Science for the Public; WGBH Forum Network; The Astonishing Rise of Mental Illness in the US

Welcome to the science for the public lecture series science for the public is an organization committed to bringing science information issues to the general public. Visit our website for our program to Stevens and learn. Hello. I'm a fan stabbed for science for the public and I welcome you to our community television program public science. Tonight's guest addresses a major public issue the widespread use of psychiatric medications in our society and more particularly the long term effects of many of those drugs. Robert Whitaker is a widely acclaimed science writer. He's the author of Mad in America and the mapmakers wife. In addition to his latest and highly praised book that he'll discuss here Anatomy of an epidemic in this book he takes up the issue of psychiatric medication drugs that initially seemed so promising for treatment of many types of mental

impairment such as anxiety depression ADHD bipolar ism and schizophrenia have actually led to an epidemic of dental and cognitive problems. Whitaker provides us with the historical background the data and the politics of these medications. Although he's been very busy on his latest book signing tour he's generously agreed to give a presentation about the many challenges he encountered in developing the information in this book. I think what he reveals will make all of us more aware of how vigilant modern citizens must become by bringing this information to the public in such a thorough and clear manner. He has performed a major public service after his talk. Robert Whitaker will take questions. Please keep in mind that this program is being recorded and if you have asked a question you are in effect giving us permission to record you.

This program will be aired on Belmont media center stations and it will be accessible on blip TV via a link on the science for the public website. This program will also be accessible on the WGBH PBS forum network and the link will be provided on the science for the public website. When the page is set up on the network and now we're very honored to welcome Robert Whitaker. Thank you for having me. Thank you. It is both a pleasure and an honor to be here tonight and I thank you for this invitation. And what really pleased me about this invitation is Yvonne asked me not just to talk about the book that I have been talking a lot about the book but really about the challenges as a journalist in writing this type of book. And actually it's a question I haven't spoken about before but it is a question that I dealt with the whole time I was researching this book the whole time I was reporting this book and it really does raise a profound question as to how the public gets its

information and who should be delivering the information and so one of things we're going to be looking about tonight is the journalist's role and really maybe the medical profession's role in in talking to the public in delivering information to the public. So I think you'll see by the end of this talk the question is Why am I having to deliver this information as a journalist maybe it should have come to you in other people really from the medical community. OK. Here's the dilemma as a journalist when you write when you begin that this book presents OK what is the book about the book is about a medical puzzle. And when we look at what our society knows about psychiatric medications the story arsis our society has told itself goes like this. 1055 Thorazine arrived in asylum medicine and this was the first anti-psychotic medication and this ushered in a psycho pharmacological revolution this great leap forward in our care of mental disorders. We got anti-psychotics we got an eye depressant drugs we got anti-anxiety drugs. And as the story goes

Thorazine is what made it possible to empty the state hospitals and take care of the severely mentally ill in the community that's a step forward. You hear in the names a sense that we've now discovered drugs that are antidotes to mental disorders think about this anti-psychotics approach either doing something specific to psychosis. Antidepressants all that tells you of sort of drugs that fit into almost a antibiotic model of medicine. You think of the anti we're looking in the next part of this story that we believe in is that these drugs in fact fix chemical imbalances in the brain we've all heard this that mental disorders were discovered to be caused by chemical imbalances and these are antidotes to those chemical imbalances. And then going forward we even have the sense that this revolution in care has unfolded in two steps. We had a first generation of psychiatric medications thorazine you know the trade secret Canada presence volume and cetera. And then beginning in 1907 Prozac arrived on the market and this was the first of the second generation psychiatric drugs in the second generation. That was the

SSRI selective serotonin re-uptake inhibitor. New Anna depressants they were said to be better than the old tri sick leaks. And then we got what are known as a typical anti-psychotics thing drugs like Cyprus and respect all. They were said to be better than the old standard anti-psychotics. And so if you really hear this it's a revolution that unfolded in two steps. And by the way if you look in 1908 a U.S. surgeon general at that time David Satcher wrote a treatise on mental health in this country and that's the story he told. He said before the arrival of thorazine psychiatry lacked treatments that could prevent people from becoming chronically ill. Then we got these drugs and today we enjoy. Why. A number of treatments that are safe and effective for mental disorders. It's a story of medical progress of a leap forward. Now is the first thing that I did in this book was look at a very simple metric and that is the number of disabled mentally ill in our society and also look on a per capita basis and how is it changed during as this revolution has unfolded. Because of

course we would expect that if we now have effective medications that at the very least the per capita disability rate should stay the same or in fact go down right. I mean normally when you have effective medications you see this increase in the ability of the people to function well in society. So if you go back to 955 at the start of the psycho pharmacological revolution there were about five hundred sixty five thousand in state and county mental hospitals and that is seen at that time as the disabled mentally ill population. However if you drill into that data a bit more you find that about there is only actually about three hundred sixty five thousand people with psychiatric diagnoses. The other 200000 really were people with other types of ailments ailments such as Alzheimers disease in stage syphilis alcoholism not psychiatric problems. So we had about three hundred sixty five thousand people under state care at that time. And thats a disability rate of roughly one hundred forty one in every 470 people. OK. Now as researchers have tracked that number the the number of disabled

mentally ill in our society forward into the air era of the institutionalization. It's not an exact it's not an exact metric that as you go forward but what they've looked at is how many people receive SSI or SSDI. These are government disability payments because they're disabled by mental illness Okay that means they're on government care because they can't function well enough in society to earn their living. And that's that's not my metric tracking this forward that's what other researchers have done so I'm just following in their path. OK. 1987 at the moment that Prozac arrives in the market we have one in every excuse sorry we have one point to five million people on SSI and SSDI in 1900 when Prozac arrives. That's a disability rate excuse me of roughly one in every 184 So we went from one in four hundred sixty eight to one in every hundred eighty four. Now from 1997 forward we have the same metric. Right. We're just going to follow the people on SSI or SSDI. And and so we get these new

drugs and we really embrace this form of care right since Prozac arrived. Sales of psychiatric medications we spent about 800 million in 1907 today we're spending over 40 billion dollars in the United States and using on psychiatric medications and I depressants by the way we spend more on am I sick and I depressants the United States than the gross national product of Cameroon. It gives you a sense of how how much we've embraced this form of care. What's happened to the it SSI and SSDI numbers since Prozac arrived in the next 20 years. The number of people on government disability due to mental illness tripled it went to four million people today. Every day in the United States 365 days a year. Eight hundred fifty adults are being added to the SSI and SSDI rolls due to mental illness. OK that's quite an epidemic actually. There's another thing that you look at if you look at the disability numbers what's happening to the children if they're severely mentally ill their families and caregivers can also get an SSI payment in

