Mad in America

Bad Science, Bad Medicine, and the Enduring Mistreatment of the Mentally Ill


By Robert Whitaker

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An updated edition of the classic history of schizophrenia in America, which gives voice to generations of patients who suffered through “cures” that only deepened their suffering and impaired their hope of recovery

Schizophrenics in the United States currently fare worse than patients in the world’s poorest countries. In Mad in America, medical journalist Robert Whitaker argues that modern treatments for the severely mentally ill are just old medicine in new bottles, and that we as a society are deeply deluded about their efficacy.

The widespread use of lobotomies in the 1920s and 1930s gave way in the 1950s to electroshock and a wave of new drugs. In what is perhaps Whitaker’s most damning revelation, Mad in America examines how drug companies in the 1980s and 1990s skewed their studies to prove that new antipsychotic drugs were more effective than the old, while keeping patients in the dark about dangerous side effects.

A haunting, deeply compassionate book — updated with a new introduction and prologue bringing in the latest medical treatments and trends — Mad in America raises important questions about our obligations to the mad, the meaning of “insanity,” and what we value most about the human mind.


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Grateful acknowledgment is made for permission to reprint from: Walter Freeman and James Watts, Psychosurgery, second edition, 1950. Courtesy of Charles C. Thomas, Publisher, Ltd., Springfield Illinois.

“We are still mad about the mad. We still don’t understand them and that lack of understanding makes us mean and arrogant, and makes us mislead ourselves, and so we hurt them.”

—David Cohen


The first edition of Mad in America was published in 2002, and now I am being given an opportunity, for a second time, to update this history. I know this is a rare opportunity, and I think it can best be used by having the update answer this question: Has Mad in America, as a history that so directly challenged conventional histories of psychiatry, stood the test of time?

And if so, what does our society need to do to remake its care for the “mad” today?

In the first edition, I explained in the preface how I’d come to this subject, and it bears repeating, for it reveals my mindset when I first researched the subject. My interest was born of curiosity about research that revealed a public health failure at a time when the public discourse was all about the great progress psychiatry had made in treating schizophrenia. I began this journey from a place of intellectual confusion: I had come upon information that didn’t fit with what I “knew” to be true.

My journalistic experience up to that moment had been fairly conventional for someone who had spent years writing about science and medicine. In the 1980s and early 1990s, I worked as a medical and science writer for the Albany Times Union, in Albany, New York. In 1994, after a year spent as a Knight Science Journalism Fellow at MIT in Cambridge, Massachusetts, I worked for a time as director of publications at Harvard Medical School, and it was there I was schooled in the importance of evidence-based medicine. Next, I cofounded a publishing company called CenterWatch that reported on the business aspects of the clinical trials industry, and it’s fair to say that—at least at first—we were an industry-friendly publication. However, while writing about that subject, I came to hear of abuses of psychiatric patients in research settings, and I proposed doing a series on this topic for the Boston Globe, as I had written for the newspaper before.

Now, this was a particularly heady time for American psychiatry. The narrative being told to the public at that time was that researchers had discovered that mental disorders were due to chemical imbalances in the brain and that a new generation of psychiatric drugs were able to fix those chemical imbalances. Risperdal and Zyprexa had recently been brought to market, heralded as breakthrough medications that were helping people diagnosed with schizophrenia “go back to work.” They were like “insulin for diabetes,” a metaphor that told of an extraordinary advance in psychiatric care, and this was the very narrative of progress that provided an ethical context for one aspect of our Boston Globe series.

The series had multiple parts. We wrote of studies funded by the National Institute of Mental Health in which researchers had given psychotic patients chemical agents—methylphenidate, ketamine, and such—expected to make them worse, with the thought that this would help them better understand the “chemistry” of madness. We wrote about the financial influences that had been present during the clinical trials of Risperdal and Zyprexa, which had led, among other things, to recruiting practices that put study volunteers in harm’s way. And finally, we told of how psychiatric researchers, with funding from the National Institute of Mental Health, had conducted a number of studies that involved withdrawing schizophrenia patients from their antipsychotic medication (almost always abruptly) and then assessing how quickly and how often they relapsed.

These relapse studies, we wrote, were unethical, because these drugs were understood to be like insulin for diabetes. Researchers would never withdraw insulin treatment from diabetics to see how quickly they became ill again, so why would psychiatric researchers do this to people diagnosed with schizophrenia?

