SHAME

A Review Of Robert Whitaker's Mad In America: Bad Science, Bad Medicine, And The Enduring Mistreatment Of The Mentally Ill.

By Nathaniel S. Lehrman, M.D.

Drug company scams are finally becoming increasingly visible. And a new book shows how much they harm the most seriously mentally ill.

The front page of the May 17 Wall Street Journal compared the use of a generic drug selling for less than $50 a dose with that of another new, highly-promoted product costing $7,000, and concluded that it is the drug manufacturers' financial clout, rather than a drug's effectiveness, which influences doctors' prescribing choices. The May 28 Washington Post reported that "the American Psychiatric Association GlaxoSmithKline Convention" was one member's characterization of its just-ended annual meeting. "Each of the 19,000 attendees was given a gray bag with the insignia of the meeting and the orange logo of GlaxoSmithKline PLC, the maker of the antidepressant Paxil." Pharmaceutical companies paid the APA about $50,000 for each of several dozen symposia at the meeting, so they could "control which scientists and papers were presented and help shape the presentations." Convention revenues, primarily from drug companies, "represent about 22 percent of all Association funding."

Psychiatry has been my specialty since 1947. The fundamentally flawed basis of drug company influences within it have now been exposed by Robert Whitaker's masterful Mad in America: Bad Science, Bad Medicine, and the Enduring Mistreatment of the Mentally Ill.

Neuroleptic drugs are the basis of this multi-billion dollar enterprise. Do they help schizophrenic patients - as has been claimed since their introduction in the 1950's - or harm them? Whitaker answers this key question by proving that the drugs are harmful, and that psychiatry, paid off by the drug companies, refuses to face its consequently worsening treatment results.

The first half of the book catalogs the often-shameful history of psychiatric treatment: surgical removal of organs, multiple dental extractions, insulin-induced comas, and the widely-acclaimed, Nobel-prize-winning lobotomy - the ice-pick operation. He maintains that psychiatrists' search for physiological causes of mental illness underlies both these various horrors and what he sees as their continuation - the neuroleptic drugs originally called "chemical lobotomies."

The book's second half, which has evoked psychiatric fury, examines the drugs and their effects: how their original acceptance, as aids to psychotherapy by helping patients talk more easily, resulted from skillful but dubious drug company public relations ploys; how their gradual subsequent authentication as the heart of treatment, rather than as ancillaries, transformed psychiatry into an increasingly mechanical, dehumanized profession which treats patients by "diagnostic label" - prescribing drugs supposedly specific for the numbered "disorder" in the American Psychiatric Association's Diagnostic and Statistical Manual (DSM); how the organization and provision of patient care has been eclipsed by drug and brain research as the path to psychiatric success and power; how the drugs themselves harm patients' brains; and how, despite media hoopla about brave new substances, today's treatment results are far worse than in times past .

The centrality of drugs has led to the almost complete disappearance of individualized treatment by psychiatrists - psychotherapy or counseling. Whatever close personal relationships still exist in treatment situations - formerly (and still properly) seen as the essence of good psychiatric care - are now supplied by lower-paid, non-medical professionals: psychologists, social workers and nurses.

Wagging the dog of psychiatric treatment by the tail of drug research has been another result of psychopharmaceutical primacy. The chairs of medical school psychiatry departments, who shape psychiatric training, are selected increasingly for their fund-finding skills - drug company grants are plentiful - rather than for abilities to provide and organize effective care. Medical schools' bottom lines thus supersede the needs of the patients they train doctors to treat; one result has been the virtual disappearance of psychotherapy/counseling training from residency programs.

The psychiatric literature shows, Whitaker reports, that the drugs themselves "do not fix any known brain abnormality nor do they put brain chemistry back into balance. What they do is alter brain functions in a manner that diminishes certain characteristic symptoms." They blunt and distort patients' emotionality, thus reducing both their explosiveness and their ability to think. The drugs also cause severe brain changes "associated both with tardive dyskinesia and an increased biological vulnerabilty to psychosis."

