Robert Whitaker answers reader questions on pharma marketing and psychiatric drugs

On the Mad in America podcast this week, we continue our reader Q&A with Mad in America founder Robert Whitaker. In Part 1, we discussed Mad in America, the biopsychosocial model and the history of psychiatry. For Part 2, we will be covering reader questions on pharmaceutical marketing and issues with psychiatric treatments including psychiatric drugs and electroconvulsive therapy. Thank you to all of you who took the time and trouble to send in your questions.

The transcript below has been edited for length and clarity. Listen to the audio of the interview here:

James Moore: Mary has sent in some questions and her first is, in the past, there were other tools used to at least try to help folks in crisis. Has anyone investigated how alternative therapies were diminished and basically vanquished? Was it related to medical insurance or government programs?

Robert Whitaker: It was related to 1980 and the third edition of the Diagnostic and Statistical Manual. If you go before 1980, back to DSM-I and DSM-II, those books tell of how psychiatric disorders often are reactions to difficulties in the environment or, say, to stressors in the family. There was always a core group of biological disorders, but that was a small group.

That was the understanding in the ’70s, that social things did count. Then what happened in the 1970s? Psychiatry as a profession said, “we’re under siege. Our future and our survival are threatened. Why is it threatened? Because there is an anti-psychiatry movement saying we function more as a means of social control than as medical doctors.” Benzodiazepines, their most famous and popular drugs, were seen as addictive and harmful. Their psychotherapy was not seen as any better than talk therapies offered by psychologists and counselors. There was a report that their diagnostic categories were invalid and unreliable. And finally, there were two things culturally that happened that made psychiatry say, we need to remake ourselves.

One was the movie One Flew Over the Cuckoo’s Nest, which presented the staff in a mental hospital as crazier than the patients and, frankly, brutal and oppressive. And then there was a paper published in Science by David Rosenhan. What he did in this experiment was he sent ordinary people to mental hospitals and they said they were hearing words like thud, etc. They were all admitted into the hospital and diagnosed with schizophrenia and never found out as imposters even though they stopped complaining about that word and never behaved poorly.

Now, there have been questions raised about that study but, nevertheless, in the 1970s, that hit like a bang, that we don’t know what insanity is. Five days or so after that paper appeared, the American Psychiatric Association (APA) said we have to redo our diagnostic manual. We’re going to set up a task force. And as they did this, they said, how can we rebrand ourselves? We can rebrand ourselves as doctors in white coats, as medical doctors. Now, how do you do that? You call psychiatric difficulties diseases of the brain.

There was no research that justified this rebranding, this re-conceptualization of what happened to human beings. This is new.

The minute that the APA published DSM-III, they had to sell this new model of thinking to the public, and they launched a big PR effort with money from the drug companies. Once that happens, health insurance companies say okay, if it’s a disease in the brain, why should we pay for talk therapy? Why should we pay for anything else? We’ll just pay for you to get the pill that fixes the disease. So that’s what happened.

But it’s important to understand that it happened because American psychiatry in the 1970s felt its future as a medical discipline was under siege. It was being threatened. And they rebranded themselves as doctors in white coats, they literally put on white coats, and what do doctors in white coats do? They fix illnesses in the brain. That’s when we begin hearing about chemical imbalances. And that’s when this completely false narrative was told to us.

Moore: A follow-up question from Mary. She asks, Did psychiatry become involved with the “Decade of the Brain”? Just for context, the decade of the brain was defined as the period between 1990 and 1999, and it was part of a large effort involving the National Institute of Mental Health and the National Institutes of Health to enhance public awareness of the benefits to be derived from brain research.

Whitaker: Yes, these fit in hand in glove. Part of the decade of the brain was the message to the public that we were discovering all these incredible things about the brain, making great advances, and of course, we’re going to decode the human genome during this time as well. So that becomes the larger context. Society is saying, “Wow, we’re learning so much from brain research.” And now psychiatry says, we’re at the forefront of this work because we’ve discovered the molecule for depression. We’ve discovered the molecule for psychosis and schizophrenia, and we now have drugs that fix those imbalances like insulin for diabetes.

