Mad in America: Bad Science, Bad Medicine, and the Enduring Mistreatment of the Mentally Ill is a 2002 book by medical journalist Robert Whitaker, in which the author examines and questions the efficacy, safety, and ethics of past and present psychiatric interventions for severe mental illnesses, particularly antipsychotics. The book is organized as a historical timeline of treatment development in the United States.
Mad in America received positive reviews from the general public and mixed reviews from the medical community, which criticized some bias in sourcing but nonetheless acknowledged the need to address the critical questions raised by the book regarding modern psychiatry.
Synopsis
Part One: The Original Bedlam (1750–1900)
Part One describes early treatments like a spinning chair which could reach 100 revolutions per minute, the Tranquilizer Chair which immobilized patients, and water therapies.[1]:12–13,16 Whitaker then describes moral treatment, dating back to 1793 and the French Revolution and established in the U.S. by Quakers in 1817, in which lay superintendents treated the mentally ill in small homes with great kindness and had good outcomes: About 35 to 80 percent of patients were discharged within a year, the majority of them cured. Pennsylvania Hospital reported that about 45 percent of patients were discharged as cured and 25 percent discharged as improved. In Worcester State Hospital, 35 percent were chronically ill or had died while mentally ill.[1]:36 Dr. George Wood, a visitor, reported in 1851:
...you encounter persons walking, conversing, reading or variously occupied, neatly and often handsomely dressed, to whom as you pass you receive an introduction as in ordinary social life; and you find yourself not unfrequently quite at a loss to determine whether the persons met with are really the insane, or whether they may not be visitors or officials in the establishment.[2]
Part Three describes the discovery of phenothiazines and the advent of the neuroleptic drugs that were derived from them, such as chlorpromazine (Thorazine) by Rhône-Poulenc in France, and its purchase by Smith, Kline & French (today known as GlaxoSmithKline). The drug "produced an effect similar to frontal lobotomy", according to early reports by the company's lead investigator.[1]:154–55 Whitaker says that pharmaceutical advertising, articles published in the scientific literature, and stories in the media of "miracle drugs" transformed Thorazine into a healing drug.[1]:158
In Part Three, Whitaker also describes the American (but not for example British) propensity to classify patients as "schizophrenic", as well as the error (confusion of schizophrenia with the yet-to-be-discovered encephalitis lethargica) in the original classification by Emil Kraepelin, which psychiatry chose to not revisit and fix.[1]:167,169 Whitaker then describes three pathways that dopamine may take in the human brain, and quotes first-person accounts of the effects of antipsychotic drugs on individuals.[1]:162–164,176–187
He calls a 1996 New York Times advertisement by a consortium of pharmaceutical companies a "bald-faced lie": the group sought to say that the cause of psychosis and schizophrenia is an abnormal dopamine level and that their drugs worked by altering the level of dopamine.[1]:199 Whitaker then criticizes some American studies, and points out the work of George Crane at the National Institute of Mental Health to get tardive dyskinesia recognized, which up to that point had largely been touted as a symptom of schizophrenia, and he contrasts the dosages that British doctors were comfortable in prescribing (300 milligrams per day of Thorazine) with what American psychiatrists prescribed (1,500 up to perhaps 5,000 milligrams per day).[1]:200–202,204–209
He sees irony in the fact that The New York Times reported on Soviet forced use of neuroleptic drugs (which Florida Senator Edward Gurney called "chemicals which convert human beings into vegetables") in "psychiatric jails", but called the same drugs "widely acknowledged to be effective" when reporting on American schizophrenic patients.[1]:216–218
Whitaker describes the demise of modern-day moral treatment in a short history of Loren Mosher's Soteria Project, funded by the U.S. while Mosher was chief of schizophrenia at NIMH.[1]:226 He attributes the results in a World Health Organization 1979 study of outcomes for schizophrenia patients (which found better outcomes in undeveloped countries like India, Nigeria and Colombia than in developed countries like the United States, England, Denmark, Ireland, Russia, Czechoslovakia and Japan) to doctors in the developed world who maintained their patients on medications.[1]:226–229
