4 Mayıs 2010 Salı

The Astonishing Rise of Mental Illness in America

In 1987, prior to Prozac hitting the market and the current ubiquitous use of antidepressants and other psychiatric drugs, the U.S. mental illness disability rate was 1 in every 184 Americans, but by 2007 the mental illness disability rate had more than doubled to 1 in every 76 Americans. Robert Whitaker was curious as to what was causing this dramatic increase in mental illness disability. The answers are in his new book, Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America (Crown Publishers, April 2010).
Whitaker’s findings will create a problem for both Big Pharma and establishment psychiatry, but his credentials and his craftsmanship will make it difficult to marginalize him.

Whitaker is the author of four books including Mad in America, about the mistreatment of the mentally ill; and as a reporter for the Boston Globe, he won a George Polk Award for medical writing, a National Association of Science Writers Award for best magazine article, and was a finalist for a Pulitzer Prize. In the tradition of Michael Pollan, Eric Schlosser, and other investigative reporters who get taken seriously, Whitaker is scrupulous, fair, and describes complex phenomena in a way that is easy to understand.
Levine: So mental illness disability rates have doubled since 1987 and increased six-fold since 1955. And at the same time, psychiatric drug use greatly increased in the 1950s and 1960s, then skyrocketed after 1988 when Prozac hit the market, so now antidepressant and antipsychotic drugs alone gross more than $25 billion annually in the U.S. But as you know, correlation isn’t causation. What makes you feel that the increase in psychiatric drug use is a big part of the reason for the increase in mental illness?
Whitaker: The rise in the disability rate due to mental illness is simply the starting point for the book. The disability numbers don’t prove anything, but, given that this astonishing increase has occurred in lockstep with our society’s increased use of psychiatric medications, the numbers do raise an obvious question. Could our drug-based paradigm of care, for some unforeseen reason, be fueling the increase in disability rates? And in order to investigate that question, you need to look at two things. First, do psychiatric medications alter the long-term course of mental disorders for the better, or for the worse? Do they increase the likelihood that a person will be able to function well over the long-term, or do they increase the likelihood that a person will end up on disability? Second, is it possible that a person with a mild disorder may have a bad reaction to an initial drug, and that puts the person onto a path that can lead to long-term disability. For instance, a person with a mild bout of depression may have a manic reaction to an antidepressant, and then is diagnosed with bipolar disorder and put on a cocktail of medications. Does that happen with any frequency? Could that be an iatrogenic [physician-caused illness] pathway that is helping to fuel the increase in the disability rates?
So that’s the starting point for the book. What I then did was look at what the scientific literature -- a literature that now extends over 50 years -- has to say about those questions. And the literature is remarkably consistent in the story it tells. Although psychiatric medications may be effective over the short term, they increase the likelihood that a person will become chronically ill over the long term. I was startled to see this picture emerge over and over again as I traced the long-term outcomes literature for schizophrenia, anxiety, depression, and bipolar illness. In addition, the scientific literature shows that many patients treated for a milder problem will worsen in response to a drug-- say have a manic episode after taking an antidepressant -- and that can lead to a new and more severe diagnosis like bipolar disorder. That is a well-documented iatrogenic pathway that is helping to fuel the increase in the disability numbers
Now there may be various cultural factors contributing to the increase in the number of disabled mentally ill in our society. But the outcomes literature -- and this really is a tragic story -- clearly shows that our drug-based paradigm of care is a primary cause.
Levine: I have a clinical practice and I have seen several examples of what you are talking about, and I had previously read several of the scientific studies that you detail in Anatomy of an Epidemic, so I am not exactly a naïve reader. However, in reading your book and seeing the enormity of the problem and just how much overwhelming evidence there is for a horrible crisis, I started getting a little sick to my stomach. I wonder, as you got into the research, did you start drawing comparisons to Rachel Carson and Silent Spring? Specifically, this is such a huge unnecessary tragedy, affecting several million people including children, yet there is virtually no discussion of it in the mass media.
