Wednesday, February 9, 2011

Carlat's Response to Whitaker - A Discussion at Last

We left off with a self-proclaimed “refutation” and “repudiation” by Andrew Nierenberg of Harvard that neither refuted nor repudiated “Anatomy of an Epidemic” by Robert Whitaker. In a response to a grand rounds delivered by Whitaker at Mass Gen on Jan 13, Dr Nierenberg accused Whitaker of “misinformation, simplistic interpretations of statistics, faulty reasoning, and wrong conclusions,” but when the dust cleared the perpetrator of these crimes turned out to be Dr Nierenberg himself.

Throw in his gratuitous personal attacks on Whitaker and we have clear evidence of a psychiatrist gone wild. Of all things, Whitaker came out totally unscathed.

I’m sure we can fashion an ancient Chinese proverb from Dr Nierenberg’s oppositionally defiant behavior, but the clear lesson is that virtually all refutations are doomed to fail (even against such palpably absurd beliefs as “creation science”). Refuting the refuter, needless to say, is like shooting fish in a barrel.

So would a more reasoned approach, say one that actually acknowledged the validity of Whitaker’s arguments, have been far more effective? Funny you should ask.

Daniel Carlat produces The Carlat Report and is the author of “Unhinged,” which is highly critical of Pharma marketing dressed up as science. In late Jan, in the first of a two-part review on his blog, Carlat noted:

My overall take is that Whitaker has his basic facts right, and that he communicates them in a compelling style that I envy. But I disagree with his interpretation of the facts.

Now we’re getting somewhere.

Dr Carlat restates Whitaker’s thesis that the steep rise in psychiatric disabilities over recent years has coincided with a similar rise in psychiatric meds prescriptions. Yes, this is true, Dr Carlat agrees, but “correlation does not imply causation.” To say that med use has actually caused the disability, as Whitaker claims, is a stretch. There are other factors involved, Dr Carlat says, including:

There are more psychiatric disorders to diagnose - 297 in the current DSM, about the same as the DSM-III-R from 1987 (at 292), a bit more than the DSM-III of 1980 (at 265), a lot more than the DSM-II of 1968 (at 182), and a whole lot more than the DSM-I of 1952 (at 106). Dr Carlat contends that “the rise in diagnosis has been largely driven by changes in disease classification and subsequent training - not by toxic medications.”

Dr Carlat also notes that because there are more treatments available, doctors have more of an incentive to make a diagnosis. In other words, doctors are not inclined to make a diagnosis for something they cannot treat.

Then Dr Carlat mentions the obvious: That a major reason for the rise in psychiatric disabilities probably has to do with the changed status of psychiatric disabilities. Eligibility has been expanded, thresholds lowered.

To expand on Dr Carlat, a whole disability industry has grown up to facilitate a normally arduous application process. Clinicians and social workers routinely advise even good prognosis patients that they may qualify for disability. A fairly new specialty of disability lawyers is there to assist. Both political parties are more than happy to play along, as those on disability are not counted as being unemployed.

To tie this into a bow: Dr Carlat offers his views by way of “interpretation” rather than “repudiation.” Whitaker may not have shown cause and effect, but neither did he. Instead, Dr Carlat is presenting credible alternatives, supported by his own set of facts. This is the way to make a case.

Let’s forget for the time being whose arguments are more credible. One thing we can all agree on is at last we have a discussion going, something Whitaker wanted all along. Finally, a discussion, not a Nierenberg hissy fit.

More to come ... 


Tony Previte said...

Yes, this is a discussion, this is what they look like! What I find interesting is that in reading Robert Whitaker's book, I didn't come away from it thinking he looked at the epidemic as being caused by the medications. Yes, he does use that language and the tone definitely lends itself to that, but when you read it in it's entirety it paints the picture of an entire ecosystem of illness, not just a "Drugs are Bad" mantra.

I've said as much in other comments I've made, so I won't repeat myself, but it is also interesting that in talking to people who've read Anatomy of an Epidemic that you get so many different ideas of what they read. Some people read it as just that... a "Drugs are Bad" mantra, black and white, throw away the drugs and the world will be rainbows and puppy dogs. And hey I can't blame people for taking that attitude. It's as if people take away from it exactly what they want to see... which explains the attacks from academia... they DON'T want to see an expose of their craft. How dare some low-life journalist pick apart their research and findings...there's no way a non-academic person can understand the nuance of the data.

News-flash... people still do read and write english and no amount of flowery language and verbal diarrhea is going to obscure the data from mere mortals. Some of those mere mortals are pretty damned smart.

I also liked the disability aspect that Carlat throws in. I saw it first hand yesterday at a Peer Employment orientation. All but me, were in one way or another supported by the state healthcare system and others were on SSI. "I" was the lone person in a room of approximately 30 people NOT on some kind of state sponsored aid.

There's a reality slap for ya!

John McManamy said...

Hey, Tony. Right on the money. The antipsychiatry crowd is definitely interpreting Whitaker along the "throw away your meds" line. I wouldn't give Whitaker the time of day if that were my interpretation. Then we have Nierenberg and his ilk with his "how dare that low-life journalist crash our party" approach.

The book is definitely way more than either extremes make of it, with many ways of interpreting and discussing it, which is why I have devoted so many blog posts to it.

As for the disability aspect, definitely. Whenever I walk into a gathering of patients, I am most definitely in the minority, a fact that greatly distresses me and why Whitaker's book resonates with me.

Once on disability, an individual joins the "invisible world," forgotten and neglected. Those charged with helping us declare Mission accomplished for pushing us into this world.

Things really need to change.