by Robert Whitaker

Crown, 404 pp., $26.00

About three-quarters of the way through Robert Whitaker’s expose of the psychiatric drug industry, Anatomy Of An Epidemic, I found myself beginning to worry. Whitaker’s claim is that contrary to what we have been told, psychiatric medications actually cause far more mental illness than they cure. Chapter by chapter, he had built a damning case at which to nod and wince—but now I was neck-deep in the chapter on antidepressants, and I was no longer nodding but reading with concern.

For several years back in my 30s, I had sought desperately for an antidepressant that would “cure” me of my longstanding depression and associated shyness; that would, as psychiatrist and author Peter Kramer infamously wrote in his own book, Listening To Prozac, make me “better than well.” I had tried and flunked not just Prozac, but a half-dozen other antidepressants, often combined with other psychoactive drugs that psychiatrists believed might “potentiate” the antidepressant effect: lithium, synthetic thyroid, speed (Dexedrine), an anti-narcolepsy drug (Provigil), bromocriptine, naltrexone, Depakote, amantadine. None of these drugs or drug combinations ever succeeded in doing much more than ruin my sleep, and I had long ago given up the quest for a magic bullet in favor of the quieter avenues of talk therapy. Yet now I found myself wondering: in those few years of drug experimentation, had I inadvertently made myself more rather than less vulnerable to future bouts of depression? Had I in fact damaged my brain, as the studies cited in the chapter I was now reading implied was a very real possibility?

I’ll most likely never know. And in fact, I’m not all that worried. The greatest danger of brain damage, the book asserts, is for persons who are “maintained” by their doctors not just intermittently, but continuously for many years on antidepressants or other psychiatric medications. The conventional wisdom is that maintenance in this manner helps prevent relapse back into depression—or back into schizophrenia, if one is taking antipsychotics; or back into anxiety, if one is taking an “antianxiety” medication such as Xanax. After reading Anatomy Of An Epidemic, I am thankful that I am not being maintained in this manner. I do not have to worry if the antidepressant I am taking every day is accelerating cell death in the hippocampus, an area of the brain important for mood and memory; or if the antipsychotic I am taking is causing my frontal lobes to shrink, eventually giving me what amounts to a drug-induced lobotomy; or if my antianxiety medication is destroying brain receptors in such a way as to possibly make my anxiety symptoms permanent.

Enough preamble; let’s talk about the book itself. In Anatomy Of An Epidemic we have a message that is deliberately alarming; that goes out of its way to deconstruct and debunk what we have been told for decades not only by the pharmaceutical industry and by psychiatry as a profession, but by our most trusted news sources on mental health issues—e.g. science-friendly publications such as TIME magazine and the New York Times. ^[1] So you may well ask: with the media and medical establishments firmly in favor of psychiatric drugs, is Whitaker’s book worth reading, or merely an alarmist screed?

This question is less rhetorical than it may seem. In fact, for many people it could be a very threatening question if taken seriously. Let us say that you take psychiatric medications yourself, or that your spouse or partner or child takes them; if so, you might very well be forced by reading Anatomy Of An Epidemic to consider a decision you would rather not have to make—namely, whether to take yourself or your kids off the drugs to minimize or hopefully reverse what may already be a process of progressive incapacity, slow at first, not so slow later on. There would be some major downsides to quitting: for one, the possibility of feeling very sick mentally and physically until your brain and body hopefully healed; for another, the need to negotiate alternative social support or therapy in the absence of drugs; and then finally, the fact that you would be holding a decidedly minority view on the topic, with everyone from family to doctors saying you were crazy and making a mistake.

So—if you or someone you love is indeed on medication, you may even at this moment be weighing such potential downsides in your mind, and concluding that it is easier to skip this book and keep going with the drugs. You may rationalize that after all, every drug has its side effects, but the short-term benefits are so clear (in your case, or in your children’s case, etc.) that it is worth it. And besides, why should we not trust our best news institutions to tell us the truth? Why listen to some crank who insists we are in peril, when he might be wrong?

