Mad in America
Encyclopedia
Mad in America: Bad Science, Bad Medicine, and the Enduring Mistreatment of the Mentally Ill is a controversial book by Robert Whitaker
published in 2002 which is highly critical of the psychiatric profession. Problems with many historical aspects of treatment, as well as antipsychotic
s, are covered. The book received mixed reviews within the medical literature, which noted issues of bias in sourcing but nonetheless felt the discussion of social issues in psychiatry was important. The book received some better reviews from the lay press.
Whitaker, a medical journalist who was a finalist for a 1999 Pultizer Prize, has never suffered mental illness himself. He told WNET
that members of his extended family have suffered it, a situation he believes he shares with most Americans.
, dating back to 1793 and the French Revolution and established in the U.S. by Quakers in 1817, in which lay superintendents treated the mentally ill in small homes with great kindness and had good outcomes: About 35 to 80 percent of patients were discharged within a year, the majority of them cured. Pennsylvania Hospital reported that about 45 percent of patients were discharged as cured and 25 percent discharged as improved. In Worcester State Hospital
, 35 percent were chronically ill or had died while mentally ill. Dr. George Wood, a visitor, reported in 1851:
which did away with moral treatment in favor of forced sterilization of the mentally ill, and led to newly invigorated fields of psychiatry
and neuroscience
whose experts practiced insulin coma
, metrazol
convulsion, forced electroshock
, and lobotomy
.
Part Three describes the invention of the neuroleptic
drug chlorpromazine
(Thorazine) by Rhône-Poulenc
in France, and its purchase by Smith, Kline & French (today known as GlaxoSmithKline
). The drug "produced an effect similar to frontal lobotomy", according to early reports by the company's lead investigator. Whitaker says that pharmaceutical advertising, articles published in the scientific literature, and stories in the media of "miracle drugs" transformed Thorazine into a healing drug.
Whitaker says that marketing money from pharmaceutical companies began to flow to the American Medical Association
in 1951, a year after Thorazine was synthesized, because of the Durham-Humphrey Amendment
to the Federal Food, Drug, and Cosmetic Act
which "greatly expanded the list of medications that could only be obtained with a doctor's prescription".
In Part Three, Whitaker also describes the American (but not for example British
) propensity to classify patients as "schizophrenic", as well as the error (confusion of schizophrenia
with the yet-to-be-discovered encephalitis lethargica
) in the original classification by Emil Kraepelin
which psychiatry chose to not revisit and fix. Whitaker then describes three pathways that dopamine
may take in the human brain, and quotes first-person accounts of the effects of antipsychotic drugs on individuals.
He calls a 1996 New York Times advertisement by a consortium of pharmaceutical companies a "bald-faced lie": the group sought to say that the cause of psychosis and schizophrenia is an abnormal dopamine level and that their drugs worked by altering the level of dopamine. Whitaker then criticizes some American studies, and points out the work of George Crane at the National Institute of Mental Health
to get tardive dyskinesia
recognized, and he contrasts the dosages that British
doctors were comfortable in prescribing (300 milligrams per day of Thorazine) with what American psychiatrists prescribed (1,500 up to perhaps 5,000 milligrams per day).
He sees irony in the fact that The New York Times reported on Soviet forced use of neuroleptic drugs (which Florida Senator Edward Gurney called "chemicals which convert human beings into vegetables") in "psychiatric jails" but called the same drugs "widely acknowledged to be effective" when reporting on American schizophrenic patients.
Whitaker describes the demise of modern-day moral treatment in a short history of Loren Mosher's Soteria Project, funded by the U.S. while Mosher was chief of schizophrenia at NIMH. He attributes the results in a World Health Organization
1979 study of outcomes for schizophrenia patients (which found better outcomes in undeveloped countries like India
, Nigeria
and Colombia
than in developed countries like the United States
, England
, Denmark
, Ireland
, Russia
, Czecholslovakia and Japan
) to doctors in the developed world who maintained their patients on medications.