He then describes 50 years of American scientists doing experiments on schizophrenia patients: to intentionally exacerbate their symptoms and study the results. He compares the doctors' behavior, unfavorably, to 1947 after American trials of Nazi doctors ended in the Nuremberg Code for ethics in human experimentation.[1]:235,247
Part Four: Mad Medicine Today (1990s–present)
Part Four is Whitaker's description of drug trials for the newer atypical antipsychotics. He says that many of these trials were stacked in favor of the drug being proposed by eliminating the placebo, or by comparing multiple doses of the new drug against a single, very high dose of the old one.[1]:273–274 He says that the pharmaceutical companies and the press used their influence to make claims for these drugs (some claims that the Food and Drug Administration had explicitly asked them not to make).[1]:227Risperidone and olanzapine, for example, were both claimed to have fewer side effects than the first generation of antipsychotics. Whitaker also tells the stories of patients whose deaths were caused by drug trials, but were not mentioned to the public.[1]:269–272
Epilogue
Whitaker calls it a type of medical fraud that schizophrenics are told that they suffer from too much dopamine or serotonin activity and that drugs put these brain chemicals back in "balance".[1]:290 And suggests that it would not be tolerated to mislead patients with verified pathological disease such as cancer and heart disease. He writes, "Little is known about what causes schizophrenia. Antipsychotic drugs do not fix any known brain abnormality, nor do they put brain chemistry back into balance. What they do is alter brain function in a manner that diminishes certain characteristic symptoms...".[1]:291 Which in various parts of the book he claims or alludes to the drugs having this effect on all other fundamental aspects of personality and behaviors, including the ability to take care of oneself, a notion he later explores more critically in Anatomy of an Epidemic.
Reception
Recognizing Whitaker for marshalling evidence, a reviewer writing for the Chicago Tribune thought his hopes for moral treatment were admirable but inadequate.[3] Writers for The Baltimore Sun and In These Times both liked the book but wondered why the author did not mention Thomas Szasz, a critic of psychiatry.[4][5]
Scholarly journal reviews
Clinical psychologist Claudia Bukszpan Rutherford acknowledged that though the author holds an extreme position, the book's insight into many of the problems of clinical psychiatry over the years has good points: "While at times his lack of editorial restraint actually distracts from his message, and one may not agree with all of his arguments, his topic is a vital one that has needed to be raised for quite some time, and one which will hopefully be a catalyst for further discussion."[6]
The book was also reviewed in JAMA, where reviewer Daniel J. Luchins, MD, of the University of Chicago observed the review of scientific literature to be biased at times. Despite this, Luchins concluded the book was of value in highlighting social aspects of treatment in psychiatry.[7]
Physician J. van Gijn, reviewing the book for the New England Journal of Medicine, writes that "the book is more of an indictment than a historical account", and starts by pointing out that Whitaker "virtually equates mental illness with schizophrenia; depression and other psychiatric disorders are mentioned only parenthetically." Van Gijn summarizes the pre-1950 coverage of the book without much commentary, but then criticizes the rest of the book. Specifically, he questions Whitaker's assertion that Kraepelin's schizophrenia patients in fact suffered from encephalitis lethargica. With regard to antipsychotic medication, van Gijn notes that "Although there may be truth in the notion that dosages of antipsychotic drugs in the United States are higher than necessary, the author weakens his position by issuing continuous and unrelenting condemnations (for instance, 'The Nuremberg Code doesn't apply here'), despite a dearth of evidence to support them." Van Gijn then describes Whitaker's attack on the dopamine hypothesis of schizophrenia as "simplistic reasoning", and concludes that "Although [Whitaker] is widely read on the subject, the facts are largely arranged to suit his prejudice, especially in the chapters on drug treatment. American psychiatric institutions may have their failings in the current management of patients with schizophrenia, but they deserve better critics."[8]
Psychologist Clare Mundell, PhD, writing for the Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry said Mad in America "should be required reading not only for mental health professionals, but also for those who still question whether profit has eclipsed patient care as the primary force in medicine in this country."[9]
