Review of "Mad in America"

By Robert Whitaker
Perseus Publishing, 2002
Review by Christian Perring, Ph.D. on Jan 16th 2002
Mad in America

Mad In America is a powerfully troubling argument against the way that psychiatry treats schizophrenia and other major mental illnesses.  The first two parts of the book set out the history of treatment for the insane in the US and Europe from 1750 until 1950, and Whitaker’s account does not differ significantly from others, such as Edward Shorter’s, although it is shorter and highlights different details.  But while other accounts say that since the Second World War, the availability of neuroleptic medication has meant a dramatic improvement in the treatment of schizophrenia, Whitaker argues the new medications are comparable in their dangerousness and ineffectiveness to the barbaric ‘remedies’ that were forced on patients in earlier times.  The essential question for any reader of Mad In America is whether Whitaker presents compelling evidence for his claims. 

The problem that nearly all readers will face in assessing Whitaker’s criticisms of psychiatry is that they, like me, are not experts in psychopharmacology.  They, like me, will not know the relevant scientific literature concerning the testing of medications or the detailed history of psychiatric treatment in the twentieth century – and, unfortunately, merely having read a few books on the subject does not make one an expert.  Furthermore, if Whitaker is right, then readers will have strong reasons to doubt the opinions of most experts, since one of his main claims is that they do not face the real evidence that is available concerning the danger and lack of effectiveness of medication.  Under the influence of the pharmaceutical industry, from the 1960s psychiatric experts changed their descriptions of neuroleptic drugs from “brain damaging” to “virtually free of side-effects” and ignored the studies that show that unmedicated schizophrenics have a lower rate of relapse than those who take medication.  Whether they are corrupt or simply unwitting pawns of the drug companies, on Whitaker’s view, most psychiatrists do not have an unbiased understanding of the evidence; it follows that readers should read psychiatrists’ predictable protests about Mad in America with a great deal of suspicion.

Most readers of Mad in America will have the luxury of waiting to see what happens in this debate.  We can hope that some neutral institution will be able to assess Whitaker’s claims about both neuroleptic medication and the new ‘atypical’ medications for schizophrenia.  This may require finding researchers who do not have financial relationships with the pharmaceutical industry, and in the US, there are few such people.  Even federal research bodies such as the National Institute of Mental Health employ researchers who are tightly connected with drug companies.  It seems that we may need to look to research done in other countries where there is more done to avoid financial influence tarnishing the objectivity of scientific testing of new medications and more effort is made to evaluate the efficacy of alternative treatments.

However, some readers of this book will themselves have a diagnosis of schizophrenia, or will have a family member or close friend with that diagnosis.  They will face a far more difficult decision: whether to accept the recommendation of psychiatrists to take neuroleptic or atypical medication for their condition, or to take a different course.  On what basis can patients or legal guardians make such a decision?  What can family and friends of people diagnosed with schizophrenia say to them that might be helpful when deliberating about medication?  I know that if I had a family member with a diagnosis of schizophrenia, I would now be very scared about the possible long-term effects of medication after reading Mad in America.  Let me say a little about how I might think through the issues.

Whitaker is not the first person to make worrying claims about the effects of medication for schizophrenia.  The most well known critic of psychiatric medication is Peter Breggin, and he has a large section of his Toxic Psychiatry devoted to the dangers of treatments of psychiatry.  While Breggin has asked some difficult questions, I’ve never found him a very compelling critic of psychiatry: he has been too closely tied with the antipsychiatric view that mental illness is a myth, and his understanding of psychiatric illness often seems problematic.  For example, he thinks that schizophrenia is not a brain disease but is instead a “psychospriritual crisis.”  (Toxic Psychiatry, p. 24).  His writing style seems a little too sensational to ring true, and, far more importantly, his discussion of the empirical literature is on the brief side.  He makes a great many accusations in the hope that some will stick, but in the end, he undermines his own credibility.  While I think it is very important that there should be people focusing on the efficacy and safety of medications, I have not been convinced by Breggin’s arguments that psychiatric medication is always the wrong choice.

By way of contrast, I found the arguments of Whitaker far more convincing and worrying.  His writing style, for what it is worth, is clear and careful; even though he goes into the details of empirical studies in surprising depth, and even when he makes extremely grave accusations (backed up by explanations and references to the academic literature as well as interviews) his tone is calm.  The book is well written and the argument is easy to follow.  He keeps his focus on his central claims: current psychiatric treatment for schizophrenia increases the danger of relapse, so patients would be better off with no treatment. 

The clinical approach to schizophrenia that seems most promising to Whitaker is the gentle “moral treatment” started by the York Quakers in England at the end of the eighteenth century and brought to America in the nineteenth century in Philadelphia, Boston, and New York.  By 1841, there were sixteen private and public asylums in the US.  He cites evidence that 60-80% of patients admitted to these asylums in the first half of the nineteenth century were discharged as “cured” or “improved.”  But then other more invasive or brutal treatments started to become popular, and treatment for insanity never again achieved the success it did during that period.  It is clear that Whitaker would favor an attempt to replicate the results of the Quakers achieved in their asylums, treating people with severe mental illnesses gently and giving them time for their period of insanity to pass. 

One of the problems for research into testing new psychiatric medications these days is that it is difficult to find patients who have never taken any psychiatric medication and to compare the results in a double blind studies with patients randomly assigned to either the test group or the control group.  Double blind studies are especially hard to perform because psychiatric medication for schizophrenia has such obvious side effects that patients may be able to tell whether they are getting the medication or a sugar pill, and so the study is not “blind” at all.  Studies that would be able to compare medication against no treatment may be flawed or they simply have not been done.  Far more frequent are comparisons between different medications, where one is shown to be more effective than another.  Whitaker explains some of the methodological problems of many of these experiments, casting doubt on the apparently positive results they give for new medications. 