That fits into the decade of the brain like a hand in a glove—this was the promise being realized. And that’s why we heard that drugs like Prozac made you better than well. We can tinker with the brain and we can give you the personality you want and we can make you happy. That was part of the insanity that was being pitched to the public, that we are all just sort of robots dependent on our chemicals. The decade of the brain provided the context to make the chemical imbalance story resonate with the public.

Moore: The next question is from Dan, who says psychiatry as a whole is extremely reluctant to acknowledge that the current system of psychiatric mental health care has harmed large numbers of people. However, for the rest of medicine, this is not an existential crisis. The general practitioners who currently prescribe the majority of antidepressants could drastically cut back their prescribing and it wouldn’t affect them that much. They have lots of other things to worry about. What could be done to get the rest of medicine involved? If we could get the rest of medicine to look at the evidence, then maybe they might be willing to apply some pressure to help change things. What could be done to force the issue?

Whitaker: That’s a great question. Obviously, the problem is the other doctors, especially the GPs and primary care physicians, they don’t know the evidence base for these drugs. They just presume that they’re helpful because that’s what they are told by their colleagues in psychiatry. Now, I do think there’s a general message starting to get out to primary care doctors that these antidepressants aren’t so great. Even if they don’t know the literature, there is an increasing acknowledgement that often the drugs don’t work and there are withdrawal problems.

How does the general practitioner get this message? Does it come through the research literature, or does it filter through the public dialogue as a whole? It filters to them through the public dialogue as a whole. They’re not reading the psychiatric literature. I do think that Mad in America and others have helped bring up the story of long-term difficulties with these drugs. I think that antidepressants have lost their lustre even with GPs. Now the problem for primary care physicians is that they get patients coming to them who are still living with that mainstream media message that an antidepressant is a solution to all ills. So they come to the GP and say, I want an antidepressant, that’s why I’m here.

There is something called the allopathic compulsion, which is an old term saying that when someone comes to an allopathic doctor, they don’t expect to go home with advice. They expect to go home with a pill or some form of treatment. When their primary care physician prescribes a pill, it fulfills that allopathic compulsion. It’s a medical ritual. Also, the GPs unfortunately are feeling that they have to get this person out of the office in 15 minutes. They can’t sit down with the patient for an hour and talk about life changes.

So really, we need psychiatry to say loud and clear, do not prescribe an antidepressant on the first visit, especially for the mildly depressed. We need psychiatry to give a message to the medical community that these drugs need to be used differently. Is that possible? That’s the hope.

Moore: Here in the U.K., there is more talk about deprescribing, acknowledging that if an older person ends up on a cocktail of psychiatric drugs, blood pressure drugs, pain medication, sedatives, then the cumulative burden of all those medications actually just creates longer-term patients.

Whitaker: I think the U.K. is a leader in this deprescribing area. It’s not happening so much in Scandinavian countries or Latin American countries. It’s starting a little bit in Brazil. But the U.K. is the one that’s pushing it forward and I think it’s because there is a critical psychiatry network there that has some reputation within the larger field. There are some good consumer groups there too. I think the National Health Service is also more responsive to the concerns around money and creating permanent patients with all the corresponding physical problems. Deprescribing is touched upon in the United States now and then, but it’s not nearly the topic it is in the U.K. It just hasn’t entered the mainstream narrative the way it has in the U.K. But hopefully, as the U.K. does this and makes it a routine part of practice, that practice will be exported to the U.S. and other countries. That is a hopeful sign for sure.

And that goes back to something on we can learn from each other. Mad in America, by being able to report on what’s happening in the U.K., helps bring that story to other countries as well as practitioners.