Whitaker: A journalist friend of mine, who was a long-time reporter at the Washington Post and Newsday, said that he too was reminded of Silent Spring when he read Anatomy of an Epidemic. And, in fact, I was stunned by much of what I found when I was researching the book, and I did at times become overwhelmed by the magnitude of the tragedy. Let me give a specific example. When you research the rise of juvenile bipolar illness in this country, you see that it appears in lockstep with the prescribing of stimulants for ADHD and antidepressants for depression. Prior to the use of those medications, you find that researchers reported that manic-depressive illness, which is what bipolar illness was called at the time, virtually never occurred in prepubertal children. But once psychiatrists started putting “hyperactive” children on Ritalin, they started to see prepubertal children with manic symptoms. Same thing happened when psychiatrists started prescribing antidepressants to children and teenagers. A significant percentage had manic or hypomanic reactions to the antidepressants. Thus, we see these two iatrogenic pathways to a juvenile bipolar diagnosis documented in the medical literature. And then what happens to the children and teenagers who end up with this diagnosis? They are now put on heavier-duty drugs and often on a drug cocktail, and you find that they do poorly on that treatment. You find that a high percentage end up “rapid cyclers,” which means they have severe “bipolar” symptoms, and that they can now be expected to be chronically ill throughout their lives. We also know that the atypical antipsychotics [such as Risperdal and Zyprexa] prescribed to bipolar children cause a host of physical problems, and there is pretty good evidence that they cause cognitive decline over the long term. When you add up all this information, you end up documenting a story of how the lives of hundreds of thousands of children in the United States have been destroyed in this way. In fact, I think that the number of children and teenagers that have ended up “bipolar” after being treated with a stimulant or an antidepressant is now well over one million. This is a story of harm done on an unimaginable scale.
So why hasn’t the media reported on this? The answer is that the media, when it covers medicine, basically repeats the narrative fashioned by the academic doctors who are leaders in the particular discipline, and in this case, academic psychiatrists have told a story of new illnesses -- like juvenile bipolar illness -- being “discovered,” and of drugs for those treatments that are safe, effective and necessary. They tell this story to the public even as their own studies find that their juvenile bipolar patients -- who when they first came to a psychiatrist might simply have been “hyperactive” or struggling with a momentary bout of depression -- are ending up with severe bipolar symptoms and can now expect to be chronically ill for life. The problem is that our society trusts academic doctors to tell an honest story, and in this corner of medicine, it's quite easy to document -- and I did document this in Anatomy of an Epidemic -- that academic psychiatry has belied that trust.
Levine: Let’s get to the issue of psychiatric medications fixing “chemical imbalances.” This idea was absolutely crucial in making Prozac and other antidepressants attractive to depressed patients. However, these days even much of the psychiatry establishment has backed off the idea that depressed people have too little serotonin between their synapses and that antidepressants fix this chemical imbalance. Maybe it’s just me, but I can’t help but see the comparison between Big Pharma and the Bush Administration, which told Americans that the U.S. needed to invade Iraq because Saddam Hussein had weapons of mass destruction and he was connected to Al Qaeda. Of course, the Saddam Hussein-Al Qaeda connection was simply a lie, and the WMD rationale proved to be false. Do you believe that Big Pharma and establishment psychiatry were lying about this chemical imbalance theory at the time Prozac hit the market in 1988, or do you believe that they had hoped this theory was true because it sold drugs -- and it just turned out to be wrong?
Whitaker: The low-serotonin theory of depression was first investigated in the 1970s and early 1980s, and those studies did not find that people diagnosed with depression had “low serotonin.” As the NIMH [National Institute of Mental Health] noted in 1984 at the conclusion of such investigations: “Elevations or decrements in the functioning of serotonergic systems per se are not likely to be associated with depression.” So why was the public told differently?
The answer is a bit complicated. In the late 1970s, the market for psychiatric drugs declined and psychiatry suddenly saw itself as a profession under “siege,” having now to compete with a burgeoning number of psychologists and other non-physician therapists for patients. In response, the profession -- at its highest levels -- decided to sell the public on a biomedical model of mental disorders, as that model would naturally emphasize the importance of taking “medications” for a disease and it was only psychiatrists who could prescribe those drugs. This story-telling began with the publication of DSM-III in 1980, which the American Psychiatric Association (APA) heralded as a grand “scientific achievement,” and then soon the APA was announcing that great discoveries were being made about the biology of mental disorders. And once psychiatry began to tell a story that wasn’t science based, but rather was best described as a marketing campaign, I think it began to believe its own marketing slogans. I don’t know this for a fact, but I am willing to bet that Bush, Rumsfeld, Cheney and others began to believe their own public pronouncements about weapons of mass destruction and a Saddam Hussein-Al Qaeda connection, and I think something similar to that happened in American psychiatry when Prozac came to market. The field stopped looking at the science that showed that the low-serotonin theory of depression had basically already flamed out, and instead began to believe its own propaganda.
