Thursday, May 24, 2012

Collision Course: Whitaker vs Torrey

This is the second in a series of pieces dealing with Fuller Torrey’s response to Robert Whitaker’s 2010 “Anatomy of an Epidemic.” In his review, Dr Torrey asserts that on matters of schizophrenia and antipsychotic drugs, “Whitaker got it mostly wrong.”

My first piece laid out the background to the controversy, namely my view (spread across numerous pieces throughout 2010 and 2011) that Whitaker had not made his case that psychiatric meds have caused a mental illness epidemic. Nevertheless, he made a very strong “case to answer,” one that demands a considered point-by-point response, preferably from a leading psychiatrist. More then two years went by since the publication of “Anatomy,” with no signs of intelligent life from psychiatry. Last week, Torrey broke the silence. Better late than never.

The same day that Torrey published his review, Whitaker in a blog post issued an angry rebuttal that cited Torrey for at least four instances of “dishonesty,” as well as using the occasion to attack Torrey and the Treatment Advocacy Center for its aggressive stance on assisted outpatient treatment (which a good many of us - myself included - also have serious issues with).

Lost in the noise was that on key points Whitaker has failed to respond to Torrey’s criticisms. Let’s get started:

The 1994 Outcome Study

Whitaker’s Position:

In the foreword to his book, Whitaker says that he “encountered two research findings that didn’t make sense.” One of these was a 1994 study conducted by researchers at Harvard, which found that “outcomes for schizophrenia patients in the United States had worsened during the past two decades ...”

He says no more about the study and makes no further mention of it in the rest of his book.

Torrey’s Response:

In his review, Dr Torrey notes that what the study actually said was “quite different,” namely that when a broad definition of schizophrenia was in vogue, outcomes were a lot better. Moreover, “the data showed a clear improvement in outcomes during the 1960s and 1970s following the introduction of antipsychotic drugs.” Outcomes worsened during the 1980s and 1990s, “which the authors attributed to the introduction of a narrow definition of schizophrenia.”

The broad and narrow definitions are no mere diagnostic quibbling. The narrow (DSM) version (introduced in 1980) mandates six months of symptoms.

Torrey also noted that Whitaker “later added that the worsened outcomes were due to the use of antipsychotic drugs.”

Whitaker’s Comeback:

In his blog post, Whitaker claims that he only mentioned the study in passing in the foreword to his book, as something that “piqued my curiosity,” thus implying that his use of the study was not worthy of Torrey’s attention. Surprisingly, in his defense, Whitaker acknowledges that the study authors said exactly what Torrey said they said, namely:

... the researchers reasoned that improved outcomes in the middle part of the century were due to both a change in diagnostic criteria that broadened the definition to include patients who were less ill at disease onset and then to the introduction of neuroleptics.

Then Whitaker served up his own theory of why maybe - sort of - the study supports his thesis anyway. (We won’t get into that here.)

Torrey’s big mistake? Whitaker made no specific reference to this study when he talked about worsened outcomes on antipsychotic medications, as Torrey stated in his review. This brought down Whitaker’s wrath in the form of “dishonesty moment number one" for Torrey.

Actually, though, on page 118 of his book, Whitaker says, “We have followed the trail of documents to a surprising end ...” Why wouldn’t we assume the Harvard study was part of that paper trail?


Dishonesty moment to Whitaker, big time. This is an egregious example of a journalist misciting a study to serve his own ends, then conveniently forgetting about it when the actual facts failed to support his thesis. This is hardly the only example of Whitaker’s highly selective cherry-picking in his book. Torrey was perfectly correct to call out Whitaker.

As for Torrey’s “dishonesty moment,” using a flimsy pretext to brand a critic as dishonest violates all the basic principles of playing well with others.

Finally, Whitaker totally failed to address Torrey’s extremely relevant point concerning broad and narrow diagnostic criteria. More about that, coming right up ...

The WHO Outcome Study

Whitaker’s Position:

Whitaker devotes considerable attention in his book to two World Health Organization studies that found that those with schizophrenia in developing countries had much better outcomes than those in developed nations. As Whitaker reported in his book (p 111):

... the bottom line is clear: In countries where patients hadn’t been regularly maintained on antipsychotics earlier in their illness, the majority had recovered and were doing well fifteen years later.

Whitaker then goes on (p 119) to link this study to other studies to conclude that “evidence for long-term recovery rates are higher for nonmedicated patients appears in studies and investigations of many different types.”

