Also by Robert Whitaker Mad in America The Mapmaker’s Wife On the Laps of Gods To Lindsay May you sing “Seasons of Love” again and be filled with joy CONTENTS Foreword Part One: The Epidemic 1. A Modern Plague 2. Anecdotal Thoughts Part Two: The Science of Psychiatric Drugs 3. The Roots of an Epidemic 4. Psychiatry’s Magic Bullets 5. The Hunt for Chemical Imbalances Part Three: Outcomes 6. A Paradox Revealed 7. The Benzo Trap 8. An Episodic Illness Turns Chronic 9. The Bipolar Boom 10. An Epidemic Explained 11. The Epidemic Spreads to Children 12. Suffer the Children Part Four: Explication of a Delusion 13. The Rise of an Ideology 14. The Story That Was … and Wasn’t Told 15. Tallying Up the Profits Part Five: Solutions 16. Blueprints for Reform Epilogue Notes Acknowledgments FOREWORD The history of psychiatry and its treatments can be a contentious issue in our society, so much so that when you write about it, as I did in an earlier book, Mad in America, people regularly ask about how you became interested in the subject. The assumption is that you must have a personal reason for being curious about this topic, as otherwise you would want to stay away from what can be such a political minefield. In addition, the person asking the question is often trying to determine if you have any personal bias that colors your writing. In my case, I had no personal attachment to the subject at all. I came to it in a very back-door manner. In 1994, after having worked a number of years as a newspaper reporter, I left daily journalism to cofound a publishing company, CenterWatch, that reported on the business aspects of the clinical testing of new drugs. Our readers came from pharmaceutical companies, medical schools, private medical practices, and Wall Street, and for the most part, we wrote about this enterprise in an industry-friendly way. We viewed clinical trials as part of a process that brought improved medical treatments to market, and we reported on the financial aspects of that growing industry. Then, in early 1998, I stumbled upon a story that told of the abuse of psychiatric patients in research settings. Even while I co-owned CenterWatch, I occasionally wrote freelance articles for magazines and newspapers, and that fall I cowrote a series on this problem for the Boston Globe. There were several types of “abuses” that Dolores Kong and I focused on. We looked at studies funded by the National Institute of Mental Health (NIMH) that involved giving schizophrenia patients a drug designed to exacerbate their symptoms (the studies were probing the biology of psychosis). We investigated the deaths that had occurred during the testing of the new atypical antipsychotics. Finally, we reported on studies that involved withdrawing schizophrenia patients from their antipsychotic medications, which we figured was an unethical thing to do. In fact, we thought it was outrageous. Our reasoning was easy to understand. These drugs were said to be like “insulin for diabetes.” I had known that to be “true” for some time, ever since I had covered the medical beat at the Albany Times Union. Clearly, then, it was abusive for psychiatric researchers to have run dozens of withdrawal studies in which they carefully tallied up the percentage of schizophrenia patients who became sick again and had to be rehospitalized. Would anyone ever conduct a study that involved withdrawing insulin from diabetics to see how fast they became sick again? That’s how we framed the withdrawal studies in our series, and that would have been the end of my writing on psychiatry except for the fact that I was left with an unresolved question, one that nagged at me. While reporting that series, I had come upon two research findings that just didn’t make sense. The first was by Harvard Medical School investigators, who in 1994 announced that outcomes for schizophrenia patients in the United States had worsened during the past two decades and were now no better than they had been a century earlier. The second was by the World Health Organization, which had twice found that schizophrenia outcomes were much better in poor countries, like India and Nigeria, than in the United States and other rich countries. I interviewed various experts about the WHO findings, and they suggested that the poor outcomes in the United States were due to social policies and cultural values. In the poor countries, families were more supportive of those with schizophrenia, they said. Although this seemed plausible, it wasn’t an altogether satisfactory explanation, and after the series ran in the Boston Globe, I went back and read all of the scientific articles related to the WHO study on schizophrenia outcomes. It was then that I learned of this startling fact: In the poor countries, only 16 percent of patients were regularly maintained on antipsychotic medications. That is the story of my entry into the psychiatry “minefield.” I had just cowritten a series that had focused, in one of its parts, on how unethical it was to withdraw schizophrenia patients from their medications, and yet here was a study by the World Health Organization that seemingly had found an association between good outcomes and not staying continuously on the drugs. I wrote Mad in America, which turned into a history of our country’s treatment of the severely mentally ill, to try to understand how that could be. I confess all this for a simple reason. Since psychiatry is such a controversial topic, I think it is important that readers understand that I began this long intellectual journey as a believer in the conventional wisdom. I believed that psychiatric researchers were discovering the biological causes of mental illnesses and that this knowledge had led to the development of a new generation of psychiatric drugs that helped “balance” brain chemistry. These medications were like “insulin for diabetes.” I believed that to be true because that is what I had been told by psychiatrists while writing for newspapers. But then I stumbled upon the Harvard study and the WHO findings, and that set me off on an intellectual quest that ultimately grew into this book, Anatomy of an Epidemic. part one The Epidemic