by Robert Whitaker
Perseus Press, 334 pages, $27.00
by Roy Porter
Oxford University Press, 241 pages, $22.00 Not too long ago, a group of experts met to devise strategies for bringing mental health professionals up to speed on the newest treatments for mental illness. Those include the latest entries in the lucrative and growing field of psychopharmaceuticals, with their promise - finally - of an effective treatment for schizophrenia. Robert Whitaker's Mad in America: Bad Science, Bad Medicine, and the Enduring Mistreatment of the Mentally Ill and Roy Porter's Madness: A Brief History remind us that we need to consider the lessons of history. And their accounts leave us wondering whether the experts, along with everyone else, have been too quick to accept the glowing reports of success.
To be fair, one might also wonder whether Whitaker, an investigative journalist, has told a slightly selective story as he describes how, in the early 1990s, drug testing moved from academic settings to for-profit testing groups; how academic expertise became for sale; and how drug companies scrambling for market share touted success stories. But Whitaker's work is well documented, and the patterns over time laid out by both authors are reinforcing.
Dissimilar in style, approach, and size, the two works are surprisingly complementary. Porter provides a deft examination of how Western cultures from antiquity through modern times have tried to explain and treat insanity, while Whitaker probes in depth the mostly uncaring and usually ineffective way America has treated the "mad."
Porter's work is a brief history - and a quick read. For those concerned about care for the mentally ill, it should at least be scanned before delving into Whitaker's more detailed study. According to the cover of an advance copy of Madness, Porter has published more than 80 books and is considered "the most highly acclaimed and prolific medical historian of this generation." Yet, oddly, his book lacks footnotes, and some statements call out for attribution. How do we know, for instance, that "over 200,000 people - mainly women - were executed during the witch craze" in the 1500s? Did someone keep a tally? But Porter does offer "notes" for further reading.
Where Porter's book intrigues with brief sketches, Whitaker paints a full picture. For instance, Porter writes: "Psychosurgery and other shock therapies signal the wish of well-meaning psychiatrists to do something for psychiatry's forgotten patients; they have, in turn, been criticized for being grotesque, quackish, brutal and hubristic. Invasive treatments equally reflect the powerlessness of patients in the face of arrogant and reckless doctors, and the ease with which they became experimental fodder." Whitaker provides case histories and full descriptions of such techniques and the people who developed and used them.
Whitaker, a medical journalist, has taken on what is considered one of the "dirty little secrets" of American medicine - the care of the mentally ill. The investigations that led to this book were inspired, he explains, by studies in medical literature showing that Americans with schizophrenia have actually fared worse over the past 25 years, despite the array of new drugs. Studies also show that people in developing countries who have no access to these expensive drugs have done far better.
Whitaker's quest to understand why the medical profession has failed the more than 2 million Americans who suffer from schizophrenia took him back to the early days of this country, when the "mad" were restrained in cells and paraded before the public like animals. He found that Quaker physician Benjamin Rush started a movement to treat the mentally ill with kindness, despite having introduced such bizarre-sounding treatments as bleedings and an immobilizing "tranquilizer chair."
This "moral treatment" prevailed during much of the 19th century. The mentally ill were diverted from their delusions and kept busy with activities such as gardening and games. The underlying philosophy was that if they were treated as rational beings, they would emerge from the hospital as rational beings. But moral treatment threatened those physicians who led the asylum-building movement, in which cathartics, bloodletting, and drugs were used.
Whitaker describes other "advanced" treatments for the mentally ill, usually espoused by the leading practitioners of the times: removal of teeth and other body parts, spinning, ice-water baths and cold wraps, and electroshock therapy. One particularly popular treatment was insulin-induced coma, a treatment that Whitaker suspects gained popularity because it made patients more docile and easier to handle, and because it allowed hospitals with insulin wards to claim they were providing modern scientific medicine for the insane. As a forerunner to electroshock therapy and lobotomy, insulin comas were a turning point in medical treatment for the mentally ill, Whitaker explains. "Brain trauma, as a supposed healing therapy, was now part of psychiatry's armamentarium."
In that sense, insulin treatments might also be considered a forerunner to modern psychopharmacology, for many drugs also make patients more docile. Whitaker maintains, "Trials [of these new drugs] again and again simply looked at whether the drugs knocked down the visible symptoms of psychosis and ignored what was really happening to the patients as people." Further, he reports, "evidence of the harm caused by the drugs was simply allowed to pile up, then pushed away in the corner where it wouldn't be seen."
As is often the case with investigative journalism, Whitaker's work raises far more questions than it answers. One question is whether his findings apply only to the treatment of the mentally ill, or whether they reflect more general problems. One reference to the administration of mental hospitals in the 1870s seems disturbingly prescient: "Instead, they sought to hire superintendents who could manage budgets wisely and were willing to scrimp on spending for patients and, in the best manner of political appointees, grease the patronage wheels. The good superintendent was one who could ensure that supply contracts went to friends of the board." Are some of today's hospitals, health plans, and health maintenance organizations any different?
