[D66] Mental Illness Is Not in Your Head - Boston Review

[René Oudeweg]

bostonreview.net
<https://bostonreview.net/articles/mental-illness-is-not-in-your-head/?s=09>



  Mental Illness Is Not in Your Head - Boston Review

Marco Ramos
39-50 minutes
------------------------------------------------------------------------

/Mind Fixers: Psychiatry’s Troubled Search for the Biology of Mental
Illness/ <https://wwnorton.com/books/Mind-Fixers/>
Anne Harrington
W. W. Norton, $17.95 (paper)

/Desperate Remedies: Psychiatry’s Turbulent Quest to Cure Mental
Illness/ <https://www.hup.harvard.edu/catalog.php?isbn=9780674265103>
Andrew Scull
Harvard University Press, $35 (cloth)

In 1990 President George Bush announced
<https://www.loc.gov/loc/brain/proclaim.html> that “a new era of
discovery” was “dawning in brain research.” Over the next several
decades the U.S. government poured billions of dollars into science that
promised to revolutionize our understanding of psychiatric disorders,
from depression and bipolar disorder to schizophrenia. Scientists
imagined that mental illnesses in the future might be diagnosed with
genetic tests, a simple blood draw, or perhaps a scan of your brain. New
pharmaceuticals would target specific neurochemical imbalances,
resulting in more effective treatments. The 1990s, Bush declared, would
be remembered as “The Decade of the Brain <https://www.loc.gov/loc/brain/>.”

This brave new world of brain research also promised to free us of the
stigma and discrimination attached to mental illness and addiction for
centuries. Localizing psychiatric disorders in the brain would make them
chronic medical diseases—like diabetes and high cholesterol—instead of
individual moral failings or deficiencies in character. While it was
impossible to predict exactly what the future would bring, there was an
overwhelming sense that psychiatric science was going to crack the
“mystery” and “wonder” of this “incredible organ,” as Bush called it.

The reality of psychiatric practice is far less glamorous than the
optimistic visions I grew up with.

Looking back as a psychiatrist and historian today, I find that these
hopes feel quaint. They remind me of other misplaced visions of
technological futures from the twentieth century: flying cars, pills for
a whole day’s nutrition. The reality of psychiatric practice is far less
glamorous than the visions of its future that I grew up with. Thirty
years later we still have no biological tests for psychiatric disorders,
and none is in the pipeline. Instead our diagnoses are based on criteria
in a book, the /Diagnostic and Statistical Manual of Mental Disorders/
(often called, derisively, the “bible” of American psychiatry). It has
gone through five editions in the last 70 years, and while the latest
edition is almost 100 pages longer than the last, there is no evidence
that it is any better than the version it replaced. None of the
diagnoses is defined in terms of the brain.

We also have not had any significant breakthroughs in treatment. For
decades the pharmaceutical industry has churned out dozens of
antidepressants and antipsychotics, but there is no evidence that they
are more effective than the drugs that emerged between 1950 and 1990.
People with serious mental illness today are more likely to be homeless
<https://www.treatmentadvocacycenter.org/storage/documents/backgrounders/smi-and-homelessness.pdf>
or die prematurely than at any point in the last 150 years, with
lifespans
<https://www.frontiersin.org/articles/10.3389/fpsyt.2019.00855/full>
that are 10 to 20 years less than the general population. Biological
research has also failed to reveal /why /psychiatric drugs help some
patients but not others. When a patient asks me how an antidepressant
works, I have to shrug my shoulders. “We just don’t know, but we do have
evidence that there’s about a 30 percent chance that it will help your
mood.” Perplexed, one patient responded, “Doesn’t it have to do with
neurotransmitters or something?” I sighed, “Yes, that was the theory for
a while, but it didn’t pan out.”

And how about stigma? As anthropologist Helena Hansen has argued
<https://www.emerald.com/insight/content/doi/10.1108/S1057-6290(2012)0000014008/full/html>,
the neuroscience of addiction has often reinforced stigma by reducing
substance use to an individual problem, instead of the result of
structural factors rooted in longer histories of racial violence.
American psychiatrists also diagnose Black and Brown patients with
disproportionate rates of schizophrenia compared to white patients—a
disparity that psychiatrist-sociologist Jonathan Metzl traces
<https://www.penguinrandomhouse.com/books/206267/the-protest-psychosis-by-jonathan-m-metzl/>
to psychiatrists in the 1970s who pathologized Black activism as
“psychosis.” Finally, Black patients experiencing mental health crises,
including children
<https://jamanetwork.com/journals/jamapediatrics/article-abstract/2783706>,
are more likely
<https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2775602>
to experience the violence of being physically restrained, tied to their
beds in ways that resemble the experiences of asylum patients over a
century ago.

In 2015 the former director of the National Institute of Mental Health
(NIMH), Thomas Insel, crystallized this disillusionment:

    I spent 13 years at [NIMH] pushing on the neuroscience and genetics
    of mental disorders, and when I look back . . . I realize that while
    . . . I succeeded at getting lots of really cool papers published by
    cool scientists at fairly large costs—I think $20 billion—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.

