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.