Mad in America: Bad Science, Bad Medicine and the Enduring Mistreatment of the Mentally Ill.

Mad in America: Bad Science, Bad Medicine and the Enduring Mistreatment of the Mentally III, by Robert Whitaker, 334 pp, hardcover, $27, ISBN 0-7382-0385-8, Cambridge, Mass., Perseus Publishing, 2002.

Robert "taker's superb 2002 volume asks a fundamental question: does current psychiatric treatment help its patients? After proving that it doesn't, he demonstrates its considerable and increasing harm. These revelations make this volume perhaps the most important psychiatric book of the 21 st century.

The first half of the book examines the treatment of insanity before the psychiatric drug era, which began in the 1950s. The second half examines the increasingly harmful drug treatment that has dominated psychiatry since.

Two contrasting attitudes toward the insane have long coexisted within psychiatry: seeing them either as "beings without their reason, descended to the level of animals" and therefore requiring "harsh therapeutics to tame and subdue them," or as our "brethren, fellow human beings worthy of our empathy." These attitudes evoke different, though often overlapping ways of relating to patients: working upon them, as if they were anesthetized, and working with them, as physicians do in all chronic illnesses. While raving patients may require being worked upon against their will, their autonomy should be restored as soon as possible, rather than continuing them indefinitely under the control of others.

The age-old notion of the insane as permanently different from the rest of us received ideological support from the eugenics movement of the 1920s, and the biological psychiatry of today. Over the years, doctors with these views have subjected patients to a "bounty of remedies"--all touted and then dropped.

The 19th century featured purges, emetics, bleedings, and "drowning therapy," intended "to break the patient's will and make him learn that he had a master." The early 20th century was characterized by gynecological surgery, hormone therapy, and dental and intestinal surgery (supposedly with 85 percent cures, but actually with 43 percent fatalities), and deep sleep therapy. Then came the shock treatments: insulin, metrazol, and electroshock; lobotomy, which won the 1949 Nobel Prize; and then the drugs. Whitaker suggests that, "head trauma had replaced the whip of old for controlling the mentally ill" (p 106).

To Dr. Philippe Pinel (1745-1826) and his humanitarian successors, treatment was to be based on kindness and understanding. Finding little help for patients from remedies prescribed in medical texts, Pinel focused instead on "management of the mind" ('traitement morale'). He talked to his patients, listened to their problems, and came to appreciate their many virtues. And his treatment results were much better than those ofhis colleagues.

In the early 19th century, British Quakers' similar emphasis on working with patients evoked comparably good results. So did "moral treatment" in mid19th century Massachusetts mental hospitals. Good results were also obtained in the 1980s by Dr. Loren Mosher's Soteria project. Its deliberate destruction by psychiatric officialdom is but one of the many scandals Whitaker reveals.

Psychiatry's takeover by drugs began in 1954 with the introduction of chlorpromazine (Thorazine). Reports of the drug's short-term symptom reduction were used successfully by its manufacturer, Smith, Kline and French (SKF), for state-by-state public hospital proselytizing. Although the drug was originally marketed as an adjunct to psychotherapy-helping patients discuss their problems-it (and its successor drugs) came largely to be seen instead as the definitive treatment for schizophrenia.

The advent of the drugs created a "profound rift in the doctor-patient relationship in American psychiatry" (p 96), and therefore in the nature of the specialty. Acting upon patients increasingly replaced acting with them. The drugs' unpleasant effects made patients reluctant to take them, as shown by the high drop-out rates in investigative studies. Claiming, according to an SKF psychiatric journal advertisement, that "mental patients are notorious drug evaders," the company created a liquid chlorpromazine that they could not escape. Forced drug treatment was further enhanced in 1963 with introduction of long-lasting injectables. A single injection, usually good for a week, made resistant patients "cooperative enough to take whatever drug and whatever mode of drug administration is chosen for them" (p 213).

Labeling patients, and drugging according to the labels--which often takes but a few minutes--has replaced attention to each patient's unique problems. People "with widely disparate emotional and behavior problems [are] regularly funneled into a single diagnostic category, schizophrenia, and then treated with neuroleptics. At that point, their behavior and underlying brain chemistry did become more alike. They would all show evidence of drug-induced deficiency in dopamine transmission" (p 174).

The neuroleptic drugs "induce a brain pathology, similar in kind to encephalitis lethargica and Parkinson's disease." They "do not fix any known brain abnormality, nor do they put brain chemistry back into balance. What they do is alter brain function in a manner that diminishes certain characteristic symptoms. We also know that they cause an increase in dopamine receptors, which is a change associated both with tardive dyskinesia and an increased biological vulnerability to psychosis" (p 291).

Nevertheless, a New York Times Magazine advertisement on Aug 18, 1996, by America's pharmaceutical companies proclaimed that "scientists now know that schizophrenia and psychosis can result when the brain has abnormal dopamine levels. Because of recent advances, drugs that are able to alter dopamine levels free many patients from the terrible effects of mental illness." To Whitaker, this advertisement shows how "a scientific hypothesis had finally given way to a boldfaced lie" (p 199).

Further doubts about these drugs' value are cast by at least two sets of retrospective studies. Long-term follow-ups in this country and in Europe show far higher recovery rates in patients who stopped taking medication, compared to those who continued with them. And the World Health Organization found far worse treatment results in advanced countries where medication use is heavy, such as in the U.S., England, and Japan, than in poorer ones, such as India, Nigeria, and Colombia, where far fewer psychiatric drugs are used. Only a third of patients in the wealthier countries recover, as opposed to two-thirds in the poorer ones.

But the drug companies became even more blatant. In the 1990s they began heavily publicizing new "atypical" drugs as "breakthrough" treatments. After clozapine (Clozaril), which allegedly produced fewer other side effects than older drugs, was found to have a dangerous side effect of its own--agranulocytosis--it was marketed with weekly blood tests: at $9,000 per year. This opened the door for risperidone (Risperdal), Janssen's new blockbuster, which the Washington Post called "a glimmer of hope for a disease that until recently had been considered hopeless." It was to be marketed at $240 per month, or more than 30 times the cost of chlorpromazine.

In 1996, risperidone's sales topped $500 million, a sum greater than that spent on all other neuroleptics combined. Next came Eli Lilly's olanzapine (Zyprexa), which cost patients almost $10 a day, and whose sales in 1998 exceeded $1 billion in the United States alone. That year, sales of antipsychotic drugs hit $2.3 billion, about six times what they had been before risperidone. Creation of private "research" facilities, which could skillfully "cook" the results submitted to the Food and Drug Administration, was one reason for these drugs' wide acceptance. Only now are the serious side-effects of the "atypicals"--including gross weight gain and the creation of diabetes--and questions about whether they are any better than their predecessors, finally being addressed.

When writing this book in 2002, Whitaker doubted whether any rethinking would occur about the "merits of a form of care that is bringing profits to so many." But, he insists, "the day will come when people will look back at our current medicines for schizophrenia, and the stories we tell to patients about their abnormal brain chemistry, and they will shake their heads in utter disbelief."

Disclosure: I am quoted twice in the book, but have no financial interest in it.

Nathaniel S. Lehrman. M.D.

Roslyn, N.Y.