It does not help that academic psychiatry today feels out of touch. Many
people have underscored the profound importance of mental health amid
the social isolation of the pandemic, racial violence in our society,
and the increasingly hyper-competitive culture of schools, sports, and
the market. But academic psychiatry’s almost singular focus on
brain-based research has meant that the profession has been largely
absent from these conversations. And for what? All the “cool papers” on
neurobiology have won academic grants and helped professors get
promoted, but they have not meaningfully impacted the diagnosis and care
of the millions of people suffering psychic distress.

How did we end up here? If we have failed to understand psychiatric
disorders biologically, what happens when we examine them historically?
Two recent books by historians explore the crisis in biological
psychiatry, tracing the political, economic, social, and professional
factors that led psychiatrists to attempt to pin the reality of mental
illness—and the legitimacy of the profession—on the brain. Written by
leading historians in the field, these are big books, in heft and scope,
that cover two hundred years of the profession’s failures. They reveal
that U.S. psychiatry, across its history, has been dangerously
susceptible to hype and “cool,” ranging from enthusiasm for brain
dissection in the 1890s to the fanfare surrounding neurotransmitters and
genetics a century later.

Understanding the undulating history of psychiatric hype and crisis is
crucial today as the profession builds toward its next trend:
psychedelics, already heralded as a “renaissance
<https://www.newyorker.com/books/under-review/the-science-of-the-psychedelic-renaissance>”
and psychiatry’s “next frontier
<https://pll.harvard.edu/course/psychedelic-assisted-psychotherapy-next-frontier?delta=0>.”
These two histories demonstrate that the academic and corporate pursuit
of such hype has neglected the perspectives of communities most affected
by psychiatric research and care, resulting in significant psychological
and bodily harm. The strengths and limitations of these important books
push academic psychiatrists to reexamine our priorities. They challenge
us to envision a future world where the billions of dollars invested in
biological research are instead redistributed to the communities who
need it most—in order to provide the resources necessary for radically
reimagined forms of care that center whole humans instead of just brains.

------------------------------------------------------------------------

In /Mind Fixers: Psychiatry’s Troubled Search for the Biology of Mental
Illness, /Anne Harrington argues that the current crisis is just the
latest in a long line of failures to discover the biology of mental
illness over the last two centuries. In this sweeping study, the history
of psychiatry undulates like the boom and bust of a speculative market.
First a wave builds with enthusiastic promises of revolutionary
breakthroughs that will change psychiatry as we know it. Then the wave
collapses, as psychiatrists fail to deliver on those bold promises.
Crisis ensues, and after the requisite finger-pointing, the next wave of
psychiatric revolution begins to build. Rinse and repeat.

Psychiatry, across its history, has been dangerously susceptible to hype.

The first “revolution” in American psychiatry that Harrington tracks
arrived in the nineteenth century. At the time, large lunatic asylums
dominated the psychiatric landscape, such as the Blackwell’s Island
hospital on what today is called Roosevelt Island in New York City.
These institutions were designed to cure patients with mental disorders
by placing them in the hospitable environment of the asylum
architectural space. However, a series of journalistic exposés revealed
that these asylums were overcrowded and underfunded with patients living
in deplorable, instead of therapeutic, conditions. For example, in 1887,
journalist Elizabeth Seaman, who wrote under the pen name Nellie Bly,
went undercover as a patient in Blackwell’s Island Hospital and exposed
horrible acts of brutality in her best-seller /Ten Days in a Mad-House./
Asylum psychiatry faced a crisis of public trust.

As Harrington explains, European neuroanatomists came to the rescue.
Unlike asylum physicians, anatomists were pessimistic about the
potential for a cure. Building on eugenic theories, they believed that
asylum patients were “degenerates” who were biologically unfit to cope
with the stresses of modern life. But they also believed that the
mentally ill could provide a service to society after their deaths by
offering their brains to science. The dissection of their pathological
brains, the anatomists hoped, could reveal the biological causes of
mental suffering.

As the asylum transformed from a therapeutic institution into a site for
research over the course of the late nineteenth century, thousands of
dissections were performed on the bodies and brains of mostly poor
patients without their consent. Harrington concludes that they revealed
“more or less nothing.” The problem was that neuroanatomists had no idea
what they were looking for. The psychiatrist Karl Jaspers summed up
these anatomical efforts as a “brain mythology.” Neuroanatomical
dissection was a bust.

Abandoning the therapeutic nihilism of neuroanatomists, the second push
for biological psychiatry swung to the other extreme. The early
twentieth century in the United States was a period of unbridled,
desperate experimentation on patients’ bodies in the desperate search
for a cure. Andrew Scull’s new book /Desperate Remedies: Psychiatry’s
Turbulent Quest to Cure Mental Illness/ gives a chilling account of a
period characterized by an “orgy of experimentation.” While covering
much of the same historical ground as Harrington’s study, Scull’s more
vivid account demonstrates that the foundations of biological psychiatry
were built on violence inflicted on the bodies of women, the poor, and
people of color. During the period from 1910 to 1950 in the United
States, Scull argues, researchers treated their vulnerable patients “as
objects, not sentient beings.” With few legal rights at the time,
patients had little recourse for protesting doctors’ invasive and
haphazard experiments on their bodies.

