Anatomy of an Epidemic
|Original title||Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America|
|Published||2010 (Crown Publishing Group)|
Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America is a 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.
In the book, Whitaker tries to answer that question and examines the long-term outcomes for the mentally ill in the U.S. In April 2011, Investigative Reporters and Editors (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."
Whitaker begins by showing that the antipsychotics, benzodiazepines and antidepressants were discovered as side effects during research for antihistamines (specifically promethazine), 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 quietude"; 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 dopamine "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."
So far there is no clear and convincing evidence that monoamine deficiency accounts for depression; that is, there is no 'real' monoamine deficit.
— Stephen Stahl, Essential Psychopharmacology
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 267 thousand schizophrenia patients in state and county mental hospitals, and eight years later, there were 253 thousand, 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, began shipping their chronic patients to nursing homes.
Whitaker acknowledges that psychiatric medications do sometimes work but believes that they 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."
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 antipsychotics 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.
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 reaches the age of eighteen, Whitaker says the child often becomes a disabled adult.
Review of data and statistics
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 School, 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.
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 Services. 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.
Whitaker presented his views at a psychiatric Grand Rounds at Massachusetts General Hospital on January 13, 2011, where his data and approach were critiqued by psychiatrist Andrew Nierenberg. Additional criticism has come from psychiatrist and author Daniel Carlat. Whitaker has responded to critics on his website.
Other examples of positive feedback are
The idea of a feedback from a defense contributing to the problem was told in the story "Hero Worship" in the TV show STNG. The ships shields being turned on created a feedback loop that would destroy the ship.
In nuclear science it is know as Positive power co-efficient of reactivity. "Reactivity is directly related to the tendency of the reactor core to change power level: if reactivity is positive, the core power tends to increase." The Canadian MAPLE nuclear reactors were cancelled on part for a positive power co-efficient of reactivity in 2008.
- Mad in America (2002) by Robert Whitaker
- Big Pharma (2006) by Jacky Law
- Side Effects (2008) by Alison Bass
- Bad Pharma (2012) by Ben Goldacre
- Rethinking Madness
- Fitzpatrick, Laura (May 3, 2010). "The Skimmer". Time. Archived from the original on 23 September 2010. Retrieved October 5, 2010.
- Burch, Druin (April 7, 2010). "Does psychiatry make us mad?". New Scientist (Reed Business Information). Archived from the original on 25 October 2010. Retrieved October 5, 2010.
- Good, Alex (May 21, 2010). "Book review: Anatomy of an Epidemic". The Record (Metroland Media). Archived from the original on 26 October 2010. Retrieved October 5, 2010.
- Whitaker, p. 7
- "IRE Awards 2010". Investigative Reporters and Editors. Retrieved 2011-05-11.
- Whitaker, Robert (2010). Anatomy of an Epidemic. Crown Publishing Group. pp. 48–54. ISBN 978-0-307-45241-2.
- M. Bowers; Heninger, GR; Gerbode, F (1969). "Cerebrospinal fluid 5-hydroxyindoleactiic acid and homovanillic acid in psychiatric patients". International Journal of Neuropharmacology 8 (3): 255–262. doi:10.1016/0028-3908(69)90046-x. PMID 5796265.
- R. Papeschi; McClure, DJ (1971). "Homovanillic and 5-hydroxyindoleacetic acid in cerebrospinal fluid of depressed patients". Archives of General Psychiatry 25 (4): 354–358. doi:10.1001/archpsyc.1971.01750160066012. PMID 5116990.
- M. Bowers (1974). "Lumbar CSF 5-hydroxyindoleacetic acid and homovanillic acid in affective syndromes". The Journal of Nervous and Mental Disease 158 (5): 325–330. doi:10.1097/00005053-197405000-00003. PMID 4823933.
- M. Asberg; Thorén, P; Träskman, L; Bertilsson, L; Ringberger, V (1976). ""Serotonin depression"--a biochemical subgroup within the affective disorders?". Science 191 (4226): 478–480. doi:10.1126/science.1246632. PMID 1246632.
- J. Maas; Koslow, SH; Katz, MM; Bowden, CL; Gibbons, RL; Stokes, PE; Robins, E; Davis, JM (1984). "Pretreatment neurotransmitter metabolite levels and response to tricyclic antidepressant drugs". American Journal of Psychiatry 141 (10): 1159–1171. PMID 6207736.
