Recently, the biopsychiatric take on depression and many other mental disorders has come under attack. We’ve been told that many psychiatric illnesses are caused by a “chemical imbalance” in the brains of the affected and that common antidepressants and antipsychotics work to correct it. The only problem? That whole concept was known to be wrong 25 years ago. Why, then, are so many people handed prescriptions that purport to fix their imbalances?
Robert Whitaker began researching for a series on abuses of psychiatric patients for the Boston Globe with a self-professed conventional understanding of psychiatry. But as he delved deeper into the scientific literature, he found surprising results. Where was the proof of the chemical imbalance? Why did short-term outcome studies show improvement with drug treatment, but long-term outcome studies showed medicated patients faring worse than their unmediated counterparts?
Whitaker’s research eventually became Anatomy of an Epidemic, a detailed work of scientific journalism that questions our current psychiatric paradigm. I had the chance to speak with him recently to discuss how there’s such a broad disconnect between psychiatric research and the common perception of how psychiatric issues are solved.
You wrote in your introduction to Anatomy of an Epidemic about how when you were first introduced to the study of psychiatry, you were initially convinced of the correctness of the current, popular understanding. Yet, Anatomy of an Epidemic is quite skeptical of this paradigm. How did that change happen for you?
I really got interested in a backdoor manner. I was doing a series for the Boston Globe on abuses of psychiatric patients in research settings and I had a completely conventional understanding of psychiatry. I thought we were getting ever better at understanding the biological causes of schizophrenia and other mental disorders, and I thought that drugs fixed chemical imbalances.
That was the context. It was a four-part series and one of the parts covered situations in which doctors had withdrawn anti-psychotics from schizophrenia patients. We wrote that was unethical because you would never withdrawn insulin from a diabetic, so why would you withdrawn anti-psychotics from a schizophrenia patient?
But through the course of writing that piece I came across some outcome studies that really raised questions about that whole story. In particular, there was a study done by Harvard researchers that looked at longer-term outcomes over the last hundred years for schizophrenia patients. They found that outcomes for schizophrenic patients had actually declined over the last 100 years, and that outcomes are actually currently no better today than they were in 1900. That study was published in 1994. So, I was thinking to myself, that doesn’t make any sense.
Secondly, I came upon studies by the Word Health Organization, which twice found that outcomes for schizophrenic patients were much better in poorer countries. Specifically, in three — India, Columbia and Nigeria — than in the US and in other rich countries. They actually found that living in a rich country is a “strong predictor” that you won’t fully recover from schizophrenia. I wondered why that would be, since we’re so pound of our modern medical progress.
If you look into those studies, you find that the after the first one the WHO investigators hypothesized that maybe the reason for the better outcomes in the poorer countries was that they were more medication compliant. So they monitored the anti-psychotic usage in the second study and they found that they used anti-psychotic medications very differently in the poorer countries. They more often used them over the short-term, only keeping sixteen-percent of the patients on the medications long-term. So, I was just curious as to why the outcomes were so poor in developed countries.
As you go through the book and the evidence starts piling up, it seems like study after study of people who have been medicated are consistently doing so much worse. Were you shocked as you began to put together all this data that went against the conventional medical understanding?
I was shocked, and I was continually shocked, as I moved my way through the research, initially starting with studies dealing with antipsychotics use for schizophrenia. I was shocked by how consistent the story was as you began to focus on long-term outcomes as opposed to short-term outcomes. The very first one-year studies show the outcome that the medicated patients are more likely to be hospitalized and then you start following these landmark studies in order, you kind of follow your way through the research studies that begin looking at long-term outcomes and you see the same outcomes coming up again and again. First you see it with antipsychotics. I was surprised to see that by the late 1970s, people were saying “Uh oh, are we basically making this disorder more chronic?”
