Anatomy of an Epidemic

Robert Whitaker's Anatomy of an Epidemic is a shocking book.

This book explores some hard questions. Why has the number of disabled mentally ill in the United States tripled recently? Are the long-term health outcomes of this medication better than no medication? Once we start taking drugs for our mental illnesses, do we end up on a path that almost ensures we continue to take drugs?


Whitaker touches on a very interesting feedback loop discovered by two Canadians:

neuroleptics put a break on dopamine transmission, and in response the brain puts down the dopamine accelerator. If the drug is abruptly withdrawn, the brake on the dopamine is suddenly released while the accelerator is still pressed to the floor. The system is now wildly out of control, so too the dopaminergic pathways in the brain. … The severe relapse suffered by many patients withdrawn from antipsychotics was not necessarily the result of the “disease” returning, but rather was drug-related. … both psychiatrists and their patients would regularly suffer from a clinical delusion: They would see the return of psychotic symptoms upon drug withdrawal as proof that the antipsychotic was necessary and that it “worked.” The relapsed patient would then go back on the drug and often the psychosis would abate, which would be further proof that it worked. Both Dr. and patient would experience this to be true, and yet, in fact, the reason that the psychosis abated with the return of the drug was that the brake on the dopamine transmission was being reapplied, which countered the stuck dopamine accelerator.

The two Canadians explained: “The need for continued neuroleptic treatment may itself be drug-induced.” In short, initial exposure to neuroleptic intervention puts patients onto a path where they would likely require drugs for life. Over time, with prolonged exposure, the dopaminergic pathways tend to become permanently dysfunctional.

“While there is no question that, once patients are placed on medication, they are less vulnerable to relapse if maintained on neuroletpics. But what,” Whitaker asks, “if these patients had never been treated with drugs to begin with.

The results were eye-opening. Over a very short period of time it appears that people placed on medication for mental disorders show improvement—medicated patients show a marginal improvement. However, over a longer period, outcomes unquestionably favor those who remain unmedicated. At about the one year mark unmedicated patients start to overtake their medicated counterparts in overall health. The data after that point is not even close as unmedicated patients continue to outperform over 2, 5, 10, and 15 years.

Take, for example, medicated v. unmedicated depression. Can it really be that antidepressants, which are so popular with the public, worsen long-term outcomes? The data, Whitaker argues, clearly says yes. But what does the alternative look like. Does unmedicated depression lead to a better long-term course?

A study conducted by the World Health Organization in fifteen cities around the world aimed at assessing the value of screening for depression seems to offer some insights. “Altogether,” Whitaker writes, “the WHO investigators identified 740 people as depressed, and it was the 484 who weren't exposed to psychotropic medications that had the best outcomes.” Not only did they enjoy better general health but their depression symptoms were much milder. And fewer of them were judged to be mentally ill. The patients treated with antidepressants suffered the most. The WHO researchers wrote that the “study does not support the view that failure to recognize depression has serious adverse consequences”.

It's easy to see how this all comes together. Over the short term, those who take medication see their symptoms improve. They presume this is evidence that the drugs work and their doctors think the same. However, this short-term reduction of symptoms is not materially greater than what is seen in patients treated with a placebo. The initial use of drugs, however, puts them onto a problematic long-term course. “if they stop taking the medication, they are at a high risk of relapsing. But if they stay on the drugs they will likely suffer recurrent episodes of depression, and this chronicity increases the risk they will become disabled.” It's a trap.

If you're interested in learning more purchase a copy of Anatomy of an Epidemic.

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