All Psychiatry Is Personal

Last week I went to a presentation by Robert Whitaker, author of the bestselling and controversial book Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America. Having spent a lot of time in the pharmaceutical trenches, I think my perspective on psychiatric meds is a little different from his, but there were two things in particular that impressed me. First, he does a great job of presenting complex information, from basic neurotransmitter science to protocols for the studies he references. Even more importantly, he stays off soapboxes and bandwagons. He presents the data he has, explains what it indicates, and suggests positive alternatives to our current ways of treating mental illness.

Whitaker's book is frequently used as a justification for not taking antidepressants, or for castigating pharmaceutical companies for overselling them. His work is far more nuanced than that. At the risk of adding to this oversimplification, I think his three most important points are:

  • There are compelling studies that show that those who are not given antidepressants and antipsychotics may have a significantly higher long-term success rate than those who are. (Short-term interventions with medication usually appear to be moderately more successful than using no medications at all.)

  • Using medications over the long term may lead to neurological changes that decrease the brain's capabilities and make relapses more likely.
  • Creating a strong social network that supports people through these grueling periods is one of the most important components of a successful cure.
  • These studies and their conclusions -- which have been vociferously challenged by others in the field -- are not based simply on traditional psychiatric evaluations (which have some degree of subjectivity) but on more objective criteria, including the number of people who relapse or end up on long-term disability compared with those who return to active, productive lives.

    As someone who has been on psychiatric medications for about 15 years -- including an impressive cocktail that seems to have been what pulled me out of a two-year breakdown -- you'd think I wouldn't want to hear these facts. But many years ago I came to the conclusion that it is my brain and I'd play the hand dealt me, including the consequences of whatever mind-altering substances I'd thrown at it, from the LSD of my youth to the caffeine, alcohol, and prescription meds (and, OK, a little marijuana tincture) that I continue to indulge in. (One could argue that my family or society may also have to pay that price, but that is a topic I'll take up in a future post.)

    So, after Whitaker's talk, I focused instead on what his work tells me about myself, other people, and us humans in general:

    1) While I won't resort to Mark Twain's famous quip that "there are three kinds of lies: lies, damned lies, and statistics," I will suggest that while it's important to be informed by statistics, it's equally important to listen to our hearts, our guts, or any other intuitive body part when making personal medical decisions.

    Practically speaking, Whitaker's statistics are "too late" for the millions of us who have been taking psychiatric medications for years, and for the millions who have taken marijuana and other drugs. (His research suggests that marijuana and other recreational drugs can also be significant factors in depression.)

    At this point my gut tells me that going off my meds would be foolhardy. This is no time to risk being thrown off the apple cart when I know how it feels to be crushed underneath it. And if someone in extremis asked me for advice, I would both mention Whitaker's work and describe my experience -- before insisting that they go to a psychiatrist and make up their own troubled mind.

    2) His work demonstrates yet another eerie parallel between the history of cancer and that of mental illness: It's really hard to tell which treatments are dead ends and which are milestones on the long road to a cure.

    Many people are alive today because of other patients' willingness to suffer the pain of experimental cancer treatments; including thousands of children who died in the mid 1900s during the tortuous path to achieving an up-to-90-percent cure rate for acute lymphoblastic leukemia (ALL), the most common form of childhood leukemia. We admire the bravery of those patients. Will we eventually admire the bravery of those of us who have participated -- wittingly or not -- in the decades-old search for psychiatric medications that might lead to more successful cures?

    3) As far as I'm concerned, one of Whitaker's contentions is unassailable. Whether you take medications or not, the stronger your support system -- family, community, and society in general -- the better able you are to withstand what William Styron called the "veritable howling tempest in the brain."

    Unfortunately, many people don't have that support system -- including a shocking number of children and teenagers dealing with that "howling tempest" in the midst of dysfunctional families, dangerous neighborhoods, and overwhelming peer and media influences in terms of the foods they eat, the drugs they do, the video impressions they get, and the exercise that they don't.

    We decry treating symptoms instead of causes. But to suggest that we have to do something about the fact that these children are overmedicated without acknowledging that they are also overabused, underfed, and inadequately mentored is equally myopic.

    People all over the country are doing remarkable work to improve psychiatric care for people of all ages. You'll find them throughout the social services and the traditional and alternative medical communities, and even within the much-maligned "Big Government" and "Big Pharma." Whatever you think of Whitaker's book, he has clearly made a significant contribution to this quest.

    In the meantime, many people have to decide right away which path to travel in hopes that it will pull them out of the darkness. Many people have to decide right away how to help a child who, for days or months, can't sit still, has gained 50 pounds "for no reason," or bursts into tears at the slightest provocation.

    To paraphrase Tip O'Neil, ultimately all psychiatric care is personal. Regardless of their decision(s), people who struggle with depression and psychosis deserve our support and respect.

    For a good overview of the controversy surrounding Whitaker's work, see John Mcmanamy's blog KnowledgeIsNecessity.

    For an interesting psychiatrist's view on trying to balance Whitaker's results with the challenges of providing day-to-day treatment, see Sandra Steingard's December 2013 article in the Washington Post.