Moreover, the chemical-imbalance story did more than just spur sales of drugs. It provided psychiatris ts with a desirable public image. They were now like doctors in infectious medicine and other respected specialties, their medications “like insulin for diabetes.” The chemical-imbalance story told of medical progress, of a discipline that was unlocking the mysteries of the brain. Indeed, when Prozac came to market, there were newspaper stories about how psychiatry now had a new reason to “feel proud,” and how its public image had improved. So in the late 1980s and early 1990s, the chemical imbalance story is not one that tells of how lying moved into the heart of the field, but rather how professional delusion did.
At some later point, however, as the chemical imbalance story repeatedly fell apart, psychiatrists in the research community understood that they were telling a “fib.” I can still remember -- this was the summer of 1998 -- when I questioned a prominent academic psychiatrist about whether the chemical imbalance story was really “true” and he replied by stating that it was a “useful metaphor” that “helped patients understand why they needed to take their medication.” This really is the tragedy of modern psychiatry -- it became a medical discipline devoted to telling a public story that made its drugs look good, as opposed to telling a story rooted in honest science.
Levine: Big Pharma and their partners in establishment psychiatry would like the general public to believe that the only critics of psychiatry are Scientologists. In reality, most scientists who are critics of psychiatry are also critics of the pseudoscience of Scientology. It is my experience that serious critics of psychiatry are not anti-drug zealots. For example, I know that you have talked with “psychiatric survivors” -- ex-patients who want to reform mental health treatment. David Oaks, one of the leading activists in the psychiatric survivor movement, often repeats that some members of his MindFreedom organization continue to take their psychiatric drugs while many choose not to, and what MindFreedom and other psychiatric survivors are fighting for is truly informed choice and a wider range of treatment options. Do you think that David Oaks’s fight is the right one?
Whitaker: Big Pharma and their partners in establishment psychiatry have smartly used Scientology to defuse criticism of their medications. I honestly believe that if Scientology weren't around, then our society could have a much more rational discussion about our drug-based paradigm of care. As for the position taken by MindFreedom and other psychiatric survivors, I basically do think that is the right one to take, with two caveats. In order to make a “truly informed choice,” a person needs to know the long-term effects of a treatment. It’s not enough for people to be fully informed about the immediate “side effects” of a drug. People need to be presented with information about whether such treatment has been shown to better the long-term course of the disorder, or worsen it. They need to be told about long-term physical and cognitive problems that often arise with every day use of psychiatric drugs. So providing people with a “truly informed choice” is a tall order.
My second caveat is this: As a society, we expect the medical community to develop the best possible form of care. We do not expect a medical community to offer a therapy that regularly leads to a bad end. And so, if we were to draw up a blueprint for reforming the current paradigm of care, it would be nice if the psychiatric community would try to develop therapeutic approaches that involved using psychiatric medications in a selective, cautious way that best promoted good long-term outcomes. In other words, I think psychiatry does have a responsibility to develop a true evidence-based model for using its drugs, a model that incorporates the long-term outcomes data. In the solution section of Anatomy of an Epidemic, I write of how doctors and psychologists in northern Finland use antipsychotics in a selective, cautious manner when treating first-episode psychotic patients, and their long-term outcomes are, by far, the best in the Western World. So if you believe in evidence-based medicine, then American psychiatry should look to the Finnish program as a model for reform. Doctors have a responsibility to lead, but I think that you see in David Oaks’ position a belief that establishment psychiatry in America cannot be trusted to provide such leadership. He’s right to believe that, of course, and that's what is so tragic about modern American psychiatry.

Why do so many women have depression?

Novelist Allison Pearson is the latest in a long line of high-profile women to talk publicly about their depression. All these women had the pretty terrific lives – or that's how it looked from the outside. So what went wrong?
Allison Pearson, author of I Don't Know How She Does It, has written for the Daily Mail about her depression. Photograph: Suzanne Plunkett/AP
In 2002, Allison Pearson emerged as the chief chronicler of a very modern female malady: the crazed pursuit of the perfect life. Her novel, I Don't Know How She Does It, which started life as a column in the Daily Telegraph, told the story of that rarely sighted beast, a female hedge fund manager, and followed her struggle to juggle two children with her very full-time job. The protagonist, Kate Reddy, may have had a nanny and a husband who was both gainfully employed and nifty in the kitchen, but her life seemed full of comic anxieties. (The novel opened with her attempts to "distress" some Sainsbury's mince pies that her daughter was taking to school, so that they looked appropriately, maternally, handmade.) And while the book depicted an aspirational bubble that floats way over most of our heads, it found an immediate audience. In fact, it became a bestseller, the film rights were sold, and Oprah Winfrey – that essential filter of the modern female experience – described it as a "bible for the working mother".