That conventional narrative provided a moral context that proved rewarding to us. The series won a George Polk Award for medical writing and was a finalist for the Pulitzer Prize in Public Service. Given that response to the series, I could have been expected to remain emotionally invested in the “insulin for diabetes” metaphor. Yet, by the time the series was published, I had begun to wonder if there was something amiss with that conventional narrative of progress in psychiatry, and my questions grew in the months immediately afterward.

The first seed of doubt was planted by David Oaks, who directed a psychiatric-survivor organization called MindFreedom. I called him to ask about the antipsychotic-withdrawal studies, expecting that he would say how awful they were and that, since people with diabetes would never be taken off their medications, these studies were an example of how people diagnosed with schizophrenia were devalued in our society. However, while he condemned the studies for their abrupt-withdrawal design, he said there were plenty of good reasons that people diagnosed with schizophrenia—as he had been many years earlier—didn’t want to take antipsychotic drugs. This surprised me, and I went back to leading schizophrenia researchers to ask about this perspective. The researchers all told me that many people with schizophrenia lacked insight into their illness and that this was why they didn’t understand that they needed the drugs.

That sounded like the type of reply that the powerful use to dismiss the powerless, and if there is one thing a journalist is supposed to do, it is to listen to the stories of those who are, in one way or another, disenfranchised. David Oaks now had my ear.

Even more to the point, I soon stumbled upon two research findings that didn’t fit with what I knew. First, in a 1994 article, Harvard Medical School researchers had reported that outcomes for schizophrenia patients had worsened during the past twenty years. Schizophrenia patients were now faring no better than they had in 1900, when various water therapies—needle showers and prolonged baths—were the preferred treatments of the day. Second, the World Health Organization had twice found that schizophrenia outcomes in the United States and other developed countries were much worse than those in the poor countries of the world. Suffer a psychotic break in a poor country like India or Nigeria, and chances were that in a couple of years you would be doing fairly well. But suffer a similar break in the United States or another developed country, and it was likely that you would become chronically ill.

These were outcomes, of course, that belied the narrative of medical progress that I had believed in and that had served as the moral context for the Boston Globe series. And so I wondered: Why had schizophrenia outcomes worsened in the past twenty years? How could it be that long-term outcomes for those diagnosed with schizophrenia were no better than in 1900? And why did those diagnosed with schizophrenia fare so much better in India and Nigeria than in the United States? Or, to put it another way: Why should living in a country with rich resources and advanced medical treatments for illnesses of every kind be so toxic to those who are severely mentally ill?

Those questions were what motivated me to write Mad in America. I was trying to understand a public health failure, and as I researched this subject, I quickly realized that the past could serve as a foil for understanding the present. This history of American psychiatry begins with the founding of the first hospital in the colonies, by Pennsylvania Quakers in 1751, and from there one can trace a path, however winding and twisted, to the poor outcomes of today. It is a history that contains one surprise after another. For instance, we think of the 1800s as a time when the insane were routinely chained up and neglected, and yet in the early nineteenth century there arose a form of humanitarian care that has never been equaled since. Go forward one hundred years and the path detours into one of the darkest chapters in America’s history, and there you can find the seed for today’s failure.

As can be seen by the book’s subtitle, Mad in America related a history that contradicted the accepted wisdom. Our society believed that psychiatry had made great progress in treating schizophrenia, a belief that was particularly transcendent in 2002, and yet history told of a modern therapeutic failure and the “enduring mistreatment” of the seriously mentally ill.

The publication of Mad in America stirred a fair amount of controversy, and there were any number of prominent psychiatrists who, in their reviews of the book, reminded readers of the conventional wisdom and talked about how infuriating it was that a book like this had been published. Perhaps my favorite such review was written by Jeffrey Lieberman, who at that time was a professor of psychiatry and pharmacology at the University of North Carolina School of Medicine and who later became president of the American Psychiatric Association. This book, he wrote, “presents misguided and dangerous fabrications. [The] drugs used to treat psychotic disorders represent scientific breakthroughs comparable in significance to the discovery of antibiotics for infectious disease, antihypertensives for cardiovascular disease, and insulin for diabetes.”

Or, as another reviewer wrote, Mad in America was “rank heresy.”

