Posted by: thealienist | July 19, 2011

An Analysis of “Anatomy of an Epidemic”: Part I

One recent book that has many people talking is Anatomy of an Epidemic, by Robert Whitaker.  This book is a challenging read and throws the gauntlet down to psychiatrists who believe that medications are helping their patients.  The book is extensively researched and refers to a great deal of data.  Despite this, I believe that his conclusions are wrong.   I hope over the next several months to address his book in several posts.  Today, I will start with his first chapter.

Chapter I:  A Modern Plague.  Mr. Whitaker begins his book by outlining the scope of the mental illness problem, especially in America.  Indeed, the facts he marshals are impressive.  Next, sets up the straw man that he intends to destroy.  He introduces the antipsychotics, antidepressants, and antianxiety agents.  He notes that these are based on advances in neuroscience and molecular biology.  And he shows that the excitement about these treatments was promoted by promoted by the media and believed by the psychiatric profession.  Once he has set up this straw man, then it is time to reveal his real point.  He says (on page 5),

“Given this great advance in care, we should expect that the number of disabled mentally ill in the United States, on a per-capita basis, would have declined over the past fifty years.  We should also expect that the number of disabled mentally ill, on a per-capita basis, would have declined since the arrival in 1988 of Prozac and the other second-generation psychiatric drugs.  We should see a two-step drop in disability rates.  Instead, as the psychopharmacology revolution has unfolded, the number of disabled mentally ill has accelerated further since the introduction of Prozac and the other second-generation psychiatric drugs.  Most disturbing of all, this modern-day plague has now spread to the nation’s children.”

Thus, Mr. Whitaker sets out his goal for his book.  Before proceeding with his demonstration, he explicitly lays out the central question — “If we have treatments that effectively address these disorders, why has mental illness become an ever-greater health problem in the United States?”  After presenting some eye-opening statistics about the rate of disability among the mentally ill, he provides the answer his going to focus on.  He asks, “Could our drug-based paradigm of care, in some unforeseen way, be fueling the modern-day plague?”  He proposes that the following information will answer the question,

1.  “A history of science that unfolds over the course of fifty-five years, arises from the very best research, and explains all aspects of our puzzle.”

2.  “The history must reveal why there has been a dramatic increase in the number of disabled mentally ill.”

3.  (The history) “must explain why disabling affective disorders are so much more common now than they were fifty years ago.”

4.  (The history) “must explain why so many children are being laid low by serious mental illness today.”

5.  ‘We should be able to explain why [such a history] has remained hidden and unknown.”

Critique:

In his first chapter, Mr. Whitaker has used rhetorical technique to effectively advance his position.  Still, his technique reveals that his effort is designed to sway opinion and not to prove fact.  This is not to say that he does not cite relevant facts or cites them incorrectly, but is simply to say that his goal is not to prove that his hypotheses are true.

First, let’s address the straw man argument he is making.  He constructs this straw man (and names it “psychiatry”) that is only a caricature of psychiatry as it really exists.  It sprang into existence when medications were discovered and its scope of its interests contains only drugs and biological causes of mental illness.  Lest you think that I am exaggerating, on pages 10 and 11, this straw golem is described as reshaping society, teaching about chemical imbalances, teaching children in the schoolyard that they have something wrong with their brains, and teaching children about the nature of humankind.  And even more amazingly (we will discover), he is doing it all by himself!  I don’t think that Mr. Whitaker is going to have to work too hard to kill this straw man.  It’s a pretty easy one to take shots at.

Second, Mr. Whitaker often uses enthymemes to make weak points stronger.  An enthymeme is an argument in which one part of a syllogism is omitted or implied.  There is nothing technically wrong with this, but they can become so familiar to us that we do not keep our guard up and evaluate the implied premise or conclusion.  For example, a policeman might say, “He has the stolen money, so he must be the robber.”  He thus implies the premise that “only the robber could have the stolen money.”  A good lawyer would make the implied premise explicit and evaluate its truth.

Now, let’s look at some of Mr. Whitaker’s enthymemes quoted above.

“Given this great advance in care, we should expect that the number of disabled mentally ill in the United States, on a per-capita basis, would have declined over the past fifty years.”

We can look at this as an “if-then” statement as follows:  If a great advance in care for the mentally ill in the United States has occurred over the past fifty years, then the number of disabled mentally ill in the United States , on a per-capita basis, will have declined over this same period.  Is this true or false?  How would you know?  Is there anything that logically makes this statement necessarily true or obviously false?

The problem arises because this is not a complete syllogism.  Mr. Whitaker left out either a premise or a conclusion.  If you agree with him, then what are you assuming?  If you disagree with him, what are you assuming?  For example, we could complete a valid syllogism with statement 2 below:

1)  A great advance in care for the mentally ill in the United States has occurred over the past fifty years.

2)  Quality of care is the only factor that determines disability rates for the mentally ill, or all other factors affecting disability rate for the mentally ill are relatively unchanged over the past fifty years.  (I just made this one up, but it seems to be what Mr. Whitaker wants us to imply.)

3)  Therefore, the number of disabled mentally ill in the United States , on a per-capita basis, will have declined over this same period.

What do you think about statement 2?  Did you realize that this (or something very like it) was what was left implied? If Mr. Whitaker had made this statement explicitly, then in order to prove his point he would have to show that statement 2 was true or likely to be true.  I do not believe it.

Now that you have seen an example, try your hand at a few other enthymemes from the first chapter of Anatomy of an Epidemic.

We should also expect that the number of disabled mentally ill, on a per-capita basis, would have declined since the arrival in 1988 of Prozac and the other second-generation psychiatric drugs. 

We should see a two-step drop in disability rates. 