He then describes fifty years of American scientists doing experiments on schizoprenia patients: to intentionally exacerbate their symptoms and study the results. He compares the doctors' behavior, unfavorably, to 1947 after American trials of Nazi doctors ended in the Nuremberg Code
for ethics in human experimentation.
s. He says that many of these trials were stacked in favor of the drug being proposed by eliminating the placebo
, or by comparing multiple doses of the new drug against a single, very high dose of the old one. He says that the pharmaceutical companies and the press used their influence to make claims for these drugs (some claims that the Food and Drug Administration
had explicitly asked them not to make). Risperidone
and olanzapine
, for example, were both claimed to have fewer side effects than the first generation of antipsychotics. Whitaker also tells the stories of patients whose deaths were caused by drug trials but were not mentioned to the public.
activity and that drugs put these brain chemicals back in "balance". He writes, "Little is known about what causes schizophrenia. Antipsychotic drugs do not fix any known brain abnormality, nor do they put brain chemistry back into balance. What they do is alter brain function in a manner that diminishes certain characteristic symptoms....".
decided the book was one of the best histories of 2002. Discover
magazine placed it among the year's best science books. Recognizing Whitaker for marshalling evidence, a reviewer writing for the Chicago Tribune
thought his hopes for moral treatment were admirable but inadequate. Writers for The Baltimore Sun
and In These Times
both liked the book but wondered why the author didn't mention Thomas Szasz
, a critic of psychiatry.
writes that one of his physician friends "felt as bruised as a sinner who had been denounced by a strident evangelical preacher" upon reading Whitaker's Mad in America.
David Pilgrim, writing "News of scandal is a few decades too late" for Times Higher Education, focuses on the book's shortcomings, saying, "The semi-academic froth he generates distracts the reader from a legitimate outrage, which is not his alone. It was shared by many others well before 1998" (the year Whitaker began writing on mental health).
Physician Larry S. Goldman wrote a highly critical review of the book in Medscape Today
, stating that it "looks as if it were commissioned by Scientologists
." Goldman writes that Whitaker "is ready to throw the baby out with the bath water" because Mad in America fails to acknowledge any biological abnormalities in schizophrenia, while at the same conceding that Whitaker's argument that the true causes of schizophrenia
are not known is correct. Goldman also writes that the book promotes something akin to a conspiracy theory
"because it strings together many decades of disparate flops into a unifying theme of ongoing catastrophe." Goldman concludes that the "overheated style" of the book "tends to undermine some of its more important points, such as the unhealthy symbiosis between the US pharmaceutical industry and much of the psychiatric research community and the ever-present miserliness of public mental healthcare systems."
Clinical psychologist Claudia Bukszpan Rutherford similarly acknowledges the book's insight into many of the problems of clinical psychiatry over the years has good points, but is hampered by the author's extreme position and lack of investigation into what improves the prognosis of schizophrenia in underdeveloped countries. She adds that his minimizing of the severity and impact of the illness itself takes away from criticism of treatment.
The book was also reviewed in JAMA
, where reviewer Daniel J. Luchins, MD, of the University of Chicago observed the review of scientific literature to be biased at times. He noted the book omitted a key five year follow up study published in 1981 by May and colleagues, which showed some benefits from treatment with antipsychotics in patients with schizophrenia. Despite this, Luchins concluded the book was of value in highlighting social aspects of treatment in psychiatry.
Physician J. van Gijn, reviewing the book for the New England Journal of Medicine
, writes that "the book is more of an indictment than a historical account," and starts by pointing out that Whitaker "virtually equates mental illness with schizophrenia; depression and other psychiatric disorders are mentioned only parenthetically." Van Gijn summarizes the pre-1950 coverage of the book without much commentary, but then criticizes the rest of the book. Specifically, he questions Whitaker's assertion that Kraepelin's schizophrenia patients in fact suffered from encephalitis lethargica
. With regard to antipsychotic medication, van Gijn notes that "Although there may be truth in the notion that dosages of antipsychotic drugs in the United States are higher than necessary, the author weakens his position by issuing continuous and unrelenting condemnations (for instance, “The Nuremberg Code
doesn't apply here”), despite a dearth of evidence to support them." Van Gijn then describes Whitaker's attack on the dopamine hypothesis of schizophrenia
as "simplistic reasoning," and concludes that "Although [Whitaker] is widely read on the subject, the facts are largely arranged to suit his prejudice, especially in the chapters on drug treatment. American psychiatric institutions may have their failings in the current management of patients with schizophrenia, but they deserve better critics."