1987 there were sixteen thousand two hundred children in America who received the payment because of a mental disorder or mental illness. All right. We now start medicating kids today at 600000. And now there's 250 children per day going on SSI and the other thing you see that's happening to these children they hit age 18. They're going right on to lifelong disability they're going on to the government program. So you see a medical puzzle set up. We have a societal belief that these medications represent a revolutionary advance in the treatment of mental disorders. And I will say and I think we all know this is true. Do we know that the psychiatric medications can help people during times of acute psychiatric distress. Absolutely. I think that's true we've seen people help in that way. Do we know in fact that many people stabilize well on the medications. Yes we do. OK I know that true. I know that I know many such people. And you can hear those voices in our society. At the same time however and here comes the puzzle. We have this extraordinary rise in a

disability rate that seems at odds with the story of a revolutionary advance in care and one church that necessarily raises a question. It seems it seems odd but here's the question Is it possible that our drug based paradigm of care for some unforeseen reason is in fact fueling this epidemic. All right and that's the puzzle I'm asking in here. And once you raise that question you really have two subsidiary questions that you're going to want to look at in the scientific literature. One is you're going to want to look at how do psychiatric medications affect the long term course of major mental disorders schizophrenia and I do it for four major adult disorders in the book. Schizophrenia anxiety depression bipolar disorder. Do they shift it. The long term course for the better. In other words make it more likely people are able to work that they're going to be less symptomatic more functional or for some odd reason when we look at outcomes in the aggregate do you see in fact that they shift outcomes for the worse compared to the

sort of natural spectrum of outcomes sort of increase the risk of disability increased the fact that the amount of time people spend symptomatic that's one of things we're going to want to look and see what the scientific literature has to say about that question. All right you can see it's a valid scientific question. The other possibility when you look at this disability data is this. Is it possible that you take a person with a mild psychiatric problem let's say a mild bout of depression. You put him. They go in and they get treated with a psychiatric medication CNN a depressant. And let's say they now have a bad reaction to that drug. Let's say that with the depressed person on a man a depressant ends up having a manic episode in response. Now this is well known that this can occur. Then once they have that manic episode what's going to happen they're going to be diagnosed now with bipolar and now they've moved from a milder problem into a much more severe problem. And the disability rate for bipolar is much higher than for depression. So you can see in that possibility basically an eye after

genic or drug cos pathway that you may have a sense a certain percentage of people have a bad rate come in with a mild problem have a bad reaction to a drug and end up on this path of disability. OK so that's the two possibilities we want to look at as we go through the scientific literature. Now why does doing this book present a problem for a journalist. And it does it presents a big problem and it's one that I really struggled with as I wrote this book. On the one hand it's a it seems like an obvious thing for a journalist to do. OK we have a societal problem I mean disability numbers are not good. I mean obviously that's not a good outcome. Our spending on mental disorders in this country doubled in the last eight years. So you can see we want to make change we want to get better outcomes so that seems like something a journalist should focus on. The problem is by even raising those questions and you can see it I'm raising that as a heretical question. Our society believes this. Our psychiatric

establishment believes these drugs represented a profound leap forward in medical care. So it's a question that seems at odds with what society knows to be true. It's at odds with what psychiatry knows to be true. The medical establishment knows to be true. So right away I mean this sort of heretical position and the other problem for a journalist is this what does a medical journalist normally do when normally they go to the experts in essence and their job is to sort of in essence translate what those experts say is true for the general public. But by the very sort of nature of the question I'm asking here and the medical puzzle. I'm really in this position of possibly saying to the medical profession you don't know your own scientific literature and you're deluded. That's really it so I'm in this odd position in relationship to the experts in the field. And it's a really profoundly sort of difficult position an uncomfortable position to be. Now because

if one asked me to sort of talk to us about a journalist will I want to tell you how I ended up here. OK a little bit of the history how did I end up asking this heretical question I've been writing about medicine and science really about 20 years before. And what happened was in 1909 I had been a newspaper reporter covering general stuff before that. In 1909 I was at the Albany Times Union newspaper and I was made the features reporter covering medicine and science. This began my career and Sky's coverage writing about medicine science. I do that first a few years there in 1902 I came to Cambridge on a fellowship at MIT a Knight Science Journalism Fellowship it's a mainstream fellowship. Shortly after that I actually left daily newspapers for a while was the director of publications at Harvard Medical School you can see I'm all right in the mainstream here. After that I actually left that to co-found a company called sensor watch that reported on the business x aspects of the clinical development of new drugs. Who are our readers I mean was it regular

journalism our readers were pharmaceutical companies academic medical centers doctors. So I'm absolutely in the mainstream up at this time and then in 1988. During this time I had that company I also continued to write magazine articles occasionally and newspaper articles and in the summer of 1998 while I still have this company I stumbled upon some problems of some of the abuse of psychiatric patients in research settings. So I said Aha. Let me but let me go take this. I'll make a proposal to the Boston Globe to do a series on this. They accepted it and saw that we did a four part series. Now during that four part series one of the things we focused on as an ethical were studies that involved with drawing anti-psychotic medications from schizophrenia patients. Now why would that be unethical and why did I think it was unethical. Well it was because my understanding at the time was that schizophrenia was caused by too much dopamine in the brain right in the drugs block dopamine activity and therefore they help balance the dopaminergic pathways they help

