Drug Busted

Psychiatry & Mad, Bad Medicine

In 1998, Robert Whitaker, a journalist specializing in reporting on the business of clinical drugs, co-wrote a series of articles for the Boston Globe about abuses of psychiatric patients in research settings. One study he reported on involved withdrawing schizophrenia patients from their antipsychotic medications. To him, this was an outrage. Everyone knew that antipsychotics treated schizophrenia. They were like insulin for diabetics. Who would take diabetics off their insulin, just to see what happened to them?

The series was well-received, and it might have been the end of his research on psychotropic drugs had it not been for two odd developments over the course of it. First, he'd asked Jeffery Lieberman, who would later become president of the American Psychiatric Association (APA), to point him to the studies that had shown antipsychotics to be an effective treatment for schizophrenia comparable to insulin for diabetics. "We don't have those studies," Lieberman said. "That's just a metaphor that gets people to understand why they should take the drugs."

Whitaker was shocked. Was there really no data behind this claim? He called Janssen Pharmaceutica, maker of Risperdal, a new drug being marketed to "fix" schizophrenia, along with a few other neurotransmitter disorders, and got the same answer. There were no studies, and the claim that the drugs are like "insulin for diabetes" is "just a metaphor."

Second, he'd come across reports of studies that had been done, but that did not fit the metaphor. In 1994, a group of Harvard Medical School investigators had announced that outcomes for schizophrenia patients in the United States had worsened over the prior two decades. And the World Health Organization had twice found that schizophrenia outcomes were better in poor countries, where only a small fraction of patients were regularly maintained on the drugs, compared to the developed world, where they had become standard treatment. How could this be?

Medication by Metaphor

As a fact-driven journalist, he found these revelations troublesome. And so, through this "back door," so to speak, he set out to look more deeply into how we as a society are treating our mentally ill. The result was Mad in America: Bad Science, Bad Medicine, and the Enduring Mistreatment of the Mentally Ill (2001), a disturbing exposé in which he surveyed two centuries of "mad medicine" therapies, most of which amounted to silencing and dulling the minds of the suffering, and argued that today's medicalized treatment model is little better. Mad in America documents an appalling amount of systemic indifference and corruption, encompassing psychiatry, the pharmaceutical firms, and trusted public health organizations ostensibly advancing patient wellness, including the National Institutes of Mental Health (NIMH) and the National Association for Mental Illness (NAMI).

In his follow-up book, Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America (2010), Whitaker argues that the psychopharmacology revolution has not only not made lives better, but has in fact fueled an epidemic of the very conditions it purports to be correcting. As it turns out, far from being like "insulin for diabetics," the chemical "cures" have regularly served to worsen, rather than improve, patient wellness, as evidenced by a clear, documentable rise in chronic, and in many cases debilitating, mental illness. Anatomy of an Epidemic delves into the science of the brain and the medications to explain how and why this is so.

Psychiatry's Science Envy

The first antipsychotics arose out of a 1940s quest for a "magic bullet" to kill worm-borne illnesses. Researchers noticed that a particular compound had antihistaminergic properties that suppressed the body's natural shock response to wounds. A French physician began using it in surgeries and noticed that it had a tranquilizing effect on patients: they remained conscious, but appeared emotionally separated from the world around them, as if by a glass wall. When psychiatrists learned of this effect, they compared it to surgical lobotomy, which at the time was considered cutting-edge therapy. And indeed, as it turned out, the drug, called chlorpromazine, did block some of the same brain activity as did lobotomy, and it was likened to chemical lobotomy.

Anti-anxiety agents arose similarly, but out of a different quest, when researchers noticed that a group of agents made rats docile and apathetic. Even when stressors were introduced into their environment, they did not display the typical stress-induced responses. These agents were developed into drugs some later called "happy pills" or "don't give a damn" pills. And antidepressants came out of a search for a tuberculosis cure, when a backup synthetic fuel developed by Nazi scientists was observed to rouse lethargic tuberculosis patients.

The first generation of these drugs were called neuroleptics, a word coined in 1955, because of their observed effect to restrain or "take hold" of a person's nervous system. "We have to remember that we are not treating diseases with this drug," psychiatrist E. H. Parsons said at the time. "We are using a neuropharmacologic agent to produce a specific effect." Time magazine accurately reported in 1954 that "there is no thought that chlorpromazine is any cure for mental illness, but it can have great value if it relaxes patients and makes them accessible to [talk therapy] treatment."

But other news outlets planted seeds for an expanded narrative, whether they realized it or not. Science magazine was the first to compare neuroleptics to insulin, in 1958, and the New York Times was first to use the term "antidepressant," in 1959.

