My summer reading has been grim lately, focused on medicine’s failings. I recently reviewed Medical Nihilism, in which philosopher Jacob Stegenga mounts a scathing critique of medicine, arguing that many common treatments don’t work very well, if at all.
In this post, I look at Mind Fixers: Psychiatry’s Troubled Search for the Biology of Mental Illness by historian Anne Harrington, which corroborates and complements Medical Nihilism. Mind-Fixers is more measured than most critiques of psychiatry. Harrington seems almost pained to deliver bad news, making her indictment all the more damning.
Upbeat accounts of modern psychiatry, like A History of Psychiatry by Edward Shorter, present it as a story of good science triumphing over bad. 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 story is false, Harrington asserts. She 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 “overreached, overpromised, overdiagnosed, overmedicated and compromised its principles.”
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 insanity 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. Researchers hoped other mental disorders might also have relatively simple causes and cures.
Harrington’s book chronicles the largely futile efforts of scientists to find such 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 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 an article in the popular magazine Saturday Evening Post gushed that lobotomies transform the mentally ill from “ineffectives” into “useful members of society. A world that once seemed an abode of misery, cruelty and hate is now radiant with sunshine and kindness toward them.” In fact, lobotomies often caused severe disability or death. Of the four treatments mentioned above, only electroconvulsive therapy continues to be practiced. It can provide short-term relief from severe depression, but relapse rates are high.
The eugenics movement, which assumed mental illness is hereditary, sought to eradicate it by preventing the mentally “unfit” from reproducing. Early in the 20thcentury California and other states passed laws legalizing sterilization of mental-hospital inmates. In 1942, Harrington notes, the American Journal of Psychiatry urged killing 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 practical and ethical flaws of these biological methods allowed psychological approaches to mental illness to flourish. By the mid-20thcentury psychoanalysis, the theory/therapy invented by Freud, was dominating American psychiatry. Psychoanalysts insisted that mental illnesses had psychological causes and were best treated by psychological remedies, namely talk therapy. The influence of psychoanalysis waned in the 1950s with the advent of drugs for treating 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 by being too cold—or, conversely, too protective. A 1945 magazine article on this trend asked, “Are American Moms a Menace?”
But modern bio-psychiatrists are Harrington’s main target. She details how in the past few decades, as prescriptions for psychiatric medications soared, their limitations have become increasingly apparent. Many 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, she 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 viewed psychiatrists as “salespeople,” who were 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. (This is the practice that Stegenga calls “disease-mongering.”) Manufacturers of selective serotonin reuptake inhibitors (SSRIs) promoted the “chemical imbalance” theory of depression in advertising, even as research was discrediting that theory. Meanwhile, Harrington notes, many pharmaceutical companies, frustrated by the slow pace of research on the biology of mental illness, have “abandoned the field of psychiatry altogether.”
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) said recently that psychiatry has had “no good ideas about molecular targets for diagnoses and treatments since the 1950s.” [Harrington’s paraphrase, and her 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 various 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 Jacob Stegenga calls “gentle medicine” and what others call “medical conservatism.” I hope psychiatrists take heed. Mind-fixers, fix yourselves.
Postscript: Anne Harrington will talk about Mind Fixers at Stevens Institute of Technology, Hoboken, N.J., on Wednesday, September 25, at 4 p.m. The lecture is free and open to the public.Further Reading:
Responses from Readers:
Randolph Nesse MD: I appreciated your review of Anne Harrington's book. I loved the book. The field of psychiatry really is in a swamp. I fear, however, that pleas to spend more time with patients and less time with drug reps won't have an impact. A book like hers is published every year, and the field just goes on. I wonder if you have seen my new book Good Reasons for Bad Feelings: Insights from the Frontier of Evolutionary Psychiatry. It argues that an evolutionary foundation can make psychiatry more like the rest of medicine, not by reductionist investigations, but by distinguishing symptoms from diseases and looking at how selection shaped capacities for anxiety, depression and all the rest. I think you would like it. It offers a genuinely new way forward.
Karl Dahlke: Forgive me if I am a bit arrogant on this, but I think you, and everyone you interview, are rather missing the point - perhaps deliberately, since the truth is a bitter pill to swallow. The vast majority of mental illness in America is situational, not clinical. We live in constant fear and anxiety because we have no health insurance, and could die, or become permanently disabled, or at least bankrupt, at the slightest illness or injury. Minorities are terrified of the police, the first responders of mass incarceration, who currently house 1.5 million innocent slaves. Unless you can hide in your basement like a Jew in 1940 Germany, there is almost no way to avoid the slave catchers. Hard working aliens who have never committed a crime in their life are terrified of ICE. Even some privileged white people scrape and crawl and work 12 hour days for $9 an hour and still can't feed their families. Mental illness is endemic because of social policy, and if we fixed the ills of our nation, millions of Americans would start to feel better right away, and could put their SSRIs back on the shelf.
Keith Riggle: I've added "Mind Fixers" to my reading list, since I agree with Harrington's diagnosis and prescription for psychiatry. Much of it applies to the medical profession as a whole, especially disease mongering and following the money. No doubt the book will be criticized because Harrington is a historian, not a psychiatrist. I see that she has also authored or edited several related books, including "The Cure Within: A History of Mind-Body Medicine," "Visions of Compassion: Western Scientists and Tibetan Buddhists Examine Human Nature," and "So Human a Brain: Knowledge and Values in the Neurosciences." The blurb for "The Cure Within" states, "Can mind-body practices from the East help us become well? When it comes to healing, we believe we must look beyond doctors and drugs; we must look within ourselves. Faith, relationships, and attitude matter." Undoubtedly Harrington's views about mind-body medicine, Buddhism, and values colored her views in "Mind Fixers," which may also be a source of criticism.
They don't disturb me, however, as they resonate with my views about the mind and body, and I think the values of patients have gotten lost in the dry talk about the evidence of benefits versus risks. I recently read an op-ed in JAMA that I also agree with, "Evidence vs Consensus in Clinical Practice Guidelines." The point of the authors, Benjamin Djulbegovic, MD, and Gordon Guyatt, MD, is that there's currently a false dichotomy between evidence-and consensus-based clinical guidelines because all evidence requires interpretation, so all guidelines should be both evidence- and consensus based. No evidence speaks for itself, even if it comes from high quality randomized clinical trials. Another important reason they say this is because of "the third principle of evidence-based medicine: evidence can never dictate the optimal course of action, it should always be considered in the context of values and preferences." I think that is an important principle of medical nihilism, as well.