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<h1 class="reader-title">Mental Illness Is Not in Your Head -
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<p><a href="https://wwnorton.com/books/Mind-Fixers/"
data-wpel-link="external" target="_blank"
rel="external noopener noreferrer"><em>Mind Fixers:
Psychiatry’s Troubled Search for the Biology of
Mental Illness</em></a><br>
Anne Harrington<br>
W. W. Norton, $17.95 (paper)</p>
<p><a
href="https://www.hup.harvard.edu/catalog.php?isbn=9780674265103"
data-wpel-link="external" target="_blank"
rel="external noopener noreferrer"><em>Desperate
Remedies: Psychiatry’s Turbulent Quest to Cure
Mental Illness</em></a><br>
Andrew Scull<br>
Harvard University Press, $35 (cloth)</p>
<p>In 1990 President George Bush <a
href="https://www.loc.gov/loc/brain/proclaim.html"
data-wpel-link="external" target="_blank"
rel="external noopener noreferrer">announced</a> 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 “<a href="https://www.loc.gov/loc/brain/"
data-wpel-link="external" target="_blank"
rel="external noopener noreferrer">The Decade of the
Brain</a>.”</p>
<p>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.</p>
<p>The reality of psychiatric practice is far less
glamorous than the optimistic visions I grew up with.</p>
<p>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 <em>Diagnostic and Statistical
Manual of Mental Disorders</em> (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.</p>
<p>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 <a
href="https://www.treatmentadvocacycenter.org/storage/documents/backgrounders/smi-and-homelessness.pdf"
data-wpel-link="external" target="_blank"
rel="external noopener noreferrer">homeless</a> or die
prematurely than at any point in the last 150 years,
with <a
href="https://www.frontiersin.org/articles/10.3389/fpsyt.2019.00855/full"
data-wpel-link="external" target="_blank"
rel="external noopener noreferrer">lifespans</a> that
are 10 to 20 years less than the general population.
Biological research has also failed to reveal <em>why </em>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.”</p>
<p>And how about stigma? As anthropologist Helena Hansen
has <a
href="https://www.emerald.com/insight/content/doi/10.1108/S1057-6290(2012)0000014008/full/html"
data-wpel-link="external" target="_blank"
rel="external noopener noreferrer">argued</a>, 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 <a
href="https://www.penguinrandomhouse.com/books/206267/the-protest-psychosis-by-jonathan-m-metzl/"
data-wpel-link="external" target="_blank"
rel="external noopener noreferrer">traces</a> to
psychiatrists in the 1970s who pathologized Black
activism as “psychosis.” Finally, Black patients
experiencing mental health crises, including <a
href="https://jamanetwork.com/journals/jamapediatrics/article-abstract/2783706"
data-wpel-link="external" target="_blank"
rel="external noopener noreferrer">children</a>, are <a
href="https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2775602"
data-wpel-link="external" target="_blank"
rel="external noopener noreferrer">more likely</a> 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.</p>
<p>In 2015 the former director of the National Institute
of Mental Health (NIMH), Thomas Insel, crystallized this
disillusionment:</p>
<blockquote>
<p>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.</p>
</blockquote>
<p>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.</p>
<p>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.</p>
<p>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 “<a
href="https://www.newyorker.com/books/under-review/the-science-of-the-psychedelic-renaissance"
data-wpel-link="external" target="_blank"
rel="external noopener noreferrer">renaissance</a>”
and psychiatry’s “<a
href="https://pll.harvard.edu/course/psychedelic-assisted-psychotherapy-next-frontier?delta=0"
data-wpel-link="external" target="_blank"
rel="external noopener noreferrer">next frontier</a>.”