Yet I urge you to reconsider and read Anatomy of An Epidemic anyway, even with all the doubts your mind can muster. And I will devote the rest of this review to reasons why. Most of what I say will be picking through highlights from the book, but even these highlights should serve to illustrate the cogency and thoroughness of Whitaker’s reporting and reasoning. And they should illustrate as well why you should not, in fact, necessarily trust large news organizations to know what they are talking about. And not automatically trust your shrink or your GP on this issue, either, if they are of the conventional thinking. Please note that I will discuss objections to the book’s thesis near the end of the review, so it will not be unbalanced in that regard.

A paradox leads to a challenge

At heart, Whitaker’s challenge to conventional wisdom is simple. Two mental-health booms have coincided in the U.S. since the 1950s: a boom in severe mental illness, and a boom in the invention and prescription of psychiatric drugs that supposedly treat these illnesses with great success. It’s a clear paradox. Shouldn’t the invention of new and better drugs see a decline in rates of mental illness, not an increase? One possibility would be that the true rate of mental illness is more or less the same, but more people are getting diagnosed than ever before thanks to changes in societal standards and improved outreach. Another possibility would be that societal problems such as the loss of the extended family have increased, thereby making it harder for mentally fragile people to find the support they once enjoyed outside of institutions and drugs. Such arguments may have some merit, but Whitaker asserts that clean data collected since the 1970s and 1980s suggests there is an additional dynamic going on that cannot be explained in this way. In fact, he says, these figures clearly show a dramatic increase in the real rate of severe mental illness in this country.

And this double boom in both drugs and mental illness is not the only paradox. Another is illustrated by a series of studies by the World Health Organization. These studies have found that outcomes for schizophrenia, an especially difficult mental illness, are much better in poor countries like Nigeria and India than in rich countries like the U.S. In poor countries, most schizophrenia patients over a period of years recover and return to work; in rich countries, the opposite is true: most never recover, and most never return to work. Why might this be? It is worth quoting Whitaker at length here, to show the pains he takes in his reporting and reasoning:

Although the WHO investigators didn’t identify a reason for the stark disparity in outcomes, they had tracked antipsychotic usage in the second study, having hypothesized that perhaps patients in the poor countries fared better because they more reliably took their medication. However, they found the opposite to be true. Only 16 percent of the patients in poor countries were regularly maintained on antipsychotics, versus 61 percent of the patients in the rich countries. Moreover, in Agra, India, where patients arguably fared the best, only 3 percent of the patients were kept on an antipsychotic. Medication usage was highest in Moscow, and that city had the highest percentage of patients who were constantly ill.

Whitaker sets up his argument with these and similar paradoxical figures. There are two possibilities, he tells us: either psychiatric drugs really do work as advertised, helping people recover from severe mental illness and stay recovered; or they don’t work as advertised, but instead make people worse. Either way, he suggests, long-term outcome data for affected persons in the U.S. ought to reflect what is happening. Either outcomes will be better with drugs, or they will be worse with drugs. And with that he invites us to follow us into the body of the book, where we will learn how these drugs were discovered, how they have been marketed, and how they have actually affected the lives of people taking them—and taking them not just for a few weeks or months, as required for a typical drug company study, but for the years and decades that constitute maintenance in conventional psychiatric treatment.

1. ^[1] It is worth noting that the Times did not review the book, but did choose to give op-ed space to Peter Kramer so that Kramer could rebut the positive review of the book that appeared in The New York Review of Books. (I noted that positive review in an earlier post on this site, which you can find here.) And although TIME on the other hand did review the book, the review was a single back-page paragraph. This can be compared to the news features TIME regularly runs on mental illness in which drugs are a key component of treatment: see for example the last page of Health Checkup: Kids and Mental Health, Oct. 21, 2010, which virtually mandates drug treatment for bipolar children—a tactic Whitaker argues leads to worse outcomes for children as surely as it does for adults. ↩

The story was a group effort by several reporters (as is typical for deadline pieces about shocking disasters) and was for the most part soberly factual. And yet, strangely, the last seven paragraphs managed to twist the incident into a peculiar and unsupported vein of speculation: the actions of this lone Norwegian gunman, the Times asserted, were somehow proof that Al Qaeda and similar groups were either now, or would be soon, upping the scale of their attacks on Western countries. Here are the key paragraphs that carried this assertion:

Terrorism specialists said that even if the authorities ultimately ruled out Islamic terrorism as the cause of Friday’s assaults, other kinds of groups or individuals were mimicking Al Qaeda’s brutality and multiple attacks.

