Saturday, November 12, 2011

Rebutting Whitaker: Not Such a Good Idea

In Oct last year, I began a series of pieces based on Robert Whitaker’s shot heard ‘round the world, his 2010 book “Anatomy of an Epidemic.” Whitaker’s astonishing thesis is that psychiatric meds have been a contributing factor to the apparent global rise in mental illness.

Yes, we know our meds may make us worse rather than better, but this comes up in the context of side effects or trade-offs (such as weight gain and cognitive impairments). Whitaker goes a step farther in claiming that many of our meds actually worsen the very conditions they were meant to alleviate, namely:
  • Long-term antipsychotic use may bring on psychosis.
  • Long-term antidepressant use may bring on depression and affective instability.
  • Any kind of antidepressant use may turn those who never experienced mania in their lives into life-long bipolars.
In my initial series of blog pieces and numerous follow-ups, I took serious issue with Mr Whitaker’s fast and loose interpretation of the scientific evidence he cites in his book, not to mention his mindlessly unqualified endorsements of the antipsychiatry movement and his ill-informed cheap shots against advocacy groups that actually get off their asses and help people, such as NAMI (disclosure: I serve on the board of NAMI San Diego).

But I also concluded that Mr Whitaker had made the equivalent of a “case to answer,” a strong prosecutorial argument that demands an equally strong counter-argument from the other side. In other words, until psychiatry can present a convincing case of its own - on point, with strong scientific evidence - any fair-minded jury would have to decide in favor of Whitaker.

So, for right now, in the absence to date of any credible marshaling of the facts from psychiatry, Whitaker stands as the most authoritative voice on psychiatric treatment. A very sad state of affairs.

Yes, Daniel Carlat in two blog pieces (see my reviews: A Discussion at Last, and When Is Speculation Justified?) raised some thoughtful concerns, but he came across more like a woman (and in rare cases a man) on a first date wondering how to dress for the occasion. Andrew Nierenberg, one of psychiatry’s leading authorities on mood disorders, in a grand rounds debate, purported to “refute” and “repudiate” Whitaker, only to embarrass himself and his profession in a DSM-worthy display of disordered thinking and outrageous conduct. (See Part I and Part II to "Whitaker vs Quack Psychiatry.")

The latest criticism of Whitaker is in the form of a two-part piece (Part I and Part II) on "Behavioral Healthcare" by William Glazer MD. Dr Glazer runs his own consultancy, and has been affiliated with Yale and Harvard. Dr Glazer is a welcome voice to the conversation, but from the very beginning he sets up his counter-argument to fail.

“Rebuttal: Questioning the validity of ‘Anatomy of an Epidemic'”, reads the title to his first piece. “Whitaker's claims are ‘sensational’ but scientifically unsound,” reads the subheading.

So, to meet his own criteria in making his case, Dr Glazer would have to prove the falsity of Whitaker’s argument. Not only that, he would have to demonstrate that there is no scientific basis to Whitaker. The catch is that Whitaker is no mere flat-earther engaging in pseudo-science. His conclusions - as far-fetched as they may appear to someone considering the issue for the first time - are strongly grounded in findings published in mainstream journals, not to mention the observations of some of the leading experts in the field.

In addition, to shoot down Whitaker, Dr Glazer would have to marshal his own scientific evidence. This would involve citing studies that convincingly demonstrate the long-term efficacy and safety of numerous classes of psychiatric meds. You would think this would be a very easy mission to accomplish, but these studies simply do not exist. Here, for instance, is a key disclosure from the Depakote product labeling:

The effectiveness of valproate for long-term use in mania, i.e. for more than 3 weeks, has not been demonstrated in controlled clinical trials.

An older version of the labeling read:

The effectiveness of Depakote ER for long-term use in mania, i.e. for more than 3 weeks, has not been systematically evaluated in controlled clinical trials.

So here is the situation: We know it is common psychiatric practice to prescribe Depakote for long-term use in stable patients to prevent relapse or recurrence into mania. Yet the drug has only been successfully tested on a floridly manic group of patients for three weeks.

This is hardly an isolated example. Time and time again, in picking through the long-term data, (with the possible exception of lithium) all we come up with are the equivalent of 18-minute gaps in the tape.

Are we to conclude, then, that psychiatry is “scientifically unsound?” Yes, indeed, if we are to apply Dr Glazer’s extremely reckless terminology. I trust you get the point: The truth is certainly out there, but the facts are extremely hard to come by. The best we can do is make intelligent guesses based on the very limited information available to us.

In a sense, psychiatric treatment equates to meteorological forecasting - impressive in the short-term but highly problematic over the long-haul.  

So forget about rebutting Whitaker. Psychiatry is in no position to do that. The best it can do is interpret the same data in a way that helps all of us make informed decisions. I’m still waiting.

More to come ...


Corinna West said...

