Harvard Book Store; WGBH Forum Network; Robert Whitaker: Rise of Mental Illness in America

So tonight I'm pleased to welcome Robert Whitaker. He joins us tonight to speak on his book Anatomy of an epidemic. Magic Bullet psychiatric drugs and the astonishing rise of mental illness in America. It's a lovely symphony of turning off like. It is comforting to think that great strides have been made in medicine and the technology we use to treat illnesses. One area that according to Mr. Whitaker isn't improving is that of mental health the number of Americans diagnosed with disabling mental illness has tripled over the last two decades despite new medications and cocktails in anatomy of an epidemic. Mr. Whitaker explores the disturbing trend and reveals the causes and catalysts for increasingly unwell population. New Scientist writes that Whitaker wants us to believe psychiatry itself is to blame and that scientific incompetence and corrupting self-interest have prevented reliable assessments of mental disorders and treatments alike. His arguments are worryingly as sane and consistently based on evidence they amount to a provocative yet reasonable thesis one whose astonishing intellectual punch is delivered with the

gripping vitality of a novel. Whitaker manages to be damning while remaining stubbornly optimistic in this in throwing and frighteningly persuasive book. An award winning journalist and science writer Mr. Whitaker was the director of the public publications at Harvard Medical School and is the co-founder of the publishing company center watch which covers the pharmaceutical clinical trials industry. He's written for various publications including the bot's the Boston Globe and which an article series he co where it was a finalist for the 1999 Pulitzer Prize for public service. His previous works include mad in America the mapmakers wife and on the laps of gods. And now will you please join me in welcoming Robert with me. Thank you. First of all thank you all for coming. One of the great fears of every person who writes a book is that they'll come to a bookstore and no one will show up so this is really a pleasure to see you all. Also there are a number of people here tonight who I interviewed for the book and I just

want to publicly say to everyone who I did interview I owe you a big debt of gratitude and thank you. The book is about many things but at the heart is a very simple question that I think we as a society do desperately need to address. And that's this question this paradigm of care we've embraced this drug based paradigm of care. If you look at psychiatric drugs do they improve the long term course of mental disorders and we're talking about long term as opposed to short term. So in other words to anti-psychotics improve the long term course of schizophrenia to antidepressants improve the long term course of depression and do drugs for bipolar Do they improve the long term course. And believe it or not you will have a hard time finding any sort of research that really focuses on that question. Well what our research tends to focus is on short term reduction of symptoms. So what I'm really doing in this book is looking at the question I think so many people do want to know is when you get on medications are you sort of improving your outcomes to have fewer

symptoms. Go back to work or you'll be able to work to have good physical health. That's where I think the very core question I think that most people when they end up in this situation want to know. And really I think this book is one of the first efforts really to see what the science has to say about that question. This is very much you know we talk about in the United States about medicine should be evidence based. And really this book is looking at what is the evidence for long term outcomes. OK and that's what I think is fresh and new about it. Now of course if the common wisdom is of course these medications improve the long term course. If you read histories of psychiatry they'll talk about this story. They will say that Thorazine was introduced in one thousand fifty five and into asylum meant medicine and that it should in a cycle pharmacological revolution a great advance in the care of mental disorders. You'll see some histories will say that the introduction of Thorazine was as profound as the introduction of penicillin for fighting bacterial disorders so this incredible

leap forward this common wisdom also goes like this that the revolution in this cycle pharmacological revolution has unfolded in two steps. We had a first generation of drugs Thorazine try sickly Canada presence with IOM etc. and then in 1907 we got a second generation starting with Prozac and these were safer and more efficacious than the old ones. And then of course after and then after we got we got a new and a presence. We got new atypical anti-psychotics as well. And then of course this was it was with Prozac that our society really embraced the use of these drugs spending on psychiatric medications has increased more than 40 fold in the United States since 1907. We actually spend more on antidepressants in the United States than the gross national product of Cameroon. Give you an example of how much we've embraced this form of care. So. And by the way in 1909 the surgeon general at that time David Satcher sort of he issued a big report on that on mental health in America. And this is the story told of a story of this great advances in

care. And he said thanks to these drugs we now have treatments that prevent people from becoming chronically ill. OK. Now if that's true you would think the level of sort of disability in our society due to mental illness would have on a per capita basis would have declined since 1955 and maybe would have gone through a two step decline. First a decline from one thousand fifty five to one thousand nine hundred seven. And then a second decline when we got the better drugs. So the sort of framework for this book starts with looking at what has happened to disability rates in the last 50 years this is just the beginning question. And here's the data you find when you do that in one thousand fifty five there were around five hundred fifty five thousand people in state and county mental hospitals. OK. However if you really dig into that data about 200000 of those people were not there with psychiatric problems they were there with Alzheimers syphilis related dementia alcoholism etc. There were actually only about three hundred fifty five thousand people

with psychiatric diagnoses. OK so that's at the start of this revolution and that's a sort of a group of people under the care of government at that time. Now obviously we went through this period of deinstitutionalization where we said we're going to take care of those who can't care for you know they're sort of severely mentally ill in the community. And one of things will do them will give them a payment of disability payments either SSI or SSDI their federal disability payments and what researchers have done said if you want to track the growth of sort of the severely mentally ill in our society under government care you have to compare the hospital population of one thousand fifty five. This is not my comparison by the way with the SSI and SSDI group going forward. So you go to 1907 how many people one point to five million are now on SSI or SSDI due to mental disorders. Now we hit this we we embrace a Prozac etc.. And over the next 20 years that tripled to four million people. And in just in terms of a per capita rate it's six times what it was in terms of sort of those.