Moore: The next question is from DB. Rumor has it that within medicine, psychiatry is seen as the least intellectually taxing medical field, is there any truth in this?

Whitaker: That’s a long story going back to when psychiatry first emerged as people who ran asylums. There has long been a sense that psychiatrists were not real doctors, although, in the 1950s, they had their moment in the sun. Then, in the 1970s, The New York Times published an article called “Psychiatry’s Anxious Years, “and part of it was that medical students looked down on those who chose psychiatry as their speciality. And why did they do that? Because they didn’t think it was a real medical speciality, and that people who went into this discipline weren’t—now I’m just going to say what the thought was—they weren’t as smart. Psychiatry attracted people who weren’t just quite up to snuff with the other doctors.

And by the way, that article said how few doctors and residents were choosing to go into psychiatry.

It’s still the case. If you look at American psychiatrists now, so many of them come from abroad. I don’t mean to be diminishing people from other countries in any way, they obviously can be great doctors. But you see a lot of American psychiatrists now that are not American-born. And the reason for that is there is still a prejudice against psychiatry as a discipline, that it isn’t as difficult and as demanding as the other disciplines. It’s the surgeons and the heart specialists who see themselves at the top of this pyramid of doctors. But if you have this pyramid, there’ll be many people thinking psychiatrists are at the bottom.

Moore: We’re going to move on to a few questions now about the use of psychiatric drugs and other treatments. So this first one is from John, who says, I see people of all ages who get on one drug or a cocktail of psychiatric drugs and do well in the long term with maybe some drug changes and adjustments of dose along the way. They can often function better or hold down a job. In other words, the drugs seem to have made their life better. Is that possible?

Whitaker: Of course. When we talk about drugs worsening long-term outcomes, we’re looking at what is the spectrum of outcomes you see in nature. You can look at that as what happened before the drugs, but you can also look at studies in which you have medicated and unmedicated patients. And your form of care is doing harm if, in the aggregate, it’s worsening outcomes. In other words, you see more chronicity, and you see more functional impairment. You see that time and time again in long-term studies of antipsychotics, antidepressants, in fact all psychiatric drugs.

For example, with depression, the natural course of depression was seen as, if you have a case of pretty severe initial depression, 50% will get better within some period of time. We are talking about hospitalized depression. Half will get out and will never have another episode of depression. There was a second group that will also get better, and then maybe every three or four years have another episode. Only about 20% [of first-episode patients hospitalized for depression] would become chronically ill.

So in order to have an antidepressant therapy not do harm, it has to beat that natural spectrum of outcomes. However, what we see with antidepressants is that fewer people on the drugs, over the long term, are doing well in terms of remission of symptoms, time without symptoms, and employment levels. That said, there are some people on antidepressants who do fine and find them helpful. There are some people on antipsychotics, of course, who do fine and find them helpful.

For instance, we know from the Harrow study that of the people with a diagnosis of schizophrenia who got off medications, 40% were in recovery long term versus 5% for those on meds. So the 5% on meds, they are doing well, but it’s still lower than the natural recovery rate you see with the off-meds group.

When a person says “I’m doing okay on these drugs,” they are one of those people (with a better outcome). Maybe I’m on one drug, two drugs or three drugs, and I’m working and I have a decent social life. Even then, you don’t know what that person’s life would have been like if they had been given a different form of care right from the start. Maybe one that minimized long-term drug use, or focused on psychosocial care and life changes. What would their life have been like? We don’t know. That person doesn’t know what that possibility might have been.

So even their self-judgment is not proof of the merits of the drugs, even for themselves, because they lack knowing what would have been possible for them. I just want to say that some people are doing fine on the drugs and I’m so happy when that happens. That’s great. But you have to look at the evidence base over the long term when you think about how drugs might be used. And even for the individual, you don’t really know what the course of your life might have been if you hadn’t gone down this medicated path.