In a rejoinder to Goldman's review, physician Nathaniel S. Lehrman disagrees with Goldman, and writes that "Whitaker is right," and goes on to agree with the main points in the book, namely that antipsychotic
drugs cause brain damage
, that despite "psychiatrically produced misconceptions," they "do not fix any known brain abnormality nor do they put brain chemistry back into balance. What they do is alter brain functions in a manner that diminishes certain characteristic symptoms." Lehrman then writes that all the data accumulated on the neurobiology of schizophrenia "has hardly helped patient care."
writing for the Treatment Advocacy Center called it "histrionic" and "deeply disappointing." Clare Mundell writing for the Journal of the American Academy of Psychoanalisis and Dynamic Psychiatry, said Mad in America "should be required reading not only for mental health professionals, but also for those who still question whether profit has eclipsed patient care as the primary force in medicine in this country."
Robert Whitaker (author)
Robert Whitaker is an American journalist and author, writing primarily about medicine, science, and history.- Early career :He was a medical writer at the Albany Times Union newspaper, in Albany, N.Y., from 1989 to 1994. In 1992, he was a Knight Science Journalism fellow at MIT. Following that...
published in 2002 which is highly critical of the psychiatric profession. Problems with many historical aspects of treatment, as well as antipsychotic
Antipsychotic
An antipsychotic is a tranquilizing psychiatric medication primarily used to manage psychosis , particularly in schizophrenia and bipolar disorder. A first generation of antipsychotics, known as typical antipsychotics, was discovered in the 1950s...
s, are covered. The book received mixed reviews within the medical literature, which noted issues of bias in sourcing but nonetheless felt the discussion of social issues in psychiatry was important. The book received some better reviews from the lay press.
Whitaker, a medical journalist who was a finalist for a 1999 Pultizer Prize, has never suffered mental illness himself. He told WNET
WNET
WNET, channel 13 is a non-commercial educational public television station licensed to Newark, New Jersey. With its signal covering the New York metropolitan area, WNET is a primary station of the Public Broadcasting Service and a primary provider of PBS programming...
that members of his extended family have suffered it, a situation he believes he shares with most Americans.
Part One: The Original Bedlam (1750–1900)
Part One describes early treatments like a spinning chair which could reach 100 revolutions per minute, the Tranquilizer Chair which immobilized patients, and water therapies. Whitaker then describes moral treatmentMoral treatment
Moral treatment was an approach to mental disorder based on humane psychosocial care or moral discipline that emerged in the 18th century and came to the fore for much of the 19th century, deriving partly from psychiatry or psychology and partly from religious or moral concerns...
, dating back to 1793 and the French Revolution and established in the U.S. by Quakers in 1817, in which lay superintendents treated the mentally ill in small homes with great kindness and had good outcomes: About 35 to 80 percent of patients were discharged within a year, the majority of them cured. Pennsylvania Hospital reported that about 45 percent of patients were discharged as cured and 25 percent discharged as improved. In Worcester State Hospital
Worcester State Hospital
Worcester State Hospital was a Massachusetts state mental hospital located in Worcester, Massachusetts.The hospital and surrounding associated historic structures are listed as Worcester Asylum and related buildings on the National Register of Historic Places.-Early History:Once known as the...
, 35 percent were chronically ill or had died while mentally ill. Dr. George Wood, a visitor, reported in 1851:
Part Two: The Darkest Era (1900–1950)
Part Two describes the rise of eugenicsEugenics
Eugenics is the "applied science or the bio-social movement which advocates the use of practices aimed at improving the genetic composition of a population", usually referring to human populations. The origins of the concept of eugenics began with certain interpretations of Mendelian inheritance,...
which did away with moral treatment in favor of forced sterilization of the mentally ill, and led to newly invigorated fields of psychiatry
Psychiatry
Psychiatry is the medical specialty devoted to the study and treatment of mental disorders. These mental disorders include various affective, behavioural, cognitive and perceptual abnormalities...
and neuroscience
Neuroscience
Neuroscience is the scientific study of the nervous system. Traditionally, neuroscience has been seen as a branch of biology. However, it is currently an interdisciplinary science that collaborates with other fields such as chemistry, computer science, engineering, linguistics, mathematics,...
whose experts practiced insulin coma
Hypoglycemia
Hypoglycemia or hypoglycæmia is the medical term for a state produced by a lower than normal level of blood glucose. The term literally means "under-sweet blood"...