Also alarming are recent cases of clear fraud that have occurred in some important drug trials.  Whitaker goes into the details, which do not need repeating here.  He acknowledges that these cases of unethical behavior by researchers do not show that medications are unsafe, but they do suggest that there are not sufficient safeguards to prevent breaches in scientific procedure.  The picture he paints is of a testing process that is vulnerable to the corruption of individuals ready to make money from drug companies at any cost, with drug companies ready to turn a blind eye to such irregularities because it helps them in their grab for the huge profits they can make from a new medication. 

Combining this with the history of psychiatry in the first half of the twentieth century, when the mentally ill in America were considered by many prominent scientists and politicians to be genetic defects that should not be allowed to breed, Whitaker’s book leaves one to conclude that psychiatry is in a deep crisis.  In its rush to become more biological and avoid the accusations of being pseudoscientific that came from its affiliation with psychoanalysis, it has linked itself too closely with the financial interests of the pharmaceutical industry.  Psychiatry tries to give the impression that it has left its dark past long behind, but in fact it may actually just be repeating the mistakes of the past.  Whitaker concludes in the last line of the book, “The day will come when people will look back at our current medicines for schizophrenia and the stories we tell to patients about their abnormal brain chemistry, and they will shake their heads in utter disbelief.”

As I have said, Whitaker’s arguments are powerful and need to be taken very seriously.  They put in a difficult position both those who need to decide whether to take medication for schizophrenia, and those who need to decide whether to encourage or discourage someone they love to take medication.  They need to ask whether there are any reasons to doubt Whitaker’s claims.

One issue that will occur to some is that Whitaker is not a psychiatrist himself; he is an investigative journalist.  Some may say that since he himself is not a psychiatric expert, he is not qualified to make judgments on these issues.  But this would be a weak response, since it is simply an ad hominem prejudice, and does not address Whitaker’s argument at all.  He has clearly researched his book very carefully, and has gathered and assessed the views of many researchers in the field, and his arguments cannot be so easily dismissed.

More problematic is the fact that Whitaker does not address the problems of assessing the positive results of the Quaker asylums and comparing them with modern treatments.  Unless one knows what kind of illnesses those people classified as insane in the early nineteenth century actually had, it makes little sense to compare the high rates of success in treatment with the current success rates.  Indeed, it seems that there is very little data concerning the relapse rates for those treated in the asylums, so we have little basis to judge how successful the moral-treatment actually was.

Also worth noting is the fact that Whitaker spends little time discussing the experience of schizophrenia itself and the seriousness of the illness, and this seems like a weakness of the book. While Breggin downplays the seriousness of the condition by calling it a psychospiritual crisis, Whitaker gives very little description of schizophrenics at all.   But many would say that paying attention to the experience and behavior of schizophrenics shows that they need to be protected against themselves, and that we need to protect society from them.  Whether or not the medications currently in use actually stop the symptomatic delusions or simply stop patients from acting on them, they are effective in changing the behavior of people with schizophrenia.  That much is uncontroversial.  Whitaker has not made a strong case that there is a viable alternative to using medication – unless we bring back large-scale compulsory hospitalization, which was abandoned because it was though too expensive and simply fostered the helplessness of patients. 

In considering how best to treat someone diagnosed with schizophrenia, I’d also keep in mind that the FDA does regulate new medication and the US does have a number of regulatory bodies concerned with the safety of medications.  Whitaker himself often quotes from FDA reports in making his case against medications, and the cases of scientific fraud were ones that were uncovered.  It is certainly not the case that the pharmaceutical industry is unregulated; there are safeguards in place.  Even if these safeguards are not perfect, there’s still reason to think that they are playing an important role.  Unless one is ready to come to the conclusion that government and regulatory bodies are utterly in the pocket of big business and that none of the scientists working in these areas has any integrity, one should acknowledge that there is evidence for the relative safety of FDA approved medication.

Finally, if I were making a decision for a family member, I would also take into account the advice of psychiatrists and other mental health professionals I trust, who have a great deal of experience with the treatment of schizophrenia.  Even though the current health care system is putting psychiatrists into the role of pill-prescribers and leaving other, less well paid, workers to do the rest of the work in the care of the mentally ill, it still remains true that most mental health professionals I know care deeply about their patients.  The health care system may be bureaucratic and may turn individuals into faceless cases, but people who work with patients chose their work for a reason, and that reason is rarely the money, since they could make more money more easily by doing something else.

So, even after being so impressed by Mad in America, I think I would advise a family member diagnosed with schizophrenia to take the advice of psychiatrists if I knew those psychiatrists and had developed a relationship with trust with them.  Most of all, I’d fight to get the best care for my family member.  (I recommend Jay Neugeboren’s book Transforming Madness for an inspiring discussion of the care available for people with severe mental illness; Neugeboren’s discussion indeed lends some credence to Whitaker’s faith in moral-treatment.)  If anything is clear from the available evidence, it is that medication alone will not solve the problems of schizophrenia.  

That said, Mad in America shows how pressing is the need for the public to be able to get an unbiased assessment of current psychiatric treatment, untainted by the profit motive of the pharmaceutical industry.  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.  I strongly recommend this book to anyone interested in the current state of psychiatry. 

© 2002 Christian Perring. First Serial Rights.

Christian Perring, Ph.D., is Chair of the Philosophy Department at Dowling College, Long Island. He is editor of Metapsychology Online Review. His main research is on philosophical issues in psychiatry. He is especially interested in exploring how philosophers can play a greater role in public life, and he is keen to help foster communication between philosophers, mental health professionals, and the general public.


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