Book Review: Anatomy of an Epidemic

[Edit 12/06/15: After reading some critical commentary on this book that reveals its strong bias, I'm less convinced by the anti-medicine arguments. Reader beware.]

Psychiatry has apparently undergone a "psychopharmacological revolution", discovering drugs such as the atypical antipsychotics, Prozac, lithium, and the  benzodiazepines, to name a few, which appear to be promising candidates as "magic bullets" to cure a range of mental illnesses: schizophrenia, depression, bipolar disorder, anxiety, ADHD, etc... Finally, we've discovered the biological bases of mental illnesses, and have effective drugs for treating them.

If that is the case, we would expect that the incidence of mental illness and their disabling impact would be reduced today, compared to the late 1980s.

Instead, the reverse has occurred, with 1,100 adults and children being added to government disability rolls in the US every day, leading Whitaker to ask, "Why has the number of disabled mentally ill in the United States tripled over the past two decades?" In other words, what can explain this epidemic of mental illness?

What beliefs do you hold about drugs and mental illnesses?

• That all mental illnesses are caused by a chemical imbalance in the brain, and that psychiatric medications restore this balance?
• That psychiatric medications for psychotic, anxious, depressed or hyperactive patients are "like insulin for a diabetic"?
• That psychiatric medications have been scientifically shown to be efficacious and safe? 

These are all common claims made by psychiatrists and pharmaceutical companies alike, messages which have been purposefully disseminated to the public, and which are now, to a large extent, considered "common knowledge".

Indeed, prior to reading this book, I held these beliefs, at least to some extent, given the very limited (one lecture) knowledge of psychopharmacology I learned in Biological Psychology last semester. However, Whitaker's book, by telling "the story that wasn't told", shows how ill-conceived these beliefs may be, leaving the reader feeling disturbed about the scientists, the industry, and the ethical implications of our current standard of care, in which psychiatric medications, undeservedly, play a starring role.

Whitaker's Argument

Whitaker's central claim is that psychiatric drugs have in fact contributed to the epidemic of mental illnesses (over and above, and making a greater contribution than other factors like social changes), worsening long-term outcomes. That is, a large proportion of mental illnesses may be maintained and even caused by iatrogenic processes; caused by the medications themselves. This is a rather counterintuitive and even shocking thesis, but through a thorough review of the literature and interviews with psychiatrists and patients, Whitaker presents a well-supported and compelling argument, showing us that:

• We still don't really know the biological bases of mental illnesses, so "magic bullets" can't really exist.
• Psychiatric drugs have transformed mental illnesses which used to have good long-term outcomes and recovery rates in the pre-psychopharmacology era to chronic illnesses that "require" constant medication with limited prospects for recovery.
• Psychiatric drugs may cause, rather than fix chemical imbalances in the brain by messing with the normal neurotransmitter pathways and mechanisms, leading to a range of long-lasting compensatory mechanisms in the brain.
• Side effects of these medications have deleterious effects on the physical health and cognitive function of patients.
• Children are being groomed to become lifelong patients by being diagnosed and medicated early on, and these medications may be used for the purposes of behavioural control, rather than the wellbeing of the child.
• There are effective alternatives to drug therapy, such as psychosocial care for schizophrenia, and exercise as an antidepressant
• Psychiatry and pharmaceutical companies are working in cahoots, and go to extensive lengths to deceive us, by hiding negative results and reporting false information in scientific journals. Why? The legitimacy of the field of psychiatry and a whole lot of $$$$$$ are at stake!
• And those who disagree are quickly shut up.

These are all disturbing points that are well worth at least considering.

Bottom Line

Today, mental illnesses are often compared to physical illnesses, which has contributed to the destigmatisation of mental illnesses. Yet, this process has also contributed to the normalisation of the use of psychiatric drugs.

However, while there probably remains a valid role for psychiatric drugs, perhaps they should be used in a selective, limited, and cautious manner, not right at the outset, and not as a long-term solution.

Moreover, with the health, wellbeing and lives of millions of patients at stake, doctors, scientists and pharmaceutical companies need to be honest about what these drugs can and can't do. There needs to be an honest scientific discussion about these matters.

