Revisiting a debate: Does psychiatry overmedicate?
Host William Dubin (left), chair of psychiatry at Temple, and author Robert Whitaker, a critic of the long-term use of psychiatric medications. He spoke at Temple University Hospital's Episcopal Campus. RON TARVER / Staff Photographer
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When Robert Whitaker's book, which questioned the extensive and long-term use of medications in psychiatry, was published in 2010, doctors treated him like a "heretic," he said.
So it has been something of a vindication that people like William Dubin, chair of psychiatry at the Temple University School of Medicine, have started inviting him to speak to their peers and students.
"It can, of course, be tense. It can be difficult," he said. "On the other hand, increasingly, the receptions have been more open-minded, and I think, actually, psychiatry is trying to rethink their use of medications."
At Dubin's request, Whitaker spoke Wednesday to medical students and psychiatry residents at Temple University Hospital's Episcopal Campus about that book, Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America.
The crowd of at least 100 was attentive as Whitaker, a former reporter who has written four books, spoke for an hour without slides - the machine wasn't working - or notes in a chapel next to the hospital.
Dubin read the book eight months ago after his brother, also a psychiatrist, recommended it. Dubin asked his residents to read it too.
"I think he has an important message," Dubin said. "We teach a lot of his principles." He agrees that psychiatrists often overmedicate. He thinks insurance companies should get more of the blame than Whitaker gave them. He called their financial incentives "pernicious."
Whitaker said he became intrigued by the apparent increase in psychiatric disability despite the widespread use of psychiatric medications. The number of adults receiving federal disability payments because of mental illness rose from 1.25 million in 1987 to four million in 2007. Much of that was because of an increase in mood disorders, such as bipolar disorder.
Whitaker wondered, "How do psychiatric medications shape lives over the long term?"
He conceded that many factors might affect disability rates and that the numbers were not proof that medications were at fault. But, he said, psychiatric disability is rising in other countries that promote chronic use of psychiatric drugs as well.
"This has happened in country after country that has adopted this paradigm of care," he said.
His talk focused on schizophrenia, the most disabling of mental illnesses. He said evidence has mounted that antipsychotic drugs help some patients with acute psychotic symptoms, but that patients who do not take them all the time are ultimately more likely to recover.
"I think the evidence is quite clear that, unfortunately, the medications don't improve long-term outcomes," Whitaker said.
He said some studies showed that people who have taken the drugs have more relapses and more serious ones. Some researchers theorize that changes in brain chemistry promoted by the drugs make patients more vulnerable, but Whitaker said this has not been proved.
He is especially impressed with a program that began in northern Finland in 1992. "They now have the best outcomes in the Western world," he said. Doctors there use an intensive form of family therapy called "open dialogue," and emphasize good diet and exercise. When possible, the only drugs they give patients with acute psychosis are meant to help them sleep.
Another group gets antipsychotics, but only for a short while. A third group seems to need the drugs long-term.
Most of the Finnish patients are working or back in school after five years, he said.
He said a new group in the United States, the Foundation for Excellence in Mental Health Care, plans to fund two replication projects in Massachusetts to subject the approach to more rigorous scientific analysis.
Taken together, the studies show that medication has a valuable role, Whitaker said. "The real challenge for psychiatry is figuring out for whom and for how long, rather than one size fits all."
He thinks the U.S. needs a different system of care, one that relies less on medication and more on psychosocial supports. What are the odds of that happening? "It seems to be counter to the larger currents in American society," he said.
After the talk, psychiatry resident Komal Nayak said she often saw patients who had been prescribed multiple drugs. She agreed that "you've got to be more cautious in what you're prescribing."
But Mona Masood said doctors worried that patients would "self-harm," and Megan Gilman said she had seen patients who were "incredibly distressed" by their hallucinations. Doctors feel the need to address that.
Dubin thinks doctors should be "parsimonious" with the medications and spend more time getting to know their patients. He thinks exposure to people like Whitaker is good for students.
"We should bring in people like him," he said, "who are going to make people think and be provocative."
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