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.