Who Would I Be Off My Meds

Unshrunk: A Story of Psychiatric Treatment Resistance by Laura Delano; Viking, 352 pp., $30

Some years ago, in a condition of acute emotional distress, I found myself in the office of the resident psychologist on a unit of a mental institution. Sitting in this psychologist’s office on day four of my incarceration, I was wracked by a kind of psychic claustrophobia; I was miserable and scared and desperate to get out. Fueled by panic, I pleaded tearfully that I needed to go home.

The psychologist said that leaving in my present state would be a bad idea—and she wasn’t wrong—but then she asked if I’d ever had a manic episode or been diagnosed with bipolar disorder. I had not, I told her, and I was not having one now. But she seemed determined to pin this diagnostic label on me. At that moment of distress, I had little confidence in my own judgment about anything, but I am pretty sure of this: though I have received a number of psychiatric diagnoses over the years (a passel of anxiety disorders, plus major depression) that apply with fluctuating degrees of aptness to the lumpy and mutable human personality that is me, I am not and have never been manic. Her insistence that I might be only made my anxious agitation worse—which in turn reinforced her conviction that I was indeed a bipolar patient in the throes of mania.

My reaction to all this was despair, because this woman, representing the institution to which I had entrusted my fragile mental health, seemed to have no idea what she was talking about, an impression she reinforced by riffling through the pages of the DSM-V—that is, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, the so-called bible of psychiatry—trying to remind herself of the various symptoms of bipolar and other possible disorders that she believed might be afflicting me. This was like watching a pilot try to land a plane while consulting the aircraft’s instruction manual. It did not, to put it mildly, bolster my confidence in her clinical judgment.

I tell this story not to indict the psychologist’s acumen but because she was a particularly vivid distillation of an abiding reality: much of psychiatric diagnosis and treatment still consists of a bunch of blindfolded researchers and clinicians playing pin-the-tail-on-the-donkey. And yet millions today find themselves trapped in the psychiatric-pharmacological-industrial complex, guinea pigs subjected to the prevailing and then evanescing trends in mental health treatment.

Over the decades, these trends have ranged from bloodletting, to pulling teeth, to Freudian psychoanalysis, to inducing malaria fevers (via infected rat bites), to the prescription of heroin, to partial lobotomies, to insulin comas, to electroshock therapy, to the “miracle drugs” of the 1960s and ’70s (the Thorazine-era antipsychotics and tricyclic antidepressants), to the “miracle drugs” of the 1990s (the Prozac-era profusion of SSRI antidepressants), to “atypical antipsychotics,” to psychedelics, to transcranial magnetic stimulation, to ketamine infusions, to the numerous acronymed variants of psychodynamic psychotherapy—CBT, DBT, ACT, EMDR, etc. The efficacy of just about all of these treatments can be distilled to this: some treatments work some of the time. Most of them, in fact, work about a third of the time. Which happens also to be true of placebo treatments.

Revolutionary new theories about the roots of psychiatric disorders—“the serotonin hypothesis of depression” or “the chemical imbalance theory of mental illness”—turn out to be, at best, grossly oversimplified and, at worst, faux-medicalized voodoo. “It remains difficult to refute a critique that psychiatry’s most fundamental characteristic is its ignorance,” declared a 2022 review in Neuron, which concluded that efforts to identify the underlying cause of mental illness “have been a litany of failures.” A decade earlier, Tom Insel, then the head of the National Institute of Mental Health, had acknowledged that the DSM was hardly scientific and should perhaps be retired—which is unlikely to happen because pharma and insurance companies rely on its classifications. And yet despite—or maybe because of—all this, some 60 million American adults, including about one in five American women, are now on psychiatric medications.