We're going to you know under government come care due to disability per capita rate as increase sixfold since 1955. So you can see at the very least it raises a puzzle why as we got these therapies that the idea is that they prevent crime to city they in they they knock down symptoms they enable us to live normal lives. Why has the disability rate soared so much. And to give you a sense of the extent of this epidemic today. Eight hundred fifty. I don't know how many people are in the room let's say there's 150 people in this room. Every day in the United States. Eight hundred fifty new people go on to SSI or SSDI due to mental disorder. So think of six times as crowd that's how many people going on to the rolls every day and virtually once they go on. Very few are leaving those roles. So at the very least you can see that this is a concern for our society that we should think is there some way we can stem it. Now the second thing about the dissident disability numbers what's happening with the children in

1907. Children if they have a severe mental illness they can also qualify for an SSI payment or their families can in 1907 there are roughly sixteen thousand five hundred such children on disability rolls due to severe mental illness. Today there are 600000. OK it's a 35 fold increase This is of course during the era when we are medicating kids. Makes you think that maybe something's wrong by the way those kids that are getting diagnosed and medicated as kids are going right are many of them and on that on those SSI rolls when they hit 18 they're going right onto the adult SSI and SSDI roles. So again these numbers are the kasian for asking ourselves is this paradigm of care really working. Now I want a little bit of a disclaimer here. There's no question that psychiatric medications help many people get through sort of acute episodes of acute episodes of distress that's absolutely clear. We'll talk about that in a second. And then the second part is there's no question that some people stabilized

well on these medications and find them helpful. And nothing we're going to say here tonight that disputes that fact that truism. But what we're really talking about in this book and what is looking at is how does this paradigm of care how do these medications affect the long term course of outcomes in the aggregate. OK we're going to be a big picture look at this. If that makes sense because you may have a spectrum of outcomes a variability of response to drugs. So we want to look at how it affects you know group as a whole. But that doesn't deny the fact that they may be a helpful to certain people. OK. And all the one other thing. This is not a medical advice book at all. So do not take the book as medical advice do not take it as a sense that you know if you if you have some regimen of treatment that you you might want to change that that's not what this book's about. This book is about. Sort of making known the long term evidence to investigate what's going wrong and then hopefully to stir up a conversation in our society to make this long

term evidence known and sort of alter the conversation and stem the semitone epidemic and see if we can think of alternatives that would be better. OK real quickly if you want to. And what this book does really is put the standard wisdom under a microscope and then we're going to flesh out how these drugs do change the long term course. But one thing as we know part of the story about progress is that these drugs fix chemical imbalances in the brain. In other words researchers have found that say depression is caused by low serotonin in the brain and that these drugs then up serotonin and therefore they fix that chemical imbalance. I don't have time to go through that tonight because they sort of want me to be done in a certain you know 30 35 minutes. But you will read word that word that hypothesis arose from it did not arise from discoveries about what was happening in say depressed people were to Rose from is they understood how the drugs acted on the brain so for example they came to

understand that and I depressants blocked the normal re-uptake of serotonin and therefore theoretically increase certain energy levels. And then once they did that they hypothesized that since these drugs theoretically work that people with depression had the opposite problem. OK so the it was a hypothesis that arose to sort of explain why the drugs might work and put them in a framework of sort of anti medications like antibiotics. But you will find if you read this book that that was investigated in the 1700s that I bought this early 1980s it was investigated for depression. It was investigated for schizophrenia and they found that prior to people being medicated they did not have any chemical imbalance. OK. So anybody who's been told that they have a chemical imbalance and that the drug is fixed fixing it is just not unfortunate it's not true. OK. And there was a guy named Kenneth Candler who was a. An investigator and an editor at one of the

psychiatric journals and I think was around 2005 he summed up this whole pursuit in this way. He said We have looked for simple chemical imbalances as the underpinnings of mental disorders and we have not found them. OK. So once you understand that you've got to say then what do the drugs do. If they're not fixing a chemical imbalance how are they affecting the brain. And real quickly if you look at say for example how does Prozac affect the brain. Well what's the biological story. And it goes like this. Prozac what happens of course if we look at how neurons communicate in the brain. One neuron the pre-snap the neuron will release the neurotransmitter into the synaptic gap right. And then that neuron that neurotransmitter will bind on receptors on the post neuron in that cell the neurons communicate. So what happens with Prozac is the neurotransmitter serotonin comes into the synaptic gap the synaptic cleft Prozac prevents the re-uptake of that into the pre-snap to