The best way to evaluate any treatment is to examine its effect on patients. Patients and non-patient research subjects (some of them physicians) describe the same horrendous subjective effects from neuroleptics. One woman told a 1975 United States Senate hearing that they led her "to the most fatalistic and despairing moments I've had on this planet. The only way I can describe the despair is that my consciousness was being beaten back."

The long-term effects of neuroleptics on patients had already been recognized by the mid-1980's. "A fairly clear profile of the long-term course of 'medicated schizophrenia' had emerged in the medical literature," Whitaker writes. "The drugs made people chronically ill, more prone to violence and criminal behavior, and more socially withdrawn. Permanent brain damage and early death were two other consequences of neuroleptic use."

Other data also demonstrate neuroleptics' harm. A 1994 Harvard study showed that treatment results in schizophrenia had worsened over the previous twenty years, during which time the treatment focus had shifted almost entirely to drugs. Treatment results in Third World countries, which use neuroleptics much less than we, are far better than ours. Of the 2,941 schizophrenic patients admitted in 1943 - before the drug era - to all of New York State's mental hospitals, 44% had been discharged five years later without ever being readmitted. In 2002, fifteen thousand former mental patients, almost all on medication, were the subject of a recent New York Times series about the adult homes into which they had been sent.

Whitaker's startling book has evoked strong reactions. Loren R. Mosher, M.D., former chief of the Center for Studies of Schizophrenia at the National Institute of Mental Health, called it "investigative journalism at its scholarly, perceptive, and explanatory best; an insightful, courageous expose of how madness went from 'out of mind, out of sight' to a source of massive corporate profits." Marcia Angell, M.D., former editor-in-chief of the New England Journal of Medicine (who left that position after a dispute over the handling of possible conflicts of interest among Journal reviewers) lauded it as "fascinating and provocative." Many lay publications praise it.

The three psychiatrists who reviewed the book all attacked it - by impugning Whitaker personally rather than by refuting any of his important points. One called the book "propaganda masquerading as fact." Larry S. Goldman, M..D. of Chicago, author of an educational drug-interaction CD program, writing in Medscape, called it an example of "when good journalists go bad," and suggested that the book "looks as if it were commissioned by Scientologists." E. Fuller Torrey, M.D., one of psychiatric drugging's strongest supporters, wrote that although Whitaker has heretofore been "known as a serious medical writer for the Boston Globe, Mad in America rarely ascends to the level of that newspaper; rather, it mostly descends to the level of the tabloid Globe, available at supermarket check-out counters."

The heart of Whitaker's book is the drug companies' unholy influence on all of psychiatry. It is ironic that Dr. Goldman acknowledges the importance of "the unhealthy symbiosis between the U.S. pharmaceutical industry and much of the psychiatric research community" (but says Whitaker's "overheated style" undermines the criticisms his book gives), while Dr. Torrey, regarding "the excess influence and profits of the pharmaceutical industry," calls it "unfortunate that Whitaker did not turn his attention to [this] real problem in American psychiatry."

Psychiatry is a mess, primarily because the drug-pushers have taken it over, and succeeded in suppressing, diverting or diluting long-needed criticism. Out of its Mind: Psychiatry in Crisis, the title of a 2001 book by Harvard professor J. Allan Hobson, M.D., accurately describes the current state of the specialty. Ann Braden Johnson's elegant 1990 book, Out of Bedlam, which exquisitely delineated the utter incompetence of public psychiatry, was dismissed by the media by being reviewed together with an inferior book published at the same time. Prof. Elliot S. Valenstein's scientifically precise 1998 book, Blaming the Brain -The Truth about Drugs and Mental Health, also got the cold shoulder. The major media have similarly marginalized the contributions of Peter Breggin, M.D. Will America allow Whitaker's immense, important contribution to be buried also?