Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America, by Robert Whitaker, Crown, 404 pp. | $26
In 1909, the German chemist Paul Ehrlich invented Salvarsan, a cure for syphilis. It was a momentous accomplishment, and not only for the afflicted. Ehrlich had intentionally designed the drug to attack the bacteria that cause syphilis. It was, he said, something new in medicine: a “magic bullet.”
The idea that doctors could draw a bead on a disease and kill it seemed to validate the Enlightenment conceit that the mysteries of nature would eventually yield to human inquiry. It also granted doctors a new source of authority. After 2,500 years of trial and error with dubious potions and pills, they could now claim that they knew precisely what caused disease and how it could be remedied.
It was only a matter of time before doctors and drug companies recognized the opportunity hidden in Ehrlich’s invention. They could use their scientific authority to convince us that our everyday travails are actually diseases for which they have the treatment. Of all the terrain stalked by medical gunslingers, perhaps none has provided happier hunting than our interior landscapes. Our psychic suffering, they have declared, is caused by biochemical imbalances that can be corrected by their drugs.
Behind the magic-bullet claims, however, rests a much less miraculous reality. Scientists have yet to prove the existence of those imbalances or to specify the biochemical mechanisms behind the effects of the drugs, which were discovered largely by accident. In the absence of that knowledge, doctors prescribe the drugs based on experience rather than theory; the bullets may be magical, but physicians are often shooting them in the dark. The best evidence that mental illnesses are brain diseases is that drugs, at least some of the time, make people feel better. Nonetheless, doctors confidently tell patients about their chemical imbalances, usually as prelude to a prescription. Patients then deduce that their improvement on drugs means that they were sick to begin with and that they should continue to take their meds, no matter the side effects or cost, just as they would (in the industry’s favorite analogy) if they had diabetes.
The magic-bullet model may not pass scientific muster, but it succeeds wildly as myth. Science journalist Robert Whitaker is not the first critic to point this out. Neither is he the first to show how the American Psychiatric Association has fashioned a diagnostic scheme, based on those mythical brain dysfunctions, that has allowed doctors to medicalize (and medicate) a broad swath of common, if undesirable, human behavior and experience. Nor does he break new ground by arguing that the burdens of the disease model go well beyond the expense and side effects of drugs and the stigma of being labeled mentally ill, and right to our understanding of ourselves as “slaves to our neurotransmitters.” But there is something new, and startling, in his broadside against psychiatry. Whitaker argues that it is true that 850 adults and 250 children are becoming psychiatrically disabled every day, and that they are indeed suffering from biochemical imbalances, but that those imbalances are caused by the very drugs used to treat them. Whatever the ontological status of psychiatric diseases to begin with, he claims, once patients start taking the drugs, the myth becomes reality.
Whitaker has braided together three strands of evidence from the psychiatric literature, focusing on four common mental illnesses: bipolar disorder, schizophrenia, major depression, and anxiety disorder. First, he cites more than 50 long-term studies showing that, since the advent of psychiatric drugs in the 1950s, treatment outcomes for these illnesses have actually gotten worse. For instance, he recounts research showing that people treated with drugs for bipolar disorder or schizophrenia are significantly worse off after 15 years than those who didn’t take drugs and that people who take antidepressants are more likely to develop chronic depression over the long haul than those who don’t. Rather than waiting for symptoms to remit on their own, Whitaker argues, doctors confronted with suffering patients prescribe drugs that will only make them worse and then treat the resulting symptoms with more drugs.
Second, Whitaker provides epidemiological evidence. Not only has the prevalence of mental illnesses skyrocketed in the 50 years since psychiatric drugs were introduced; their severity has also increased, at least to judge from the rates of disability in the population. Using the Social Security rolls as his database, Whitaker has determined that the psychiatrically disabled comprised one in 469 Americans in 1955 and one in 76 in 2007. These numbers point to an often hidden liability of the epidemic: at $1 million per patient, increased mental disability is a “cost that our society will not be able to afford.”
Finally, Whitaker cites the side effects—the tics and seizures associated with antipsychotic drugs or the sexual dysfunction caused by antidepressants—as evidence that the drugs’ magic is not so benign. He also describes animal studies revealing anatomical pathologies—such as drug-induced increases in density of dopamine receptors (“like having a psychosis-inducing agent built into the brain,” says one scientist) or “swollen and twisted” neurons caused by antidepressants—as evidence that main and side effects alike are the result of anatomical changes wrought by the drugs upon the brain. The claim that the drugs restore the brain’s normal chemical balance, he says, conceals the more disturbing truth that they “perturb the normal functioning of neurotransmitter pathways in the brain.”
If Whitaker is right, and the epidemic of mental illness is caused by physicians who treat it, then we are in the midst of the biggest scandal in the history of modern medicine. He makes his case lucidly and without getting mired in the jargon or statistical arcana of his opponents. He also includes compelling interviews with patients, many of whom have had devastating experiences that seem to support Whitaker’s claim that the drugs mostly worsen psychological suffering. This combination is likely to persuade many readers, especially in an era in which psychiatry is under attack from all quarters.
But Whitaker’s argument rests on the same flawed infrastructure that underlies psychiatry. Correlation is not causation. That many people who take psychiatric drugs get worse doesn’t mean that drugs are the cause of their suffering any more than their improvement would mean that drugs are the cure. In this crude materialism, Whitaker is no less reductionist than the psychiatrists he takes on. He also overlooks other possible causes of the “epidemic.” Increased psychiatric disability rates, for instance, may reflect reduced stigma, easier access, economic uncertainty, and the increasing numbers of lawyers specializing in procuring disability status. Worsening courses of mental illness may be related to the increased atomization of American society. And, most important, to tell a person that his suffering is due to a biochemical disease is to bestow upon him a new identity—that of the chronically ill person. When the patient behaves accordingly, it may not be because of the drugs themselves, but because of the context in which they are prescribed.
Psychiatry has plenty to answer for, especially in its unjustified claims to possess magic bullets for our anguish. But in Anatomy of an Epidemic, Whitaker has merely fashioned his own magic bullet, which the industry could easily deflect with its claims of efficacy, statistical or otherwise. It would have been enough for Whitaker to muster his voluminous evidence in service of a more disturbing (and demonstrable) problem: that psychiatry doesn’t deserve its authority, that it has substituted a baseless certainty for the much more complex truths about who we are and what ails us.