The Skeptics Society & Skeptic magazine

In Mind Fixers: Psychiatry’s Troubled Search for the Biology of Mental Illness,¹ Harvard historian of science Anne Harrington concludes about American Psychiatry that “firm understandings of major mental illnesses and their underlying biology continue to elude the field” (p.272). Harrington cites hundreds of published articles and books demonstrating her major conclusion that the biology of serious mental disease remains a mystery. Such a pessimistic verdict is paired with the implication that treatment of emotional disease has shown little progress, largely as a consequence of inadequate biological comprehension. In Chapter 1, Harrington describes questionable early-20^th century psychologically based treatment efforts for hysteria and traumatic psychic war disability. In 1913, Treponema pallidum bacteria that caused Syphilis were found in the brains of patients suffering from the neurological psychiatric disease “General Paresis.” Later antibiotic remedies that destroyed Treponema also ended Neurosyphilis. Surely, one would think, the same kind of scientific advance could generate a cure for schizophrenia or depression? Alas this has not happened even by today.

But the book extensively describes the time period after 1910 when influential Swiss neurologist and emigrant to America Adolph Meyer emphasized that psychiatrists must study mental illness from a biological perspective. The following year (1911), psychiatrist Eugen Bleuler also Swiss who coined the term “Schizophrenia” agreed. He claimed that although this disabling disease had psychological characteristics its origins was organic pathology of the brain. Both physicians asserted that understanding mental illness required more than investigation of pertinent lifetime social and mental data, and must include the actual inspection of brain specimens and the study of heredity and genetics.

In Part I of her book, “Doctors’ Stories,” Harrington examines the history of concerted efforts by American Psychiatry to identify the biology of mental illness. Her comprehensive examination of research findings convinces her that most seriously ill patients whom we treat certainly do have a genuine disease. As a physician I too have no doubt that this is so. For her — and for me — this is certainly why Vladimir Horowitz, probably the finest classical pianist of the 20^th century, couldn’t perform between 1953 and 1965. He suffered from a profound Depression Disorder, recovery from which was achieved only through repeated electroshock therapy.²

In Part II, “Disease Stories,” Harrington reviews theories about the alleged brain causes of three disabling major mental illnesses: Schizophrenia, Depression, and Mania-Depression. These diseases afflict millions of Americans and lead to severe personal suffering, in addition to the large societal and economic cost from lost work and impaired social engagement. However, there is a serious omission in this section of the book: the necessary exploration of a fourth major mental disease, addiction. This disorder has caused 200,000 American opioid overdose deaths over the past 15 years³ and its absence from Mind Fixers is notable because of these drugs’ lethality. Even more relevant is that our understanding of the biology of addiction is considerably better than any of the three illnesses included in Harrington’s survey. Naturally occurring brain chemicals such as GABA (gamma-aminobutyric acid), glutamates, and dopamine have been identified as critical neuro-substances in this psychopathology. Their inhibitory and stimulatory functions, chemistry, and neurological substrates are well understood. As a consequence of this scientific advance in knowledge, effective medications such as methadone, buprenorphine, and naltrexone have been successful in ameliorating the ravages of both legal and illegal opioid substances.⁴ Also this comprehension during the last half century has generated sleeping medicines in the form of benzodiazepines that are far safer than barbiturates which were a major source of accidental overdose deaths during the 20^th century So in this scientific medication domain, there has indeed been considerable progress.

In Part III, “Unfinished Stories,” Harrington explores American surgical and medical treatments for major mental illnesses over the past century. These procedures were based on the claim that brain abnormalities were being corrected. This section describes widespread adoption of treatments employing seizures induced through malaria, insulin coma, metrazol shock, or electroconvulsive therapy (ECT). Harrington dramatizes the 1935 discovery by Portuguese psychiatrist Antonio Moniz of a psychosurgical procedure severing fibrous connections in the brain’s prefrontal cortex. The following year, 1936, American neurologist Walter Freeman modified the procedure and called it a lobotomy. With his neurosurgeon partner James Watts, they performed their first prefrontal brain surgery. Between 1935 and 1965, almost 50,000 similar procedures were performed, mostly on women in the U.S. and UK. Side effects included weight gain, seizures, incontinence, surgical deaths, and suicide, as well as reductions in initiative, alertness, empathic sensibility, and independent functioning. In return, the benefits were few — observed primarily in patients’ passive cooperation with care providers. Harrington finds the intervention inappropriate and unethical, and condemns this procedure.

