Is Psychiatry Facing an Existential Crisis?

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Review of Desperate Remedies: Psychiatry’s Turbulent Quest To Cure Mental Illness by Andrew Sculll. Harvard University Press. 494 pp.

Like other medical professionals, psychiatrists present themselves as experts in diagnosing and treating illnesses. On both fronts, Andrew Scull maintains, psychiatry is in trouble. Despite some success in addressing milder forms of mental distress, psychiatry has failed to solve the puzzles posed by the gravest illnesses: schizophrenia, bipolar disorders, and acute depression.

In Desperate RemediesScull, an Emeritus Professor of Sociology at the University of California, San Diego, and the author of, among other books, Madness in Civilizationprovides a provocative and often persuasive analysis of psychiatry since it emerged as a branch of medicine specializing in the management and cure of “lunacy.”

Psychiatry’s dominant paradigms, Scull indicates, have produced therapeutic remedies of limited efficacy, or worse. Honesty about “this dismal state of affairs” is preferable to denying reality, he writes, because the latter is “classically seen as a sign of serious mental disorder.”

Scull’s book is a must-read for those who have been – or fear they will be – touched by mental illness. The rise of psychiatry, he reminds us, was linked to the emergence of asylums based on the premise that a carefully calibrated regimen could restore lunatics to sanity. By the end of the 19th century, however, therapeutically inclined institutions had become “mausoleums with a mad, captive population.”

Psychiatrists then reinvented themselves as “bio-psychologists.” Deploying an array of treatments for what had been deemed intractable diseases over the objections of family members, they claimed substantial success rates. Convinced that sepsis acting on brain cells caused psychosis, Henry Cotton removed the teeth and tonsils of asylum inmates. The insulin coma therapy of Manfred Sakel, “the Pasteur of Psychiatry,” was hailed as a treatment for schizophrenia. In 1927, Julius Wagner-Jauregg won the Nobel Prize in Medicine for inoculating syphilis patients with malaria. In 1949, Egas Moniz, the pioneer of frontal lobotomies, became psychiatry’s second Nobel Laureate.

During World War II, Scull reveals, breakdowns among a massive number of soldiers cast doubt on claims that mental illness was caused by biological or hereditary defects, opening the door to psychiatric careers outside asylum doors—and for Freudian psychoanalysis, which had been “distinctly” a minority taste” among psychiatrists, many of whom recoiled at its reliance on sexual fixations.

In the 1950s and 60s, psychoanalytic training was the ticket to success for academic psychologists and lucrative high-status outpatient practices. The model — that mental illness and health were points along a continuum — led to suggestions that psychoanalysis could resolve social and political as well as private conflicts.

Critics were already pointing out, however, that “talk therapy” lacked a scientific foundation, relied on rhetoric about the id, ego, and superego and anecdotes about sessions to declare cured patients, and was utterly ineffective with psychosis. In time, Scull points out, a backlash against psychoanalysis contributed to the return, albeit in a different form, of biological psychiatry.

The de-institutionalization of mentally ill people in the late 20th century, Scull suggests, was fueled in part by critiques of psychiatry’s competence. Whatever its causes, the closing of state hospitals left millions of “lost souls cycling between the streets and shelters, with periodic trips to jails when their behavior becomes too disturbing or threatening.” Differential treatment of mentally ill patients by race, which extended back to the Heyday of asylums, was exacerbated by drastic cuts in public provisions for them.

Scull also launches a withering assault on psychopharmacology. As clinical psychologists and social workers, who accept smaller fees, came to dominate talk therapy, psychiatrists found their fate closely tied to the drug industry. Some endorsed the narrative that new drugs were acting on the disease itself; many knew they were prescribing medications addressing symptoms, not causes. Symptomatic relief, Sculll acknowledges, “is real and dramatic, and its importance should not be minimized.” But even symptomatic relief is far from universal. And as those of us who watch TV ads know, many drugs have debilitating side effects which often cause patients to stop taking them. The pharmacological revolution, moreover, resulted in an explosion in cases and costs. With one in five high school boys and one in 11 girls now diagnosed with ADHD, the United States, for example, accounts for about 92% of worldwide expenditures for treatment drugs.

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Most important, it seems to me, in his analysis of the Diagnostic and Statistical Manual of Mental Disorders, Scull demonstrates that editors realized psychiatry “could not establish chains of causation for any major form of mental disorder” or design reliable diagnostic tests. Their response, Scull writes, was akin to that of 18th-century physicians trying to create an orderly classification of clinical material. With decisions made by majority vote, the number of syndromes in the DSM multiplied, as did the list of symptoms (only some of which would justify a diagnosis) and the elevation of depression as one of the most common afflictions. Some critics assert that the DSM has “transformed the visissitudes of everyday life [excessive eating, normal grief, temper tantrums] into ‘illnesses.’”

If psychiatry is to survive, Scull concludes, psychiatrists must be more candid about the limits of their knowledge. They can legitimately point to progress with mild forms of mental distress. But they should acknowledge that madness remains a mystery they – and we – must redouble our efforts to solve. The best way to start, Scull writes, is to combine the insights from neuroscientists and geneticists with an understanding of the social dimensions of mental illness and the insights of clinical psychiatrists.

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