Robert Whitaker: Anatomyof an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America
Hebrew Translation by Liat Plen-Levartovsky
Foreword by Pesach Lichtenberg
Tel Aviv (Israel): Focus Press; 2017 (331 pages)
Reviewed by Robert H. Belmaker

            In December2017 Robert Whitaker visited Israel for a festive book launching of the Hebrew translation of his book Anatomy of an Epidemic which was originally published in English in 2010, following Whitaker's first book Mad in America, published in 2001. The USA publication of Anatomy of an Epidemic was followed by a review in The New York Review of Books in June 2011 by Marcia Angell, the former editor of the New England Journal of Medicine. Although the book review was laudatory, it was followed by several angry letters to the editor by angry psychopharmacologists(Oldham, Carlat, Friedman, Nierenberg 2011). The book launching included an extensive exposition by Robert Whitaker and by way of appropriate disclosure I should say that I also had a magical dinner with the author and an opportunity to tour with this charming, erudite and almost missionary author while reading his book before the launching. I also read his prior book Mad in America in English, as it has not yet been translated into Hebrew.

            The book launching of Anatomy of an Epidemicin Hebrew comes at a special time for psychiatry in Israel and perhaps the first two books by Whitaker presaged this special time at a world level. Academic biological psychiatry has come to the conclusion that the dopamine hypothesis of schizophrenia and the monoamine hypothesis of affective disorder are no longer heuristic or useful models for teachingpsychopharmacology.The research in schizophrenia and depression clearly presupposes multiple neurotransmitter abnormalities explanations more at the circuit level. The genetic factors that were promised to be at our doorstep duringthe last 30 years have yielded a realization that the clear genetic predispositions to schizophrenia, bipolar disorder and other mental disorders are strong but perhaps no stronger than predispositions to various normal personality traits such as extroversion, dominance and anxiety proneness. Thus, Whitaker's critical view of psychiatry comes at a time when biological models could be seen to be in retreat, although a more charitable view is that they are becoming more sophisticated and more realistic. In the same direction, it is well accepted among psychopharmacologists that the placebo/active drug difference has been declining over the last decade both for depression and for psychosis. While not completely explained, these differences highlight the large percentage of patients who do not get well with current treatment, as well as the large percentage who do get well even without active drug treatment over the course of their illness.

            Whitaker takes the above findings and combines a critical historical presentation of the above-accepted facts with a questionable conspiracy theory about why these last 30 years happened. As a participant in the history of biological psychiatry from 1972 until today- almostfivedecades - I found the enterprise exciting and I felt that the dopamine hypothesis and monoamine hypothesis were heuristic and generated much new data which I certainly had hoped would have led to more true cures than has actually happened. I was critical from early on of the pharmaceutical company influence but I cannot find myself agreeing with Whitaker that a historical conspiracy of the profit motive of the pharmaceutical companies with academic psychiatry was the central factor in the history of these last fivedecades.

            One very positive aspect of Whitaker's writing is his discussion of the history of psychiatry from the point of view of the patient. I feel that I have been changed as a psychiatrist for the better since reading this book. In a way I could compare this only to my first reading of a feminist book on the role of women in history, a biography of Abigail Adams, which suddenly made me realize how the subjective voice of women had been heard so little in medical, academic and political debate.

Whitaker's claim that patients who endured psychosis before the era of modern psychopharmacology were more appreciative of their care, more accepting of themselves and their illness and ultimately more complete human beings despite their illness, hit a cord in my soul as a physician. I am pained that so many of our patients today dislike their treatment, are not adherent to their treatment and seem to disrespect those who provide their treatment.

I am not a historian and cannot evaluate Whitaker's scientific and methodological sampling of patient's subjective descriptions of mental illness and its treatment over the past 200 years in America. However, I think his claim is worth our thinking about. His book is hard going for a psychiatrist and it is easy to become angry at his many generalizations, scientific hyperboleof small uncontrolled studies and scaremongering about unproven hints of possible neurotoxicity of psychotropic drugs, which he seems to regard as proven fact. I doubt the public would give much respect to a similar book claimingthat diet beverages have caused the obesity epidemic or that cellphones are the cause of brain tumors and that immunizations for measles are the cause of autism. However, to the extent that these original journalistic and concerned polemics contribute to our continued reexamination of our own methods anddedication to our patients, then I think we should, as physicians sworn to uphold the Hippocratic oath, accept the anger expressed at our profession in this book, the way we accept the anger of a patient: with ability to hear out another person, with respect for any kernel of truth there may be, with confidence in our own training and strength and ability to change and with ability to forgive those distortions and slurs which we do not deserve.

References:

Angell M. The Illusions of psychiatry. The NewYork Review of Books July 14, 2011.

Oldham J, Carlat D, Friedman R, Nierenberger (letters) Angell M (reply). The Illusions of Psychiatry: An Exchange. The New York Review of Books August 18, 2011.

Whitaker R. Mad in America: Bad Science, Bad Medicine, and the Enduring Mistreatment of the Mentally Ill. New York: Perseus Publishing Basic Books; 2001.

Whitaker R. Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America; New York: Crown Publishers; 2010.

October 4 2018