"Anatomy of an Epidemic": Relevant or Not?

Patient Expert

Perhaps you have read Robert Whitaker's 2010 "Anatomy of an Epidemic." I have given considerable attention to the book on my personal blog, "Knowledge is Necessity," but I have only made passing reference to it here, which I will explain later. Let's begin ...

Robert Whitaker is a journalist and outspoken critic of psychiatry. His 2002 book, "Mad in America," is a scathing indictment of medical (mis)treatments for the mentally ill over the past couple of hundred years, and "Anatomy" picks up where "Mad" left off. In "Anatomy," Whitaker makes the extraordinary assertion that mental illness is on the rise because of meds, not in spite of meds.

Part of his argument concerns a point I have been raising for years, one advanced by the leading bipolar authorities and backed by patient testimony - that antidepressants may considerably worsen the course of bipolar disorder by inducing mania and speeding up cycling. In addition, certain individuals with unipolar depression (especially those with highly recurrent episodes) may find themselves at risk.

Whitaker presses this line of attack by noting that certain individuals have experienced their first manic episode on an antidepressant, essentially turning someone with unipolar depression into someone with bipolar disorder. Likewise, antidepressants have complicated the course of bipolar to the extent that the illness is far less manageable than it used to be.

One of the problems with antidepressants, according to Whitaker, is that patients build up a tolerance to the drug. The drug may boot you out of your current state, but long-term administration may actually create the ironic effect of raising the risk of a reoccurring depressive episode. Giovani Fava of the University of Bologna uses the term "oppositional tolerance," where the brain essentially fights back against the antidepressant.

Something similar may be going on with antipsychotics. Whitaker cites Guy Chouinard and Barry Jones of McGill University in support of the proposition that long-term antipsychotic use may induce "supersensitivity psychosis," again based on the principle of of the brain fighting back against the drug and overshooting back to the condition it was meant to prevent.

Whitaker carries the argument further by pointing to a study by Harrow and Jobe of the University of Illinois that tracked 64 patients with schizophrenia over 15 years. The true finding of the study was that patients identified at intake with a "good prognosis" (such experiencing their first outbreak at a later age) were far more likely to have better long-term outcomes. Many of these patients had also been successfully weaned off their antipsychotics.

Whitaker interpreted the study to mean that the patients in the study who remained on antipsychotics fared worse over 15 years than the ones who went off. This may have been a legitimate "secondary analysis," but this is not what the study measured for. Otherwise, the study would have been conducted on two "randomized" (ie very similar) patient groups, and such a study may well have produced a very different finding.

Since the publication of "Anatomy of an Epidemic," Whitaker has become a hero amongst a growing community of consumers who are fast (and justifiably) losing their faith in psychiatry. Psychiatry response to Whitaker has been to play dead, which is a damning in its own right. Whitaker's arguments - whether you agree with him or not - certainly provide food for thought. I strongly recommend reading his book, and for you to reach your own conclusions.

As I stated earlier, I gave Whitaker's book considerable play on my personal blog "Knowledge is Necessity," but not here at HealthCentral. The subtitle to Knowledge is Necessity reads, "Musings on Mental Health: From God to Neurons." Indeed, two of my pieces from the last week actually did involve God, and Whitaker and his attack on the credibility of psychiatry fits right into these cosmic themes.

By contrast, my focus here on HealthCentral is far more concentrated, namely on the day-to-day challenge of living with our illness, and in this regard Whitaker adds little to the conversation. Mind you, that is no excuse for my tardiness in writing this, but, basically Whitaker is telling us what we already know, namely:

  • Antidepressants are not such a good idea for treating bipolar. We already know of the mania and rapid-cycling risk. We know that psychiatric treatment guidelines explicitly warn against their use without a concurrent mood stabilizer. We know that a major NIMH-underwritten study (STEP-BD) found no added benefit with an antidepressant in the cocktail.
  • Long-term antipsychotic administration is best avoided, if possible. Treatment guidelines recommend their use in the short-term for treating depression and bipolar (depending on the particular antipsychotic), but owing to their onerous side effects, only recommend their use over the long term if symptoms persist and in the event of breakthrough episodes.

What is particularly illuminating is what Whitaker left out of his book. Namely, he did not attack lithium and mood stabilizers such as Depakote and Lamictal. Trust me, if he could find a bad thing to say about any class of med in his book, whether justified or not, he said it. As well as antidepressants and antipsychotics, he attacked benzodiazepines (on very solid grounds) and ADHD meds (sort of making things up as he went along).

So why the silent treatment on mood stabilizers? Because they work? Because they are comparatively safe? Whitaker does make passing reference to the fact that lithium would work a lot better were it not for the fact that a lot of us are now much more difficult to treat, thanks to the destabilizing effects of antidepressants.

So is Whitaker's general silence and one passing reference a back-handed endorsement for mood stabilizers over the long term? If he thinks mood stabilizers may help us out, why can't he bring himself to say it? Can you see why I have a problem or two with Whitaker?

As always, I am very interested in hearing from you. If you have read Whitaker's book, please let us know what you think and how it may have changed your thinking. Comments below ...