Posted by: thealienist | July 28, 2011

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

I hope this post will be short.  It seems unfair to expect much out of a chapter entitled, “Anecdotal Thoughts,” but Robert Whitaker felt it was important enough to include, so I will cover it.

Mr. Whitaker starts out this chapter with a story about a visit to the Depression and Bipolar Support Alliance meeting at McLean Hospital in Belmont, Massachusetts.  His description of the event and of his conversations with members of the group provides an apparently fair and respectful picture of the group, its composition, and the unexpected (to Mr. Whitaker) frequency of employment difficulties of the group members.  He then outlines his purpose in relating four anecdotal stories related to him by group members.  He states on page 16, “Still, as we set out to solve this puzzle of a modern-day epidemic of disabling mental illness in the United States, anecdotal accounts can help us identify questions that we will want to see answered in our search of the scientific literature.”

Mr. Whitaker is careful to note that anecdotes have very limited usefulness.  This is true and is due to the fact that while they tell a story about what happened, they cannot tell us a story about what would have happened to other people or what might have happened if things had been done differently.  Still, the first anecdote that he relates is about a woman who had a positive response (by her own admission) to risperidol.  This woman’s history is full of psychological stressors, traumas, possible psychosomatic illnesses, drug use, and eventually behavior that led to an initial diagnosis of bipolar disorder and a later diagnosis of schizoaffective disorder.  She was treated with a variety of medications that apparently allowed to to complete a college degree and form a lasting romantic relationship.  Mr. Whitaker notes that she repeatedly contacted him to say how her medication “saved” her.  She did note that she had some problems with the medication including stiff muscles from haloperidol, “depression” (not defined) from the lithium, possible beginnings of tardive dyskinesia, weight gain, and a subjective sense that she has reduced empathy.  Mr. Whitaker notes that she is not working and feels that the side effects of the medication contribute to her inability to work.

If Mr. Whitaker had stopped here, he could have concluded reasonably that hers was a life improved (but certainly not perfected and certainly accompanied by side effects) by her medications.  Instead, he chooses to ask questions that either are contradicted by his anecdote or cannot even be addressed by it.  He asks, “Is hers a story of a life made better by our drug-based paradigm of care for mental disorders, or a story of a life made worse?”  Well, Mr. Whitaker, she says that she was “saved” by her medication.  She was able to complete her degree and begin a long-term relationship.  Can we not trust her own assessment of her improvement?  He also asks, “How might her life have unfolded if when she suffered her first manic episode in the fall of 1978, she had not been immediately placed on lithium and Haldol, the doctors instead trying other means — rest, psychological therapies, etc. — to restore her sanity?”  This supposes that there are other therapies that have proven successful in treating manic episodes.  Currently, this is not an accepted assumption.  Once someone becomes manic to the point described in this patient’s history, you cannot make them rest or engage in psychotherapy.  He also asks, “Of if, once she had been stabilized on those medications, she had been encouraged to wean herself from the drugs?”  Well, we know from her story that she stopped (not weaned) herself from the drugs on multiple occasions and had relapses.  Would weaning her from the drugs have prevented her multiple relapses?  We can’t tell, but we have evidence that continuing medications reduces frequency of relapse.  He asks several other unanswerable questions before ending with “And if she had been able to fare well without drugs, how much more might she have accomplished in her life?”  As my father-in-law used to say (quoting Don Meridith), “If ‘ifs’ and ‘buts’ were candy and nuts, we’d all have a merry Christmas.”

After posing all of these questions, Whitaker admits, “There is, of course, no way of knowing what a life without medications might have been like for Cathy Levin.  However, later in this book we will see what science has to reveal about the possible course her illness might have taken if, at that fateful moment in 1978, after her initial psychotic episode, she had not been medicated and told that she would have to take drugs for life.”  Finally, Ms. Levin provides Mr. Whitaker with the straw man quote to wrap up this story,  “They don’t have any sense about how these drugs affect you over the long term.  They just try to stabilize you for the moment, and look to manage you from week to week, month to month.  That’s all they ever think about.”  I understand that this is Mr. Levin’s belief and that it might be true in some cases, but this seems to be more of a statement of Ms. Levin’s frustration than an meaningful statement of the mental status of the “psychiatry” golem.

The second anecdote is an inspiring and informative tale of a man who grew up isolated from his peers due to cultural differences, abused by his father, and into amphetamines, marijuana, and cocaine.  He eventually was diagnosed with schizophrenia.  He was medicated with haloperidol (which he did not like) and was suicidal on several occasions.  He continued to have worrisome behaviors (trying to have a gun smuggled into the hospital and helping patients escape the hospital) that resulted in further efforts to control his behavior.  Finally, something changed and he began to improve to the point that he is now a custodial father and an advocate for the mentally ill.  Mr. Whitaker would like us to believe that what changed was his “tonguing” his medications (hiding them in his mouth and spitting them out later).  Certainly, that was a change, but are we really willing to believe that this patient’s psychotic and disruptive behavior was caused by the medication rather than the medication being given in response to his behavior.  Of course, all I can do is guess (since I do not know this man), but I am more likely to believe that this man began controlling his behavior better and needed less medication.  Mr. Whitaker asks, “Given that his recovery began when he stopped taking antipsychotics, is it possible that some people ill with a serious mental disorder, like schizophrenia or bipolar illness, might recover in the absence of medication?”  Of course this begs the question.  How does Mr. Whitaker know that stopping the medication coincided with the start of his recovery?  It is just as likely (or more in my opinion) that his recovery was the cause of him stopping taking medication.

The third anecdote is a touching story about a woman initially diagnosed with major depression but eventually with bipolar disorder.  However, this story has both both good points to make and unfortunate errors.  It starts of with an error.  Mr. Whitaker describes the subject as seeming “like the last person who might have a life of mental illness awaiting her. She came from an accomplished family — her mother was a professor at Wellesley, while her father taught at several Boston-area colleges — and Monica was a child who excelled at whatever she chose to do.”  This is important (with the exception of mental retardation)– mental illness is not an intellectual problem; it is not a moral problem; it is not due to a lack of talent or skill.  To suggest otherwise is to slander the suffering.  Unfortunately, both Mr. Whitaker and the woman in question both revisit this fallacy repeatedly.  Now, on with the touching part of the story…  This woman initially suffered an intense depressive episode for which she was treated with an tricyclic antidepressant (an older type).  As sometimes happens, she began having symptoms characteristic of bipolar disorder.  There is conflicting opinion about whether this constitutes a change in diagnosis or whether such patients are still more characteristic of major depression than bipolar disorder when they are off medications.  Regardless, this started this woman down a long path of medications in an attempt to stabilize her mood.  She was tried on numerous antidepressants but these left her frequently suicidal.  Ultimately, she found more stability off the antidepressants and on lithium.  Though she finds the lithium helpful, she feels that she is not as artistically creative while on lithium.  This anecdote is the most disappointing because the American Psychiatric Association has recognized that antidepressants increase the risk of mood instability and recommends that most antidepressants be used with caution (and never alone).  It is disheartening to hear of patients suffering because of improper use of antidepressants (though it is not clear whether this was generally recognized during the time that this particular patient was being treated with antidepressants).  Still, this should not be continuing to happen!

The last anecdote focuses on a woman who may have been misdiagnosed with bipolar disorder and for whom treatment for bipolar disorder seems to have caused more problems than she would otherwise have gone through.  Mr. Whitaker cites this story as an example of the dangers of sloppy and imprecise diagnosis magnified by the significant side effects of psychiatric medications.  Good story.  You should read it.

The chapter closes with a discussion of Attention Deficit Hyperactivity Disorder (ADHD) and bipolar disorder in children.  Mr. Whitaker relates the stories of two families with young children facing a psychiatric diagnosis.  One family chooses to put their child on medication and one does not.  The stories illustrate well the difficulty that parents face when dealing with mild to moderate problems in behavior.  Mr. Whitaker poses some meaningful and important questions at the end of this section such as:  “Were there studies showing that drug treatment for ADHD or juvenile bipolar illness is beneficial over the long term?”  Good question.  “If you put a young child on a drug cocktail that includes an antipsychotic, how will it affect his or her physical health?”  Another good question.  “Can the child expect to become a healthy teenager, a healthy adult?”  Another very good question.  On the other hand, his first question (unfortunately a leading one) was “‘Did their child really suffer from a chemical imbalance?”  Is this question really important?  Sure, I don’t suggest that people be told that they have a chemical imbalance if we do not know that they have one.  When my patients come to me and say that they have a chemical imbalance, I try to give them a better understanding of what they are dealing with than this tremendously oversimplified statement.  Still, does it matter what the underlying cause is if there is effective treatment?  If the physician and the patient (or patient’s family) are paying attention to the good questions mentioned above, does it matter?

Why does Mr. Whitaker feel the need to include the question “did their child really suffer from a chemical imbalance?”  The pragmatist would say that the answer does not matter.  The fact THAT something works (as indicated by addressing the other questions Mr. Whitaker proposes) is more important than WHY it works.  The scientist might find it important because it is an interesting question and that piece of knowledge would be good to have.  With regard to the parent, however, I would expect that they would be closer to the pragmatist.  If so, then why lead with the above question?  I can think of a few possible arguments (but we must rely on conjecture because Mr. Whitaker did not make it explicit why this is important).

First possible argument:          1) “Psychiatry” believes that mental illness is due to a chemical imbalance.

2)  This book will show that they do not know that mental illness is due to a chemical imbalance.

3)  People who assert things they do not know to be true are deceiving you.

4)  “Psychiatry” is deceiving you.

Second possible argument:     1)  Medications, as chemicals, are only useful if they address chemical imbalances.

2)  Mental illnesses are not due to any known chemical imbalances.

3)  Medications are not useful to treat mental illnesses.

Third argument:                           1)  Medications cause chemical imbalances.

2)  Chemical imbalances cause conditions that look like mental illnesses.

3)  Medication-caused chemical imbalances cause conditions that look like mental illnesses.

There may be many close variations of these arguments one might think of, but I think that these two (or something like them) might be the reason that Mr. Whitaker needs to include the above question.  The first argument is interesting but unfortunately it is a straw man argument.  The second argument is based on a fallacy (the first premise), but this may simply be left unstated in the enthymeme (see part one of this series).  Now I don’t believe that Mr. Whitaker believes the second argument.  He goes out of his way to state that some people may benefit from some medications.  He has also been reported to have been supportive of psychiatric treatment in his previous writings.  Still, I think that some of the emotional impact that his book relies on is based on this unstated argument.  Finally, the third argument is one that he is just introducing in this chapter and one that will be pursued throughout the book.  It is a well-contructed argument whose truth value depends on the truth and generalizability of its premises.  I think it might be true for some particular individuals but not generalizable enough to explain the “epidemic” he wants to address.

Finally, some closing remarks.  In this chapter, Mr. Whitaker continues to wear his medication blinders.  He presents interesting case reports full of numerous potentially helpful facts, then (like the straw man “psychiatry” that he creates) chooses to focus only on the chemical explanation.  Could it not be the abuse his subjects experienced, the chronic stressors they encounter, the illegal drugs they used, or the demands of the society they live in that account for their recurrent illness and disability?  This chapter personalizes the problem of chronic mental illness but only pretends to focus our attention on a solution.


