Anti-Psychiatry and The Anatomy of a Non-Epidemic

Anatomy of an Epidemic

Anti-psychiatry is a pseudoscience that is based on denying the existence of mental illness, rejecting the efficacy of mainstream science-based treatment and demonizing medical doctors who specialize in psychiatry. The anti-psychiatry movement is very diverse and include individuals with very different views on economy and liberty and not all anti-psychiatry proponents agree with all three core beliefs.

Some creationists reject the notion of psychiatric conditions because they think that mental illness is a form of satanic contamination of an immaterial soul and scoff at mainstream treatments do not involve a scriptural perspective on original sin. Some people who embrace alternative medicine or new age belief systems think that depression is just a result of too much negative energy and that if they just think positively or take homeopathy, they will attract good things in life. Even some secular atheists have jumped on the anti-psychiatry train, either by shrieking about “reductionism” or buying into irrational and evidence-free conspiracy theories about how psychiatrists supposedly regularly kidnap, torture and murder their patients.

Robert Whitaker is an anti-psychiatry journalist and author who has written many articles and books arguing against mainstream psychiatry, including a paper in the bottom-of-the-barrel quack journal Medical Hypotheses that was not peer-reviewed at the time. His general approach is to mischaracterize how modern psychiatry looks at the causes of mental illness and spread misinformation about psychiatric medications by misusing old studies while ignoring their flaws and ignoring hundreds of studies that contradicts him.

E. Fuller Torrey is an American psychiatrist with a special research focus on schizophrenia. He runs Stanley Medical Research Institute and founded Treatment Advocacy Center. A while back Torrey wrote a scathing review of the latest anti-psychiatry book written by Whitaker. That review, called Anatomy of a Non-Epidemic: How Robert Whitaker Got It Wrong, will be discussed in additional detail in this post, because it is one of the best refutations of anti-psychiatry claims available on the Internet.

What did Whitaker get right?

Despite being one of the most prominent anti-psychiatry proponents and activists in the world and promoting a ton of pseudoscientific nonsense, Whitaker does get some things right.

Pharmaceutical companies sometimes behave unethically and they have been convicted of many improprieties, lapses and even criminal offenses. There are reasons to have a critical discussion of expanding diagnostic criteria and the excessive treatment of children with psychopharmaceuticals.

However, Whitaker succumbs to irrational pseudoscience and the abuse of real science in his zealous attack on psychiatry and medical doctors. Let us look at a couple of examples.

How Whitaker abuses several schizophrenia outcome studies

Like many proponents of pseudoscience, Whitaker just takes the studies that he thinks support his position, mangle them until they appear to confirm his claims and ignores the broader scientific literature.

Whitaker cites a 1994 schizophrenia outcome study and suggest that the outcomes for people with schizophrenia has gotten worse despite ample access to antipsychotic medication. What he fails to take into account is that the clinical definition of schizophrenia has changed several times over time and that this is not adjusted for in the study and the paper itself never claims that outcomes have worsened. In fact:

It is an analysis of schizophrenia outcomes throughout the twentieth century, linking outcomes to diagnostic criteria. When a broad definition of schizophrenia was in vogue, outcomes were better but when a narrow definition was in vogue, outcomes were worse, as would be expected. The data showed a clear improvement in outcomes during the 1960s and 1970s following the introduction of antipsychotic drugs, then a worsening in the 1980s and 1990s. The authors attributed this to the introduction of a narrow definition of schizophrenia, requiring six months of symptoms to qualify for the diagnosis, in DSM-III introduced in 1980. They concluded “that diagnostic criteria have had a consistent and predictable impact on outcome before and during the era of modern biomedical therapeutics. The authors did not claim that the outcome of schizophrenia had actually worsened.

A similar fate hits Whitaker’s discussion of the WHO outcomes studies that compare industrial to a developing nations. Whitaker claims that the apparent better outcomes in the developing nations (where there is little use of antipsychotics) over the industrialized nations (where antipsychotics are wildly used) shows that antipsychotics do not help and in fact hinder improvement. What Whitaker fails to understand is that the WHO center in developing countries in the study included many people (in some studies as many as 50% of patients in the study) who did not have true schizophrenia, but rather acute reactive psychosis, which have better outcome than schizophrenia. Furthermore, newer and more robust studies have discredited this claim:

Cohen et al. (2008) examined 23 schizophrenia outcome studies in 11 low-and-middle income countries and concluded that there is “a need to reexamine the conclusions of the WHO studies.” Messias et al. (2007) suggested that an increased mortality among the sickest patients in developing countries may have created an illusion that outcomes among other patients were better. And most recently Teferra et al. (2011) reported five years outcome data on 321 schizophrenia patients in rural Ethiopia with results sharply at variance with the WHO results.

The WHO has also retracted and altered their original claim.

Why does Whitaker ignore individuals with untreated schizophrenia?

Whitaker spends a lot of time discussing and misusing scientific studies on people with schizophrenia who have not been treated with antipsychotics. But he forgets one crucial aspect, namely the outcomes of people today who live with schizophrenia without medication. Torrey delivers yet another powerful blow to Whitaker:

Whitaker clearly believes that schizophrenia should be treated without medication if at all possible. However he fails to focus any attention on the fact that on any given day in the United States half of all individuals with schizophrenia, or about one million people, are not being treated. This is a huge natural experiment to test his thesis. Many of these individuals are found in public shelters, sleeping under bridges, in jails, and in prisons. If Whitaker had spent more time in these settings observing the outcome of this natural experiment, instead of delivering lectures on his vision of the impending antipsychotic apocalypse, he would have written a very different book.