Take the American psychiatrist Henry Cotton, who appears in both
Harrington and Scull’s accounts. In the 1910s and ’20s, Cotton was
convinced that all psychosis was septic in origin—a result of an
infection—because it had been demonstrated that one condition, called
“general paralysis of the insane,” was caused by the syphilis spirochete
/Treponema pallidum/ in the brain. Based on this unproven theory of
septic psychosis, Cotton concluded that psychosis could be treated by
the surgical removal of potential sources of infection from patients’
bodies. Cotton maimed and killed thousands of patients as he surgically
removed teeth, appendices, ovaries, testes, colons and more in the name
of curing psychosis. The death rate of Cotton’s colectomies was later
determined to be more than 44 percent, with women representing a
disproportionate number of his victims.

Another example Scull examines is the Viennese physician Julius
Wagner-Jauregg, who thought that inducing high fever and convulsions
might help psychiatric patients. He won the Nobel Prize of Medicine in
1927 for using malaria to induce high fever to treat patients with
general paralysis of the insane. Harrington points out that at the
famous St. Elizabeths Hospital in Washington, D.C., certain patients
with chronic psychosis, who were among the most socially marginalized,
were turned into “malaria reservoirs” who stored the parasite in their
bodies so that it could be distributed to other patients.

Scull suggests that the most extreme experiment during this period was
lobotomy. The procedure initially involved applying local anesthesia to
the head, drilling through the skull, and cutting the frontal lobes of
the brain with a blade. The surgeon stopped cutting the brain when the
patient began to get “confused.” The innovation earned Portuguese
neurologist Egan Moniz a Nobel Prize of Medicine in 1949. Walter
Freeman, who popularized the procedure in the United States, later
innovated an approach that required insertion of an ice pick through
each eye socket into the brain. Lobotomies were performed by the tens of
thousands in the 1940s and ’50s, again disproportionately on women.
Freeman described the effects of the procedure as changing his patients
into people who were more like “domestic invalid or household pet” so
that their behavior was easier for families and institutions to control.

In Harrington’s study, the history of psychiatry undulates like the boom
and bust of a speculative market.

Sterilization was another invasive procedure popularized in American
psychiatry during this period. Based on older theories of degeneracy,
sterilization was a eugenic rather than therapeutic tool: it was meant
to keep people with mental illness from passing on their “bad stock.”
The ethically fraught practice made its way to the Supreme Court in the
infamous /Buck v. Bell/ case in 1927, when Associate Justice Oliver
Wendell Holmes, Jr., argued that society was justified in seeking to
“prevent those who are manifestly unfit from continuing their kind.” In
the decade that followed the decision, some 28,000 Americans diagnosed
with “feeble-mindedness” were sterilized.

Scull and Harrington conclude that the only effective treatment that
psychiatry today has inherited from this period of frenzied and
dangerous experimentation is electroconvulsive therapy (ECT). Believing
(falsely) that seizure disorders and schizophrenia were antagonistic
diseases, the Hungarian psychiatrist Ladislav Meduna sought to induce
seizures with the powerful stimulant Metrazol in schizophrenic patients
in the 1930s. As a result of the sheer violence of the treatment, about
40 percent of patients suffered compression fractures of their spines.
The practice was adapted over time to make it safer for patients,
eventually evolving into ECT, which continues to be used in American
psychiatry today. Current research demonstrates that ECT is safe and
effective in the treatment of depression, but like researchers in the
1930s, we still do not know why or how it works.

------------------------------------------------------------------------

Rejecting this violent experimentation on the body, the next crop of
psychiatric revolutionaries turned, instead, to an approach that focused
solely on the mind: psychoanalysis. Sigmund Freud arrived in the United
States in 1909, but his ideas did not take hold in the profession until
after World War II. Experiences treating traumatized soldiers taught
psychiatrists that the war’s psychological wounds could be just as
devastating as their physical injuries.

Psychoanalysis developed what Scull calls a “fragile hegemony” over the
field in the postwar period. Harrington emphasizes that psychiatrists
turned to Freud’s work because they believed it provided a distinctly
/medical /approach to mental illness: an intervention, namely
psychoanalysis, elucidated and treated the underlying cause of the
patient’s symptoms in the unconscious. By the 1950s most psychiatry
residency training programs in the United States were led by
psychoanalysts, and many influential analysts consolidated their
professional power by denigrating earlier somatic approaches. In 1948,
for example, an influential group of analysts argued that lobotomy was
not a therapy but rather a “man-made self-destructive procedure that
specifically destroys” parts of the brain essential to humanity. Figures
in popular culture also saw psychoanalysis as a solution to broader
problems facing American society. At the annual conference of the
American Psychiatric Association in 1948, President Harry Truman stated
that “experts in the field of psychiatry” were essential for
safeguarding American “sanity,” which was the “greatest prerequisite for
peace.”