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.</p>
<hr>
<p>In <em>Mind Fixers: Psychiatry’s Troubled Search for
the Biology of Mental Illness, </em>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.</p>
<p>Psychiatry, across its history, has been dangerously
susceptible to hype.</p>
<p>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 <em>Ten Days in a
Mad-House.</em> Asylum psychiatry faced a crisis of
public trust.</p>
<p>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.</p>
<p>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.</p>
<p>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 <em>Desperate
Remedies: Psychiatry’s Turbulent Quest to Cure Mental
Illness</em> 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.</p>
<p>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 <em>Treponema pallidum</em> 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.</p>
<p>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.</p>
<p>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.</p>
<p>In Harrington’s study, the history of psychiatry
undulates like the boom and bust of a speculative
market.</p>
<p>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 <em>Buck v. Bell</em>
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.</p>
<p>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.</p>
<hr>
<p>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.</p>
<p>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 <em>medical </em>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.”</p>
<p>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, <a
href="https://psychnews.psychiatryonline.org/doi/full/10.1176/appi.pn.2019.10b11"
data-wpel-link="external" target="_blank"
rel="external noopener noreferrer">stormed</a> the
annual conferences of the American Psychiatry
Association (APA) and successfully demanded the removal
of homosexuality from the profession’s catalogue of
disorders.</p>
<p>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:</p>
<blockquote>
<p>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!</p>
</blockquote>
<p>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 <a
href="https://global.oup.com/academic/product/madness-in-the-city-of-magnificent-intentions-9780190852641?cc=us&lang=en&"
data-wpel-link="external" target="_blank"
rel="external noopener noreferrer">shown</a> 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.</p>
<p>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 <a
href="https://www.nybooks.com/articles/2022/02/24/liberation-psychology-frantz-fanon-appiah/"
data-wpel-link="external" target="_blank"
rel="external noopener noreferrer">critiqued</a> the
anti-Black violence of colonialism to imagine more
liberatory forms of care. And in Latin America, my own <a
href="https://www.degruyter.com/document/doi/10.1515/9781478012221-011/pdf"
data-wpel-link="external" target="_blank"
rel="external noopener noreferrer">work</a> 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.</p>
<p>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 <a
href="https://www.science.org/doi/10.1126/science.179.4070.250"
data-wpel-link="external" target="_blank"
rel="external noopener noreferrer">published</a> an
experiment, titled “On Being Sane in Insane Places,” in
the journal <em>Science</em>. 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
<a
href="https://www.grandcentralpublishing.com/titles/susannah-cahalan/the-great-pretender/9781538715260/"
data-wpel-link="external" target="_blank"
rel="external noopener noreferrer">shown</a> 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.</p>
<p>The turn to biology has not meaningfully impacted
treatment, but it has been wildly successful as a
marketing strategy for psychopharmaceuticals.</p>
<p>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. <a
href="https://psycnet.apa.org/record/1963-03211-001"
data-wpel-link="external" target="_blank"
rel="external noopener noreferrer">Research</a> from
as early as the 1960s <a
href="https://www.newyorker.com/magazine/2005/01/03/the-dictionary-of-disorder"
data-wpel-link="external" target="_blank"
rel="external noopener noreferrer">showed</a> 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.</p>
<p>The publication of the third edition of the DSM in 1980
heralded the birth of what proponents explicitly <a
href="https://jamanetwork.com/journals/jama/article-abstract/397571"