fix the root cause of schizophrenia. And so we said well it's not. And as I called the people they said the drugs are like insulin for diabetes that's what the experts told me. Well then I said well why would you ever withdraw anti-psychotic medications from schizophrenia. You wouldn't do it from people's kids friends. You wouldn't would you have a drug withdraw do studies with it where you withdrew insulin from diabetics you wouldn't do it right. So we right that this is abusive and it's you know it's an example of abuse of psychiatric patients and and that's serious by the way we did other abuses as well. It won some awards it went to George Polk Award it was a finalist for the Pulitzer Prize. So at this point I'm absolutely comfortable as a medical journalist not following a mainstream thing. But what happens as I was doing the reporting for that series I came upon two studies that I didn't know what two outcome studies related to schizophrenia that totally didn't make sense. The first one was a study by Harvard Medical researchers that looked at outcomes for schizophrenia patients and this was published I think in

1994. And they had found that outcomes for schizophrenia patients had actually declined in the past 15 years. And here's the kicker. And we're now no better than they were in 1900 when water therapies were the order of the day. Now remember I'm a believer at this point in the story of progress and all the sudden it come upon this big picture outcome study they say things haven't improved since 1900 sort of the lies that story of progress. Now then I also looked at there was also a Studies by the World Health Organization and the studies went back to 1969. And what it did in the World Health Organization had done is they had compared outcomes in precut pretty poor countries of the world schizophrenia outcomes specifically India Colombia and Nigeria with outcomes in the U.S. and seven six other rich countries. They do this one time and they find it's a five year study and they find that outcomes are much better in the poorer countries of the world. They wonder how can that be. So they're going to repeat the study and by the way the diagnoses are being made by Western doctors.

OK. And they hypothesized as they repeated this study maybe the reason oen by the way stopped for a second. They concluded that the outcomes were so different the divergence in outcomes was so profound that living in a developed country was a strong predictor that a person would never fully recover from schizophrenia. So there's this real sense of failure. And so they hypothesize that in fact maybe the thing is in the poor countries people are more medication compliant. They take their medications more regularly so they look at medication usage in that second study. Now two things happened in the second study. Indeed once again they said our first out of her first findings are confirmed outcomes are much better in the poorer countries of the world. Then they looked at medication usage. And here comes the surprise in the poor countries of the world. Only 16 percent of patients were regularly maintained on anti-psychotic medications whereas of course in the developed countries that was the standard of care. So you can see why these gave me pause. These ran

exactly the contrary. They directly contradicted what I had just written about in the Boston Globe which was that you should never take people with schizophrenia off their anti-psychotic medications that's abusive. We know they fix chemical imbalances. So I was left with this sense of confusion. And what I did at that point is I got a contract to write Madden America's first book that really was ended up two things. One it became a history of the treatment the severely mentally ill in our society. OK from colonial times till today. But the second part of the book really was to look at this modern failure. Why are outcomes better in the poor countries of the world than they are here. Right. And also to look at this question of medication usage. Is there some reason that the fact that they're not keeping everybody on medication in the poorer countries of the world is that and some reason actually helping get better outcomes. And by the way India who study the World Health Organization study by far the best outcomes were in rural India and there they had almost nobody on the medications long term.

All right so that's how I got to man America real quickly. You know I go through the research literature mainstream research literature and when you do that. Indeed and we're going to go through this in just a minute so you'll see what the science has to say. But you do come at the end to understand why it's sort of a selective use of the meds would in fact lead to better outcomes. So I published that book and what happens. This was my first experience as a heretic in our society. Some people you know many people like the book I rip other you know certain reviewers praised it. It's not taught in certain colleges and other people just dammed it big time and especially psychiatrists. My favorite review of this sort was written by a Chicago psychiatrist in his opening line of his review was this the Fox Television never wants to do a show on good journalists gone bad. They can start with Robert Whitaker and Matt in America.

So but the point is it's a difficult position to be a journalist contradicting the sort of conventional wisdom. Even though the only thing I did in this book and you're going to see it in a second is look at what the mainstream research actually showed. Long term studies of those doing nothing more than what any sort of evidence based reviewer would do. That book comes out as Yvonne said I then wrote another book I wanted to get away from psychiatry frankly wrote another book called The baker's wife nonfiction and another book called on the lips of God which deals with the racial massacre or the court case. But I kept being asked to speak about this topic and finally someone asked me to do a paper on this topic and I said OK. And to expand beyond schizophrenia so I said let me look at the disability data. I looked at it and you got the same problem in essence that I saw with schizophrenia. Is that something doesn't add. Up. So that's how I ended up writing this book but you can see it. I guess the point of

this is this. I was a believer and I followed actually a very traditional journalistic path to writing this book and that was trying to solve a puzzle. It's trying to solve a problem. OK. Now the way what we're going to do in anatomy of the epidemic what I do is I like I do as I chart the long term outcomes literature for. As I said for disorder schizophrenia anxiety depression and bipolar disorder. And in doing that I also look at are are we going to find I attribute any pathways as well and then I look at what's happening to children when we look at long term outcomes as you know we've even barked at this and in part embarked in this extraordinary medical experiment where we are medicating a sizable percentage of our children. And how's that turning out. How are those children doing long term. Again that's the second part of the book now sort of as a first step on this. It's I want to talk about the evidence based on what we're going to do here achievement.