neurons. OK so that's why it remains in the gap longer than normal. And that's why they say theoretically it ups the serotonergic level but what does the brain do. The brain is this extraordinarily flexible organ and it has these feedback mechanisms. And so when that happens the brain says this is a problem because actually the re-uptake mechanism is a way that the message is terminated it's a way you keep that message sharp. So the brain says this is a problem and it actually now dials down its own serotonergic machinery and what it will do it does this way. You take that drug the the pre-snap to neurons will stop start releasing less Sara Tonin The normal for a period of time. That's the first compensation. The second common Satori thing is that the post synaptic neurons will actually decrease their density of their receptors for that neurotransmitter. So you'll actually end up with a few a lower density of receptors than normal. The point of this is that it's not a

normalizing paradigm it's an abnormal lising paradigm. And there was a guy named not a guy named the former head of it and I am the H. There's also the provost of Harvard University now Steve Hyman. He's a neuroscientist and in 1906 he did it. He wrote a actually absolutely brilliant paper in my opinion that described how psychiatric medications work on the brain. What he says is they perturb neurotransmitter systems and that in response to that perturbation the brain goes through common Satori adaptations of the type i just told you. And then he says at the end of this conference a Tory process and he says it's go undergoing these Compean Satori adaptations in order to try to maintain its normal homeostatic balance so to speak to maintain the normal functioning of those pathways. And he says at the end of this adaptation the brain and I quote is functioning in a manner that is both qualitatively and quantitatively different than normal.

OK so if you really go into the biology of this and we get away from sort of the marketing slogans what we find is that unfortunately psychiatry was unable to find the sort of biological underpinnings of disorders. They did not find that people with mental disorders have some characteristic chemical problem that they did. But they found inversely that the drugs actually caused this change in the brain and if you want to think about it what's happening and this will sort of I think help frame this thinking about what's happening with Prozac. So that's putting down these sort of accelerator on serotonergic activity the brain responds by putting down the brake. And this is the new way your brain is operating. You've got one part the drug acting as an accelerator and your brain making adaptations to try to put on the opposite thing the brake and basically that will happen with all drugs so say for example with anti-psychotics they block dopaminergic neurons in their brain. So that's acts as a brake. What is the

brain do it goes through changes to put down the accelerator. Now that does not mean that these drugs are good or bad. It just says to you that if it's not a normalizing thing we're not fixing chemical imbalances in the brain that's one thing. So the second thing once you understand that biology you can see why they might have a lot of side effects that's number one and number two you can also see why over the long term as opposed to the short term they might be problematic. OK and really if that's sort of the Achilles heel of this revolution in fact that we didn't find the biological sort of underpinnings of this. OK real quickly on the long term outcomes in the book I do this for different disorders I do it for schizophrenia. I do it for anxiety. I do it for depression. I do it for bipolar disorder. And then I also do it for children disorders as well. And basically in terms of the mechanism of this what you want to do is you want to find out what was

the old sort of natural course of the disorder before the medications flesh that out. What did that epidemiological study say everything about from how often did it sort of clear up on its own how often did people relapse. How often did they stay well that sort of thing how what were their employment rates. And that becomes sort of a baseline to see what happens after we go into the medicated era. I think I thought I'd run through it real quickly for one of the disorders just to see how surprising the data is. And I'll see if I can do this in about 10 minutes because I know they want me to finish it fairly quickly and I'll do it for schizophrenia. And the reason I do it for schizophrenia is I know probably there's more interest in depression. There may be more interest in bipolar disorder but just in terms of how the science unfolded this sort of paradox we're going to see in the outcomes literature really first became known in evidence with schizophrenia in the anti-psychotics So it sort of follows how the science proceeded. The other thing

that's key is this if if in most settings here what you what you will say about and I psychotics it's an ethical not to treat people people who have psychotic symptoms with an an eye to an anti-psychotic and it's an ethical to withdraw that medication from anybody with schizophrenia or psychotic diagnosis. So and our society is geared up to deliver anti-psychotics to people who are in the system etc.. So if there's any place where we should see the long term outcome saying that this form of care works and is improving things it's in this it's in within this diagnosis. OK. Real quickly we think of schizophrenia as a disorder that is necessarily chronic with a bad sort of declining end. One of the things I did for this book is look at what was the outcomes for first episode schizophrenia for patients diagnosed from one thousand forty five ten thousand nine hundred fifty five the decade before. We got Thorazine and it's quite