Responses

  1. Interesting post. I will say right up front that it has been several months since I read this book.

    My life story certainly matches Robert Whitaker’s argument, that medications are worsening mental illnesses. I gave up with meds after 15 years because nothing treated the depression associated with bipolar disorder (lithium worked on the mania, but now that I am older, I no longer get mania, it seems). One and a half years off meds, my behavior is better, the agitation is gone (probably was akathisia in hindsight), but the severe depression is still with me. I function better because my relationships are better, due to the behavior problems going away within a few months of stopping medications. I didn’t stop meds because I felt better, and I had been in continuous agitated hell for years. The mental illness is much more tolerable now, but still awful. I had been functioning on and off for many years until I took meds. My brother was functioning on and off until he took meds, then also became continuously dysfunctional. We were told that it was common for mental illnesses to get worse as a person ages. He improved off meds also. The bipolar I have used to be classic, no question about the diagnosis, not at all. so anyway, there are2 life stories that match Whitaker’s thesis, but of course, they are anecdotal, and we can’t re-run our lives. I was literally kicking holes in the walls and breaking expensive possessions while I was on meds, which I NEVER did when younger (before meds) and now that I am off meds, I don’t break anything. Go ahead and blame my docs for not seeing the akathisia, but I was inpatient a few times, and none of those doctors figured it out either. I think this might be common! Instead, some of them tagged me “borderline” even though the problem behaviors suddenly appeared in my 30’s. Again, this is anecdotal, but my husband is so happy to have me off the meds. If I do get severe mania again, someday, then we will have to think hard about what to do.

    It is true that we mental patients were taught about the “chemical imbalance” stuff. Whether you personally taught that is irrelevant – the drug company and NAMI brochures out in the office waiting room teach this, as well as NAMI and bipolar and schizophrenia support websites and books and everywhere! Everybody in the general public “knows” that mental illnesses are a “chemical imbalance” and you must “take your meds like a diabetic takes insulin.” Good for you if you never grossly simplified like this, but you are not the only one teaching your patients.So the chemical imbalance stuff is not a straw man, people in the public really believe that mental illnesses are caused by chemical imbalances. whitaker has to address this issue.

    NAMI stuff and brochures in the waiting room NEVER talk about how trauma or previous drug use, etc. contributes to mental illnesses. To be fair to my doctors, they did address the trauma stuff with me, to a SMALL extent. Of course, they can’t fix the trauma in my life that was in the past, so it was kind of irrelevant. I never used illegal drugs,so that was never brought up and I don’t know what doctors say.

    My take away message from whitaker’s book was that mental illnesses are not caused by chemical imbalances. And the meds that are used to treat mental illnesses may be worsening the course of mental illnesses by making symptoms more intense and chronic, with LONG TERM USE of psychiatric drugs. So the first part of the “argument” doesn’t really matter, because he has a stand alone argument that the meds just don’t work well in the long term. Whatever caused the mental illnesses to begin with is irrelevant. It’s just that the argument that places like NAMI use, persuading patients that they MUST use the meds, is based on the chemical imbalance idea. If bipolar or schizophrenia or depression are caused by chemical imbalances and you won’t take pills to rebalance those chemicals, you are doomed to a horrible life. That is what groups like NAMI have been saying, for years now.

    • Cats,

      I’m sorry that you had such a long time wrestling with medications, but I’m glad you are doing better now. I hope you never have to face an (or another (I’m not sure)) manic episode. I wish your story was more rare, but bipolar depression is a very difficult issue to address.

      Now for some (hopefully not too disagreeing comments). First, I don’t think that it is irrelevant that I teach my patients that the “chemical imbalance” theory of mental illness is way too oversimplified. Sure, there are many other voices out there that harp on this issue, but that does not make those of us who teach a more complicated (but I think much more accurate) view of mental illness irrelevant. Second, I do not believe that work with past trauma is irrelevant. Of course the traumatic event(s) happened in the past and the past cannot be changed, but the effects of the past continue into the present. Psychotherapy can change our understanding of our trauma and alter the way it affects our life. I don’t know if you need to address a past trauma, but many of my patients do. And they benefit from it.

      Finally, as we go through the book, I think I will be able to show that Whitaker does not prove that mental illness is not a chemical imbalance. I think he does show that sometimes (some would say often) mental health professionals say more than they can know and present a complicated issue as if it were very simple. I would agree with this, but I think Whitaker takes it too far. I also do not believe that he shows that long-term use of medications is harmful, but these arguments will come in later chapters. We’ll see if I can make this case satisfactorily when we get there.

      Thanks for writing. I hope you and your brother continue to do well.

  2. “I hope this post will be short.”

    LOL my post was supposed to be short too. I guess I am avoiding the laundry!

    • Cats,

      I know. I seem constitutionally unable to write a short post. I’m glad you can take it in good humor.

  3. “The fact THAT something works… is more important than WHY it works.” Not if you don’t know what harm you do by not understanding what the drug is doing.

    As for Whitaker’s treatment of the “chemical imbalance” hypothesis: Recall that one of his premises is that, if the hypothesis were true, mentally ill people SHOULD be helped by drugs that ostensibly correct their chemical imbalances. This does not appear to be the case, according to data that Whitaker produces and that others have documented (e.g. Irving Kirsch).

    Whitaker’s principle argument, it seems to me, is that psychoactive drugs produce MORE harms than benefits. His pathophysiology is speculative (I’m sure you’ll produce more colorful adjectives), but his conclusion appears to be largely correct.

    As for ADHD: Whitaker doesn’t address the 3-year follow-up to MTA in the book, but he mentions it elsewhere, and provides a link to the full text at his web site. http://madinamerica.com/madinamerica.com/Children_files/3-year%20followup%20of%20the%20NIMH%20MTA%20Study.PDF

    Briefly, there’s no long-term benefit for stimulant medications in children diagnosed with ADHD.

    • Rob,

      You are getting a little ahead of the argument. First, you know that I addressed the harm issue in my post. Saying that a medication works takes into account its potential for harm (i.e. a medication that cures your infection but leaves you deaf and on dialysis is not a “working” antibiotic). Second, psychiatric medications do help at least some people. Whitaker’s own stories show this. As we continue thorugh the book, I think I will be able to show that Whitaker’s arguments are not sound and do not prove what you think they do. Also, I do not believe that (properly used) psychiatric drugs do more harm than good. I do not believe that Whitaker has shown this, either. This argument will be more productive as we delve further into the book, though.

      Finally, with regard to the study you link to, you sure are selective about how you interpret the data. The results of the study were that medication and behavioral therapy both appear to improve functioning and to be equally effective at three years (though there was no untreated control group to compare them to). You fail to mention, however, that the medicated subjects showed a faster response than the behavioral therapy group did. Is it your belief that YOU are the one who should tell a family that they should not take advantage of medications because YOU don’t like them? (I can’t imagine you taking this stance with your libertarian views.) Perhaps a more fair representation of this research to distressed families is that their children can be helped in several ways, with their choice of ways being influenced by the desired speed of the effect and potential side effects.

  4. (I can’t imagine you taking this stance with your libertarian views.)

    In fact, many’s the time I’ve told a mother that I’m prescribing a medication not because I think her child needs it but because she asked me to. I’m also sure to document this conversation in the chart.

    As for MTA, faster response, identical endpoint. It suits the 21st century desire to get the problem solved yesterday.

    Another coda on Libertarianism: This part of the discussion would be moot if the meds were available OTC and the family paid for them out of pocket. Hey, we Libs can dream, can’t we?

    • Rob,

      Well, this is one of the problems I have with libertarianism. How you can argue that a medication is harmful (especially if misused) then argue for supplying it over the counter makes no sense to me. It also seems surprising that you would suggest (though not state outright) that it is somehow inappropriate for people to want to end their distress quickly. If they can do so with acceptable (to them) risk, who are we to see it as a problem?

      • I’ll concede the second point, John. There’s nothing wrong with wanting your symptoms to go away quickly, as long as you are willing to own the attendant risks.

        The first point is terribly important and subtle. And it goes to some of the core issues of freedom and responsibility. I may use my best powers of persuasion to argue the pros or cons of a particular drug or treatment for a person. But at the end of the day, that person owns his body, and the decision as to what to put in his body is his.

        Does that exempt me from the privilege of arguing about safety and efficacy in the blogosphere?

        In any case, the antecedent argument here is over the existence of mental illness. I have no problem with people taking drugs to make there troubles go away. My problem begins when those same people are coerced, forced, or tricked into taking those drugs.

        The “tricked” part comes in when we tell the putative drug taker that he has a chemical imbalance that must be corrected. Or that he has something else “wrong” with his brain.

  5. I’m another anecdote. I was diagnosed with major depression (but was functional – working, etc). I reluctantly went to a psychiatrist after a referral from my PCP. The shrink told me I had chemical imbalance for which I needed drugs to treat. I was told I would have to take drugs for teh rest of my life. By the time they got through with me I had been on dozens of psych meds and hospitalized four times. I went from being depressed but functional to being cuckoo nuts, which of course was attributed to my worsening mental illness not to the treatment. Like so many I was told ECT was my last hope. Long and short of it is a very good thing happened. I became so depressed I could no longer drag myself to the psychiatrist or to the pharmacy, and I ran out of money. Several months of being off the psych meds and I was a new woman. I have taken nary a psych med in years. I work full time in an intellectually challenging career and am not in the special menial job for mental patients that was recommended for me – the one employers get a tax break for taking on. In fact, my present situation would stun my previous psychiatrist who had pretty much deemed me a hopeless, chronic mental patient.

    Sadly, I have seen this happen to other people, too. I know of a woman who was a 4.0 student in college, mildly depressed, went to see a psychiatrist and became bipolar and nonfuctional. Her whole identity became wrapped around the bipolar diagnosis. There sure are a lot of us anecdotes out there, but the studies don’t typically look at those who got worse on meds and improve off them.

    I think Rob’s statement is right on. “I have no problem with people taking drugs to make there troubles go away. My problem begins when those same people are coerced, forced, or tricked into taking those drugs.”

    I wish the psychiatrist had not mislead me by telling me I had a “chemical imbalance.” I had as Rob would call it a problem of living. I had been through a really bad, traumatic situation and needed a decent therapist not a pile of drugs. I wish I had known that then.

    • Anonymous,

      There seem to be many out there who share experiences similar to yours. I hope that it is helpful for you (and those who have had similar experiences with psychiatrists) to share these experiences. I also hope that we all learn the appropriate lessons from the combined experiences of people who seek help for their problems. Just like the positive experiences reported by patients does not invalidate the negative experiences of others, the negative experiences do not negate the positive.

      So what are we left to learn? Perhaps it is that recovery from mental illness is more complex than both patients and psychiatrists would like to believe and that both need to work as partners for successful treatment. If either one cannot work with the other, it is probably best for both to acknowledge this and find another partner for treatment.

      I hope that you continue to improve with whatever assistance you find necessary. Thanks for your post.

  6. sorry. paragraph above should have read: “… the ANTERIOR argument here is…people taking drugs ‘to make THEIR troubles go away’….” the latter clause should have been set off in quotation marks to indicate that the drug taker intends to diminish his own suffering, irrespective of what the drug actually does or doesn’t do. The word ‘defrauded’ could have been usefully substituted for the word ‘tricked’, but I wanted to avoid the monetary connotation.

    • Rob,

      You showed admirable restraint :~b

  7. I guess i wasn’t clear. What I meant by whether mental illnesses are caused by chemical imbalances or not doesn’t matter all that much if the meds are not doing a good job in the long run. That latter issue is the one that is crucial in psychiatry. I don’t really give a rip what causes bipolar, i just wish the meds would have worked, and also, that the meds would not cause so much harm. I find it hard to believe that the meds help anyone, given the CATastrophe they were for my brother and me (I really do love cats!) If there were a med that worked, without intolerable side effects, then I would take it. After all the lies about the atypical antipsychotics, now I wouldn’t feel safe taking a breakthrough med even if one showed up.

