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