Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America (2010)

By Robert Whitaker - 30 Q&As - Book Summary

The number of Americans receiving federal disability payments because they are disabled by mental illness rose from 1.25 million in 1987 to 3.97 million in 2007. Children on the SSI rolls for psychiatric reasons went from 16,200 to 561,569 in the same period, a thirty-five-fold increase. Eight hundred and fifty adults and two hundred and fifty children newly qualify for these payments every day. The numbers do not describe a stable population coping with a fixed burden of illness. They describe a population that is being produced. Anatomy of an Epidemic (2010, updated 2015) is the documentation of that production, assembled almost entirely from NIMH-funded research, peer-reviewed outcome studies, federal disability records, and the published admissions of senior figures within American psychiatry. The argument Robert Whitaker builds is that the psychopharmacological revolution beginning with Thorazine in 1954 and accelerating with Prozac in 1987 has not reduced the burden of serious mental disorder. It has multiplied it, by converting episodic conditions into chronic ones through the brain’s compensatory adaptation to drugs that were never doing what they were claimed to do.

Whitaker came to this work through medical journalism rather than psychiatry. He had covered the medical beat at the Albany Times Union, co-founded CenterWatch (a publication serving pharmaceutical companies, medical schools, and Wall Street with industry-friendly coverage of clinical trials), and co-written a 1998 Boston Globe series criticising NIMH-funded research that withdrew schizophrenia patients from antipsychotics. He began as a believer in the prevailing story. The WHO finding that schizophrenia outcomes were dramatically better in poor countries where only 16 percent of patients were maintained on antipsychotics is what broke that frame. His first book, Mad in America (2002), traced the history of American treatment of the severely mentally ill; Anatomy of an Epidemic is the extension of that investigation through every major class of psychiatric drug. The book’s first review, by a Harvard Medical School assistant professor in the Boston Globe, compared Whitaker to AIDS denier Thabo Mbeki, and no other major newspaper reviewed it. Time, New Scientist, and Salon eventually published positive notices. The work has since produced a research foundation, an annual conference, and citations in JAMA Psychiatry editorials recommending the prescribing model Whitaker proposed.

When the book appeared, the chemical-imbalance theory had been the public face of psychiatry for more than two decades. The DSM-III revolution of 1980, led by Robert Spitzer at Columbia, had recast psychiatry as a discipline of discrete medical diseases defined by symptom checklists. The NIMH’s Depression Awareness, Recognition and Treatment program, launched in 1988 with pharmaceutical-industry funding, had told the public that depression was “common, serious and treatable” through medication. The APA, NAMI, and the pharmaceutical companies had developed overlapping leadership, shared messaging, and complementary roles in a public-information apparatus that presented the broken-brain story as settled science. What was already known and buried at the time of publication: the chemical-imbalance theory had been quietly abandoned by its leading proponents through the 1990s. Elliot Valenstein in 1998: “The evidence does not support any of the biochemical theories of mental illness.” Surgeon General David Satcher in 1999: “The precise causes of mental disorders are not known.” Kenneth Kendler, co-editor of Psychological Medicine, in 2005: “We have hunted for big simple neurochemical explanations for psychiatric disorders and have not found them.” The MindFreedom hunger strike of 2003 had asked the APA for a single citation supporting the broken-brain story, and the APA had been unable to produce one. None of this had reached the public.

Whitaker is not a terrain theorist. He works within mainstream neuroscience and accepts that neurons, neurotransmitters, and pharmacological mechanisms function as the establishment describes them. What makes his work valuable from a terrain perspective is that he documents — entirely from inside the establishment’s own data — the same pattern Shelton described nearly a century earlier: an acute condition suppressed by pharmaceutical intervention, the suppression adding new symptoms, the new symptoms attributed to disease progression rather than treatment, the patient driven from episodic distress into chronic disability. Martin Harrow’s fifteen-year longitudinal study found 40 percent of schizophrenia patients off antipsychotics in recovery against 5 percent of those who stayed on. The NIMH’s STAR*D trial found fewer than 20 percent of antidepressant-treated patients reaching sustained remission. Carolyn Dewa’s Canadian data show medicated workers more than twice as likely to go on long-term disability than unmedicated workers with the same diagnosis. The Open Dialogue programme in Western Lapland returns roughly 80 percent of first-episode psychotic patients to work or study within five years, most never exposed to an antipsychotic. The full summary reconstructs the evidence Whitaker assembled and the response the field made to it. By the book’s accounting, the population being treated and the population becoming disabled are increasingly the same population, and the disability is the treatment’s principal long-term effect.

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