    This means a lot to me for psychiatrists to know this, to save other patients from what I went through: most of the meds caused agitation, behavioral disinhibition, and cognitive problems directly, and these things appear to have caused my very poor behaviors (property destruction, suicide attempts etc). I can’t be the only one on the planet like this. Perhaps these things are common mechanisms whereby people get worse on meds. They just can’t control their behavior anymore. Turns a nice person into a total jerk. I work very hard at controlling my behaviors, so I don’t have what I call emotional diarhhea all over others. The meds made that control impossible. In addition, I think a few of these meds actually made me angry about stuff that normally doesn’t bother me. The difference in my behavior at home is shocking. My husband is practically doing cartwheels over it. and I still have severe depression.

    Every adult has to control their behavior much of the time – that’s part of growing up. I think many of the meds are interfering with this control, so patients act out more. Please think hard on that issue. As I said, it means a lot to me. I don’t want other people losing relationships because of side effects.

    If you are stuck with doing 15 min med checks, like what I get, it seems hopeless, though. Standard around here is a 15 min med check every 3 months, even for bipolar and schizophrenia, unless major med changes are being made. How can the doc even know what behavior is normal for that patient?

    • Cats,

      Good points. Mercifully most of my patients have not faced what you have. Meds do help some people, but patients and their doctors should be open to the possibility that they are in a group that are best helped by other medications or other types of treatments. I’m glad you’re finding a better way. I hope you find a way to get control of the depression you’re fighting.

  8. What I find interesting about your analysis is that when a patient reports a positive anecdotal experience as to medication, that is accepted as a fact without question.

    But if a patient reports a negative experience and credits their improvement to stopping the meds as George did (the guy who tongued his medication), then doubt is expressed.

    In other words, psychiatry loves anecdotal evidence when it suits their purposes but criticizes it when it doesn’t.

    • AA,

      You have misread me. I do not assume that positive anecdotal evidence is a fact and hold negative experience in doubt. I think you just made that up. (Perhaps it is what you expected to see.)

      On the other hand, Whitaker says that the patient’s improvement started when he started tonguing the pills. Did it? How would he know? Is it not as likely that his improvement started before this and led to him tonguing his pills? If so, where did this improvement come from? Apparently not the pills, since it continued after he stopped taking them. Could it not simply have been that he changed his way of dealing with life and found ways to behave that worked better for him? To me, this is a much better explanation for the anecdote.

      I hope you continue to stop by, but I would encourage you to read more carefully before you attribute attitudes to others that they have not expressed.

  9. OK, as a psych patient who has been needlessly medicated for over a decade, I feel obligated to weigh in here.

    First, a quick background. I was prescribed Paxil at age 14 for what was, in hindsight, perfectly understandable situational anxiety over my dad’s cancer diagnosis. But I was assured by my psychiatrist that Paxil was safe and that it would be effective for my anxiety.

    Well, he was wrong on both counts. It did zilch for my anxiety and gave me debilitating withdrawal when I tried to taper according to his regimen which was, in hindsight, nearly cold-turkey. I spent three of the most terrifying days of my life bedridden with brain-zaps and a sensation that my brain was cooking.

    I promptly saw him a few days later screaming for answers. He didn’t have any. If anything, he looked puzzled and admitted he didn’t know what was going on. His only solution was to go back on the Paxil.

    That was one of the most frightening days of my life. Instantly my life flashed before my eyes and I wondered what being on this stuff long-term would do to my brain’s maturation. I knew, deep down, that psychiatry had no answers. It still doesn’t.

    Flash forward to 2006, when I went on Effexor. I immediately noticed a deadening of my sexual function and a blunting of my emotions, which I hadn’t experienced before. Almost overnight I suffered from the following symptoms: no morning erections, less firm erections, almost zero response to erotic visual stimuli (looking at attractive women felt like looking at cardboard), very low libido, decreased orgasmic pleasure, decreased sensation in my penis, and blunted emotional response and motivation.

    This occurred a few months before I reached a milestone in my life, one I had been waiting for for ten years: my first romantic relationship. To my horror, I realized I was not capable of being emotionally engaged or sexual with my girlfriend. It was not merely stress or anxiety. I had been anxious on dates before but my robust libido always overpowered it. No, this was different.

    Eventually the relationship ended, and one of the reasons she cited was that our sex life “wasn’t working.” I cannot tell you how shattering it was to have this milestone slip through my fingers due to being on a drug I didn’t even need to be on in the first place.

    I eventually tapered off the Effexor and am now on Lexapro. Regardless of being off the Effexor, every one of my symptoms remains, with a few random, spontaneous remissions of my symptoms that seem to occur every few months and can last for a few days.

    My symptomology is quite consistent with those suffering with PSSD (Post-SSRI-Sexual Dysfunction), a condition in which sexual (and often emotional) dysfunction lasts long after an SSRI is discontinued, sometimes for years or even seemingly indefinitely (some have been suffering with it for over a decade). It is also officially in the scientific literature (I’ve included article citations at the end of this post), and there is currently a yahoo group called SSRIsex with over 1,000 members (young and old, male and female) currently suffering with it, as well as a youtube video of a courageous young man who suffers from it (link also included below).

    Will I regain my sexual function and emotional response when I taper off the Lexapro next year? Who knows? Who knows because psychiatry just says, “Who cares?” and doesn’t research it.

    My ultimate fear (and the fear of many suffering from protracted withdrawal or PSSD) is that they will be swept under the rug and they’ll just be another tragic example of innocent victims of corrupted medicine.

    And now for my responses to your post:

    To the following statement: “He asks several other unanswerable questions before ending with “And if she had been able to fare well without drugs, how much more might she have accomplished in her life?” As my father-in-law used to say (quoting Don Meridith), “If ‘ifs’ and ‘buts’ were candy and nuts, we’d all have a merry Christmas.”

    They may be unanswerable in this context, but Whitaker is being true to his use of the anecdotal stories by using them as a springboard for dialogue (and, ideally, future studies), which is his mission statement for the book (that is, to “solve a puzzle” and start a discussion). And, I might add, these are questions psychiatry isn’t asking but I can assure you patients DESPERATELY want answers to. Not a day goes by that I don’t ask myself what life would be like if I hadn’t gone on the meds. I know for a fact I would have avoided the devastating side effects of these meds I didn’t even need if Whitaker’s book was out when I was first prescribed them. If I had read Whitaker’s book before I went to a psychiatrist, it would have provided me the kind of informed consent I needed to dodge a major bullet. That’s just how it is, at least in my experience. And please don’t say “well, we didn’t know about the corruption back in ‘98” — the point is it shouldn’t have been there in the first place, and that psychiatry was all too willing to overlook it to save its professional hide from the anti-psychiatry fallout of the ‘70s and keep the medical model train a-rollin’.

    *And a tip for next time: You might not want to resort to patronizing trivialities like your Meredith quote, which is the kind of smug dismissal of patient’s experiences that wins psychiatrists no points with their patients. If you’re tempted to say such things in the future, I’d advise you put the mouth on pause.

    In fact, Whitaker hasn’t just sat around hoping psychiatry would answer these questions with studies. He’s started a foundation, the Foundation for Excellence in Mental Health Care, a non-profit that has already conducted workshops to answer some of these questions, such as if a first-episode schizophrenic patient can recover without meds so less patients have to deal with haunting questions like “what more could I have accomplished with my life if I didn’t go on drugs?” Has psychiatry conducted workshops and expressed interest in such studies? Nope. But Whitaker has. Actions, not words, Mr. Alienist.

    About the patient George Badillo, you said: “Mr. Whitaker would like us to believe that what changed was his ‘tonguing’ his medications (hiding them in his mouth and spitting them out later). Certainly, that was a change, but are we really willing to believe that this patient’s psychotic and disruptive behavior was caused by the medication rather than the medication being given in response to his behavior. Of course, all I can do is guess (since I do not know this man), but I am more likely to believe that this man began controlling his behavior better and needed less medication.”

    At least as I read it, I don’t think the issue with this patient was that the meds caused his behavior outright, but that they just didn’t work and perhaps worsened the existing symptoms. For the nine years of his life he was on the meds, he steadily declined (including a suicide attempt) and ultimately landed in a mental ward, which was the nadir of his life. And we don’t really need to guess about the medication’s effects, as we can listen to what he says (which is exactly what many psychiatrist don’t do): “[Once I began tonguing my medication] I could think again. The antipsychotic drugs weren’t letting me think. I was like a vegetable, and I couldn’t do anything. I had no emotions. I sat there and watched television. But now I felt more in control. And it felt great to feel alive again.”

    Also, a small point. You say: “How does Mr. Whitaker know that stopping the medication coincided with the start of his recovery?”

    Well he doesn’t know, and he never stated he did know. Again, he’s just asking if it’s possible that stopping the meds helped him recover. That’s precisely what the planned studies in the foundation will hopefully be addressing.

    Control, I believe, is the word here. My own experience, along with the experiences of fellow psych patients, has convinced me that it is the LABEL of mental illness and the suggestion a patient has a “broken brain” and will need to take meds for life that is the most damaging, not the meds. The patient subtly relinquishes control of their health to a third party. This can be devastating. Once the patient is free of the haze of the drugs, they can regain a sense of control that is invigorating and it causes a percolating effect that increases self-esteem and recovery.

    In fact, this sense of control, hope and self-esteem has already had clinical success with the “open dialogue” therapy of Finland, which is mentioned in the book. From the book, pps 339: “In those sessions, the therapists did not worry about getting the patient’s symptoms to abate. Instead, they focused the conversation on the patient’s past successes and achievements, with the thought that this would help strengthen his or her ‘grip on life.’ The hope, said Rakkolainen, ‘is that they haven’t lost the idea that they can be like others'”

    I think the idea that “they can be like others” is what is so cruelly missing from current treatments for schizophrenia because of the labeling. In fact, I think restoring the hope that schizophrenics can “be like others” may in itself be enough to start the healing process. Badillo’s post-med clarity speaks to this.

    Will Hall has a similar story of someone who recovered from schizophrenia once he left psychiatry. It wasn’t until he stopped running from what scared him the most — his voices — and embraced them and LISTENED to them that he began to recover. The voices pointed him to past trauma that he needed to experience to begin to recover. The voices were his body’s alarm bell that he desperately needed to acknowledge his pain before he could heal. All the meds did for him was give him side effects and silence his voices, which was actually the worst thing for him. In fact, Hall’s psychiatrists were doing the exact opposite of what the Finnish Open dialog psychiatrists were doing: that is, they WERE worrying “about getting the patient’s symptoms to abate,” which, considering Hall’s poor psychiatric outcome, strengthens the case for open dialog therapy. Psychiatry often makes the same mistake humans have made for as long as there’s been humans: it believes that if something feels bad, it must be bad. No — sometimes it’s a warning that must be listened to before things get worse. Numbing the symptom just kicks the can down the road, sometimes to disasterous consequences.

    I should also mention Hall also chooses to be unmedicated even though he sometimes slips into deep depression (sometimes with suicidal thoughts) because the flip side is he can still feel joy, which he couldn’t feel if he were on meds.

    Also: When Hall was first admitted to a psych ward, he had heard from the patients that a patient had just killed himself. They said it wasn’t from his illness, but from the side effects of the medication. Indeed, psych medications can, in some cases, be worse than the illness.

