Five Big Ideas On Mental Illness

One of the most pressing issues we face as a society is a mental illness. Few of us escape its ravages - and no one escapes its social burdens. As a historian of psychiatry, I’ve spent half a century trying to understand and make sense of the ways we’ve tried to address and treat mental illness.  

My new book, Desperate Remedies, Psychiatry’s Turbulent Quest to Cure Mental Illness, starts with the birth of the asylums in the reformist zeal of the 1830s and ends with the crisis in psychopharmacology and the latest efforts to find a genetic basis for schizophrenia and bipolar disorder.   

Desperate remedies

People with serious mental illness have been unusually vulnerable to therapeutic experimentation. Often greeted as great breakthroughs by the medical establishment and the press, many deeply intrusive interventions have subsequently been shown to be seriously misguided.  

To mention only a handful: there were programs to induce fevers by deliberately infecting patients with malaria; to surgically remove teeth and tonsils (as well as stomachs, spleens, cervixes and colons); to bring patients to the brink of death through insulin comas and to induce artificial epileptic seizures (an approach some still swear by despite evidence it can wreak havoc on memory); and most dramatically of all, to sever brain tissue by thrusting an ice-pick through the eye socket into the brain. (Egas Moniz, who invented the lobotomy in 1935, won the Nobel Prize in 1949 for his innovation.) 

Today, we are seeing great enthusiasm for such novel therapies as deep brain stimulation and ketamine for depression, and a renewed interest in psychedelics as therapy for mental disorders. 

The scientific basis for these interventions is limited at best, and past experience suggests that the latest fads might best be treated with scepticism.

Women and people of color were targets for experimentation

Legally and morally, those suffering from psychosis and severe depression have often been regarded as non-persons, incapable of making rational decisions.  But differential treatment has been particularly marked for women and racial minorities. 

Take lobotomy. In its heyday in the 1940s and 50s, 60 per cent or more of those operated on were women.  Black Americans, particularly those seen as violent, were also singled out for lobotomies.   

When asylums were created in the nineteenth century, Black Americans were either segregated into separate wards or institutionalized in asylums for the “coloured” insane. “Separate but equal” as always meant appalling and dire.  

When America abandoned asylums in the late twentieth century in favour of the euphemistically named “community care,” many black Americans struggling with mental illness were caught up in the endless cycle of the flophouse, the streets, and jails, with only brief encounters with psychiatric facilities that tried to pacify them with anti-psychotics.  

The Los Angeles County Jail is now the world’s largest psychiatric institution. Black Americans are 9.6 per cent of the county’s population, but 31 per cent of the prisoners, and almost 44 per cent of those diagnosed with serious mental illness.

Community care is a sham

For more than a century, America invested vast amounts of economic and intellectual capital in support of the idea that the best response to serious mental illness was to put its victims into mental hospitals where they could be treated by physicians who initially believed they could cure them.

By the early 1950s, these places housed more than half a million people. But mental hospitals came under sustained assault, dismissed as snake pits that systematically damaged and dehumanized those they confined.  By the 1990s, they had essentially vanished from the scene. 

Deinstitutionalisation was proclaimed a grand reform. A more tolerant and hospitable community would instead welcome the mentally ill back into society and provide effective and humane treatment in its midst.   

It was a fairy story. The decanting of patients, many suffering from acute psychosis, took place with virtually no advance planning or provision for housing or the other needs of those with disabling mental illnesses. This is a major source of the contemporary explosion of homelessness. 

Asylums were founded in the nineteenth century to rescue the mentally ill from jails and prisons. Today, the largest providers of psychiatric services in the US are the Los Angeles County Jail, Rikers Island Jail in New York, and the Cook County Jail in Chicago.

There is no psychiatric penicillin

The psychopharmacological revolution that began in the early 1950s has unquestionably benefitted some patients, relieving their hallucinations and delusions and enabling them to resume some semblance of a normal life.  

Anti-depressants have improved the lives of some of those taking them, and new forms of psychosocial therapy and cognitive behavioural therapy have helped those with less serious forms of mood disturbance. 

And yet the drugs provide only a measure of symptomatic relief, and they do so for only a minority of those prescribed them. Moreover, they carry with them a heavy burden of side effects, side effects that are sometimes permanent and extremely serious.  

Controlled studies show that anti-depressants are only marginally more effective than placebo. Their side effects can be debilitating and enduring.  Anti-psychotics do little to alleviate the most damaging negative effects of schizophrenia: blunted affect, social withdrawal, disorganized thoughts, poverty of speech, and an inability to function in a social environment. 

When the National Institute of Mental Health sponsored a large-scale study comparing three so-called atypical or second-generation anti-psychotics with a drug from the nineteen-fifties, the modern drugs fared no better than the first-generation drug.  

Between 67 per cent and 82 per cent of the patients dropped out, depending upon which drug they were taking, either because the treatment was not working, or because they found the side effects intolerable. 

Contemporary psychiatry is facing a crisis

The year 2013 saw the publication of the 5th edition of its diagnostic system, DSM 5, even larger than its predecessors, which continued to adopt a tick-the-boxes approach to diagnosis. It was promptly denounced by the head of NIMH, Thomas Insel, and his immediate predecessor, Steven Hyman of Harvard, in the harshest terms.  

Hyman called it “an absolute scientific nightmare totally wrong in a way [its authors] couldn’t have imagined.”  Insel announced that his institute would ignore its categories when funding future research on mental illness.  Psychiatrists, he wrote scornfully, “actually believe [these DSM] diagnoses are real. But there’s no reality.  These are just constructs.  There’s no reality to schizophrenia or depression.”  

If the diagnosis is a mess, the prospects for improving the pharmacological treatment of a mental illness are also bleak.  Virtually all the major drug companies have announced that they are disbanding or sharply curtailing their research on psychopharmacology. 

Finally, the therapeutic payoff from four decades of betting on biology as the singular source of mental illness seems to have run aground. The decoding of the human genome raised hopes that the genetic origins of schizophrenia, bipolar disorder, and depression would soon be discovered.  That has not happened.  

Four decades of neuroscientific research have produced little therapeutic value. Don’t take the word of a sociologist.  When Thomas Insel stepped down as head of NIMH, he spoke of what he had achieved:  “I spent 13 years at NIMH really pushing on the neuroscience and genetics of mental disorders, and when I look back on that I realize that while I think I succeeded in getting lots of really cool papers published by cool scientists at fairly large cost – I think USD 20 billion – I don’t think we moved the needle in reducing suicide, reducing hospitalisations, [or] improving recovery for the tens of millions of people who have a mental illness.” 

Insel is right. People with serious mental illness live, on average, fifteen to twenty-five years less than the rest of us. And that gap is growing, not diminishing. Perhaps we should try something different.