Two recent Tools for Transformation articles ("Transforming our thinking about psychiatric medications," featured in the July/August and September issues of Behavioral Healthcare) 1, 2 examined the views of Robert Whitaker, author of Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America, a recent book that attempts to debunk the value of psychiatric medications.
When I expressed concern about the validity of Whitaker's views, I was invited to write a reply. But first, a few comments to put my reply into context:
First, I want to draw a clear line between the work of the interviewers and that of the interviewee. Drs. Ashcraft and Anthony are leaders in the “recovery movement.” In the words of Dr. Ashcraft's organization, Recovery Innovations, this movement seeks “To create opportunities and environments that empower people to recover, to succeed in accomplishing their goals, and to reconnect to themselves, to others, and to meaning and purpose in life.”
Second, since my community psychiatry days in New Haven, Conn., I have admired Bill Anthony's work at Boston University's Center for Psychiatric Rehabilitation. This work has developed much of the evidence base on which the recovery movement is built. And, at present, Bill and I are collaborating on a project related to that work.
Third, I have, throughout my 30-plus year career in psychiatry, seen tension between the recovery movement and what I will call a “treatment as usual (TAU) crowd.” This crowd is made up of some of the mental health professionals who work in publicly funded facilities providing treatment to people suffering from severe and persistent mental illnesses like schizophrenia, bipolar disorder and depression.
At times, this tension has been expressed negatively, through divisions: consumer vs. the “treatment establishment,” prescriber vs. non-prescriber, the biological orientation vs. the social, and the American Psychological Association vs. the American Psychiatric Association.
At other times, this tension has expressed itself positively in the emergence of “best practice” programs that integrate diverse views in the name of better treatment. I have found that the TAU crowd, of which I was a member in my 18 years of direct service at the Connecticut Mental Health Center, has evolved significantly over the last 30 years, due in no small part to the contributions of the recovery movement.
Lastly, for purposes of disclosure: 1) I have had a longstanding collaborative (and productive) relationship with the pharmaceutical and insurance industries, 2) I believe that collaborations between industry and the behavioral health field are critical for the advancement of patient care, and 3) I treat persons with diverse behavioral health concerns and rely in part on medications when it is medically necessary to do so.
Concerns about Whitaker's work
In my view, it was unfortunate that Drs. Ashcraft and Anthony used Whitaker's work, which has never been subjected to serious scientific scrutiny, as a means to promote the values of the recovery movement. Instead, they might have asked others, including academic researchers who have published studies of medication- and non-medication-based treatments for populations with serious mental illness.
Whitaker casts the discourse about psychiatric medication in terms that inflame professional and public opinion. It may also undermine the interests of those who seek and need care by casting doubt on legitimate and available treatment methods.
But I am getting ahead of myself. I'll discuss that point later. (See Part 2 in the November/December issue). Let me now make my case.
The Ashcraft/Anthony articles highlight three of Whitaker's main arguments:
that new psychiatric medications introduced since the late 1980s, particularly the antipsychotics and the antidepressants, have caused an increase in psychiatric diagnoses and disability.
that pharmacological theories can explain how these medications have caused this increase in psychiatric morbidity, and,
that there has been a kind of conspiracy, in which drug companies and “psychiatry” collaborated to “mislead” everyone about the benefits of new psychiatric medications.Let's consider these arguments one at a time.
Argument 1: Newer psychiatric medications have caused increased psychiatric morbidity
If we examine epidemiologic evidence from the National Comorbidity Survey, as reported in the New England Journal of Medicine:3
There was no significant difference in the estimated prevalence of any DSM-IV disorders-substance abuse, depression, anxiety, bipolar disorder and schizophrenia-between the period from 1990 to 1992 (29.4 percent) and the period of 2001 to 2003 (30.5 percent). The 1990 to 1992 findings were based on 5,388 face-to face interviews, while the 2001-03 NCS replication study findings were obtained through 4,319 similar interviews in that period.
The estimated prevalence of serious (5.3 percent vs. 6.3 percent), moderate (12.3 percent vs. 13.5 percent), or mild (11.8 percent vs. 10.8 percent) disorders did not change significantly during the same survey periods either.
These figures hardly support the notion of an “epidemic” of mental illness, the assertion on which Whitaker rests his case, as well as the provocative title of his book.
Whitaker correctly notes that the National Comorbidity Survey found an increase in the number of people receiving psychiatric treatment from 1991 to 2003, from 20 percent to 32 percent. This observation, while correct, must be viewed in the context of other facts that offer alternate explanations:
Since the introduction of the first DSM in 1950, there has been a three-fold increase in the number of conditions to be diagnosed. Some believe that this increase is also the result of a conspiracy between psychiatry and the drug companies. (See Part 2 in the November/December issue.)
The period between 1991 and 2003 saw the emergence of many new treatments for psychiatric conditions. Given this level of innovation, it is logical to expect that more people would be treated.
The fact that just 32 percent of Americans with psychiatric disorders were treated from 1991-2003 means that most continue to go untreated. If anything, such data would argue for more treatment for individuals with psychiatric disorders. And, I suspect that those in the recovery movement would agree.
Whitaker is also correct to note that more individuals filed successful claims for psychiatric disabilities in the past two decades. But there is no evidence available to suggest that the increase in psychiatric disability claims was caused by the use of psychiatric medications.
Epidemiology teaches us that in order to show a cause-and-effect relationship between a disease predictor (psychiatric medications) and an outcome (disability rates) one must consider “cohort effects.” These describe variations in the characteristics of an area of study over time (e.g., in the incidence of psychiatric disability from 1991 to 2003) among individuals defined as having shared temporal experiences that might be risk factors for the area of study. In this case, shared temporal experiences would include political, economic, social, or treatment forces that had an impact on the incidence of psychiatric disability.
Have forces impacted the incidence of psychiatric disability in the period from 1991 to 2003? I believe they have. While I'm sure that readers can suggest many possible cohort effects, here are several that make sense to me:
The ongoing inadequacy of funding for community-based services in the wake of deinstitutionalization.
The growing disparity in the distribution of wealth among individuals. (Note: To learn more about the relationship between wealth and psychiatric disability, read The Spirit Level by Wilkinson and Picket.4
Changes in disability entitlement policy that have made it easier to qualify for disability status in recent years than it was in 1991-93.
Whitaker asserts that the World Health Organization's finding of higher rates of schizophrenia in developed countries compared to less-developed countries offers further support for the contention that psychiatric medications cause disabilities. But again, I question this contention based on cohort effects, such as the prevalence of trained mental health professionals in less-developed nations.
Whitaker's argument that the use of psychiatric medications has caused an increase in psychiatric disability is a hypothesis in need of testing, not a fact. A properly designed study to test this hypothesis would have to rule out many possible confounding factors. And no such study has been proposed or conducted.
Based on the available evidence, Whitaker's argument that psychiatric medications cause psychiatric disability is, at best, speculative. While this argument is sensational enough to grab popular attention, particularly when it's combined with a dose of pharmacologic theory and a hint of conspiracy, it simply cannot pass scientific muster.
The dissemination of this idea runs the risk of confusing both clinicians and the lay public. (See Part II of Dr. Glazer's discussion in the November/December issue of Behavioral Healthcare.)
NOTE: Dr. Glazer has collaborative relationships with Eli Lilly and Merck.