Book Review

Mad in America: Bad Science, Bad Medicine, and the Enduring Mistreatment of the Mentally Ill

N Engl J Med 2002; 346:2096June 27, 2002

Article

Mad in America: Bad Science, Bad Medicine, and the Enduring Mistreatment of the Mentally Ill
By Robert Whitaker. 334 pp. New York, Perseus, 2002. $27. ISBN: 0-7382-0385-8

This book is more of an indictment than a historical account, in keeping with its subtitle. The author, a medical journalist, virtually equates mental illness with schizophrenia; depression and other psychiatric disorders are mentioned only parenthetically. The story starts on a positive note, with the establishment of proper medical wards for the insane in Pennsylvania Hospital, around 1800. This occurred in the wake of the work of Pinel, who in 1793 was the first to free psychiatric patients from their chains, in Paris. The medical approach, sometimes still harsh, was followed by the heyday of “moral treatment,” between the 1840s and the 1880s, in Pennsylvania Hospital and elsewhere in the United States. It was modeled on the Quakers' retreat in York, England (in 1796), where patients were treated with compassion and respect.

Alas, from there the road only went downward. The overcrowding of psychiatric hospitals with persons with syphilis, alcoholism, and dementia, as well as the lack of dedicated personnel, led to the departure of philanthropists and the restoration of the medical model, under the leadership of neurologists. Subsequently, the eugenics movement led to inhumane measures. The first was prohibition of marriage among the insane (in more than 20 states, between 1896 and 1914); the next was compulsory sterilization, performed in thousands of U.S. citizens between 1907 and World War II. Until the 1930s, psychotic behavior was most often treated with “hydrotherapy” (in fact, old-fashioned forms of restraint combined with the use of cold baths or wet packs). Other physicians acted on idiosyncratic theories and removed female organs, parts of the gut, or teeth, or they induced malarial fever.

In the 1930s, new treatments followed each other in rapid succession: coma induced by insulin, seizures induced by pentylenetetrazol, electroshock treatment, and finally, prefrontal lobotomy. Moniz took the lead with this operation (in Lisbon, Portugal, in 1935) and was followed the next year by Freeman and Watts in the United States. It was especially in the decade after the war, after Freeman had introduced the transorbital technique, that more and more patients were regarded as candidates for prefrontal lobotomy. The state of lethargy in which most patients were left after this “minor operation” did not detract from its popularity. The fact that outcome assessment was so biased can be attributed not only to naive optimism; in addition, discharge from an institution was regarded as a success in itself. State asylums encouraged any measure that removed patients from their care, and reports of success would bring in new research money, especially from the Rockefeller Foundation. When the popularity of lobotomy waned, in the mid-1950s, more than 20,000 patients had undergone this procedure.

One might think that the advent of antipsychotic drugs (starting with chlorpromazine, in 1954) would have marked the beginning of a more positive chapter in the history of American psychiatry. Not so, at least in the author's eyes. He regards American treatment regimens involving the use of antipsychotic drugs as no less disabling and brutal than the methods used in earlier times. Although there may be truth in the notion that dosages of antipsychotic drugs in the United States are higher than necessary, the author weakens his position by issuing continuous and unrelenting condemnations (for instance, “The Nuremberg Code doesn't apply here”), despite a dearth of evidence to support them. How can he be so certain that persons with Kraepelin's schizophrenia in fact suffered from encephalitis lethargica and that therefore today the outcome of the disease is seen in an unnecessarily gloomy light? Indeed, finding normal levels of dopamine in the cerebrospinal fluid of persons with unmedicated schizophrenia does not support the “dopamine hypothesis,” but to call it “a bald-faced lie” is simplistic reasoning. It is true that blocking dopamine receptors often leads to akathisia (an irresistible urge to move), but what is proved by citing (without naming the authors) a study in which 79 percent of mentally ill patients who had tried to kill themselves suffered from akathisia? Or by citing one in which 50 percent of all fights on a psychiatric ward involved patients who suffered from akathisia? And what point is made by telling the sad story of a female patient who was eventually found murdered in Central Park? Or by recounting the story of fraudulent psychiatrists who made money by entering nonexistent patients into well-funded pharmaceutical trials? Such criminal behavior has occurred in other specialties and does not by definition disprove the efficacy of the drugs being studied.

Similarly, the author tries to prove his point that neuroleptic drugs make patients worse, rather than better, by repeatedly comparing series of treated and untreated patients from different institutions, with inherent differences in referral patterns and severity of illness. It is precisely for such weaknesses of design that he chides the industry-driven clinical trials that introduced “atypical” antipsychotic agents such as risperidone and olanzapine. Rightly so, but by this time critical readers will have lost faith in the author's arguments. Although the author is widely read on the subject, the facts are largely arranged to suit his prejudice, especially in the chapters on drug treatment. American psychiatric institutions may have their failings in the current management of patients with schizophrenia, but they deserve better critics.

J. van Gijn, M.D.
University Medical Center Utrecht, 3584 CX Utrecht, the Netherlands
j.vangijn@neuro.azu.nl