Friday, February 11, 2011

Carlat's Response to Whitaker - When is Speculation Justified?

We left off with a psychiatrist, via his blog, actually engaging Robert Whitaker, author of “Anatomy of an Epidemic,” in a discussion. In the first of two blog posts, Daniel Carlat, producer of The Carlat Report and author of “Unhinged,” acknowledged that Whitaker had “his basic facts right,” but disagreed “with his interpretation of the facts.”

This was a refreshing contrast to Andrew Nierenberg’s Psychiatrists Gone Wild performance in reaction to Whitaker’s recent grand rounds at Mass General.

Whitaker’s central thesis is that the reason psychiatric disabilities are much higher today is because of widespread meds use rather than despite widespread meds use. Dr Carlat says there are more plausible explanations for the higher disabilities rate, namely people today are more likely to pick up both a diagnosis and a disability simply by passing Go.

This lack of constancy, contends Dr Carlat in his second post, applies to the diagnosis of schizophrenia, as well, which back in the old days seemed to have been used as a catch-all for all manner of unusual behavior. The pre-DSM-III (1980) studies Whitaker largely relies on, says Dr Carlat, would have included a lot of patients who did not have true schizophrenia and thus would have done just fine without a schizophrenia med.

Dr Carlat has a point, but if you were to exclude the studies Whitaker cites based solely on this criteria, then you need to exclude EVERY schizophrenia study from this era, including authoritative gene studies that showed schizophrenia is clustered in families and is inherited from generation to generation, as well as all the evidence in support of Thorazine’s efficacy.

But for the sake of argument, let’s throw out two ancient long-term WHO studies that Whitaker heavily relied on showing that schizophrenia patients in developing countries (where psychiatric meds are in short supply) had a far better course and outcome than patients in developed countries. Let’s substitute, instead, a 2004 WHO study that employed DSM-IV criteria to measure 12-month prevalence rates of various serious mental disorders (not including schizophrenia) in 14 countries. That survey found, amongst other things, that Nigeria had the lowest rate of mood disorders (0.8 percent) while the US had the highest (9.6 percent).

Not exactly on point, but definitely on pattern. Something strange is clearly going on.

There is one modern study almost entirely on point, which Whitaker employs as his trump card. This is the now famous 2007 “Harrow study” conducted by Martin Harrow of the University of Illinois, which indicated that schizophrenia patients not on meds fared way better over 15 years than those on meds. The catch is the study measured for something quite a bit different, which Whitaker fails to mention in his book.

Dr Carlat stated the obvious, namely that “observational” studies of this type are not likely to yield definitive conclusions. Moreover, it stands to reason that the ones who do well off their meds are likely to be a different breed of patient.

Indeed, it was precisely this issue that Dr Harrow concerned himself with. The true finding in his study was that a certain subgroup of “good prognosis” patients (such as ones with a prior work history) fared better over the long haul off meds than on meds, suggesting that "not all schizophrenia patients need to use antipsychotic medications continuously throughout their lives."

In an earlier piece, I issued Whitaker a moving violation for reporting this study as if it were a clinical trial testing for the efficacy of antipsychotic medications.

But then comes a point where criticism becomes quibbling. Dr Nierenberg egregiously crossed that line when he went postal on Whitaker. Dr Carlat is in the safe zone, but did he miss the big picture? Basically, if someone is shouting Fire! through a cell phone, you investigate whether there is a fire. You don’t get into a discussion about whether the caller ran over his alloted cell phone minutes.

Pulling data from an earlier study to reach a different type of finding goes on all the time in academia. It’s called a “secondary analysis” and when it’s done right it vastly increases the value of the original data. Basically, Whitaker performed his own secondary analysis.

So then the question becomes one of whether Harrrow’s data justifies Whitaker’s conclusions. The answer is yes - to a point. Clearly the patients who fared best in Harrow’s study were the ones off their meds. Whitaker is on very safe ground here. But then he presses his luck by concluding that it was the antipsychotic medications that worsened the outcomes of the ones on their meds. Here, he has stepped into the quicksand of speculation, and Dr Carlat correctly takes him to task.

In his blog, Whitaker defends himself against earlier similar charges by arguing that the Harrow data applies across all the subgroups of patients in his study. But in a 64-patient study parsed into numerous subgroups, we're taking of differences measured in low single figures. (Thanks to Ruminations on Madness for this observation).