Hi John,

What I've heard is that many doctors who take the time to fully dig into Whitaker's research end up coming to agree with him. It's tougher for doctors than mental health survivors because for us it's a good news story telling the possibility of complete recovery and exiting the mental health system.

I do ask, please, that you correctly identify those of us that are psychiatric survivors and leaders of our mental health recovery civil rights movement. Antipsychiatrists are completely different people with different agendas. Folks like to use the antipsychiatry insult to denigrate our work and lumping us together is just about as inaccurate as trying to rebut Whitaker.

We need as much accurate, well researched info out there as possible.

John McManamy said...

Hey, Corinna. I suspect these supportive docs are fearful of speaking out for fear of professional recrimination. We need them to speak out. Reform only comes from the bottom-up, not the top down. The future of psychiatry depends on the docs you refer to speaking up.

I take your point about correct identification. I know we're on the same page. Here's a quote from a recent piece of yours:

"I’m not anti-medication, but I am anti-bullshit. I know that medications truly help some people,and some people do well on them. Those people should feel free to continue using them. However, I think all people should be given honest information about psychiatric meds before being put on them."


But we probably have different views as to how we define antipsychiatry, so let me clarify my position:

Critics of psychiatry-as-usual - who include just about everyone - are not antipsychiatry. As you said, antipsychiatrists are completely different people. But I'm not sure if Whitaker appreciates this. The last chapter to Whitaker's book is very strange, and this is what I was referring to in my critical comments.

In that chapter, Whitaker bubbled with enthusiasm over a cheap antipsychiatry publicity stunt. David Oaks was one of those involved in this stunt. I have major issues with those who claim that mental illness is not real.

I'm seeing a lot of "anti", but little or no "pro." I don't want to impugn to integrity of Mr Oaks, but I do not view him as a spokesperson for recovery.

Perhaps I should drop the term antipsychiatry altogether, especially if I'm only creating confusion, but I could use your guidance on this.

I would have been far more impressed had Whitaker focused on people actually engaged in showing others the way to wellness. Certainly, this would have been worth writing about. The "pro" stuff.

Your personal recovery story on your blog is an outstanding example of the "pro." I wish Whitaker had written about you or others like you. I'm very glad Gianni Kali reprinted your piece on her Beyond Meds blog.

There is a lot of "anti" in Ms Kali's positions, but the "pro" in her central message so outweighs the anti that I would never consider her anti. I told her this when she challenged me on this point some two years back.

But she isn't writing to please me. I respect her integrity enough that she is free to tell me to f- off.

One of my worries is that antipsychiatry will hijack the recovery movement. They are nihilists, but are also opportunists.

Please don't interpret my reply as my final word. I am more than open to being nudged into making course corrections. So - please - let's keep a constructive dialogue going. Feel free to take issue with me.

To readers: Corinna is very actively involved in recovery. Her blog "Wellness Wordworks" is well worth checking out:

Lizabeth said...

Part of me will always wonder if the ADs I was on ignited the BP2. The other part of me remembers having BP2 symptoms as a child, especially anxiety, insomnia, and extreme anger.
But I have to deal in the now. Now I know how I feel without meds vs. how I feel with them. Speaking for myself, I'm keeping my meds.

If I had been caught with effective, non med intervention as a child, I might be saying the opposite. But I am 56 and thats not what happened. I feel better about myself now than I have in my whole life.

John McManamy said...

Hey, Lizabeth. I'm definitely in your corner. There is another twist - mood stabilizers (eg lithium, Depakote, Lamictal) are the only major class of psychiatric meds that Whitaker did not attack in his book. My view: very good long-term meds strategies can be based on very low doses of these meds, bumping up to higher doses as needed. Also, instead of handing out antidepressants like candy, docs should consider as a first option stabilizing patients with a mood stabilizer. There is a lot of potential for antidepressants to do immediate harm. The immediate harm potential of mood stabilizers is very remote by comparison.

And most important: The Lamictal is working for you. I'm so glad your story has a happy ending. :)

Participatory Concepts in Mental Health Care said...

Hi John,

I am not a mental health professional, nor do I have a scientific background.

I do agree that knowledge is a necessity when it comes to mental health care, but so is common sense.

Professionals seem to have the upper hand when it comes to knowledge and having a voice of influence.

There are many underlying medical conditions and substances that can induce psychosis/mania and be misdiagnosed as bipolar disorder or schizophrenia.

Among the substances known to induce mania/psychosis are prescription medications.

Even the routine use of over-the-counter cold medicine can induce psychosis resulting in a misdiagnosis of schizophrenia.

Patients suffering from symptoms of any mental disorder should question whether or not the medical professional they are dealing with is using "best practice" in their assessment.

Personally I know of many individuals who have been misdiagnosed with bipolar disorder/schizophrenia.

Among them is a 21 year-old woman from Rochester, NY who was originally diagnosed with bipolar disorder, and as her symptoms progressed it was found she was suffering from a fatal disease, Creutzfeldt–Jakob disease.

