Tuesday, May 29, 2012

Whitaker vs Torrey: Digging Deeper

This is the third in our 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.” The same day that Torrey published his review, Whitaker in a blog post issued an angry rebuttal and his own counter-attack.

Previously, we examined Whitaker’s use of two studies he cited in support of his thesis that mental illness is on the rise because of psychiatric medications rather than despite them.

In the first instance, Torrey busted Whitaker for blatantly misrepresenting one study’s findings. The study involved a mere passing reference, but was illustrative of the highly selective cherry-picking that Whitaker employs throughout his book. Whitaker counter-attacked, accusing Torrey of “dishonesty,” but failed to answer the charge.

In the second instance, Torrey dismissed two WHO studies that Whitaker heavily relied upon, characterizing them as “discredited.” Essentially, Torrey (citing various researchers) interprets these studies as an apples-to-oranges comparison. The studies (which found better outcomes among the third-world patients surveyed) - serve as a textbook example of why no finding can be taken at face value. Basically, both Torrey and Whitaker were justified in interpreting these studies the way they did. It would have been helpful, however, had Whitaker addressed Torrey’s apples-to-oranges issue. Instead, he issued another gratuitous “dishonesty” charge.

Let’s move on ...

The Harrow-Jobe Study

Whitaker’s Position

This 15 (later 20)-year longitudinal study, published in 2007, served as Exhibit A in Whitaker’s case against antipsychotic medications. In his book, Whitaker interprets the study results to advance his claim that patients with schizophrenia fare worse on meds over the long-term than those not on meds. According to Whitaker (p 115):

...The off-med group began to improve significantly, and by the end of 4.5 years, 39 percent were “in recovery” and more than 60 percent were working. In contrast, outcomes for the medication group worsened during this thirty-month period. ...

Whitaker in his book did note that Harrow in an interview attributed better outcomes to “stronger sense of self” and “better personhood,” but Whitaker did not elaborate why these factors were significant. Instead, he kept his focus exclusively on meds vs non-meds.

Later in his book (p 311), Whitaker accuses both the NIMH and NAMI of failing to promote (and by implication suppressing) the study’s optimistic finding:

... I also searched the NMIH and NAMI websites for some mention of the studies listed above and I found zilch. ... Forty percent of those off medications recovered over the long term! But that finding directly contradicted the message that NAMI has promoted to the public for decades ...

Torrey’s Response

In his review, Dr Torrey points out that the Harrow-Jobe study is not exactly the hot news that Whitaker makes it out to be. Since at least as far back as 1938, Torrey reports, numerous schizophrenia outcome studies have found that “on average one-quarter of the patients recovered completely, one-quarter had a continuous illness, and the other half had intermediate outcomes between these two extremes.”

Of critical importance, citing one researcher: “There are relatively benign and malignant forms of illnesses generally diagnosed as schizophrenia.” This leads to what the study was really all about, with Torrey noting that “Harrow et al. even explicitly state that their study provides no evidence on whether very long-term use of antipsychotic medication produces undesirable effects for some SZ [individuals with schizophrenia].”

Once again, we have an apples-to-oranges issue. As I observed in a number of previous blog posts, rather than comparing a meds group to a non-meds group as we are used to seeing in clinical trials, the study actually compared a “good prognosis” group to a “bad prognosis” group. These patients were identified at the beginning of the study, then followed over 15, then 20 years.

Predictably, the good prognosis group had better results, with more of them in a position to go off their antipsychotics and to function well. But, according to Torrey, Whitaker twisted these findings to serve his own purposes:

Using tortured logic, he asserts that the Harrow et al. study proves that long-term antipsychotic use causes brain damage and is responsible for many of the symptoms of schizophrenia, when in fact the study does nothing of the kind.

Whitaker’s Comeback

In his blog post, Whitaker breaks down those parts of the Harrow-Jobe study that showed how all the subgroups of non-medicated patients fared better without antipsychotic medications. This includes both “good prognosis” patients and “bad prognosis” patients. Says Whitaker:

Although [Harrow] didn’t provide the global data for these two subtypes, he did report this finding: “In addition, global outcome for the group of patients with schizophrenia who were on antipsychotics were compared with the off-medication schizophrenia patients with similar prognostic status. Starting with the 4.5-year followup and extending to the 15-year follow-up, the off-medication subgroup tended to show better global outcomes at each follow-up.”

In other words, in every subgroup of patients (by prognostic type), those off medication had better long-term outcomes (in the aggregate).

Whitaker (predictably) assigns another “dishonesty moment” to Torrey. This is based on the fact that Whitaker did not cite the Harrow-Jobe study for the proposition “that long-term antipsychotic use causes brain damage and is responsible for many of the symptoms of schizophrenia,” as Torrey claimed. Rather, Whitaker kept his interpretation to outcomes.

Nevertheless, Whitaker in his book (p 118-119,) linked the Harrow-Jobe study to a study that did suggest that “drugs made patients more vulnerable to psychosis over the long-term,” and (p 120) he noted that “we can also see how this drug-induced chronicity has  contributed to the rise in the number of disabled mentally ill."

What Harrow et al Actually Say

From a 2005 article (free on PubMed):

More recent data of ours suggest that some of the schizophrenia patients who go off antipsychotics are a different type of patient. They have better premorbid developmental achievements, have more favorable prognostic characteristics, and are more resilient and less vulnerable to psychopathology (or “healthier”), leading to their better functioning.

And from the 2007 article Whitaker refers to (you have to pay $50 for this, the abstract is free):

The results suggest that the subgroup of schizophrenia patients not on medications was different in terms of being a self-selected group having better earlier prognostic and developmental potential.

And the key finding from the wider dataset (including patients with other diagnoses), in a 2009 article (available free on PubMed):

A more external locus of control is related to fewer periods of recovery, to both depressed mood and psychosis, and to various aspects of personality.

Locus of control (LOC) “refers to the extent to which an individual perceives events in his or her life as being a consequence of his or her actions, and thus under his or her perceived control.” Internal LOC is good. External LOC is bad.

Of the schizophrenia patients in recovery over 15 years, according to the 2009 article, 67 percent had internal LOC. In the overall sample, 75 percent had internal LOC.

Basically, Harrow et al are telling us that an individual’s personal make-up is a key predictor to recovery, perhaps THE key. In their study, these were the patients more likely to go off their meds and do well off their meds. In the authors’ own words (2007):

Patients who are internally orientated and have better self-esteem are the types of patients who are more likely, if their functioning improves, to urge that they try functioning without medications ...

This is worth restating: According to Harrow et al, based on their study findings, doctors should be encouraged to consider taking a good prognosis patient who is doing well off his or her meds. This is an entirely different proposition than what Whitaker would have us believe - namely, get EVERYONE off their meds as soon as possible.

Whitaker doesn’t say this in so many words, but the thrust of his interpretation of the study  - namely “that the drugs worsened long-term outcomes” (p 118) - leaves himself open to Torrey’s charge of using “tortured logic.”

What Whitaker is doing is making a “secondary analysis,” a common and legitimate practice that can often yield far more interesting insights than the primary analysis. The catch is that you have to read Whitaker’s book microscopically to know he is making this of kind analysis. He certainly does not trumpet Harrow et al’s real findings, much less explain them, and this is disturbing, to say the least.

This brings us to the crucial question, does Whitaker’s secondary analysis hold up?

To be continued ... 

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