Mad in America
By Robert Whitaker
Perseus Publishing. 334 pps. ISBN 0-7382-0385-8
When it comes to individual suffering, family grief, wasted lives, and public expense, no public health problem–not heart disease or cancer–even comes close to schizophrenia. As Robert Whitaker’s Mad in America shows, the history of the treatment of schizophrenia for the past 250 years has pitted the medical hawks–advocates of somatic approaches–and the social/psychological doves–believers in non-medical treatments, who in the mental health field have been drawn mostly from psychoanalysis and family therapy.
Whitaker’s book underscores that the fight between hawks and doves is still raging, only with new protagonists. “Big Pharma,” the huge drug companies that are among the most profitable corporations in the world, are the new hawks. Whitaker’s best chapters tell the shocking story of the collusion between them and their supposed watchdogs, the for-profit centers that conduct clinical trials for the purpose of testing the new antischizophrenic drugs.
Whitaker largely restricts his examination of the complicated issue of schizophrenia treatment to the question of drugs or no drugs. His thesis is that, since the phenothiazine drugs, such as thorazine, stelazine, and Haldol, were introduced in the ’50s, psychiatric medication has “caused” the condition of people with schizophrenia to deteriorate. This is, he asserts, just the latest in the long series of mistakes psychiatry has made in the treatment of chronic mental illness. Whitaker describes in horrific detail the cruelties that psychiatrists since the 18th century have invented to punish patients out of their delusions or stupefy them into submission. In the 20th century, a succession of putative medical “cures”–insulin coma, metrazol convulsions, electroshock, and prefrontal lobotomy–just led to more suffering. Sponsored by illustrious foundations (Rockefeller and Carnegie, among others) these cures brought their inventors prizes (a Nobel in Medicine for Egas Moniz, the inventor of the lobotomy) and visited their, literally stunning, effects on hundreds of thousands of patients.
Whitaker makes the case that all these early treatments damaged the brain, leading to a state of indifference and producing a “domestic invalidism” that doctors and other caretakers preferred to the labor and cost of institutional restraint. Legislatures, happy to disguise their budget-cutting as medical treatment, discharged many of these stupefied patients to families or to nursing homes.
While focused on the struggle he sees between innocent patients and evil doctors, Whitaker unfortunately ignores the documented successes of those pragmatists who see themselves as neither hawks nor doves in the grand debate. The best results in the treatment of schizophrenia have been achieved by those who have combined family support, psychoeducation, behavioral training, and supported living; those who explicitly inform clients and families about medication, the role of family interaction, and the individual psychology of schizophrenia. Whitaker dismisses this community psychiatry approach as simply a cover for a cynical coalition of drug companies and psychiatrists aiming to get people on damaging medication.
Believing that medication is the root of the problem, Whitaker disputes Emil Kraepelin’s original definition of schizophrenia as a long-term illness marked by long stretches of deterioration in functioning. He dismisses longitudinal studies showing that 25 years after the first episode, a third of patients diagnosed schizophrenic are still symptomatic and that the two-thirds that have recovered suffer many emotional ups and downs.
The studies he cites actually show that there is a large group of patients diagnosed schizophrenic (estimates vary between 10 and 50 percent ) who will do well on no medication or just enough medication to control the acute symptoms. But most of the studies say it’s difficult to predict which patients these will be, a question that may only be answered by extensive hospital observation or long, careful community follow-up. Furthermore, patients managed successfully off medication require intensive social therapy and support of a kind that is fast disappearing from clinics and training programs. In fact, most of the studies Whitaker cites to support his countermedication stance were actually designed to document the importance of special social care, carried out by dedicated and well-trained staff, not the consequences of medication-free treatment.
The problem with Whitaker’s analysis is that schizophrenia is too complex for the either/or simplicity of “drugs” or “no drugs.” If drugs are given cautiously, the right environment may indeed, over time, promote eventual recovery and freedom from drugs for two-thirds of schizophrenic patients. But what about the other third? Furthermore, Whitaker ignores anything psychiatry has done right in improving drug treatment, like taking patients off drugs between relapses, or safely lowering doses, or the use of anti-Parkinson’s drugs to decrease side effects.
By setting up a dichotomy between medication and recovery, Whitaker makes the difficult job of caring for patients in the community even harder. He ignores the important work so many clinicians today are doing in providing family and social support that reduces the need for medicine over the long haul with schizophrenics and has been shown to yield the best outcomes. Further developing those approaches, rather than just demonizing medication, is the most promising path toward lessening the suffering caused by a condition we still understand so imperfectly.
Christian Beels, M.D., is former director of the Public Psychiatry Fellowship at the New York State Psychiatric Institute. Margaret Newmark is former supervisor in the Family Support Demonstration Project at the New York State Psychiatric Institute. Address: 865 West End Avenue, New York, NY 10025. E-mails to the authors may be sent to email@example.com. Letters to the Editor about this department may be sent to Letters@psychnetworker.org.