I was surprised, actually, by how fleshed-out the story was about the paradoxical long-term effects of the drugs. Then I was surprised that you begin to see it everywhere. If you look at cross-cultural studies, you see it. You see it in Courtney Hardings studies. Then you get MRI technology, which is showing that antipsychotics shrink the brain, and as that happens you get some functional impairment. By the time that the 2007 report came out by Martin Harrow, there were fifteen years of outcomes for medicated and unmedicated patients. By this time I expected the unmedicated patients to do much better.
Are we basically making this disorder more chronic?
That’s what he indeed reported and found. Even though it seemed so startling and so contrary to what you would expect to find given societal expectations, it was exactly what I expected to find.
You discussed the underlying causes of the psychiatric revolution in pharmacology in terms of psychiatry seeking, in a way, validation from the general medical community. The medical community began to develop medications (antibiotics) and was also able to hone in on the physical causes behind many diseases. Then the psychiatric community tried to follow suit.
I think we have to understand why psychiatry embraced the drugs in such a big fashion and also why they conceived of them in the ways they did. Why they came to see them as “antipsychotics’ as opposed to “major tranquilizers,” as drugs that were actually “fixing” something wrong in the brain.
I think there are twin impulses. First, psychiatry always has been the stepchild of medicine. The larger medical disciplines have always looked down on psychiatrists as not being as “scientific” and psychiatry was, historically, not as well-respected. That lack of respect has two parts. One is that psychiatry got its start in mental hospitals. It was superintendents of hospitals who, I think in 1854, formed an association that grew into the American Psychiatric Association. Initially, they were seen more as caretakers than modern physicians.
Then the whole Freudian thing became popular after World War II. Physicians thought that Freudians weren’t scientific. In popular culture, there’s often been deriding of psychiatrists as mad doctors, as in, they’re a little mad themselves.
You have the existence of this inferiority complex. It’s quite well recognized. What’s the way out of that inferiority complex? It’s to put on the white coat, so to speak. You start seeing your own form of care in terms of an infectious disease model. You have drugs for diseases in the same way the general practitioner can prescribe an antibiotic.
Also, we can’t forget that antibiotics just really revolutionized everything. I mean, at the time, people were suddenly no longer dying from bacterial infections. We also got the vaccines.
There were “magic bullets” that knocked out bacterial infections and “magic bullets” that inoculated you from Polio. The general sense, in the 1950s, was that science was uncovering the mysteries of illness and that science was advancing at an extraordinary pace. That sort of made psychiatry, as a profession, prone to believe that it was going to make the same advances too. When they found drugs that do change people – and antipsychotics certainly change behaviors and change thinking processes and movements, etc.— that whole era of progress lent itself to thinking, “Now we have made this great discovery.”
One of the most shocking things that you pull from medical literature in your book is that there is no proof of an innate chemical imbalance in people who are depressed and in people who have other mental disorders. Yet it’s such a part of our narrative, our pop-cultural medical understanding. Most people who take antidepressants would tell you that they suffer from a chemical imbalance, and their doctors would tell them that. Even drug commercials promoting antidepressants talk about the chemical imbalance.
Yet you claim it’s never been conclusively proven that imbalances exist. You talk about how these drugs work in a different way; they actually create an imbalance that is often beneficial in the short-term to some patients. How has this chemical imbalance situation been so accepted in our culture without really having a basis in literature?
There was a survey that came out awhile back that said something like 80% of American “know” that depression is a chemical imbalance. The whole thing starts out as a bit of wishful thinking, so to speak, but certainly as a valid hypothesis. What I say in the book is that the researchers came to understand a certain class of drugs act on the brain and, using an antibiotic model, they basically hypothesized that the disease was due to the opposite problem.
They found that antipsychotics blocked dopamine, so they hypothesized that the opposite, an overabundance of dopamine, was the cause of psychosis. The first classes of antidepressants, in one way or another, kept serotonin or norephinepherine in the synaptic cleft longer than normal, therefore upping those levels, so they hypothesized that the opposite, a deficiency in serotonin levels, was at the root of depression.