“If it does turn out to be someone with more political motivations, it shows these groups are learning from what they see from Al Qaeda,” said Brian Fishman, a counterterrorism researcher at the New America Foundation in Washington. “One lesson I take away from this is that attacks, especially in the West, are going to move to automatic weapons.”

How could an otherwise straightforward news story, reported and carried by one of the most respected news organizations in the U.S., deviate into an ugly fantasy that made no sense in the context of the facts? And which might strike some observers as likely to stir up anti-Islamic prejudice without reason? These questions become especially pertinent—indeed, ironic— in light of the fact that today’s story in the Times carries further reports that the killer was not just right-wing, but “a gun-loving Norwegian obsessed with what he saw as the threats of multiculturalism and Muslim immigration.”

It would be easy to blame the newspaper and the reporters as sloppy at best, irresponsible at worst. Yet the Times really is one of the better newspapers in this country, and likewise its staff. So there must be some explanation other than simple irresponsibility. And in fact, having worked in newspapers myself for 10 years, I think I know the answer: the reporters, under pressure of deadline and group loyalty, and with editors looking over their shoulders even more than usual, felt compelled to obey journalistic conventions in every particular.

The last seven paragraphs of the story, including the two quoted above, do indeed veer away from fact and into speculation—but one of the conventions for breaking news stories in the Times and elsewhere is to include exactly such speculation, so long as “experts” and government officials can be found to provide it. This is especially true when not all the facts are yet known about why something happened. A classic journalism cliche is “One dead Englishman equals 10 dead Frenchmen”; to this we might add, “It would be irresponsible if we said it, but it’s fine if an official or an expert says it.”

To show how conventions distorted this particular story, here are the last seven paragraphs with my commentary explaining how they were likely arrived at. You can first read the paragraphs by themselves, then click the link to see my comments.

American counterterrorism officials cautioned that Norway’s own homegrown extremists, with unknown grievances, could be responsible for the attacks.

Initial reports focused on the possibility of Islamic militants, in particular Ansar al-Jihad al-Alami, or Helpers of the Global Jihad, cited by some analysts as claiming responsibility for the attacks. American officials said the group was previously unknown and might not even exist.

There was ample reason for concern that terrorists might be responsible. In 2004 and again in 2008, the No. 2 leader of Al Qaeda, Ayman al-Zawahri, who took over after the death of Osama bin Laden, threatened Norway because of its support of the American-led NATO military operation in Afghanistan.

Norway has about 550 soldiers and three medevac helicopters in northern Afghanistan, a Norwegian defense official said. The government has indicated that it will continue to support the operations as long as the alliance needs partners on the ground.

Terrorism specialists said that even if the authorities ultimately ruled out Islamic terrorism as the cause of Friday’s assaults, other kinds of groups or individuals were mimicking Al Qaeda’s brutality and multiple attacks.

“If it does turn out to be someone with more political motivations, it shows these groups are learning from what they see from Al Qaeda,” said Brian Fishman, a counterterrorism researcher at the New America Foundation in Washington. “One lesson I take away from this is that attacks, especially in the West, are going to move to automatic weapons.”

Muslim leaders in Norway swiftly condemned the attacks. “This is our homeland, this is my homeland,” said Mehtab Afsar, secretary general of the Islamic Council of Norway. “I condemn these attacks, and the Islamic Council of Norway condemns these attacks, whoever is behind them.”

Journalists themselves—or at least the more reflective among them—are often quite aware of the hollowness of such conventions as relying on politicians and experts for seeming “objectivity.” Russell Baker, a longtime newsman who became a feature columnist for the Times, was particularly stinging on this point. As he wrote in a 1985 column titled “Groundhogs and Journalists“:

I am often asked what is the most disagreeable aspect of the journalist’s trade. At one time my answer would have been “covering the Thanksgiving Day parade,” a chore that can forever maim the spirit of any person not easily moved to superlatives by vast quantities of inflated rubber.

