Mad in America: Bad Science, Bad Medicine, and the Enduring Mistreatment of the Mentally Ill (2002)

Mad in America: Bad Science, Bad Medicine, and the Enduring Mistreatment of the Mentally Ill is a 2002 book by medical journalist Robert Whitaker, in which the author examines and questions the efficacy, safety, and ethics of past and present psychiatric interventions for severe mental illnesses, particularly antipsychotics. The book is organized as a historical timeline of treatment development in the United States.

Mad in America received positive reviews from the general public and mixed reviews from the medical community, which criticized some bias in sourcing but nonetheless acknowledged the need to address the critical questions raised by the book regarding modern psychiatry.

Synopsis

Part One: The Original Bedlam (1750–1900)

Part One describes early treatments like a spinning chair which could reach 100 revolutions per minute, the Tranquilizer Chair which immobilized patients, and water therapies. Whitaker then describes moral treatment, dating back to 1793 and the French Revolution and established in the U.S. by Quakers in 1817, in which lay superintendents treated the mentally ill in small homes with great kindness and had good outcomes: About 35 to 80 percent of patients were discharged within a year, the majority of them cured. Pennsylvania Hospital reported that about 45 percent of patients were discharged as cured and 25 percent discharged as improved. In Worcester State Hospital, 35 percent were chronically ill or had died while mentally ill. Dr. George Wood, a visitor, reported in 1851:

...you encounter persons walking, conversing, reading or variously occupied, neatly and often handsomely dressed, to whom as you pass you receive an introduction as in ordinary social life; and you find yourself not unfrequently quite at a loss to determine whether the persons met with are really the insane, or whether they may not be visitors or officials in the establishment.

Part Two: The Darkest Era (1900–1950)

Part Two describes the rise of eugenics, which did away with moral treatment in favor of forced sterilization of the mentally ill, and led to newly invigorated fields of psychiatry and neuroscience whose experts practiced insulin coma, metrazol convulsion, forced electroshock, and lobotomy.

Part Three: Back to Bedlam (1950–1990s)

Part Three describes the discovery of phenothiazines and the advent of the neuroleptic drugs that were derived from them, such as chlorpromazine (Thorazine) by Rhône-Poulenc in France, and its purchase by Smith, Kline & French (today known as GlaxoSmithKline). The drug "produced an effect similar to frontal lobotomy", according to early reports by the company's lead investigator. Whitaker says that pharmaceutical advertising, articles published in the scientific literature, and stories in the media of "miracle drugs" transformed Thorazine into a healing drug.

Whitaker says that marketing money from pharmaceutical companies began to flow to the American Medical Association in 1951, a year after Thorazine was synthesized, because of the Durham-Humphrey Amendment to the Federal Food, Drug, and Cosmetic Act which "greatly expanded the list of medications that could only be obtained with a doctor's prescription".

In Part Three, Whitaker also describes the American (but not for example British) propensity to classify patients as "schizophrenic", as well as the error (confusion of schizophrenia with the yet-to-be-discovered encephalitis lethargica) in the original classification by Emil Kraepelin, which psychiatry chose to not revisit and fix. Whitaker then describes three pathways that dopamine may take in the human brain, and quotes first-person accounts of the effects of antipsychotic drugs on individuals.

He calls a 1996 New York Times advertisement by a consortium of pharmaceutical companies a "bald-faced lie": the group sought to say that the cause of psychosis and schizophrenia is an abnormal dopamine level and that their drugs worked by altering the level of dopamine. Whitaker then criticizes some American studies, and points out the work of George Crane at the National Institute of Mental Health to get tardive dyskinesia recognized, which up to that point had largely been touted as a symptom of schizophrenia, and he contrasts the dosages that British doctors were comfortable in prescribing (300 milligrams per day of Thorazine) with what American psychiatrists prescribed (1,500 up to perhaps 5,000 milligrams per day).

He sees irony in the fact that The New York Times reported on Soviet forced use of neuroleptic drugs (which Florida Senator Edward Gurney called "chemicals which convert human beings into vegetables") in "psychiatric jails", but called the same drugs "widely acknowledged to be effective" when reporting on American schizophrenic patients.

Whitaker describes the demise of modern-day moral treatment in a short history of Loren Mosher's Soteria Project, funded by the U.S. while Mosher was chief of schizophrenia at NIMH. He attributes the results in a World Health Organization 1979 study of outcomes for schizophrenia patients (which found better outcomes in undeveloped countries like India, Nigeria and Colombia than in developed countries like the United States, England, Denmark, Ireland, Russia, Czechoslovakia and Japan) to doctors in the developed world who maintained their patients on medications.

He then describes 50 years of American scientists doing experiments on schizophrenia patients: to intentionally exacerbate their symptoms and study the results. He compares the doctors' behavior, unfavorably, to 1947 after American trials of Nazi doctors ended in the Nuremberg Code for ethics in human experimentation.