We're going to this friend I psychotics again there's a reason we're going to do it but what's we're going to spend the most the time and then I'll go real quickly on me and I depressants I'm bipolar it's the reason I thought it would be good to focus on anti-psychotics is this if there's any class of drugs that we as a society should be sure has a benefit. It's anti-psychotics for schizophrenia. I mean I'm talking about as a benefit for improving outcomes in the on the whole in the aggregate. OK. And there are any facts of course. Our society is is is set up in fact to ensure that people so diagnosed take these drugs sometimes are under court orders to take these drugs. If not there's a lot of sort of social pressure to do so. So given that our society behaves in this way there should be a really solid evidence base stretching back 50 years that says this is an evidence based good thing to do with basically everybody with schizophrenia. OK. Does that make sense. So if we find something that contradicts that boy this would be quite surprising we find in the evidence base. So what is the evidence base for the

use of these medications and there of course is an evidence base. If you brought in a psychiatrist and say are we. We have our evidence base and it consists of two parts. If you take 100 people with psychotic symptoms OK and you randomized them into two arms and one group you give and let's say a newly psychotic and you give one group drug and one group the Siebel at the end of six weeks no question these psychotic symptoms have abated more in the drug treated group. OK. And that means that's why they're considered efficacious for FDA purposes. They curb acute episodes of psychosis better than placebo. And there's a lot of evidence to show that that is indeed true. I mean there's been many studies of this type. Now once people are on medications the question is how long should they stay on right and what psych psychiatry did to study that question is they ran what are known as a relapse studies or withdrawal studies. They would take schizophrenia patients who had stabilized well on the medications and they have to be stabilized because they basically have to be asymptomatic.

And now of the hundred responders good responders will take 50 and keep them on the drug. And the other 50 they'll abruptly withdraw from the medication. OK. And sure enough those abruptly withdrawn time and time again relapse at a greater rate. And so researchers said psychiatry psychiatric researcher said Aha you see when we withdraw the medication the disease returns the disease symptoms return. Therefore the drug must be preventing the relapse of the return of the disorder they're preventing relapse OK. And that becomes a evidence based rationale for maintaining people on medications. And if you go into the research literature and you see what is our evidence base those are the two forms of evidence base they have. OK. What's missing. There's nothing in that evidence space that tells you anything about increasing employment rates increasing functionality in society. The relapse just tells you whether going back to the hospital isn't all. But there's another thing. Imagine we run a different study. Imagine we run a study with a hundred people. First episode people with schizophrenia and now we put 50 on

medication which started down the medication path and we keep the other 50 we don't expose them to medication at all. OK. This group is basically going to be the natural spectrum of outcomes for schizophrenia right. What is do we have any information that this drug treated group really is doing better long term than this never exposed group. Is it beating sort of the natural spectrum of outcomes for schizophrenia. We don't know that the evidence base doesn't tell us that. And in not in 2002. Emanuel stip who's a psychiatrist well-known psychiatrist at the University of Montreal he writes an editorial on European psychiatry. And here's what he says. After 50 years of neuroleptics are we able to answer the following simple question neuroleptics are anti-psychotics OK are neuroleptics effective in treating schizophrenia. There was he said quote no compelling evidence on the matter when long term is considered. This is his major review of the literature and then he says this. He says if we wish to base psychiatry on evidence based

medicine we run a genuine risk in taking a closer look at what has long been considered fat. Now why is this important. It shows that the endeavor I'm going to have in this book looking at the long and how long term outcomes are altered is in fact not heretical from a scientific point of view. That's actually what the mainstream psychiatry says we need to be doing. All right. It's heretical from a political point of view. It's a radical sort of from a financial point of view. It's so but that's where the heresy comes from it actually does not come from within psychiatry what mainstream psychiatry says is we lack evidence that we're improving the long term outcomes for the better. OK. So can you indeed. She is me just for a second. Can we. But if you look at a manual step piece and we lack evidence he's not saying we were finding that maybe the evidence is there showing where worsening outcomes. Or in fact that maybe drugs should be used in a different manner. So what my challenges is to go through the mainstream scientific literature studies done by the end I made by the World Health Organization

and see if we can put together a story of how drugs indeed affect the long term course of schizophrenia. All right. And I think this is a model that we're going to apply for depression in the book anxiety in the dobro bipolar disorder in the book and really with the children as well. OK the first thing you want to try to do is find out what were outcomes like before the drugs were introduced. Say from one thousand forty five to one thousand fifty five. Now the understanding is that people schizophrenia became chronically ill. Right. They're just going to they're going to be in the hospitals are not going to get out. Well if you actually go to the epidemiological literature from 1045 you're immediately are surprised because they did do many studies the first episode of people with first episode schizophrenia. And here's what they found time and time again. At the end of five years from that moment of first hospitalization roughly 70 percent would be out living in the community. And this charge rates are actually discharge rates within 18 months should be at 65 70 percent but at the end of five six years 70 percent would be living in the community. OK now by the way they're not on

disability because there's no disability framework in our society at that time outside of the mental hospitals employment rates as best as I can find are at least 50 percent and up. Many of the women in fact are married so they're there. Remember back in the 50s not that many people are working outside but that have this what's called an the customary social role or something like that they're functioning in that social role over 50 percent by the way there's a study in England that looked at this question to same thing. Over 50 percent of their people were functioning OK people schizophrenia five years later were functioning OK in society meaning able to take care of themselves. All right so that gives you a little bit different understanding of a baseline sort of outcomes for schizophrenia. Real quickly did these drugs enable deinstitutionalization That's the second part of her story to keep bits of information in one thousandth the Thorazine comes in one thousand fifty five.