surprising. You will find for example a first episode schizophrenia patients admitted to hospitals roughly 70 percent would be discharged within 18 months. It was just a small 30 you know 20 30 percent that was staying longer. And I thought you would look at where they were five years later there would be roughly 70 75 percent living out in the community not on disability. And about half would be working and that many would be married etc. so there was really a spectrum of outcomes. OK. It wasn't necessarily this chronic disorder we think of it. The first long term study of anti-psychotics was done by the end I made in the early 19. Sixties and here was the design. Three different groups this was a hospitalized first episode patients got an anti-psychotic. The fourth group got placebo and sure enough after six weeks the drug treated patients were doing better. Their psychotic symptoms had abated more than in the placebo group. And this becomes actually the first element in our evidence base for the use of anti-psychotics and real quickly before I go to what happened at the year

long follow up. The other part of the evidence base for anti-psychotics is this for long term use. You take people who have stabilized well on anti-psychotics. OK then the question is how long should they maintain them and they ran studies like this. They would take one half that would keep them on the drug the other half they would abruptly withdraw from the medication and those who abruptly withdrew relapsed at a much higher rate than those who were stayed on the drug and that became the evidence base for maintaining people on the medication. Just so you know that's where that came from. But we're going to look at that maybe a withdrawal effect obviously. Anyway going back to that first study done in the 1960s. So at six weeks the drug treated patients were doing better. But what happened in a year. They found that it was the drug treated patients that were more likely to be re hospitalized. OK so right at the very first moment in the year in the scientific literature we see this hint of a paradox. Short term efficacy and perhaps long term chronicity. And this is the very first one term study we have. Now if

you if you go back and look at what doctors are saying in the 60s about schizophrenia patients treated with anti-psychotics they noticed something odd. They keep saying yeah we stabilize them but then they are coming back to the hospital with great regularity. And this is what you hear the thing that the revolving door syndrome. They're just coming back left and right. They notice something else they notice that people who are relapsing after exposure to medications anti-psychotics seem to be having more severe relapses than their placebo Lancers. So something seems not quite right so in the 1970s the end I'm age ran three trials to sort of really investigate this question about the merits of anti-psychotics as a treatment for schizophrenia. All three studies had this basic design. And by the way one was done in-house it in IMH The second was done by the head of schizophrenia studies at a name age and third was a researcher in California so this is top guys in the country right now. All three had this design they had in the

experimental. They were randomized either to a conventional treatment everybody put on neuroleptics right away and the other arm. They were not put on neuroleptics right away but they were treated with psycho social care and the idea was that we'll see if some people can get better and three for six weeks without use of meds and then will only use meds in those that aren't getting better so it's really a selective use model. OK what happened in those three studies. In each instance the selective use model produce better results that's number one. Second in each instance more than 50 percent of the patients were able to get better and stay better in follow up periods that range from one to three years without exposure to medication. OK so it was a minority of patients that need to be put on. And finally in each case it was the never exposed group that had the best outcomes from one to three years. And if you read what the researcher said each time they said if we are interested in long term functioning and long term good outcomes we really should be thinking about trying to keep people

off the medications with these first episode patients. Now in addition at the same time the guy that ran the end I made study in-house guy by name and William Carpenter said. But we have a bigger problem here if we're getting more relapse rates higher relapse rates in the drug treated group. Is it possible he raises this issue. Is it possible we are increasing the biological vulnerability psychosis with these drugs over time increasing the sort of. Then there would be natural. And you can see the moment this means it means like you know these drugs are designed to treat psychosis. That's their benefit. And if they're increasing the biological vulnerability to psychosis you really have to say well what's the remaining benefit at least for a group as a whole at that time when in response to that two guys from McGill University explain he thought what was happening and it goes back to the sense of how the drugs act on the brain. So drugs block dopaminergic receptors that's acting like a break. The brain

responds by increasing the number of dopaminergic receptors in its brain and it also starts pumping out more dopamine for at least for a period of time. And he and his guys said Barry Jones said the brain is becoming super sensitive to dope. I mean and now watch what had they said and watch what happens when you withdraw the medication So here's the new balance you've got a breakdown dopaminergic transmission the brain responds by putting down the accelerator. Now you do with Rawl trial where you remove the brake and what you got left. You got an accelerator that really puts that dopaminergic system into high gear. And that's the reason you're getting such a high relapse rate. It's not the natural it's really a withdrawal effect that high relapse rate. By the way there's been very few studies where they did graduate to see what was happening. They said OK so that's a problem. In other words that's why this is they call this dopaminergic super sensitivity that's making people more biologically vulnerable to psychosis than they normally would be. But they said what's that what happens now if you keep people on these drugs long term.

Well you have this new way that the brain is functioning or you have an accelerator down and and a breakdown at the same time it's one of the Imagine driving your car like that mile after mile. It tends to wear things out. And so what they said is that basically these dopaminergic pathways with time are going to start to become a little dysfunctional. So you see this one of the dopaminergic pathways is to the basal ganglia what happens to some people on your left it's long term. They start developing tardive dyskinesia. That's a sign that the dopaminergic pathway to the basal ganglia is becoming dysfunctional. There's another pathway to the limbic system. And these guys said when that happens when that starts to become dysfunctional you're going to get the psychosis that sort of settles into the brain. You're going to get tired of psychosis et cetera. Now this all happens in the early 1980s this concern. You can see what a big problem it is for psychiatry. It's a big threat et cetera. And basically at this point psychiatry had this collective gasp. What should they do with this information. And really they just put it aside they said that's just a hypothesis.