But like the boom and bust of revolutions before it, psychoanalysis
failed to deliver on its overambition, and the almost exclusive focus on
the mind did little to prevent psychiatric harm against vulnerable
communities. In the 1970s gay activists vocally protested the
pathologization of their sexuality in American psychiatry. These
activists, including some gay psychiatrists, stormed
<https://psychnews.psychiatryonline.org/doi/full/10.1176/appi.pn.2019.10b11>
the annual conferences of the American Psychiatry Association (APA) and
successfully demanded the removal of homosexuality from the profession’s
catalogue of disorders.

The problem for activists in gay, feminist, Black Power, and disability
movements in the 1970s was that institutional psychoanalysis embraced
and conformed individuals to white, ableist, heterosexual, and upper
middle-class norms. For those whose identities challenged such norms,
psychotherapy was more likely to harm than heal. As members of the
Chicago Gay Liberation Front proclaimed in a 1970 leaflet written to the
American Medical Association:

    We homosexuals of gay liberation believe that the adjustment school
    of therapy is not a valid approach to society. . . . Mental health
    for women does not mean therapy for women—it means the elimination
    of male supremacy. Not therapy for blacks, but an end to racism. The
    poor don’t need psychiatrists (what a joke at 25 bucks a
    throw!)—they need democratic distribution of wealth. OFF THE
    COUCHES, INTO THE STREETS!

Their call to abandon the couch for the street was an indictment of an
academic psychoanalytic profession, composed largely of white men, that
had reified, instead of challenged, structures of oppression in American
society. Many American analysts at mid-century held the belief, for
example, that Black people did not possess the psychological
sophistication required for psychoanalytic work on the couch.
Furthermore, historian Martin Summers has shown
<https://global.oup.com/academic/product/madness-in-the-city-of-magnificent-intentions-9780190852641?cc=us&lang=en&>
that in institutions that treated Black patients, psychoanalysts
reinforced older, racist stereotypes of a “distinctive black psyche,”
even in the face of data and clinical experience that undermined such a
notion.

To be sure, more radical visions of psychoanalysis emerged in the
political fervor of 1960s and ’70s, but you have to look beyond Scull
and Harrington’s accounts to find them. In the French colony of Algiers,
for example, Martinique-Born psychiatrist Frantz Fanon famously
critiqued
<https://www.nybooks.com/articles/2022/02/24/liberation-psychology-frantz-fanon-appiah/>
the anti-Black violence of colonialism to imagine more liberatory forms
of care. And in Latin America, my own work
<https://www.degruyter.com/document/doi/10.1515/9781478012221-011/pdf>
has shown how Marxist psychoanalysts in the early 1970s imagined a
“psychotherapy of the oppressed” that tied mental health to social and
political liberation from capitalism and U.S. imperialism. But these
radical efforts in the Third World were far removed, geographically and
politically, from the mainstream psychoanalysis discussed in these two
books.

For Scull and Harrington, perhaps the most damning blow to the
legitimacy of American psychiatry came from within the profession
itself. In 1973 forensic psychiatrist David Rosenhan published
<https://www.science.org/doi/10.1126/science.179.4070.250> an
experiment, titled “On Being Sane in Insane Places,” in the journal
/Science/. His famous study concluded that psychiatrists could not
distinguish sanity from insanity. For the experiment, Rosenhan sent
eight “pseudo-patients” who pretended to hear the words “empty,” “dull,”
and “thud” for interviews at psychiatric hospitals. Rosenhan found that
all eight were admitted to the hospital by psychiatrists; their average
length of stay was nineteen days. All but one of the patients were given
a diagnosis of schizophrenia on discharge. Journalist Susannah Cahalan
has more recently shown
<https://www.grandcentralpublishing.com/titles/susannah-cahalan/the-great-pretender/9781538715260/>
that Rosenhan fabricated many of his results, but at the time the paper
shook the foundations of the profession and broke psychoanalysis’
tenuous grip on the field.

The turn to biology has not meaningfully impacted treatment, but it has
been wildly successful as a marketing strategy for psychopharmaceuticals.

Enter the biological psychiatrists of the 1980s, who laid the groundwork
for the biological revolution we find ourselves in today. Partly in
response to Rosenhan’s study, this new coalition of psychiatrists blamed
the crisis in professional legitimacy on psychoanalysis. Its
obscurantist theories, they argued, were more jargon than substance and
had turned American psychiatry into a Tower of Babel, where
psychiatrists could barely communicate meaningfully with each other.
Research <https://psycnet.apa.org/record/1963-03211-001> from as early
as the 1960s showed
<https://www.newyorker.com/magazine/2005/01/03/the-dictionary-of-disorder>
that diagnosis among psychiatrists was not reliable statistically—that
is, psychiatrists often disagreed on diagnosis even when assessing the
same patient. The influential psychiatrist Robert Spitzer believed that
the solution was to radically reform a book that most professionals had
ignored: the DSM. Spitzer and the DSM-III Task Force gutted the
psychoanalytic underpinnings of the manual and replaced it with what
they believed were clear and objective criteria for each illness based
on observable aspects of patient behavior that could guide treatment and
research.