For these reasons, this book is a must-read for physicians, mental health professionals and students alike, as well as those who are currently on psychiatric medications or considering taking them, to be fully informed of both sides of the argument.

Finally, perhaps this book reveals how irrational it may be, though typical of a "quick fix" society, to hope for "magic pills" to cure the ailments of something as complex as the mind.

I welcome your views...

Please, discuss!

The Mindful Way Through Exams

What do you associate with the word, "exams"? Stress? Work? Pressure? Tunnel-vision? I think these are some fairly common conceptions of what exam periods usually look like. However, I also believe that this is not an inevitable fate. While it is usually true that exam preparation involves increased demands of our physical and mental resources, I hope to explain here how mindfulness can be a particularly effective buffer against psychological stress. By studying with intention, starting or maintaining a formal practice, taking mindful breaks and maintaining a mindful attitude, exams can be a period of focused learning that remains simply another aspect of your life, rather than an all-consuming stressful experience.

Conscious Studying

Mindfulness, as the art of conscious living, applies to any area of life. This includes approaching study with purpose and intention.

Compare these illustrative examples:

Mindless Studying

• Pseudo-studying
• Studying with Facebook and your work open in two windows side-by-side and your phone next to you
• Studying while watching TV
• Autopilot studying
• Indiscriminately revising all content regardless of how well you already know it
• Passively reading/flipping through the textbook
• Copying your notes over and over again
• Punitive studying
• Locking yourself in the library (or your room) from 8am-12am with a 6-pack of Red Bull and no breaks

Conscious Studying 

• Reviewing flash cards with a spaced repetition function so you only study relatively unfamiliar content
• Making mind-maps to summarise and integrate your subject
• Practicing problem sets and past exams
• Practicing writing essays in exam conditions
• Splitting up your final essay into clearly defined stages with time limits:
• Find XX relevant sources (4 hours)
• Compile relevant evidence, with citations, from the sources in one document under headings of the topics you may want to address (3 hours)
• Given your research, rethink the structure of your essay and come up with a possible argument (2 hours)
• Write paragraph 1
• Write paragraph 2
• etc...
• After leaving for a day or two, edit for structure
• Edit for spelling/grammar
• Final sanity edit

Conscious studying is simply a more effective approach; by cutting out the distractions and being more specific about what you want to achieve, you get more done in less time and with less pain.

Formal Practice

Exams is as good a time as any to establish a formal practice. After all, mindfulness is associated with reduced anxiety and stress (Hofmann, Sawyer, Witt, & Oh, 2010; Evans et al., 2007), and increased working memory capacity and sustained attention (Chambers, Lo, & Allen, 2008). 

Apart from these performance-related benefits, mindfulness meditation can support your general sense of wellbeing. In a time when we are probably relatively focused on getting stuff done, taking 5 or 10 minutes to simply be with the breath brings you back to the present, helps you get back in touch with yourself, cultivates a sense of peace, and reduces perceived time pressure, when you realise that taking a few minutes to just be won't kill your study schedule.

So how do you do it?

Find a time that works for you. It may be first thing in the morning, last thing at night, or before dinner, for example.

There are a variety of possible practices, including mindfulness of the breath, mindfulness of the body, mindfulness of sounds and thoughts, and the body scan. I'll just provide the instructions for mindfulness of the breath here (repeated from Mindfulness in a Nutshell). However, you can easily substitute "sensations of the breath" for the sensation of your body as a whole, for sounds in the environment, or for an awareness of your thought-stream. The basic idea of mindfulness is to choose an object of attention and to constantly bring your attention back to it.

1. Sit upright with wakefulness and dignity
2. Bring your attention to the sensations of the breath in the belly or nostrils, or wherever else you can feel the breath. Stick with this location for the session.
3. Feel the full duration of each in-breath and each out-breath.
4. When you notice that your mind is no longer on the breath (this is inevitable!), notice what is on your mind in that moment, and let it go, then escort your attention back to the breath.

