On April 26, 2015, Jeffrey Lieberman, former president of the American Psychiatric Association, stirred up controversy by calling investigative journalist Robert Whitaker a “menace to society” on CBC radio because Whitaker, in his book Anatomy of an Epidemic, had challenged the long-term effectiveness of psychiatric medication.
But is it Whitaker or Lieberman who has been a menace to society?
Lieberman, the APA president through May 2014, is currently making the media rounds with his new book Shrinks. But earlier in his career, Lieberman conducted experiments in which patients diagnosed with schizophrenia were given a psychostimulant drug with Lieberman’s expectation that this drug would be “psychotogenic” (induce symptoms of psychosis), and this deterioration in fact occurred.
Robert Whitaker, as an investigative journalist, won the George Polk award for medical reporting and was a finalist for the Pulitzer Prize for Public Service for his 1998 Boston Globe series “Doing Harm: Research on the Mentally Ill” (co-authored with Dolores Kong). In this series, Whitaker uncovered how Lieberman and other psychiatrists, exploring the biology of psychosis, conducted experiments on more than 2,000 patients in which certain drugs were administered and other drugs withheld in the expectation of worsening symptoms.
The Nuremberg Code of research ethics, established after the horrific human experiments by doctors in Nazi Germany, states that medical experiments on human subjects “should be so conducted as to avoid all unnecessary physical and mental suffering and injury.” This is obvious ethics, as one would hope that only Nazi doctors would see nothing wrong with using human subjects to test whether hypothesized harmful agents are in fact harmful.
In his Globe series, Whitaker details how psychotic symptom exacerbation and provocation experiments were pioneered in 1974 by David Janowsky, who reported success in developing a new tool for studying schizophrenia. Janowsky found that giving diagnosed schizophrenics the psychostimulant drug methylphenidate (Ritalin, Concerta) caused “a dramatic intensification of pre-existing symptoms, such as hallucinations and delusions” and that other psychostimulants such as amphetamines also exacerbated psychosis. Janowsky’s work established the idea that psychosis-inducing drugs could be used as “challenge agents” for studying psychosis.
In Lieberman’s own 1987 review of 36 studies in which psychostimulant drugs were administered to patients diagnosed with schizophrenia, he concluded that among psychostimulant drugs, methylphenidate has the greatest “psychotogenic potency.” And so Lieberman, in his subsequent experimentation on patients diagnosed with schizophrenia, administered methylphenidate, the psychostimulant with greatest likelihood to do damage.
In 1987, Lieberman conducted a study in which he administered methylphenidate to 34 stable outpatients previously diagnosed with schizophrenia. In this experiment, previously stabilized patients were not only administered methylphenidate but taken off standard antipsychotic drugs until psychotic symptoms reappeared.
In a 1990 study co-authored by Lieberman, “Behavioral Response to Methylphenidate and Treatment Outcome in First Episode Schizophrenia,” the introduction states, “In order to examine the relationship of psychotogenic response to psychostimulants and acute treatment response in treatment-naïve, first-episode psychotic patients, we administered intravenous methylphenidate to first-episode patients.”
On the face of it, this experiment, in which a drug is administered to induce a psychotic reaction, is cruel enough. But it gets worse. Lieberman’s subjects were as young as 14 years old, and he did this experiment on “first-episode psychotic patients,” the majority of whom, research shows, ordinarily recover. Lieberman reports in matter of fact manner that the symptom of distrustfulness “significantly increased following the administration of methylphenidate.” So, patients after having a psychotic episode are administered intravenously a psychostimulant drug designed to induce more psychotic behaviors, and they become more distrustful. It would be remarkable if such “treatment” would not make someone distrustful of doctors, perhaps for the remainder of their lives.
Lieberman reports his schizophrenic subjects and their families were “willing and able to sign informed consent.” The Nuremberg Code states: “The voluntary consent of the human subject is absolutely essential. This means that the person involved should have the legal capacity to give consent.” Who in their right mind would give consent for themselves or for a family member for a procedure that was hypothesized to make a patient worse?
In Whitaker’s Globe 1998 series within the segment “Testing Takes Human Toll,” he interviewed Lieberman about his and other psychotic symptom exacerbation and provocation experiments. Lieberman asserted, “To say that increasing a particular symptom—like hearing voices for a couple of hours in somebody who has been hearing voices for 10 years—is causing [suffering] rather seems like a stretch.”