The real study that looked at whether these drugs are any sort of impacts celebrating discharge rates was done by California as I think it's 1958 1959. He looked at all of the first episode schizophrenia patients admitted in two years and all of its hospitals and it found two things One that the discharge rate for those not treated with medication because not everybody was being treated as a matter of course was 88 percent within 18 months I think it was the discharge rate for those treated with neuroleptics was 74 percent. It was actually lower. The other thing they found was that hospitals were adopting a new form of care at varying rates that hospitals that used the drugs the least had the highest discharge rates. The hospitals that use the drugs the most had the lowest discharge rates. So all's you can say is in terms of first episode schizophrenia patients that isn't evidence that these accelerated the discharge of those first episode patients as far as the chronic load in 1055 there were about 200 in 65000 prior schizophrenia patients in the hospitals

eight years later it hadn't budged really it was about 10000 people less. So when does the institutionalization of the clinic happen it happens when we pass Medicare Medicaid legislation which says to the states if you shift your chronic patients from the state mental hospitals to nursing homes or shelters in the community will pay half of that money. OK it was really a legislative change that led to deinstitutionalization. OK. Now the long term outcomes literature. The first good study of anti-psychotic medications was done in the early 1960s it was done by the end I mean it has four arms four different groups three of the groups get treated with an anti-psychotic it's just three different anesthetics The fourth is treated with placebo after six weeks there is no question the drug treated groups are doing better. OK. There's psychotic symptoms have abated to a greater degree. However if you look at the placebo arm there are many patients that in fact are getting better just as not as fast. And that becomes actually the study that launches the sense that these are of eth effective drugs still cited today.

What doesn't get cited today is the one year follow up study and one year later the researchers found something odd. They found that those treated with placebo actually were less likely to be re hospitalized than any of the drug treated groups. At the end of one year. A lower we hospitalisation rate not drug usage is not controlled real well in that it's not controlled at all in that year so we don't really know drug exposure. But right at the beginning of the research outcomes literature we see the hint of a paradox. Drugs that are effective over the short term for some reason may be increasing the chronicity of the disorder of the long term. And this really is the faery first study we have that looks gives us any sort of long term outcomes. Let's now what you notice. Remember doctors at this time in the 60s still have some memory of treating people without meds schizophrenia patients without meds and they start noticing people relapsing real frequently now. They say they're coming back to the hospital in droves and they label this the revolving door syndrome. So it seems like

people are now coming back more frequently than before and they noticed something else too. They noticed that people on meds are actually having more severe relapses or people who've been exposed than those who have never been exposed. So not only does it seem like they're coming back more frequently it seems like they're having more severe relapses. OK so that this leads in the 1970s to the end I'm age to run three trials where they revisit this question of whether patients really are best served over the long term by being treated with within a psychotic medications. And here was the design of the three studies and I actually like the design. Basically. We're going to have an experimental arm OK and an experimental arm we're not going to put the newly psychotic patients and we schizophrenia patients on meds on anti-psychotic medications. But if they're after for six weeks they're not getting better than we are. OK so it's a selective use and we're going to see if there's a percentage of people anyway that can get better without being put on the meds. And then the other arm is going to be treated conventionally. OK. So it's not really a no drug garments that's called a

selectee drug arm. And the other thing that's key to understand in this experimental group it's not just placebo treatments. They're going to get sort of cycle social care community care. We're going to see if we can get people through these psychotic breaks with with sort of that sort of environmental care does that make sense. OK what do they find in who runs these studies. One is done in-house by and I'm h a second was done by Lauren Moshe who is the head head of the schizophrenia section at the end I'm H. And the third is done by a guy named Maurice Rappaport at the University of San Francisco in Cow universe of California at San Francisco. Point is this is mainstream stuff. OK. And I made stuff. All three studies basically have the same results and the same result is this that the experimental arms have better results overall in the aggregate the sort of selective use of medication that's number one. Number two at least 40 percent of the patients in the experimental arm get better and stay better in follow up periods that range from one to three years without ever having been exposed to anti-psychotic medication. OK there's apparently some group that can

get better and stay better. That's the second finding. And the third finding is that it's this group that somehow can get through that psychotic break without being exposed to medication that has the best overall long term outcomes the best functioning. OK and I just want to read you what the findings were in the 1970s from these three studies. Here's Maurice Rappaport and he's one of the he ran a three year study. He says our findings suggest that anti-psychotic medication is not the treatment of choice at least for certain patients. If one is interested in long term clinical improvements. Many unmedicated while in hospital patients showed greater long term improvement less pathology at follow up fewer hospitalizations and better overall functioning in the community than patients who were given that stored Zene while in the hospital. OK that's one finding. Here's Lauren Moesha of the second group. OK. He's the head doctor at schizophrenia doctor in our country at the time. He says contrary to popular views minimal use of anti-psychotic

medications combined with specially designed psycho social intervention for patients newly identified with schizophrenia spectrum disorder is not harmful but appears to be advantageous. We think that the balance of risks and benefits associated with the common practice of medicating nearly all early episodes of psychosis should be re-examined. Well again what do you see here. You see this sense that if we're interested long term we should have a sort of selective use of care. The third guy William Carpenter said. Here's what I think is happening it seems like those who go through their psychotic break unmedicated. Actually are learning some coping strategies and he says those that didn't and they were used to it and that by going through the psychosis and sway they're better able to cope with subsequent like stresses. So there actually was some advantage for some people for going through the symptoms in this way. But then he raises a really key question I'm talking about William carpenter. And it's really sort of an old god moment for Psychiatry says

there's no question that once patients are placed on medication they're less vulnerable to relapse if maintained on neuroleptics. But what if these patients had never been treated with drugs to begin with. We raise the possibility that anti-psychotic medication may make some schizophrenia patients more vulnerable to future relapse than would be the case in the natural course of the illness. So he's saying at this moment maybe these drugs actually increase the biological vulnerability of psychosis over the long term. That's why you're getting these increased relapse rates etc. and you can see why this is such a problem for psychiatry is that all drugs have a respect that profile if we're making people more and the benefit obviously with anti-psychotics as we knock down psychosis. But if they're increasing the vulnerability to do that target symptom where is the benefit at least in the aggregate. OK. And at that time by the way two researchers from the University of Montreal in art and Barry Jacobs Barry