By the 1970s, psychotropic drugs replaced surgical and shock interventions in the treatment of major mental illnesses. Of the latter, only ECT is still considered to have proven and safe efficacy. In her chapter False Dawn, Harrington thoroughly investigates the proliferation of pharmaceutical therapies. Neuroleptic medications like chlorpromazine, haloperidol, olanzapine, and lithium did (and do) calm agitated psychotic patients — they were effective in suppressing delusions, paranoia, and hallucinations. However, they had little impact on so-called “negative” symptoms such as inertia, apathy, and social withdrawal. Debilitating physical side-effects had to be ignored, including tremor and rigidity, movement disorders called tardive dyskinesia, fatal blood conditions, and metabolic abnormalities. Later research comparing the effect of antidepressant agents like Paxil, Prozac, and Zoloft for depressed patients with tight control groups found that 75 percent of the improvement could be attributed to a placebo effect.⁵

The benefits of these new medications for the mentally ill were welcomed by the public, widely accepted by physicians, and exploited by the profit-seeking pharmaceutical industry. Harrington cites Marcia Angell, a former editor-in-chief of the prestigious New England Journal of Medicine who wrote that drug corporations that manufactured psychiatric drugs had become no longer an “engine of innovation, but a vast marketing machine.”⁶ Similarly, the National Alliance on Mental Illness (NAMI) — a powerful patient-advocacy group — had once effectively lobbied for humane patient treatment. But “by 2010, 75% of NAMI’S budget came from the Pharmaceutical industry” (p. 251), endangering its independence.

The major parts of Harrington’s book described above contain three compelling examples of other major psychiatric failures.

1. Diagnosis

The dominant system of American psychiatric diagnosis since 1952 as represented in Harrington’s book is commonly called the DSM (Diagnostic Statistical Manual of Mental Disorders), now in its fifth edition. The DSMs categorized mental disorders by describing psychiatrists’ and psychologists’ imprecise but agreed-upon symptoms, and diagnoses had no genetic or biological referents. As a result, the nosology was doomed to fail. Psychiatrists who wanted their field to be closer to medicine intended the DSMs to make psychiatry more a precise quantitative discipline than a psychological descriptive one. However, the classifications represented specialized interests and biases, and financially rewarded members of the American Psychiatric Association, the profitable insurance industry, and large pharmaceutical corporations. In 1973 the pathological diagnosis of homosexuality was removed from DSM II through a vote of APA members, engineered by Robert Spitzer, Professor of Psychiatry at Columbia University Medical School. The use of an association’s vote to legitimatize or disallow a medical psychiatric diagnosis harmed the DSM’s reputation and alleged validity among empirical medical scientists according to Harrington.

That same year, 1973, American a persistently skeptical psychologist David Rosenhan published an article titled “On Being Sane in Insane Places” in the prestigious journal Science. He described how he and his associates got themselves admitted to a dozen mental hospitals in five different US states through reporting having an experience of a brief auditory hallucination. They described that voices they heard were often unclear, sounding “empty,” “hollow,” or like a “thud.” When pressed, they offered the interpretation “My life is empty and hollow.” All eight were admitted, seven of them diagnosed as schizophrenic and one as manic-depressive. They were, in fact, a psychology graduate student, three psychologists, a psychiatrist, a pediatrician, a housewife, and a painter (three women, five men), none of whom had had any history of mental illness. Outside of the faux auditory hallucination and false names, they were instructed to tell the truth after admission, to behave normally, and to claim that the hallucinations had stopped. Despite nurses reporting that the patients were “friendly” and “cooperative” and “exhibited no abnormal indications,” none of the hospital psychiatrists or staff detected the experiment, while consistently treating these normal persons as abnormal patients.⁷

More recently in 2007, editor emerita of the American Journal of Psychiatry Nancy Andreasen seriously criticized the DSM. Its checklist approach, she said, had “led to a decline in careful clinical evaluation.”⁸ In 2012, Duke University’s Chairman of Psychiatry, Allen Frances, Chairman of the DSM-4 task force argued that DSM diagnoses relied on fallible subjectivity rather than objective biological tests.⁹ I myself contributed to the debate in 2013, arguing that the diagnosis of PTSD in the DSM-5 lacked validity.¹⁰ That same year, Dr. Thomas Insel, Director of the National Institute of Mental Health, also rejected the value of the DSMs. He said that the NIMH would conduct all new clinical funded research into the causes of mental disorders activities while ignoring DSM nosology (p. 267). This further damaged the prestige of the APA’s DSM classification system.

2. Hostility Toward Biological Models

A second failure to make psychiatry more medical and to concentrate on the biological brain contributions to mental disease was the consequence of outright opposition by the American psychoanalytic movement from 1940 to 1985. During the early 1960s, the chairperson of almost every major department of Psychiatry was a psychoanalyst. A few analysts did endorse psychotropic drugs, thinking that they could make even very sick patients amenable to psychoanalysis, but they were in the minority.