data-wpel-link="external" target="_blank"
rel="external noopener noreferrer">called</a> 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.</p>
<p>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<em>. </em>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.</p>
<p>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 <a
href="https://www.psychologytoday.com/us/blog/madness-in-civilization/202204/thomas-insel-and-the-future-the-mental-health-system"
data-wpel-link="external" target="_blank"
rel="external noopener noreferrer">reflected</a> 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.”</p>
<hr>
<p>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.</p>
<p>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 <a
href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7451317/"
data-wpel-link="external" target="_blank"
rel="external noopener noreferrer">offered</a>
influential physicians at prestigious academic centers
drug samples, lucrative consulting gigs, and other
incentives to peddle their products.</p>
<p>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 <a
href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3302834/"
data-wpel-link="external" target="_blank"
rel="external noopener noreferrer">disclosed</a>
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 <a
href="https://www.jstor.org/stable/43854371"
data-wpel-link="external" target="_blank"
rel="external noopener noreferrer">contributed</a> 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.</p>
<p>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 <a
href="https://www.fda.gov/about-fda/fda-basics/fact-sheet-fda-glance"
data-wpel-link="external" target="_blank"
rel="external noopener noreferrer">46 percent</a> 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 <a
href="https://www.nature.com/articles/d41586-020-01911-7"
data-wpel-link="external" target="_blank"
rel="external noopener noreferrer">distort</a>
evidence of safety and efficacy, <a
href="https://www.scientificamerican.com/article/trial-sans-error-how-pharma-funded-research-cherry-picks-positive-results/"
data-wpel-link="external" target="_blank"
rel="external noopener noreferrer">hide</a> negative
results and side effect data, and <a
href="https://www.propublica.org/article/drug-company-used-ghostwriters-to-write-work-bylined-by-academics-documents"
data-wpel-link="external" target="_blank"
rel="external noopener noreferrer">hire</a>
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.</p>
<p>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 <a
href="https://www.apa.org/about/policy/resolution-psychotherapy"
data-wpel-link="external" target="_blank"
rel="external noopener noreferrer">shown</a> 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 <a
href="https://www.cdc.gov/nchs/products/databriefs/db419.htm"
data-wpel-link="external" target="_blank"
rel="external noopener noreferrer">one in six</a>
Americans took a psychiatric medication in the last
year.</p>
<p>The real crisis in academic psychiatry is that there is
no crisis.</p>
<p>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 <a
href="https://www.hup.harvard.edu/catalog.php?isbn=9780674015999"
data-wpel-link="external" target="_blank"
rel="external noopener noreferrer">shown</a>, 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.</p>
<p>Perhaps the worst news is that Big Pharma, having
created and capitalized on psychiatric markets, is now
jumping ship. Anthropologist Joe Dumit has <a
href="https://www.tandfonline.com/doi/abs/10.1080/01459740.2017.1360877"
data-wpel-link="external" target="_blank"
rel="external noopener noreferrer">shown</a> 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. <a
href="https://www.nature.com/articles/480161a"
data-wpel-link="external" target="_blank"
rel="external noopener noreferrer">Almost all</a> 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.</p>
<p>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.</p>
<p>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 <em>listened </em>to
patients in the 1950s, he emphasizes.</p>
<p>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 <a
href="https://mitpress.mit.edu/books/distance-cure"
data-wpel-link="external" target="_blank"
rel="external noopener noreferrer">argued</a>,
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.</p>
<p>With the decline of psychoanalysis, therapy has
continued to verge toward corporate automation.
