Anatomy of a Non-Epidemic

E Fuller Torrey, legendary these last 30 years in schizophrenia research and advocacy for the biological understanding of that illness (and others), reviewed Robert Whitaker's Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America, which had come out a few years before.  I had heard of Whitaker's book, touted quietly to me by a psychologist, and had run across reference to it a few other times. I was a bit surprised that it hadn't simply vanished like so many other books trying to scramble up evidence that schizophrenia was all some huge misunderstanding on the part of psychiatry and the medical profession.  Surprised because the evidence for that POV had largely not changed in the last twenty years - unless I had missed something that hadn't come to Dartmouth Medical School or the psychiatrists I work with. Somehow it persisted, but as it wasn't taking the world by storm around here I saw no need to follow up.  I just wondered.

Torrey makes a persuasive case, which I find he usually does.

In its 396 pages Whitaker got many things right, including criticism of the broad DSM diagnostic criteria for mental illnesses; the reckless prescribing of psychiatric drugs for children; and the prostitution of many psychiatric leaders for the pharmaceutical industry. Indeed, regarding the last, Whitaker may have understated the problem, based on recently released court documents detailing how the pharmaceutical industry secretly controlled the Texas Medication Algorithm Project.

When it came to schizophrenia and antipsychotic drugs, however, Whitaker got it mostly wrong. He made so many errors it is difficult to know where to begin, so I will begin where he did. In his Preface Whitaker says that his research on the book began when he encountered “two research findings that just didn’t make sense”: a 1994 schizophrenia outcome study (Hegarty et al. 1994) and the World Health Organization (WHO) studies “which had twice found that schizophrenia outcomes were much better in poor countries.”

I looked up that Texas Medication Algorithm Project reference, and it does seem to be seedy in parts, though "controlled" turns out to be a bit overstated. Janssen did end up paying $158M to settle, so that's not chopped liver. These are the sorts of reasonable complaints that can be leveled against Big Pharma, though usually not all of them at once, just one at a time: kickbacks, ignoring some studies and highlighting others, outcomes that seem to favor the expensive drugs under patent rather than the older medicines which are now generics.  But note.  This isn't Big Pharma making up illnesses that don't exist, or suppressing evidence of natural cures that are just as good, or making people believe they are sick. It's thumb-on-the-scale stuff, not denial-of-reality.  That's my default view of conspiracy theories and corporate corruption accusations, based on getting tired of investigating fevered claims.

Which is bad enough, and deserves big punishment.

Favoring newer drugs isn't all just money-chasing either (though some of it is).  There are usually specifics that pharmaceutical companies are trying to improve, because of problems with the old medications.  Side effects, because of the impact on long-term health (kidneys, livers) and the subsequent effect on compliance, just for openers. There was a reason why haloperidol replaced throrazine, and olanzepine replaced haloperidol.