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(2003). Journal of American Academy of Psychoanalysis, 31:581-584

Book Reviews - Edited By Joseph P. Merlino, M.D., M.P.A.

Mad in America: Bad Science, Bad Medicine, and the Enduring Mistreatment of the Mentally Ill: Robert Whitaker, Perseus, Cambridge, MA, 2002, 334 pp., $27.00.

Clare E. Mundell, Ph.D.

This chronicle of the history of treatments for schizophrenia should be required reading not only for mental health professionals, but also for those who still question whether profit has eclipsed patient care as the primary force in medicine in this country. Whitaker has meticulously researched his book, which covers 250 years of treatments for the mentally ill. Even the most skeptical reader will be unable to come away from the book feeling at all sanguine about psychiatric care in America.

Whitaker asks several questions in the book that contemporary psychiatry is obligated to answer. For instance, why do schizophrenics in developing countries have much better outcomes than those patients in developed countries? Why do neuroleptics continue to constitute the standard of care for first break psychotic patients, despite convincing evidence that this approach is ineffective at best, and harmful at worst? Why do psychosocial treatments continue to be shortchanged in health care budgets, despite ample evidence that they constitute the greatest hope for psychotic patients? Why, instead, do hospitals routinely spend thousands of dollars per patient per year on new drugs that work no better than older, less expensive drugs, and may work no better than placebo?

Whitaker sets the stage for these questions with a thorough history of treatment for psychotic patients, beginning with a compelling account of the “moral treatment” movement of the early 1800s. He argues that recovery occurred in at least half of the patients treated in the U.S. under this approach to care, which included residence in comfortable, pleasant surroundings, treatment by compassionate, patient staff, and the availability of ample activities for skill-development and recreation. (This approach, of course, is similar to the principles underlying today's psychosocial rehabilitation programs, most of which cannot fulfill their mission because of chronic under-funding). The rise of large state facilities in the late 1800s, coupled with physicians' complaints that moral treatment was not “scientific” enough, marked the demise of the moral treatment movement. Whitaker's history suggests that this “rudimentary” form of treatment may have been, ironically, the most successful in the history of treatment for serious mental illness.

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