- J. Lacasse; Leo, Jonathan (2005). "Serotonin and depression: a disconnect between the advertisements and the scientific literature". PLOS Medicine 2 (12): 1211–1216. doi:10.1371/journal.pmed.0020392. PMC 1277931. PMID 16268734.
- M. Bowers (1974). "Central dopamine turnover in schizophrenic syndromes". Archives of General Psychiatry 31 (1): 50–54. doi:10.1001/archpsyc.1974.01760130034005. PMID 4835986.
- R. Post; Fink, E; Carpenter Jr, WT; Goodwin, FK (1975). "Cerebrospinal fluid amine metabolites in acute schizophrenia". Archives of General Psychiatry 32 (8): 1063–1068. doi:10.1001/archpsyc.1975.01760260127011. PMID 1156113.
- J. Haracz (1982). "The dopamine hypothesis: an overview of studies with schizophrenic patients". Schizophrenia Bulletin 8 (3): 438–458. doi:10.1093/schbul/8.3.438. PMID 6127808.
- T. Lee; Seeman, P; Tourtellotte, WW; Farley, IJ; Hornykeiwicz, O (1978). "Binding of 3H-neuroleptics and 3H-apomorphine in schizophrenic brains". Nature 274 (5674): 897–900. Bibcode:1978Natur.274..897L. doi:10.1038/274897a0. PMID 683328.
- D. Burt; Creese, I; Snyder, SH (1977). "Antischizophrenic drugs: chronic treatment elevates dopamine receptor binding in brain". Science 196 (4287): 326–327. Bibcode:1977Sci...196..326B. doi:10.1126/science.847477. PMID 847477.
- M. Porceddu; Ongini, E; Biggio, G (1985). "[3H]SCH 23390 binding sites increase after chronic blockade of D-1 dopamine receptors". European Journal of Pharmacology 118 (3): 367–370. doi:10.1016/0014-2999(85)90151-7. PMID 2935413.
- A. MacKay; Iversen, LL; Rossor, M; Spokes, E; Bird, E; Arregui, A; Creese, I; Synder, SH (1982). "Increased brain dopamine and dopamine receptors in schizophrenia". Archives of General Psychiatry 39 (9): 991–997. doi:10.1001/archpsyc.1982.04290090001001. PMID 7115016.
- J. Kornhuber; Riederer, P; Reynolds, GP; Beckmann, H; Jellinger, K; Gabriel, E (1989). "3H-spiperone binding sites in post-mortem brains from schizophrenic patients: relationship to neuroleptic drug treatment, abnormal movements, and positive symptoms". Journal of Neural Transmission 75 (1): 1–10. doi:10.1007/BF01250639. PMID 2563750.
- Martinot, JL; Peron-Magnan, P; Huret, JD; Mazoyer, B; Baron, JC; Boulenger, JP; Loc'h, C; Maziere, B et al. (1990). "Striatal D2 dopaminergic receptors assessed with positron emission tomography and [76Br]bromospiperone in untreated schizophrenic patients". American Journal of Psychiatry 147 (1): 44–50. PMID 2293788.
- L. Farde; Wiesel, FA; Stone-Elander, S; Halldin, C; Nordström, AL; Hall, H; Sedvall, G (1990). "D2 dopamine receptors in neuroleptic-naive schizophrenic patients. A positron emission tomography study with [11C]raclopride". Archives of General Psychiatry 47 (3): 213–219. doi:10.1001/archpsyc.1990.01810150013003. PMID 1968328.
- Hietala, J; Syvälahti, E; Vuorio, K; Någren, K; Lehikoinen, P; Ruotsalainen, U; Räkköläinen, V; Lehtinen, V; Wegelius, U (1994). "Striatal D2 dopamine receptor characteristics in neuroleptic-naive schizophrenic patients studied with positron emission tomography". Archives of General Psychiatry 51 (2): 116–123. doi:10.1001/archpsyc.1994.03950020040004. PMID 7905257.
- Stahl, Stephen (2000). Essential Psychopharmacology. Cambridge University Press. p. 187. ISBN 0-521-64154-3.