Now that’s okay. That’s a hypothesis, and when you see them raise that, they do raise it in the manner of a hypothesis. But what’s remarkable to me is how quickly they began to find it not to be so. In other words, when they actually looked at schizophrenic patients, did they actually have higher levels of dopamine? You find that falling apart pretty quickly. The low serotonin theory of depression, in some ways, had fallen apart by 1984. In other words, studies weren’t finding this characteristic low serotonin in depressed patients.
What you find is it’s not just that psychiatric researchers didn’t find it to be so, they continued to investigate the low serotonin theory for another 20 years, and constantly they were coming up with basically nothing. Not only were they not finding that patients, before they were medicated, had low serotonin, they were finding, in essence, a normal range of serotoninic activity. They were actually disproving their hypothesis. It wasn’t just that the hypothesis remained unproven.
You see clearly that there arrived this marketing message presented around the release of Prozac and the other SSRIs, and it really was a marketing message, it’s the only way to put it. It was a way to sell drugs. It was a way to sell biological psychiatry.
What’s stunning is that there’s this sort of betrayal. Somehow psychiatry and drug companies, and really the NIMH together, thought it was okay to tell people they had chemical imbalances when really the science hadn’t found that to be true.
The chemical imbalance theory really was a marketing message, it’s the only way to put it. It was a way to sell drugs.
I remember after the release of Risperdal (an antipsychotic drug given to schizophrenics), I called Janssen Pharmaceuticals and I asked the person, “I hear these drugs fix chemical imbalances. They fix they the surplus dopamine and other neurotransmitters. Could you just refer me to the actual studies that show that to be so? I’d like to read the studies.” Right away the person on the phone said, “Well that’s not really true.” They said it’s a metaphor we use to get people to take the drugs.
I asked why it was okay to lie to people. They said, something to the effect of, “We know the drugs are good and we need a way to explain to people why they need to take them.” That’s how quickly things fell apart. When I just simply said, show me the data.
That’s so interesting that they so readily discussed that with you on the phone.
Yeah, well there was nothing for them to point to. And what’s amazing, unrelated to Anatomy. There have been a number of papers that have appeared since Anatomy was published featuring people admitting that that theory doesn’t hold true. One of them is from Tom Insel, head of NIH until 2010, sort of going over this flaw in our thinking: that simply because a drug does one thing that people necessarily suffer from the opposite.
Another thing that happened to me since the book came out, I was asked to speak at Massachusetts General Hospital. It was a pretty tense time and they had another person respond, Massachusetts General Hospital psychiatrist Andrew Nierenberg, and he kind of took me to task for saying that psychiatry had not been an honest storyteller in our society. He objected.
I said, what about the chemical imbalance theory? Academic psychiatry has been telling us this story about a chemical imbalance and you know that’s not true. And here’s what he said: “Oh no we didn’t. We’ve known that’s an outdated model for 25 years. We moved on 25 years ago.” I said to him, “Well I agree. I agree that your science showed it was an outdated model 25 years ago, but I’m pretty sure you failed to communicate that to the public.”
Another part of the irony around the chemical imbalance theory is that the drugs create the very physiological imbalance that was hypothesized to cause the problem in the first place. That was stunning when you find out, for example, that because the drugs block the re-uptake of serotonin, the brain tries to compensate by decreasing its density of serotonergic receptors. The real irony here – and this is part of the cause of the long-term chronicity – is that the drugs do create a chemical imbalance. In fact, they create the deficiency hypothesized to create the disease in the first place.
Once you go through the science, you have an obvious question. Why don’t we know this? Why do we believe in chemical imbalances when they’re not so? Why don’t we know the long-term outcome data? Why is there this extraordinary gap between public understanding and what the science is showing? That leads you to the trail of commerce pretty quickly. What you do see is that the storytelling forces are shaped by money.
First, as a society we invest our trust in academic psychiatrists to be the experts who will inform us of the nature of these disorders and to do so in an accurate way. They will inform us of the safety and efficacy of the treatments accurately. It’s quite clear that what happened, beginning in the 1980s, particularly within psychiatry, is that many psychiatrists in the academic fields began working for pharmaceutical companies as spokesmen. They were promoting a guild interest as well; in other words, an interest that fit well with the explanation of biological psychiatry.
