Since I interviewed Robert Whitaker for AlterNet in 2010, after the publication of Anatomy of an Epidemic, the psychiatry establishment has pivoted from first ignoring him, to then debating him and attempting to discredit him, to currently agreeing with many of his conclusions. I was curious about his take on the recent U-turns by major figures in the psychiatry establishment with respect to (1) antipsychotic drug treatment, (2) the validity of the “chemical imbalance” theory of mental illness, and (3) the validity of the DSM, psychiatry’s diagnostic bible. And I was curious about Whitaker’s sense of psychiatry’s future direction.
Bruce Levine: In 2013, the director of the National Institute of Mental Health (NIMH), Thomas Insel, announced—without mentioning you— that he agreed with your conclusion that psychiatry’s standard treatment for people diagnosed with schizophrenia and other psychoses needs to change so as to better reflect the diversity in this population. Citing long-term treatment studies that you had previously documented, Insel came to the same conclusion that you had: in the long-term, not all but many individuals who have been diagnosed with psychosis actually do better without antipsychotic medication. Was it gratifying for you to see the U.S. government’s highest ranking mental health official agreeing with you?
Robert Whitaker: Shortly before Thomas Insel wrote that blog, I had posted my own on madinamerica.com, related to a recent study by Lex Wunderink from the Netherlands. Wunderink had followed patients diagnosed with a psychotic disorder for seven years, and he reported that those randomized, at an early date, to a treatment protocol that involved tapering down to a very low dose or withdrawing from the medication altogether had much higher recovery rates than those maintained on a regular dose of an antipsychotic.
I wrote that in the wake of Wunderink’s randomized study, if psychiatry wanted to maintain its claim that its treatments were evidence-based, and thus maintain any sort of moral authority over this medical domain, then it needed to amend its treatment protocols for antipsychotics. I don’t know if Dr. Insel read my blog, but his post did nevertheless serve as a reply, and as you write, he did basically come to the same conclusion that I had been writing about for some time.
I suppose I took some measure of personal gratification from his blog, for it did provide a sense of a public acknowledgment that I had indeed been “right.” But more important, I felt a new sense of optimism, hopeful that maybe psychiatry would now really address this issue, which is so important to the lives of so many people. A short while ago, the New York Times published a feature story on Dr. Insel, noting that he had recently raised a question about the long-term use of antipsychotics, which had caused a stir in psychiatry because it contradicted conventional wisdom. That is a sign that perhaps a new discussion is really opening up.
Bruce Levine: In Anatomy of an Epidemic, you also discussed the pseudoscience behind the “chemical imbalance” theories of mental illness—theories that made it easy to sell psychiatric drugs. In the last few years, I’ve noticed establishment psychiatry figures doing some major backpedaling on these chemical imbalance theories. For example, Ronald Pies, editor-in-chief emeritus of the Psychiatric Times stated in 2011, “In truth, the ‘chemical imbalance’ notion was always a kind of urban legend—never a theory seriously propounded by well-informed psychiatrists.” What’s your take on this?
Robert Whitaker: This is quite interesting, and revealing I would say. In a sense, Ronald Pies is right. Those psychiatrists who were “well informed” about investigations into the chemical imbalance theory of mental disorders knew it hadn’t really panned out, with such findings dating back to the late 1970s and early 1980s. But why then did we as a society come to believe that mental disorders were due to chemical imbalances, which were then fixed by the drugs?
Dr. Pies puts the blame on the drug companies, but if you track the rise of this belief, it is easy to see that the American Psychiatric Association promoted it in some of their promotional materials to the public, and that “well-informed” psychiatrists often spoke of this metaphor in their interviews with the media. So what you find in this statement by Dr. Pies is a remarkable confession: psychiatry, all along, knew that the evidence wasn’t really there to support the chemical imbalance notion, that it was a hypothesis that hadn’t panned out, and yet psychiatry failed to inform the public of that crucial fact.
