The scandal of the century

If Robert Whitaker is right (Anatomy of an Epidemic: Magic bullets, psychiatric drugs, and the astonishing rise of mental illness in America. Crown Publishers, 2010) it's the psychiatric profession, in a grand conspiracy with the drug companies, the National Institute of Mental Health, and the National Alliance for the Mentally Ill.

I have long insisted here that psychiatric medications should be swallowed only as an act of desperation, but I have to admit even I hadn't fully put the picture together the way Whitaker does. Let me first run down some stone cold facts that he adduces; then I'll talk a bit about his interpretations and point out where there is a bit of room for criticism. Even so, his central thesis remains pretty bullet proof, in my view.

Drug advertisements and reports in popular media have the public pretty well convinced of a basic story about mental illness in general - whether it's depression, so-called bipolar disease, schizophrenia, "anxiety disorder" or basically new diseases like Attention Deficit Hyperactivity Disorder or "social phobia." (ADHD actually maps partly onto an entity that's been recognized for quite a while, as does social phobia, which used to be called shyness. But the medicalization and specific diagnostic criteria for these conditions are recent.) The story is that these are diseases, caused by chemical imbalances in the brain, which are corrected by the appropriate drugs.

This is undeniably false. No consistent abnormalities of neurotransmitters or anything else have been detected in the brains of unmedicated people diagnosed with these various diseases. However, the drugs themselves do cause abnormalities in both the numbers of receptors for, and the production of, particular neurotransmitters, which can be long lasting or even irreversible. So the only reason people with these diseases have these abnormalities is because they have taken drugs which have caused them. That's a cold fact.

The really bad news is that once a person has these drug-induced abnormalities of the brain, stopping the drug causes withdrawal effects, including a rebound of the symptoms of the disease. That's because the abnormalities result from the brain trying to restore normal operation, e.g. reducing the number of serotonin receptors in response to a continual flood of serotonin. So when you stop the drug, you really do have a serotonin deficiency, even though you didn't before, and that makes you sick.

The even worse news is that before the era of psychopharmacology, the various diseases which are now viewed as inevitably chronic and disabling, requiring possibly life-long medication, and which now have millions of Americans on the disability roles, were usually self-limiting. The vast majority of people with depression just got better after a while. As a matter of fact, so did people with schizophrenia, which we have been told to believe is almost inevitably progressive and irreversible. What we now call bipolar disease was very rare, and usually remitted on its own after no more than two or three manic episodes. Now it is disturbingly common, chronic, and devastatingly disabling.

Whitaker's claim is the worst news of all -- that the chronicity of these diseases is largely caused by medications. In fact, bipolar disease, in most cases, is caused initially by antidepressants. Most people with the disease never would have experienced any manic episodes if they hadn't been given antidepressants. The other side effects of these "medications" are equally devastating -- and greatly shorten people's lives.

Ritalin for ADHD is equally pernicious. It makes kids who are a pain to their teachers sit down and shut up, but it doesn't do the children any good. In fact their academic performance does not improve, their physical stature is stunted, and they develop other behavioral and cognitive problems. The drug is not treating the patient, it is treating problems the patient is causing for other people.

Whitaker believes this situation developed because psychiatry was losing its raison d'etre. You didn't need to be an MD to counsel people. But if mental illness is really a biological problem that can be treated with prescription drugs, psychiatrists are back in business. The problem with this is that the drugs were not developed as treatments for any known etiology of disease. Instead researchers observed that they made animals say, docile or hyperactive or whatever; and then they tried them out on people who seemed agitated or depressed. Indeed, agitated people got calmer and depressed people got more hyperactive. So they decided that the disease was caused by a lack of whatever the drugs had to offer and there you are. As Whitaker and others have pointed out, this is like concluding that pain is caused by a morphine deficiency.

The studies that won FDA approval for these drugs were all for short terms. Longer term studies inevitably find that people who are unmedicated do better. Actually a lot better. This is also a cold fact.

So Whitaker's accusation is essentially that billions of dollars have been wasted and hundreds of thousands of lives destroyed by what amounts to nothing more than the most pernicious quackery. It gets even worse as the pharmaceutical revolution has been extended to children. Children are normally emotionally labile, and if they suffer from trauma or neglect they can obviously develop serious emotional and behavioral problems. But now they're being diagnosed right and left with "biopolar disorder" and fed psych meds which are essentially destroying their brains, while their real problems go unrecognized and unaddressed.

Wow.

This is all open to some criticism on a couple of grounds, which basically come down to what is called confounding by indication. People who are not on drugs are doing better either because people who don't take drugs do better; or people who do better don't take drugs. It's hard to tell which, since the longer term studies are observational rather than experimental. And the data from the pre-psychopharmaceutical past are hard to compare with modern epidemiological data because the diagnostic liability was different. Would all of those people diagnosed with schizophrenia in the past have gotten the same diagnosis today? Probably not.

Nevertheless, I will tell you as a regular reader of BMJ that the attitude toward psych meds in Europe is a lot more skeptical than it is in the U.S. In the UK, the first prescription for depression is exercise -- which by the way is highly effective -- and it is now considered that antidepressants are of use only in cases of severe, intractable depression. There are various programs for drug free treatment of schizophrenia which seem to be quite successful. All this tossing people pills for shyness and rambunctiousness just doesn't happen.

But when the first response to somebody who is feeling down in the dumps is to throw anti-depressants at them -- and that is exactly what happens -- we're in a really bad place.

Fortunately, the medical establishment is starting to think twice. Harvard's Joseph Beiderman, the one person most responsible for popularizing the drugging of children, has been dinged for undisclosed conflicts of interest: "After a three-year investigation, Massachusetts General Hospital and Harvard Medical School found that Dr. Joseph Biederman and two other psychiatrists violated conflict of interest rules and, as a result, face sanctions." Whitaker tells us that:

Joseph Beiderman may have been the KOL ["Key Opinion Leader in the parlance of drug marketers] who did the most to help the pharmaceutical industry build a market for its products. To a large extent, juvenile bipolar illness was his creation, and children and adolescents so diagnosed are often treated with drug cocktails Pharmaceutical companies paid Beiderman $1.6 million for his various services from 2000 to 20007 . . . . Beiderman also got [Johnson and Johnson] to pay $2 million to create [a center he runs] at Massachusetts General Hospital. . . . Beiderman has been the Pied Piper of pediatric bipolar disease, and we can see [in a document describing the mission of the center] the future that he was laying out for the children given this diagnosis. They were being groomed to be lifelong consumers of psychiatric medications.

So now he'll have to spend the next two years under somewhat closer supervision, without explaining or admitting in public exactly what the heck he did wrong. That'll teach 'em.

Update: Somebody wants to see the references. Whitaker provides them here. I am reasonably familiar with this literature so my endorsement of certain conclusions is with substantial basis. The basic fact that there is no known etiology for any of the mental disorders under discussion, and no evidence that they result from "chemical imbalances" which are corrected by these drugs, is generally accepted by experts of all stripes, including those who still advocate use of the drugs. It is not by any means a radical or niche opinion.