Whitaker refers to the research of Harrow and Jobe9 in his contention that long-term antipsychotic treatment causes increased pathology. The Harrow and Jobe study is a marvelous 15-year follow-up of 64 schizophrenic patients—not an easy study to perform, in fact, a true labor of love. Twenty of these patients did not receive antipsychotic medications, and the researchers noted that their outcomes were more likely to be better than what was seen in the 44 patients who received antipsychotics.
Is it the disease or the treatment?
Whitaker’s conclusion is that long-term use of antipsychotics is not necessary for or may be harmful to patients’ functioning. He dismisses the fact (brought out clearly by the study authors) that the untreated patients in this nonrandomized observational study were likely to have been self-selected (ie, they were healthier and elected not to take antipsychotics). Whitaker reverses cause and effect to sustain his argument. Standard clinical logic would conclude that the poor outcomes in the antipsychotic-treated patients were a function of their illness—not the treatment. (Interested readers may want to see E. Fuller Torrey’s excellent analysis of Whitaker’s “tortured logic” in the schizophrenia studies.10)
The Harrow and Jobe study, by virtue of its design, is severely limited in its ability to generate clear and conclusive evidence that antipsychotics cause or increase morbidity over time. Ask Harrow and Jobe if you don’t believe me. The value of the Harrow and Jobe study is at the level of hypothesis generation. It suggests that not all schizophrenia patients require long-term medications. The question is, which ones?
The same type of discussion can be applied to Whitaker’s treatment of antidepressants, antianxiety agents, and mood stabilizers. He consistently employs a reductionist mentality to reach the “astonishing and startling” (Amazon.com’s advertisement words for the book) conclusion that our drugs have caused an “epidemic” of increased psychopathology in the major psychiatric disorders.
What to make of all this?
Should we accept the analysis of a journalist who (1) to my knowledge, has not treated a patient or implemented a study and (2) reaches conclusions that run counter to well-established practice guidelines? Whitaker’s ideological viewpoint, which is implied throughout the book, is that our guidelines are inaccurate and driven by industry and our own need for income—that we are dishonest brokers. Beauty is in the eye of the beholder.
I would predict that if the authors of the studies on which Whitaker relied convened a meeting to critically discuss the book, the vast majority would vote against this journalist’s idiosyncratic conclusion.
No one will argue that there is a dearth of long-term studies, defined as longer than 2 years, of the enduring effects of psychiatric medications. If Whitaker’s work stimulates more long-term research, then it serves the field. But while we wait for that research, should we change our practice to fit this journalist’s thesis that our medications cause poor outcomes? My answer is no.
Occupying the doctor-patient relationship
As practitioners, we work with our patients and provide for them the best treatment that we can, based on their preference, available evidence, and our judgment. We work collaboratively with each patient to weigh the risk to benefit ratio of long-term prescriptions over time. Risk to benefit calculations are no easy task. It is difficult to identify whether one patient requires long-term treatment following a good response to short-term treatment. Ideally, these decisions proceed within a solid alliance that we establish with the patient and others. Successful alliances require trust.
Books (and blogs) that go out for public consumption alleging conspiracy among doctors that results in epidemics and offering a prejudiced review of select literature run the risk of distorting that trust. (I am interested in hearing about direct experiences that you may have had in which articles, blogs, or books of the kind that I have discussed have altered existing treatment plans—positively or negatively. Contact me at firstname.lastname@example.org or 305-293-3555.)
We and our patients do not need to have that trust hijacked by misguided, “astonishing and startling” conclusions presented in publications such as Anatomy of an Epidemic. It is our obligation to protect that trust.