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Bulletin of the History of Medicine 77.1 (2003) 207-208



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Robert Whitaker. Mad in America: Bad Science, Bad Medicine, and the Enduring Mistreatment of the Mentally Ill. Cambridge, Mass.: Perseus, 2002. xviii + 334 pp. $U.S. 27.00, $Can. 41.50 (0-7382-0385-8).

Written by a medical journalist, Mad in America is purportedly a history of the failed treatment of the severely mentally ill in America from colonial times to the present. I use the term "purportedly" because the book is overwhelmingly a prosecutorial brief designed to prove that psychiatric treatments since the eighteenth century have been a disaster that has only worsened the condition of patients diagnosed as schizophrenic, while fostering the illusion that psychiatry was a scientific medical specialty. The only exception was early nineteenth-century moral treatment: created by English and American Quakers as an alternative to harsh medical therapeutics, this humane therapy was appropriated, distorted, and transformed by asylum doctors concerned with protecting their jurisdiction and asserting medical dominance. The resulting science of psychiatry ushered in "a truly dark period in American history" (p. 38) that persists to the very present.

In a series of well-written chapters, Robert Whitaker traces the travails of severely mentally ill persons. The eugenics movement, he argues, created a context in which the mentally ill were stigmatized because of the threat that their inferior genetic makeup posed to the health and well-being of the American people. The emphasis on segregation of the insane and the introduction of the humiliating procedure of sterilization set the stage for such invasive interventions as insulin coma, metrazol convulsive therapy, electroshock, and prefrontal lobotomy during the 1930s and 1940s.

Whitaker reserves his greatest criticisms, however, for what he calls "modern-day alchemy"—the use of psychiatric drugs that has become characteristic during the last half-century. Nearly half of the book is devoted to an analysis of these drugs, which Whitaker regards as an unmitigated disaster. He praises a World Health Organization study conducted in the early 1970s that allegedly revealed far better outcomes in India, Nigeria, and Colombia where drug therapies were [End Page 207] rarely deployed. The widespread use of psychiatric drugs in the United States, Whitaker argues, resulted from a convergence of two elements. First and foremost was drug company greed. Second was the desire of psychiatrists to prove that they, like their medical brethren, had safe and effective drugs, and thus should retain their monopoly over the care of the mentally ill. "Hubris," he concludes, "is everywhere, and in mad medicine, that has always been a prescription for disaster. . . . The day will come when people will look back at our current medicines for schizophrenia and the stories we tell to patients about their abnormal brain chemistry, and they will shake their heads in utter disbelief" (p. 291).

The clarity of Whitaker's historical analysis, however, is achieved by including all evidence that validates his interpretation while blithely excluding all data to the contrary. Mad in America is not a work of history; it is a one-sided polemic that reduces an extraordinarily complex subject to utter simplicity. To argue that moral treatment was a threat to asylum physicians is simply wrong. To posit a close relationship between eugenics on the one hand and psychiatry and somatic therapies on the other is equally erroneous. To disregard the fact that the custodial character of the mental hospital during the first two-thirds of the twentieth century was due in part to the fact that more than half of all first admissions were individuals over the age of sixty-five is to misunderstand the myriad functions of that institution. To ignore evidence presented by Morton Kramer that suggests that release rates for nonelderly patients were improving between 1916 and 1950 (Morton Kramer et al., A Historical Study of the Disposition of First Admissions to a State Mental Hospital: Experience of the Warren State Hospital during the Period 1916-50, 1955) is to ignore the reality of mental hospital functions...

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