Later I amended this judgment after being sent to work in Washington. There the journalistic code required “objectivity,” which forbade a reporter to write of, say, Sen. Blattis: “Lying as usual, Sen. Blattis declared today . . . ”

This obligation to assist in dignifying inferior men was even more dispiriting than the obligation to gush with enthusiasm for rubber floats. It made you feel inhuman, as though you were nothing more than a megaphone for the convenience of frauds.

An excellent book on the problems with conventional news reporting used to be Reading the News, a collection of essays published in 1986 and edited by Robert Manoff. However this book is apparently out of print, and I don’t have anything else to recommend at the moment. More pressing is the question of what we can do as the reading public to push for more responsible reporting from our remaining news institutions. At the moment I have no answer. Personally, I no longer read the front page of the Times anymore, whether in hard copy or online—but that is not a solution.

Yet perhaps the story may change. Several books have recently been written that call the mantra into question; and negative information continues to come forth. Especially diligent in unearthing scary facts is journalist Robert Whitaker, author of one of these recent books, Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America. His latest blog post at Psychology Today summarizes several studies claiming that antidepressants may do worse than simply not work—they may actually worsen depression, via a phenomenon called “tardive dysphoria.” Whitaker isn’t shy about speculating about dire scenarios:

But now here we are 40 years later, with perhaps ten percent of American adults taking an antidepressant, and researchers are writing about “oppositional tolerance,” and drug-induced “tardive dysphoria.” That is surely a health outcomes story that needs to investigated, and if we want to put this into an even sharper moral context, we need only consider this: Many teenagers are now being prescribed an antidepressant, and when they take the drug, their brains will develop “oppositional tolerance” to it. What percentage of these youth will end up with drug-induced tardive dysphoria, and thus suffer a lifetime of chronic depression?

Many people are already leery of the antidepressants they feel they must take. If word spreads of studies like these, I can imagine all hell breaking loose. But what narrative will patients choose to replace the current one? And where will they turn if not to drugs?

Expert on Mental Illness Reveals Her Own Fight

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Update and related post: Should “wounded healers” confess to their wounds?

The review is titled The Epidemic of Mental Illness: Why? and the books involved are The Emperor’s New Drugs: Exploding the Antidepressant Myth, by Irving Kirsch, Basic Books, 226 pp., $15.99 (paper); Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America, by Robert Whitaker, Crown, 404 pp., $26.00; and Unhinged: The Trouble With Psychiatry—A Doctor’s Revelations About a Profession in Crisis, by Daniel Carlat, Free Press, 256 pp., $25.00.

The reviewer herself, Marcia Angell, is bylined as former editor in chief of The New England Journal of Medicine, so it would be hard to argue that she is a naive audience for the topic. Although the review is already online, it is forward-dated to the June 23 issue of the magazine; it is billed as the first of two parts, so we must wait till the second installment arrives to find out exactly where Angell stands. From what she has written so far, though, she seems extremely sympathetic to the anti-medication arguments in all three books. If you are at all interested, you should read the review yourself; but here are a few snippets that I find particularly arresting.

When it was found that psychoactive drugs affect neurotransmitter levels in the brain, as evidenced mainly by the levels of their breakdown products in the spinal fluid, the theory arose that the cause of mental illness is an abnormality in the brain’s concentration of these chemicals that is specifically countered by the appropriate drug. For example, because Thorazine was found to lower dopamine levels in the brain, it was postulated that psychoses like schizophrenia are caused by too much dopamine. Or later, because certain antidepressants increase levels of the neurotransmitter serotonin in the brain, it was postulated that depression is caused by too little serotonin . . .

. . . the main problem with the theory is that after decades of trying to prove it, researchers have still come up empty-handed. All three authors document the failure of scientists to find good evidence in its favor. Neurotransmitter function seems to be normal in people with mental illness before treatment.