Moore: Another one on drugs and treatments from Neil, who says in light of the extensive documentation of harms associated with the long-term use of anti-psychotics and SSRIs, I’m interested in Bob’s thoughts on whether there is still potential for a consumer or survivor defined psychiatric harm reduction approach to medication that looks at psychiatric medication as a short term option that needs to be reinforced with other forms of psychological, social, and community support for individuals.

Whitaker: That’s why we need a grassroots rebellion. We’ve talked about the fact that the change is not going to come from those in power. But if you have a grassroots, peer-supported demand for change, and if that grassroots consumer demand grows, that can lead to change.

In Oregon right now, there is funding for four respite houses that are going to be peer-run. If you have a time of difficulty, you can go into a respite house and find some safety and some time to recover. So peers formed their own narrative and as that narrative grows among the population, that really can start becoming the dominant narrative.

For example, we would not be hearing about all the withdrawal problems with antidepressants if it weren’t for the internet. That’s where the voices of patients began to spread and be heard and collected. If we didn’t have that, would you even have surveys by the professionals looking at this harm? This shows the power of the internet to give life to peer-run harm reduction initiatives and practices. That’s one of the reasons, by the way, that Mad in America has personal stories, and that we also have blogs talking about these initiatives such as respite houses.

Moore: This is from Kent who says, why is the critical psychiatry community often so skeptical of psychedelics? Unlike nearly all the failed treatments that litter psychiatry’s history, psychedelics do not constrict and darken the mind, they can expand and illuminate it. Are psychedelics not compatible with the mission of critical psychiatry?

Whitaker: I love this question and it’s timely. First of all, I’m skeptical of psychedelics being incorporated into medical practice and being seen as a form of medicine because I think that that ability to illuminate and expand the mind may start to be lost when we’re talking about clinics giving out psychedelics.

I just came back from a conference in Brazil and there was a talk about psychedelics by a practitioner who has a lot of knowledge about how indigenous people use them. He said, the psychedelic experience doesn’t happen outside of a context for taking these drugs, and you need that context for the psychedelic to be a source of illumination and expanding the mind.

But now psychiatry is adopting psychedelics as their drug and there are ketamine clinics. That’s a very different context than being in some environment where you’re going to prepare yourself for a journey.

We also have to know that psychedelics are drugs that change your mind, whether it be LSD, whether it be ayahuasca or even marijuana. So there is always a potential for harm. If you look at newly diagnosed psychotic patients that come into emergency rooms, so many of them have been doing either prescribed or illicit drugs. I know we’re not supposed to say this, but you do see that people who are using marijuana have an increased risk of having a psychotic episode.

So this question, I think, presents psychedelics as drugs that provide illumination and expand the mind. I’ve taken psychedelics a couple of times when I was young. I took peyote and I took LSD a couple of times. They were memorable experiences. I will say that afterwards, I felt my mind was a little different, more open to different possibilities. But we can’t think of psychedelics as drugs that are going to simply replace other drug therapies because that takes the experience out of context.

If I’m given a psychedelic by a psychiatrist in a clinic, I just don’t have much faith in that. We also have to remember that the history of psychiatry is about one therapy after another being hailed as the new great therapy. Now we’ve started putting psychedelics in that boat, and I think if we make it something that is prescribed by doctors, it will be an unmitigated disaster.

Moore: I guess also there’s the risk of kind of reifying this concept that the psychedelic is maybe providing something deficient or wrong in your brain. It’s continuing this idea that there’s something wrong in you that needs an external influence to correct, isn’t it?

Whitaker: That’s the whole point. When you make it a drug that’s fixing something wrong with you, the idea that ayahuasca or LSD or peyote or any of these drugs fix some known biological problem is just the height of stupidity.

Moore: Okay, a couple more on drugs or treatment. So this is DB again, he asks what was the rationale for advising people to stay on SSRIs for at least six months after feeling better. Given the longer you take the drug, the more severe the withdrawal symptoms, does this increase the chance patients will have withdrawal symptoms which will therefore be misdiagnosed as relapse? Did pharma know this and was this therefore a way of engineering lifelong customers of these drugs?