This is the medical and cultural context in which Laura Delano’s bracing and heroic book, Unshrunk, arrives. Delano writes with the hard-won authority of the longtime patient. She provides a searing narrative of her descent into the hell of pharmacological imprisonment, and then her climb out of it to freedom from medication dependence and her ultimate rejection of the term mental illness. She impugns the overblown claims Big Pharma has made about how effectively psychiatric medications work, and she punctures the oversimplified explanations biological psychiatry has provided for why they ostensibly work. She writes insightfully, at times lyrically, about not just her own psychological condition but also our culture’s:

I sometimes wonder if talk therapy has become a source of absolution in the way that weekly confessional has historically been for many churchgoers—and whether … therapists have become proxies for priests. … The doctor handing me my prescription note, the soporific piano on the pharmacy hold line, the crunch of stapled bag passed over the register, the squeeze and twist of the white cap, the soft weight of pills in palm, the bitterness of chemicals dissolving on tongue: all of this, my sacrament.

For many readers, Delano’s book will provide useful revelations about the realities of biomedical psychiatry; other readers will find in Delano’s tale a validation of their own experiences of immiseration by misprescribed psychiatric medications. For these reasons, among others, this is a valuable and important book. But I worry it is possibly also a slightly dangerous one. Because for all the controversy about psychiatric drugs, there is compelling evidence that the right psychiatric medication at the right time can save lives.

Delano’s own story is harrowing and powerful. At age 13, she is undone by the pressure of high expectations and ends up in her first psychiatrist’s office. For the next decade and a half, she becomes “a professional psychiatric patient.” Diagnosed at various times with bipolar disorder, borderline personality disorder, substance use disorder, and an eating disorder, she cuts herself, drinks herself into blackouts, does repeated stints in psychiatric wards, and tries to commit suicide. She sees, by my count, at least a dozen psychiatrists whom she sketches with mostly sympathetic understanding but at times with deservedly savage irony. One (older, male) psychiatrist seems creepily preoccupied with her sex life, and at the end of the book she writes acidly that the psychiatrists’ case reports she has quoted from are “best understood as works of imaginative historical fiction.”

Over the years, she is prescribed a devil’s apothecary of medications: Ambien, Prozac, Effexor, Lexapro, Provigil, lithium, Lamictal, Topamax, Seroquel, Ativan, Klonopin, Neurontin, Antabuse, Naltrexone, Abilify, Risperdal, Cymbalta, Wellbutrin, Celexa. This procession of medications begins with Depakote, a so-called mood stabilizer, prescribed to her in early high school for her (ostensible) bipolar disorder. When she resists taking it, her therapist says, sounding like some Disney movie witch-temptress, “You want to feel happier, Laura, don’t you?”

Thus begins her journey into the heart of psychopharmacological darkness and, eventually, back out again. After initially resisting the diagnoses imposed on her and the pills thrust at her (she hides them in a jewelry box), she eventually accepts her status as a mentally ill person. But for Delano, as for so many others, the quest to treat a putative mental illness with medication becomes an Alice-in-Wonderland quest to mitigate or treat the ill effects of the previous medication by switching to, or augmenting with, a new one. When Delano becomes unable to “make it through a day without obliterating myself with alcohol,” she ends up in Alcoholics Anonymous, which she says provided more relief than the psychiatric establishment ever had. “I felt new space open up in me, and in it, the arrival of an unsettling question: Who would I be off my meds?”

Around this time, Delano picks up a book called Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America (2010), by the journalist Robert Whitaker, who provides an aggressively skeptical look at the history of psychopharmacology as well as case vignettes of individuals who had suffered long-term damage from psychiatric medications. The book hits Delano with the force of revelation: “Holy shit. It’s the fucking meds.” Red pilled, as it were, by this book about pills, she suddenly perceives a new reality. “Is it possible that psychiatry’s medication-based standard of care is actually causing people to become psychiatrically disabled?” she asks, building on Whitaker’s (controversial) argument that medications like Prozac, Zoloft, and Lexapro are exacerbating or even causing the conditions they are designed to treat. “Is it possible, in other words, that the treatment is making people sick?”

Whitaker’s book fuels Delano’s determination to escape psychiatry’s dominion. With tremendous effort and a lot of suffering, she weans herself off all medications. She connects directly with Whitaker and begins writing blog posts for his website, Mad in America, describing her misadventures in psychopharmacology. Eventually she goes on to found her own nonprofit organization, Inner Compass Initiative, which aims to help people get “beyond psychiatric drugs and diagnoses.” Inner Compass Initiative provides information about the dangers of psychiatric medication, as well as critiques of biological psychiatry. This is—if taken with a grain of salt—useful information for someone contemplating a course of pharmacotherapy, or for those wanting to wean themselves off psychiatric medication. The step-by-step guidelines for how to taper medications safely and carefully are exceptionally valuable.

