The Drug-Based Approach to Mental Illness Has Failed. What Are Alternatives?

I photographed Anatomy in my office this morning. The shadows are supposed to add an ominous touch.

HOBOKEN, OCTOBER 11, 2024.  I haven’t read a more consequential work of science journalism than Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America. Robert Whitaker presents evidence that bio-psychiatry, which views mental illness as biochemical disorders best treated with medications, has failed. Whitaker is an award-winning journalist, author of two other books on mental illness and publisher of the website madinamerica.com, which provides informed critiques of mental-health care. Below is an updated Q&A I carried out with him in 2020. I’ve highlighted especially pertinent quotes. —John Horgan

Horgan: Anatomy of an Epidemic argues that medications for mental illness, although they give many people short-term reliefs, cause net harm. Is that a fair summary?

Whitaker: Yes, although my thinking has evolved somewhat since I wrote that book.

I am more convinced than ever that psychiatric medications, over the long term, cause net harm. I wish that weren’t the case, but the evidence just keeps mounting that these drugs, on the whole, worsen long-term outcomes.

However, my thinking has evolved in this way: I am not so sure anymore that the medications provide a short-term benefit for patient populations as a whole. When you look at the short-term studies of antidepressants and antipsychotics, the evidence of efficacy in reducing symptoms compared to placebo is really pretty marginal and fails to rise to the level of a “clinically meaningful” benefit.

Furthermore, the problem with all of this research is that there is no real placebo group in the studies. The placebo group is composed of patients who have been withdrawn from their psychiatric medications and then randomized to placebo. Thus, the placebo group is a drug-withdrawal group, and we know that withdrawal from psychiatric drugs can stir myriad negative effects. A medication-naïve placebo group would likely have much better outcomes, and if that were so, how would that placebo response compare to the drug response?

In short, research on the short-term effects of psychiatric drugs is a scientific mess. In fact, a 2017 paper that was designed to defend the long-term use of antipsychotics nevertheless acknowledged, in an off-hand way, that “no placebo-controlled trials have been reported in first-episode psychosis patients.” Antipsychotics were introduced 65 years ago, and we still don’t have good evidence that they work over the short term in first-episode patients. Which is rather startling, when you think of it.

Horgan: Have any of your critics made you rethink your thesis?

Whitaker: When the first edition of Anatomy of an Epidemic was published (2010), I knew there would be critics, and I thought, this will be great. This is just what is needed, a societal discussion about the long-term effects of psychiatric medications.

I have to confess that I have been disappointed in the criticism. They mostly have been ad hominem attacks—I cherry-picked the data, or I misunderstood findings, or I am just biased, but the critics don’t then say what data I missed or point to findings that tell of medications that improve long-term outcomes. I honestly think I could do a much better job of critiquing my own work.

I do want to emphasize that critiques of “my thesis” regarding the long-term effects of psychiatric drugs are important and to be welcomed. See two papers in particular that take this on (here and here), and my response in general to such criticisms, and to the second one.

Horgan: When I criticize psychiatric drugs, people sometimes tell me that meds saved their lives. You must get this reaction a lot. How do you respond?

Whitaker: I do hear that, and when I do, I reply, “Great! I am so glad to know that the medications have worked for you!” But of course I also hear from many people who say that the drugs ruined their lives.

I do think that the individual’s experience of psychiatric medication, whether good or bad, should be honored as worthy and “valid.” They are witnesses to their own lives, and we should incorporate those voices into our societal thinking about the merits of psychiatric drugs.

However, for the longest time, we’ve heard mostly about the “good” outcomes in the mainstream media, while those with “bad” outcomes were resigned to telling their stories on internet forums. What Mad in America has sought to do, in its efforts to serve as a forum for rethinking psychiatry, is provide an outlet for this latter group, so their voices can be heard too.

The personal accounts, of course, do not change the bottom-line “evidence” that shows up in outcome studies of larger groups of patients. Unfortunately, that tells of medications that, on the whole, do more harm than good.

As a case in point, in regard to this “saving lives” theme, this benefit does not show up in public health data. The “standard mortality rate” for those with serious mental disorders, compared to the general public, has notably increased in the last 35 years.

Robert Whitaker: “I am more convinced than ever that psychiatric medications, over the long term, cause net harm.”

Horgan: Do you see any promising trends in psychiatry?

Whitaker: Yes, definitely.

You have the spread of Hearing Voices networks, which are composed of people who hear voices and offer support for learning to live with voices as opposed to squashing them, which is what the drugs are supposed to do. These networks are up and running in the U.S., and in many countries worldwide.

You have Open Dialogue approaches, which were pioneered in northern Finland and proved successful there, being adopted in the United States and many European countries (and beyond.) This practice puts much less emphasis on treatment with antipsychotics, and much greater emphasis on helping people re-integrate into family and community.

You have many alternative programs springing up, even at the governmental level. Norway, for instance, ordered its hospital districts to offer “medication free” treatment for those who want it. In Israel, you have Soteria houses that have sprung up (sometimes they are called stabilizing houses), where use of antipsychotics is optional, and the environment—a supportive residential environment—is seen as the principal “therapy.”

