Reply to Dr. Larry S. Goldman's Medscape General
Medicine Review of Robert Whitaker's Mad in America: Bad Science,
Bad Medicine, and the Enduring Mistreatment of the Mentally Ill
June 14, 2002
from Medscape General Medicine [TM]
Nathaniel S. Lehrman, MD
Rank heresy is the essence of Robert Whitaker's
book, Mad in America: Bad Science, Bad Medicine, and the Enduring
Mistreatment of the Mentally Ill. Its heresy is simple: (1) that
prescribed psychiatric drugs, now a multibillion-dollar industry,
harm schizophrenic patients rather than helping them; and (2)
that psychiatry, paid off by the drug companies, refuses to face
its worsening treatment results. Despite the fierce attacks on
both author and book by Larry S. Goldman, MD, and other psychiatrist-reviewers,
Whitaker is right.
Goldman acknowledges that the first half of Whitaker's
book "catalogues well ... some terribly shameful chapters
in the history of the care of the mentally ill." Those "shameful
chapters" include surgical organ removal, multiple dental
extractions, and insulin-induced comas, as well as the widely
acclaimed, Nobel-prize-winning lobotomy ice-pick operation.
Whitaker sees such "shameful chapters"
as continuing into the present. Goldman, who disagrees, opens
his review with a personal attack on Whitaker as a "normally
highly regarded, award-winning science writer," who represents
a "terrific" example of "When Good Journalists
Go Bad," and whose book "looks as if it were commissioned
Whitaker's blasphemous questioning of psychotropic
drugs and their effects is the key issue. Do they help schizophrenic
patients -- as is almost universally accepted since their introduction
in the 1950s -- or do they harm them? Whitaker shows how their
original acceptance resulted from skillful but dubious drug company
public relations ploys. Goldman defends their acceptance by criticizing
Whitaker's attack on "the medicalization of mental illness
and the treatments that this framework has spawned." But
Goldman's defense of "medicalization" conceals the real
issue, drugs -- even though the words "drugs" and "medication"
appear nowhere in his review -- and psychiatry's replacement of
individualized, humane care by diagnostic, label-based drugging.
One unfortunate result, which Goldman omits, has been the relegation
of psychiatrists to medication control only, while nonmedicals
address patients' real problems.
Antipsychotic drugs cause brain damage. Whitaker
points out that despite popular, psychiatrically produced misconceptions,
they "do not fix any known brain abnormality nor do they
put brain chemistry back into balance. What they do is alter brain
functions in a manner that diminishes certain characteristic symptoms."
They blunt and distort patients' emotionality, thus reducing both
their explosiveness and their ability to think. They also cause
changes "associated both with tardive dyskinesia and an increased
biological vulnerability to psychosis." But Goldman says
Whitaker "takes a few kernels of sad truth about psychiatric
care, puffs them up into a very large bucket of popcorn, and leaves
lots of other important cobs in the field."
The book's second half shows the huge extent to
which the tail of psychopharmaceutical research now wags the dog
of psychiatric treatment. The chairmen of medical school psychiatry
departments, who shape psychiatric training, are selected increasingly
for their fund-finding skills -- and drug company grants are plentiful
-- rather than for their ability to provide or organize effective
care. The bottom line thus supersedes patients' needs. A 1994
Harvard study showed that treatment results in schizophrenia had
worsened over the previous 20 years, during which time the treatment
focus had shifted almost entirely to drugs. While "the incredible
data that have accumulated on the neurobiology of schizophrenia,"
which Goldman criticizes Whitaker for ignoring, may make newspaper
headlines, it has hardly helped patient care.
Whitaker shows how these drugs, originally presented
as assisting psychotherapy by helping patients talk more easily
(at first they were called "chemical lobotomies"), have
so taken over psychiatry that individualized treatment by psychiatrists
-- psychotherapy/counseling -- has almost completely disappeared.
Whatever counseling and close personal relationships still exist
in treatment -- once (and still properly) seen as the heart of
psychiatric care -- are now supplied by nonmedical (and lower-paid)
professionals: psychologists, social workers, and nurses.
Gloomy about psychiatry's short-range prospects,
Whitaker closes by looking forward to the day "when people
will look back at our current medicines for schizophrenia and
the stories we tell to patients about their abnormal brain chemistry,
and they will shake their heads in utter disbelief." Refusing
to genuflect before the sacred "science" of psychiatry,
Whitaker has written one of the decade's most valid, valuable,
and important criticisms of the specialty.
Editor's Note: Larry Goldman was provided with a
copy of this letter and declined to respond.
Nathaniel S. Lehrman, MD, Clinical Director, Retired,
Kingsboro Psychiatric Center, Brooklyn, New York.
Medscape General Medicine 4(2), 2002. © 2002