, metrazol
Pentylenetetrazol
Pentylenetetrazol , also known as metrazol, pentetrazol, pentamethylenetetrazol, Cardiazol or PTZ, is a drug used as a circulatory and respiratory stimulant. High doses cause convulsions, as discovered by the Hungarian-American neurologist and psychiatrist Ladislas J. Meduna in 1934...
convulsion, forced electroshock
Electroconvulsive therapy
Electroconvulsive therapy , formerly known as electroshock, is a psychiatric treatment in which seizures are electrically induced in anesthetized patients for therapeutic effect. Its mode of action is unknown...
, and lobotomy
Lobotomy
Lobotomy "; τομή – tomē: "cut/slice") is a neurosurgical procedure, a form of psychosurgery, also known as a leukotomy or leucotomy . It consists of cutting the connections to and from the prefrontal cortex, the anterior part of the frontal lobes of the brain...
.
Part Three: Back to Bedlam (1950–1990s)
Antipsychotic
An antipsychotic is a tranquilizing psychiatric medication primarily used to manage psychosis , particularly in schizophrenia and bipolar disorder. A first generation of antipsychotics, known as typical antipsychotics, was discovered in the 1950s...
drug chlorpromazine
Chlorpromazine
Chlorpromazine is a typical antipsychotic...
(Thorazine) by Rhône-Poulenc
Rhône-Poulenc
-History of the company:The Company was founded in 1928 through the merger of Société des Usines Chimiques du Rhône from Lyon and Établissements Poulenc Frères from Paris founded by Étienne Poulenc, a 19th century Parisian apothecary and brought to prominence by his second and third sons Emile...
in France, and its purchase by Smith, Kline & French (today known as GlaxoSmithKline
GlaxoSmithKline
GlaxoSmithKline plc is a global pharmaceutical, biologics, vaccines and consumer healthcare company headquartered in London, United Kingdom...
). The drug "produced an effect similar to frontal lobotomy", according to early reports by the company's lead investigator. Whitaker says that pharmaceutical advertising, articles published in the scientific literature, and stories in the media of "miracle drugs" transformed Thorazine into a healing drug.
Whitaker says that marketing money from pharmaceutical companies began to flow to the American Medical Association
American Medical Association
The American Medical Association , founded in 1847 and incorporated in 1897, is the largest association of medical doctors and medical students in the United States.-Scope and operations:...
in 1951, a year after Thorazine was synthesized, because of the Durham-Humphrey Amendment
Durham-Humphrey Amendment
The Durham-Humphrey Amendment explicitly defined two specific categories for medications, legend and over-the-counter . This amendment was co-sponsored by former vice president and senator Hubert H. Humphrey Jr., who was a pharmacist in South Dakota before beginning his political career...
to the Federal Food, Drug, and Cosmetic Act
Federal Food, Drug, and Cosmetic Act
The United States Federal Food, Drug, and Cosmetic Act , is a set of laws passed by Congress in 1938 giving authority to the U.S. Food and Drug Administration to oversee the safety of food, drugs, and cosmetics. A principal author of this law was Royal S. Copeland, a three-term U.S. Senator from...
which "greatly expanded the list of medications that could only be obtained with a doctor's prescription".
In Part Three, Whitaker also describes the American (but not for example British
United Kingdom
The United Kingdom of Great Britain and Northern IrelandIn the United Kingdom and Dependencies, other languages have been officially recognised as legitimate autochthonous languages under the European Charter for Regional or Minority Languages...
) propensity to classify patients as "schizophrenic", as well as the error (confusion of schizophrenia
Schizophrenia
Schizophrenia is a mental disorder characterized by a disintegration of thought processes and of emotional responsiveness. It most commonly manifests itself as auditory hallucinations, paranoid or bizarre delusions, or disorganized speech and thinking, and it is accompanied by significant social...
with the yet-to-be-discovered encephalitis lethargica
Encephalitis lethargica
Encephalitis lethargica or von Economo disease is an atypical form of encephalitis. Also known as "sleepy sickness" , it was first described by the neurologist Constantin von Economo in 1917. The disease attacks the brain, leaving some victims in a statue-like condition, speechless and motionless...
