Introduction
In "Anatomy of an Epidemic," investigative journalist Robert Whitaker delves into the alarming increase of mental illness in America over the past few decades. He explores how the introduction and widespread use of psychiatric medications have contributed to this epidemic, challenging the common belief that these drugs are the solution to mental health problems.
Whitaker's book presents a thought-provoking and often unsettling examination of the history of psychiatric medicine, the pharmaceutical industry's influence, and the long-term effects of psychoactive drugs on patients. Through meticulous research and compelling arguments, he raises important questions about the current state of mental health treatment in the United States.
The Accidental Discovery of Psychoactive Drugs
The story of modern psychiatric medications begins in the years following World War II. Between 1954 and 1957, researchers stumbled upon compounds that affected the central nervous system while searching for treatments for infectious diseases. These accidental discoveries led to the development of the first psychoactive drugs.
Unlike traditional drug development, which typically involves identifying the cause of an ailment and then creating a medication to address it, these new drugs were introduced without a clear understanding of how they worked or what specific conditions they should treat. This lack of targeted research and thorough testing would have significant consequences in the years to come.
One of the first psychiatric drugs to hit the market was Thorazine, developed by Smith, Kline & French. Despite being tested on fewer than 150 psychiatric patients, it was approved by the FDA in 1954 and marketed as a treatment for schizophrenia, anxiety, and bipolar disorder. This set a precedent for the rapid introduction of psychoactive drugs with limited testing, a practice that would continue in the following decades.
The Dark Side of Psychiatric Medications
While these new drugs were initially hailed as miracle cures, it soon became apparent that they came with a host of serious side effects and long-term consequences. Whitaker argues that prolonged use of psychiatric medications can cause significant and lasting changes to a person's neural functions.
Some of the most commonly prescribed drugs, such as selective serotonin reuptake inhibitors (SSRIs) for depression, can lead to an excess of serotonin in the brain. This can trigger episodes of mania in some patients. Antipsychotic medications, which work by blocking dopamine, can cause tremors and impaired motor function similar to those experienced by people with Parkinson's disease.
Other common side effects of psychiatric medications include:
- Memory loss
- Reduced learning ability
- Weight gain
- Suicidal thoughts
- Apathy
Perhaps most alarmingly, neuroscientist Nancy Andreasen published research suggesting a direct correlation between the use of antipsychotic drugs and brain shrinkage. The longer a patient takes these medications and the higher the dosage, the more significant the reduction in brain size.
Another major issue with psychiatric drugs is the difficulty patients face when trying to stop taking them. Withdrawal can cause severe symptoms, including insomnia, panic attacks, and even seizures. These withdrawal effects can last for months and are often mistaken for a relapse of the original condition, leading doctors to put patients back on medication.
The Snowball Effect of Prescriptions
Whitaker describes a troubling pattern in which patients often end up taking multiple psychiatric drugs to combat the side effects of their initial medication. For example, a patient prescribed an SSRI for depression might experience manic episodes as a side effect. This could lead to a diagnosis of bipolar disorder and the prescription of an antipsychotic drug. The side effects of the antipsychotic might then require additional medication, and so on.
This snowball effect can result in patients taking as many as six different psychoactive drugs per day. Each new prescription increases the risk of harmful interactions and makes it even more challenging for patients to eventually stop taking medication.
The Rise of Mental Illness Diagnoses
As the availability and use of psychiatric drugs increased, so did the number of people diagnosed with mental disorders. Since 1955, when these drugs were first introduced, the number of Americans considered mentally disabled has risen dramatically.
Between 1987 and 2007, the number of mentally disabled people qualifying for federal assistance more than doubled, going from one in every 184 Americans to one in every 76. This increase coincides with the expanding criteria for mental illness established by the American Psychiatric Association (APA).
The APA's Diagnostic and Statistical Manual of Mental Disorders (DSM) now includes four broad categories of mental illness:
- Anxiety disorders (including phobias and PTSD)
- Mood disorders (such as severe depression and bipolar disorder)
- Impulse-control disorders (like ADHD)
- Substance-use disorders (including alcoholism and drug abuse)
These categories are so wide-ranging that a survey conducted by the National Institute of Mental Health between 2001 and 2003 found that 46 percent of the population met the criteria for at least one mental illness. Many of these individuals qualified for multiple diagnoses.
