Revisiting Psychiatric Treatment of Children
ZENIT: What do you hope to see come from this conference?
Whitaker: I hope that the conference will bring widespread public attention to this question, of whether the medicating of children with psychiatric drugs is helping those children grow up and thrive, or whether this practice, on the whole, is causing a great deal of harm. This is a very profound question, and I hope this conference will encourage societies to investigate it.
ZENIT: As one of the keynote speakers, you were asked to speak about the general history of psychiatric treatment, while others spoke about what science has to say about their effects. Could you highlight some of the main points in your talk?
Whitaker: The accepted wisdom is that the arrival of chlorpromazine in asylum medicine in 1955 kicked off a psychopharmacological revolution, this great advance in care. Chlorpromazine is remembered today as the first "antipsychotic," and soon the field gained new antidepressants, and new anti-anxiety drugs. Then, starting in the late 1980s, a second generation of psychiatric drugs came to market, said to be safer and more effective than the first. That is a story of continual medical progress.
Yet, as this revolution has unfolded, the burden of mental illness in western societies has increased. Disability rates due to mental illness have soared, and this is particularly true during the past 25 years, since Prozac came to market. Furthermore, the long-term outcomes for major mental disorders have, if anything, gotten worse during the last 25 years.
Thus, you have a puzzle: if the medications are so helpful, why is the burden of mental illness increasing? Why haven't long-term outcomes improved?
The prescribing of psychiatric drugs in children really began in the United States in 1980, when the American Psychiatric Association created the diagnosis of attention deficit disorder for the first time, when it published the third edition of its diagnostic and statistical manual. Then, if you look at the growth of this practice, of prescribing psychiatric medications to children, it is easy to identify the commercial forces involved. And finally, this is being done in the absence of good evidence that the medications help the children over the long term.
ZENIT: This conference focused a great deal on the negative ramifications of psychotropic drugs. In your research, have you found there to be cases where the use of such drugs, even in children, may be necessary? Cases where psychotherapy simply is not an option?
Whitaker: There certainly is evidence that psychiatric drugs can be helpful in some adults over the short term, and there are some adults who do well on them over the long term. The problem is that you don't find evidence that the medications improve long-term outcomes in the aggregate.
As for whether there are times when the use of drugs in children may be necessary, I don't really know how to answer that. I suppose there are times when they can be helpful, say in quieting a disturbed child, but the problem is that initial use opens the door to long-term use. And long-term use is going to change that child's brain, and we don't have evidence that is likely to help the child.
I know that some people think there is good evidence that the short-term use of stimulants in children diagnosed with ADHD can be helpful. But again, I don't know of evidence that shows that this benefits children in the long term, and there is plenty of evidence of risks associated with long-term use of ADHD medications.
So, personally, I wish societies would put their money and efforts into developing other ways to help disturbed children, methods that don't rely on psychiatric drugs.
And remember, human societies have existed for several thousand years, and, up until recently, were able to raise their children without using psychiatric drugs. Why do we suddenly find it so impossible to do that today?
ZENIT: What are some of the long-term effects of psychotropic drugs, both for the person taking them, and potentially for society as a whole?
Whitaker: If you look at the scientific evidence, you find that psychiatric drugs increase the chronicity of major mental disorders over the long term. This is what I wrote about in my book Anatomy of an Epidemic.
For instance, prior to the arrival of antidepressants, depression was seen as an episodic illness, with a fairly benign long-term course. Today, in the Prozac era, it runs a much more chronic course. Giovanni Fava, a professor of psychology at the University of Bologna in Italy, for years has been raising the question in medical journals: do antidepressants, over the long-term, induce changes in the brain that make people more biologically vulnerable to depression?
You also find that experts in bipolar disorder acknowledge that outcomes are worse today than they were 40 years ago. People so diagnosed suffer more acute bipolar episodes, and much more low-level depression between acute episodes than they used to. In particular, functional outcomes – that is to say employment rates – have worsened over the past 40 years. The U.S. experts who have written about this decline in outcomes – Ross Baldessarini, Carlos Zarate, and Frederick Goodwin – have different explanations for it, but one thought is that it is due to prescribing antidepressants and antipsychotics to bipolar patients, and how these drugs may worsen their long-term outcomes.
The scientific story of the long-term effects of antipsychotics on people with schizophrenia and psychotic disorders may be more complicated, and certainly more controversial. But you do find, in the research literature, worries that antipsychotics worsen long-term outcomes, at least in the aggregate. That was the finding in the one long-term study conducted in the U.S., which was funded by the National Institute of Mental Health. The patients diagnosed with schizophrenia who got off antipsychotics, as a group, had much better long-term outcomes than those who stayed on antipsychotics. As the lead researcher, Martin Harrow, stated at a meeting of the American Psychiatric Association in 2008, "I conclude that patients with schizophrenia not on antipsychotic medication for a long period of time have significantly better global functioning than those on antipsychotics."
So, I think one worry about taking psychiatric drugs is that, over the long term, you run the risk of becoming more chronically symptomatic. The drugs also have many side effects – emotional, physical, and cognitive.
As for their effect on society, it's clear that their widespread use increases the burden of mental illness in that society. For instance, in the United States, the number of adults receiving a disability payment due to mental illness has increased from 1.25 million in 1987 to more than 4.5 million today. Numerous other countries have reported similar increases in disability – Iceland, Ireland, the United Kingdom, Denmark, Germany, Sweden, New Zealand, Australia, and so on. That is the bottom line for societies: the widespread use of psychiatric drugs leads to mental illness becoming an ever greater problem in their society.
ZENIT: What, in your opinion, has caused medical practitioners to rely excessively on drugs to treat emotional and behavioral disorders?
Whitaker: It's a combination of factors. One is that the drugs do generally work over the short term, in the sense that they may relieve distressing symptoms better than placebo, and that gives medical practitioners a reason to prescribe them. The second is that the prescribing of drugs is quick; the doctor doesn't have to invest much time in the healing process. Alternative therapies may take more time, and the recovery process may take place more slowly (but may be more enduring.) And the third reason is this: there is a commercial force at work.
During the 1980s, pharmaceutical companies in the United States began paying academic psychiatrists to serve as speakers, advisors, and consultants. As a result, leading American psychiatrists vigorously touted a drug-based paradigm of care, and because the United States is such a big market, with such outsized influence, their statements had a big effect on global psychiatric practices. In addition, the makers of these medications often employed the same marketing method in other countries; they knew that if they could funnel money to the academic psychiatrists in those countries, it would help build a market for their drugs.
I should also note that the paradoxical long-term effects of psychiatric drugs are not so easily seen. That is a perspective that arises from a careful review of the scientific literature, across many decades of research. Short term studies may tell us the drugs work; the doctors who prescribe them may see that they often work; and academic psychiatrists tell us that they work. The story about their negative long-term effects is not so immediately evident, and thus is easily ignored or missed when psychiatrists develop their treatments.
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