And you really say we're not going to deal with this and we're going to put this information away and we're really going to retreat to this idea. All patients need to be on anti-psychotics. And I'm not going to go through this but if then the question is What does the data show since 1985 since this theory happened. Well there's a number of observational studies that compare long term outcomes of medicated and unmedicated patients in other words are not randomized you'll see in the book what those outcomes are. There's also research that's been done with MRI eyes looking at what happens to the brain when people go on medications and looking at the drug induced changes and whether those drug induced changes are associated with improvements or worsening of symptoms. But I'll give you one study. And this is an example of dozens of long term studies for each of the different disorders that you'll find in this book. And I bet you and I know you didn't read about this study in any newspaper but it's an example of the information that we as a society need to know. In the early 1980s the and I am h funded a study by a psychologist named Martin

Harrell at the University of Illinois he's a psychologist in the study was this. He took 64 newly diagnosed schizophrenia patients at two Chicago Hospitals one public one private because this way he got an ethnic good ethnic mix and he just began following them up. He looked at a year two and a half years four and a half years 7 1/2 years 10 15 and looked at how they were doing. Were they working. Were they symptomatic. Had they been in the hospital the past year. And were they taking medications. OK it's just a an observational study. What did he and this is the best long term follow up study that's been done in the past 30 years. OK. We don't generally study people this long. So we should all know the outcome for this. Here was the outcome at the end of two years those off medication were doing slightly better than those on medication. Then over the next two and a half years the collective fates of the two groups begin to diverged. Those on medication did not get better. Where those off medication continued to improve

such that at the end of four and a half years 40 percent of those off medication were in recovery which meant they were working asymptomatic and had a pretty good social life versus six percent of those on medication. So the recovery rate was eight times higher for those on medication now that divergent stayed for the next 10 years so at the end of 15 years the recovery rate for those off meds was 40 percent. The recovery rate for those was 5 percent on meds and actually if you look at Harold's data he had three groups. I mean through times of outcomes he had recovered. So so terrible. OK. The on meds or the off meds group broke down like this 40 percent were recovered 40 percent roughly in that middle group and only about 15 percent in the in the terrible group and the on meds group that stayed long term it was 5 percent recovered. About 40 45 percent in the middle and 40 45 percent in the terrible group. So it wasn't just that the recovery rate was 8 times

higher for the non medicated group. It was also that the priest number of a percentage of the continually medicated group that was in the really poor outcomes group. MARTIN Harrell presented his data at the I was at the 2008 American Association the annual meeting of the American Psychiatric Association. MARTIN Harrell presented these data and here's what he will Here's what he told people there. He said Just so you know unless the whole point of this is to make this book you know that it is in fact very evidence based he said. I conclude that that schizophrenia patients not on anti-psychotic medication have better global functioning over the long term. Now the only thing I would say on this is it fits with this previous story I was telling you and the questions we should know this. It never appeared in a single American newspaper until finally I gave a little talk at

Wooster and then there was the look it was a local reporter and the reporter did indeed mention it. But when that data came out when that important long term study came out did the American Psychiatric Association promote it. No. Did National Alliance for mentally ill promote it. No. Did the and I major issue a press release on it. No and really that's what I'm saying is the problem here is we don't know this long term outcome data. And what this long term outcome data tells you for this disorder we say is hopeless is that maybe we could do much better if we remembered those studies in the 70s and we used drugs selectively. And we tried not to put everyone on drugs right away. And you know the beauty of the schizophrenia story is there's a group in northern Finland who in 1902 decided to use medications in that selective way. And they've been following their patients now for 20 years and they have by far the best long term outcomes in the western world and here are their outcomes. OK unless you want to know this is possible.

At the end of five years 85 percent of their first episode psychotic patients are working or back in school. Only 15 percent are on disability. Of the 85 percent that are working are back in school those are considered sort of in the employment pool. They have a lower unemployment rate than the Finnish population as a whole. OK. In terms of their medication use five years out only one third of their patients have ever been exposed to anti-psychotic medication and only 20 percent are taking the drugs on a regular basis. Now you can see the beauty of this story is that it's not a no drug story. It's the best you story. And it's absolutely consistent with this long body of research. So in other words if you go up to northern Finn they'll say oh yeah we find a place for the drugs we find that sometimes are helpful and we find that a minority need to be on the meds it's absolutely not no an anti-medication think it is a pro medication use of medications because it is a best use it's an evidence

based use of medication. And it speaks to what is possible. And the problem is we need to know that and that's one of the the reasons for this book is to disturb discussion where we include what this what is happening long term real quickly if you look what's happening with the benzodiazepines its own story and basically long term. Everybody knows if Stan Burns was long term you get a lot of disability with the pencils Munter you get some you get some cognitive problems you get some physical problems etc. and that's sort of acknowledged in mainstream medicine. If those of you interested in depression you will see that the course of medicated depression is remarkably worse today than it was in the pre anti-depressant era. In fact outcomes for depression were considered so good in the Priano Depression era they said how are we going to use these drugs. He said Hopefully we can. And it was like 80 85 percent would recover in the course of a year etc.. They said we can use these drugs to accelerate recovery. OK but their recovery rate so good we're going to have a hard time beating that