Let us take that one more time: at any given day, one million people with schizophrenia are not receiving treatment with medication. Despite the beliefs of Whitaker, they are not doing so good. Quite the opposite, they are living extremely impoverished lives. That we, as a society, cannot offer them housing and medical help is astonishingly disgusting. Contrary to Whitaker, we need to expand and develop mental health services, including housing, medical treatment, antipsychotics and psychotherapy wherever possible.

Why did millions of people have schizophrenia prior to the discovery of antipsychotics?

Whitaker believes that schizophrenia is caused by antipsychotic medications. However, there have been millions of people with schizophrenia before the discovery of antipsychotics starting in the 1950s, so this effectively disproves the core premise of Whitaker’s anti-psychiatry nonsense. Here is how Torrey puts it:

But if schizophrenia is largely a product of antipsychotic drug use, who were those millions of people in state psychiatric hospitals beginning in the early 1800s until antipsychotics were introduced in the 1960s? This question seems to perplex Whitaker and he has no good answer. He weakly offers an explanation put forth by Mary Boyle, an English psychologist and author of Schizophrenia: A Scientific Delusion? Citing a 1990 paper by Boyle, Whitaker claims that “many of Kraepelin’s dementia praecox [schizophrenia] patients were undoubtedly suffering from a viral disease, encephalitis lethargica, which in the late 1800s had yet to be identified” (pp. 90-91). In fact, encephalitis lethargica is a well-defined syndrome which followed the 1917 influenza pandemic (Ravenholt & Foege, 1982). There is no evidence whatsoever that it existed prior to that time or continued beyond about 1930.

So despite a weak attempt to explain those millions of people with schizophrenia before antipsychotics were ever used clinically, the pseudoscientific narrative of Whitaker ultimately goes down in flames. Antipsychotics are not the cause of schizophrenia and this is perhaps the ultimate coup de grâce of anti-psychiatry.

This critical review written by Torrey covers many more examples where Whitaker distorts and mischaracterizes psychological research on schizophrenia and is well worth a read for anyone interested in the dangers of anti-psychiatry. A cached version of this review is also available here.

Emil Karlsson

Debunker of pseudoscience.

2 thoughts on “Anti-Psychiatry and The Anatomy of a Non-Epidemic

  • October 28, 2016 at 13:25
    Permalink

    While I appreciate critical discussions about the topic, I find your style unfair.

    You begin by defining ‘anti-psychiatry’ as a collection of scientific non-sense. Alright. But then you immediate associate Robert Whitaker with this definition. This is unjust, even if you do not agree with his position. A necessary discussion is hard when you start with accusing somebody else of having a pseudo-scientific standpoint. Sorry, but this has no style and only discredits your (maybe valid) arguments.

    Also, you accuse him of having positions that I have never heard him say. For instance, you imply that he “believes that [ALL! – added by me] schizophrenia is caused by antipsychotic medications.” Just because there were people with schizophrenia before, does not exclude the possibility that antipsychotic have a *long-term* negative effect.

    You say, “contrary to Whitaker, we need to expand and develop mental health services, including housing, medical treatment, antipsychotics and psychotherapy wherever possible.” I believe he would agree, excluding the antipsychotics medication part.

    Last, but not least, the fact that many untreated patients “are found in public shelters, sleeping under bridges, in jails, and in prisons” says more about the US society than over drug use and misuse.

    If you are really interested in a scientific debate with the goal that patients are treated in the best possible way, you should discuss on a different level than simply saying that what you do not agree with is pseudo-science. I think, Robert Whitaker asks the right questions and these questions are worth discussing in a different way.

    Btw, even if you do not post this comment, think about it for a second!

  • October 28, 2016 at 17:54
    Permalink

    While I appreciate critical discussions about the topic, I find your style unfair.

    Not an argument.

    You begin by defining ‘anti-psychiatry’ as a collection of scientific non-sense. Alright. But then you immediate associate Robert Whitaker with this definition. This is unjust, even if you do not agree with his position

    If you read the post carefully, I explicitly say that the “anti-psychiatry movement is very diverse and include individuals with very different views on economy and liberty and not all anti-psychiatry proponents agree with all three core beliefs.”

    A necessary discussion is hard when you start with accusing somebody else of having a pseudo-scientific standpoint.

    It is not an accusation. It is a demonstrable fact.

    Also, you accuse him of having positions that I have never heard him say. For instance, you imply that he “believes that [ALL! – added by me] schizophrenia is caused by antipsychotic medications.”

    If Whitaker does not believe that antipsychotics cause the symptoms of schizophrenia, why did he attempted to explain away cases of schizophrenia by appealing to the flawed idea of Mary Boyle? The pages where he claims this can be found in the original review.

    Just because there were people with schizophrenia before, does not exclude the possibility that antipsychotic have a *long-term* negative effect.

    But it does exclude the idea that antipsychotics can explain a considerable portion of schizophrenia cases, since even the most generous interpretation of his claims would mean that there are millions of people with the psychiatric condition before the advent of antipsychotics.

    The arguments provided by Whitaker that antipsychotic causes more harm than benefit in the long-term have been refuted. It is based on his misreading of scientific research and failure to understand the impact of differences in clinical definitions across time and space.

    You say, “contrary to Whitaker, we need to expand and develop mental health services, including housing, medical treatment, antipsychotics and psychotherapy wherever possible.” I believe he would agree, excluding the antipsychotics medication part.

    The problem is that eliminating antipsychotics out of the equation will likely reduce the benefit of the other treatments, since people with psychotic delusions and hallucinations are probably not going to benefit as much from psychotherapy. It is well-established that a combination of treatments is better than they are individually.

    I think, Robert Whitaker asks the right questions and these questions are worth discussing in a different way.

    Asking questions is great. Hiding behind “just asking questions” and making incredibly flawed claims and mischaracterization of studies, however, is not great.

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