By doing so, psychiatry allowed a “little white lie” to take hold in the public mind, which helped sell drugs and of course made it seem that psychiatry had magic bullets for psychiatric disorders. That is an astonishing betrayal of the trust that the public puts in a medical discipline; we don’t expect to be misled in such a basic way.
But why now? Why are we hearing these admissions from Dr. Pies and others now? I am not sure, but I think there are two reasons.
One, the low-serotonin theory of depression has been so completely discredited by leading researchers that maintaining the story with the public has just become untenable. It is too easy for critics and the public to point to the scientific findings that contradict it.
Second, a number of pharmaceutical companies have shut down their research into psychiatric drugs [see Science, 2010], and they are doing so because, as they note, there is a lack of science providing good molecular targets for drug development. Even the drug companies are moving away from the chemical-imbalance story, and thus, what we are seeing now is the public collapse of a fabrication, which can no longer be maintained. In the statement by Dr. Pies, you see an effort by psychiatry to distance itself from that fabrication, putting the blame instead on the drug companies.
Bruce Levine: And recently, establishment psychiatrists have even been challenging the validity of psychiatry’s diagnostic bible, the DSM. Last year, NIMH director Insel, citing the DSM’s lack of scientific validity, stated that the “NIMH will be re-orienting its research away from DSM categories.” And psychiatrist Allen Frances, the former chair of the DSM-4 task force, has been talking about how the DSM is a money machine for drug companies (“Last Plea To DSM-5: Save Grief From the Drug Companies”), and Frances thoroughly trashed the DSM-5 in his 2013 book Saving Normal.
Robert Whitaker: I think this challenging of the validity of DSM is, in many ways, potentially much more of a paradigm-changer than are the scientific reports that detail how the medications may be causing long-term harm. Our current drug-based paradigm of care, which presents drugs as treatments for the symptoms of a “disease,” stems from DSM III. The APA [American Psychiatric Association] and its leaders boasted that when DSM III was published in 1980, that the field had now adopted a “medical model,” and thus its manual was now “scientific” in kind.
In fact, the APA had adopted a “disease model,” and if you carefully read the DSM III manual, you saw that the authors acknowledged that very few of the diagnoses had been “validated.” The APA’s hope and expectation was that future research would validate the disorders, but that hasn’t happened. Researchers haven’t identified a characteristic pathology for the major mental disorders; no specific genes for the disorders have been found; and there isn’t evidence that neatly separates one disorder from the next. The “disease model,” as a basis for making psychiatric diagnoses, has failed.
We are now witnessing, in Insel’s statements and those by Allen Frances, an acknowledgment of this failure. And here is why this is potentially such a paradigm-changer: The foundation of any medical specialty begins with its diagnostic manual, which should be both reliable and valid. If the disorders listed in a manual haven’t been validated, then you can’t conclude they are “real,” in the sense of the disorders being unique illnesses, and the diagnoses being useful for prescribing an appropriate treatment.
Thus, when Insel states that the disorders haven’t been validated, he is stating that the entire edifice that modern psychiatry is built upon is flawed, and unsupported by science. This is like the King of Psychiatry saying that the discipline has no clothes. If the public loses faith in the DSM, and comes to see it as unscientific, then psychiatry has a real credibility problem on its hands, and that could prove to be fertile ground for real change.
Bruce Levine: So do you feel you have accomplished your mission? And can dissident mental health professionals—who have for years been talking about invalid diagnoses, pseudoscientific theories of mental illness, and drug treatments that cause moderate and acute problems to become severe and chronic ones—now have reasons to be optimistic about their profession? Or are you pessimistic that the recent admissions of establishment psychiatry will result in substantive changes in treatment?
Robert Whitaker: This is a good question, and I vacillate in my personal response between guarded optimism and complete pessimism. From an intellectual, scientific standpoint, I think psychiatry is facing a deep crisis. There is an understanding, within psychiatric research circles, that the DSM diagnoses haven’t, in fact, been validated. And, at the very least, there is a recognition that psychiatry’s drug treatments are inadequate. In 2009, Insel wrote an article stating: “For too many people, antipsychotics and antidepressants are not effective, and even when they are helpful, they reduce symptoms without eliciting recovery.” And I do think that my book Anatomy of an Epidemic has contributed to an awareness of the limitations of the drugs, and at least a discussion, in some psychiatric circles, that the drugs may be worsening long-term outcomes.
