Mad in America

Mad in America

Black cover with white letters: MAD IN AMERICA, with a new preface and afterword by the author, BAD SCIENCE, BAD MEDICINE, AND THE ENDURING MISTREATMENT OF THE MENTALLY ILL, Robert Whitaker. Orange border around a photo of a young man standing in a straight jacket. Top says, "Perhaps the most important psychiatric book of the 21st century. —Journal of American Physicians and Surgeons"
Author	Robert Whitaker
Original title	Mad in America: Bad Science, Bad Medicine, and the Enduring Mistreatment of the Mentally Ill
Publisher	Perseus Publishing
Publication date	2002
ISBN	978-0-465-02014-0

Mad in America: Bad Science, Bad Medicine, and the Enduring Mistreatment of the Mentally Ill is a controversial book by Robert Whitaker published in 2002 which is highly critical of the psychiatric profession. Problems with many historical aspects of treatment, as well as antipsychotics, are covered. The book received mixed reviews within the medical literature, which noted issues of bias in sourcing but nonetheless felt the discussion of social issues in psychiatry was important. The book received some better reviews from the lay press.

Whitaker, a medical journalist who was a finalist for a 1999 Pulitzer Prize, has never suffered mental illness himself. He told WNET that members of his extended family have suffered it, a situation he believes he shares with most Americans.

Synopsis

Part One: The Original Bedlam (1750–1900)

Part One describes early treatments like a spinning chair which could reach 100 revolutions per minute, the Tranquilizer Chair which immobilized patients, and water therapies. Whitaker then describes moral treatment, dating back to 1793 and the French Revolution and established in the U.S. by Quakers in 1817, in which lay superintendents treated the mentally ill in small homes with great kindness and had good outcomes: About 35 to 80 percent of patients were discharged within a year, the majority of them cured. Pennsylvania Hospital reported that about 45 percent of patients were discharged as cured and 25 percent discharged as improved. In Worcester State Hospital, 35 percent were chronically ill or had died while mentally ill. Dr. George Wood, a visitor, reported in 1851:

"...you encounter persons walking, conversing, reading or variously occupied, neatly and often handsomely dressed, to whom as you pass you receive an introduction as in ordinary social life; and you find yourself not unfrequently quite at a loss to determine whether the persons met with are really the insane, or whether they may not be visitors or officials in the establishment."

Part Two: The Darkest Era (1900–1950)

Part Two describes the rise of eugenics which did away with moral treatment in favor of forced sterilization of the mentally ill, and led to newly invigorated fields of psychiatry and neuroscience whose experts practiced insulin coma, metrazol convulsion, forced electroshock, and lobotomy.

Part Three: Back to Bedlam (1950–1990s)

Chlorpromazine, marketed in the U.S. as Thorazine, was first synthesized by Rhône-Poulenc in 1950.

Part Three describes the invention of the neuroleptic drug chlorpromazine (Thorazine) by Rhône-Poulenc in France, and its purchase by Smith, Kline & French (today known as GlaxoSmithKline). The drug "produced an effect similar to frontal lobotomy", according to early reports by the company's lead investigator. Whitaker says that pharmaceutical advertising, articles published in the scientific literature, and stories in the media of "miracle drugs" transformed Thorazine into a healing drug.

Whitaker says that marketing money from pharmaceutical companies began to flow to the American Medical Association in 1951, a year after Thorazine was synthesized, because of the Durham-Humphrey Amendment to the Federal Food, Drug, and Cosmetic Act which "greatly expanded the list of medications that could only be obtained with a doctor's prescription".

In Part Three, Whitaker also describes the American (but not for example British) propensity to classify patients as "schizophrenic", as well as the error (confusion of schizophrenia with the yet-to-be-discovered encephalitis lethargica) in the original classification by Emil Kraepelin which psychiatry chose to not revisit and fix. Whitaker then describes three pathways that dopamine may take in the human brain, and quotes first-person accounts of the effects of antipsychotic drugs on individuals.