It’s easy to see what is at stake in these competing narratives. Our society has organized its thinking about schizophrenia and other psychotic disorders around the conventional narrative, which makes treatment with antipsychotics the centerpiece of care. Our funding of psychiatric services, our laws, and our social policies all reflect that thinking. But if the counternarrative told in Mad in America has historical and scientific merit, then it calls upon our society to radically rethink psychiatric care and how we spend our public health dollars. We would also need to rethink our legal and social policies toward those we deem “mad.”

It is now 2019, and updating Mad in America presents both a challenge and an opportunity. The challenge is to update the book in a way that preserves the integrity of the history that was told in the first edition. For that reason, the text and the epilogue remain the same. That history was told at a particular time, and it remains the same.

The opportunity can be found in the updated afterword. It is not meant to be a history of psychiatry since 2002 but rather, through a review of research since that time, a means to see which of the two competing narratives—the conventional narrative told in 2002 or the counternarrative told in Mad in America—has best stood the test of time.

Once that science has been reviewed, it becomes possible, in the afterword, to explore how the conventional narrative may be changing today, and the possible opportunities such change presents.

Robert Whitaker

January 2019



Terror acts powerfully upon the body, through the medium of the mind, and should be employed in the cure of madness.

—Benjamin Rush1

A VISITOR TO THE “mad” wards of Pennsylvania Hospital at the turn of the nineteenth century would have found the halls astir with an air of reform. A few years earlier, in 1796 to be exact, the lunatics had been moved from unheated, dingy cells in the basement, where they had often slept on straw and been confined in chains, to a new wing, where their rooms were above ground. Here the winter chill was broken by a coal-fired stove, and occasionally the mad patients could even take a warm bath. Most important of all, they now began to receive regular medical treatments—a regimen of care, physician Benjamin Rush proudly told the Pennsylvania Hospital overseers, that had “lately been discovered to be effectual in treating their disorder.”2

The introduction of medical treatments had been a long time coming. In 1751, when Quakers and other community leaders in Philadelphia had petitioned the Pennsylvania colonial assembly for funds to build the hospital, the first in the colonies, they had told of medical care that could help restore sanity to the mad mind. “It has been found,” wrote Benjamin Franklin, who authored the plea, “by the experience of many Years, that above two Thirds of the Mad People received into Bethlehem Hospital [in England] and there treated properly, have been perfectly cured.”3 English mad-doctors had indeed begun making such claims and had even published books describing their effective treatments. However, while Franklin and his fellow Quakers may have hoped to bring such medicine to the colonies, they also had a second reason for building the hospital. There were, they wrote, too many lunatics “going at large [who] are a Terror to their neighbors, who are daily apprehensive of the Violences they may commit.” Society needed to be protected from the insane, and it was this second function—hospital as jail—that had taken precedence when the hospital opened in 1756.

In those early years, the lunatics were kept in gloomy, foul-smelling cells and were ruled over by “keepers” who used their whips freely. Unruly patients, when not being beaten, were regularly “chained to rings of iron, let into the floor or wall of the cell… restrained in hand-cuffs or ankle-irons,” and bundled into Madd-shirts that “left the patient an impotent bundle of wrath.”4 A visiting reverend, Manasseh Cutler, described the sorry scene:

We next took a view of the Maniacs. Their cells are in the lower story, which is partly underground. These cells are about ten feet square, made as strong as a prison… Here were both men and women, between twenty and thirty in number. Some of them have beds; most of them clean straw. Some of them were extremely fierce and raving, nearly or quite naked; some singing and dancing; some in despair; some were dumb and would not open their mouths.5

The lunatics also had to suffer the indignity of serving as a public spectacle. After the hospital opened, visiting the mad had quickly become a popular Sunday outing, similar to visiting a zoo. Philadelphians were eager to get a glimpse of these wretched creatures, with good sport on occasion to be had by taunting them, particularly those restrained in irons and easily roused into a rage. So frequent were the public’s visits, and so disturbing to the insane, that the hospital managers erected a fence in 1760 “to prevent the Disturbance which is given to the Lunatics confin’d in the Cells by the great Numbers of People who frequently resort and converse with them.”6 But even an iron fence couldn’t keep the public at bay, and so in 1762, the hospital, trying to make the best of an unfortunate situation, began charging a visitor’s fee of four pence.

All of this began to change once Rush arrived at the hospital in 1783.

