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.[1]

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 by Scientologists."

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 Medscape