Last month we introduced you to Robert Whitaker and the findings in his newest book, The Anatomy of an Epidemic (see part one in the July/August issue). For some of you, his story may have validated suspicions about a seeming alliance between some in psychiatry and the pharmaceutical industry. For others, his story generated strong disagreement ( see sidebar).
We're looking forward to continuing this conversation because we think it's long overdue. Medication plays an extremely important role in the field of behavioral health-on a very personal level for those of us who take it; on a political level for those who debate its usefulness; on a social level when it is used to manage or control behaviors, and on many other levels as well.
We need to talk about it, question it, agree and disagree about it, and find our own perspective. Self determination and self efficacy is an essential element of recovery. It's through conversations like this one that we can each find our own way.
In Part I, Robert argued that there's a fundamental problem that needs to be fixed: studies regarding the impact of psychiatric medications have not been fairly designed and the pharmaceutical industry has not been an “honest storyteller” about the total impacts of medication use.
In Part II, we begin by asking Robert his thoughts on the relationship of recovery and medications.
Bill and Lori: We're very passionate about providing recovery opportunities for people. What role do you think the recovery paradigm plays in creating alternatives for medication effects and effectiveness?
Robert: I believe that a robust recovery paradigm would set forth long-term goals of self determination that promote good physical health, good social interaction, and employment. I don't think the data show that medications, on the whole, necessarily promote such goals.
Bill and Lori: We couldn't agree more. Right now it seems like we are trying fit recovery into a medication paradigm. What if we could turn this around and have medication be part of a recovery paradigm? Instead of being the framework and primary intervention, it would be one of many interventions used to promote recovery. Can you say more about this?
Robert: Ultimately, I think we need a new paradigm built on the framework of psychosocial and recovery practices. Drugs would be used as an adjunct, both for curbing acute episodes of psychiatric distress and as agents that might help some people over the long-term. But if you want a system that promotes robust recovery, you need protocols that encourage selective, cautious use of the drugs. I believe [these] would make being in recovery and off medication a REAL long-term goal. That [being off meds] used to be seen as part of a full recovery (see Harding's definition), and I believe it is possible for many people, if only we had a different paradigm of care.
Bill and Lori: We agree. We know of programs that do this so we know it's possible. However, there are many people who would disagree with both of us even if we presented them with information that supported our position. What do you think the strongest part of your argument is?
Publication of “Transforming our thinking about psychiatric medications” in the July/August issue generated some feedback. This column contained the first part of a two-part Bill Anthony/Lori Ashcraft interview with Robert Whitaker, author of Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America.
That feedback will be heard in our October issue, led by Bill Glazer, MD, a psychiatrist who authors our Rx Resources column. Bill's questions about Whitaker's book-and the Ashcraft/Anthony article-start with the very beginning, as Ashcraft and Anthony state that “the question we will explore with Robert is this: ‘Why has the number of disabled mentally ill people in the US tripled over the past two decades?’”
Says Glazer: “The authors accept Whitaker's misinformation and validate it with this question. Here are the facts: Whitaker's claim that psychiatric drugs increase the rates of psychiatric disorders has been severely criticized by experts in the field. The claim has been more provocative and inflammatory than controversial. If it were true, one would expect to see a steady increase in the prevalence of mental disorders in the population.
“The epidemiologic evidence shows otherwise. As Ronald Kessler reported in the New England Journal of Medicine (2005), data from the National Comorbidity Survey show that the prevalence of anxiety, mood and substance disorders has been stable: it was 29.4 percent in 1991 and 30.5 percent in 2003. This is hardly an “epidemic” of mental illness, on which Whitaker rests his case (and the title of his book).
“What did increase during this period was the number of people receiving treatment: from 20 percent in 1991 to 32 percent in 2003 … [but this means that] the vast majority of mentally ill Americans [still] did not receive any treatment. These are people with life-threatening illnesses at high risk of suicide who have impaired functioning. And they are the patients for whom psychotropic drugs can be life-saving.