We have learned a lot and know very little

From The sorrows of psychiatry by Alison Abbott, a book review of Mind Fixers: Psychiatry’s Troubled Search for the Biology of Mental Illness by Anne Harrington.

The reviewer is somewhat critical of Harrington's work but it sounds like a pretty clear and comprehensive review of the history of a well intended but as yet still immature field. We still do a terrible job of defining mental illness, diagnosing mental illness and treating mental illness.

In January 1973, Science published an article called ‘On being sane in insane places’. The author, psychologist David Rosenhan, described how he and seven other healthy people had reported themselves to a dozen psychiatric hospitals, claiming to hear voices uttering odd words such as ‘thud’ or ‘hollow’ — a symptom never reported in the clinical literature. Each person was diagnosed with either schizophrenia or manic-depressive psychosis, and admitted; once inside, they stopped the performance. They were released after an average of 19 days with diagnoses of ‘schizophrenia in remission’ (D. L. Rosenhan Science 179, 250–258; 1973).

One research and teaching hospital, hearing about the study, declared that its own staff could never be so deceived. It challenged Rosenhan to send it pseudopatients. He agreed, but never did. Nonetheless, the hospital claimed to have identified 41 of them.

Psychiatric hospitals, it seemed, could recognize neither healthy people nor those with mental illnesses. Rosenhan’s study exemplifies much of what went wrong in twentieth-century psychiatry, as biologists, psychoanalysts and sociologists struggled for supremacy. Science historian Anne Harrington takes us through the painful history of that struggle in the enthralling Mind Fixers, which focuses particularly on the United States.

[snip]

By the 1990s, it was clear that major advances had stalled, and that psychiatrists’ diagnostic criteria (for example in the US Diagnostic and Statistical Manual of Mental Disorders, introduced in 1952 and now in its fifth edition) were less than helpful (see D. Dobbs Nature 497, 36–37; 2013). The pharmaceutical industry, after a series of stymied attempts to squeeze more profit from their ageing arsenals, pulled out of psychiatry.

This is where Harrington stops. She argues, unconvincingly, that the burden of mental disorders should be divided up: psychiatrists should devote themselves to solving the problem of serious psychoses, and should concede responsibility for what she describes as mental suffering that is not a true illness to therapists and social workers.

I disagree. This is the time for all parties to join forces. What the research of the past decades has shown us most convincingly is that biology and environment work powerfully together on the brain and the mind — and that psychiatry has hit its roadblock because we know too little about how the brain functions. Professionals need to advance with respect for both the limits of our understanding and the modest knowledge we have gained in the twenty-first century. The road to better therapies might be rocky, but in my view there is little reason for pessimism.

Harrington's review of the history is depressing. At every stage, for the better part of a century and a half, we have had faddish treatments which are implemented at great cost and with great certainty only to come to wreck on the rocks of reality. When failure is too blatant to ignore, the door is opened to a new fad. The next to fail.

It is no vice to fail while venturing into unknown terrain. It is galling to claim the mantle of power and expertise and coercion while failing.

We know dramatically more than we did a century and a half ago and yet we know very little that is useful when considering just how many of our modern plagues (substance abuse, suicide, extreme violence, unhealthy and self-destructive behaviors, etc.) are rooted in some form of mental illness. The compelling goal to find a way to address mental illness remains far outside our grasp.