Robert Whitaker Speaks

On the last day of March, an overflowing crowd heard Robert Whitaker speak at the Brattleboro public library.  A writer and journalist, Whitaker has researched various medical issues with a particular focus on mental health for 25 years.  He has written two books, the first, ‘Mad in America’, was a history of psychiatric treatment in the United States since colonial times, and the second, ‘Anatomy of an Epidemic’, detailed the rise of the use of psychotropic medications in treating the mentally ill over the last half century and the consequences thereof.

The latter book drew a great amount of attention, winning an award for investigative journalism in 2010 and also making its author something of a spokesperson for change in the way that the mentally ill are currently treated in the United States.

What makes his work so influential is the fact that it is data driven.  There is no agenda other than presenting statistics and facts from a vast array of research studies pertaining to an array of outcomes of psychiatric treatment.  But it is with this data that Whitaker has given statistical credence to the observations of an increasing number of clinicians and, more importantly, the experience of many people with mental illness.

Whitaker’s presentation began with a simple question:  if our current widely accept model of relying on psychiatric medications to treat mental illness is effective why has there been such a dramatic increase in the number of people who have gone on disability for mental illness since the ‘revolution in psychopharmacology’ introduced these drugs?  In the same vein, he also wondered why the diagnoses of depression, bipolar and anxiety have skyrocketed.

Another corollary to these questions pointed out in the forward of his book is that studies from the Harvard Medical School during the 1990’s indicated that over the previous 20 years treatment results for schizophrenia patients had gotten worse and were, in fact, no better than outcomes from a century before.

Whitaker had also come across a study from the World Health Organization that indicated treatment outcomes for schizophrenics were much better in poorer countries where only a small proportion of the patients were treated with psychiatric drugs.

The above-mentioned ‘revolution’ began with the introduction of the drug chlorpromazine, marketed as Thorazine, in the 1950’s.  Originally developed in France a few years earlier as an anti-malarial drug, it was soon apparent that it had a profound sedative effect.  After gaining approval by the FDA, it was introduced as the first psychiatric medication and hailed as the single greatest advance in psychiatric care in modern history.

Perhaps compared to the standards of care in the years before - electroshock therapy, lobotomies (which literally scrambled the frontal lobes of patients), and life long institutionalization, there was reason to hope that heralded a new, golden era in psychiatry.

But Thorazine, like virtually all of its successors in the years to come, had a very dark side as well.  The side effects that eventually lead to it to falling into disuse affected just about every bodily system including the respiratory and cardiovascular systems, the liver, the hormonal and immune systems, the central nervous system and most especially the neuromuscular system. Patients would have spasms and twitching of various muscles, difficulty swallowing, and a restlessness that kept them in perpetual motion.  It also led to ‘pseudo-parkinsonism’, which means, amongst many symptoms, there would be shuffling gate, drooling, a mask-like face and tremor.  Perhaps the worst – or at least the most distinctive side effect was tardive dyskinesia.

Tardive dyskinesia is a hallmark of not only Thorazine but later generations of anti-psychotic medications.  It is characterized by repetitive and rhythmical involuntary movements of various muscles in the face and sometimes the limbs. Unfortunately, it is also irreversible in most case even after discontinuing the causative drug.

Despite these problems, Thorazine was for a time widely used.  Whitaker points out that the rationale that encouraged psychiatrists to do so was based on studies showing that patients had fewer psychotic events on the drug than those who were withdrawn from it.

He points out that those patients taken off Thorazine were done so abruptly and what was really being observed were the withdrawal symptoms from the drug.  This of course invalidates any conclusions that might have been drawn except the fact that people felt terrible during withdrawal.  This ‘rebound syndrome’ is a not uncommon phenomenon in which the body reacts to the sudden termination of a drug by producing increased symptoms until it adapts – if it can.

This last point, the ‘if it can’, is the other uncontrollable fact in the Thorazine study and relates to one of the key points that Whitaker makes.

Not only Thorazine but also its successors, the second generation of drugs rolled out about three decades later like Prozac, were all specifically designed to block or otherwise tamper with neural pathways.  These are basically the routes of the nervous system that transmit information.  While the targeted chemicals were different, Thorazine was aimed at the neuroendocrine transmitter (that is, it is both a hormone and a neurotransmitter) dopamine and the second-generation drugs are aimed at the neurotransmitter serotonin, the concept was very much the same.

The evidence of research and clinical experience now shows that once these pathways are disturbed, the alterations are oftentimes permanent.  Persons put on these drugs, especially those put on them for years, and especially those that are put a ‘cocktail’ of drugs, will, even if they successfully withdraw from them at some point, more than likely have altered brain chemistry thereafter.

In other words, there are millions of people who can’t go home again.  Once they are led down this road, their minds will never be the same and their hopes of returning to ‘normalcy’ or mental health will be dashed.

Perhaps this also sheds light on the basic question Whitaker posited when he began his research for “Anatomy of an Epidemic”. That is, if psycho-pharmaceutical medications are so effective, why has the number of people on disability for mental illness exploded since their introduction?

The epidemic of chronically mentally ill persons today is iatrogenic – meaning it is caused by the medical treatment.    Whitaker cites research about schizophrenia revealing that in the decade before the introduction of Thorazine, the majority of patients after initial hospitalization had good long-term outcomes.  Current research also indicates that similar outcomes for unmedicated schizophrenics.

In contrast, today only 5% of medicated schizophrenics show long-term recovery. The contrast points out the likelihood that the use of these drugs is keeping people chronically ill.

Research further elucidates the difference in what might be called the ‘arch of illness’ between medicated and unmedicated schizophrenics.  If one looks at the first two years after the initial psychotic episode, the outcomes of medicated patients in terms of the number of subsequent episodes is better than the unmedicated population.

But if one looks at a time span of five years or longer, the data shows something quite different: the unmedicated population does better than medicated patients. They are better able to overcome their condition and return to normal lives.

It may seem surprising or counterintuitive, but the implications are clear.  The current pharmaceutical-centric model for treating the mentally ill does not cure people over the long term.  So, this becomes the trade off: the drugs control extreme behaviors and there are less episodic crises for the first several years, but it also results in a large population of chronically ill persons, most of whom will never return to normal, unmedicated lives.

What then might be an alternative approach?  Whitaker suggests that there is in fact a successful model for treating the mentally ill that does not rely on pharmaceutical intervention as a primary modality.  It is found in the Finnish town of Tornio.

Tornio is located in the region of western Lapland that historically had one of the highest rates of schizophrenia in Europe.    From the late 1960’s a group of psychiatrists there created a new therapeutic paradigm based on a number of principles, the two most central of which are placing a focus on listening to and dialoguing with patients as well as creating a team around the patient to restore their social network of family, friends and community.

Underlying this approach is the realization that each patient is an individual with unique experiences and a personal story, even though that story may be expressed through hallucinations or delusions.   It is not when an individual is silenced but when he or she is heard that healing can begin.