The lunatics could not have hoped for a more kind-hearted man to be their advocate. Born of Quaker parents, Rush was constantly championing liberal, humanitarian reforms. As a young man, he had been a member of the Continental Congress and a signer of the Declaration of Independence. He’d advocated for the abolition of slavery and prison reform, and he brought this same compassion to his treatment of the mad. At his request, the hospital’s governing board built a new wing for the insane patients, which was completed in 1796, and soon many patients were enjoying the comforts of rooms furnished with hair mattresses and feather beds. Those who were well behaved were allowed to stroll about the hospital grounds and engage in activities like sewing, gardening, and cutting straw. Rush also believed that games, music, and friendship could prove helpful, and the hospital even agreed to his request that “a Well qualified Person be employed as a Friend and Companion to the Lunatics.”7 The insane, he explained to hospital attendants, needed to be treated with kindness and respect. “Every thing necessary for their comfort should be provided for them, and every promise made to them should be faithfully and punctually performed.”8

But such humanitarian care could only go so far. Rush was also a man of science. He’d studied at the University of Edinburgh, the most prestigious medical school in the world at the time. There, he’d been mentored by the great William Cullen, whose First Lines of the Practice of Physic was perhaps the leading medical text of the day. The European mad-doctors had developed a diverse array of therapeutics for curing madness, and Rush, eager to make Pennsylvania Hospital a place of modern medicine, employed their methods with great vigor. And this was treatment of an altogether different type.

They Are Brutes, Aren’t They?

One of the first English physicians to write extensively on madness, its nature, and the proper treatments for it was Thomas Willis. He was highly admired for his investigations into the nervous system, and his 1684 text on insanity set the tone for the many medical guides that would be written over the next 100 years by English mad-doctors. The book’s title neatly summed up his view of the mad: The Practice of Physick: Two Discourses Concerning the Soul of Brutes. His belief—that the insane were animal-like in kind—reflected prevailing conceptions about the nature of man. The great English scientists and philosophers of the seventeenth century—Francis Bacon, Isaac Newton, John Locke, and others—had all argued that reason was the faculty that elevated humankind above the animals. This was the form of intelligence that enabled man to scientifically know his world, and to create a civilized society. Thus the insane, by virtue of having lost their reason, were seen as having descended to a brutish state. They were, Willis explained, fierce creatures who enjoyed superhuman strength. “They can break cords and chains, break down doors or walls… they are almost never tired… they bear cold, heat, watching, fasting, strokes, and wounds, without any sensible hurt.”9 The mad, he added, if they were to be cured, needed to hold their physicians in awe and think of them as their “tormentors.”

Discipline, threats, fetters, and blows are needed as much as medical treatment… Truly nothing is more necessary and more effective for the recovery of these people than forcing them to respect and fear intimidation. By this method, the mind, held back by restraint, is induced to give up its arrogance and wild ideas and it soon becomes meek and orderly. This is why maniacs often recover much sooner if they are treated with tortures and torments in a hovel instead of with medicaments.10

A medical paradigm for treating the mad had been born, and eighteenth-century English medical texts regularly repeated this basic wisdom. In 1751, Richard Mead explained that the madman was a brute who could be expected to “attack his fellow creatures with fury like a wild beast” and thus needed “to be tied down and even beat, to prevent his doing mischief to himself or others.”11 Thomas Bakewell told of how a maniac “bellowed like a wild beast, and shook his chain almost constantly for several days and nights… I therefore got up, took a hand whip, and gave him a few smart stripes upon the shoulders… He disturbed me no more.”12 Physician Charles Bell, in his book Essays on the Anatomy of Expression in Painting, advised artists wishing to depict madmen “to learn the character of the human countenance when devoid of expression, and reduced to the state of lower animals.”13

Like all wild animals, lunatics needed to be dominated and broken. The primary treatments advocated by English physicians were those that physically weakened the mad—bleeding to the point of fainting and the regular use of powerful purges, emetics, and nausea-inducing agents. All of this could quickly reduce even the strongest maniac to a pitiful, whimpering state. William Cullen, reviewing bleeding practices, noted that some advised cutting into the jugular vein.14 Purges and emetics, which would make the mad patient violently sick, were to be repeatedly administered over an extended period. John Monro, superintendent of Bethlehem Asylum, gave one of his patients sixty-one vomit-inducing emetics in six months, including strong doses on eighteen successive nights.15 Mercury and other chemical agents, meanwhile, were used to induce nausea so fierce that the patient could not hope to have the mental strength to rant and rave. “While nausea lasts,” George Man Burrows advised, “hallucinations of long adherence will be suspended, and sometimes be perfectly removed, or perhaps exchanged for others, and the most furious will become tranquil and obedient.” It was, he added, “far safer to reduce the patient by nauseating him than by depleting him.”16