- Whitaker, Robert (Spring 2005). "Anatomy of an Epidemic: Psychiatric Drugs and the Astonishing Rise of Mental Illness in America" (PDF). Ethical Human Psychology and Psychiatry (Springer) 7 (I): 1. Retrieved October 11, 2010.
- Warner, R. (1985). Recovery from Schizophrenia. Boston: Routledge & Kegan Paul. p. 74.
- N. Lehrman (1961). "Follow-up of brief and prolonged psychiatric hospitalization". Comprehensive Psychiatry 2: 227–40. doi:10.1016/s0010-440x(61)80015-1.
- Cole, J. (1959). Psychopharmacology. Washington DC: National Academy of Sciences. pp. 142, 386–87.
- L. Epstein (1962). "An approach to the effect of ataraxic drugs on hospital release rates". American Journal of Psychiatry 119: 246–61. PMID 13890431.
- Silverman, C. (1968). The Epidemiology of Depression. Baltimore: Johns Hopkins Press. p. 139.
- Lipinski, Jed (April 27, 2010). ""Anatomy of an Epidemic": The hidden damage of psychiatric drugs". Salon (Salon Media). Archived from the original on 2 October 2010. Retrieved October 9, 2010.
- Whitaker, p. 208
- Whitaker, p. 210
- Robert Whitaker (2010). "Anatomy of an Epidemic". Crown. p. 303.
- Whitaker, p. 343
- F. Dimeo (2001). "Benefits from aerobic exercise in patients with major depression". British Journal of Sports Medicine 35 (2): 114–17. doi:10.1136/bjsm.35.2.114. PMC 1724301. PMID 11273973.
- K. Knubben (2007). "A randomized, controlled study on the effects of a short-term endurance training programme in patients with major depression". British Journal of Sports Medicine 41 (1): 29–33. doi:10.1136/bjsm.2006.030130. PMC 2465130. PMID 17062659.
- A. Strohle (2009). "Physical activity, exercise, depression and anxiety disorders". Journal of Neural Transmission 116 (6): 29–33. doi:10.1007/s00702-008-0092-x. PMID 18726137.
- Whitaker, chapters 11 and 12
- Whitaker, Robert. "Mad in America". Retrieved October 10, 2010.
- Jacobs, Andrew (March 10, 1999). "20 Journalists, Including 2 Times Writers, Win Polk Awards". The New York Times. Retrieved October 10, 2010.
- Weintraub, Karen (May 10, 2010). "The downside of meds". The Boston Globe (The New York Times Company). Retrieved October 9, 2010.
- Robert Whitaker (April 22, 2010). Anatomy of an Epidemic. C-SPAN. Retrieved October 9, 2010.
- Whitaker, pp. 309–310
- Whitaker, p. 310
- Rosen, Dennis (April 14, 2010). "Tying the rise in mental illness to drugs used in its treatment". The Boston Globe (The New York Times Company). Retrieved October 9, 2010.
- Angell, Marcia (June 23, 2011). "The Epidemic of Mental Illness: Why?". and Angell, Marcia (July 14, 2011). "The Illusions of Psychiatry". The New York Review of Books. Retrieved September 23, 2011.
- Horgan, John (September 18, 2011). "Are Psychiatric Medications Making Us Sicker?". The Chronicle of Higher Education. Retrieved September 23, 2011.
- "What About Bob? USA Mental Health Agency May Cancel Journalist Robert B. Whitaker as Keynoter of "Alternatives 2010"". MindFreedom International. July 21, 2010. Archived from the original on 24 October 2010. Retrieved October 10, 2010.
- Whitaker, Robert (October 6, 2010). "SAMHSA, the Alternatives Conference, and the Story of an Opportunity Lost". Psychology Today blog. Sussex Publishers.
- Goldberg, Carey (Jan 19, 2011). "Special Report: Do Psych Drugs Do More Long-Term Harm Than Good?".
- Carlat, Daniel J. (Jan 21, 2011). "Robert Whitaker's Anatomy of an Epidemic: The Carlat Take".
- "Answering the Critics". Retrieved March 30, 2013.
- Whitaker, Robert (April 13, 2010). Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America. Crown (Random House). ISBN 978-0-307-45241-2.
- 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)