marketplace was its prescribing powers . . . it consciously sought to tell a public story that would support the use of its medications, and embraced the ‘medical model’ of psychiatric disorders.”

But many studies show that psychiatric drugs – such as anti-depressants – are highly effective. There are tens of thousands of people who will attest to benefits of these drugs. Many say they simply couldn’t survive without them.

Whitaker counters he is not advocating the total avoidance of drugs. The short-term effects of many drugs are clearly beneficial. But, he says, when you look at the long-term impact of them, the literature consistently shows incredibly poor outcomes, with many becoming chronically ill as a result.

Most of these studies, he says, have received little or no coverage or have been “spun” to veil the real findings. It’s not in the interests of psychiatry or the pharmaceutical industry to highlight them.

He says the literature shows that many people can recover without recourse to drugs. As a result, more caution is needed and drugs should be administered more sparingly.

“You have to raise the question of what happens to medicated patients in the long term, compared with what happened in previous times,” he says.

There are obvious lines of attack against Whitaker’s findings: one is that the rise in the number of disabled mentally ill people is not due to medication, but may be due to other factors such as better diagnosis.

Whitaker says: “I agree that the correlation between the two – increased use of psychiatric medications and increased disability numbers – does not mean that the increased use of psychotropics caused the rise. But I never claimed that it did. As I say in the opening chapter of the book, the disability numbers simply raise a question.”

He agrees that the broadening of diagnostic categories has led to an ever-greater number of adults and children under the “psychiatric tent”. But, he maintains, if psychiatric medications were effective long-term treatments which helped people function well, then that increase in diagnosis and treatment shouldn’t lead to a rise in disability. “If you have drugs that exacerbate the long-term course of an ‘illness’ or can transform a milder illness into a more serious one, then the more that illness is diagnosed and treated, the greater the toll that illness will take on society.”

What makes Whitaker’s findings so powerful are that he did not come to this area with the baggage of an anti-drugs zealot or as part of an anti-psychiatry crusade. The opposite was the case.

As a reporter, he remembers investigating a trial involving the withdrawal of drugs from psychiatric patients – in which researchers carefully tallied the number of patients who became sick again and had to be re-hospitalised – and considering the practice to be outrageous and unethical.

“I began this long intellectual journey as a believer in the conventional wisdom,” he says. “I believed psychiatric researchers were discovering the biological causes of mental illnesses and that this knowledge led to the development of a new generation of drugs that helped ‘balance’ brain chemistry.”

There is a way forward, according to Whitaker, and it lies in parts of the world which have the best outcomes.

Western Lapland in Finland has adopted a form of care for its psychotic patients that has produced astonishingly good long-term outcomes, he says.

In follow-up checks after both two and five years, 80 per cent of first- episode psychotic patients in the region were either employed or back at school. Yet only about one-third of the patients were ever exposed to anti-psychotic medication, and only 20 per cent end up taking the drugs on a continual basis.

The questions for psychiatry, then, are urgent. Is our medical model of care really working? Does it help people struggling with psychiatric illness to get well and stay well? Is there a reason to believe the medicating of children will help them grow into healthier adults? As for now, we have lots of questions, but precious few definitive answers.

Robert Whitaker is due to speak at the Edmund Burke Theatre, Arts Building, TCD at 2pm on Saturday and also at the D4 Ballsbridge Inn, Dublin, on March 2nd at 7.30pm (see seminars.ie). He is also due to speak in Athlone and Cork. See tinyurl.com/68wxjup