80 85 percent recovery rate and the other thing you'll see it with the depression once people recover they often stayed well for months or years it's and before they had another bout. And right away what do you notice when they start use nano depressants doctors are saying yeah my patients are getting better faster but they're also relapsing more and more quickly and. Right. We changing the drug to a chronic course. Lots of data in fact. Nor did this change to a chronic course if you look in textbooks Here's what they say. We used to think outcomes for depression were good but now in modern epidemiological studies tell us that it's a chronic and pernicious disorder. So they acknowledge the switch in the from an episodic to a chronic or through a chronic course. By the way there was a guy from Italy who raised this whole problem in 1996 I think these drugs are making people they're actually depressive genic long term. We need to investigate this a guy a famous guy a Harvard Medical School that McLean's Ross Balderson really said

yes we need to investigate this. This is what it looks like the drugs in fact are depressed the genic over the long term. And then Donald Klein from Columbia University wrote writes back in psychiatric news nobody is interested in that question. The FDA doesn't care. The end I mates doesn't care. We don't care. So stop talking about it. And you can see the sort of betrayal of a lot of human beings with that comment. You'll see in the book there's a lot of studies now that compare sort of untreated depression long term course that treated depression you'll see the outcomes are quite consistent. Again it doesn't mean that nobody with an antidepressant is helped We're just talking about aggregate. The change in the aggregate outcomes. Finally bipolar if you want to know why are we having such a rise in the number of people on disability. It's very much related to bipolar bipolar used to be a rare disorder of affecting

maybe one in 5000 people in one thousand fifty five there were roughly twelve thousand five hundred people hospitalized with manic depressive illness. Of course today it's said to affect somewhere between one in every 50 people. So the question is why are so many. Why do we get this an incredible rise in the number of people diagnosed. There's two reasons. One is in fact of course we've expanded the diagnostic boundaries. The other reason is in fact exposure to drugs. If you look at people who end up with a bipolar diagnosis a high percentage have either been using illicit drugs before they sort of have their manic episode or in fact they've been on an anti-depressant. And so what you see here is a possibility that people will be on antidepressants there that will stir a manic episode and that will push them into the bipolar camp. The evidence that's real strong in this in terms of the conversion rate from you know polar to bipolar. It's about it's much much higher with anti-depressant exposed people as opposed to the natural conversion rate. This is a big thing that's fueling

the disability numbers is use of antidepressants and illegal drugs that push people into this bipolar camp as far as outcomes for bipolar illness compared to before. Before it was seen as having a relatively good prognosis. Now it's seen as a chronic disabling disorder. You just cannot believe the deterioration in bipolar outcomes in modern times. In fact at the 2008 meeting there was even a session on how bipolar patients today are much more symptomatic before they're much more likely to be rapid cyclers employment rates in the pre drug era for bipolar patients were 85 percent. Today they're down to about 35 percent. The other big difference is bipolar patients in the pre drug era did not show any signs of long term cognitive decline. Today they are. And the other big thing that you're seeing with these drug cocktails that are now used to treat bipolar the outcomes of course are putting people on three four drugs at a time. Outcomes are really starting to

deteriorate now in the cognitive decline is becoming an ever greater problem. We're also getting early death now in bipolar patients. We're getting all sort of physical problems. It is something of a medical Trainwreck when you see actually the change in outcomes. I got to stop when you look at children as well you can imagine this is the background for long term children outcomes. If you look at what's happening to kids say put on ADHD something for just for stimulants something like 10 to 25 percent of kids exposed to a stimulant will convert to bipolar over the course of the time. And what's what's happening to bipolar kids they're ending up as rapid cycler is ultra rapid cyclers. It is really a sort of. It's a discouraging thought. And last thing here is OK I'm going to call it. So what's the purpose of this. The purpose of this is what real quickly what's the purpose of this book. It's not for you to believe say oh I heard Bob Whitaker give a talk and he said things are

really bad. That's not it. The point is is if we can have a discussion what does the evidence show. What does the Science Show. Why are outcomes worse today than they were 40 years ago. And I really say we have a challenge and one I would urge people is if the book is set up as sort of a intellectual journey we start with this belief why do we believe in the drugs. What is the evidence for it. And there is evidence for it. There's also clinical perceptions that's evidence for it. Again it's like I said some people benefit from it. But then we'll take you through this. This history of science that repeats over and over again. And what will you you will see is sort of episodic disorders switching to much more chronic disorders where people are more consciously symptomatic and then you'll also see a cognitive decline show up you'll see physical problems show up you'll see sort of this increasing burden. So what I urge you not to believe a single thing I said tonight. But read for yourself. Confront