Jones excuse me came up with a biological explanation for what was going on and it's really sort of brilliant science. And here's what they said. Psych at anti-psychotic drugs work by blocking dopamine receptors in the brain and they actually block somewhere between 70 90 percent of a particular dopamine receptor called the D2 receptor. OK. So it puts the break on dopamine transmission. Now the theory had been of course that people with schizophrenia had an overactive dopamine systems and they investigated that and they said listen I can do this real quickly. So here's the thought here's how the neurotransmitter systems act in the brain. So this is the thought of what causes schizophrenia you have pre-snap the neurons that release dopamine into the synaptic neural synaptic left and then that that molecule binds with receptors on the Post's inapt neurons so the theory was that with schizophrenia either these precent epic neurons put out too much dopamine OK or converse Lee there were too

many dopamine receptors in too many receptors on the post and up to neurons one of two things happened. They investigate this and they find that in unmedicated patients that's not so. OK. And in fact I could tell you how they invest it and take some time. But for example Steven Hyman in his 2000 Steven Hyman is the provost at Harvard University. He's the former director of the and I am a cheese a neuroscientist and in his book 2002 book molecular neural pharmacology he sums up this whole research into the dopamine hypothesis of schizophrenia he says. There is no compelling evidence that a lesion of the dopamine system is a primary cause of schizophrenia. They just didn't find that chemical imbalance in the unmedicated patients. OK. But what happens to medicated patients and what the Montreal guy what was found was this the drugs act as an as a break and dopamine transmission. The brain says Oh that's a problem. And it tries to compensate for that break. And it does so in two ways the pre-snap the neurons for at least a period

of time. Now start pumping out extra dopamine. OK that's they're trying to put the accelerator down and the potion haptic neurons increase the density of their dopamine receptors. Now the brain is super sensitive to dopamine so the drugs were actually found to cause the very sort of pathology or abnormality that was hypothesized to cause psychosis in the first place. And that's the increase that these guys that's the increased biological vulnerability. You can see again we have this southern Oh my God moments. And they say for example neuroleptics I'm talking about our age should not Injun's I say neuroleptics can produce a dopamine dopamine super sensitivity that leads to both this kinetic and psychotic symptoms. An implication is that the tendency toward psychotic relapse in a patient who has developed such a super sensitivity and they all do is determined by more than just the normal course of course of the illness. OK. Now look let's now go back to the withdrawal studies. Remember what's happened you go on

drug blocks X is a break brain responds by putting down the accelerator. OK now let's abruptly withdraw the break what do you got left. You got an accelerator down and this is the reason they said you're getting all these severe relapses. Because they are now indeed in an unbalanced state. OK does that make sense. But then they said but now let's look at what's happening long term. Imagine a car you drive where you got the accelerator down in the breakdown at the same time. It might sort of be where on the car. And they said it looks like the same thing happens to the dopaminergic pathways. They start to become dysfunctional after time. So for example one of the pathways in the brain is to the basal ganglia the basal ganglia controls motor movement. And they say what do we see with patients that are on these drugs for a longer period of time we start to see tardive dyskinesia tardive dyskinesia is often you'll see this you'll see people licking their lips and the tongue will just keep going around that's just one of many symptoms. White is the basal ganglia can no longer control the tongue

movement. So the base that we see tardive dyskinesia and that's a sign that the basal ganglia is actually mis functioning OK. All right. So that's a sign it's beginning personally dysfunctional. Well the N-words and a second pathway goes to the limbic system the limbic system is seen as a mediator of psychosis. And these guys said well if we're getting dysfunction now we're probably getting dysfunction in the limbic system. And they say and sure enough they find that that happens as well and by the way these dysfunctions seem to hit at about 5 percent per year. So after 1 year 5 percent of patients have started to skin age after two years it's 10 percent after three years. It's 15. And here's what they said. This leads to something we call Tarte of psychosis. And when the start of psychosis sets in the illness appears worse than ever before. New schizophrenia symptoms or original symptoms of greater severity will appear. The third sort of pathway goes to the frontal lobes. If that pathway starts to become to this functional you get they said you're going to get cognitive decline and sure enough you see cognitive the mind over time as well. So 19 I think it's 78 as this is all coming

together the science has come together Jonathan Cole the father of American psycho pharmacology who did that very first study in the 1960s at the end I inmate's he writes a paper called is the cure worse than the disease. And he says listen we've got this problem we've got tardive dyskinesia we have this relapse problem and he says at the very what our studies show is that at least 50 percent of patients treated with schizophrenia would do better off the meds. And I said we urge all practitioners to give everybody a chance to go off their meds. Look at this we want to avoid this long term problem. So you see at this moment 20 years into the revolution there really is a sense in the science. Something has gone awry and at the very least we should have sort of selective use of the manse. OK what happens after that. This story gets lost it gets hushed up. It's the we're no longer going to talk about this and why not. What happens is in 1980 psychiatry undergoes quote basically a revolution within itself. Before this we have sort of Freud and ideas about

mental disorders in the DSM the Diagnostic and Statistical Manual. And we also have ideas of neurosis et cetera in 1080 they publish a new new manual DSM 3. And this new manual is going to present the the medical model of disorders that these are brain diseases just like cancer. And schizophrenia is a brain disease like cancer and if that is so these people obviously need to be on the drugs for life. Now the problem with the S in three is it was a political statement. It was a statement basically designed to revive psychiatry. It was designed to protect the prescribing powers of psychiatry. And and sort of because psycho the sale's psychiatric drugs in the 1970s actually goes down and psychiatry felt that was in competition with a lot of therapist social workers psychologists. This was a way to revitalize psychiatry. And as part of this new story they committed to telling this medical model story is they no longer willing to consider this sort of paradoxical long term concern. They're no longer going to talk about supersensitive psychosis. They're just not going to talk about these