Psychologists and social workers today <a
href="https://www.dissentmagazine.org/article/therapy-with-a-human-face"
data-wpel-link="external" target="_blank"
rel="external noopener noreferrer">often search</a>
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.</p>
<p>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 <a
href="https://psilocybinalpha.com/data/psychedelic-drug-development-tracker"
data-wpel-link="external" target="_blank"
rel="external noopener noreferrer">conducting</a> 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 <a
href="https://www.fda.gov/news-events/press-announcements/fda-approves-new-nasal-spray-medication-treatment-resistant-depression-available-only-certified"
data-wpel-link="external" target="_blank"
rel="external noopener noreferrer">approved</a> for
treatment-resistant depression. Researchers and
journalists, such as Michael Pollan, have <a
href="https://michaelpollan.com/books/how-to-change-your-mind/"
data-wpel-link="external" target="_blank"
rel="external noopener noreferrer">dubbed</a> 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.</p>
<p>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 <a
href="https://neo.life/2020/10/inside-the-movement-to-decolonize-psychedelic-pharma/"
data-wpel-link="external" target="_blank"
rel="external noopener noreferrer">valuation</a> of
$1.1 billion.</p>
<p>A pill, however effective, cannot abolish the carceral
and capitalist system that is the source of so much
trauma.</p>
<p>Not to be left out, Big Pharma is also up to its usual
tricks. As I have noted <a
href="https://www.vice.com/en/article/pajkjy/opinion-the-new-ketamine-based-antidepressant-is-a-rip-off"
data-wpel-link="external" target="_blank"
rel="external noopener noreferrer">elsewhere</a>,
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 <a
href="https://neo.life/2020/10/inside-the-movement-to-decolonize-psychedelic-pharma/"
data-wpel-link="external" target="_blank"
rel="external noopener noreferrer">perpetuates</a>
Euro-American exploitation of Indigenous knowledge,
plants, and land in settler colonies.</p>
<p>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.</p>
<hr>
<p>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 <em>en
masse </em>from institutions with few resources and
little support, leading to high rates of homelessness
among people with serious mental illness.</p>
<p>But this story overlooks the silent and subtle ways
that incarceration has become further intertwined with
psychiatry. As historian Anne Parsons has <a
href="https://uncpress.org/book/9781469669472/from-asylum-to-prison/"
data-wpel-link="external" target="_blank"
rel="external noopener noreferrer">argued</a>, “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.</p>
<p>Moreover, sociologist Anthony Ryan Hatch has <a
href="https://www.upress.umn.edu/book-division/books/silent-cells"
data-wpel-link="external" target="_blank"
rel="external noopener noreferrer">argued</a> 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 <em>technocorrections, </em>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.</p>
<p>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.</p>
<p>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, <em>Healing: Our Path
from Mental Illness to Mental Health</em>, 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 <a
href="https://www.madinamerica.com/2022/04/thomas-insel-future-mental-health/"
data-wpel-link="external" target="_blank"
rel="external noopener noreferrer">maintained</a> 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 <a
href="https://www.theverge.com/2016/5/5/11592622/this-is-fine-meme-comic"
data-wpel-link="external" target="_blank"
rel="external noopener noreferrer">no crisis</a>.</p>
<p>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.</p>
<p>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 <a
href="https://www.upress.umn.edu/book-division/books/decarcerating-disability"
data-wpel-link="external" target="_blank"
rel="external noopener noreferrer">work</a> 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.</p>
<p>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
<a href="http://www.ctbailfund.org/"
data-wpel-link="external" target="_blank"
rel="external noopener noreferrer">peer support</a>, <a
href="https://www.pathwaysvermont.org/what-we-do/our-programs/soteria-house/"
data-wpel-link="external" target="_blank"
rel="external noopener noreferrer"><em>soteria</em>
houses</a>, and <a
href="https://www.eatip.org.ar/quienes-somos"
data-wpel-link="external" target="_blank"
rel="external noopener noreferrer">political protest</a>.
In Los Angeles last year, for example, a vocal coalition
of community organizers, academics, and officials
successfully <a
href="https://la.curbed.com/2019/8/13/20803756/mens-central-jail-los-angeles-contract-vote"
data-wpel-link="external" target="_blank"
rel="external noopener noreferrer">stopped</a> 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.</p>
<p>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. <a
href="https://jamanetwork.com/journals/jama/article-abstract/2702871"
data-wpel-link="external" target="_blank"
rel="external noopener noreferrer">Burnout</a> and <a
href="https://jamanetwork.com/journals/jama/article-abstract/2589340"
data-wpel-link="external" target="_blank"
rel="external noopener noreferrer">depression</a> 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
<a
href="https://www.guernicamag.com/its-all-in-your-head/"
data-wpel-link="external" target="_blank"
rel="external noopener noreferrer">put it</a>, “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, <em>What is the right
drug for me?</em>, but also: <em>What would the world
have to look like for me not to need drugs at all?</em></p>
<p>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.</p>
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