In any event, although the drug histories are interesting in themselves, what's important to note here is that none of these agents arose out of any brain research. They were all developed for other purposes and then introduced into psychiatry because they produced side effects that were seen as helpful to psychiatric patients—the antipsychotic and anti-anxiety drugs as quieters, and the antidepressants as energizers.

The Chemical Imbalance Theory

It wasn't until after all this that the "chemical imbalance" theory emerged. In the early 1960s, neurologists began to learn how these drugs affected brain function and neurochemical messaging. They discovered that chlorpromazine blocked about 70 percent of the brain's dopamine receptors, thereby resulting in reduced dopamine activity. Given this association, then, between reduced dopamine activity and the observed tranquilizing effect, researchers hypothesized that schizophrenia was caused by too much dopamine in the brain.

In the case of the antidepressants, it was discovered that they boosted levels of serotonin, another chemical messenger in the brain. Therefore, it was similarly hypothesized that depression was caused by too little serotonin.

In 1963, the NIMH conducted a six-week trial of chlorpromazine and other neuroleptics and pronounced them more effective for symptom reduction than placebos. And with that, writes Whitaker,

the transformation of the psychiatric drugs was basically complete. In the beginning, [chlorpromazine] and other neuroleptics had been viewed as agents that made patients quieter and emotionally indifferent. Now they were "antipsychotic" medications. Muscle relaxants that had been developed for use in psychiatry because of their "taming" properties were now "mood normalizers." The psychic energizers were "antidepressants." All of these drugs were apparently antidotes to specific disorders, and in that sense, they deserved to be compared to antibiotics. They were disease-fighting agents, rather than mere tonics.

Or, as the metaphor put it, they were like "insulin for diabetics."

Studies were conducted in the later 1960s and the 1970s to further test the hypotheses, at least indirectly, and failed to confirm them. But never mind the details. By this time the momentum of the metaphor and the theory giving it a coating of legitimacy outpaced sound science. Even harrowing reports of neuroleptics being used in the USSR to punish dissidents failed to deter the psychiatric faithful.

Malpractice: From Inducing an Effect to Inducing Illness

Six-week trials are far too limited to give reliable data on drug efficacy regarding something as complex as human emotions and the brain, and in the course of time the brain stubbornly refused to fit the theory or submit to the metaphor. The brain is an extraordinary organ with its own neuroplastic feedback mechanisms, and further research uncovered how it responded to psychoactive drugs.

Here's what happens in the case of the antipsychotics. Researchers discovered that the artificially induced dopamine suppression provokes two compensatory responses in the brain. First, the brain increases secretion of dopamine from the "sending" neurons, and second, it increases production of dopamine receptors on the "receiving" neurons.

The increased secretions appear to drop off after the drug is withdrawn, but the added receptors remain. This oppositional tolerance explains why coming off the drugs can be so problematic, and by the mid-1980s, researchers had affirmed that this receptor up-regulation was entirely iatrogenic, meaning entirely drug-caused.

With this knowledge, then, can you see how prolonged use of an antipsychotic might actually create a chemical imbalance where one did not previously exist? Indeed, the journal Current Neuropharmacology recently reported on antipsychotic-induced Dopamine Supersensitivity Psychosis (DSP), bluntly stating that "investigators noticed significantly more psychosis in patients that were persistently treated with antipsychotics than [in] those that were not."

The low-serotonin theory of antidepressants was also put to the test, and it, too, failed. This was reported by the NIMH in 1984, but the psychological complexities of human distress were swept aside by a combination of the marketing genius of Eli Lilly (which introduced Prozac in 1987), other vested interests (including the APA), and people's natural tendency to trust doctors. All these factors led to widespread belief in a false narrative.

Recovering Soul Care

The word psychiatry comes from two roots that together mean "soul heal"—psyche (mind, or soul) plus iatreia (healing, or care). In 1800s America, the Quakers took a radically humane (for the time) approach to psychiatric care for the insane. They combined psychosocial care with moral discipline in comfortable, home-like settings, and their method produced good results in terms of restoring troubled souls to independent, healthy living. This should come as no surprise to those of us with a biblical understanding of the human person. Ordinary people caring for others can lead to remarkable soul-healing over time.

But the paradigm twentieth-century psychiatry adopted, along with the theories it put forth, was predicated on a purely physical model of the human person. Utterly devoid of soul or mind, this model ironically renders the very concept of a psychiatric cure by medication incoherent. In some ways, psychiatry lost its mind. In other ways, perhaps, it sold its soul.

Psychiatric quagmires aside, although twenty-first century psychiatry is quietly dropping the chemical imbalance theory, in the United States, some 80 percent of people still "know" that low serotonin causes depression. Robert Whitaker created MadInAmerica.com in 2008, and the site has grown into a formidable community, education center, and evidence-based catalyst for rethinking psychiatric care. Hopefully, these efforts will foster recovery, not only of sound science, but also of some heart, mind, and soul to the profession.