Online reviews
David Pilgrim, writing "News of scandal is a few decades too late" for Times Higher Education, focuses on the book's shortcomings, saying, "The semi-academic froth he generates distracts the reader from a legitimate outrage, which is not his alone. It was shared by many others well before 1998" (the year Whitaker began writing on mental health).[10]
Physician Larry S. Goldman wrote a critical review of the book in WebMD's Medscape Today, claiming that Whitaker "is ready to throw the baby out with the bath water" because Mad in America fails to acknowledge any biological abnormalities in schizophrenia, while at the same conceding that Whitaker's argument is correct in the sense that the true causes of schizophrenia are not known. Goldman concludes that the "overheated style" of the book "tends to undermine some of its more important points, such as the unhealthy symbiosis between the US pharmaceutical industry and much of the psychiatric research community and the ever-present miserliness of public mental healthcare systems."[11]
In a rejoinder to Goldman's review, physician Nathaniel S. Lehrman disagrees with Goldman, and writes that "Whitaker is right", and goes on to agree with the main points in the book, namely that antipsychotic drugs cause brain damage, that despite "psychiatrically produced misconceptions", they "do not fix any known brain abnormality nor do they put brain chemistry back into balance. What they do is alter brain functions in a manner that diminishes certain characteristic symptoms." Lehrman then writes that all the data accumulated on the neurobiology of schizophrenia "has hardly helped patient care."[12]
Lehrman later wrote in the official journal of the conservative political organization the Association of American Physicians and Surgeons, the Journal of American Physicians and Surgeons that Mad in America is "perhaps the most important psychiatric book of the 21st century."[13]
Christian Perring, editor of Metapsychology Online Review and who was impressed by the book, wrote, "Even though Whitaker himself could be accused of being overly critical of psychiatry, his argument against schizophrenia medication is cogent enough to urgently require an answer."[14]
E. Fuller Torrey writing for the Treatment Advocacy Center called it "histrionic" and "deeply disappointing."[15]
Physician Marcia Angell, MD, writing a two-part review for The New York Review of Books, called this and similar books "powerful indictments of the way psychiatry is now practiced", documenting "the 'frenzy' of diagnosis, the overuse of drugs with sometimes devastating side effects, and widespread conflicts of interest."[16][17]
↑ Van Gijn, J. (2002). "Book Review Mad in America: Bad Science, Bad Medicine, and the Enduring Mistreatment of the Mentally Ill by Robert Whitaker. 334 pp. New York, Perseus, 2002. $27. 0-7382-0385-8". New England Journal of Medicine. 346 (26): 2096. doi:10.1056/NEJM200206273462620.
Antipsychotics, previously known as neuroleptics and major tranquilizers, are a class of psychotropic medication primarily used to manage psychosis, principally in schizophrenia but also in a range of other psychotic disorders. They are also the mainstay, together with mood stabilizers, in the treatment of bipolar disorder. Moreover, they are also used as adjuncts in the treatment of treatment-resistant major depressive disorder.
Psychosis is a condition of the mind that results in difficulties determining what is real and what is not real. Symptoms may include delusions and hallucinations, among other features. Additional symptoms are incoherent speech and behavior that is inappropriate for a given situation. There may also be sleep problems, social withdrawal, lack of motivation, and difficulties carrying out daily activities. Psychosis can have serious adverse outcomes.
A psychiatric or psychotropic medication is a psychoactive drug taken to exert an effect on the chemical makeup of the brain and nervous system. Thus, these medications are used to treat mental illnesses. These medications are typically made of synthetic chemical compounds and are usually prescribed in psychiatric settings, potentially involuntarily during commitment. Since the mid-20th century, such medications have been leading treatments for a broad range of mental disorders and have decreased the need for long-term hospitalization, thereby lowering the cost of mental health care. The recidivism or rehospitalization of the mentally ill is at a high rate in many countries, and the reasons for the relapses are under research.
