When I wrote Anatomy of an Epidemic, one of my foremost hopes was that it would prompt mainstream researchers to revisit the scientific literature. Was there evidence that any class of psychiatric medications—antipsychotics, antidepressants, stimulants, benzodiazepines, and so forth—provided a long-term benefit? Now epidemiologists at Columbia University and City College of New York have reported that they have done such an investigation about antipsychotics, and their bottom-line finding can be summed up in this way: Psychiatry’s “evidence base” for long-term use of these drugs does not exist.
This is a finding, published in the American Journal of Orthopsychiatry, that profoundly undercuts the societal narrative that has been driving psychiatric care in our society for the past sixty years.
In the conventional narrative of psychiatry’s history, Thorazine, which is remembered today as the first “antipsychotic,” is said to have kicked off a “psychopharmacological revolution” when it arrived in asylum medicine in 1954. Thorazine, wrote Edward Shorter, in his book A History of Psychiatry, “initiated a revolution in psychiatry, comparable to the introduction of penicillin in general medicine.” Soon psychiatry was touting that it had discovered “antidepressants” and “anti-anxiety” agents, and that narrative—of a medical specialty that had developed chemical antidotes to mental disorders—became fixed in the public mind, and drives psychiatric care today.
I once believed that narrative, but by the time I had finished researching Mad in America, which was published in 2002, I was convinced that it was out of sync with the scientific literature. It was, I wrote in one chapter, the “story we told ourselves.” Then, in 2004, I wrote a paper titled “The Case Against Psychiatric Drugs: A 50-year record of doing more harm than good,” which was published in Medical Hypotheses. In Anatomy of an Epidemic, which was published in 2010, I expanded on this argument, as I believe there is a long line of research, stretching across more than five decades, that reveals that antipsychotics worsen outcomes over the long term.
By writing that journal article and that book, I was challenging the conventional narrative, and the evidence for that “counter-narrative” is of many types: retrospective studies, a few randomized studies, cross-cultural studies, long-term naturalistic studies (such as Martin Harrow’s), MRI studies, and animal research into why antipsychotics “fail” over the long-term. It is that collective body of evidence that I find convincing, and in 2015, I updated that argument once more in for a new edition of Anatomy of an Epidemic. The case against antipsychotics grows stronger and stronger.
The paper published in the American Journal of Orthopsychiatry is titled “Weighing the Evidence for Harm from Long-term Treatment with Antipsychotic Medications: A Systematic Review. “ Nancy Sohler, from City College of New York, and a team of five epidemiologists from Columbia University, note that their study was occasioned by my writings on this topic. They wrote:
“Recently, Robert Whitaker advanced a troubling interpretation of the evidence base for long-term use of antipsychotic medication. He reviewed a number of epidemiological and clinical studies and concluded that antipsychotic medications are an iatrogenic cause of chronicity in schizophrenia, and that these medications may lead to the deterioration of patients’ health and well-being over time. His explanation rested on the notion that antipsychotic medication may induce a hypersensitivity to dopamine. We were concerned by Whitaker’s findings and wondered whether a systematic appraisal of published literature would produce the same results.”
So this was the very inquiry that I hoped Anatomy of an Epidemic would provoke. Let mainstream researchers take a trip through the scientific literature, and see what they would conclude.
In their “systematic appraisal of published literature,” Sholer and colleagues searched for studies that met two criteria: they had to be at least two-years in length and they needed to “permit a comparison of patients who were exposed to antipsychotic medications with patients who were not exposed to medications over the 2-year follow-up period.” They identified 18 studies that met this criteria, and then they assessed–in a yes, maybe, or no fashion–whether the reported results supported the hypothesis that antipsychotics worsen long-term outcomes.
Now, in my opinion, the researchers were reluctant to conclude that a study showed harm, even when the researchers themselves drew such a conclusion. For instance, in their assessment of Martin Harrow’s long-term study of psychotic patients, they concluded that his findings were “mixed” in terms of whether they showed long-term harm from drug usage. But in Harrow’s report on their 20-year outcomes, he noted that in every subgroup of patients, outcomes were worse for the medicated group, and when he compared those patients who took antipsychotics throughout this lengthy period, versus those who got off by year two and never took them again, it was the medication-compliant patients who, by far, had worse outcomes, and on every domain of functioning. As Harrow stated in 2008, at the American Psychiatric Association’s annual conference, “I conclude that patients with schizophrenia not on antipsychotic medication for a long period of time have significantly better global functioning than those on antipsychotics.” But these researchers did not find such results a “yes” in terms of their supporting a hypothesis that antipsychotics worsen long-term outcomes.
I also think the “evidence” that can be reviewed in regard to this question is much broader than the studies that Sholer and colleagues selected. Cross-cultural studies, MRI studies, animal models of psychosis, and reviews of serious adverse effects, such as tardive dyskinesia, are also relevant to this question of whether the drugs do more harm than good over the long-term.
But that is not important here. The important result from this study was this: “We found the published data to be inadequate to test this hypothesis.”
This is a stunning admission. Even though psychiatrists have been prescribing these drugs for 60 years and have been telling their patients that they should stay on these medications indefinitely, the profession never spent the necessary effort to assess whether this drug treatment actually benefits patients over the long-term. This conclusion also reveals that psychiatry, when it boasts of its treatments being “evidence-based,” is making a rather hollow boast.
It is important to understand too that in the realm of evidence-based medicine, it is the obligation of the medical specialty to find evidence that its treatments are helpful, and not vice versa. In other words, it is not the responsibility of critics to find evidence showing harm done; the responsibility rests with the profession to show evidence of a treatment benefit.
In sum, this study shoots one more arrow into the conventional narrative that drives societal thinking today. In that narrative, the antipsychotics occupy a central role. These are the drugs that kicked off the psychopharmacological revolution and made it possible to empty the mental hospitals. These are the drugs that are presented to the public as an absolute necessity for psychotic patients. Read Jeffrey Lieberman’s book Shrinks, and you see this conventional narrative on display. But this study reveals that it’s a narrative woven from a profession’s own desire to tell a narrative of progress, to itself and to the public, rather than a narrative grounded in science.
As for a referendum on Anatomy of an Epidemic, I think this review helps advance the discussion. The researchers didn’t find, in their review of studies that met a certain criteria, evidence that allowed any conclusion to be drawn about the long-term merits of antipsychotics. What is needed now is to broaden the evidence reviewed, so that it includes the MRI research (showing drug-induced brain shrinkage), the cross-cultural evidence, the animal evidence, and a chalking up of all the adverse events from antipsychotics. At that point, researchers might conclude that the pieces of the evidence puzzle all fit together, and they paint a consistent picture of harm done.
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.