You have the U.N. Special Rapporteur for Health, Dainius Pūras, calling for a “revolution” in mental health, one that would supplant today’s biological paradigm of care with a paradigm that paid more attention to social justice factors—poverty, inequality, etc.—as a source of mental distress.

All of those initiatives tell of an effort to find a new way. But perhaps most important, in terms of “positive trends,” the narrative that was told to us starting in the 1980s has collapsed, which is what presents the opportunity for a new paradigm to take hold.

More and more research tells of how the conventional narrative, in all its particulars, has failed to pan out. The diagnoses in the Diagnostic and Statistical Manual (DSM) have not been validated as discrete illnesses; the genetics of mental disorders remain in doubt; MRI scans have not proven to be useful; long-term outcomes are poor; and the notion that psychiatric drugs fix chemical imbalances has been abandoned.

Horgan: Do you see any progress toward understanding the causes of mental illness?

Whitaker: Yes, and that progress might be summed up in this way: researchers are returning to investigations of how we are impacted by what has “happened to us.”

The Adverse Childhood Experiences study provides compelling evidence of how traumas in childhood—divorce, poverty, abuse, bullying and so forth—exact a long-term toll on physical and mental health. Interview any group of women diagnosed with a serious mental disorder, and you’ll regularly find accounts of sexual abuse. Racism exacts a toll. So too poverty, oppressive working conditions, and so forth. You can go on and on, but all of this is a reminder that we humans are designed to respond to our environment, and it is quite clear that mental distress, in large part, arises from difficult environments and threatening experiences, past and present.

And with a focus on life experiences as a source of “mental illness,” a related question is now being asked: what do we all need to be mentally well? Shelter, good food, meaning in life, someone to love and so forth—if you look at it from this perspective, you can see why, when those supporting elements begin to disappear, psychiatric difficulties appear.

I am not discounting that there may be biological factors that cause “mental illness.” While biological markers that tell of a particular disorder have not been discovered, we are biological creatures, and we do know, for instance, that there are physical illnesses and toxins that can produce psychotic episodes.

However, the progress that is being made at the moment is a moving away from the robotic “it’s all about brain chemistry” toward a rediscovery of the importance of our social lives and our experiences.

Horgan: I fear that American-style capitalism doesn’t produce good health care, including mental-health care. What do you think?

Whitaker: It’s clear that it doesn’t.

First, we have for-profit health care that is set up to treat “disease.” With mental-health care, that means there is a profit to be made from seeing people as “diseased” and treating them for that “illness.” Take a pill! In other words, American-style capitalism, which works to create markets for products, provides an incentive to create mental patients, and it has done this to great success over the past 35 years.

Second, without a profit to be made, you don’t have as much investment in psychosocial care that can help a person remake his or her life. There is a societal expense, but little corporate profit, in psychosocial care, and American-style capitalism doesn’t lend itself to that equation.

Third, with our American-style capitalism (think neoliberalism), it is the individual that is seen as “ill” and needs to be fixed. Society gets a free pass. This too is a barrier to good “mental health” care, for it prevents us from thinking about what changes we might make to our society that would be more nurturing for us all. With our American-style capitalism, we now have a grossly unequal society, with more and more wealth going to the select few, and more and more people struggling to pay their bills. That is a prescription for psychiatric distress. Good “mental health care” starts with creating a society that is more equal and just.

Horgan: If the next president named you mental health czar, what would be at the top of your To Do list?

Whitaker: Well, I am pretty sure that’s not going to happen, and if it did, I would quickly confess to my being utterly unqualified for the job. But from my perch at Mad in America, here is what I would like to see happen in our society.

As you can see from my answers above, I think the fundamental problem is that our society has organized itself around a false narrative, which was sold to us as a narrative of science. In the early 1980s, we began to hear that psychiatric disorders were discrete brain illnesses, which were caused by chemical imbalances in the brain, and that a new generation of psychiatric drugs fixed those imbalances, like insulin for diabetes. But what can be seen clearly today is that this narrative was a marketing story, not a scientific one.

What we need now is a new narrative to organize ourselves around, one steeped in history, literature, philosophy, and good science. I think step one is ditching the DSM. That book presents the most impoverished “philosophy of being” imaginable. Anyone who is too emotional, or struggles with his or her mind, or just doesn’t like being in a boring environment (think ADHD) is a candidate for a diagnosis.

We need a narrative that, if truth be told, can be found in literature. Novels, Shakespeare, The Bible—they all tell of how we humans struggle with our minds, our emotions and our behaviors. That is the norm; it is the human condition. And yet the characters we see in literature, if they were viewed through the DSM lens, would regularly qualify for a diagnosis.

At the same time, literature tells of how humans can be so resilient, and that we change as we age and move through different environments. We need a narrative that replaces pessimism with hope.

Further Reading:

Check out Whitaker’s book Anatomy of an Illness and webzine Mad in America.

I delve into treatments for mental illness in “The Meaning of Madness,” chapter five of my book Mind-Body Problems. See also my column “Why Freud Still Isn’t Dead.”