Chlorpromazine (CPZ), marketed under the brand names Thorazine and Largactil among others, is an antipsychotic medication. It is primarily used to treat psychotic disorders such as schizophrenia. Other uses include the treatment of bipolar disorder, severe behavioral problems in children including those with attention deficit hyperactivity disorder, nausea and vomiting, anxiety before surgery, and hiccups that do not improve following other measures. It can be given orally, by intramuscular injection, or intravenously.
Typical antipsychotics are a class of antipsychotic drugs first developed in the 1950s and used to treat psychosis. Typical antipsychotics may also be used for the treatment of acute mania, agitation, and other conditions. The first typical antipsychotics to come into medical use were the phenothiazines, namely chlorpromazine which was discovered serendipitously. Another prominent grouping of antipsychotics are the butyrophenones, an example of which is haloperidol. The newer, second-generation antipsychotics, also known as atypical antipsychotics, have largely supplanted the use of typical antipsychotics as first-line agents due to the higher risk of movement disorders in the latter.
The atypical antipsychotics (AAP), also known as second generation antipsychotics (SGAs) and serotonin–dopamine antagonists (SDAs), are a group of antipsychotic drugs largely introduced after the 1970s and used to treat psychiatric conditions. Some atypical antipsychotics have received regulatory approval for schizophrenia, bipolar disorder, irritability in autism, and as an adjunct in major depressive disorder.
Olanzapine, sold under the brand name Zyprexa among others, is an atypical antipsychotic primarily used to treat schizophrenia and bipolar disorder. For schizophrenia, it can be used for both new-onset disease and long-term maintenance. It is taken by mouth or by injection into a muscle.
Akathisia is a movement disorder characterized by a subjective feeling of inner restlessness accompanied by mental distress and an inability to sit still. Usually, the legs are most prominently affected. Those affected may fidget, rock back and forth, or pace, while some may just have an uneasy feeling in their body. The most severe cases may result in poor adherence to medications, exacerbation of psychiatric symptoms, and, because of this, aggression, violence, and/or suicidal thoughts. Akathisia is also associated with threatening behaviour and physical aggression in mentally disordered patients. However, the attempts to found potential links between akathisia and emerging suicidal or homicidal behaviour were not systematic and were mostly based on a limited number of case reports and small case series. According to the latest available evidence of the highest quality, akathisia by itself cannot be reliably linked to the presence of suicidal behaviour in patients treated with antipsychotic medication.
Edwin Fuller Torrey, is an American psychiatrist and schizophrenia researcher. He is associate director of research at the Stanley Medical Research Institute (SMRI) and founder of the Treatment Advocacy Center (TAC), a nonprofit organization whose principal activity is promoting the passage and implementation of outpatient commitment laws and civil commitment laws and standards in individual states that allow people diagnosed with severe mental illness to be involuntarily hospitalized and treated throughout the United States.
Aripiprazole, sold under the brand names Abilify and Aristada, among others, is an atypical antipsychotic. It is primarily used in the treatment of schizophrenia and bipolar disorder; other uses include as an add-on treatment in major depressive disorder and obsessive compulsive disorder (OCD), tic disorders, and irritability associated with autism. Aripiprazole is taken by mouth or via injection into a muscle. A Cochrane review found low-quality evidence of effectiveness in treating schizophrenia.
Tardive dyskinesia (TD) is a disorder that results in involuntary repetitive body movements, which may include grimacing, sticking out the tongue or smacking the lips. Additionally, there may be chorea or slow writhing movements. In about 20% of people with TD, the disorder interferes with daily functioning. If TD is present in the setting of a long-term drug therapy, reversibility can be determined primarily by severity of symptoms and how long symptoms have been present before the long-term drug has been stopped.