    Oryx Cohen is another psychiatric survivor who has also embraced the good and bad of his past symptoms (mostly manic states) which he could only do once off meds. He is also convinced his manic states have helped him grow quite a bit and that he had “Some great visions that I will take with me forever” and “Some very spiritual experiences that I’m not ashamed about [that are] now a part of who I am.” His full story is linked at the end of this post. Take note of the sense of self-control and insight he has gained since being off the meds.

    As for the chemical imbalance debate: all I can say is it’s alive and well in mainstream psychiatry. None other than psychiatrist and author Dan Carlat admits to using it in his practice. In his 2010 publication UNHINGED, pop goes the weasel on page 74:

    “While it is true that most of our drugs affect neurotransmitters in various ways, when psychiatrists start using what I call neurobabble, beware, because we rarely know what we are talking about. I fall into this habit with patients all the time. When I find myself using phrases like ‘chemical imbalance’ and ‘serotonin deficiency,’ it is usually because I’m trying to convince a reluctant patient to take a medication.”

    I find this admission most worrying because it reveals that Carlat, a practicing psychiatrist of sizable influence and respect (he publishes his own CME newsletter), not only keeps the “chemical imbalance” theory alive, but knows that it is unproven and yet still tells his patients this theory in order to get them to take their medication. This sounds like lying to me, which is not only a stunning body blow to the doctrine of informed patient consent, but also a flagrant violation of the “do no harm” doctrine.

    Compounding this is the recent Webmd “Expert Blog” post by psychiatrist Thomas L. Schwartz entitled “How Antidepressants Work, Part One,” in which he makes these statements:

    “Are mental illnesses caused by brain chemical imbalances? Sometimes, but often not. We have known this for years. This is not new news. We tell patients about these imbalances as it is easy to understand. Just like adding insulin for diabetics who have no insulin, it is a replacement.”

    How else to read this but as an attempt to keep the chemical imbalance theory alive? And this post was only made on Monday (the 25th). The link to the full post is here: http://blogs.webmd.com/mental-health/2011/07/how-antidepressants-work-part-one.html

    In another blog post entitled “Brain Building Blocks — Mystery Molecule,” he presents five quiz questions to readers to identify the neurotransmitter Serotonin, with this statement:

    “If through genetics, stress, or trauma I become less available or depleted in the brain, I may cause symptoms of sadness, despair, guilt, worthlessness or suicidal thoughts.”

    Once again the “chemical imbalance” theory is at work here.

    I should tell you that webmd is the mainstream online point of entry for medical issues and is read by millions of patients worldwide. This is hardly a disreputable website and is often listed by consumer watchdog groups as a trustworthy site.

    Frankly, I find such bold attempts at keeping the chemical imbalance theory alive shocking considering it’s 2011. In fact, it’s not just shocking — it’s dangerous. This dynamic alone of lying to patients about the chemical imbalance theory opens up the wide possibility that an untold number of patients (most likely millions over the decades) have been unnecessarily prescribed psychiatric medication and exposed to distressing symptoms they could have completely avoided.

    At least in this context, THIS is why it is indeed at least equally important to know WHY something works as well as simply knowing that it works.

    In conclusion, I would like to say that I’m not anti-psychiatry. I truly believe that meds can — and do — help people. I’m not merely humoring psychiatry here either. I’ve seen people who are transformed by meds (including one I met at a psychiatric survivor convention!). But, psychiatry’s storytelling has been corrupted and one-sided for too long, and frankly it deserves an ice-pick to the eye considering the terrible harm it can cause to a segment of the patient population (PSSD, protracted withdrawal) that it continues to largely ignore.

    *PS: I think your statement “This book is a challenging read and throws the gauntlet down to psychiatrists who believe that medications are helping their patients” is spurious. It reads like an emotional argument by a psychiatrist who feels threatened. He’s not “throwing down the gauntlet” to psychiatrists who “believe that medications are helping their patients,” but if anything is throwing down the gauntlet on widespread corruption in psychiatry that is still largely unknown to the public (at their peril) and makes his own arguments (largely, that the long-term outcomes of psych patients can be worse than those untreated, which is at least partially responsible for the skyrocketing disability rates). If anything, he’s angry that psychiatrists don’t have better tools at their disposal to help their patients, as the literature (or “evidence base”) is so clouded by corruption and endorses only pills in neon. If you read the book this way, I think it opens up considerably.

    *PPS (!): I know at least one patient who is on disability for protracted SSRI withdrawal that has lasted seven years. I of course can’t speak to how typical her experience is, but those people are certainly out there, and there are certainly others I’ve read about who are living with their parents/relatives because they can no longer work due to their withdrawal symptoms.

    PSSD Citations:

    -Bahrick, Audrey S., and Mark M. Harris, “Sexual Side Effects of Antidepressant Medications: An Informed Consent Accountability Gap.” Journal Of Contemporary Psychotherapy, Vol 39(2), June 2009, pp 135-143.
    -Csoka A, Bahrick A, Mehtonen O. Persistent sexual dysfunction after discontinuation of selective serotonin reuptake inhibitors. Journal of Sexual Medicine [serial online]. January 2008;5(1):227-233.
    -Farnsworth K, Dinsmore W. Persistent sexual dysfunction in genitourinary medicine clinic attendees induced by selective serotonin reuptake inhibitors. International Journal of STD & AIDS [serial online]. 2009;20(1):68-69.
    -Bahrick, Audrey S, “Post-SSRI Sexual Dysfunction.” ASAP Tablet, Vol 7(3), Sept 2006, pg 2.
    -Kauffman, R., Murdock A. “Prolonged Post-Treatment Genital Anesthesia and Sexual Dysfunction Following Discontinuation of Citalopram and the Atypical Antidepressant Nefazodone.” The Open Women Health Journal, 2007 (1), 1-3.
    -Bolton J, Sareen J, Reiss J. Genital anaesthesia persisting six years after sertraline discontinuation. Journal of Sex & Marital Therapy [serial online]. July 2006;32(4):327-330.

    PSSD Youtube Video:

    Oryx Cohen Story:

    -http://www.power2u.org/articles/recovery/recovery_stories/oryx.html

    • Psychtruth,

      Thanks for your post. I’m sorry that you have had such a prolonged fight with various antidepressants. I rarely use paroxetine (Paxil) any more simply because of the difficulty that some of my patients have had coming off of it. As for the sexual side effects of the medications you have been on, I hope that you find your way out of this soon. It certainly is a significant problem for most of the serotonergic antidepressants. Thanks for being open and addressing problems that patients should be informed about.

      I do not agree with your statement that “psychiatry says, ‘Who cares?'” about sexual dysfunction on SSRI’s. I did a quick Medline search and found 181 citations for the combination of sexual dysfunction and SSRI’s. I know it is frustrating not the know more about this and not to be able to reduce this problem more efficiently, but there are people out there who care and who are working on finding a solution. Lumping all psychiatrists together under one label is not a realistic view of the field.

      With regard to your view of me being patronizing with my Don Meredith quote, I also disagree. This quote has nothing to do with “dismissing of patient’s experiences.” I have dismissed no one’s experience. What I am questioning is the usefulness of the question that Whitaker asks. (According to the book it was not a question that apparently interested the patient until Whitaker interviewed her.) The truth of the matter is that none of us will ever know “what would have happened if….” We can never turn the clock back and try a different road. True, we can do research and see what the possibilities were and what probabilities might have applied, but we will never know what would have happened to a particular individual at a particular time. Science does not allow us to apply population data of this kind with certainty to individual cases.

      The part of your post about Whitaker’s foundation is very interesting. This work will likely be much more valuable than his book. For example, you jump ahead in the book (which is why I have not addressed this yet) and cite the Finnish study on schizophrenia. Whitaker looks at this with his medication blinders on and sees the major point to be the reduced use of medications, but there are many more differences between average American experience with schizophrenia treatment and the Finnish study than mere medication use. This prevents such research from determining the role of medication in long-term disability. His foundation’s research may reveal the true complexity of the situation. That would indeed be valuable.

      With regard to your defense of Mr. Whitaker’s anecdote featuring George Badillo, Mr. Whitaker does say that the his recovery started with him tonguing the medication. That does not make sense to me. Something changed before he started tonguing the medication so that he decided to start tonguing the medication. The absence of a particular medication cannot be the cause of avoiding that same medication. It seems much more reasonable to me to attribute his avoidance of medication to something that happened before (where we generally find causes).

      I generally agree with you on the control issue. I think it is more important than many realize. I’m not such a big fan of blaming labels for dysfunction, though. Still, your experience is illuminating, and I’ll give it more thought.

      Next, the “chemical imbalance” theory. What can I say? We have some evidence that supports it and some that doesn’t. I think that those who focus on the positive evidence and conclude that it is an adequate explanation for mental illness make a mistake. I also think that those who focus on the negative evidence and say that it has nothing to do with the solution make a similar mistake. I think that as we learn more about mental illness, we will find that its causes are very complex and encompass dynamic interactions among genetics, neurochemical pathways, past experiences, general body physiology, personality issues, and conscious and unconscious processes.

      Finally, I don’t think my statement concerning Whitaker “throwing the gauntlet down” is spurious. We’ll see as I continue through my posts about the book. I think it will be easy to show that he is clearly demanding that psychiatry demonstrate its effectiveness, especially with regard to medications. Your comment about “an emotional argument by a psychiatrist who feels threatened” seems out of place. Where did you see the emotional argument? Also, his book is not about corruption. If you read it this way, you miss his point. He notes corruption to explain his central point — that medications are causing the epidemic of psychiatric disability. That pretty clearly looks like a gauntlet to me.

      Thanks for your post and for the citations and video you included. I hope you will stay around for the rest of the posts and contribute as you see fit.

  10. With all due respect, I stand my what I said. Also, I feel you’re not telling the whole story in your analysis. You’re attributing what the negative remarks the patients have made to Mr. Whitaker which is why I criticized you for discounting negative anecdotal reports. You’re acting like he put words in their mouth when he did no such thing.

    I am going to paraphrase the relevant exert from the book because I can’t cut and paste it. But George reports that when he tongued the medication, he could think again as he felt like a vegetable and couldn’t do anything. He had no emotions.

    Also, I wanted to address this statement you made:

    “We can’t tell, but we have evidence that continuing medications reduces frequency of relapse. ”

    Sorry for getting away from the analysis of the book but this is a pet peeve of mine. In my opinion, your evidence is contaminated because you make no attempt to distinguish withdrawal from a relapse. Dr. Glenmullen, one of your colleagues, reports patients stuck for years on meds that didn’t need them due to suffering withdrawal symptoms.

    This fallacy is as bad as the chemical imbalance theory which thankfully, you do recognize for its failings.

    There is alot more I want to say about your analysis but this post would go on forever

    • AA,

      Stand by what you say if you want, but what you are asserting is not what I said. I also did not discount negative reports. If you think I did, please show where I did it.

      With regard to “telling the whole story in [my] analysis,” this is the problem with anecdotes — there is no definitive analysis. I cannot prove that things happened one way or another, and neither can Mr. Whitaker. My explanation of what may have happened is just as valid as his (though I believe mine is more logical).

      I don’t know where you get the idea that I think Mr. Whitaker is putting words into the mouths of those he interviews. I trust that he is quoting them accurately (at least I have never heard of him doing otherwise). What I am trying to do is to see if the conclusions he draws are justified. I do not believe that they are.

      Finally, with regard to the subject of withdrawal vs. relapse, this is a problem that does not have an easy solution. We do have scientific evidence that staying on medication reduces the risk of relapse. Some believe, like you, that what is really happening is that those who are withdrawn from medications are not relapsing but having a physical and emotional response caused by having been on medication. Unfortunately, this is not usually a productive area to discuss because no matter how slowly I taper someone off a drug, there will be someone who sees any return of symptoms as a drug-induced problem. With regard to Dr. Glenmullen, sure there are people who are on medications and find it difficult to get off of them. Whether they needed the medications at one time or not, I cannot tell. I would agree with you that we need to be careful about this, but it does not change the fact that many are helped by medications and function well in society.