So do we dismiss Whitaker’s speculations as out-of-hand? Absolutely not. The DSM-IV - psychiatry’s diagnostic bible - is basically speculation bound between two covers. Every prescription for a psychiatric med that a doctor writes is a speculation approved by the FDA.

We must never forget the big picture: If our meds worked the way Pharma claims and psychiatry believes, we wouldn’t have mental illness to kick around anymore. Instead, we have an epidemic. So what the hell is going on? Someone has to start speculating. Dr Carlat, to his credit, seems to have acknowledged this in the conclusion to his second post:

Over the last few days, I've spent many hours thinking and writing about Anatomy of an Epidemic. Mostly, I've chipped away at its central thesis, and yet the fact that this powerful book has riveted my attention for so long means something. It's fascinating. It's enthralling. And it is the work of a highly intelligent and inquiring mind - a person who is struggling to understand the nature of psychiatric treatment.  Put it on your reading list, and join the debate.


Amy Karon said...

I discovered this blog a few days ago and was delighted. I'm a graduate journalism student who's developing a specialty in mental health (my background is in public health/epidemiology, so I'm trying to learn as much as I can now about mental illness and treatment).

I'd like to comment a bit about schizophrenia, which I wrote about recently after reading Elyn Saks' 'The Center Cannot Hold' and Inez Holger's 'The Origin of Fear.' Both Saks and Holger have paranoid schizophrenia; both seem to be living full, rewarding lives. And both emphasis the many necessary factors for them to 'recover' from schizophrenia. Saks emphasizes psychotherapy and support from her friends and husband; she says her work has also been key to keeping her engaged and hopeful. Holger mentions early diagnosis and her innate perseverance, but says her marriage ("to a man brave enough to walk down the aisle with me even though I still hallucinated") was the single most important factor in her recovery. Yet having schizophrenia can be a tremendously isolating experience. I wonder to what extent social support in recovery from schizophrenia has been studied, and to what extent, if any, psychiatrists incorporate this when working with patients.

Regarding comparing the prevalence of mood disorders across cultures, I want to offer a word of caution. Mood disorders don't manifest the same way cross-culturally (the New York Times had a great article on this a couple of days ago). Failing to take those differences into account, to account for discrepancies in countries' health care systems, will bias study results.

John McManamy said...

Hey, Amy. Welcome to Knowledge is Necessity, and welcome to mental health journalism. I had the pleasure of meeting Ron Kessler as a mental health journalist and asked him in effect, "What is it with those Nigerians?"

He was very gracious, but had no answer.

Our local NAMI honored Elyn Saks in 2009. I've also heard her speak at the APA and have her book (which I need to read). Her recovery story parallels that of John Nash, who I heard say in effect that his recovery started when he finally started receiving recognition for his work.

The isolation factor is huge, in SZ and all the rest of mental illness. It is touched on a lot by researchers, but is not their central focus. There is an emphasis in teaching social skills as part of psychiatric rehab, which addresses isolation. But rehab seems divorced from the rest of clinical practice. A good friend of mine informed me that the world class researchers at the university she works at have no awareness of the club house movement.

Club houses are very much dedicated to putting people with serious mental illness in a positive environment.

I have an article on my website on isolation and introversion. Check out:

Re the cultural factors, yes. Ethan Waters has a good book on this (I only read his article in the NY Times). I comment on this and 2004 WHO study at:

I also have a more personal approach at:

Plus I note specific cultural differences at:

As you see, I can go on forever. Again. welcome and please keep commenting. :)

Amy Karon said...

Thanks for the welcomes, John, and for your comments and particularly for the resources you share. I hadn't heard of club houses yet -- I look forward to learning more about them. I have your blog on my feed reader, so I'll stay in touch. :)

Best, Amy

Anonymous said...

There is more than a chance that Whitaker is right in his interpretation. After all, Soteria House and the Quakers were also more successful than drugs.

Anonymous said...

You might also want to talk to people who have taken psychiatric drugs and have found they are able to function much better off them. I did things when I was on them I didn't know I was doing. I also developed myoclonic spasms; they kept stacking one drug on top of another until I decided I'd had enough. God only knows how much damage they did to my brain and my body, but I will never take another one of them.

Anonymous said...

You certainly can't argue with Whitaker's conclusion that there is going to be a terrible price to pay for people taking all these psychiatric drugs either. We are going to have an epidemic of people dying early and with early onset movement disorders. These drugs are highly toxic. I'd suggest you try Dr. Grace Jackson's "Drug Induced Dementia: A Perfect Crime".