The Difficult Progress of a New Idea

One month ago, on October 5th, over 150 people gathered in Carpenter Hall at Dartmouth College.  They heard Robert Whitaker, journalist and winner of the 2010 Investigative Reporters and Editors award for his book on psychotropic medication, Anatomy of an Epidemic. Mr. Whitaker gave a riveting, sometimes shocking account of what he has called “our societal delusion about the merits of psychiatric drugs.”   However, the headlines and take-away message were neither riveting nor shocking; they only repeated messages we’ve heard in the last several decades: psychotropic drugs are overused but we don’t know what else to do.

The real message got lost in conciliation. Mr. Whitaker told me that he doesn’t like to upset people and he tries to bring the message in a way they can hear.  And indeed, he reassured the audience that he was “agnostic” about the benefit of drugs.  However, I’ve read his book and talked with him and he’s “gnostic.”  He has reached a conclusion—that our culture’s turn to drugs has been a blunder.

Mr. Whitaker recognizes how far he shifts from conventional wisdom.  In his book’s epilogue, he describes the discomfort of holding beliefs out-of-sync with society.  There he quotes Edwin Whipple:  “Few dare to announce unwelcome truth.”  Indeed, Mr. Whitaker bears a heavy burden, because his discoveries make us rethink how we’ve treated mental pain and malfunction.  Mr. Whitaker told me he feels like Copernicus, and in so far as he has exposed our delusional faith in drugs, he’s right.

Here’s Mr. Whitaker’s revolutionary message.  This isn’t the message delivered by psychiatry and the pharmaceutical industry—that drugs fix chemical imbalances and restore healthy brain functioning.  No, his message is that drugs derange neurotransmitter pathways and the brain overcompensates; when the drugs are withdrawn, the system is unbalanced. The rise in bi-polar illness, Mr. Whitaker argues, is linked to the use of illegal drugs, legal stimulants, and legal anti-depressants—all substances that dysregulate neurotransmitter systems.  The long-term outcomes for schizophrenics on medication are clear—their prefrontal cortices receive less input because dopamine activity is blocked, and they shrink.  Before drugs, mental illness was episodic and self-limiting; patients usually returned to work.  Now, it is degenerative and mental patients are swelling the disability rolls.  Today, one out of 76 Americans is disabled by mental illness and one out of 45 working-age Americans receives disability. A writer for The Chronicle Review (September 23, 2011) heard Mr. Whitaker’s Copernican message loud and clear: psychotropic drugs may be the biggest case of iatrogenesis—harmful medical treatment—in history.

At the Upper Valley lecture, however, Mr. Whitaker sometimes adopted Galileo’s strategy, prudent recantation.  During the discussion, he conceded that 1/3 of schizophrenics will likely need meds long-term.  Now, even this concession exposes a problem in standard practice in the United States, where virtually all psychotic patients receive a prescription and the melancholy news that they are forever disabled.  But hadn’t Mr. Whitaker just told us that anti-psychotic drugs shrink and injure the brain?  Wouldn’t he, wouldn’t we, want to protect that 1/3 from these injuries and find alternative treatments?

In fact, we already have an alternative. For 100 years, we’ve had psychotherapy, informed by psychoanalysis.  Psychotherapy, the collaboration of two human minds, harnesses the brain’s natural growth potential, advances at a natural rate of change, and enriches inner life.

This non-drug treatment has worked even for serious mental illness.  In the 1960s, Bertram Karon compared the efficacy of psychoanalytic psychotherapy, drugs, and the two combined to treat schizophrenia.  The study was small, but the 36 subjects were some of the most seriously impaired.  Karon found that those who had psychoanalytic psychotherapy and no drugs showed the greatest decline in thought disorder, which in turn led to fewer hospitalizations.  At the two-year follow-up, patients who had psychotherapy (alone or with drugs) had spent half as much time re-hospitalized as the drug-only patients.

Psychoanalytic therapy for depression, anxiety, and complex mental disorders has yet stronger evidence for it’s effectiveness. (See Jonathan Shedler’s 2010 review in American Psychologist.)  The Journal of the American Medical Association stunned the health care field in 2008 when it published a meta-analysis of 23 studies of long-term psychodynamic psychotherapy.  The long-term psychotherapy patients did significantly better than those who had shorter-term treatments.  Most importantly, analytic patients continued to improve when treatment ended, but shorter-term therapy patients did not.  Because medicated patients did worse, none of the patients in the final meta-analysis had used medication.

So here’s the final tally, a tally that’s been hard for us to calculate while under the enchantment of drugs.  Meds are easy, but they have negative side-effects, muck-up the brain, and leave it dysregulated when they are withdrawn.  Psychotherapy takes time, money and hard work, but it teaches life-long skills and sets in motion a growth process that continues long after treatment ends.  Drugs promote self-ignorance; analytic psychotherapy promotes self-knowledge.

Analytic psychotherapy or medication?  It’s beginning to look like a no-brainer.

Society took the road most easily traveled when it chose the pharmaceutical re-engineering of the human brain.  This was a wrong turn.  Mr. Whitaker, uneasy though it makes him, has exposed the staggering costs of this wrong turn.  Chemical coercion of the human brain hasn’t worked.  Acknowledging this sad truth could lead to collective wisdom.