) in the original classification by Emil Kraepelin
Emil Kraepelin
Emil Kraepelin was a German psychiatrist. H.J. Eysenck's Encyclopedia of Psychology identifies him as the founder of modern scientific psychiatry, as well as of psychopharmacology and psychiatric genetics. Kraepelin believed the chief origin of psychiatric disease to be biological and genetic...
which psychiatry chose to not revisit and fix. Whitaker then describes three pathways that dopamine
Dopamine
Dopamine is a catecholamine neurotransmitter present in a wide variety of animals, including both vertebrates and invertebrates. In the brain, this substituted phenethylamine functions as a neurotransmitter, activating the five known types of dopamine receptors—D1, D2, D3, D4, and D5—and their...
may take in the human brain, and quotes first-person accounts of the effects of antipsychotic drugs on individuals.
He calls a 1996 New York Times advertisement by a consortium of pharmaceutical companies a "bald-faced lie": the group sought to say that the cause of psychosis and schizophrenia is an abnormal dopamine level and that their drugs worked by altering the level of dopamine. Whitaker then criticizes some American studies, and points out the work of George Crane at the National Institute of Mental Health
National Institute of Mental Health
The National Institute of Mental Health is one of 27 institutes and centers that make up the National Institutes of Health...
to get tardive dyskinesia
Tardive dyskinesia
Tardive dyskinesia is a difficult-to-treat form of dyskinesia that can be tardive...
recognized, and he contrasts the dosages that British
United Kingdom
The United Kingdom of Great Britain and Northern IrelandIn the United Kingdom and Dependencies, other languages have been officially recognised as legitimate autochthonous languages under the European Charter for Regional or Minority Languages...
doctors were comfortable in prescribing (300 milligrams per day of Thorazine) with what American psychiatrists prescribed (1,500 up to perhaps 5,000 milligrams per day).
He sees irony in the fact that The New York Times reported on Soviet forced use of neuroleptic drugs (which Florida Senator Edward Gurney called "chemicals which convert human beings into vegetables") in "psychiatric jails" but called the same drugs "widely acknowledged to be effective" when reporting on American schizophrenic patients.
Whitaker describes the demise of modern-day moral treatment in a short history of Loren Mosher's Soteria Project, funded by the U.S. while Mosher was chief of schizophrenia at NIMH. He attributes the results in a World Health Organization
World Health Organization
The World Health Organization is a specialized agency of the United Nations that acts as a coordinating authority on international public health. Established on 7 April 1948, with headquarters in Geneva, Switzerland, the agency inherited the mandate and resources of its predecessor, the Health...
1979 study of outcomes for schizophrenia patients (which found better outcomes in undeveloped countries like India
India
India , officially the Republic of India , is a country in South Asia. It is the seventh-largest country by geographical area, the second-most populous country with over 1.2 billion people, and the most populous democracy in the world...
, Nigeria
Nigeria
Nigeria , officially the Federal Republic of Nigeria, is a federal constitutional republic comprising 36 states and its Federal Capital Territory, Abuja. The country is located in West Africa and shares land borders with the Republic of Benin in the west, Chad and Cameroon in the east, and Niger in...
and Colombia
Colombia
Colombia, officially the Republic of Colombia , is a unitary constitutional republic comprising thirty-two departments. The country is located in northwestern South America, bordered to the east by Venezuela and Brazil; to the south by Ecuador and Peru; to the north by the Caribbean Sea; to the...
than in developed countries like the United States
United States
The United States of America is a federal constitutional republic comprising fifty states and a federal district...
, England
England
England is a country that is part of the United Kingdom. It shares land borders with Scotland to the north and Wales to the west; the Irish Sea is to the north west, the Celtic Sea to the south west, with the North Sea to the east and the English Channel to the south separating it from continental...
, Denmark
Denmark
Denmark is a Scandinavian country in Northern Europe. The countries of Denmark and Greenland, as well as the Faroe Islands, constitute the Kingdom of Denmark . It is the southernmost of the Nordic countries, southwest of Sweden and south of Norway, and bordered to the south by Germany. Denmark...