Torrey’s Response:

Dr Torrey in his review evinces far less enthusiasm, noting that the WHO study claim “has continued to be criticized over the years and has now been largely discredited.” At issue, once again, is broad and narrow diagnostic criteria. Citing various sources, Torrey notes that many of those enrolled in the third world centers probably did not have true schizophrenia (some of the patients were referred by religious and traditional healers). More likely, the researchers were dealing with a good number of those suffering from “acute reactive psychosis,” which have much better outcomes than schizophrenia.

Torrey also cites a five-year 2011 study on a cohort of Ethiopian patients with findings that contradict the WHO studies. Finally:

Faced with such criticisms, the authors of the WHO studies have recently modified their claims, stating that “we do not argue that the prognosis of schizophrenia in developing countries is groupwise uniformly milder” and acknowledging that “the proportions of continuous unremitting illness…did not differ significantly across the two types [developed and developing] of setting.”

Whitaker’s Comeback:

Predictably, Whitaker assigns Torrey another “dishonesty moment.” This is based on the fact that far from “modifying their claims,” the authors of the WHO studies in the same paper Torrey cited actually vigorously defended their findings. Says Whitaker:

Dr. Torrey, in his review, was intent on discrediting the findings from this WHO study, which reported superior outcomes in poor countries where only a small percentage of patients were regularly maintained on antipsychotics. To do so, he implied that the WHO investigators now agreed with the critics of the study, when that is not true.


We have a big wet loogie on the table, which Whitaker fails to address, namely: The authors of the WHO studies have explicitly acknowledged that the patients in the third-world countries had a milder prognosis than those in the developed countries. Why is this important? If we are comparing apples to oranges, then the findings of the WHO study are totally meaningless.

More likely, the “apples to oranges” controversy merely raises questions about the study rather than discredits it, as Torrey maintains. If anything, the WHO study is a textbook example of why no finding can be taken at face value. Certainly, we all know this when it comes to clinical trials sponsored by drug companies.

What is particularly disturbing is that Whitaker would have been aware of the “apples to oranges” controversy when he wrote "Anatomy of an Epidemic." Yet he makes only a fleeting reference to it in his book, and only in the context of vindicating the first WHO study (as if there were no reason to question the second study). A straightforward and thorough stating of the controversy would hardly have undermined both studies' findings or Whitaker’s thesis. If anything, preemptively dealing with this concern would have greatly strengthened Whitaker’s argument, along with his credibility.

Instead, we are left with the feeling that Whitaker is hiding something.

Keep in Mind ...

In past blog posts, I have been supportive of Whitaker, but I have also not hesitated to point out numerous examples of where he played fast and loose with the facts, or where - quite frankly - he failed to turn in his homework. I continue to be supportive of Whitaker, but I also support any critic of Whitaker acting in good faith. In my 13 years researching and writing on mental illness, one vital lesson stands out loud and clear: Never - never-ever-ever - take anyone (and I include myself here) at face value. Always maintain a healthy skepticism, even if the party involved claims to be speaking for you - especially if the party involved claims to be speaking for you.

To act otherwise is to place your life on the line. Our illness takes no prisoners.

Much more to come ...  


Stanley Holmes said...

Thanks for being one of the most independent and intelligent critic in the world of mental illness. You are one in the small minority who has no allegiance to pharma or the psychiatric establishment, as well as no allegiance to anti-pharma or anti-psychiatric groups.

It is a refreshing stance.

The only difficult part is your call to not take your own words at face value, and to maintain a healthy skepticism towards you. I hope you won't mind if I at times, I don't take that last call at face value, because I am sometimes skeptic about it :-). It's not that irrational to assume your word and research does matter.

Willa Goodfellow said...

Thanks to Torrey and thanks to you, John, for following through with this. I know a lot less about schizophrenia than mood disorders, and so have avoided this fray. The apples to oranges issue clouds a lot of mental health research. Andreasen's longitudinal study might have provided data -- I don't know. Its loss is all the more lamentable.

Do you have more coming?

John McManamy said...

Thanks, Stan. :)

John McManamy said...

Hey, Willa. The truth is so elusive. When citing a study, I tend to say "suggests" rather than "proves". If I say "found," I restrict myself to the immediate facts of the study. Thus the WHO study did "find" that those in the study from certain third-world studies did have better outcomes. The study does "suggest" a number of things: social support, antipsychotics non-use, genes-environment. But it obviously doesn't "prove" any of these things. We can still use the findings "in support" of an argument than long-term antipsychotic use may worsen outcomes. Proof? This is a way higher standard.

We have so few longitudinal studies. Pulling the plug on Andreasen is the equivalent of burning down a library.

John McManamy said...

Oh, one more thing, Willa. Yes, there will be more blog posts on this. This is the "conversation" we have all been waiting for.