Beyond the callousness of his response to Whitaker, Lieberman is simply not telling the truth. Recall his 1990 study was done on “first-episode psychotic patients,” not on “somebody who has been hearing voices for 10 years.”
Lieberman is elsewhere dishonest—or amazingly ignorant. In justifying why he called Whitaker a “menace to society,” Lieberman stated on CBC radio that research does not support Whitaker’s claim that many people diagnosed with serious mental illness do better in the long term without psychiatric medication. But the validity of Whitaker’s claim was acknowledged in 2013 by the director of the National Institute of Mental Health who pointed to some of the same research as had Whitaker. The NIMH director in fact concluded, “We need to ask whether in the long-term, some individuals with a history of psychosis may do better off medication.” It is difficult to imagine that Lieberman is ignorant of the NIMH director’s agreement with Whitaker.
Lieberman’s psychotic symptom exacerbation and provocation studies are not his only experiments that have upset ethicists. Lieberman’s CAFE (Comparison of Atypicals in First Episode of Psychosis) study on the effectiveness of antipsychotic drugs, conducted between 2002-2005, has been severely criticized by Carl Elliott, bioethics professor at the University of Minnesota. Elliott detailed how one CAFE subject who committed suicide was coerced into the study, and because of his psychotic state was incapable of giving informed consent.
Why Would the APA Elect Lieberman President?
Whitaker’s Boston Globe series was actually not about Lieberman per se but was really an indictment of the institution of psychiatry for large-scale psychotic inducement research. Whitaker wrote:
In their published accounts, doctors have told of injecting mentally ill patients with drugs designed to exacerbate their delusions and hallucinations. In prestigious journals, they have described studies in which they withheld effective antipsychotic medication from desperate patients who stumbled into hospital emergency rooms. In precise, clinical terms, they have reported how they deliberately stopped giving medication to stabilized schizophrenic patients to see how quickly they became sick again. These studies were designed to gain knowledge that might lead to improved treatments for schizophrenia and related illnesses. But the experiments offered no possibility of therapeutic benefit to the subjects and exposed them to some measure of psychic pain and risk of long-term harm. Moreover, this controversial line of experimentation has been marked by repeated instances in which researchers failed to fully disclose the risks to the mentally ill patients and obscured their true purposes.
Adil Shamoo, professor of biochemistry at the University of Maryland School of Medicine and founder of the journal Accountability in Research, compared these psychotic symptom exacerbation and provocation studies to the Tuskegee syphilis studies in which infected black men were denied treatment. Shamoo told Whitaker in 1998, “I think [these psychotic provocation experiments] are in a category that is worse than Tuskegee. . .There are large numbers [of subjects], and these are current practices. Do they cause harm? Of course they do.”
Psychotic exacerbation and provocation experiments, Whitaker reported, were conducted by prominent researchers at the National Institute of Mental Health and at close to a dozen leading medical schools. Patient subject for these studies were largely drawn from outpatient clinics, Veterans Affairs hospitals, state mental institutions, and emergency rooms—settings that regularly provide care to the poor and uninsured. Whitaker noted, “In the few studies that recorded the ethnic makeup of patients, 54 percent were minorities.”
Not surprisingly, Whitaker also discovered that researchers routinely failed to fully disclose the true purposes of their experiments, and withheld information about risks, “The Globe’s review of informed-consent forms for symptom-exacerbation studies at the NIMH [National Institute of Mental Health] and four other leading psychiatric institutions failed to turn up a single one in which the researchers directly stated that a chemical agent would be used purposely to exacerbate psychotic symptoms.”
George Annas, chairman of the Health Law Department at Boston University School of Public Health, told Whitaker, “We let researchers do things to people with mental illness that we would never let them do to people with physical illness.”
Why would the American Psychiatric Association elect Lieberman president in 2012? Because psychiatry sees nothing wrong with these psychotic symptom exacerbation and provocation experiments.
Non-sociopathic people feel guilt or shame for having induced suffering in other human beings, so how could the APA not feel guilt or shame about Lieberman and other psychiatrists conducting experiments that create psychotic symptoms and suffering? The answer to this question takes us to a very dark place.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.