Whitaker: Maybe pharma knew that there would be trouble coming off their drugs because by the late 1970s, they were beginning to understand that research was showing your brain adapted to these drugs. In other words, it was changed by these drugs. But that’s not how the continual maintenance practice actually came about.

When antidepressants were first introduced, the understanding was that depression was an episodic disorder and it would likely resolve on its own. Antidepressants could be used to speed up that natural recovery process.

Here’s what happened though. You put people on these drugs and then they began to find that once people came off they frequently relapsed.

So, are you going to see that relapse as a return of the disease, or as a withdrawal effect?
And so after three, four, six months on the drug, you run studies where you take the drug away—and by the way, when they first did this, it was pop, abrupt withdrawal—and you’re going to see this rebound effect and you’re going to see people relapse more frequently. But that is seen as evidence for maintaining people on antidepressants.

Once that happens, are drug companies thrilled? Sure, because now they are converting episodic patients into lifelong patients, and that is a prescription for great profits. You want lifelong customers. So the drug companies are going to let psychiatry carry the ball on this and remain mute about withdrawal effects as much as possible.

Moore: The next question is from Wendy who asks, how can we work together to stop electroconvulsive treatment?

Whitaker: I’ll go back to that we’re not lobbyists. However, we do provide information about ECT. The information is that it does cause cognitive deficits long-term in a high percentage of people. There’s no evidence that it is effective beyond 30 days.

What Mad in America can do is keep on promoting and publishing this information. We have a new report coming out that’s about ECT in kids. Why you would give ECT in kids with developing brains is beyond me. But what I remember from this research is that 70% suffer cognitive deficits. Now, you would think that doctors would say, oh my God, do not give ECT to kids. But instead, the researcher sort of said, well, that’s okay because we’re eliminating the depression.

There is a long history of research showing that ECT harms the brain. When it was first introduced, it was understood to cause a “closed head injury.” That is what a concussion is. So, you’re in a car accident and you bang your head, you don’t see a gash, but you’ve been concussed.

Here’s how researchers made that connection. People who were depressed and who had suffered a closed head injury in an accident, they were not depressed for a while. What seems to happen is the body floods the brain with a sort of hormonal effort to repair the damage, and that provides an uplift. But the uplift you get from depression with ECT seems to be because it’s responding to brain damage.

Anyway, the answer is this. Know the research evidence. The evidence is overwhelming. Promote that at every possibility.

Moore: In the U.K., I know that John Read, Chris Harrop and others have been doing quite a lot of work to look at the evidence base to support ECT. In the U.K. at least, the number of psychiatrists willing to do that procedure has tailed off in the last five or 10 years. Is it similar in the States?

Whitaker: Not at all. We don’t have anything close to a John Read and his cohort doing research in the United States. All we can do is import what they’re finding, and so that’s what we do. John of course did a paper with Irving Kirsch. Now Irving is from the United States, but he doesn’t have the same platform in American medicine that John is gaining throughout the world. So, unfortunately, you don’t see in our press stories about harm from ECT. You don’t see in our mainstream press stories about loss of memory or cognitive deficits. This is the problem. There is this narrative in the United States that ECT is the most effective treatment there is. And if antidepressants don’t work, go have some ECT treatment.

Moore: The last couple of questions are related to the pharmaceutical industry. This is another question from DB who says, generally speaking, marketing targets younger people with the intent of creating lifelong customers. Does pharma take the same approach, do you believe?

Whitaker: It certainly did in the 1990s. What happened in the early 1990s was that the adult market for antidepressants was being saturated. There was a meeting at one point and the pharmaceutical companies said, what are untapped markets? How about the kids? We’re not yet prescribing them to kids.