  11. Alienist —

    Thanks for your prompt and detailed reply. To some of your points —

    “I rarely use paroxetine (Paxil) any more simply because of the difficulty that some of my patients have had coming off of it.”

    A lot of patients are angry about such statements (I’m not angry at you, because I know you say that statement as a caring practitioner) because it reveals that they really were, indeed, guinea pigs. It’s really quite amazing that none of the studies on SSRI efficacy took withdrawal symptoms into consideration, and instead just mistook withdrawal for relapse. Something tells me that the fact that this may be withdrawal instead of relapse must have occurred to at least one researcher or psychiatrist, and yet there was no interest in following up on this supposition, to the peril of patients who had to find out the hard way that Paxil and other SSRIs cause bad withdrawals.

    “I do not agree with your statement that “psychiatry says, ‘Who cares?'” about sexual dysfunction on SSRI’s. I did a quick Medline search and found 181 citations for the combination of sexual dysfunction and SSRI’s. I know it is frustrating not the know more about this and not to be able to reduce this problem more efficiently, but there are people out there who care and who are working on finding a solution.”

    Perhaps I wasn’t clear enough. I didn’t mean general SSRI sexual dysfunction. I was talking about PSSD. In that case, it really does appear psychiatry isn’t interested, as those seven articles I cited are the only ones I am aware of specifically looking at PSSD. And certainly no researcher has taken up the issue of PSSD for research into its pathology for a possible treatment some day. But that hasn’t stopped the 1000+ members of SSRIsex to try everything from yohimbe to testosterone to dopamine agonists like Requip to vitamins to Inositol and everything in between to try to treat it. The patients are experimenting on themselves because psychiatry hasn’t researched it.

    “The part of your post about Whitaker’s foundation is very interesting. This work will likely be much more valuable than his book.”

    I don’t entirely agree with your statement that the foundation will be “much more valuable” than the book for the simple reason that the foundation largely wouldn’t have existed without the book. In a nutshell, Whitaker says this about the foundation:

    “The Foundation came to be in a rather roundabout way. After Anatomy of an Epidemic was published in April of 2010, I began to hear from a number of mental health professionals who wanted to discuss its implications. Several psychiatrists in the Boston area contacted me, and they formed a group that began meeting on a semi-regular basis. I heard from Jack Rockefeller, who was then director of Windhorse, a provider of care in Western Massachusetts, and we discussed forming an “institute” that would fund research and “evidence-based” pilot projects that might involve using medications in a more selective way. Most important, leaders of several provider organizations and peer groups in Oregon began taking steps to publicize the issues raised in Anatomy of an Epidemic. The book looks at how psychiatric medications shape long-term outcomes, and the Oregon discussion soon focused on this question: Did our drug-based model of care need to be rethought?”

    In fact, I personally know at least two physicians (one a primary care physician, and one a psychiatrist) that read the book and were then inspired to help reform psychiatry. The psychiatrist began reading the book with relish because he was looking forward to debunking it. After he was done with the book he realized Whitaker was on to something and emailed him asking how he could help and then served on the foundation’s board for a period of time. In fact, in a message board post, he even used the very same phrase of “throwing down the gauntlet” on psychiatry, but took that as a positive thing! No joke. He, like the other Boston-area psychiatrists, didn’t spend time passionately debunking his book point by point, but instead chose to focus their efforts on working with him for real psychiatric reform that a growing number of patients want.

    And the primary care physician went even further. His name is Mark Foster. After reading Whitaker’s book, he had an awakening to how often (and carelessly) he was prescribing medications to his patients (including children). He became much more selective about prescribing and was open to working with patients to withdraw them from the medication if they so wished. This, as well as his blog posts on Whitaker’s blog, resulted in his firing from his primary care job (a link below is to Whitaker’s post about his firing which also speaks about Foster’s “revolution in his head” about psychiatry that ANATOMY caused). But he didn’t let that stop him. He is now planning on starting the country’s first psych med withdrawal clinic in Colorado with a psychiatric survivor. The link below is to his speech about his professional re-awakening he gave at a psychiatric reform convention, as well as the ten guiding principles for his clinic. I highly urge you to read this (as well as the comments) to get a view of the impact of Whitaker’s book.

    Whitaker’s book has indeed begun achieving its goal of sparking a wide-scale debate about the safety and efficacy of meds and how best to use them. Yes, not everyone will agree with all of Whitaker’s points, but the debate and the efforts for real reform are what’s most important, and it’s striking that a journalist — not a psychiatrist — was the one to initiate this dialogue. Considering the amount of debate the book has sparked and the foundation it has created, I have good reason to believe psychiatry would still be high on SQD (status quo dust) if it weren’t for Whitaker, and it all started with ANATOMY.

    In fact, I invite you to email, call, or meet Whitaker in person. He is quite personable and open-minded. On the left-hand side of his website homepage he lists his speaking schedule. He is actually speaking at the APA’s Institute on Psychiatric Services in October in San Francisco which you could attend if you’re local.

    This is just my opinion, but I think directly engaging with him and the psychiatric reform movement is a better use of your time than doing what other psychiatrists have already done and attempt to debunk Whitaker’s book. Believe it or not, both Whitaker and I firmly believe voices from all sides of the psychiatric spectrum (including those critical — even hostile — of his book) enrich the dialogue. You could directly ask him your questions about Badillo’s story and the good questions you have about any lurking variables of care, culture, society etc in the FInnish Open dialogue therapy. For what it’s worth, I still think we need to at least TRY open dialogue therapy in this country. We have to start somewhere. You might also want to contact Will Hall or Oryx Cohen and hear their stories of recovery. This would go a long way to bridging the gap between psychiatry and the psych reform movement.

    All of that to say this: I believe the time has come for psychiatry to stop fighting Whitaker or exclusively spending its time criticizing him and instead start working WITH him. Whitaker has no plans to go anywhere, and neither do I or any other members of the psychiatric reform movement. Our numbers only grow with each day, and believe it or not, we really WOULD like cooperation and input from psychiatrists like you.

    About the “emotional argument.” I felt that your choice of words in your statement, “This book is a challenging read and throws the gauntlet down to psychiatrists who believe that medications are helping their patients,” especially the phrase “psychiatrists who believe that medications are helping their patients,” revealed a belief that he was attacking well-intentioned psychiatrists (perhaps I’m wrong). Again, I don’t think he’s attacking the psychiatrists, but the corruption of psychiatry which has prevented them from delivering the best care possible. I think it’s only natural for psychiatrists to take this book personally (how could they not?) but I’m suggesting that what Whitaker is really criticizing is the SYSTEM (that is, the evidence in the evidence-based medicine and the corruption by big Pharma and psychiatric KOLs). And I think the corruption is very much part of his central point: if the pharmaceutical companies hadn’t hid negative data and inflated positive data and hadn’t been so successful at selling the meds to psychiatry and the public as safe and robustly effective for everything from Premenstrual Dysphoric Disorder to social anxiety to even diabetic neuropathy and low back pain, the meds would have been used much more selectively and responsibly, and much of the “epidemic” of disability could have been avoided. To help answer his question about the epidemic (and to pose additional questions), he “follows the money” all the way back to the corruption of science and psychiatry itself by big Pharma and corrupted psychiatrists, as outlined in the “Tallying up the profits” chapter. I honestly didn’t see him throwing down the gauntlet on psychiatrists who believe the meds are helping their patients.

    And a gauntlet on corruption and the validity of the research on psychiatry is precisely what is needed, because psychiatry certainly needs more than a gentle nudging at this point to get the message as, considering the titanic amount of corruption in the field (Biederman, Nemeroff, Schatzberg, ghost-written articles and textbooks, TMAP, etc), psychiatry wasn’t exactly doing a great job policing itself.

    At this point, I really do urge you to contact Whitaker with any further questions you have about his book. PLEASE don’t read this as me discrediting your questions or as viewing you as “hopeless” or “stubborn.” I’m just making you aware of how available Whitaker is to talk and how you directly speaking with him could be an important step in moving the dialogue forward (actually a historic one — I don’t know of any blogging psychiatrist that has read his book, critiqued it on their blog, and then followed up with Whitaker about their questions on the book). As I currently understand it, he won’t be on the road for another month, so now would be a great time to speak with him. It’s not often we have the luxury of being able to talk so directly to an author about his book.

    **PS: I have some issues with what you said in response to AA’s post. Your comment:

    “Finally, with regard to the subject of withdrawal vs. relapse, this is a problem that does not have an easy solution. We do have scientific evidence that staying on medication reduces the risk of relapse. Some believe, like you, that what is really happening is that those who are withdrawn from medications are not relapsing but having a physical and emotional response caused by having been on medication. Unfortunately, this is not usually a productive area to discuss because no matter how slowly I taper someone off a drug, there will be someone who sees any return of symptoms as a drug-induced problem.”

    Again, we don’t know how valid that scientific evidence that staying on meds reduces the risk of relapse is because it’s very possible (likely, even) that at least some of the studies mistook withdrawal for relapse, and an increasing number of researchers are becoming aware of this. And I don’t think getting to the bottom of this is quite as murky as you think. There are some tell-tale signs of withdrawal, such as the “brain zaps” that are unique to withdrawal. Same thing for autonomic disturbances like cortisol rushes that cause withdrawing patients to bolt up in blind panic once dropping off to sleep. Panic attacks too can surface in withdrawal when they were never there before or on meds, as well as insomnia. Many, MANY patients say that their withdrawal symptoms were unique or far more severe than the original symptoms. If patients get these symptoms rather quickly after discontinuation, it’s likely it is withdrawal, not relapse.

    Also, you don’t have to believe that “those who are withdrawn from medications are not relapsing but having a physical and emotional response caused by having been on medication” because it’s in the literature. Eli Lilly sponsored a symposium to address the issue of SSRI withdrawal and researchers Jerrold Rosenbaum and Murizio Fava of Mass General found the rate of withdrawal syndrome to be as high as 80 percent. Also, a cursory EBSCO database search for “SSRI discontinuation syndrome” yielded over 200 results. Don’t you think it’s reasonable to suspect that at least some of those patients abruptly withdrawn from SSRIs in the studies were having withdrawal, considering the figures I just quoted and that indeed withdrawal IS a “productive area to discuss”? It’s important to discuss because if it’s even partially true, this casts much doubt on the ability of SSRIs to cut the rate of relapse.

    Ideally what a study looking into withdrawal would do is follow a patient who is freshly prescribed an SSRI for a year or two and then observe what happens when they abruptly discontinue the medication. A patient baseline of symptoms before SSRIs would be established, as well as patient reports of how they feel while on SSRIs. Then the patient would be withdrawn from the medication rather abruptly to match the conditions of the studies that are suspected of mistaking withdrawal for relapse. If we can replicate those studies’ conditions while monitoring for withdrawal symptoms, I think that would be very revealing and would throw the relapse efficacy studies into deep doubt.

    In fact, Italian researcher Giovanni Fava and his assistant Carlotta Belaise are currently taking case studies of those suffering from protracted SSRI withdrawal syndrome to study withdrawal syndrome itself. Link is below.

