The thesis of Robert Whitaker’s book, “Anatomy of an Epidemic,” is simple.
We are in the middle of a mental health epidemic. He writes, “…in 1955, 1 in 468 Americans was hospitalized due to a mental illness….In 1987, there are 1.25 million Americans receiving an ssi or ssdi payment because they are disabled by mental illness, or 1 in every 184 Americans.”
That epidemic is caused according to Whitaker largely as a consequence of the use of psychotropic medication. Medication causes brain chemistry to change in such a way as to make a person susceptible to relapses in the very illness it is trying to help manage. The cure, in Whitaker”s view is not just worse than the disease. It causes the disease.
His book is an extremely important book. To many people who label themselves psychiatric survivors, or by some similar term, it is proof positive of the evil they believe psychiatry is.
Is there really a “mental health epidemic” in the sense that Whitaker means? Putting aside his question,for purposes of this post, about the consequences of medication, do his conclusions hold validity? Are we facing the widespread increase of psychiatric disability?
For Whitaker the answer is clear. There is more, much more “psychiatric disability” now than there used to be before psychotropics were widely used. He points as I quoted above to the number of people in psychiatric hospitals in 1955 and the amount of people on disability now and his point seems clear. Since psychotropic medication began the numbers of people labeled as “psychiatrically disabled” have sharply risen. What is going on?
Personally, I believe we are in a mental health crisis, but the crisis is not the one Whitaker describes. Help is availible and more than anything else many people simply dont have access to the help they need. Virtually every state has reduced its mental health budget to the point of danger. The mentally health system is fragmented, poorly organized, and needlessly complicated. If you are poor, or if you live in a small town or rural area access is particularly bad. Many programs or options in treatment simply havent survived the budget crunch.
We are being flooded with veterans with serious mental health issues courtesy of their military experience. More veterans now commit suicide than soldiers who die in the wars we are fighting. It has become more dangerous to come home than to fight in combat. Jails have become our largest mental health centers. Some studies say as many as 80% of the homeless have serious mental health issues. And one person attempts suicide every minute…. Every minute.
I believe treatment works. but not treatment defined simply as the provision of psychotropic medication. The medical model is inadequate and incomplete. Maybe I dont know the right people, but I dont know of anybody -professional or otherwise- who seriously believes that it is true anyway. No one I know believes that mental illness is simply a matter of biological factors. People are cultural, political, economic, spiritual, and historical creatures and all those factors are important. To reduce it all to biology is foolish. But to assume that because some people have tried to reduce it to biology that biology plays no role is equally foolish.
In addition mental health stigma is real and pervasive. It is not just “mental illness”, but the experience of “mental illness” in this culture and in this time that is a source of misery. One study I read said that the employment rate for people with “mental illness” was only 40%. Recovery is a real thing and many people with diagnosed mental illness lead fruitful, happy, and effective lives. How can this statistic be real other than the effect of stigma and the many destructive stereotypes that are held so unfairly?
In many places the value of the recovery model has gained a lot of traction. People need people and people who have “been there” have a lot to offer to those who are “now there.” The secret to mental health recovery is not how well you treat people as patients, but how well you treat them as people. In some places and for some professionals the recovery model is not well understood and has little effect on the daily lives of people seeking help. But it is a movement that is growing and changing what mental health is.
I think without question many people’s lives have been negatively effected by medication. You would have to be deaf, dumb and blind not to know that. Many people I know have suffered through what I could easily be called “torture” trying to find a medication that helps with their issues and that has side effects they can live with. And for some there has been no answer. But as Whitaker acknowledges and I know from personal experience many others have been helped and helped a lot. You would have to be deaf, dumb, and blind not to realize that also. I dont really think we know why they work when they work and I am afraid we are only beginning to realize how much harm they do for some people.
But I dont think reality is nearly as simple as Whitaker’s figures would make it appear. In trying to reduce things to one factor I think he leaves out many factors that are equally vital to understanding mental health in this country.