One of the reasons for that lack of prescribing to kids was the understanding that ups and downs, and emotional upheaval were normal for kids and teens. They were filled with angst but it passed. Two, the understanding was that trials of antidepressants in kids hadn’t shown the drugs to be effective.

However, pharmaceutical companies, eyeing this market, began paying thought leaders in American psychiatry to say, “Oh, now we understand that depression is a real illness in kids.” Now they have to show that antidepressants are effective in kids. Yet, what they found, when they did their trials over and over again, was they weren’t effective and they increased the suicide risk.

At that point, what happened was a collusion between pharmaceutical companies and the thought leaders. They began spinning their data and hiding suicide risks. Eli Lilly managed to design a trial that minimized the placebo response in kids and thereby showed that Prozac was “effective.” In nearly all the other trials, the drug did not beat placebo even in the remission of symptoms.

So there was a targeting of youth to expand the market of antidepressants, and the pharmaceutical companies built that market in concert with thought leaders, and that is a story of harm done.

Then we got juvenile bipolar disorder. That also used to be seen as a disorder of a maturing personality, but then we had Joseph Biederman saying, “we’re finding this in kids as young as two, and you maybe need to medicate people as young as two.” The makers of the new atypical antipsychotics, specifically Risperidone, are helping to fund that idea.

The next thing you know, we have a disorder that wasn’t even seen as ever happening in kids becoming quite common in kids. If you get a diagnosis of juvenile bipolar, that’s a diagnosis that sets you on a path to be a permanent patient for life. A career as a mental patient. Again, if you can create young patients and turn them into lifelong patients, that’s a very profitable model.

The irony is that the companies that built this, their patents on their drugs ran out, so they’re no longer enjoying those profits because of the off-label drugs.

So, was this a story of pathologizing kids in order to serve market needs? Absolutely, and the very people that should have protected children from it, psychiatrists, failed to do so. It’s one of the greatest harms that has come from the disease model. Of course, ADHD is part of this as well.

Moore: On to the final question, again from DB about the pharmaceutical industry. How can we counter the misrepresentation of critical views as stigmatizing mental illness and pill shaming by the mental health industrial complex and its key opinion leaders?

Whitaker: It’s another great question. That goes to this idea of killing the messenger, that you’re doing harm by stigmatizing and shaming people.

First of all, you know what builds stigma? They’ve done studies and it is when you say the problem is inside the person’s head, because then other people say, oh they lack control over themselves. They can’t help themselves or they’re defective.

Which would you rather be told? That you have a defective brain and you’re going to be defective all your life, or that bad things happened to you? Which identity would you rather have? Which is less stigmatizing?

Also, if someone’s having trouble, which is more stigmatizing in society? It’s quite clear that when you promote the disease model, that is what adds to stigmatization. But it’s been so effective that now some kids want to adopt these identities on social media.

As far as pill shaming, at least within Mad in America and for most critical psychiatrists, it is about informed consent and it’s about letting the public know what we really know about these drugs and what we know about other possibilities. I don’t know anyone who’s saying shame on you for taking the drugs.

When you hear this blame being placed on critics of psychiatry, it just means they are trying to kill the messenger. If they had evidence that outcomes were improving and people were flourishing much more with medications, that’s what they would point to, but they can’t point to such evidence.

So when I hear that criticism about pill shaming and doing harm, I say to myself, these people have to kill the messenger because they can’t provide an evidence-based argument.

Moore: Perfectly summed up. Thank you to everyone who took the time to send in some fantastic questions and thank you Bob for taking time to respond to them. It’s been fascinating to hear you talk about these things.

Whitaker: My pleasure. And I think this is important to invite questions and help it be known what we do at Mad in America, what our purpose is, what our processes are, what impact we think we have and what answers we have to these attacks. I think sometimes we don’t do a good enough job of informing our readership about what our philosophy is and what’s behind what we do. So, thank you for thinking of this and organizing it, and we did get through a lot of questions.