But in terms of accomplishing my mission, well, I guess my “mission” would be to see that our society would actually build a system of care that was truly “science” based, particularly in its use of psychiatric drugs. I think this is such an important story for our society, and one of extraordinary moral importance when it comes to medicating children and adolescents, none of whom could be said to have really “consented” to such treatment. I turned madinamerica.com into a webzine with the hope that by providing a forum for a community of writers interested in “rethinking psychiatry,” and combining their voices with reports of research that provide a foundation for such rethinking, it could become a real force for change. We’ll see if that happens, but our readership is steadily increasing.
I should note, as you say, that dissident mental health professionals have been plugging away at promoting such change for a long time. I hope that madinamerica.com is providing that community a forum for voicing their criticisms, and making them known to a larger audience.
And now for why I can be so pessimistic. Even as the intellectual foundation for our drug-based paradigm of care is collapsing, starting with the diagnostics, our society’s use of these medications is increasing; the percentage of children and youth being medicated is increasing; and states are expanding their authority to forcibly treat people in outpatient settings with antipsychotics drugs. Disability numbers due to mental illness go up and up, and we don’t see that as reason to change either. History does show that paradigms of psychiatric care can change, but, in a big-picture sense, I don’t know how much is really changing here in the United States.
I think dissident mental health professionals also have to confront this question. Can they be hopeful that their professions will change their ways, and their teachings? I think so, but there is so much that needs to be done.
Bruce Levine: Is it really possible for psychiatry to reform in any meaningful way given their complete embrace of the “medical model of mental illness,” their idea that emotional and behavioral problems are caused by a bio-chemical defect of some type? Can they really reform when their profession as a financial enterprise rests on drug prescribing, electroshock, and other bio-chemical-electrical treatments? Can psychiatry do anything but pay lip service to a more holistic/integrative view that includes psychological, spiritual, social, cultural, and political realities?
Robert Whitaker: I think we have to appreciate this fact: any medical specialty has guild interests, meaning that it needs to protect the market value of its treatments. If it is going to abandon one form of treatment, it needs to be able to replace it with another. It can’t change if there is no replacement in the offing.
When the APA published DSM III, it basically ceded talk therapy to psychologists, counselors, social workers, and so forth. Psychiatry’s three domains, in the marketplace, were diagnostics, research, and the prescribing of drugs. Now, thirty-four years later, we see that its diagnostics are being dismissed as invalid; its research has failed to identify the biology of mental disorders to validate its diagnostics; and its drug treatments are increasingly being seen as not very effective or even harmful. That is the story of a profession that has reason to feel insecure about its place in the marketplace.
Yet, as you suggest, this is why it is going to be so hard for psychiatry to reform. Diagnosis and the prescribing of drugs constitute the main function of psychiatrists today in our society. From a guild perspective, the profession needs to maintain the public’s belief in the value of that function. So I don’t believe it will be possible for psychiatry to change unless it identifies a new function that would be marketable, so to speak. Psychiatry needs to identify a change that would be consistent with its interests as a guild.
The one faint possibility I see—and this may seem counterintuitive—is for psychiatry to become the profession that provides a critical view of psychiatric drugs. Family doctors do most of the prescribing of psychiatric drugs today, without any real sense of their risks and benefits, and so psychiatrists could stake out a role as being the experts who know how to use the drugs in a very selective, cautious manner, and the experts who know how to incorporate such drug treatment into a holistic, integrated form of care. If the public sees the drugs as quite problematic, as medications that can serve a purpose but only if prescribed in a very nuanced way, then it will want to turn to physicians who understand well the problems with the drugs and their limitations.
That is what I think must happen for psychiatry to change. Psychiatry must see a financial benefit from a proposed change, one consistent with guild interests.