But it’s clear they were being paid a lot to expand markets, to expand diagnostic boundaries to promote drugs, to spin data, to tell a false story about chemical imbalances. That’s a really big story in that we’re seeing academic psychiatry in a mistaken light. In the past, we’ve seen them as these independent experts worried about health, but unfortunately they were getting paid a lot of money to promote a commercial story. There’s a misalignment there.
When you’re talking about pharmaceutical companies, you discuss the tremendous amount of money at work and how they influence top medical psychiatrists and studies. Could you talk a little about this? Also, are groups that seek to educate the public and to advocate for the mentally ill — like the National Institute of Health’s DART educational program (Depression Awareness, Recognition and Treatment Program) and NAMI (The National Alliance on Mental Illness) — encouraging the use of medication and expanding the idea that depression is often under-diagnosed?
The DART story is interesting because it shows how the mind of the American population was changed. Before the DART campaign, if you were to go around and ask adults about depression, they would say, “It’ll pass. You have to make changes. You look to friends. You do different things in your life and depression will pass. It’s a transient and episodic thing.” Then the federal government, through the National Institute of Mental Health, tried to change that idea and they did it successfully. They came up with this brochure; they told us depression is a brain disorder. You see a brochure and it’s got the government’s stamp on it.
In the past, we’ve seen psychiatrists as these independent experts worried about health, but unfortunately they were getting paid a lot of money to promote a commercial story.
But if you dig into the story behind DART, you find that it has commercial forces behind it as well. One, it’s partially funded by Eli Lilly, the maker of Prozac. Two, the people now in charge of the NIMH used to be the head of the PR arm of the American Psychiatric Association. You see within the NIMH there are forces that come from psychiatry that are trying to expand the biological psychiatry model. They’re obviously doing that to expand guild interest, and frankly because money is flowing from pharma to psychiatrists as well. You see that happening. The NIMH, this pristine government agency, it has outside commercial influences.
Finally, with NAMI, if any group should be pure, you would think it would be the parents of the severely mentally ill. They have a moral authority when they speak on what they know to be true. NAMI itself has had this ideological agenda right from the beginning, which is to escape from the old Freudian view of schizophrenia, the idea that it’s the mother’s fault. It certainly isn’t the mother’s fault.
Nevertheless, it gives them an ideological reason for them to embrace drugs, and a definition disease that eliminates their responsibility. And frankly, it’s pretty easy to see that both psychiatry and pharmaceutical companies saw this organization as a voice to capture, so to speak. Precisely because of its moral authority. They started funneling different grants and money to people. You see the financial channel operating as well. [Ed. note: You can check out the donors to NAMI for the final quarter of 2011, in this PDF.]
You mentioned Eli Lily and their response to data showing Prozac being associated with suicidal ideation, and how scientology and its views on psychiatry entered the picture.
I made a little joke in the book about psychiatry secretly funding scientology, but really, it couldn’t have worked out better for the pharmaceutical companies and biological psychiatry. The reason is that, of course, it delegitimizes criticism. The fact that scientology is so visibly attacking biological psychiatry and attacking psychiatric drugs delegitimizes all criticism. Scientologists clearly do have a cult-like status and they clearly do have an agenda. The fact that they’re so visible makes it very easy for psychiatry and pharmaceutical companies to say, “This is just criticism coming from that crazy group.”
Some of the stuff, they’ve gone into the data and they’ve brought out some information. Because it was scientology and CCHR that was out front with the criticism and raising questions and raising accusations that these drugs were causing suicide and violence, just made it really easy for pharmaceutical industry and Eli Lily to have it dismissed. If we didn’t have Scientology. Imagine it doesn’t exist and there’s no such group raising criticism. The questions around whether Prozac can stir violence or could cause someone to become suicidal or homicidal would have had a lot more traction.