problems that arose in the late 70s. OK. We hushed it up. So now real quickly what does research show since that time. Because now we all know in society people with schizophrenia need to be on these drugs you all know that I know that I knew that in 1998. So was this concern that shows up in the 1970s that they were perhaps worsening the long term disorder and people should be on selectively do his research then support that concern. Or does it in fact support the common understanding we have today all people schizophrenia should be on drugs for life. Real quickly we have MRI studies now. The MRI studies are done in the 1900s. They find that people these medications do two things that cause the basal ganglia to swell. They cause the frontal lobes to shrink over time. Then a researcher named Rachel Gerth universe of Pennsylvania said aha maybe as these morphological changes happen symptoms improve which makes sense if you believe the drugs work as drug comes in causes change in the brain. Symptoms will lessen. Unfortunately they found the reverse that over the period of three years as these changes in the brain happens

as the basal ganglia swells you these these changes are associated with a worsening of positive symptoms that Salusa Nations and a worsening of the negative symptoms. Then the second thing that you have is you have a. MRI study done by Nancy Andreas and Nancy Andreas and was the long term editor of The American Journal of Psychiatry. She started studying a large group of patients in the early 1990s. She found that over time and by the way we're also talking about the atypical anti-psychotics. These drugs do indeed shrink the frontal lobes as that shrinkage occurs you see a couple things you see cognitive decline set in after about five years. And you also see a worsening of the negative symptoms the lethargy So the MRI studies again sort of support that worrisome pattern we saw in the in the 1970s and then we have what are known as observational studies. Real quickly Courtney Harding from the University of Boston studied the long term outcomes of a group of patients that had been on the back wards of of what Vermont State Hospital in the 1950s she looked at how they were doing 25 30 years later. And here's what she found in one part

really good news. One third of those who were seen as hopeless were now completely recovered. They were working good social lives they were asymptomatic they just weren't quote schizophrenia anymore. All of them shared one thing. All of them as Courtney Harding reported have long since got off their medications. OK she said it is a myth that people need to be on their medication for life. Then we have the World Health Organization study that found out things are better where the drugs are selectively used. Then there's a final study of this done by the end I'm age by Martin herro. He followed a group of schizophrenia patients in the early from the early 1980s. What did he find at the end of 15 years the recovery rate for those off medication was 40 percent. The recovery rate for those on medication was 5 percent. So once again you see the same sort of thing finally if you go back imagine we had a form of care that looked at this that try to avoid immediate use of the drugs and then also try to minimize people on the drugs long term what sort of outcomes would you get. Luckily in northern Finland they've been doing

this since 1992 it's an evidence based solution. And here's and here's their outcomes. At the end of five years of their first episode psychotic patients 85 percent are working or back in school. Only 15 percent are on disability in terms of medication use. About one third have been exposed to anti-psychotics and 20 percent are on the drugs long term. So that tells you an evidence based story in which we could do things much better. It's not a no drug store it's not an anti med story it's what history tells you how we could really promote better long term outcomes. So that's the story of anti-psychotics and getting a sign that maybe I better wrap this up quickly. Basically you see that same sort of thing. It's a little different for it but do you see with depression you see that depression is moved from an episodic to a chronic illness with bipolar from an episodic to a chronic illness. Employment rates for bipolar have gone from 85 percent to 35 percent today. People with bipolar did not used to show signs of cognitive decline. They do today they're much more symptomatic than they used to be. This actually is openly acknowledged in the research literature as far as the kids the kids

is a national tragedy when you look at long term outcomes what are you seeing in kids medicated particularly on the cocktails you're seeing actually cognitive decline you're seeing more severe psychiatric symptoms you're seeing disability crop up every everywhere. Real quickly and I'm aged one long term study of ADHD patients on medication being on a being on medication became a marker for deterioration long term. Last story I'll assign it up here's the thing. These long term studies never get reported to the public. They get hushed up. Now if psychiatry were doing its duty to society they would be telling you these studies and they would be coming up for this evidence based rationale where drugs were used in a more selective and Kashif cautious use. OK and we would try to minimize long term use. Some people again I do believe benefit even long term but we have this big problem. And then I as a journalist would NOT HAVING be having to write this heretical story. The only reason I'm in here. The reason I'm going over the scientific evidence is is unfortunately it's being hushed up. It's being kept

from the public. You go to all these studies long term studies time and time again they do not appear in the in the in the literature. OK that's it I've got to I got to quiet I guess. Time for a few questions. Thank you. Thank. You on the out rates of mental illness increased or hospitalizations I'm not sure which when SSDI and Medicare became available. How much of a part or how complementary is the availability of those funds. What part does that play in this whole phenomenon. Yeah that that's a fantastic question. OK so one of the things is maybe we have a government more willing to say people are disabled by mental illness and provide this funding. OK so in other words that could be an explanation for why we have this extraordinary rise from 1907 2007 the number of people on

disability due to mental illness. I think that is part of it. OK and I'll give an example. Before there was a time when if you had a mood disorder depression or bipolar. Those were not seen as disabling disorders. Most people got past the depression past the bipolar and they were expected to go back to work it was seen as episodic but they did get sort of redefined as chronic disorders. Now they actually get redefined. Once people are medicated in they start becoming more symptomatic more chronic ill. You see this switch. But here's sort of I know this is a complicated answer. Do I think that's part of it. Yes I actually do think that's part of it I also think it's part of the the rise in the number of children on SSI. We're sort of saying to ourselves these are chronic disorders these are disabling orders source and so we open up this channel of support. Now. That might explain everything except for this. When I look at the changing course of disorders long term course of medicated depression versus unmedicated

depression you definitely see this change from an episodic illness to a chronic illness. You see that in the literature with the bipolar you see it from an episodic to much more chronic. OK more symptomatic. You see in fact the employments rates going down you see the cognitive decline. So those things tell you that the medications are helping to contribute to this chronicity problem. That's number one. And you all I don't really have time on this. You really do see these eye after journey pathways where you take someone with mild depression. They say they have a manic episode. They end up bipolar and now they're on to a more severe course. And what do you see what's happening with children same sort of thing. You put kids. You diagnose them with ADHD. So this is a relatively minor problem they're not sitting still in school in class doing particularly well in class at least about 10 percent of those kids will have a psychotic manic episode in response to the stimulants when that happens they move on to a bipolar diagnosis. Then they're put on a cocktail that includes an anti-psychotic. Now they're really in trouble because those cocktails they