The Alarming Rise of Childhood Mental Illness
One of the most disturbing trends Whitaker highlights is the dramatic increase in mental illness diagnoses among children. In the 20 years between 1987 and 2007, the number of children diagnosed with a mental disorder increased more than thirtyfold. Some patients receiving these diagnoses are as young as two years old.
Mental illness is now the number one disability in children, with ten percent of all ten-year-old boys taking medication for ADHD. Approximately 500,000 children in the United States take some form of antipsychotic drug. Many of these medications are not FDA-approved for use in children, raising serious concerns about potential long-term effects on developing brains.
The Paradox of Long-Term Treatment
Whitaker argues that while psychiatric medications can provide short-term relief for some symptoms, they often cause long-term harm to the brain's chemistry. This damage can persist long after the original symptoms would have naturally subsided without medication.
For example, before the widespread use of medication, a person with schizophrenia might have experienced episodes lasting up to six months, followed by extended periods of normalcy. However, after long-term treatment with antipsychotic drugs, these episodes can become chronic and lifelong.
While some people do benefit from regularly using antidepressants, Whitaker contends that many patients who are placed on long-term drug therapy end up chronically ill. He cites research, including a 1998 study by the World Health Organization, which showed that long-term use of antidepressants was associated with an increased – not reduced – risk of long-term depression.
The Crisis in Psychiatry
To understand how the mental health field reached this point, Whitaker examines the impact of psychoactive drugs on the psychiatric profession itself. Before the introduction of these medications, psychiatrists focused primarily on Freudian analysis, viewing mental illness as stemming from unconscious conflicts often originating in childhood.
The arrival of psychoactive drugs in the 1950s shifted psychiatrists' attention to brain chemistry and neurotransmitters. They began to focus more on identifying and eliminating symptoms through medication rather than exploring patients' life stories and emotional experiences.
This new approach initially brought hope to the field, but optimism soon soured as the severe side effects of these drugs became apparent in the 1970s. At the same time, psychiatry faced growing competition from other mental health professionals, such as psychologists and social workers, who treated patients without medication.
Internal divisions further weakened the profession, with some psychiatrists rejecting the medical approach altogether, while others clung to the Freudian model or viewed mental illness as a sane response to an increasingly insane world. These conflicts, combined with the profession's relatively low status and earnings compared to other medical specialties, led to a crisis in psychiatry.
The Rebranding of Psychiatry
In response to this crisis, the psychiatric profession launched a comprehensive rebranding campaign in the 1970s. The goal was to assert their medical legitimacy and enhance their status within the broader medical community.
A key part of this effort was the publication of the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) in 1980. Unlike its predecessors, which reflected the old Freudian view of mental illness, DSM-III was designed to present psychiatry as a more scientific and medically legitimate field.
The new manual contained 265 diagnoses, a significant increase from the 182 in the previous edition. It quickly became a universal tool used by insurance companies, hospitals, courts, schools, and government agencies. The DSM-III offered a consistent guide to psychiatric diagnosis, allowing different professionals to reach the same conclusion when presented with the same patient.
However, Whitaker argues that the main goal of DSM-III was to justify the use of psychiatric medications. By breaking down each diagnosis into a list of symptoms with numerical thresholds, the manual made it easier to prescribe drugs for specific conditions.
The Pharmaceutical-Psychiatric Partnership
Whitaker devotes significant attention to the close relationship between the pharmaceutical industry and the psychiatric profession. He argues that this partnership has been driven by financial interests rather than patient well-being.
As the number of available prescription drugs increased, so did physicians' incomes. Between 1950 and 1970, doctors' incomes doubled, largely due to their ability to prescribe these new medications. Even the American Medical Association benefited, with ad revenue from drug manufacturers in their magazine rising from $2.5 million to $10 million between 1950 and 1960.
The relationship between pharmaceutical companies and the American Psychiatric Association (APA) grew to include sponsored scientific symposiums. These events, which became the APA's most popular, featured lavish dinners and paid "expert panels" that were essentially well-rehearsed advertisements for specific drugs. Psychiatrists who spoke at these events could earn between $2,000 and $10,000 per speech.