this data. Look at this data and what you'll find is none of it ever gets publicized. None of the long term data it constantly gets hidden. And what I would say is get to know it. See what you think. See if you come to the same conclusion that I did. As I went through this journey and you know the person introduced me talked about the New Scientist review like I was a physician he wrote me an email and he said when I first got your book I thought this was an outrageous premise. It couldn't be. He said but I read the evidence and he writes a lot about evidence based medicine and the history of medicine and he says he wrote this in a personal email. I am absolutely convinced now we need a big time debate for the airing of this scientific evidence. So that's all I'm really pleading here is we need to get this known. We need to get it discussed. See what you think about the evidence and do not trust what I said. OK thanks. And that's in terms of what we would do with his day to start studying

that because it hasn't really been study. The answer to your question though is sort of twofold. There is some sense that the brain will reverse. OK. In other words if you come off gradually and you let let's say the accelerator down just a bit by bit the brain will sort of compensate that allowed let off the it do the opposite by bit and return to normal. OK. So that's why many people can go out gradually successfully. What's unclear to me is and there is some evidence it that the longer you're on the harder it gets to get off. And the question is is the reversibility lost a bit. I don't know. But they really haven't studied graduates role and they haven't studied what happens to the brain. You know as that withdrawal process happens and how reversible it is it cetera so that's the sort of thing we need to think about. Real quickly there's a group called advocates that pride provides services out in western Annot and in Framingham. And they're seeing so many of their clients die early. 40 50 from

all the special atypical anti-psychotics they have they surveyed their clients to say what's the first thing you want most. What's the one thing you want. You know the client said we want supported drug withdrawal and others we want to chance to go off our meds with support and not have our support yanked we don't want to have our you know funding cut or services cut. And the doctor out there says he's willing you know he's a good guy and they want to even see like let's say they do get a flare up of symptoms to try to not necessarily immediately put people off back on meds and see if they can get him through that process. And he wants to see what are the five year outcomes. We desperately need studies like that. And that's an example I think that if you know this evidence you can start thinking differently about what to do in an and. And again my own thing is if you know this evidence will come up with a way to use the meds in a selective sort of cautious manner the way the Fins do and it's not a what the meds are always bad. But how can we use them selectively

cautiously to improve people's health in outcomes where this is really a great question. What is schizophrenia. It's really a group of schizophrenia it's ok it's not one thing. And I think one of things you're talking about is can you tease apart differences as to really who does benefit from the drugs and who can sort of escape from a psychotic episode and get better. So it's not a one size fits all so this is a great question. As you also know the definition of schizophrenia has changed over time too we have that problem as well. My own feeling is that's why you want to selective use. And I think that's what they're discovering in Finland as well. One thing that is happening in Finland though it's really in this nor in this area of northern Finland they used to have a really high incidence of schizophrenia there. One of the highest in Europe schizophrenia is now disappearing in the region. They've gone from roughly 30 cases per year per 100000 down to two or three you know why is it disappearing. Schizophrenia really happens when the diagnosis happens now when psychotic symptoms have remained for six months. OK. So they're they're getting these first episode patients really early when their symptoms have only been around about a month

and they are not staying psychotic long enough to be diagnosed with schizophrenia. It had a 90 percent reduction in the incidence of new cases schizophrenia since they adopted the selective use of medications. It speaks to the possibility. By the way there's a group in Western Mass it's thinking of maybe opening up a sort of pilot project based on this and that's obviously what we need. You know I have been invited every once in awhile to physician groups psychiatry groups and sometimes the response is not so good. Really but obviously money is a part of the book goes into it. But this is why we really need to have sort of a grassroots rebellion and the sense of making this data known to have a new discussion. And it's not it's not working financially for the country as a whole look at art or spending on mental disorders in this country. Big time doubled in the last six years. We can't keep going like this. And by the way if we keep putting more and more people on SSI and SSDI you know what they're going to do to services. States are going to cut the services and they're already cutting the services. So you're going to end up with

drugs drugs drugs and no services and that's not good. And I'm really glad you said this. It's not a throw the baby out. It's how do use the drugs with an evidence based medicine. But by the way real quickly now how Britons are addressing the say Britain doesn't. It's actually the there's something called the National Institute of Clinical Excellence that advises the National Health Service. They basically are saying they should not be using antidepressants as a first line of therapy for mild to moderate depression. And if you can go to a doctor in Britain now and get a prescription for exercise for depression and you literally then go to a counsellor who set you up with an exercise program you get access to a free gym. They measure your aerobic capacity by the way it turns out that depression tends to lift pretty well as your robot capacity increases. People tend to really love the green gems what are green gems that go out and do like gardening etc. jointly etc.. That's an example of a social response it's also evidence based because exercise tends to work. You know part of the thing with the salmon sort of narrowed what we consider normal way too much. I mean