Biological psychiatry or biopsychiatry is an approach to psychiatry that aims to understand mental disorder in terms of the biological function of the nervous system. It is interdisciplinary in its approach and draws on sciences such as neuroscience, psychopharmacology, biochemistry, genetics, epigenetics and physiology to investigate the biological bases of behavior and psychopathology. Biopsychiatry is the branch of medicine which deals with the study of the biological function of the nervous system in mental disorders.
Robert Whitaker is an American journalist and author, writing primarily about medicine, science, and history. He is the author of five books, three of which cover the history or practice of modern psychiatry. He has won numerous awards for science writing, and in 1998 he was part of a team writing for the Boston Globe that was shortlisted for the 1999 Pulitzer Prize for Public Service for a series of articles questioning the ethics of psychiatric research in which unsuspecting patients were given drugs expected to heighten their psychosis. He is the founder and publisher of Mad in America, a webzine critical of the modern psychiatric establishment.
The Soteria model is a milieu-therapeutic approach developed to treat acute schizophrenia, usually implemented in Soteria houses.
Loren Richard Mosher was an American psychiatrist, clinical professor of psychiatry, expert on schizophrenia and the chief of the Center for Studies of Schizophrenia in the National Institute of Mental Health (1968–1980). Mosher spent his professional career advocating for humane and effective treatment for people diagnosed as having schizophrenia and was instrumental in developing an innovative, residential, home-like, non-hospital, non-drug treatment model for newly identified acutely psychotic persons.
Jeffrey Alan Lieberman is an American psychiatrist who specializes in schizophrenia and related psychoses and their associated neuroscience (biology) and pharmacological treatment. He was principal investigator for CATIE, the largest and longest independent study ever funded by the United States National Institute of Mental Health to examine existing pharmacotherapies for schizophrenia. He was president of the American Psychiatric Association from May 2013 to May 2014.
Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America is a book by Robert Whitaker published in 2010 by Crown. Whitaker asks why the number of Americans who receive government disability for mental illness approximately doubled since 1987.
Joanna Moncrieff is a British psychiatrist and academic. She is Professor of Critical and Social Psychiatry at University College London and a leading figure in the Critical Psychiatry Network. She is a prominent critic of the modern 'psychopharmacological' model of mental disorder and drug treatment, and the role of the pharmaceutical industry. She has written papers, books and blogs on the use and over-use of drug treatment for mental health problems, the mechanism of action of psychiatric drugs, their subjective and psychoactive effects, the history of drug treatment, and the evidence for its benefits and harms. She also writes on the history and politics of psychiatry more generally. Her best known books are The Myth of the Chemical Cure and The Bitterest Pills.
Psychiatry is, and has historically been, viewed as controversial by those under its care, as well as sociologists and psychiatrists themselves. There are a variety of reasons cited for this controversy, including the subjectivity of diagnosis, the use of diagnosis and treatment for social and political control including detaining citizens and treating them without consent, the side effects of treatments such as electroconvulsive therapy, antipsychotics and historical procedures like the lobotomy and other forms of psychosurgery or insulin shock therapy, and the history of racism within the profession in the United States.
Dopamine supersensitivity psychosis is a hypothesis that attempts to explain the phenomenon in which psychosis occurs despite treatment with escalating doses of antipsychotics. Dopamine supersensitivity may be caused by the dopamine receptor D2 antagonizing effect of antipsychotics, causing a compensatory increase in D2 receptors within the brain that sensitizes neurons to endogenous release of the neurotransmitter dopamine. Because psychosis is thought to be mediated—at least in part—by the activity of dopamine at D2 receptors, the activity of dopamine in the presence of supersensitivity may paradoxically give rise to worsening psychotic symptoms despite antipsychotic treatment at a given dose. This phenomenon may co-occur with tardive dyskinesia, a rare movement disorder that may also be due to dopamine supersensitivity.
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