Delano is correct that until recently, physicians have been woefully ignorant of how difficult it can be to discontinue medication. Only when online communities of patients came together to share their stories, and advocacy groups publicized them, did doctors start to become aware of what their patients were going through. Even then, Delano writes, some psychiatrists didn’t believe what their patients were telling them about the scope of their suffering—until they themselves went on medication for depressive episodes and then had to endure withdrawal.

The force of will Delano demonstrated to escape the yoke of not just medications but the whole epistemological framework on which they rest is heroic. “I decided to live beyond labels and categorical boxes,” she writes, in a kind of Emersonian triumph of self-definition, “and to reject the dominant role that the American mental health industry has come to play in shaping the way we make sense of what it means to be human.” And the story Delano tells of 20th-century psychiatry’s effort to shed the witchcraft hokum of Freudian psychoanalysis by embracing biological psychiatry and “redefine themselves as legitimate medical authorities” is accurate. She’s right, too, that a number of large studies over several decades have cast doubt on both the efficacy of SSRI antidepressants and the biochemical theories that underlie them.

But I worry that in her zeal to break free of all institutional fetters and diagnostic categories, she overstates the case against biomedical psychiatry in ways that, in this era of antiscience populism, could be dangerous. For instance, Delano puts a lot of analytical weight on a 2022 “umbrella review,” published in Molecular Psychiatry, which supposedly analyzed all the relevant studies and found no connection between low levels of serotonin and depression. The paper’s lead author, however, was one Joanna Moncrieff, a professor of psychiatry at University College London and a dissident psychiatrist whose antipsychiatry crusade has gained her some uncomfortable bedfellows, ranging from Tucker Carlson and Robert F. Kennedy Jr. to the National Rifle Association and the Church of Scientology. The company Moncrieff keeps doesn’t necessarily mean that she, or Delano, is wrong. But it does merit the raising of a skeptical eyebrow. And in fact, a year after Moncrieff’s study was published, Molecular Psychiatry published a response by 36 researchers pointing out methodological problems with her analysis, including oversimplification, selective reporting of data, and interpretive errors. Delano doesn’t mention that.

The debate over the efficacy of psychiatric medication is complex—and distorted by professional and ideological turf wars. Delano is unquestionably correct that many drugs are grossly overprescribed. But a majority of clinicians, as well as the authors of many recent studies, would say that, for instance, antipsychotic medication for schizophrenics, or lithium for bipolar patients, can lead to significant remission of symptoms and improvements in quality of life. (A recent comprehensive review of the extant research on lithium reaffirms its status as the “gold standard” for treatment of bipolar. Delano, who dedicates a chapter to explaining how lithium is poison, would surely dispute that review as industry claptrap.) The debate over antidepressants is even more complicated and multifaceted, but some large, reputable analyses—such as a massive 2018 meta-review of 522 double-blind studies, published in The Lancet—have found that antidepressants (modestly) outperform placebos. The crudely oversimplified theory of mental illness as a “chemical imbalance” that can be rectified with drugs has been thoroughly debunked—but the idea that some medications can be effective for some patients has not been. Psychiatry poisoned and immiserated Laura Delano, as it has many others. But many people say that psychiatry and psychopharmacology have saved their lives, or the lives of their patients. (They may have saved mine.) Amid all the conflicting data in the studies and meta-reviews of studies, we are each of us always only Ns of 1.

Delano’s book is a valuable contribution to the literature on psychiatric hubris, and it will be a source of succor to the fellowship of the overprescribed. I am also grateful to Delano and Inner Compass Initiative for educating people on how to taper their prescribed drugs safely. There may well come a time when I, still reluctantly entangled in my own web of psychopharmacology, will need support, and I can think of no one more qualified to help me than Laura Delano.