The publication of the third edition of the DSM in 1980 heralded the
birth of what proponents explicitly called
<https://jamanetwork.com/journals/jama/article-abstract/397571> a
“biological revolution” in psychiatry. For evidence of this revolution,
Spitzer and others pointed to developments in psychopharmacology,
especially the introduction of the first effective antipsychotic
chlorpromazine in 1954 and biological research that examined the role of
neurotransmitters and genetics on mental illness. Research on the brain
and the body, they believed, would eventually connect the diseases
described behaviorally in the DSM-III to their underlying biological causes.

We now know that this hoped-for science never arrived; psychiatry keeps
waiting for its biological Godot. While the DSM-III and subsequent
editions, including IV and 5, have improved diagnostic reliability,
psychiatry continues to suffer from the problem of validity/. /In other
words, the collection of symptoms that defined each condition in the DSM
have still—after billions of dollars of investment—not been correlated
with robust changes in our brains, blood, or genes.

The oft-cited claim, for example, that schizophrenia has a genetic basis
has failed to pass scientific muster. As Scull discusses, after failing
to find a Mendelian set of genes that could explain schizophrenia,
researchers in the 2000s pinned their hopes on new genome-wide
association studies (GWAS) that could investigate hundreds of thousands
of base pairs in the search for genetic linkages to psychiatric
disorders. But GWAS studies have not revealed a clear genetic basis for
schizophrenia (or bipolar disorder, for that matter). While combining
hundreds of genetic sites can help explain, at best, 8 percent of the
observed variance of schizophrenia, it is still possible for an
individual to have many of these genetic variations without developing
the disease. Prominent psychiatrists Michael Rutter and Rudolf Uher have
reflected
<https://www.psychologytoday.com/us/blog/madness-in-civilization/202204/thomas-insel-and-the-future-the-mental-health-system>
on the disappointment: “Molecular genetic studies of psychiatric
disorders have done a lot to find very little. In fact, in the era of
genome-wide association studies, psychiatric disorders have
distinguished themselves from most types of physical illness by the
absence of strong genetic associations.”

------------------------------------------------------------------------

While the turn to biology has not meaningfully impacted diagnosis or
treatment, it has been wildly successful as a marketing strategy for
psychopharmaceuticals. In fact, the most significant change in
psychiatry over the last half-century might be the birth of Big Pharma,
not any revolution in biology. Psychiatric markets were attractive to
pharmaceutical companies for at least two reasons in the 1980s. First,
psychotropics are taken over long periods of time: many patients are
life-long consumers. Second, self-perception and subjective experience
play major roles in the diagnosis of mental illness. This fact, pharma
executives realized, means that demand can be influenced and manipulated
by effective marketing that positions drugs as a solution to consumers’
dissatisfaction with their lives.

In the 1990s drug companies invested millions to create
direct-to-consumer advertisements that capitalized on the biological
fervor of academic psychiatrists. These ads claimed, misleadingly, that
their drugs targeted “chemical imbalances” in the brain that cause
everyday feelings of depression and anxiety in Americans. In addition to
consumer demand, the industry also focused their considerable influence
on prescribers. Pharma offered
<https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7451317/> influential
physicians at prestigious academic centers drug samples, lucrative
consulting gigs, and other incentives to peddle their products.

Today the industry financially supports almost every journal and
scientific meeting in psychiatry. Some 69 percent of the members of the
Task Force of the current DSM-5 disclosed
<https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3302834/> financial ties
to the pharmaceutical industry—a 21 percent jump from disclosures
reported by the Task Force for DSM-IV. Pharma’s influence on the DSM has
contributed <https://www.jstor.org/stable/43854371> to an expansion of
diagnostic categories so that the concept of “mental illness” itself has
become more inclusive, increasing the size of potential drug markets.

Over the last half century, pharma has also influenced the federal
approval of drugs by the Food and Drug Administration (FDA). Today, the
FDA gets 46 percent
<https://www.fda.gov/about-fda/fda-basics/fact-sheet-fda-glance> of its
budget from companies filing drug applications (so-called “industry user
fees”), and companies conduct the safety and efficacy trials on the
drugs that they produce. This obvious conflict of interest has led
pharma to distort <https://www.nature.com/articles/d41586-020-01911-7>
evidence of safety and efficacy, hide
<https://www.scientificamerican.com/article/trial-sans-error-how-pharma-funded-research-cherry-picks-positive-results/>
negative results and side effect data, and hire
<https://www.propublica.org/article/drug-company-used-ghostwriters-to-write-work-bylined-by-academics-documents>
ghostwriters to pen academic articles. While a number of major civil and
criminal rulings have punished companies for these offenses, the
structural source of this unethical behavior—the fact that the industry
evaluates the products that it profits from—remains today.