In her worldly success, and her approach to life, it was assumed that Pearson was very similar to her protagonist. She's a high-flying journalist who has won a number of awards; her partner is New Yorker writer Anthony Lane; she has two children. In precis, it's a convincing portrait of a perfect life. But yesterday, her comic tone was jettisoned. Pearson has been writing for the Daily Mail for some years now, but this column was to be her last, she said, because she has depression. She had always wanted to be "the best kind of girl", but recently she found herself in a psychiatrist' s consulting room, assessing just how unhappy she was. The psychiatrist asked if she'd had any suicidal thoughts, and "I didn't mention the strange allure of a nearby motorway bridge at dead of night . . . Eventually, I blurted into the silence: 'Sometimes, I think it would be easier not to be. Not to be dead. I have two children, I can't leave them. But just to stop, you know. To not exist for a while.'"
Pearson went on to describe herself as a "sandwich woman", one of a generation who had waited until their 30s to have children and then, just as their offspring were "sleeping through the night, one of [their] parents fell ill". The stress of this situation – and a job on top – has taken its toll. "Is it women who are mad, or is it the society we live in?" she asked. "We always suspected there would be a price for Having it All, and we were happy to pay it; but we didn't know the cost would be to our mental health."
Over the last few months, many other stories like Pearson's have emerged – tales of apparently enviable lives laid low. In January, the popular novelist Marian Keyes posted a message on her website attesting to her "crippling depression . . . I can't eat, I can't sleep, I can't write, I can't read, I can't talk to people". In February, an inquest found that the bestselling author Susan Morgan – who wrote under the pen name Zoe Barnes – had killed herself. In March, on Desert Island Discs, the actor Emma Thompson recalled the depression she had experienced after her divorce from Kenneth Branagh in the mid-1990s, saying that she didn't think she had stayed "sane. I should have sought professional help." And over the last few years, a number of memoirs of depression have been written by women. The former Elle and Red magazine editor, Sally Brampton, wrote Shoot the Damn Dog. The former Scotland editor of the Observer, Lorna Martin, wrote Woman on the Verge of a Nervous Breakdown. And the former deputy literary editor of the Observer, Stephanie Merritt, published The Devil Within. The mood of these memoirs was captured in a long, unflinching article by the American writer Daphne Merkin in the New York Times, in which she described her depression as "the sadness that runs under the skin of things, like blood, beginning as a trickle and ending up as a haemorrhage, staining everything".
This deluge shouldn't come as a surprise; over a period of decades, study after study has suggested that women are diagnosed with depression at twice the rate of men; in recent years, one study found this specific ratio occurring across nine different countries, regardless of economics and culture. As Merritt, who has written widely on the subject, points out, these findings are open to question – "because it's possible that, for men, drug and alcohol abuse could be symptoms of a depression that they just can't articulate. It could be that women are more able to ask for help." But there is no doubt that the numbers regarding women and depression are stark – 11.2% of the female population are experiencing it at any one time.
And those figures are on the rise. Last year, an NHS study showed that between 1993 and 2007, while there had been no change in the number of common mental disorders such as depression and panic attacks in men, they had risen by a fifth for women aged 45-64. For over-75s, such disorders were twice as likely among women as men. A study of 15-year-olds in Scotland found that while 19% of girls experienced such common mental disorders in 1987, that incidence had increased to 44% by 2006 (a year in which the figure for boys reached 21%). And, last year, in the US, academics Betsey Stevenson and Justin Wolfers published a report called The Paradox of Declining Female Happiness. "The lives of women in the US have improved over the past 35 years by many objective measures," they wrote, "yet we show that measures of subjective wellbeing indicate that women's happiness has declined both absolutely and relative to men."
Of course, when studies of this kind are published – spanning the period of second-wave feminism, and showing a diminution in female happiness – the word often goes out that it is time for women to throw off their business suits and get back in the kitchen. The argument runs that feminism has failed, worn women out, and that a return to domesticity is the answer. The problem is, of course, that the domestic realm was itself a depressant – as anyone who has ever read The Yellow Wallpaper or The Feminine Mystique, watched The Stepford Wives, or lived through the 1950s, will fully realise.