, Ireland
Ireland
Ireland is an island to the northwest of continental Europe. It is the third-largest island in Europe and the twentieth-largest island on Earth...
, Russia
Russia
Russia or , officially known as both Russia and the Russian Federation , is a country in northern Eurasia. It is a federal semi-presidential republic, comprising 83 federal subjects...
, Czecholslovakia and Japan
Japan
Japan is an island nation in East Asia. Located in the Pacific Ocean, it lies to the east of the Sea of Japan, China, North Korea, South Korea and Russia, stretching from the Sea of Okhotsk in the north to the East China Sea and Taiwan in the south...
) to doctors in the developed world who maintained their patients on medications.
He then describes fifty years of American scientists doing experiments on schizoprenia patients: to intentionally exacerbate their symptoms and study the results. He compares the doctors' behavior, unfavorably, to 1947 after American trials of Nazi doctors ended in the Nuremberg Code
Nuremberg Code
The Nuremberg Code is a set of research ethics principles for human experimentation set as a result of the Subsequent Nuremberg Trials at the end of the Second World War.-Background:...
for ethics in human experimentation.
Part Four: Mad Medicine Today (1990s–Present)
Part Four is Whitaker's description of drug trials for the newer atypical antipsychoticAtypical antipsychotic
The atypical antipsychotics are a group of antipsychotic tranquilizing drugs used to treat psychiatric conditions. Some atypical antipsychotics are FDA approved for use in the treatment of schizophrenia...
s. He says that many of these trials were stacked in favor of the drug being proposed by eliminating the placebo
Placebo
A placebo is a simulated or otherwise medically ineffectual treatment for a disease or other medical condition intended to deceive the recipient...
, or by comparing multiple doses of the new drug against a single, very high dose of the old one. He says that the pharmaceutical companies and the press used their influence to make claims for these drugs (some claims that the Food and Drug Administration
Food and Drug Administration
The Food and Drug Administration is an agency of the United States Department of Health and Human Services, one of the United States federal executive departments...
had explicitly asked them not to make). Risperidone
Risperidone
Risperidone is a second generation or atypical antipsychotic, sold under the trade name . It is used to treat schizophrenia , schizoaffective disorder, the mixed and manic states associated with bipolar disorder, and irritability in people with autism...
and olanzapine
Olanzapine
Olanzapine is an atypical antipsychotic, approved by the FDA for the treatment of schizophrenia and bipolar disorder...
, for example, were both claimed to have fewer side effects than the first generation of antipsychotics. Whitaker also tells the stories of patients whose deaths were caused by drug trials but were not mentioned to the public.
Epilogue
Whitaker calls it a type of medical fraud that we tell schizophrenics that they suffer from too much dopamine or serotoninSerotonin
Serotonin or 5-hydroxytryptamine is a monoamine neurotransmitter. Biochemically derived from tryptophan, serotonin is primarily found in the gastrointestinal tract, platelets, and in the central nervous system of animals including humans...
activity and that drugs put these brain chemicals back in "balance". He writes, "Little is known about what causes schizophrenia. Antipsychotic drugs do not fix any known brain abnormality, nor do they put brain chemistry back into balance. What they do is alter brain function in a manner that diminishes certain characteristic symptoms....".
Lay press
The American Library AssociationAmerican Library Association
The American Library Association is a non-profit organization based in the United States that promotes libraries and library education internationally. It is the oldest and largest library association in the world, with more than 62,000 members....
decided the book was one of the best histories of 2002. Discover
Discover (magazine)
Discover is an American science magazine that publishes articles about science for a general audience. The monthly magazine was launched in October 1980 by Time Inc. It was sold to Family Media, the owners of Health, in 1987. Walt Disney Company bought the magazine when Family Media went out of...
magazine placed it among the year's best science books. Recognizing Whitaker for marshalling evidence, a reviewer writing for the Chicago Tribune
Chicago Tribune
The Chicago Tribune is a major daily newspaper based in Chicago, Illinois, and the flagship publication of the Tribune Company. Formerly self-styled as the "World's Greatest Newspaper" , it remains the most read daily newspaper of the Chicago metropolitan area and the Great Lakes region and is...