diminish what they make and whether they may make them less emotionally engaged. You do see cognitive decline setting in long term. They are just really problematic so we have this thing where you take a kid who's fidgeting and years later he's on this cocktail he's really on a path the wife one mental patient. So great question. I actually do think that the change in cultural standards has contributed to that rise. But we also have this problem with the medications and so and how they're used. And I do want to say emphasize I do believe medications have a place that clearly can help and to acute episodes and some people do stabilize well on them and one of the nice thing about the finished program with the first episode psychotic patients the figuring out who needs them and who doesn't. Looking you really see that's not an anti met thing that's a best use policy. Of the question. Until you mentioned the Finnish program it seemed to me that maybe there was an expectation in certain parts of the world that you just have to function

and that if there was just no option for drugs so that there is a certain level of functioning the people could do that. Maybe in places like this country where drugs are easily available and it's nicer to have drugs you can take them and go on with your life and just be more functioning. Do you see that possible with more of the maybe less critical illnesses. Because it seems that there are so many people who have found the help their every day lives. Sure did you look at that as well. Yeah this is another good question. So the focus of this book of course is why the rise in disability numbers. OK so that immediately puts you into a focus on what may be going wrong. Does that make sense and are always with these major disorders say Major Depression set or do are we seeing greater chronicity. I'm looking at that long term and then I am looking at this iatrogenic pathways. But let's say we have a large number of people and I

actually believe this is true. And I think this is your question. You question many parts and let's say people sort of have it that they're already functioning OK and let's say they're anxious or just sort of uncomfortable in life and then they go on an SSRI and then maybe get on a single low dose of Essar and you're on a single drug and five years later they're saying well I do so much better now. I hear that story over and over again. And actually I think one of the reasons we do believe in this form of care that there is a large population of people out there that come in with a a milder problem. OK. And let's say it's just anxiety and actually it's more anxiety sort of just irritation. They'll get on an SSRI for example and that. Just take the edge off a bit and actually now they are functioning better. And I think that becomes a big voice in our society for believing in the medications. And again I have met many many many people in that category and I think this is why this is important to really. So what do I want with this book. It's to

have a full body discussion. OK. And there's nothing in this full body discussion that says we can't acknowledge that truth. OK that some people apparently do really well especially if they come in with this sort of milder problem. But we also need to look at this long term outcomes data and what we need to look at data that shows if we want to improve psychotic episodes we really need to use the anti-psychotics in this sort of selective way. We do have to confront this at to generate pathways that exist. We do have to confront the fact that the major depression runs a much more chronic course today than it used to in the unmedicated era. By the way the and I may just look at this in the 1990s early 2000s they had a six year study that compared the fate of people who got treated for depression major depression those who did not actually it was those who got treated had something like a three times higher risk of cessation a primary role function a seven time higher risk of disability. Similar study was done in Canada we need we need. It incorporate that information as well.

We do have to figure out what the heck's going on with the decline in bipolar outcomes. By the way to go into the research literature there are some there arse. This is is actually a concern. You will see mainstream people saying like we think it's the antidepressants and we think it's the anti-psychotics and that's not just me. So I love this question. What we really need is a sight society exists for open honest discussion air all this information and we don't I don't really think it means you throw the psychiatric medications out the window we figure out when they can help and when they when they harm. But if we do not have a discussion that includes when Martin Harrell reports that 40 percent of schizophrenia patients off meds recovered that didn't appear in any American newspaper the best and IMH study we have it never appeared in the met an American newspaper. I gave a talk out in Wooster and it finally appeared well that needs to be headlines when it happens. And in psychiatry is can can can we can discuss this how better to use the medications. So I'm really glad you did this because I honestly believe there are

some group of people that far have found the drugs very helpful and that's great and that should be incorporated into how we use them. But we need this. We need to know all this information. Ok sorry. I hope I answered your question. OK thank you. I was wondering you mentioned some studies with the first world or the richer countries versus the third world countries and the there was an unexpected result of an improvement a long term improvement in the schizophrenic patients. And you mentioned sort of the idea that perhaps drug use was either less or was less followed. And I'm wondering was there also any attempt to see if there's any societal or family or work

type of patterns or issues that were present or not present like in the Third World that made it easier for people to do better in the long term rather for. Besides drug medication your sophistication and this actually goes a little bit to your question too as if in some of these other cultures whether maybe isn't a disability system right and people and maybe people can go work out in the fields or whatever it might be there might be lesser stressful things that actually was the hypothesis or the solution that the mainstream psychiatry settled on. That somehow in the poor countries of the world you know that people could have. There was sort of more community support number one number two in fact they didn't have a disability system so they had to find some job and that in turn the fact that they're still in society actually becomes sort of healing on its own. OK they're not isolated. I believe all that is true. OK that those are all factors and they're not just explanations. The only thing I think

you have to work in at the same time is a we did see that it's possible to recover without you know without staying on medications long term in those societies. And by the way in those who studies they eventually came back and looked at long term and the Dodos patients that they were really doing long 20 years later really doing well. That's number one and two we do have to look at our own studies back in the 70s. And then also the Finnish study. Improve long term outcomes and higher employment rates you want to use the meds in this sort of selective ways. And you actually want to try to avoid putting people down the medication path because it's so problematic. So that my answer to you is are there cultural factors involved in the who studies absolutely what can we learn from them that we can learn that maybe if you can keep people working that's good and if you can people provide cultural support that's good as well and don't isolate them in sort of disabled situations. But we also need to adjust our use of anti-psychotic medications and the the long term stuff the MRI

studies we see cognitive decline increasing with a GI that really does tell you that you want to try to minimize the use and not maximize the years. A.