    LINKS:

    -Protracted Withdrawal Study: http://survivingantidepressants.org/index.php?/topic/530-researchers-seek-prolonged-antidepressant-withdrawal-cases/

    -Mark Foster speech and principles for Clinic: http://survivingantidepressants.org/index.php?/topic/687-dr-mark-foster-speaks/

    -Whitaker’s post on Mark Foster: http://madinamerica.com/madinamerica.com/Whitakerblog/55E5019A-A259-491D-A4C2-5FA6E704EF7B.html

    • Psychtruth,

      Thanks for your posts. There are a little hard to respond to because they are so long and have so many points to them. I guess in that way they are much like mine.

      With regard to the paroxetine (Paxil) statement, I think that the public needs to know that all of the medications of every medical speciality potentially has unknown (and harmful) effects. It is not that psychiatrists use patients as “guinea pigs” particularly, but any new drug has the potential to cause unforseen effects. This is why the FDA continues drug surveillance after approval. Your expectation that doctors should remain vigilant for these effects is spot on.

      The part about the PSSD is interesting because I have not had a patient report this. My patients who had SSRI-related sexual dysfunction resolved when they stopped medication or switched to another medication less likely to produce these results. It makes me wonder just how frequent this problem is (not that this changes the distress of those who already have it). It would be a useful bit of information to pass on the patients. I’ll have to look into this more.

      With regard to my belief that Mr. Whitaker’s foundation will be more useful than his book, I still think that that is true. We’ll see if anyone else believes it when I am through reviewing it. From your description, I expect that his foundation will make more discerning judgments than his book did. I think that that will make it more valuable.

      Your stories about people who have thought more deeply about psychiatric medications due to reading Anatomy of an Epidemic are interesting and encouraging, but only if they get the message straight. The point of my review of the book is not to debunk it but to make sure that the proper lessons are learned from it. I haven’t even gotten to the meat of his argument, yet; but I hope that looking at his book as a rhetorical object of pursuasion and complementing it with an analysis of his logic and implicit assumptions will enable other readers to improve their understanding of subject. By the way (and I hope this is not talking down to you or showing my own ignorance), I always assumed that “throwing down the gaunlet” simply meant to formally challenge someone. I don’t take the challenge in a negative way.

      With regard to meeting Mr. Whitaker, I would like that some time. Still, stuck out here in West Texas we don’t often get visitors like him.

      Your comments concerning research on discontinuation/withdrawal I think still underappreciate the difficulty with the research. I have had a fairly rich career so far. I have designed and participated in many FDA- and drug company-sponsored research trials. I have sat as a reviewer of research protocols for the National Institute of Mental Health. I have had community and college based clinical practices. I have presented lectures sponsored by drug companies and by local mental health societies. (All of this is by means of disclosure, not to compare my experience to any others.) In all of this I have learned a few things relevant to this (disconinuation/withdrawal) issue. First, no one can make anyone else believe anything. There will always be someone out there who will say, “You just didn’t do it right.” And second, while you and I might be able to come to an agreement about what constitutes a withdrawal symptoms (you mentioned a couple of them that I think are valid) there would always be those who would count symptoms of depression or anxiety as simply misidentified withdrawal symptoms. Still, I think that this kind of research should be encouraged so we can get what information we can.

      Thanks again for the post and the links.

  12. Just a quick note (well, quick by my standards!) I forgot.

    To AA, you said:

    “On the other hand, Whitaker says that the patient’s improvement started when he started tonguing the pills.”

    He didn’t say that. Badillo did. The sentences in question are on pg 22, and are as follows:

    “He began tonguing the antipsychotic medication and spitting it out when the staff weren’t looking. ‘I could think again,’ he says. ‘The antipsychotic drugs weren’t letting me think. I was like a vegetable, and I couldn’t do anything. I had no emotions. I sat there and watched television. But now I felt more in control. And it felt great to feel alive again.'”

    The general upward trend of his life (with some ups and downs along the way) was simply what happened to Badillo as told to Whitaker, and Whitaker’s statement “Given that his recovery began when he STOPPED taking antipsychotics” is just a summary of what Badillo told Whitaker and what was in his story. It wasn’t Whitaker’s hypothesizing or editorializing. As a former journalist myself, I can tell you with confidence no Pulitzer prize-nominated journalist would do such a thing. In fact, Whitaker even admits “Although George’s story is clearly an inspiring one, it doesn’t prove anything one way or another about the overall merits of antipsychotics.”

    If anything, going from nothing more than what’s in the book, it appears that Badillo’s recovery accelerated once he got off the med. The “change” he felt that you hypothesize must have taken place before he began tonguing his meds must be, in my opinion, the sense of hope he felt when he was moved to a unit where he could go outside and get fresh air. This gave him hope and the epiphany to begin tonguing his meds, which then accelerated his recovery, as detailed in the book. I should mention I’ve spoken to many institutionalized patients and they all say the same thing: once they became “noncompliant” and stopped taking their meds and got a plan together for their life, everything started coming together. As one psych survivor said, the current model of instituionalized care makes you a frozen river where you go NOWHERE. Even the term “maintenance dose” has the implicit suggestion you’re not going anywhere.

    Finally, even IF it was a change in his behavior or coping skills that ultimately helped him regain his life and not whether he was on/off drugs, doesn’t that cast the efficacy of antipsychotics into doubt, at least in this case? As you said: “If so, where did this improvement come from? Apparently not the pills, since it continued after he stopped taking them.” So you have just said it’s possible the pills didn’t contribute to his recovery, which begs the question if they were needed at all in the first place, at least for Badillo. Considering the bipolar epidemic and the fact even 2-year-olds are given antipsychotics, this is a troubling premise indeed.

    This is especially troubling considering his case history where he attributes his psychosis to cocaine use (“Only then it got out of hand and the cocaine started making me think all crazy.”, pg 21). His diagnosis as a paranoid schizophrenic may very well have been a misdiagnosis because in reality it could very well have been that he just had a transient drug-induced psychotic reaction to the cocaine and if he had access to something like Soteria house or a similarly nurturing, structured and non-judgemental environment, he may have recovered from his psychosis, and his nine years of drugging and institutionalized life may have been avoided. But it was his loss as the funding for Soteria house was cut by the NIMH, even though they “grudgingly concluded, in its final review of the project, that ‘this project has probably demonstrated that a flexible, community based, non-drug residential psychosocial program manned by non-professional staff can do as well as a more conventional community mental health program” (pg 272).

    And in fact the reasoning I use above isn’t that far-out, as Whitaker asks the same thing given Badillo’s case history: “Is it possible that some people ill with a serious mental disorder, like schizophrenia or bipolar illness, might recover in the absence of medication? Is his story an anomaly, or does it provide insight into what could be a fairly common path to recovery?”

    As it happens, I just received an email from psychiatrist Ronald Pies in which he responded to a similar assertion of mine, which is below:

    “On a somewhat related note, I think that it’s entirely possible for people to grow from depression and other “extreme” mental states. Two examples: One is Will Hall. He considers himself a psychiatric survivor who only began to heal from his psychosis once he stopped his medications and listened to his voices. By listening to his voices and not running away from them with meds, he was able to untangle his childhood trauma and begin his recovery which continues to this day. He also chooses to endure bouts of severe depression (which can include suicidal thoughts) because he also gets to feel joy at times, which he couldn’t feel if he were on meds.

    The other example is Oryx Cohen, who also considers himself a psychiatric survivor. He was once bipolar and found the medication didn’t help him. Like Hall, he truly started to recover and find himself once he left psychiatry. The quote below may particularly interest you. Notice how he has a sense of control over his condition that he wouldn’t have if he were medicated, and that he thinks his mania helped him grow.

    “For me, I grew a lot from my ‘mania.’ I learned that I have some control over the way I feel, even if it is subconscious. I won’t allow myself to feel depressed, and now, I won’t allow myself to be manic either. There is a middle ground. There are great feelings that came out of being manic, but for me, these were kind of superficial. I had some great experiences while I was manic. Some great visions that I will take with me forever. Some spiritual experience of being one with nature, of being the clouds and the wind and knowing when the sun would peek again from cloud. Some very spiritual experiences that I’m not ashamed about, they are now a part of who I am.”

    Here is Dr. Pies’s response:

    “I agree with your assertion that it is “…entirely possible for people to grow from depression and other “extreme” mental states.” And, if one meets enough people like Will Hall, you may come away with the impression that his experience is typical of those who “listen” to their psychosis or depression. From my perspective over the past 30 years, as a psychiatrist, psychosis, bipolar disorder, and major depression are far, far more commonly great destroyers of life, creativity, and productivity.”

    My issue with his response is the same as Whitaker’s, as outlined in the Badillo anecdote: given the current standard of care which is to medicate psychotic patients and not let them have a chance of healing naturally in a structured environment like Soteria house, a psychiatrist with dozens of years of clinical experience could be under the false impression that organic (that is, non-medicated) recovery from psychosis is vanishingly rare, when that may not necessarily be the case simply because the resources for them to do so are not available to them (that is, like a Soteria house). Of course psychotic patients who don’t have access to such resources will dangle on a pole and do terribly until they are treated with meds. The low recovery rates of those who try to “go it alone” and recover from psychosis without meds could thus, in hindsight, turn out to be an optical illusion. Thus we owe it patients like Badillo to pick up where Mosher left off and see how much merit a resource like Soteria house has. Only then will we know how typical Badillo’s (and Will Hall’s and Oryx Cohen’s) recovery was.

    Again, the issue here is the IDEOLOGY of psychiatry (that is, the biomedical model), not psychiatrists. In fact, you could actually see psychiatrists as innocent victims of a corrupt profession slowly dying from infrastructural rot that affords psychiatrists very few tools to best help their patients. I think that’s actually true to some extent, and the sooner psychiatrists realize they sometimes only have an ILLUSION of control over their patients’ outcomes, the better. After all, power has always known one of the best ways to keep people in line is to fool them into thinking they have more control than they really do (power here being big pharma and the corrupted psychiatrists who continue to cling to the medical model because it’s their ticket to the gravy train).

    It’s all very similar to what’s happening with the economy. Ross Perot famously said we’d hear a “giant sucking sound” caused by the jobs leaving the economy, and damn if he wasn’t right. The culprit was corporate greed, which outsourced all the jobs and laid off thousands. Similarly, Big Pharma has caused a “giant sucking sound” in psychiatry, as their corporate greed (along with greedy and corrupt psychiatrists) has narrowed the modalities of care available to psychiatrists to only pills (and dwindling uses of talk therapy), and all other modalities like Soteria houses have been sucked out. Why? Because pills pay, baby. And the icing on the cake is the powers that be can count on mainstream psychiatrists to defend the status quo as psychiatrists have built their careers around the corrupted system and admitting they’ve been even partially duped could be devastating to their image and livelihood.

    And once again, the only one sounding these alarm bells is Whitaker, not psychiatry.

    • Psychtruth,

      Perhaps I did not understand exactly what Mr. Whitaker said, but even on rereading it, he seems to be asserting that the stopping of the medication was the turning point. I still don’t think so. Sure, he improved after he stopped the medication (and why not? he said he was having side effects.) But I think the turning point happened before this. I can’t prove it, but I have the experiences of my patients for whom the decision to take or not to take medications was the turning point in their treatment.

      With regard to the issue of pharmaceutical companies, I have mixed feelings. I do not think that they should bear the burden for the “epidemic” necessarily. Not that I agree with everything they do. Their funding for research should be more open for review. They should not be allowed to withhold study findings. I do not believe that they should advertise to patients. On the other hand, patients don’t get these medications on their own. The physician has been established as the gate-keeper for these medications. If they are prescribed irresponsibly, the physicians should not pass the buck to the pharmaceutical companies. In my opinion, “the buck stops here.” If the physicians want to say, “I’ve been duped!” then the appropriate response by the physician community is to not let themselves be duped any longer.