He calls a 1996 New York Times advertisement by a consortium of pharmaceutical companies a "bald-faced lie": the group sought to say that the cause of psychosis and schizophrenia is an abnormal dopamine level and that their drugs worked by altering the level of dopamine. Whitaker then criticizes some American studies, and points out the work of George Crane at the National Institute of Mental Health to get tardive dyskinesia recognized, and he contrasts the dosages that British doctors were comfortable in prescribing (300 milligrams per day of Thorazine) with what American psychiatrists prescribed (1,500 up to perhaps 5,000 milligrams per day).

He sees irony in the fact that The New York Times reported on Soviet forced use of neuroleptic drugs (which Florida Senator Edward Gurney called "chemicals which convert human beings into vegetables") in "psychiatric jails" but called the same drugs "widely acknowledged to be effective" when reporting on American schizophrenic patients.

Whitaker describes the demise of modern-day moral treatment in a short history of Loren Mosher's Soteria Project, funded by the U.S. while Mosher was chief of schizophrenia at NIMH. He attributes the results in a World Health Organization 1979 study of outcomes for schizophrenia patients (which found better outcomes in undeveloped countries like India, Nigeria and Colombia than in developed countries like the United States, England, Denmark, Ireland, Russia, Czecholslovakia and Japan) to doctors in the developed world who maintained their patients on medications.

He then describes fifty years of American scientists doing experiments on schizoprenia patients: to intentionally exacerbate their symptoms and study the results. He compares the doctors' behavior, unfavorably, to 1947 after American trials of Nazi doctors ended in the Nuremberg Code for ethics in human experimentation.

Part Four: Mad Medicine Today (1990s–Present)

Part Four is Whitaker's description of drug trials for the newer atypical antipsychotics. He says that many of these trials were stacked in favor of the drug being proposed by eliminating the placebo, or by comparing multiple doses of the new drug against a single, very high dose of the old one. He says that the pharmaceutical companies and the press used their influence to make claims for these drugs (some claims that the Food and Drug Administration had explicitly asked them not to make). Risperidone and olanzapine, for example, were both claimed to have fewer side effects than the first generation of antipsychotics. Whitaker also tells the stories of patients whose deaths were caused by drug trials but were not mentioned to the public.

Epilogue

Whitaker calls it a type of medical fraud that we tell schizophrenics that they suffer from too much dopamine or serotonin activity and that drugs put these brain chemicals back in "balance". He writes, "Little is known about what causes schizophrenia. Antipsychotic drugs do not fix any known brain abnormality, nor do they put brain chemistry back into balance. What they do is alter brain function in a manner that diminishes certain characteristic symptoms....".

Reception

Lay press

The American Library Association decided the book was one of the best histories of 2002. Discover magazine placed it among the year's best science books. Recognizing Whitaker for marshalling evidence, a reviewer writing for the Chicago Tribune thought his hopes for moral treatment were admirable but inadequate. Writers for The Baltimore Sun and In These Times both liked the book but wondered why the author didn't mention Thomas Szasz, a critic of psychiatry.

Psychiatry

Mad in America stirred some emotions in the medical profession. Richard Bentall writes that one of his physician friends "felt as bruised as a sinner who had been denounced by a strident evangelical preacher" upon reading Whitaker's Mad in America.

David Pilgrim, writing "News of scandal is a few decades too late" for Times Higher Education, focuses on the book's shortcomings, saying, "The semi-academic froth he generates distracts the reader from a legitimate outrage, which is not his alone. It was shared by many others well before 1998" (the year Whitaker began writing on mental health).