Big Pharma’s heavy influence on the profession has played a major role
in shifting the identity of the American psychiatrist—from a
psychoanalyst at mid-century to a prescriber of pharmaceuticals today.
While research has shown
<https://www.apa.org/about/policy/resolution-psychotherapy> that
psychotherapy is just as, or more, effective than drugs for anxiety,
depression, and other disorders, psychiatrists generally focus on the
prescription of drugs and send patients to psychologists and social
workers for therapy. And this shift has paid off handsomely. The
psychotropic drug industry today is worth almost $60 billion, and one in
six <https://www.cdc.gov/nchs/products/databriefs/db419.htm> Americans
took a psychiatric medication in the last year.

The real crisis in academic psychiatry is that there is no crisis.

But if the pharmaceutical industry has invested so heavily in
psychiatry, why have there been no breakthroughs in drug treatment? A
major reason is that the industry has spent billions of dollars more on
advertising psychiatric medications than on research and development of
novel drugs. As psychiatrist David Healy has shown
<https://www.hup.harvard.edu/catalog.php?isbn=9780674015999>, money
earmarked for R&D is often not intended to produce genuine innovation.
Almost all of the psychopharmaceuticals produced since 1990 have been
“copycats” that mimic older, generic pharmaceuticals, with only minor
chemical modifications. These (unfortunately named) “me-too” drugs work
no better clinically than the drugs that came before them, but their
slight biochemical novelty means that they can be patented, so that
pharma can charge insurance companies’ top dollar.

Perhaps the worst news is that Big Pharma, having created and
capitalized on psychiatric markets, is now jumping ship. Anthropologist
Joe Dumit has shown
<https://www.tandfonline.com/doi/abs/10.1080/01459740.2017.1360877> that
most psychiatric drugs will soon go off patent, so companies will be
forced to charge less for them. With the market already saturated with
pharmaceutical copycats and no significant scientific biological
breakthroughs in sight, there is suddenly little room for growth. Almost
all <https://www.nature.com/articles/480161a> of the major
pharmaceutical companies have decided to divest from psychiatric drug
research and turn to more promising sectors, especially the development
of “biologics” and other cancer drugs.

Does psychiatry, then, have a future? With the pharmaceutical well
running dry, Harrington and Scull offer few solutions beyond vague
statements about the need for humility in academic psychiatry and the
message that psychiatrists should focus on psychosocial, not just
biological, approaches to treatment.

Scull also wonders whether a return to psychotherapy might be the
answer. Outpatient psychiatry in the United States today is often based
on brief, fifteen- to thirty-minute visits that narrowly focus on
medication management and symptom check lists. Scull laments the loss of
connection that psychoanalysis represented for some (mostly privileged)
American patients at mid-century—at least psychiatrists /listened /to
patients in the 1950s, he emphasizes.

Unfortunately, psychotherapy in the last fifty years has become more
pill-like itself: standardized, quick, corporate, and cheap. In the
1980s and ’90s, managed care magnified the critiques of some
psychiatrists that the intensive and exploratory nature of long-term
psychoanalysis was a large investment in time and money with modest
gains. They advocated for faster and more affordable forms of care that
included not only drugs but also new cognitive-behavioral therapy (CBT)
techniques that, as historian Hannah Zeavin has argued
<https://mitpress.mit.edu/books/distance-cure>, devalued the healing
power of the therapist herself. Certain CBT approaches attempted to
reduce therapists’ role to largely automated dialogue and manualized
programs defined in workbooks and computer programs written for each
disorder. In the CBT model, the patient’s thoughts and feelings were
understood as scripts that could be reprogrammed, while the
introspection and psychological insight—the “listening” valued by
Scull—was denigrated by some practitioners as navel-gazing. As a result,
traditional psychoanalysis has become almost impossible to come by
today. While many therapists adopt an eclectic approach that borrows
insights from CBT and various strands of psychoanalysis in practice, the
kind of long-term, open-ended therapy that traditional psychoanalysis
represented is extremely difficult to access now. Insurance refuses to
cover it, and patients who want psychoanalysis are often forced to pay
high fees out-of-pocket.

With the decline of psychoanalysis, therapy has continued to verge
toward corporate automation. Psychologists and social workers today
often search
<https://www.dissentmagazine.org/article/therapy-with-a-human-face> for
“gig work” across growing digital platforms like Talkspace to earn
around $25 an hour with little control over their hours, fees, or
working conditions. Others engage in therapy with an artificially
intelligent (and usually feminized) chatbot. Disturbingly, these digital
apps are largely unregulated and have questionable standards of care.
Given financial pressure from insurance companies and a health system
that demands quick fixes, the future of psychotherapy frankly looks
bleak—both for patients who desire human contact and for providers whose
labor is being devalued to the point of automated erasure.

The only real source of excitement on psychiatry’s horizon seems to be
psychedelics, which Harrington mentions very briefly in her conclusion.
Non-profit organizations and academic researchers are currently
conducting
<https://psilocybinalpha.com/data/psychedelic-drug-development-tracker>
over fifty FDA trials of MDMA (ecstasy), psilocybin (magic mushrooms),
LSD (acid), mescaline, ibogaine, and ayahuasca for a wide range of
psychiatric disorders. Esketamine has already been approved
<https://www.fda.gov/news-events/press-announcements/fda-approves-new-nasal-spray-medication-treatment-resistant-depression-available-only-certified>
for treatment-resistant depression. Researchers and journalists, such as
Michael Pollan, have dubbed
<https://michaelpollan.com/books/how-to-change-your-mind/> these
developments a “psychedelic renaissance” that will revolutionize
psychiatry, open new understandings of the connection between mind and
brain, and provide benefit to thousands of patients.

