Mad in America
Author: Robert Whitaker

Overview

This book is a scathing denunciation of what the author labelled as the ‘conventional narrative‘ that ‘makes treatment with antipsychotics the centrepiece of care’ of psychotic disorders. Decrying the drug treatment of mental illness as ‘a public health failure‘, the author set out to show that this therapeutic approach is detrimental because psychiatric diseases are not biological brain disorders, and that ‘the biological underpinnings of madness remain as mysterious as ever’. The book argues that the contemporary state of psychiatric treatments with the newer antipsychotics is ‘a story marred by greed, deaths, and the deliberate deception of the American public’. With a critical perspective backed up with exhaustive research, the book challenges the philosophy of a major medical specialty and calls for a reassessment of some of its fundamental practices (pages xvi-xvii, 214-218, 231 and 253-286).

Synopsis

As a prelude to his exploration of the antipsychotic drugs, the author documented an enlightening history and commentary of schizophrenia in which he highlighted its mysteries and scientific uncertainties. Remarking that ‘the very concept of schizophrenia was born amid diagnostic confusion‘, the author argued that the boundary of normal manifestations and psychotic symptoms was difficult to define, and that psychosis is difficult to distinguish from such disorders as neurosis and manic depression. The narrative credited the ‘invention‘ of psychosis as a disease to the German psychiatrist Emil Kraepelin who first called it dementia praecox, and it attributed the term schizophrenia to the Swiss psychiatrist Eugene Bleuler. To illustrate his argument about the clinical difficulty in recognising schizophrenia, the author cited the classical 1973 study carried out by David Rosenhan in which normal subjects presenting to mental institutions were wrongly diagnosed with psychosis. And in a seemingly controversial assessment, the author quoted studies which not only show that people who are correctly labelled with the diagnosis do not conform to biological models of schizophrenia, but also studies which contradict the accepted dopamine hypothesis of schizophrenia. Based on these observations, the author made the strong claim that it is the antipsychotic agents themselves that transform normal brains into schizophrenic ones (pages 164-174, 196-199 and 235-259).

A central theme of the book was the influence of eugenics on societal attitudes to people with mental illness. Painting eugenics as the philosophy that encouraged Americans to view the mentally ill with scorn, the author chronicled the genesis of the ideology from its introduction by Francis Galton, through to its wholesale adoption ‘by graduates of Harvard, Yale, and other Ivy League universities‘. The author also described how eugenics assumed the cloak of genetics and became a pseudoscience through the research of such biologists as Charles Davenport and Aaron Rosanoff, and with the funding of such ‘industrial titans of America as Andrew Carnegie, John D. Rockefeller Jr., and Mary Harriman. The book’s depiction the unfortunate consequences of the spread of eugenics was graphic, from segregation and compulsory sterlisation of the mentally ill and other disadvantaged groups, to its adoption by Nazi Germany, the country which it said ‘took eugenic treatment of the mentally ill to its ultimate end‘, and where it ‘ran its full course‘. The author also blamed Adolf Meyer, ‘the leading figure in American psychiatry at the time’, for enabling the mistreatment of the mentally ill in poorly maintained institutions which functioned, not as ‘hospitals that provided medical care’, but as ‘facilities that served to segregate the misfits from society’ (pages 41-52, 54-58 and 62-69).

The major theme of the book is its assessment of the evidence for the effectiveness of psychotropic drugs. In a narrative that referred to the introduction of chlorpromazine into clinical use as beginning of ‘the modern era of medical treatments for schizophrenia’, the book asserted that the drug was actually first considered to be ‘a pill that hindered brain function, much in the same manner as lobotomy did’. The author argued that the gradual transformation of chlorpromazine into an antipsychotic had more to do with marketing expedience and the fiscal agenda for ‘replacing asylum care with community care’, than with the emergence of any robust scientific findings. The author contended that the public image of chlorpromazine as an effective treatment for schizophrenia was the result of a carefully crafted campaign that was not supported by the research evidence which rather showed that the drug was associated with longer hospitalisations and more frequent relapses. Maintaining that chlorpromazine caused ‘all of the traits that we have come to associate with schizophrenia’, the author concluded that ‘the story of neuroleptics’ is that of ‘drugs that induced a brain pathology, similar in kind to encephalitis lethargica and Parkinson’s disease’ even though this wasn’t the story American psychiatry sold to the public (pages 141-147, 154-164 and 195).

