Anatomy of an Epidemic: Summary of Findings. By Robert Whitaker, [email protected] 1. Disability Numbers Due to Mental Illness Are Soaring. Our society understands that the arrival of Thorazine into asylum medicine in 1955 kicked off a “psychopharmacological revolution,” leading to much better long-term outcomes for people with psychiatric disorders. Yet, the disability rate due to mental illness, as measured by adults under governmental care, has risen from one in every 468 Americans in 1955 to one in 76 today. The rise in the number of disabled mentally ill has been especially pronounced since 1987, the year that Prozac, the first of the “second-generation” psychiatric drugs, arrived on the market. The number of adults on SSI or SSDI due to mental illness has risen from 1.25 million in 1987 to more than 4 million today. The number of children and youth on SSI due to a serious mental illness has skyrocketed from 16,200 in 1987 to more than 600,000 today. 2. Affective Disorders Run a Much More Chronic Course Today than in the Pre-Drug Era. The rise in disability numbers is being driven by a sharp increase in the number of people disabled by affective disorders (depression and bipolar illness.) In the pre-drug era, the affective disorders were seen as episodic illnesses, with fairly good long-term outcomes. As George Winokur, a leading expert at Washington University, explained in a 1969 text: “Assurances can be given to a patient and to his family that subsequent episodes of illness after a first mania or even a first depression will not tend toward a more chronic course.” However, affective disorders today run a chronic course, and functional outcomes (employment rates, etc.) are much worse than they were 50 years ago. For instance, in the pre-drug era, roughly 50% of people hospitalized for first episode of manic-depressive illness were asymptomatic in long follow up studies, and only 15% to 20% became chronically ill. Various long-term studies found that 75% to 90% worked, and people so diagnosed did not show signs of long-term cognitive decline. Today, bipolar patients suffer many more acute episodes of illness and are much more likely to be rapid cyclers; they often suffer low-grade depressive symptoms in the interludes between acute episodes; only about 33% to 40% are regularly employed; and they show long-term cognitive impairment. Here is how the NIMH’s Carlos Zarate has summed up this deterioration in modern outcomes: “In the era prior to pharmacotherapy, poor outcome in mania was considered a relatively rare occurrence. However, modern outcome studies have found that a majority of bipolar patients evidence high rates of functional impairment.” 3. It Is a Myth that All People With Schizophrenia Need to be On Antipsychotic Medication All Their Lives.
In the decade prior to the introduction of Thorazine, 65% or so first-episode schizophrenia patients admitted to state mental hospitals would be discharged within 18 months, and at the end of five years, 70% to 75% would be living independently in the community. (Employment rates for the men were above 50%.) This good employment rate continued into the early 1960s. An NIMH study of first-episode patients treated either with an antipsychotic or a placebo upon initial hospitalization found that one year later 58% were employed (or functioning well as “housewives.”) Furthermore, it was the patients treated in the hospital with placebo who were the least likely to be rehospitalized at the end of one year. Since then, numerous studies have found that there is a subgroup of first-episode schizophrenia patients who can recover and fare well without the use of antipsychotic medications, and that it is this unmedicated subgroup that has the best long-term outcomes. Most recently, in an NIMH-funded study conducted by Martin Harrow at the University of Illinois College of Medicine, 40% of the schizophrenia patients off medication were recovered at the end of 15 years, versus 5% of those on medication. “I conclude that patients with schizophrenia not on
antipsychotic medication for a long period of time have significantly better global functioning than those on antipsychotics,” Harrow reported at the 2008 meeting of the American Psychiatric Association. In western Lapland in Finland, the psychiatric community has been using antipsychotics in a selective manner since 1992, and today that region has the best outcomes in the Western World. At the end of five years, 80% of first-episode psychotic patients in western Lapland are either working or back in school, and here is their medication use: only 33% have been exposed to antipsychotics, and only 20% are regularly maintained on the drugs. 4. Use of Illicit Drugs and Antidepressants is Fueling the Bipolar Boom Fifty years ago, bipolar illness was a rare disorder, affecting perhaps one in 3,000 adults. Today, one in every 40 Americans is said to suffer from the disorder. While this increase is being driven in part by an expansion of diagnostic boundaries, it is also being fueled by the widespread use of illicit drugs, and by the use of psychiatric drugs (stimulants and antidepressants.) In studies of first-episode bipolar patients, roughly one-third suffered their first bout of mania or “mood instability” after they had abused illicit drugs (amphetamines, cocaine, marijuana and hallucinogens are common culprits.) In patients diagnosed with unipolar depression, treatment with antidepressants more than triples the risk that they will convert to bipolar illness, such that 20% to 40% of long-term users of antidepressants today end up with bipolar diagnosis. In a survey of members of the Depressive and Manic-Depressive Association, 60% of those with a bipolar diagnosis reported that they had turned bipolar after exposure to an antidepressant. 5. The Medicating of Children and Youth for Mental Disorders Is Not Helping Them Thrive Over the Long-Term. In long-term ADHD studies, the medicated youth have not fared better than the unmedicated group. For instance, in a long-term study conducted by the NIMH (known as the Multisite Multimodal Treatment Study,) medication use at the end of the third year “was a significant marker not of beneficial outcome, but of deterioration.” Furthermore, children treated with stimulants are exposed to significant long-term risks; 10% to 25% convert to bipolar illness, which puts them onto a lifelong path of chronic mental illness. Twelve of 15 pediatric studies of SSRI antidepressants failed to show even a short-term benefit for the medicated group over placebo. Antidepressants can cause a host of psychiatric and physical side effects in youth; most problematic is that 25% of youth treated with antidepressants convert to bipolar illness within four years. Prior to the 1980s, which is when the prescribing of stimulants to youth became common, bipolar illness was virtually unknown in prepubertal children. Today, one percent of all American youth are said to be bipolar, and surveys of children so diagnosed have found that more than 65% turned bipolar after treatment with a stimulant or an antidepressant. Long-term outcomes for youth diagnosed with juvenile bipolar disorder are poor; they exhibit symptoms “similar to the clinical picture reported for severely ill, treatment-resistant adults,” researchers have found. 6. Conclusion.
There is evidence that psychiatric medications may be helpful over the short-term, and there are some people who fare well on the drugs long term. However, the outcomes for affective disorders have noticeably worsened during the modern drug era, and there is evidence that a significant percentage of schizophrenia patients can fare well over the long term without the use of antipsychotics. The regular use of psychiatric medications has also fueled an astonishing increase in the number of adults and children diagnosed with bipolar illness.