      • I am puzzled why you keep attributing Mr. Badillo’s remarks regarding his improvements off of antipsychotics to Mr. Whitaker when it clearly was his own statements.

        Also, in a previous response to one of my posts, you said,

        “I also did not discount negative reports. If you think I did, please show where I did it.”

        You just did in the above post when you said, “he seems to be asserting that the stopping of the medication was the turning point. I still don’t think so. ”

        In my opinion, if that isn’t discounting someone’s experience, I don’t know what is.

        By the way, i am curious, if Mr. Badillo had credited his improvements to the meds, would you still be questioning what he was saying and wonder if the improvement was due to something else besides the drugs?

        Anyway, later in the chapter, as Mr. Badillo discusses his continued improvement off of meds, he says, (not Mr. Whitaker), “If I had stayed on those drugs, I would not be where I am today. I would be stuck in an adult home somewhere or in this hospital. But I am recovered. I still have some strange ideas but now I keep them to myself. And I weather whatever emotional stress comes up. It stays with me a few weeks and then goes away.”

      • AA,

        You seem to be misinterpreting what I am saying. I did not dismiss anyone’s experience. He said he was better, and I never denied it or limited it in any way. His interpretation of why he is better is not his experience — it is his understanding of WHY he had his experience. I do have some doubt about his explanation. I think there are better ways to explain what initiated the change. This does not discount any of his story.

        Your second question is an interesting one. I do not credit any of my patients’ improvements to medication alone. I do not know what portion of their improvement is due to medications and what part is due to the changes they choose to make in their lives. I do believe that a portion of the improvement is often due to medications but I am hesitant to see the majority of the improvement to be medication-related in any of my patients. As I tell my patients, “I don’t have any medications that can MAKE you better, but I have some the can LET you be better.”

        With regard to attributing Mr. Badillo’s remarks to Mr. Whitaker, that is very simple. Mr. Whitaker chose to use those remarks to make his point. He used them because he believes them or because he believes they will further his point. If he had no opinion about their truth and felt that they were unrelated to his argument, he would have left them out. These were not randomly included by an experienced writer.

  13. I haven’t read this anywhere, but I think that part of why studies are showing antidepressants are no better than placebo is because equal numbers of people are getting worse as are getting better (which Irving Kirsch acknowledged that this may be so, and he could not tell from the data, as i recall from reading his book months ago). I think one major mechanism where people are getting worse is because of the sexual dysfunction, which likely leads to relationship conflict for many people. My psychiatrist was practically screeching at me to stay on the cymbalta, even though it was causing complete sexual dysfunction. I worked very hard in therapy to get over sexual abuse, and here, the medication was taking away a huge part of my progress. I suspect agitation is another mechanism where antidepressants make people worse, as happened to me.

    This doctor that I had for years was far too focused on the mechanics of my brain, and not paying any attention to what my mind needed, as have most psychiatrists. in the same way, antipsychotics were pushed on me by other docs, maybe because the doc was trying to save my life (the bipolar is very bad, mostly depression) but in the process, they were stealing away my reason for being, by turning me into a vegetable watching TV all day when I actually dislike watching TV. I was calmer, but everything that was me, was gone. I am better off living in my own hell.

    Practically the only psychiatrists who paid attention to me as a person, where who I am matters, have been the old psychiatrists nearing retirement. I think that is because they worked so long before the biological psychiatry got going. Unfortunately, most of them have retired and I have not been able to get one of them as a regular doc.

    Most of my psychiatrists have been nice people, but were too focused on the mechanics of this pill or that pill for depression, and lose sight of my soul (Ok, I have lost my faith in God altogether in recent years, but soul is still a good concept).

    • Cats,

      If you come across the reference to where equal number of people were getting worse as were getting better, let me know. This is not my experience in med trials, but if it is the experience of others, it would be valuable to know. I hope you find a good psychiatrist if you continue to need one. I know that they are out there. Thanks for posting.

  14. There is no reference except that Irving Kirsch mentioned it in his book. As I recall, he stated in his book that in his opinion, antidepressants are working thru placebo effect, but an alternate explanation of the data would be that as many people are being harmed by the meds as are getting better by the med’s effects (not including those getting better by placebo effect). He said that he could not tell from the clinical trials data, whether the drugs were wholly ineffective, or if the benefits of the meds above and beyond placebo effect were being cancelled out by the patients who are getting worse. I don’t think he agrees with that explanation, but he threw it out there. I think it was near the end of the book.

    As for finding a good psychiatrist, It is difficult to find ANY psychiatrist taking new patients. There is a shortage of psychiatrists here and now they seem to have started triaging care, so people with severe mental illness can actually get an appointment. And I swear, every 2 years, my psychiatrists lose their jobs or move on to another job. I just lost my doc, and this psychiatrist said she is just trying to hang on until retirement and the bean counters are running everything now and good for me that I was able to find another psychiatrist and hopefully he would stay in place for a few years. I already followed this doc around from one practice to a different one. And then a different one. I don’t know if this is a nationwide problem, but if it is, this might be an interesting topic for a blog.

    I would give up with mental health care in a second if I could. Talking about your problems over and over again just makes them worse. Don’t you think that assessing mental problems over and over gets to be a lot like sitting at home and ruminating over your misfortunes? Toxic. Now I also get to fill out a depression inventory every time I see my therapist, and honestly, I may as well put a bullet in my brain. It NEVER gets much better. See? There is the data to prove it! The measurement tools and repeated recitation of problems instill more hopelessness because I am not improving and there are YEARS of data showing that. It seems like only my social worker type person “gets” this. So she is going to help me with menu planning and organizing my home and other practical stuff, and I am deliberately not going to talk about my problems with her anymore and see if that helps a bit.

    Too long, and off topic, but I have not seen those last two issues addressed anywhere, but on the other hand, maybe these problems are not common.

    • Cats,

      Your situation sounds very frustrating. I came to west Texas because it is a medically underserved area with regard to psychiatry. It is very frustrating to me as well that there are so many patients to see but so few of us to try and help them. It makes it frustrating because if I try to spend more time with my patients, fewer patients can be seen; but if I try to see patients for more brief amounts of time, I have less opportunity to understand what is going on in their lives and what would make it better. It’s a vicious cycle for both doctor and patient.

      Overall, I think that the repeated assessment is a frustration for patients (it would be for me, too, as a patient). Sometimes, not talking about past problems can help (but I have seen it hurt more often — it depends on the patient and the doctor). I think it is most important to consider WHY I would want to talk about past problems again. If it is just to rehash the facts, then it probably will not be helpful. If it is to recognize my life as it is and to see where the effects of my past have spilled over into the present, then it can be very helpful.

      With regard to the rating scales, I think they have their place, but they will never be a good substitute for a caring, listening helper to seeks what is important to you.

  15. First I must admit I’m perplexed that you said “If they are prescribed irresponsibly, the physicians should not pass the buck to the pharmaceutical companies. In my opinion, “the buck stops here.” If the physicians want to say, “I’ve been duped!” then the appropriate response by the physician community is to not let themselves be duped any longer.”

    I’m perplexed because you then go on to admit you’ve spoken at pharmaceutical-sponsored lectures and helped design drug-sponsored trials! A large part of the reason why psychiatrists continue to be duped is precisely BECAUSE fellow psychiatrists like yourself present drug information that has been sponsored by drug companies at lectures, and psychiatrists will trust fellow psychiatrists more than a drug rep (of course Pharmaceutical companies know this). They are also duped by biased drug-company sponsored trials which you admit you have helped design. The first step for psychiatry to no longer be duped is to realize who’s doing the duping: pharmaceutical companies and corrupted psychiatrists with pharma ties.

    I’ll give you the benefit of the doubt and assume you’ve stopped such activities because you’ve had an ethical awakening (similar to Dan Carlat), but I must say it’s tempting to read your statement, “physicians should not pass the buck to the pharmaceutical companies” as simply a way of letting pharma companies off the hook because you work (or have worked) for them.

    Now for my other points:

    AA said:

    “Anyway, later in the chapter, as Mr. Badillo discusses his continued improvement off of meds, he says, (not Mr. Whitaker), “If I had stayed on those drugs, I would not be where I am today. I would be stuck in an adult home somewhere or in this hospital. But I am recovered. I still have some strange ideas but now I keep them to myself. And I weather whatever emotional stress comes up. It stays with me a few weeks and then goes away.”

    This is good evidence that speaks to Badillo’s post-med recovery and that withdrawing from the medication was the deciding factor in his recovery.

    In fact, alienist was more than willing to take another anecdotal subject’s success at their word when it was a success the subject attributed to meds. Alienist says about Cathy’s improvement which was due to meds, “Well, Mr. Whitaker, she says that she was ‘saved’ by her medication. She was able to complete her degree and begin a long-term relationship. Can we not trust her own assessment of her improvement?”

    I have the same question for alienist: “Well, Mr. Alienist, he says that ‘If I had stayed on those drugs, I would not be where I am today. I would be stuck in an adult home somewhere or in this hospital. But I am recovered.”

    Can you not trust his own assessment of his own improvement?

    Also, what do you think of my theory that if the standard of care were different and people like Badillo had access to Soteria house or Open Dialog therapy, that Badillo’s case may be more typical than we think?

    In fact, you said about Cathy’s case:

    “This supposes that there are other therapies that have proven successful in treating manic episodes. Currently, this is not an accepted assumption. Once someone becomes manic to the point described in this patient’s history, you cannot make them rest or engage in psychotherapy.”

    I don’t know if that’s entirely true, because I know that Oryx Cohen, who was institutionalized with bipolar after manic episodes, said, “I’ve spent most of the past few years off of medication. I weaned myself off slowly after both of my manic experiences.”

    Again as I stated in my last post, the current standard of care doesn’t have room for such possibilities, which may mislead psychiatrists into thinking people can’t recover from everything from psychosis or mania without meds.

    Two more examples of people who attributed their recovery to stopping medication:

    Amy Smith is a psychiatric survivor who was polydrugged with antipsychotics and other meds for many years which left her homeless and unable to care for herself. Then one day she had a dental operation which prohibited her from swallowing her pills for a few days. After those few days a haze lifted and she could feel again, very similar to Badillo’s description. It was only AFTER she stopped the meds did it click to her that the meds were her problem. If it weren’t for her dental operation, it’s likely she would have continued on the meds. It was blind luck — not a conscious decision to go off the meds. But once she was OFF the meds, the fog cleared and she started putting her life together again.

    The other example is Elizabeth Kenny. I saw her play “Sick,” which the description reads, “explores a patient’s two-year odyssey inside the most advanced healthcare system in the world — an odyssey that almost killed her.”

    She was most definitely a victim of the Drug Stress Trauma Syndrome (see below) as she was put on multiple meds to “treat” various side effects (trauma!) from her meds. It wasn’t until she went to yet another therapist that she finally had her answer as to what was going on: The therapist said, “I think you’re toxic,” meaning the meds were making her sicker. *The point to this is she never thought it was the medication and she certainly didn’t change her coping strategies or mental outlook before going off meds. YES she wanted to feel better (who wouldn’t?), but there was no behavioral change or epiphany that preceded her decision to get off the meds. It was only once she got off the meds that she began to reclaim her life.

    Also, you said:

    “With regard to the paroxetine (Paxil) statement, I think that the public needs to know that all of the medications of every medical specialty potentially has unknown (and harmful) effects. It is not that psychiatrists use patients as “guinea pigs” particularly, but any new drug has the potential to cause unforseen effects. This is why the FDA continues drug surveillance after approval.”