But doesn’t this sound all too familiar? The “psychedelic renaissance”
feels like the next Harringtonian revolution, with its bombastic claims,
massive financial investment, and at this point, uncertain benefit for
patients. The verdict is still out about efficacy, but what is already
clear is that the pharmaceutical industry has taken notice. In 2020
London-based Compass Pathways, which received seed investment from Peter
Thiel’s Thiel Capital, was the first psychedelic pharmaceutical company
to go public, with a post-IPO run-up valuation
<https://neo.life/2020/10/inside-the-movement-to-decolonize-psychedelic-pharma/>
of $1.1 billion.

A pill, however effective, cannot abolish the carceral and capitalist
system that is the source of so much trauma.

Not to be left out, Big Pharma is also up to its usual tricks. As I have
noted elsewhere
<https://www.vice.com/en/article/pajkjy/opinion-the-new-ketamine-based-antidepressant-is-a-rip-off>,
Johnson & Johnson was interested in ketamine’s benefit for depression
but could not patent the drug, because it was already a cheap generic.
J&J decided to make a copycat, chemically isolating one of the
compound’s mirror images. They called this “me-too” compound “Spravato,”
patented the drug, and now, charge almost one thousand dollars per dose.
Companies are already using similar tactics to isolate patentable
compounds from psychoactive botanicals that Indigenous communities have
used for centuries, raising ethical concerns about how the burgeoning
psychedelic industry perpetuates
<https://neo.life/2020/10/inside-the-movement-to-decolonize-psychedelic-pharma/>
Euro-American exploitation of Indigenous knowledge, plants, and land in
settler colonies.

This “psychedelic renaissance,” then, is likely just the next stage of
the larger revolution in Big Pharma that started in the 1980s. And
whatever clinical benefit psychedelics end up offering, drugs are not a
solution for the structural problems that plague our mental health
system. Big Pharma, and the academic psychiatrists who partner with
industry, will continue to profit. And psychedelics can only help those
who have access to them in our society: mostly white, upper middle-class
people with private insurance.

------------------------------------------------------------------------

While both of these impressive books cover significant historical
ground, they also miss something critical about psychiatry’s past that
limits their vision of its future: they fail to confront the
profession’s role in the mass incarceration of the Black community over
the last half-century. For Harrington and Scull, carceral approaches to
psychiatry largely came to an end, at a population level, with the
closure of large asylums and the rise of deinstitutionalization—a
movement in the 1960s that attempted to transition care from psychiatric
hospitals to communities. In this common narrative, the problem with
deinstitutionalization was one of neoliberal neglect: patients were
discharged /en masse /from institutions with few resources and little
support, leading to high rates of homelessness among people with serious
mental illness.

But this story overlooks the silent and subtle ways that incarceration
has become further intertwined with psychiatry. As historian Anne
Parsons has argued
<https://uncpress.org/book/9781469669472/from-asylum-to-prison/>, “the
asylum did not disappear” with deinstitutionalization. Instead “it
returned in the form of the modern prison industrial complex.” Some of
the largest mental health centers in the country currently operate in
prisons, and today, there are more people with serious psychiatric
illness in America’s prisons than in its remaining psychiatric
hospitals. Around 40 percent of people diagnosed with serious mental
illness will face incarceration in their lifetimes, in many cases, as a
consequence of the racist policies that undergird the ongoing War on
Drugs. This carceral mental health is highly segregated. While
psychiatric hospitals tend to house white, middle-aged patients, prisons
disproportionately confine people with psychiatric disorders who are
Black and under the age of forty.

Moreover, sociologist Anthony Ryan Hatch has argued
<https://www.upress.umn.edu/book-division/books/silent-cells> that the
use of prison psychopharmaceuticals has allowed for incarceration at the
level of the brain. Prison-policy strategists have framed
psychopharmaceuticals not as medical treatments but rather, as an
important component of /technocorrections, /that is, “the strategic
application of new technologies in the effort to reduce the costs of
mass incarceration and minimize the risks prisoners pose to society.” In
2000, some 95 percent of maximum or high-security state prisons were
distributing psychiatric drugs to incarcerated people.

These facts are missing from these books because both Harrington and
Scull are ultimately focused on elite academic psychiatrists—a community
that tends to avoid work in prisons. As Hatch notes, almost all of our
public knowledge about psychopharmaceuticals comes from their use among
the unincarcerated, while knowledge about prison psychotropics tends to
be as tightly guarded as inmates themselves. This silence is a form of
oppression that covers up both the use of psychotropics as a technology
of custodial control and the failure to provide people in prison—many of
whom are traumatized by their incarceration—with the humane treatment
that they deserve.