If we have treatments that effectively address these disorders, why has mental illness become an ever-greater health problem in the United States.

Finally (I know — tl;dr), Mr. Whitaker asks for what I believe will be impossible.  As noted above, he listed the data that he required to understand WHY we have such an increase in disability among the mentally ill.  His interest (at least for Anatomy of an Epidemic), however, is narrowly focused on medication.  We have good models describing the contributions of different factors to risk of mental illness.  We know what aspects of mental illness contribute to disability.  There is no reason that these models could not be expanded to include medication exposure.  Still, the only way to prove cause and effect is with an experiment, and I do not see an ethical way to randomly manipulate medication usage independent from all other confounding variables as would be required to test Mr. Whitaker’s hypothesis.

In summary, Mr. Whitaker’s first chapter is compelling writing.  It brings up important issues with regard to the magnitude of the problem of mental illness in our society.  Rhetorical methods are well constructed to sway and influence the reader, but a careful reading reveals the fault lines that will run through the remaining chapters and show this “anatomy” to be a distorted dissection of the body of evidence.

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Responses

  1. Well argued. Psychiatric disability has in fact become a kind of social welfare program, resulting from the increasing inability of the mentally ill to find adequate work. This may be owing to two factors: one, the gradual decline of the U.S. economy in recent decades (the soaring disability rate has obscured what may really be an unemployment rate that was rising long before the current recession), and two, the fact that the jobs that do remain available are increasingly technical and competitive and therefore less obtainable by the mentally ill. The schizophrenic who fifty years ago may have been pumping gas or working a simple factory job is today “disabled” because those jobs are no longer there.

  2. Hello John,

    First let me lay my cards on the table: I enjoyed Whitaker’s book enormously and I thought it was well-argued, with the EXCEPTION of chapter one. Obviously Whitaker is aiming at a conclusion that the drugs are making people sicker than they otherwise would be, why else would disability rates be going up? He will later pose some interesting neurobiological hypotheses (with which I’m confident you will have a great deal of fun) that suggest neuroactive substances leave brains more f***’ed up than were prior to treatment. (I look forward to your take on tardive dyskinesia).

    Whitaker makes the right observation, and the wrong diagnosis. There are other, more nuanced reasons why disability rates are heading for the stratosphere. Unfortunately, none of them make psychiatry look any better.

    The diagnostic criteria for both mental illness AND disability are so plastic and so malleable, that despite DSM-III and her successors, diagnosis creep and over-diagnosis are a near certainty. Combine this with a zeitgeist in which most people embrace enthusiastically the concept that their troubles in life are not their own fault (it’s my BRAIN!) and you have a recipe for an epidemic.

    John, unless and until we develop clear, objective, reproducible diagnostic criteria for mental illness, AND unless and until we produce clear and objective pathology, there is no reason for “an epidemic” NOT to occur!

    • Rob,

      Thanks for the post. I found the book both challenging and frustrating. I hope to simply put out a critique and let the chips fall where they may. I hope later posts prove worthwhile for you and me both.

      With regard to diagnostic creep, I also have mixed feelings. On the one hand, I think that it is helpful to try and classify human behavior and personality. On the other hand, just because we have classified it does not make it sick. Until we have a commonly agree upon way to discuss classification independent of pathology, this will continue to be a problem.

      John Casada

      • Agree. 100%, except with the suggestion that it’s helpful to try and classify human behavior and personality. I believe I know why you say so, but may I ask you to explain?

      • Just like any other phenomenon, human behavior is interesting. I think it is one of the most interesting things on the planet. Everyone except those with autism spectrum illnesses looks at those around them and tries to understand the meanings behind their neighbor’s words and actions. Some are very good at this; some are very poor; and some are in between. But most of us do this by “gut instinct.” There is nothing wrong with this. We deal with everyday physics the same way.

        Still, some people want to study their phenomenon of interest more closely. They want to see if it operates in a “lawful” way. in order to do this, we need some way of analyzing and classifying phenomena. Ideally, this should be accompanied by terminology that allows us to communicate clearly with one another. There are many different classification schemes out there — all of which have their own jargon. The most basic is the classification of behavior by the Behaviorists. This scheme is useful for those who simply want to control behavior, but I think it misses much of what it means to be human. Cognitive-Behavioral schemes seem better to me because they include thoughts, assumptions, and cognitive processes into the mix. The most complicated (but I must admit also my favorite) are the psychodynamic schemes. They seem to encompass the majority of what I believe makes us human. Unfortunately, it is also the scheme that is hardest to explain in terms of neurobiology. Oh well, that’s what makes psychiatry fun.

        I believe (just my opinion here) that as we learn to analyze and study human behavior we will face (and really are currently facing) two opposing views of humanity. The determinists will see ways to control others and shape humanity according to their own vision. The humanists will discover innumerable intricacies, adaptations, broad commonalities studded with sharp idiosyncrasies, and challenging but just-on-the-edge-of-understandable diversity in human existence. (Sorry, I wax poetic against my will). This type of information has (and I believe will continue to more and more) restore individuals who have lost control of their lives to once again be “the captains of their fates.”

        Sorry, too long of a reply. I kind of have strong feelings about this. Hope it addressed your request.

  3. I appreciate your thoughtful answer, John. I agree in general with practically all of what you said, even if I could not have said so as poetically!

    My concern with classifications branches off my Libertarian sensibilities. Psychiatric classification has tended to relieve individuals of responsibility for their behavior (I can’t help it: I’m bipolar), AND rob the individual of personal agency and sometimes liberty (Mr. X is a schizophrenic; no way I’m gonna hire him/work for him/engage him maritally or otherwise/admit him to my school/let him teach my children)


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