To complement his comprehensive review of the modern treatment of schizophrenia, the author also provided a most enlightening and comprehensive history of mental diseases. In this regard, the author went back to the 16th and 17th centuries when he said the insane were considered to be like ‘wild animals‘ who were to be ‘dominated and broken‘ by such treatments as purging, emetics, bleeding, blistering, water therapy, swinging chairs, tranquillizer chairs, spinning boards, and physical violence. Disturbingly, the author showed that these treatments were advocated by the leading physicians of the time such as John Munro, the Bethlehem asylum superintendent, and Benjamin Rush, the ‘leading authority on madness’ in America. The book then chronicled the emergence of the view that lunatics were human beings who deserve ‘to be treated with kindness and respect‘, a transformation that it attributed largely to the introduction, in the late eighteenth century, of ‘moral treatment‘ by the French psychiatrists Jean Baptiste Pussin and Philippe Pinel. The narrative also chronicled how this philosophy spread widely after the Quakers, led by William Tuke, used its principles to set up an asylum in York where they conceived of the insane, not ‘as a wild beast‘, but ‘a worthy person capable of self-governance‘ (pages 3-9, 11-13 and 19-24).

The decline of moral therapy and the the ascendance of chemical cures in psychiatric practice was one of the book’s key criticisms. The author asserted that moral treatment in America took ‘a decided turn‘ at the Hartford Retreat for the Insane where chemical and physical restraints were re-introduced. And it was to Dorothea Dix, the asylum reformer, that the book attributed ‘the downfall of moral treatment’. Arguing that her ‘successful lobbying‘ for the building of asylums was not matched by their capacity to deliver moral therapy, he said this made the asylum attendants to return to ‘maintaining order in the old way – with coercion, brute force, and the liberal use of restraints.’. Neurologists also came under the book’s censure for delivering what it referred to as ‘the final blow‘ to moral therapy. In this narrative, the author argued that it was the ‘stinging attacks‘ of such leading neurologists as Edward Spitska, Edward Seguin and Silas Weir Mitchell, that asylum doctors were ‘a pathetic lot’ with ineffectual cures, that encouraged psychiatrists to look for ‘a scientific approach to treating the mentally ill’. The author further contended that it was this search for ‘a therapeutic triumph‘ that led psychiatrists to adopt ‘a quartet of therapies‘ which he said were dreadful, generally ineffective, and seriously risky: insulin coma, metrazol convulsive therapy, electroshock, and prefrontal lobotomy (pages 25-29, 34-38 and 73-108).

Opinion

This book details the uncomfortable evolution of psychiatric treatments, from the old and abandoned practices to the current psychotropic agents. Drawing similarities between them, the book calls attention to the dearth of scientific understanding of mental illness, and the poor evidence for the effectiveness of many psychiatric treatments. Whilst his criticisms of psychiatry past and present are scathing, the author justifies them on what appears to be a well-researched history. The book’s lines of argument are well-thought out and its reasoning very logical.  The history it documents is also very well-narrated, exhaustive, and focused. The book’s argument that mental illnesses are not biological is however difficult to sustain in view of the emerging evidence the contrary. The Rosenhan study he cited has also been criticised, most ably by Susannah Cahalan in her book The Great Pretender which will be reviewed later in this series.

Overall assessment

This book makes a compelling case for reconsidering the current paradigm of schizophrenia and for a reassessment of the approach to mental illnesses as a whole. By painting a rather disturbing picture of psychotropic drugs, and by citing credible supporting evidence, it is a loud call for a reassessment of the subject. The book also highlights the risks of the close relationship of doctors with the pharmaceutical industry that goes to the heart of not just psychiatry, but medicine as a whole. The book also advocates for a return to the humanistic and moral treatment of mental illness. Beyond its core objective, this book is an exhaustive history of psychiatry, its pioneers, and its treatments, and I recommend it to all doctors.

Book details

Publisher, Place, Year: Basic Books, New York, 2019
Number of chapters: 11
Number of pages: 362
ISBN: 978-1-5416-1806-0
Star rating: 5
Price: £10.30