thought his hopes for moral treatment were admirable but inadequate. Writers for The Baltimore Sun
The Baltimore Sun
The Baltimore Sun is the U.S. state of Maryland’s largest general circulation daily newspaper and provides coverage of local and regional news, events, issues, people, and industries....
and In These Times
In These Times
In These Times is a politically progressive monthly magazine of news and opinion published by the Institute for Public Affairs in Chicago...
both liked the book but wondered why the author didn't mention Thomas Szasz
Thomas Szasz
Thomas Stephen Szasz is a psychiatrist and academic. Since 1990 he has been Professor Emeritus of Psychiatry at the State University of New York Health Science Center in Syracuse, New York. He is a well-known social critic of the moral and scientific foundations of psychiatry, and of the social...
, a critic of psychiatry.
Psychiatry
Mad in America stirred some emotions in the medical profession. Richard BentallRichard Bentall
Richard Bentall is currently appointed as a Chair of Clinical Psychology at the University of Bangor in Wales, UK and is a Chartered Clinical Psychologist. Born in Sheffield, he attended the University College of North Wales, Bangor as an undergraduate before registering for a Ph.D. in...
writes that one of his physician friends "felt as bruised as a sinner who had been denounced by a strident evangelical preacher" upon reading Whitaker's Mad in America.
David Pilgrim, writing "News of scandal is a few decades too late" for Times Higher Education, focuses on the book's shortcomings, saying, "The semi-academic froth he generates distracts the reader from a legitimate outrage, which is not his alone. It was shared by many others well before 1998" (the year Whitaker began writing on mental health).
Physician Larry S. Goldman wrote a highly critical review of the book in Medscape Today
Medscape
Medscape is a web resource for physicians and other health professionals. It features peer-reviewed original medical journal articles, CME , a customized version of the National Library of Medicine's MEDLINE database, daily medical news, major conference coverage, and drug information—including a...
, stating that it "looks as if it were commissioned by Scientologists
Scientology and psychiatry
Scientology and psychiatry have come into conflict since the foundation of Scientology in 1952. Scientology is publicly, and often vehemently, opposed to both psychiatry and psychology. Scientologists view psychiatry as a barbaric and corrupt profession and encourage alternative care based on...
." Goldman writes that Whitaker "is ready to throw the baby out with the bath water" because Mad in America fails to acknowledge any biological abnormalities in schizophrenia, while at the same conceding that Whitaker's argument that the true causes of schizophrenia
Causes of schizophrenia
The causes of schizophrenia have been the subject of much debate, with various factors proposed and discounted or modified. The language of schizophrenia research under the medical model is scientific...
are not known is correct. Goldman also writes that the book promotes something akin to a conspiracy theory
Conspiracy theory
A conspiracy theory explains an event as being the result of an alleged plot by a covert group or organization or, more broadly, the idea that important political, social or economic events are the products of secret plots that are largely unknown to the general public.-Usage:The term "conspiracy...
"because it strings together many decades of disparate flops into a unifying theme of ongoing catastrophe." Goldman concludes that the "overheated style" of the book "tends to undermine some of its more important points, such as the unhealthy symbiosis between the US pharmaceutical industry and much of the psychiatric research community and the ever-present miserliness of public mental healthcare systems."
Clinical psychologist Claudia Bukszpan Rutherford similarly acknowledges the book's insight into many of the problems of clinical psychiatry over the years has good points, but is hampered by the author's extreme position and lack of investigation into what improves the prognosis of schizophrenia in underdeveloped countries. She adds that his minimizing of the severity and impact of the illness itself takes away from criticism of treatment.
The book was also reviewed in JAMA
Jama
Jama or JAMA may refer to:* Jama Software, a privately held company in Portland, Oregon* Journal of the American Medical Association, an international peer-reviewed general medical journal...
, where reviewer Daniel J. Luchins, MD, of the University of Chicago observed the review of scientific literature to be biased at times. He noted the book omitted a key five year follow up study published in 1981 by May and colleagues, which showed some benefits from treatment with antipsychotics in patients with schizophrenia. Despite this, Luchins concluded the book was of value in highlighting social aspects of treatment in psychiatry.