A search through medline shows there are other similar cases of CJ disease presenting as mania and misdiagnosed as bipolar disorder.

Here is a narrative I wrote that was published in the Journal of Participatory Medicine earlier this year.

"Shared knowledge" is an "absolute necessity".

Mental health advocates need to find a middle ground to take a stance and start working side-by-side, rather than taking sides.


John McManamy said...

Hey, Maria. I appreciate your comments. I have always been in the middle-ground group as a journalist/advocate and believe in working side by side. But that isn't as easy as it sounds. The middle ground is rapidly shifting and doctors for the most part are not willing to work with us.

I have very good relations with a good many psychiatrists and mental health professionals. Many have been very gracious in take the time out to answer my questions and educate me. Make no mistake, I am strongly indebted to these people. For a number of years I was attending way more professional conferences than your average clinician.

As far as my professional relations go: My book was endorsed by some of the most renowned psychiatric thought leaders, including the former head of the NIMH. The leading bipolar experts honored me with the most prestigious award in the bipolar field (the Mogens Schou Award). On and on ...

But - despite this - not one of them or their organizations has ever asked me for my input, either informally or to serve on a panel, etc. In the one grand rounds I was asked to do, they practically walked out on me.

Do you see a problem here?

I understand that Whitaker faces similar resistance - that a number of scheduled grand rounds and speaking engagements got canceled on him. This happened with a SAMHSA-sponsored conference, which had to reinvite him in the face of a political firestorm.

Trust me, psychiatrists really don't want to hear from patients as equals.

As a middle-roader, I have not hesitated in calling out extremists on both ends. You see this in my commentary on Dr Nierenberg, whose behavior has been entirely unprofessional. I've also gone after antipsychiatry extremists.

We can not have a conversation dominated by the extremists shouting at each other.

Last year, I presented my commentaries on Whitaker as a conversation. I think I'm the only commentator who took a middle ground - I didn't mindlessly hero-worship him and I didn't reflexively demonize him. I was critical but also supportive and I kept stressing the issues he raised needed to be talked about.

So much so, that his book has been a central focus of my blog.

Fortunately and not-so-fortunately, I see the tide turning in Whitaker's favor. Thanks to psychiatry's lack of constructive engagement, by default Whitaker is now the leading authority on psychiatric treatment.

As a middle-roader and as an independent journalist with no financial ties to any interest group or axes to grind, I have to include Whitaker's is the most credible voice.

Also, when it comes to our own recovery, psychiatry is of very little help to us. We are on our own. Psychiatry is good in the crisis phase. They know nothing about treating us to recovery. We have to do that ourselves.

I could go on and on. But yes, middle ground and working side by side is the ideal. But psychiatry needs to display a bit of humility and respect. They are not the top dogs in this partnership.

Anyway, please keep posting. I much appreciate you taking the time to post.

Gianna said...

ha ha! I just read part of the comment thread that mentions my work. (after already linking to your two artcles, that I so enjoyed) I've never considered myself anti-psychiatry. Ever. Though early on I considered what that meant...and talked a wee bit about it.

I don't remember the conversation you speak of between you and me, though.

I've always thought you could make a good argument. I took lots of rhetoric at university...I recognize a decent argument whether I agree with it or not...and in general the truth is not whatever we's much much bigger than that.

best to you.

John McManamy said...

Hey, Gianna. Very glad to hear from you again. I hunted down our exchange. It came in relation to a piece I posted back in early 2009:

I really enjoy your comments. One time you noted a factual error of mine, which I corrected. And you always cause me to think and reassess my positions, which helps keep me honest.

Your view of the truth is spot-on. Maybe this is why I'm so sour on those who claim their version of reality is the only acceptable one.

Anyway, very glad you enjoyed my piece. Let's keep talking.

Readers: Check out Gianna's blog, Beyond Meds, at

Jean said...

Hi John

I haven't delved enough into Whittaker's theories and research to know if I agree with him on all counts, but so far what I've read of Whittaker's stance makes sense to me and I welcome his perspective.

You say Whittaker claims that 'many of our meds actually worsen the very conditions they were meant to be treating.'

YES! So very true for me. I was diagnosed with schizophrenia (simplex) and bombarded with meds to treat lethargy, apathy social withdrawal, depression, blunted emotions, lack of interest and lack of motivation. The meds had (ironically) exactly the same side effects as these so-called symptoms and they very much worsened my condition, reducing me to a zombie for five years.

It was only when I came off all meds (against medical advice) that I was able to build up a life for myself and fully recover. I know it would not be wise, or possible, for everyone to come off their meds but certainly for me, and for many others, it was absolutely right and necessary.

My experiences were a long time ago (I've been meds-free since 1974) but I know from my current work with other psychiatric survivors, and also those still within the psychiatric system, that for many of us 'our meds actually worsen the very conditions they were meant to be treating.' Thank God for people like Whittaker who are not afraid to say so.