There's nothing new, either, about burying reports that don't produce the sponsor's desired results, Whitaker says. He tells of the American Medical Association hiring a young physician in the early 1930s to investigate reports of crowded, prisonlike conditions in state mental hospitals. In visits to 174 hospitals, the physician found conditions so crowded that patients slept in hallways and dining areas, with windows barred, doors locked, and attendants who acted like prison guards. His report concluded that the purpose of these hospitals was not medical but legal. That was not what the AMA wanted to hear, so he was fired and his findings were buried. Not until conscientious objectors worked in mental hospitals during World War II were the true conditions made public.
There's also a touch of deja vu in Whitaker's description of how the Rockefeller Foundation, in the 1920s, identified psychiatry as the medical specialty most in need of reform. The foundation began pouring money into new medical school departments and research laboratories, and started supporting new treatments. Soon, scientists and medical schools were "reporting results that indicated the Rockefeller funds were being well spent." The announced successes, of course, ensured that the Rockefeller money kept coming. Sound familiar?
Though his book is ostensibly about "madness," Whitaker delves into drug trials. In doing so, he raises broader questions about the "purity" of academic research and peer-reviewed publications, the standard by which the medical profession judges new findings. Whitaker describes how drug testing became part of a new, for-profit drug testing industry, with some community physicians, hit by the new strictures of managed care and looking for ways to supplement their incomes. Traditionally, academic researchers had conducted drug trials, a process that seemed to ensure impartiality since the studies were carefully designed to eliminate any bias. But the process was slow and delays were costly to drugmakers.
The new system is much faster, but it too has drawbacks, as Whitaker reports. He cites the example of Richard Borison, a psychiatrist at the Medical College of Georgia, who developed a highly profitable business in the late 1980s and early '90s by testing new psychopharmaceuticals. Some 160 contracts from drug firms brought in more than $10 million. According to Whitaker's account, Borison and his associates enrolled patients (sometimes ignoring eligibility requirements), then fudged results, wrote reports based on those results that were published in peer-reviewed journals, and submitted findings to sponsoring companies. They banked money that ought to have gone to the medical school until a whistle-blower finally brought their activities to a halt and they were sent to prison - not for fraud but for stealing from the school.
Maybe Borison was a classic example of the proverbial bad apple. But as the new system of conducting drug trials took hold, reports of the success of the new drugs were spread through journal articles and advertisements, then picked up by the media, with little attention paid to questions not asked or answered in the more expedient testing process. While there is plenty of anecdotal evidence that some of the newer psychopharmaceuticals are effective, Whitaker notes, "one of the saddest aspects of this 'research' process and the story telling that accompanied it, is how it has left everyone in the dark about the real merits" of those drugs.
Whitaker writes specifically of "mad medicine" and drugs designed for mental illness, but his research raises questions that could be asked in other areas of medicine. If the profit motive drives the use of drugs in psychiatry to the extent that research is skewed by misleading trials, as Whitaker's investigations reveal, what happens in other high-profit areas of medicine? In cancer therapy, for instance? Or with the well advertised and heavily prescribed drugs to control cholesterol levels, blood pressure, and allergies?
Whitaker has no illusions about the potential for reform. Stories of drugs' success and the bandwagon effect have meant that more people are taking the medications. "With the new drugs presented to the public as wonderfully safe, American psychiatrists are inviting an ever greater number of patients into the madness tent," he reports. Distinctions between the sane and the not-so-sane are so blurred that even 2-year-olds are placed on anti-psychotic medications, and there have been suggestions that doctors have prescribed the drugs to guard against madness, even "though effectiveness and long-term damage remain unclear." Whitaker concludes, "Madness is clearly afoot in American psychiatry, and bad science - as so often has been the case in medicine - has helped it on its way."
Porter's slim volume raises many of the same questions Whitaker probes so thoroughly, in a subtle but equally disturbing manner. He describes a society where more and more people are said to be suffering from an ever-growing list of psychiatric problems, and "more people than ever swallow the medications, and perhaps even the theories, which psychiatry prescribes." They also, he writes, "attend various sorts of therapists, as the idioms of the psychological and the psychiatric replace Christianity and humanism as ways of making sense of self-to oneself, one's peers, and the authorities."
He concedes that the new drugs "certainly allow psychiatry itself to function better" but, echoing the doubts voiced by Whitaker, observes that "pacifying patients with drugs hardly seems the pinnacle of achievement, and any claims as to the maturity of a science seem premature and contestable."
History has many lessons, even a history of madness. Will we ever learn from them?