The Occupation of Psychiatry?
The Occupation of Psychiatry?
I’ve been thinking about the “occupy” movement lately. It occurs to me that we've witnessed it through our annual APA meetings when sign-carrying people (Scientologists?) protesting the use of ECT declared, “Psychiatry Kills.” I simply ignore them because I don’t really “get” what they are communicating.
More recently, I have been witnessing a different attempt to occupy psychiatry led by journalist Robert Whitaker, the author of Anatomy of an Epidemic. Whitaker has articulated a position that I think we should not ignore.
Whitaker's polemic, which combines ideology with evidence, reaches the conclusion that a marked increase in disabled mentally ill persons in the United States over the past 20 years is due to psychiatric medications. He writes hundreds of pages describing select studies containing hints that after antidepressants, antipsychotics, and other psychiatric medications are used to treat the acute presentations of illness, the medications backfire via specific mechanisms of action that result in worsening of illness and increased disability claims. The ideological part of his argument assumes that his hypothesis has been a closely guarded secret among researchers, clinicians, organized psychiatry, and the pharmaceutical industry. Clinicians without industry ties are not immune from this conspiracy; they are presumably motivated to employ these medications for revenue.
The psychopharmacologist in me prompted a 2-part response to Whitaker's book in a journal for which I had been writing a monthly column.1,2 I had become aware of an interview that the journal had published in which the authors (non-psychiatrists) accepted Whitaker's research efforts outright and used his work to highlight criticisms (many justified) about the way psychiatry delivers care to patients. I was also aware of Marcia Angell's embarrassingly uncritical review of Anatomy of an Epidemic in The New York Review of Books.3
The fatal flaw in Whitaker’s work is his conclusion that psychiatric medications have caused a rise in disability claims. Using garden-variety journalistic reductionism, Whitaker ignores or is unaware of the complexity that accounts for psychiatric disability. To prove that drugs cause disability, multiple factors need to be considered. Study designs and statistical analyses need to account for such factors as confounding, reverse causation, and bias. It is equally possible that the reported increase in psychiatric disability claims results from many sociocultural stressors that have emerged over the time frame in question, eg, increased separation of wealth, globalization and resultant loss of jobs, reduced stigma against psychiatric illness, change in definitions of disability, and shifts in service delivery policies.4
Is the prescription of psychiatric medications (event A) causally related to the rise in disability claims (event B)? Only journalistic speculation coupled with ideological fervor would reach such a conclusion. A properly controlled study would help identify the contribution that psychiatric medications may have made to disability claims relative to the sociocultural factors that I mention. I would love to see a retrospective multivariate cohort study of the association among bio-psycho-social factors and psychiatric disability claims between 1990 and 2010. Mark Olfson, get to work.
Another point to consider here: If the increase in disability claims were due to psychiatric medications that caused an increase in the occurrence and severity of illnesses such as schizophrenia and depression, as Whitaker claims, we’d expect to see supportive epidemiological evidence. In fact, available studies show no real change in the rates or morbidity of serious mental illnesses.5,6
In the absence of epidemiolog-ical support, Whitaker chooses to doggedly pursue the highly speculative notion that medications cause psychiatric disability by reviewing select psychopharmacological and neuroimaging studies that he thinks might explain the notion. This is where it gets sticky and cumbersome.
The studies he selects, which are legitimate efforts by reputable researchers, involve efforts to examine the long-term effects of psychiatric medications. The average practicing clinician (not to mention the layperson) is not prepared to critically assess Whitaker’s presentation.
Whitaker’s descriptions of the studies he selected are fairly accurate, but his interpretations stray from the level of available evidence and prevailing expert opinion. He consistently comes to the same erroneous conclusion: that psychiatric medications cause long-term morbidity. Over hundreds of pages, Whitaker presents these studies as though he has uncovered clues to a mystery . . . and has solved it. He covers theories such as tardive psychosis, aka dopamine supersensitivity and tardive dysphoria, and treats them more like proven realities than the speculations that they are.7,8 Thus far, concepts such as these have not swayed prevailing opinion, despite considerable academic consideration.
The studies that Whitaker incorporates in his analysis are too severely limited—when considered individually or en masse—to justify reaching such a definitive, general conclusion. They involve small samples of fewer than 1000 subjects, do not employ randomized designs, and are mostly conducted at single centers, which make them difficult to compare or generalize. Of the studies considered, I’ll focus on just one for the purpose of characterizing Whitaker’s analytical style.