In his book, he says that some people may dispute the validity of him comparing hospitalization figures with disability figures and drawing conclusions from that. He says they may say it is an “apple and oranges” comparison. I dont think they are close enough together to both be fruit.
Disability is not a diagnostic term. It is a legal one. To equate those who met the criteria for hospitalization with those who meet the criteria for disability is simply not accurate. It is a decision by Social Security not that you have a diagnosis, but that some issue negatively impacts your ability to work or maintain activities of daily living.
For many people disability is an economic decision. As I said earlier, the rate of unemployment for the “mentally ill” is far higher than that of the rest of the population. For many it is the only way to have any income.
Disability is also the pathway to health care. SSI entitles you to medicaid and medicaid means you will have access to treatment. Without it in many states you have no access to help or only access to the most stripped down version of help. In the last years as insurance has become more and more the only means to get access to the help you need and since more and more people with mental health issues have less access to private insurance it is only natural and predictable that attempts to get disability would skyrocket.
Most of the people I know either have disability or are trying to get it. In virtually every case it is either a health based or economic based decision. It is not that people are so disabled they cant work. It is that they cant get work.It is that otherwise they cant get healthcare. It is a crucial distinction.
Disability is an extremely difficult process. In Tennessee over 90% of the people who apply are turned down on first effort. Over 85% are turned down on appeal….BUT over 90% are approved if it goes before an administrative law judge. In the last years lawyers with a new speciality- getting people okayed for disability- have become common and plentiful. They have increased the amount of people who get disability because they have made it easier, if you persist, to be successful. I know one person personally who got disability without a lawyer. I dont know any who were unsucessful who did have a lawyer.
Whitaker correctly points out that societal attitudes since 1955 have changed about mental illness have changed and may have led to a reluctance to seek treatment then. But it is more than that. For many people seeking disability has become more than an admission of defeat. It has become a way to stand up for yourself and claim access to at least the possibility of economic survival, adequate health care and some kind of access to vocational rehabilitation.
Virtually every study I have read says that only 30-40% of the people who might profit from some type of mental health treatment are in the system. Whatever the reason- stigma, lack of insurance, lack of availible services, distrust of the system, bad experiences or whatever- many people who show up in the numbers dont meet his description as victims of psychotropic medication.
I think it is foolish to say that medication has not scarred the lives of many people. I cant help but wonder if years in the future people will be astonished at what we did in the name of treatment. But I simply dont believe it is that simple. “Mental illness” scars people lives. And not realizing that or trying to downplay that is unfair to millions of people who struggle everyday with trying to get from the beginning of the day to the end with the real problems they deal with. I know people who have never taken medication, who have never taken medication consistently or as prescribed, and people who take it every day whose lives have all been attacked and laid siege to by the mental health issues that torment them.
I agree with Whitaker about an important conclusion. Something is “amiss.” Too many people who need help dont get it and too often the help they do get is not as effective as we have the capability to offer. The term “mental illness” is still viewed by many people as a judgement about your value as a person and your capability to lead a fully human life. Too many people in our society die because they view death as the best solution the life they are offered.
I think we can help people. I think we can help each other. Far too often we dont. Too many people dont fall through the cracks. They live there. And I think it is about more than what kind of pills they take. This society, this system, all too often doesnt just fail people as patients. We fail each other as people.
We get so wound up in trying to find the one truth. So many people, regardless of what truth you prefer or pay allegience to, seem to always get stuck not fitting in. People are always inconvient. They have a way of not fitting into the boxes we are so sure they do fit into.
Whitaker is a great writer. His descriptions of the history of the mental health system are still among the best I have ever read. In one sense, my disagreement with him is not in saying that things are as bad as he says. In a very real sense, on another level, they are worse. My most abiding frustration is that, even considering our ignorance and the infancy of much of our knowledge, I just dont think it has to be that way.