Monday, November 14, 2011

Rebutting Whitaker: Not Such a Good Idea - Part II

On Saturday, I published a piece that said it is not such a good idea to claim to rebut (or for that matter refute or repudiate) Robert Whitaker and his 2010 book, “Anatomy of an Epidemic.” Not unless Whitaker happens to be a flat-earther making up his own facts.

The danger with framing a counter-argument in the form of a rebuttal is that you have to declare in advance that you are about to score a first-round knock-out. So, even if you win on points in 15 rounds you have lost. Earlier this year, Andrew Nierenberg of Harvard went for the knock-out, and disgraced himself and psychiatry in the process.  (See Part I and Part II to "Whitaker vs Quack Psychiatry.")

Rebuttals are hardly an impossibility, but you need to bring both your A-game and a measure of respect for the other side and all interested parties. For a stellar example, go to YouTube and view Robert Lustig’s masterful demolition of conventional and scientific wisdom concerning weight gain and obesity.

The most recent rebuttal claim on Whitaker came in the form of a confused two-part commentary by William Glazer MD on Behavioral Healthcare. In my previous piece, I showed how Dr Glazer most unambiguously failed in his claims that Whitaker’s thesis was “sensational” and “scientifically unsound.”

Would Dr Glazer have been more successful had he merely set out to knock holes in Whitaker’s arguments? Let’s examine the hole-knocking:

Whitaker advanced the novel proposition that psychiatric meds have caused an increase (rather than an expected decrease) in mental illness. Exhibit A in Glazer’s counter-argument were two authoritative population studies done ten years apart. The early 2000s data was virtually the same as the early 1990s data.

But Whitaker went a lot further back in his comparisons, digging into research from the sixties and earlier. Glazer’s comparing modern data to modern data was the equivalent of a cheap accounting stunt. This is where Glazer really sets his foot in it. In citing the mental illness prevalence data at 29 percent and 30 percent from both studies, Dr Glazer makes this extraordinary statement:

These figures hardly support the notion of an “epidemic” of mental illness, the assertion on which Whitaker rests his case, as well as the provocative title of his book.

No mental illness epidemic, Dr Glazer? Really? Let’s examine the threshold levels for what constitutes an epidemic. In 2003, the US Surgeon General declared: “We have an epidemic of childhood obesity.” How many kids were obese? Fifteen percent (triple the rate of forty years earlier).

Glazer is on far more solid ground when he takes issue with other population and disability figures Whitaker cites in his book, but this was already covered by Daniel Carlat in his two blog pieces earlier this year. (See my reviews: A Discussion at Last, and When Is Speculation Justified?) I, too, have expressed my concerns with Whitaker over this, but these hardly rate as rebuttals. Quibble all we want, we are still looking at an alarming 30 percent prevalence rate of mental illness, an epidemic.

Now we get to the meat of Whitaker’s arguments, namely: 1) Prolonged antipsychotic use may result in a form of “rebound psychosis”; 2) In many cases, schizophrenia patients may do better not on meds; 3) Prolonged antidepressant use may set up “oppositional tolerance” that worsens the course of depression.

In numerous blog pieces, I cited Whitaker with moving violations for playing fast and loose with the evidence. In short, the studies Whitaker cites do not actually prove his claims. But they do support his claims. The scientific conversation is full of this type of discourse. Thus, support that is short of proof carries a certain level of scientific validity. So - can Glazer knock out the supports? Or will he choose instead to recycle Nierenberg personal insults? You guessed it:

“Mr. Whitaker needs a basic course on principles of epidemiologic research, specifically on the concept of ‘susceptibility bias.’”

This is the same Dr Nierenberg who in debating Whitaker miscited a longitudinal study as “restrospective.” Um - who needs the basic course?

Speaking of longitudinal studies, Glazer also repeats Nierenberg’s mischaracterization of an NIMH study as a 20-year study supporting the long-term effects of antidepressants. If there were such a study, then we might have some strong counter-evidence to the “oppositional tolerance" hypothesis that Whitaker advances. Yes, there was an NIMH study, but it merely investigated long-term illness outcomes, not long-term antidepressant use. The study does not say that patients were on antidepressants for 20 years, nor does it purport to make a finding based on long-term use.

Zen koan: If psychiatrists quote howling mistatements from fellow psychiatrists enough times, do the howling misstatements eventually become scientific fact?

Yes, apparently. In the words of Dr Glazer:

The knowledge base for psychiatric medications is evolving, but it has not come anywhere near the point where conclusions can be reached about whether they cause disability. Such a conclusion should rest in the hands of scientists, not reporters.

I could go on and on, rebutting Dr Glazer's rebuttals, but I have better things to do. Instead, I will leave the last word to someone who actually knows what she is talking about. Corinna West is actively involved in the recovery movement. In a blog piece entitled, It Feels So Great To Be Off Meds, she writes: 

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. We should be told how hard they can be to get off, and that there is not a ton of research showing long term effectiveness for medications. We should be given the truth that the chemical imbalance theory has not proven to be true. We should be given help and support for getting back off the medications as soon as possible. This would be the best way to help the 40% of people that do not respond to any given medication and might actually be harmed by it. In our current system, people unhelped by medications are only given more medications as well as the message that they are doing something wrong if they’re not recovering.

1 comment:

Lizabeth said...

Wow--John I am really impressed that you remembered they were trying me on Lamictal---unfortunately because of the slow build up and my rapid cycling they added Geodon. Bad mistake, it ate my brain and sent me screeming(Litterally) to the hospital---this was about 2 years ago.
I got very, very, lucky. The pdoc there was a genius. He changed my combo. He diagnosed me with obsessive anxiety and BP2 and put me on a teeny bit of Paxil 25 mg. CR, Seroquel 300mg at night, Ambien12.5ER at night and Klonopin 1 mg tid. So, yes I would be in Whitikers, book. But in the "meds are working" category. I wouldn't fit in the American category, I was born in Canada, the daughter of two combat vets of WWII and they were first cousins besides(legal where they married)
There was MI in both the Canadien branch and the English branch so I had the double genetic whammy. I am convinced most of what I have gone thru had a biological basis even if we are not sure what it is yet. I wonder if so many people of my generation having at least one parent who went thru WWII comabat and the decreased stigma of an MI diagnosis had something to do with the increased numbers too.
I am occasionally groggy on my meds, but after a lifetime of insomnia, I stand by my statement. Until there is an effective non med treatment, readily available, I am keeping my meds.