Mindful Breaks

Even if you choose not to establish a formal practice, mindfulness can be an effective practice during study breaks. When we are studying, often we get wrapped up in the content and the learning, and in doing so, lose touch with the external world outside of our laptops or textbooks, and with ourselves. The 3-minute breathing space is a good exercise for bringing you back to the present moment, noticing everything else that is in it, including your own mental and physical state, that you have possibly been ignoring while studying. It's a good idea to study for perhaps 50 minutes before taking a 10 minute break, including a breathing space (or perhaps 25 minutes, then a 5 minutes break). An even simpler alternative for a mindful break is to just bring your attention to your breath for one minute.

Here are the instructions (again, repeated from Mindfulness in a Nutshell).

1. Awareness: Bring yourself into the present moment, asking yourself, “What is my experience right now…in thoughts…in feelings…and in bodily sensations?” Acknowledge and register your experience, even if it is unwanted.
2. Gathering: Gently redirect full attention to breathing, to each in-breath and to each out-breath as they follow, one after the other.
3. Expanding: Expand the field of your awareness around your breathing, so that it includes a sense of the body as a whole, your posture, and facial expression.

Stop! Try it now - go on, it'll only take 3 minutes!

Mindful Attitudes

Finally, and perhaps most importantly, mindful attitudes can help maintain a healthy and balanced mindset during exams.

Non-judging. Notice the tendency of the mind to label experiences as good or bad, to like or dislike. For example, you may be finding some aspects of study "boring", or feel aversion towards stressful thoughts and feelings, or label yourself as "dumb" if you don't get something, or "lazy" for procrastinating. Simply observe this judging tendency when it arises, without necessarily trying to change it. This is about developing an acceptance of your experiences, even if they are unwanted, and being gentle with yourself.

Acceptance. Seeing things as they actually are in the present, not how you would like them to be. This might involve noting that you are seriously behind on your study schedule, adjusting it, and moving on, rather than freaking out (reacting) or pretending it's all ok (denial). After an exam, this involves recognising that what has happened has happened, and letting go, without ruminating on it any further.

Beginner's Mind. A mind that is free from expectations and receptive to the unique possibilities in every moment. What happened yesterday and the day before has already happened. Whether it was productive or filled with setbacks, each day is a new day, and expectations either way can lead to disappointment. Approach each day with a fresh mind, ready to learn and tackle any problems that come up.

Trust. Everyone has their own way. You know your learning style best, so balance external guidance with a trust in your own basic wisdom and intuition.

Non-striving. Mindfulness is not about trying to get anywhere, because you are already here. This may sound like a completely bizarre attitude to invoke when it comes to exam preparation. After all, preparation, by definition, involves trying to achieve things (as was apparent in the Conscious Studying section). However, if you approach exam preparation with the idea that you need to get a certain amount of stuff done, or achieve a certain grade, then you've introduced the notion into your mind that you're not ok as you are. Thus, as paradoxial as it seems, it is worth balancing these goals with a realisation that your goals are not you, and that as long as you are breathing, there is more right with you than wrong with you.

Conclusion

Through a combination of a conscious approach to studying, formal practice, mindful breaks and mindful attitudes, mindfulness can help you to maintain balance and perspective during exams. It's a way that is not only effective, but more importantly, encourages you to be realistic, gentle with yourself, and to stay in touch with the present moment and therefore with life, which doesn't stop for exams!

References

• Chambers, R., Lo., C., & Allen, N. B. (2008). The impact of intensive mindfulness training on executive cognition, cognitive style, and affect. Cognitive Therapy and Research, 32, 303-322.
• Evans, S., Ferrando, S., Findler, M., Stowell, C., Smart, C., & Haglin, D. (2008). Mindfulness-based cognitive therapy for generalized anxiety disorder. Journal of Anxiety Disorders, 22(4), 716-721.
• Hofmann, S. G., Sawyer, A. T., Witt, A. A., & Oh, D. (2010). The effect of mindfulness-based therapy on anxiety and depression: A meta-analytic review. Journal of Consulting and Clinical Psychology, 78(2), 169-183.