Psychiatry Is Broken. Can It Fix Itself?
This book by a Harvard historian calls upon psychiatry to admit its mistakes and ethical lapses, especially “the willingness of so many of its practitioners in recent decades to follow the money instead of the suffering.”
HOBOKEN, OCTOBER 14, 2024. Mental illness has been on my mind. That’s why I just posted a Q&A with psychiatry critic Robert Whitaker. Below is an updated version of my 2019 review of a book that corroborates Whitaker’s critical perspective: Mind Fixers: Psychiatry’s Troubled Search for the Biology of Mental Illness, by historian Anne Harrington. –-John Horgan
Just 26 years ago, historian of medicine Edward Shorter, in A History of Psychiatry: From the Era of the Asylum to the Age of Prozac, portrayed modern psychiatry as a thrilling success story. Biological theories of and treatments for the brain, notably drugs like Thorazine, lithium, Valium and Prozac, displaced Freudian psychobabble and transformed psychiatry into a truly scientific discipline.
This triumphal narrative is false. In Mind Fixers: Psychiatry’s Troubled Search for the Biology of Mental Illness, historian Anne Harrington writes: “Today one is hard-pressed to find anyone knowledgeable who believes that the so-called biological revolution of the 1980s made good on most or even any of its therapeutic and scientific promises.”
Bio-psychiatry, Harrington says, “overreached, overpromised, overdiagnosed, overmedicated and compromised its principles.” Harrington seems reluctant, even pained, to deliver this indictment, making it all the more persuasive and damning.
Mind Fixers starts in the 19th century, when the insane were housed in asylums. As inmate populations rose, Emil Kraepelin and other European scientists sought to trace mental illness to its biological roots. They were encouraged by the discovery that madness was often caused by syphilis, an infectious disease that later turned out to be curable by antibiotics.
Harrington chronicles scientists’ largely futile efforts to find comparably simple biological causes and cures. She goes through the sordid history of insulin-coma therapy, electroconvulsive therapy, the lobotomy and the fever “cure.”
The latter, which assumed that high fever could purge madness from patients, called for infecting them with malaria. Some asylum patients served as “malaria reservoirs,” whose blood supplied pathogens for infecting others.
The media hailed these alleged advances, exaggerating benefits and downplaying risks. In 1942 the Saturday Evening Post claimed that lobotomies were transforming the mentally ill from “ineffectives” into “useful members of society.” In fact, lobotomies, which involved destroying tissue in the frontal lobes, often caused severe disability or death.
Of the four treatments mentioned above (insulin-coma therapy, electroconvulsive therapy, lobotomies and fever cures), only electroconvulsive therapy is still practiced. It can provide short-term relief from severe depression, but more than half of those treated relapse within a year, according to a 2013 study.
The eugenics movement, which assumed mental illness is hereditary, sought to eradicate it by preventing the mentally “unfit” from reproducing. Early in the 20th century California and other states passed laws legalizing sterilization of mental-hospital inmates.
In 1942, Harrington notes, the American Journal of Psychiatry urged euthanizing mentally disabled children (although that recommendation was never carried out). In 1933 Nazi Germany cited U.S. policies as justification for its lethal eugenics program.
The major alternative to bio-psychiatry was psychoanalysis, the theory/therapy invented by Freud. Psychoanalysts insisted that most mental illnesses have psychological causes, such as childhood trauma, best treated by psychological remedies, namely talking to a psychoanalyst. The influence of psychoanalysis waned in the 1950s with the advent of drugs for schizophrenia, bipolar disorder, depression and anxiety.
Harrington is hard on the Freudians, accusing them of arrogance, dogmatism and cruelty, especially toward women. Psychoanalysts blamed mothers for causing schizophrenia, autism and other disorders in their children; mothers were either too cold or, conversely, too smothering. A 1945 magazine article asked, “Are American Moms a Menace?”
But modern bio-psychiatrists are Harrington’s main target. She details how in recent decades, as prescriptions for psychiatric medications soared, their limitations have become increasingly apparent. Many medications are scarcely more effective than placebos, and they have severe adverse effects, including weight gain, tremors, addiction and suicide.
Meanwhile, researchers have failed to trace mental illnesses to genetic mutations, neural anomalies, viruses or other physiological factors that would justify physiological treatments. No clear-cut biological markers for any mental illnesses have been found.
Psychiatry’s biological “revolution,” which Harrington calls a “False Dawn,” now appears to have been motivated as much by greed as compassion. By the late 1980s, Harrington notes, “a critical mass of clinicians and researchers had aligned their professional interests with the commercial interests of the pharmaceutical industry.”
Speakers at the 2008 meeting of the American Psychiatric Association disclosed more than 1,300 consulting or speaking contracts with drug firms. Companies view psychiatrists as “salespeople,” who are compensated based on their ability to boost prescriptions.
Psychiatrists did their job well. Sales of medications for mental illness increased by a factor of six between 1987 and 2001. Psychiatrists and drug companies aggressively promoted drugs for mild anxiety and depression, which had not previously been considered illnesses.
Manufacturers of selective serotonin reuptake inhibitors (SSRIs) promoted the “chemical imbalance” theory of depression in advertising, even as research was discrediting that theory. Ironically, many pharmaceutical companies, frustrated by the slow pace of research on the biology of mental illness, have “abandoned the field of psychiatry altogether,” Harrington notes.
Some of the bleakest assessments of bio-psychiatry come from insiders, including two former directors of the National Institute of Mental Health, the world’s largest funder of mental-health research. Steven Hyman (director from 1996 to 2001) has said that psychiatry has had “no good ideas about molecular targets for diagnoses and treatments since the 1950s [Harrington’s paraphrase and italics].”
Thomas Insel (2002-2015) said after stepping down, “I don’t think we moved the needle in reducing suicide, reducing hospitalizations, improving recovery for the tens of millions of people who have mental illness.”
Harrington concludes her book with a call to action. She says psychiatry’s current “crisis” is also an opportunity for reform, and she urges the profession to take steps to break out of its “stalemate”:
*Psychiatry should admit its mistakes and ethical lapses, especially “the willingness of so many of its practitioners in recent decades to follow the money instead of the suffering.”
*It should stop hyping new treatments and issuing “premature declarations of victory” over mental illness and “make a virtue of modesty.”
*It should “overcome its persistent reductionist habits and commit to an ongoing dialogue with the scholarly world of the social sciences and even the humanities.”
*It should listen more carefully to self-described “survivors” of mental-health treatment.
*It should focus on severe mental illness, as it did in the past, and allow psychologists, social workers and other non-physicians to treat the “worried well.”
This final step, Harrington acknowledges, would require “great professional and ethical courage,” because it would slash psychiatry’s market share and make it less lucrative. Harrington’s prescription sounds like what some reform-minded physicians, concerned by the harm resulting from many medical interventions, call “medical conservatism.” I hope psychiatrists take heed. Mind-fixers, fix yourselves.
Further Reading:
See “The Meaning of Madness,” chapter five of my book Mind-Body Problems, plus my columns Why Freud Still Isn’t Dead and The Drug-Based Approach to Mental Illness Has Failed. What Are Alternatives? Also check out the invaluable website Mad in America.