part of the joy of life is this diversity of people being different people being eccentric and frankly people being emotional So anyway or this is a fantastic question. Because if you believe that a society should take care of those who are struggling with their minds and should provide services you're all for parity right. You're for insurance care. I certainly am. I want to provide the services but if the Parity means drugs drugs drugs and if we see that in fact that long term outcomes are so poor and that you can take say children who have this mild problem next thing you know they end up in the bipolar camp and God knows what happens to that kid. That parity is not good because really you have this possible funnel for creating sort of lifelong patients. It's a in my Can feeling it's a big concern I'll give you an example of the WHO study that sort of response to this. The WHO DID AN at 15 city screening study. OK for

depression and so it really caught a little bit complicated but they identified people who end up with four camps people two camps people. People got diagnosed and put on meds. People got diagnosed but weren't put on meds and then undiagnosed untreated. OK they were like flies on the walls in 15 cities around the world and their hypothesis was the best outcomes for people would be seen in those who got treatments and put on meds. OK the reason I said four is because actually we're two different meds use either antidepressants or benzodiazepines so that this was meant to show the benefit of screening and in essence therefore parity care right. What do they find at the end of the year that people who went undiagnosed or diagnosed in one and not medicated were less likely to be depressed at the end of the year and also had sort of better general health they were more likely to be well. And so as the World Health Organization investigators concluded. This does not show that

that screening has a benefit and that actually not being diagnosed is that bad. So in other words that's an example of exactly what you're talking about to scare necessarily help. Well certain types of care help. I mean I'm pretty sure that community care can help in a big way in helping people get an exercise in friends and all that good stuff. But if you read the long term outcomes that you read how consistent it is because I personally was shocked by how consistent it is in terms of this chronic city problem and by the way just so you know if you go when you try to find people that say Is there data showing that anti-psychotics improve the long term course of schizophrenia is there data that shows and it presents improve the long term course of depression. They will say it doesn't exist. OK so it's not that I'm missing something. This was a great question and I actually covered in the book because there's a real history here. And what happened was the history is this. In the 1970s psychiatry really was something of a failing discipline by that I mean it's the

number of residents that would go into it was declining. The therapies that the drugs were seen as not particularly helpful they were falling out of favor. And there also was this incredible rise of the therapy industry. By that I mean psychologists social workers doing talk therapy. So psychiatry as you can see if you read them they felt beleaguered all of a sudden that they talked about well circs psychiatry survive and they really made a decision. What gives us our competitive advantage in this therapeutic landscape. It's our prescribing powers. And so we need to make sure that the image of the drugs is maintained in order to maintain our competitive advantage. And you can really trace this forward and just to give an example. The head of schizophrenia studies was a guy name or nurse moshe in the 1980s he was one of these guys who ran one of these experimental studies Harvard educated he was forced out of the and I made for doing so. OK it became basically the message was if you want to pursue this sort of investigation you're not going to have much of a future in the field. So that was the first

problem. Psychiatry is a field said we've got to maintain the image of other drugs. The second thing that happened is quite clear is that the pharmaceutical companies ended up in essence. Buying the academic doctors and psychiatry you see with the academic doctors they act as consultants they act as advisors. They act as they get research grants and basic. Well basically what happens is they're making all this extra money and they serve on speaker boards etc.. They go and actually get Speaker training. Well you're not going to get all that money. You can be an advisor if you start saying like well you know maybe we should be using anti-psychotics in a selective way. So frankly the hierarchy of psychiatry was bought and I think everybody knows that now. The New England Journal of Medicine tried to do a review of antidepressants in around 2000. They couldn't really find hardly anybody who wasn't taken money. It's just and by the way the editor at that time was Marcia Angell. She wrote about this co-opting of American academic medicine and she was

canned. She was fired. OK I didn't do a cover the genetic aspects however what I did try to look at for example what is the course of unmedicated depression today another word so for example the NRA mates ran a trial in the 1990s meant to to look at that and they had it was a six year study. OK and they looked at people that had depression they end up with a group that was treated in a group that was untreated. Now obviously this is observational So maybe the people are untreated are sort of have a different personality maybe they're not as severely ill. OK. Whatever. OK I admit those carriers. But what happened when they find where they found that actually the risk of disability was roughly seven times higher in the treated group. I understand but this is all I can do is look at what is the observational data stay. I agree with that it be great to have a randomized six year study today. It would be. But all's we can do is look at what those sort of information out there that's the best we can do so what do you see in depression. It's changed the course of depression is changed. And when they do these observational

studies that do have convience what they find they find the sort of outcomes I'm talking about. Do I wish we had randomized study. Absolutely. But this is the data we have. Does that make sense. It's limited. OK that's good. Thank you thank you.