Physician Larry S. Goldman wrote a highly critical review of the book in Medscape Today, stating that it "looks as if it were commissioned by Scientologists." Goldman writes that Whitaker "is ready to throw the baby out with the bath water" because Mad in America fails to acknowledge any biological abnormalities in schizophrenia, while at the same conceding that Whitaker's argument that the true causes of schizophrenia are not known is correct. Goldman also writes that the book promotes something akin to a conspiracy theory "because it strings together many decades of disparate flops into a unifying theme of ongoing catastrophe." Goldman concludes that the "overheated style" of the book "tends to undermine some of its more important points, such as the unhealthy symbiosis between the US pharmaceutical industry and much of the psychiatric research community and the ever-present miserliness of public mental healthcare systems."

Clinical psychologist Claudia Bukszpan Rutherford similarly acknowledges the book's insight into many of the problems of clinical psychiatry over the years has good points, but is hampered by the author's extreme position and lack of investigation into what improves the prognosis of schizophrenia in underdeveloped countries. She adds that his minimizing of the severity and impact of the illness itself takes away from criticism of treatment.

The book was also reviewed in JAMA, where reviewer Daniel J. Luchins, MD, of the University of Chicago observed the review of scientific literature to be biased at times. He noted the book omitted a key five year follow up study published in 1981 by May and colleagues, which showed some benefits from treatment with antipsychotics in patients with schizophrenia. Despite this, Luchins concluded the book was of value in highlighting social aspects of treatment in psychiatry.

Physician J. van Gijn, reviewing the book for the New England Journal of Medicine, writes that "the book is more of an indictment than a historical account," and starts by pointing out that Whitaker "virtually equates mental illness with schizophrenia; depression and other psychiatric disorders are mentioned only parenthetically." Van Gijn summarizes the pre-1950 coverage of the book without much commentary, but then criticizes the rest of the book. Specifically, he questions Whitaker's assertion that Kraepelin's schizophrenia patients in fact suffered from encephalitis lethargica. With regard to antipsychotic medication, van Gijn notes that "Although there may be truth in the notion that dosages of antipsychotic drugs in the United States are higher than necessary, the author weakens his position by issuing continuous and unrelenting condemnations (for instance, “The Nuremberg Code doesn't apply here”), despite a dearth of evidence to support them." Van Gijn then describes Whitaker's attack on the dopamine hypothesis of schizophrenia as "simplistic reasoning," and concludes that "Although [Whitaker] is widely read on the subject, the facts are largely arranged to suit his prejudice, especially in the chapters on drug treatment. American psychiatric institutions may have their failings in the current management of patients with schizophrenia, but they deserve better critics."

In a rejoinder to Goldman's review, physician Nathaniel S. Lehrman disagrees with Goldman, and writes that "Whitaker is right," and goes on to agree with the main points in the book, namely that antipsychotic drugs cause brain damage, that despite "psychiatrically produced misconceptions," they "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." Lehrman then writes that all the data accumulated on the neurobiology of schizophrenia "has hardly helped patient care."

More reviews

Lehrman later wrote in the official journal of the conservative political organization the Association of American Physicians and Surgeons, the Journal of American Physicians and Surgeons that Mad in America is "perhaps the most important psychiatric book of the 21st century." Christian Perring, editor of Metapsychology Online Review and who was impressed by the book, wrote, "Even though Whitaker himself could be accused of being overly critical of psychiatry, his argument against schizophrenia medication is cogent enough to urgently require an answer." E. Fuller Torrey writing for the Treatment Advocacy Center called it "histrionic" and "deeply disappointing." Clare Mundell writing for the Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry, said Mad in America "should be required reading not only for mental health professionals, but also for those who still question whether profit has eclipsed patient care as the primary force in medicine in this country."

See also

• Liberation by Oppression (2002) by Thomas Szasz
• Big Pharma (2006) by Jacky Law
• Side Effects (2008) by Alison Bass
• Anatomy of an Epidemic (2010) by Robert Whitaker
• Bad Pharma (2012) by Ben Goldacre
• Mad Pride

External links

• Robert Whitaker's "Mad in America" a history of madness (25:40), Cambridge Community Television
• Mad in America, Whitaker and Lacasse site