And what about the anecdotal trump card we can all pull out, of our friend or relative who says that in their dark hours, it was an antidepressant that helped them more than anything else? According to the review, one of the authors, Irving Kirsch, is a psychologist at the University of Hull in the UK; he has been studying antidepressants for 15 years, and has come to the conclusion that they are essentially a kind of super-placebo: because they exhibit detectable side-effects, they convince the persons taking them of their benefits. In other words, if the side-effects did not occur, it seems very possible that the persons taking the drugs would not know to feel better. Angell summarizes Kirsch’s argument on this point this way:

[He] was also struck by another unexpected finding. In his earlier study and in work by others, he observed that even treatments that were not considered to be antidepressants—such as synthetic thyroid hormone, opiates, sedatives, stimulants, and some herbal remedies—were as effective as antidepressants in alleviating the symptoms of depression. Kirsch writes, “When administered as antidepressants, drugs that increase, decrease or have no effect on serotonin all relieve depression to about the same degree.” What all these “effective” drugs had in common was that they produced side effects, which participating patients had been told they might experience . . .

He suggests that the reason antidepressants appear to work better in relieving severe depression than in less severe cases is that patients with severe symptoms are likely to be on higher doses and therefore experience more side effects.

I wonder if this also might explain the widespread phenomenon of “poop-out,” in which a medication that had seemed helpful suddenly stops working. A placebo effect only lasts for so long before life intrudes again.

ACT was founded sometime in the late 1980s by psychologist Steven Hayes and a handful of close colleagues, but didn’t get much in the way of mainstream notice until starting in 2005, the same year I came across it. In February of that year TIME ran a feature on Hayes; and exactly 12 months later, Salon ran a Q and A interview. Both articles are worth reading, even though both get a great deal wrong—not a surprise when you consider the difficulty of explaining in words that words are not what they say they are.

In one sense, the purpose of ACT is as mundane as it is for most psychotherapies: to help people seeking relief from depression, anxiety, and similarly labeled mental health syndromes. But ACT’s means of doing so is radical, and includes among other things the tearing down of the central assumption of Western psychotherapy that mental illness is a disease state, the opposite of which is “normality.” Instead, like Buddhism, ACT asserts that human suffering is ubiquitous, brought on by conceptual thinking (i.e. “language”) that masquerades as reality. Thus the ultimate goal is not mere symptom relief, but liberation.

But where Buddhism is traditional and spiritual, ACT is science-based, heir among other things to the school of radical behaviorism espoused by B.F. Skinner. And where Buddhist techniques are slow and diffuse, some ACT techniques are quite quick. Overall the therapy resembles other brief talk therapies in that it can help many problems in a dozen or less meetings between therapist and client.

I’m an advocate of ACT even for people who don’t need therapy, yet occasionally get hung up in one area or another. From a “doing” point of view, ACT can be simple once you get it. On the other hand, the theory involved is difficult to explain, even to folks who meditate or follow other mindfulness-related pursuits, such as yoga. ACT isn’t meditation, and it isn’t just mindfulness, although mindfulness is a crucial component. The trickiest aspects of ACT, those dealing with language, are actually derived from something called Relational Frame Theory; Hayes and his colleagues developed RFT as a model both to explain ACT and to improve it. You can read a brief account of RFT here; or you can ponder this passage from an unpublished essay of mine (the 67th draft or thereabouts):

Even a kindergartner can tell you that a dime is “bigger” than a nickel, ignoring the physical reality in favor of an arbitrary social agreement. As adults, most of us can’t see thoughts as thoughts, any more than we can see the air we breath. An example of this is our tendency to treat descriptions and evaluations alike. A description such as “This teapot is red” can be checked for truth, that is, for a one-to-one correspondence with reality; an evaluation such as “I am a bad person,” on the other hand, is a blaming statement that has no truth value, only a social function. And yet we spend our lives worrying about whether we’re bad or good people, as if a self-description were as solid as a teapot.

The above is the merest hint of what RFT deals with and should not be taken very seriously. And beyond that, other psychologists outside of RFT are also doing interesting work with language as behavior—for example, Bertram Malle of Brown University has developed an expanded version of the folk theory of mind, dealing with how we create stories to explain the actions of both ourselves and other persons.