Some leaders of psychiatry were in sharp disagreement with the emphasis in psychoanalysis upon defective parenting sources and childhood stressors as a cause of psychopathology. During the mid 1950s, Samuel Guze a Psychiatry professor at Washington University in St. Louis insisted that psychiatry must instead emphasize medicine, biology, and science. Some analysts responded to widespread criticism from other psychiatrists like William Menninger, (the psychoanalytic director of The Menninger Clinic in Kansas) by establishing an influential new association called the Group for the Advancement of Psychiatry (GAP). This organization fought valiantly against “mechanistic attitudes” and opposed reliance on shock therapies and frontal lobotomy. The influence of psychoanalysis on understanding mental disorders continued to diminish during the 1970s. The reason for this was not just the opposition of a few psychiatrists like Guze. Harrington speculates that analytic theory and treatments pioneered by Freud lost legitimacy because of lack of empirical data allowing serious research evaluations.

3. De-institutionalization

A parallel factor affecting the treatment of mental illness, extensively documented by Harrington was the massive de-institutionalization of mental patients that occurred in the U.S. between 1955 and 1994. In 1955, the U.S. had 350 state hospitals housing 560,000 patients. In 1995, only 70,000 patients in 258 institutions remained even though the American population size had doubled. Harrington argues that this was a major mistake in terms of both public policy and the treatment of illness, noting that most of this population is now homeless or incarcerated. The success of “the emptying of mental hospitals” is debatable, but left-wing social planners still find it beneficial, arguing that seriously mentally ill patients require contact with communities rather than isolation in “warehouses.” This topic remains controversial, but is frequently resurrected in debates concerning responses by large cities to an increasing homeless population.

Of particular interest for American skeptics is Harrington’s extensive consideration of the psychiatric leaders like Guze and Menninger who challenged mainstream acceptance of the biological paradigm described above. Rarely does she make distinctions between crusaders, doubters, religious enthusiasts, and genuine scientists. Some rudimentary definitions are helpful in evaluation of these influences. Critics tend to assume that a medical theory is acceptable and likely valid, but want to investigate it further. Skeptics start with the null hypothesis: “It is not so. My serious doubt demands proof.” Thomas Szasz is a excellent American leader example to try to categorize fairly. Psychiatric diseases were mere myths, argued this Hungarian-American academic psychiatrist affiliated with State University of New York in his popular book, The Myth of Mental Illness.¹¹ He alleged that mental illness was a false, unproven belief that allowed psychiatrists to remove civil liberties from unconventional victims. Was Szasz a genuine skeptic who opposed making biology the central cause of serious mental illness for rational reasons? Harrington does portray Szasz as more of an ideologue or crusader than either a skeptic or critic. That he became an ally of L. Ron Hubbard’s Scientology is compatible with a quasi-religious belief rather than skeptical inquiry. (The book being reviewed does note that this later affiliation discredits Szasz’s scholarly integrity.)

However, during the past century there have been genuine influential skeptics who urged restraint against inhumane experimental practices. An important early naysayer was Roy Grinker, Sr., Director of Psychiatry at Michael Reese Hospital in Chicago (where I was trained). In 1941 at an AMA conference, this influential leader criticized lobotomy as “extremely dangerous.” As one of the procedure’s originators, Freeman derided Grinker as a naïve psychoanalyst whose views could be readily discounted. While it’s true that Grinker had some analytic training, he was also known to be passionately devoted to hard evidence. He was open-minded enough in 1960 to allow me to implement the final insulin coma procedure for schizophrenia ever performed at Reese. So, Freeman’s criticisms were certainly misguided. And, although Grinker’s objections and those of other doubters of the procedure were disregarded at the time, skeptics ultimately had the last laugh (or final sob) when Freeman’s career ended in 1967. He had lost staff-admitting privileges at Herrick Memorial Hospital in Berkeley following the post-surgery death of a lobotomized patient.

I conclude that despite Harrington’s portrayal of the field of Psychiatry as deeply compromised by errors of the past century, considerable progress has been made. The most damaging and unproven psychiatric interventions are rarely employed today. Viewed in retrospect anti-psychotic drugs were obviously superior to surgical brain procedures. And the pharmaceutical industry maintained only a partial hold over several major proven chemical therapies. For example, evidence for the effectiveness of lithium salts to treat bipolarity remains robust. As Harrington notes its low expense inhibited pharmaceutical companies’ marketing, and positive outcome studies could be trusted. The book gives insufficient credit to lithium’s continuing success in treating bipolar illness, as amply documented by Paul and Schou.¹² Admittedly the discovery of lithium’s effectiveness was unrelated to understanding its brain action, but penicillin and aspirin, staples of infection and pain management had also initially been found effective without comprehension of how they worked.

Perhaps because of the horrors of two World Wars, during the past century the Hippocratic adage primum nil nocere (“First, do no harm”) by today has found renewed widespread acceptance by the psychiatric profession. Adherence to scientific reality and critical objective research certainly has improved. The professional domain of Addiction Medicine by now has developed scientific evidence of brain mechanisms with consequent valuable treatment application. Harrington’s historical analysis is enlightening — and humbling — to those in my Psychiatry profession. But nonetheless the book minimizes the fact that skepticism and scientific rigor did correct many of Psychiatry’s most profound errors of the past 110 years.