Two views: Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America

In his 2001 book, Mad in America (1), Robert Whitaker reviewed three centuries of mental health treatments and attempted to understand why positive outcomes for patients with schizophrenia in the United States have decreased for the past 25 years. In Anatomy of an Epidemic, Whitaker returns to that research in an attempt to understand what he calls the current “psychiatric epidemic,” in which the number of Americans diagnosed and treated for mental illness more than doubled between 1987 and 2007, even though billions of dollars have been spent each year on psychotropic drugs.

Among the explanations for such an epidemic that Whitaker proposes is that mental illness has become a “profit center.” From drug companies skewing their studies in favor of medication to the entangled relationship between American psychiatry and the pharmaceutical industry, Whitaker underlines what he calls “the mistreatment of the mentally ill.” He makes the case that many psychotropic drugs once advertised as “magic bullets” may cause as much, if not more, harm than good, particularly in the long run. The reality, he says, is that “because no one knows what causes mental illness, there's no cure or palliation to be found in these pills.”

These provocative assertions could drive away readers who would view Whitaker as an antipsychiatry activist and dismiss his work outright. To these skeptics, and to all of us interested in what is happening in the field of psychiatry, I strongly recommend this book. Residents in training may also particularly benefit from this wider perspective about the profession they have chosen. Whitaker is a serious and well-informed investigative journalist. Although the reader may see bias in how the author interprets some of his findings, he makes a solid, well-researched case that is backed by evidence. Many of Whitaker's criticisms are not new, having been raised by prominent experts, including Loren Mosher (2), Marcia Angell (3), David Healy (4), and Allen Frances (5).

As much as I appreciate Whitaker's denunciation of many things that are wrong in psychiatry, I am disappointed that the people whom he blames for these developments are almost exclusively the proponents of biological psychiatry and pharmaceutical companies. If that approach has the advantage of stirring up old stereotypes and swiftly mobilizing the antipsychiatry movement, it risks missing other factors that play a role in this dangerous evolution, hence limiting our ability to fully address it. For instance, he doesn't address the impact that the for-profit health care system has had on psychiatrists' work—increasing time constraints and administrative duties. These changes have cornered psychiatrists into a position where visits are reduced to the quick “med check.”

We can also question the role of a general public who would prefer to think that problematic behaviors are essentially the result of a “chemical imbalance” amenable to quick fixes rather than fully considering the impact of psychosocial and economic problems. If Whitaker is one of the voices we ought to consider in the reshaping of psychiatric treatments in the 21st century, then mental health clinicians should be heard as well. In order to regain some of the trust we have lost with our patients and their families, we need, as a profession, to own up to our mistakes. By doing this we can hope to preserve the ability not only to offer medication when necessary but also to advocate for another essential element of the practice of healthy medicine: a dependable, honest, and more sustained relationship between doctor and patient.