Depression can, of course, have a multitude of sources – divorces, bereavements, the sea-deep pain of some childhood trauma. But those problems have always existed. I ask psychologist and author Dorothy Rowe, a leading expert on depression, where she thinks this modern stream stems from. Could it have a physical basis? Could it be that old culprit: hormones? "No, there's no evidence for that at all," she says. "I remember back in the 1980s, when I was working in Lincoln, and the received wisdom was that women got depressed after childbirth because of their hormones. It's always your hormones. But at that time, under Thatcher, there was a huge recession, and there were many men who had lost their jobs at the steelworks. Their wives could work as secretaries or in shops, and the men stayed at home with small children. You suddenly found that there was an awful lot of postnatal depression among men. That's it. It's being at home, bringing up small children, and nobody ever addressing you as yourself."
Now, says Rowe, while women are still often seen as mothers rather than individuals, there are many more pressures at play. "There's still this idea that you've got to be a wonderful mother, but you also have to have a brilliant career, and you've got to look attractive all the time," she says. "There is no way that you can maintain that and bring up children. But it's still being presented to women all the time, in every magazine, on every screen, that you should."
Martin agrees with Rowe. In her mid-30s, she was diagnosed with clinical depression, started a course of antidepressants, and eventually began a long period of therapy that brought her out of the "swamplands of the soul". She feels that: "There's massive pressure on women these days to hold down a good, rewarding, fulfilling job, but also to be a good mother, and then to look good, and to look after yourself. I think there comes a point where your body can't take it." She also suspects that we are being made sicker as a result of our culture of entitlement. Consumer culture constantly undermines the idea that sadness can be an acceptable part of our lives – instead we are taught that the perfect life is verdantly happy, and that any malady can be treated, at a cost.
"I think we're conditioned to think that sadness shouldn't be part of the human condition," says Martin. "But it is. It's like all of these difficult emotions, like loss, fear of mortality. All of these emotions that seem so difficult, so they're just pushed away – then they bubble up. Perhaps we have to become a bit better at understanding and dealing with them." She admits though, that while "it's very easy for me to sit here now and say these things, four years ago, if someone had said that I should have just come to terms with my sadness, I would have wanted to kill them."
The fact is that modern women are, as Margaret Drabble has termed us, "pioneers"; while our lives have changed inestimably over the last three decades, men's have lagged behind. We have forged careers, inched ever closer to the glass ceiling, seen our salaries increase – at the same time, we're still expected to take on the lion's share of the housework and childcare. Meanwhile consumerism has dictated that we should be forever groomed, well-dressed; that in order to have a good life we need Louboutin heels and Vuitton bags, a Botoxed brow, inch-long lashes, Cath Kidston curtains and a pastel-blue Aga. It's a situation that Pearson chronicled expertly in her novel. "Is it coincidence, " she wrote, "that we spend far more than our parents ever did on the restyling and improvement of our homes – homes in which we spend less and less time." And, crucially, she noted that "mysteriously, childcare, though paid for by both parents, is always deemed to be the female's responsibility. "
One of the most insidious aspects of this culture is that the quest for perfection seems to stop women getting help for depression as soon as they should. As Martin says, "I desperately hated the fact that I needed help. Our culture absolutely insists on us being strong, independent women, and so the idea that you actually need a bit of help, that's the biggest hurdle." Merritt agrees: "I was very reluctant to be an object of pity, or to look vulnerable. I didn't want people to think that I couldn't manage. But the problem is that the longer you leave it, the harder it becomes, and then you just start cutting corners to keep up this appearance of competence, and eventually you just implode, or explode, because you can't keep that up indefinitely. The strain of acting the part of somebody who is doing well – and then having other people who depend on you, asking you to do more and more, is a huge issue. But I think a lot of women impose that on themselves."

One obvious answer to all this is that men need to do more in the home. Another answer, says Rowe, is something that's easier said than done for many women. You have to let things slide. "Most girls are still brought up to be very good," she says, "and a good person is somebody who always feels that they can do better. We're brought up on the principle that if a job's worth doing, it's worth doing well. And actually, what women need to learn is that if a job's worth doing, it's worth doing badly – as long as you get it done. If you look around at the people who seem to cope with all that they've got to do, you'll see how women skimp things – saying, 'We'll have something out of the freezer tonight for dinner' for instance. You need to distinguish very clearly between what's essential to do properly, and what isn't essential. There's a lot of stuff that doesn't need doing."