Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America
- Robert Whitaker
Robert Whitaker has done it again! He has written a controversial book that asks if the number of disabled mentally ill in the US has tripled over the past two decades due to the increasing use of psychotropic prescription drugs such as antidepressants, anxiolytics and antipsychotics. Whitaker develops this idea on the basis of his own review of the scientific literature and interviews with neuroscientists, patients and their relatives to generate a lively picture of the current status of mental health care in the US. To illustrate his case, he provides four case reports of individuals with mental illnesses to describe their transition from highly functioning people to—he claims—chronically sick people, because of their diagnosis and treatment for a psychiatric illness.
Whitaker identifies the passage of the Food and Drug Cosmetics Act in 1938 and the Durham-Humphrey Amendment in 1951, which fundamentally changed the development and selling of drugs in the US, with more involvement of physicians in determining efficacy and safety, as key events in this process. These laws, according to Whitaker, created privileged physicians who aimed to use the latest drugs to improve their reputations. He claims that financial interests tied together the drug industry and physicians, and that this happened under the watchful eye of the American Medical Association (AMA) and other agencies who quickly adapted to and benefitted from this new reality. He further argues that this new wealth, which was shared by the drug industry, physicians and the AMA, and which was supported by Wall Street, an enthusiastic press and the federal government, not only altered research and care of people with mental illness but also sparked public interest. This “unholy alliance” may have corrupted the system and influenced the public to believe that new drugs represent a true revolution in the treatment of mental illness.
But the reality, he claims, is very different: the presented case reports paint a picture of patients caught in diagnostic classifications that do not precisely describe the complexity of their psychiatric illnesses and, of even more concern, treated with drugs that lead to a deterioration of their lives. Whitaker asserts that the use of medications in the treatment of people with mental illness is generally not associated with a beneficial outcome and is rather a marker of deterioration. Furthermore, medicated patients often show “increased symptomatology relative to those not taking medication.”
Written in very clear language, with straightforward explanations of scientific material, this book will stimulate discussions about the neurobiology and treatment of mental disorders. He asks: do the currently available medications 'fix' symptoms of psychiatric syndromes by correcting underlying neurochemical imbalances, or do the pharmacodynamic effects of psychotropic medications alter and prolong the disease process, leading to a worsening of the long-term prognosis of patients with psychiatric illnesses? Do psychotropic medications explain or at least contribute to the increasing number of mentally disabled people in the US? Are the modern medications that have been developed recently really effective and safe, or are they a major contributor to poor outcomes and the emergence of new, additional health problems such as obesity? And, finally, when administered to children, do they provide any benefit, or do they cause negative long-term consequences?
Whitaker aims to answer these questions by giving the reader an overview about the diagnostic concepts of psychiatric illnesses and their changes over time. He describes some influential historical concepts about the neurobiology of mental illnesses and how these concepts were dismissed by scientific data but continued to be used by the drug industry to create a rationale for using their drugs, for example, the serotonin deficiency hypothesis of depression, which could not be supported by scientific data but continued to be used to justify the importance of serotonin reuptake inhibitors to treat depression. He also includes some haunting examples of the multimillion dollar industry investments given to key leaders and institutions in psychiatry to continue the industry's influence in research and patient care.
Neuroscience is rapidly evolving, and new technologies allow for more complex models of mental disorders. This has forced the field to revise early, sometimes simplistic, models of the neurobiology of mental disorders. Whitaker should be given credit for increasing readers' awareness about the limitations of neuroscientists' knowledge of the neurobiology of mental disorders and their treatments.
In recent years, an accumulating body of evidence has dampened initial enthusiasm about the efficacy and safety of psychopharmacological agents. In turn, these results have highlighted the crucial need to develop new, better and more evidence-based treatments for people with mental illnesses. This is in line with Whitaker's goal to provide a critical evaluation of the accomplishments of neuroscience with the ultimate goal to improve the lives of people with mental illness.
I would have liked to have seen more appreciation of how neuroscience has acknowledged the limitations of our current knowledge about the etiology and treatment of mental disorders and how most academic institutions have started to address conflicts of interest between their faculty and drug industry to ensure unbiased research. Still, this book will stimulate interesting discussions among its readers, and I believe that this is exactly what Whitaker aimed for.
The author declare no competing financial interests.
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Neumeister, A. Mental illness mania. Nat Med 16, 1183 (2010). https://doi.org/10.1038/nm1110-1183