A near-starvation diet was another recommendation for robbing the madman of his strength. The various depleting remedies—bleedings, purgings, emetics, and nausea-inducing agents—were also said to be therapeutic because they inflicted considerable pain, and thus the madman’s mind became focused on this sensation rather than on his usual raving thoughts. Blistering was another treatment useful for stirring great bodily pain. Mustard powders could be rubbed on a shaved scalp, and once the blisters formed, a caustic rubbed into the blisters to further irritate and infect the scalp. “The suffering that attends the formation of these pustules is often indescribable,” wrote one physician. The madman’s pain could be expected to increase as he rubbed his hands in the caustic and touched his genitals, a pain that would enable the patient to “regain consciousness of his true self, to wake from his supersensual slumber and to stay awake.”17

All of these physically depleting, painful therapies also had a psychological value: They were feared by the lunatics, and thus the mere threat of their employment could get the lunatics to behave in a better manner. Together with liberal use of restraints and an occasional beating, the mad would learn to cower before their doctors and attendants. “In most cases it has appeared to be necessary to employ a very constant impression of fear; and therefore to inspire them with the awe and dread of some particular persons, especially of those who are to be constantly near them,” Cullen wrote. “This awe and dread is therefore, by one means or other, to be acquired; in the first place by their being the authors of all the restraints that may be occasionally proper; but sometimes it may be necessary to acquire it even by stripes and blows. The former, although having the appearance of more severity, are much safer than strokes or blows about the head.”18

Such were the writings of the English mad-doctors in the 1700s. The mad were to be tamed. But were such treatments really curative? In the beginning, the mad-doctors were hesitant to boldly make that claim. But gradually they began to change their tune, and they did so for a simple reason: It gave them a leg up in the profitable madhouse business.

Merchants of Madness

In eighteenth-century England, the London asylum Bethlehem was almost entirely a place for the poor insane. The well-to-do in London shipped their family lunatics to private madhouses, a trade that had begun to emerge in the first part of the century. These boarding homes also served as convenient dumping grounds for relatives who were simply annoying or unwanted. Men could get free from their wives in this manner—had not their noisome, bothersome spouses gone quite daft in the head? A physician who would attest to this fact could earn a nice sum—a fee for the consultation and a referral fee from the madhouse owner. Doctors who owned madhouses made out particularly well. William Battie, who operated madhouses in Islington and Clerkenwell, left an estate valued at between £100,000 and £200,000, a fabulous sum for the time, which was derived largely from this trade.19

Even though most of the mad and not-so-mad committed to the private madhouses came from better families, they could still expect neglect and the harsh flicker of the whip. As reformer Daniel Defoe protested in 1728, “Is it not enough to make any one mad to be suddenly clap’d up, stripp’d, whipp’d, ill fed, and worse us’d?”20 In the face of such public criticism, the madhouse operators protested that their methods, while seemingly harsh, were remedies that could restore the mad to their senses. They weren’t just methods for managing lunatics, but curative medical treatments. In 1758, Battie wrote: “Madness is, contrary to the opinion of some unthinking persons, as manageable as many other distempers, which are equally dreadful and obstinate.”21 He devoted a full three chapters to cures.

In 1774, the English mad trade got a boost with the passage of the Act for Regulating Madhouses, Licensings, and Inspection. The new law prevented the commitment of a person to a madhouse unless a physician had certified the person as insane (which is the origin of the term “certifiably insane”). Physicians were now the sole arbiters of insanity, a legal authority that made the mad-doctoring trade more profitable than ever. Then, in 1788, King George III suffered a bout of madness, and his recovery provided the mad-doctors with public proof of their curative ways.


On Sale
Sep 10, 2019
Page Count
384 pages
Basic Books

Robert Whitaker

About the Author

Robert Whitaker‘s articles on the mentally ill and the drug industry have won several awards, including the George Polk Award for medical writing and the National Association of Science Writers’ Award for best magazine article. He is also the author of The Mapmaker’s Wife and The Lap of the Gods. He lives in Cambridge, Massachusetts.

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