    Yes, the FDA continues drug surveillance after approval, but wouldn’t it be nice if there were longitudinal safety studies conducted on Prozac BEFORE it was released to the general public, especially considering many people are on this stuff for years? An ounce of prevention is worth a pound of cure. That’s why I consider myself a guinea pig: I was the unwitting “longitudinal safety” test subject. In fact, Whitaker has told me that there are already rumblings in certain psychiatric circles that antidepressant use shouldn’t continue for more than 6-12 months. Gee, that makes me feel swell.

    Also, you mentioned one of the reasons Badillo wasn’t doing well on antipsychotics was because of the side effects. I’d like to take this opportunity to call a spade a spade: feeling like a vegetable, having no emotions, and not feeling in control (as Badillo did) is TRAUMA, not mere side effects, and can thus make the patient feel worse than when they weren’t on drugs. Charles Whitfield outlines this in his journal article “Psychiatric Drugs as Agents of Trauma.” This is also an important article for you to read because it highlights the importance of identifying withdrawal syndrome through further study, because if withdrawal is continuously mistaken as relapse or even due to too low a dose of a medication, the patient may fall into the “Drug Stress Trauma Syndrome” of misdiagnosis which causes more and more drugs to be piled on to “treat” the drug-induced trauma. I’ve included a link below to the full-text.

    LINK:

    -“Psychiatric Drugs as Agents of Trauma”: http://nhne-pulse.org/wp-content/uploads/2010/12/Psychiatric_Drugs_As_Agents_of_Trauma_JRS508.pdf

    • Psychtruth,

      O.K. Let’s see if I can’t explain my comments a little more.

      First, with regard to my previous work with drug trials. You assume way too much. I took every precaution I could to design trials that were fair and interpretable. I am not ashamed of any of the trials I participated in or designed. Some of them were done with pharmaceutical company money, but they were generally well done. Some were done with government money, but they were also well done. Still (if you read my post, “Critique of Double-Blind, Randomized, Placebo Controlled Trials”), you will see that I think that these studies, though the best we have, still have problems.

      Next, yes I did do talks for drug companies. I had particular experience in treating posttraumatic stress disorder (PTSD), so when medications were getting FDA indications for PTSD, I was asked to give some talks. I never said I decieved anybody. You simply assume that I did. I believe that my talks were very fair and covered a wide variety of techniques for identifying those who needed treatment and for treating them. There is nothing for you to be confused about. I did my part to educate mental health providers and believe that I did a very good and responsible job. I never needed the ethical awakening because I have never changed my ethical beliefs.

      Third, your comparing the two anecdotes and suggesting that I am holding them to different standards is incorrect. First, Mr. Whitaker questions whether the woman in the first anecdote got better on her medications. I think we can trust her assessment of herself when she says that the medications “saved” her. The question concerning the man in the second anecdote was not whether he got better — it was what the turning point was that got him better. I think that the most important point in his story (and also in some of the anecdotes that you provide) was likely to be the choice to assert himself in guiding his treatment. I rely on patients to monitor themselves and trust their reports of how they are doing. I do not always trust their understanding of why they are doing better. Again, there is no logical problem here.

      Forth, when someone is manic, they are incapable of voluntarily relaxing or sleeping. If they wish to wait it out until their manic period is over, fine, but you cannot simply tell a manic patient to relax. It doesn’t work. If it does work, the patient wasn’t manic.

      Fifth, with regard to how the FDA works, we simply cannot have an ideal system. If we do studies long enough to ensure that we have absolute knowledge of every effect that a drug has, then we will never approve any drugs. Those who are sick will cry out for faster approval to ease suffering. If we move faster, we will have to accept some limitation of our knowledge about certain side effects. I think our current system is trying to strike a happy balance, and I think it does are pretty good job overall. It seems to be getting flack from both sides.

      Did I cover all the questions you had? If I missed something, let me know.

  16. My turning point was that I had run out of medications to try, and ECT failed too. I had such poor results with meds that a psychiatrists I had inpatient told me he thought I should never take meds again because so many of them made me a lot worse. So I stopped meds (carefully). 6 months later, my behavior was much better (not kicking holes in the walls, not breaking things, not arguing excessively) and I no longer had the intense need to cut myself open to get the insect-like crawling feeling out of me, which was the most horrible feeling for years and made me more suicidal than anything. Now, a year and half later, my behavior is better yet. I have a happy husband.

    My brother had a similar situation, He stopped breaking stuff when he got off meds, within a few weeks to months. He gets out of the house a lot more now and actually has friends.

    It is clear that meds were a disaster for me and my brother. He also got Tourette’s from psych drugs, and is humiliated by that on a daily basis because it is so severe. He barks and yips like a dog, yells out words, and jerks violently every few minutes.

    I was a geophysics PhD student and my brother was a machinist, and we are both basket cases now. My brother can’t even “pass for normal” anymore. We’re better off meds, but still functioning poorly.

    We are classic cases such as Whitaker is describing. Obviously not everyone who takes meds turns into a dysfunctional stay at home. But we did. This bipolar crap cost me my career I wanted since I was 6 years old, and also my chance to have children because I would be an unfit mom and the state would take them away. My husband’s adult son calls me every Mother’s Day and tells me that he loves me, which makes me cry . His wife was a surrogate mom, so they get it how it is when you can’t have kids. I sometimes wish I blew off taking calculus and physics in school and just got knocked up when I was 15 because what difference did it make, I am disabled anyway? My brother has his own losses to cope with. I hope my brother and me are not “medical mistakes” but I think that we probably are.

    Anyway, I brought this up because there isn’t any question about what was my turning point. the other anecdotal stories, the people described are not here. Our docs have said that we are “rare cases.” I don’t know.

    • Cats,

      I’m sorry you and your brother have had such problems. I hope that your situation is rare (for the sake of others) but I also hope you find a good source of satisfaction and meaning in your life. Thanks for writing.

  17. Alienist —

    Thanks for hanging in there with all my posts! Much appreciated.

    As for maintaining your integrity while directly involved with pharma-sponsored drug trials and lectures, I’ll take your word for it.

    As for Whitaker’s anecdotes: I think at this point I’ll have to agree to disagree with you about how patients recover off meds and when the turning point for their recovery was. Your clinical insight is valid, but so are the experiences of some patients that may very well fall outside your clinical experience.

    On your point about the FDA: your point that “we simply cannot have an ideal system” is something of a straw-man. I never said I wanted an ideal FDA. I simply want it reformed.

    I’m honestly shocked by your statement, “I think our current system is trying to strike a happy balance, and I think it does a pretty good job overall.”

    Considering that all the FDA currently requires for drug approval are two successful trials (with an unlimited amount of failed trials) that prove the drug is better than placebo (that is, better than nothing), I’d say that sets the bar pretty low. Compounding that is the FDA currently doesn’t require any evidence from drug companies that their new drug is better than any older drug, which has allowed the amount of “me-too” drugs and patent-extenders to balloon in the market. With this in mind, it’s easy to see why there are so many me-too drugs and few novel ones. Patients could certainly benefit from more novel drugs that are the result of rigorous testing, but the FDA has calibrated the drug approval process so that it’s not in the drug companies’ best interests to do such a thing.

    And I didn’t even touch on the rampant amount of iffy additional indications the drug companies successfully achieved due to the shortcomings of the FDA’s guidelines (Antipsychotics like Abilify FDA-approved as an “Add-on” to antidepressants for depression? Cymbalta approved for low back pain and fibromyalgia? Prozac re-branded as Serafem and FDA-approved for Pre-Menstrual Dysphoric Disorder? What’s going on here?) I’d like to know how someone would feel when they realized the med they were taking for their low back pain was a potent SNRI and realized they were having a terrible time withdrawing from it.

    And what about Risperdal being FDA-approved for juvenile bipolar, a diagnosis which has increased 40-fold in only 9 years? And Risperdal is of course Joseph Biederman’s pill du jour since he’s been on the J&J payroll and conducted many of their studies, and was recently spanked by Harvard for failing to disclose pharma payouts totaling in the millions. In fact, J&J gave Biederman over $2 million in 2003 to assemble KOL advisory boards to gain support among the FDA to approve Risperdal for children. Considering in 2007 the FDA approved Risperdal for schizophrenia treatment in children ages 13-17, and bipolar disorder in kids 10-17, I think Biederman and co. succeeded.

    And let’s not forget the Menaflex debacle, a direct result of political lobbying and a nice black-mark for the FDA.

    And what about all the class action law-suits that seem to spring up nearly every week about side effects (birth defects being the most frightening) that the FDA never found until it was too late?

    And what about men who have suffered PERMANENT sexual dysfunction from Propecia, and yet there is no warning of these effects on the US box, but there is on the European box? Read this statement below from a law firm handling cases about permanent Propecia effects:

    “Since 1997 when Propecia was first approved by the FDA, there have been many complaints of sexual dysfunction side effects.

    Merck, makers of Propecia and Proscar, lists known side effects to be cognitive impairment, depression and various forms of sexual dysfunction, including erectile dysfunction, reduced libido, and infertility. They warn the sexual dysfunction side effects should resolve after discontinued use of the drug. But that may not be the case.

    Since 2006, the Swedish Medical Products Agency has been following reports of men who continue to experience sexual dysfunction even after they stopped taking the prescription. Merck changed its label in several European countries, noting that sexual effects might be permanent; but label information in the United States has not been updated.”

    Why has the label warning not changed in the US? And, if the Swedish agency can follow men who have sexual dysfunction after stopping the med, why can’t the FDA? The FDA doesn’t come out looking good in this at all.

    Then, of course, there are the dozens of books on the market casting doubt (that’s putting it lightly) on the FDA, with Jon Abramson’s OVERDOSED AMERICA being perhaps the most well-known.

    In my opinion, these facts speak to an FDA that is far, far from doing “a pretty good job overall.” Sorry, but that’s a whopper.

    I totally understand your point that waiting until every single fact (good and bad) about a drug would be untenable, but are drug trials lasting a year (or two) vs. the 6-12 week standard really too much to ask, considering almost all patients will be on psych meds longer than 6-12 weeks?

    • Psychtruth,

      I understand your points and have a lot of sympathy for them. At the same time, I am deluged with patients who come to me frustrated that there are not more different medications to try or that some medication they have heard about in another country is not yet available to them to try. I think that we have a “perfect storm” here in the U.S. Very few people are educated about how drugs are developed, tested, and approved (and I don’t think Anatomy of an Epidemic improves matters much, but that is for a later chapter). Doctors are pressured to spend less time with patients or are just not willing to educate their patients about medications, side effects, monitoring response, and including additional therapeutic measures. Government agencies are under pressure to move faster but to know more (mutually exclusive goals). Many patients (who are legitimately suffering and in search of releaf) are lured by the promise of fast results and the expectation that someone besides themselves can “fix” them. Society does not want to pay for the expense of adequately treating mental illnesses (time off, intensive psychotherapy, rehabilitation, reduced work duties during re-entering the workforce). Rather than paying for full care up front, insurance rations care allowing simple cases to become chronic illnesses. There are probably many other aspects to this “perfect storm” that I haven’t mentioned. This is my main complaint with Mr. Whitaker’s book. It focuses on medication when this problem is so much larger. We can’t pick out the medication component without looking at the other components of this problem. I hope I can make this point better when we get to those chapters in the book.

      By the way, I still think the FDA is doing a pretty good job considering the many conflicting pressures they are under. They certainly are not perfect, but I think that they work hard to minimize the criticism they receive from all sides. The compromise may not suit our personal tastes, but (at least to me) their efforts are reasonable and understandable.


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