As a psychiatrist myself, I believe that an important part of this
tragedy is the silence and lack of accountability among those who
represent our field. Despite the decreasing life expectancy of people
with mental illness, high rates of incarceration and homelessness, and
the failure of the biological paradigm, the biopsychiatric research
machine just keeps growing. In his own new book, /Healing: Our Path from
Mental Illness to Mental Health/, Insel argues that the failures of
biological psychiatry’s past indicate that we should “double down on
brain research” instead of re-examining our priorities. Insel’s
successor at the NIMH, Joshua Gordon, has maintained
<https://www.madinamerica.com/2022/04/thomas-insel-future-mental-health/>
the organization’s focus on biopsychiatric research, narrowly construed.
While both Harrington and Scull point to a “crisis” in the profession
today, the scarier truth is that many in the academy are proceeding with
business as usual. The real crisis in academic psychiatry, in other
words, is that there is no crisis
<https://www.theverge.com/2016/5/5/11592622/this-is-fine-meme-comic>.

These books invite us to imagine a future where the billions invested in
biological research are instead redistributed to the communities who
need it most.

If these histories of elite academic practitioners do not show us the
whole problem, they are also not going to produce imaginative solutions.
Searching for answers requires de-centering the academy and looking to
narratives that have largely been neglected in standard histories of
psychiatry. The historical work
<https://www.upress.umn.edu/book-division/books/decarcerating-disability>
of disability activist and scholar Liat Ben-Moshe, for example, turns to
Mad communities who have embraced neurodivergence not as a medical
problem that needs to be fixed but as an identity that should be
celebrated. Mad activists and professional allies in the 1970s, such as
the antipsychiatrist Thomas Szasz, successfully demanded the abolition
of violent psychiatric hospitals and carceral practices in American
society. While this movement to deinstitutionalize psychiatry did not
result in wholesale liberation of people with disabilities in the United
States, Ben-Moshe argues that it offers important lessons about how
communities can successfully resist the structures that repress them in
the name of care.

Ben-Moshe’s work not only provides a means for critically examining the
psychiatric violence of the past but also offers what she calls
“genealogies” for thinking about futures that seem otherwise
unimaginable. Genealogies of resistance conceptualize “health” not in
terms of access to individualized treatment provided by academic
physicians but rather in terms of collective liberation from the
structural conditions that produce the vast extent of psychological
suffering and trauma. These genealogies undergird the work of
communities and professionals fighting today to abolish the carceral
system and to imagine non-violent forms of care through peer support
<http://www.ctbailfund.org/>, /soteria/ houses
<https://www.pathwaysvermont.org/what-we-do/our-programs/soteria-house/>,
and political protest <https://www.eatip.org.ar/quienes-somos>. In Los
Angeles last year, for example, a vocal coalition of community
organizers, academics, and officials successfully stopped
<https://la.curbed.com/2019/8/13/20803756/mens-central-jail-los-angeles-contract-vote>
the construction of a “psychiatric jail” and advocated for the
reinvestment of those funds into initiatives for community-based mental
health care. “Care first, jails last,” they are demanding.

There are also unexpected lessons here for more privileged communities.
Material wealth does not completely insulate people from the
psychological damage of capitalism, of course. Burnout
<https://jamanetwork.com/journals/jama/article-abstract/2702871> and
depression
<https://jamanetwork.com/journals/jama/article-abstract/2589340> are
endemic among upper middle-class physicians and medical students, to
name only one example. Over a third of students at Yale, many of whom
come from privileged backgrounds, seek mental health services for
psychic distress. As psychotherapist Gary Greenberg has bluntly put it
<https://www.guernicamag.com/its-all-in-your-head/>, “The fact is, if we
didn’t have such a fucked-up society, I’d be out of a job.”
Psychological suffering in the upper crust of society is not only
evidence that we need increased access to care, whether through
pharmaceuticals or psychotherapy. It is also a call to mobilize against
the pathogenic features of our local social climates, from toxic
training programs and high-pressure university cultures to dehumanizing
factory floors. As historian Joanna Radin encouraged me to discuss in my
undergraduate course on the History of Drugs, the question is not only,
/What is the right drug for me?/, but also: /What would the world have
to look like for me not to need drugs at all?/

Harrington and Scull surely did not intend for their books to be read
this way, but we might understand them as a call to defund biological
psychiatry in the United States—to refuse yet another promise of a
“revolution” or “renaissance” that would save an academic project that
has done little to help and lots to harm. We do not need to be
neuroscientists to know that psychological and emotional suffering is
“real” or “legitimate,” and that a pill, however effective, cannot
abolish the carceral and capitalist system that is the source of so much
trauma. As these books teach us, psychiatric paradigms are fragile, and
perhaps biology’s tenuous grip on the profession is finally easing under
the strain of recent critiques. The future of our profession, if it has
one, does not lie in tired promises of biological breakthroughs. It
depends on unearthing and embracing neglected histories and genealogies
of solidarity with the communities that academic psychiatry claims to serve.
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