The APA's revenues skyrocketed as a result of these partnerships. In 1980, the organization's revenue was around $10.5 million; by 1987, it had risen to $21.4 million. The APA even began referring to pharmaceutical corporations as "partners in industry."
The Cost to the Public
While the psychiatric profession and pharmaceutical companies profited from this arrangement, the American public bore the financial burden. Mental health services costs have risen faster than any other medical category, according to a 2009 report by the federal Agency for Healthcare Research and Quality.
In 2008, US citizens spent $170 billion on mental health services, twice as much as they paid in 2001. This figure was expected to climb to $280 billion by 2015, representing a 240-percent increase since 2001. With Medicaid and Medicare programs covering approximately 60 percent of these services, even taxpayers without mental health issues end up footing the bill.
The Lack of Long-Term Evidence
Throughout the book, Whitaker emphasizes the lack of solid evidence supporting the long-term use of psychiatric drugs. He cites several studies and expert opinions that challenge the effectiveness of these medications over extended periods.
One notable example is Jonathan Cole, often referred to as the father of American psychopharmacology. In a 1977 paper titled "Is the Cure Worse Than the Disease?" Cole reviewed evidence of long-term damage caused by psychoactive drugs. He found studies showing that at least half of all schizophrenic patients could live fruitful lives without them and concluded that antipsychotics were not the "magic bullet" that psychopharmacologists had hoped they would be.
Whitaker argues that rather than offering extensive data in support of psychiatric drugs, research actually shows them to be counterproductive in many cases. He contends that before the overprescription of these drugs became widespread, many people would recover from their symptoms and go on to lead healthy lives without long-term medication.
The Impact on Children
The author expresses particular concern about the rising use of psychiatric medications in children. He notes that many of these drugs are prescribed to children for conditions they were never approved to treat, potentially leading to severe side effects and long-term harm.
Whitaker argues that the dramatic increase in childhood mental illness diagnoses is not due to improved detection or awareness, but rather to the expanding criteria for mental disorders and the aggressive marketing of psychiatric drugs to parents and schools.
He suggests that many normal childhood behaviors are now being pathologized and treated with powerful medications, potentially altering the course of children's neurological development and setting them up for a lifetime of drug dependency.
The Need for Alternative Approaches
While Whitaker acknowledges that some individuals do benefit from psychiatric medications, he argues for a more cautious and judicious approach to their use. He advocates for exploring alternative treatments and addressing the underlying social, economic, and environmental factors that contribute to mental health issues.
The author highlights examples of programs that have achieved success in treating mental illness without relying heavily on medication. These approaches often involve comprehensive support systems, therapy, and lifestyle changes rather than a primary focus on altering brain chemistry through drugs.
Whitaker suggests that the mental health field needs to reevaluate its current practices and consider a more holistic approach to treatment. This would involve looking beyond simple chemical imbalances and addressing the complex interplay of biological, psychological, and social factors that contribute to mental health.
Conclusion
"Anatomy of an Epidemic" presents a compelling and disturbing analysis of the rise of mental illness in America and the role that psychiatric medications have played in this trend. Robert Whitaker challenges readers to question the prevailing narrative about mental health treatment and consider the long-term consequences of our current approach.
The book raises important questions about the influence of pharmaceutical companies on medical practice, the expansion of mental illness diagnoses, and the potential harm caused by long-term use of psychoactive drugs. Whitaker's work serves as a call to action for patients, healthcare providers, and policymakers to critically examine the current state of mental health care and consider alternative approaches.
While the author's arguments may be controversial and have faced criticism from some in the psychiatric community, "Anatomy of an Epidemic" provides a valuable contribution to the ongoing debate about how best to address mental health issues in our society. It challenges readers to think critically about the intersection of science, medicine, and commerce in the field of mental health and to consider the complex factors that contribute to both mental illness and recovery.
Ultimately, Whitaker's book serves as a reminder that the story of psychiatric medication is far from over. As our understanding of the brain and mental health continues to evolve, so too must our approaches to treatment. By questioning established practices and remaining open to new evidence, we may be able to develop more effective and less harmful ways of addressing mental health challenges in the future.