Physician J. van Gijn, reviewing the book for the New England Journal of Medicine
New England Journal of Medicine
The New England Journal of Medicine is an English-language peer-reviewed medical journal published by the Massachusetts Medical Society. It describes itself as the oldest continuously published medical journal in the world.-History:...
, writes that "the book is more of an indictment than a historical account," and starts by pointing out that Whitaker "virtually equates mental illness with schizophrenia; depression and other psychiatric disorders are mentioned only parenthetically." Van Gijn summarizes the pre-1950 coverage of the book without much commentary, but then criticizes the rest of the book. Specifically, he questions Whitaker's assertion that Kraepelin's schizophrenia patients in fact suffered from encephalitis lethargica
Encephalitis lethargica
Encephalitis lethargica or von Economo disease is an atypical form of encephalitis. Also known as "sleepy sickness" , it was first described by the neurologist Constantin von Economo in 1917. The disease attacks the brain, leaving some victims in a statue-like condition, speechless and motionless...
. With regard to antipsychotic medication, van Gijn notes that "Although there may be truth in the notion that dosages of antipsychotic drugs in the United States are higher than necessary, the author weakens his position by issuing continuous and unrelenting condemnations (for instance, “The Nuremberg Code
Nuremberg Code
The Nuremberg Code is a set of research ethics principles for human experimentation set as a result of the Subsequent Nuremberg Trials at the end of the Second World War.-Background:...
doesn't apply here”), despite a dearth of evidence to support them." Van Gijn then describes Whitaker's attack on the dopamine hypothesis of schizophrenia
Dopamine hypothesis of schizophrenia
The dopamine hypothesis of schizophrenia or the dopamine hypothesis of psychosis is a model attributing symptoms of schizophrenia to a disturbed and hyperactive dopaminergic signal transduction. The model draws evidence from the observation that a large number of antipsychotics have...
as "simplistic reasoning," and concludes that "Although [Whitaker] is widely read on the subject, the facts are largely arranged to suit his prejudice, especially in the chapters on drug treatment. American psychiatric institutions may have their failings in the current management of patients with schizophrenia, but they deserve better critics."
In a rejoinder to Goldman's review, physician Nathaniel S. Lehrman disagrees with Goldman, and writes that "Whitaker is right," and goes on to agree with the main points in the book, namely that antipsychotic
Antipsychotic
An antipsychotic is a tranquilizing psychiatric medication primarily used to manage psychosis , particularly in schizophrenia and bipolar disorder. A first generation of antipsychotics, known as typical antipsychotics, was discovered in the 1950s...
drugs cause brain damage
Brain damage
"Brain damage" or "brain injury" is the destruction or degeneration of brain cells. Brain injuries occur due to a wide range of internal and external factors...
, that despite "psychiatrically produced misconceptions," they "do not fix any known brain abnormality nor do they put brain chemistry back into balance. What they do is alter brain functions in a manner that diminishes certain characteristic symptoms." Lehrman then writes that all the data accumulated on the neurobiology of schizophrenia "has hardly helped patient care."
More reviews
Lehrman later wrote in the Journal of American Physicians and Surgeons that Mad in America is "perhaps the most important psychiatric book of the 21st century." Christian Perring, editor of Metapsychology Online Review and who was impressed by the book, wrote, "Even though Whitaker himself could be accused of being overly critical of psychiatry, his argument against schizophrenia medication is cogent enough to urgently require an answer." E. Fuller TorreyE. Fuller Torrey
Edwin Fuller Torrey, M.D. , is an American psychiatrist and schizophrenia researcher. He is Executive Director of the Stanley Medical Research Institute and founder of the Treatment Advocacy Center , a nonprofit organization with the goals of eliminating legal and clinical obstacles to the...
writing for the Treatment Advocacy Center called it "histrionic" and "deeply disappointing." Clare Mundell writing for the Journal of the American Academy of Psychoanalisis and Dynamic Psychiatry, said Mad in America "should be required reading not only for mental health professionals, but also for those who still question whether profit has eclipsed patient care as the primary force in medicine in this country."
External links
- Robert Whitaker's "Mad in America" a history of madness (25:40), Cambridge Community Television
- Mad in America, Whitaker and Lacasse site