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.

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 ...