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The end of psychiatry?

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Psychiatry has hit a dead-end. The pharmaceutical industry has walked away from the specialty and hasn’t produced a new drug in more than a decade, while psychiatrists can’t agree on the origins and diagnosis of so-called mental health problems such as bipolar disorder and schizophrenia, let alone how to treat them. As a result, the once-discredited electroconvulsive therapy (ECT) is making a comeback and is becoming the go-to therapy for many psychiatrists.

After using brutal therapies such as lobotomy, and ‘chemical cosh’ antipsychotics, tranquilizers and SSRI (selective serotonin reuptake inhibitor) antidepressants, the profession has had to admit it doesn’t have any long-lasting answers to the growing epidemic of mental illness.

Even the cherished belief that mental illness is genetic has been abandoned. Thomas Insel, the outgoing director of the National Institute of Mental Health (NIMH), confessed: “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 $20 billion—I don’t think we moved the needle in reducing suicide, reducing hospitalizations, or improving recovery for the tens of millions of people who have mental illness.”

If the origins of mental illness are vague, so too is the diagnosis. In an equally despairing pronouncement, Robin Murray, former dean of the London Institute of Psychiatry, said: “I expect to see the end of the concept of schizophrenia soon. Already the evidence that it is a discrete entity rather than just the severe end of psychosis has been fatally undermined . . . and the term schizophrenia will be confined to history, like dropsy.” 

In other words, mental disorders all fall somewhere on a common spectrum, with mild anxiety, for instance, being at one end and bipolar at the other.

As Andrew Scull at the University of California at San Diego tersely points out in his new book Desperate Remedies: Psychiatry’s Turbulent Quest to Cure Mental Illness (Belknap Press, 2022): “We can scarcely hope to find the cause of something if that something simply does not exist.”

We’re all crazy now

It’s a complete about-face from the traditional practice of classifying mental disorders into separate and unconnected illnesses, each with its own set of symptoms. It’s an approach that has been enshrined in the DSM (Diagnostic and Statistical Manual of Mental Disorders), the psychiatrist’s reference bible. It first appeared in 1952 with a listing of around 106 discrete mental disorders, and the latest edition—DSM-5, published in 2013—has identified 370.

This sudden explosion of mental disorders has been fueled both by the American insurance industry, which has felt more comfortable paying out on the treatment of definable conditions with an end point, and by the drug industry, which could develop chemical agents to treat a specific problem. A former DSM editor, Robert Spitzer, proclaimed that the industry was “delighted” with the widening expanse of mental health problems.

But this proliferation hasn’t sat well with everyone in the profession. Allen Frances at Duke University School of Medicine said: “DSM-5 will turn temper tantrums into a mental disorder. Normal grief will become Major Depressive Disorder; the everyday forgetting characteristic of old age will now be misdiagnosed, creating a huge false-positive population of people. Many millions of people with normal grief, gluttony, distractibility, worries, reactions to stress, the temper tantrums of childhood, the forgetting of old age and behavioral addictions will soon be mislabeled as psychiatrically sick.”

The mental disorders deemed appropriate for inclusion in the DSM are agreed upon by a panel of editors, many of whom have ties to the drug industry. 

As one former editor told James Davies of Roehampton University, the author of Sedated: How Modern Capitalism Created our Mental Health Crisis (Atlantic Books, 2022): “There was very little systematic research guiding the creation of the DSM, and much of the research that existed was really a hodgepodge—scattered, inconsistent and ambiguous. I think the majority of us recognized that the amount of good, solid science upon which we were making our decisions was pretty modest.”

This uncertainty is borne out in practice. The DSM lists 10 possible symptoms of depression; a patient will need to demonstrate five of them to be diagnosed with the condition, and presumably handed a prescription for an antidepressant—but that means the next patient could display the five other symptoms, and also be diagnosed as depressed.

Drugs? We love ‘em

Not surprisingly, treatments are just as elusive. Scull accepts that some treatments work for some of the people some of the time, but rock-solid evidence that psychiatric drugs produce long-lasting benefits isn’t there. Instead, their widespread use is more a reflection of the cozy relationship that has existed between the drug industry and the leaders of psychiatry and academics. 

The opioid scandal is the latest example of a system without independent checks and balances, and these scandals resonate down the years. GlaxoSmithKline was fined $3 billion in 2012 for criminal fraud over the marketing of its antidepressant Paxil, and just a year later Johnson & Johnson was fined $2.2 billion for concealing the harmful effects of its antipsychotic Risperdal.

Senator Chuck Grassley, chair of the Senate finance committee, started an inquiry into psychiatry’s links to the drug industry in 2007 and discovered that a leading psychiatrist, Joseph Biederman at Harvard and a colleague, had together been paid a total of $4 million to research ‘mental disorders’ such as ADHD by drug companies that were producing drugs to treat the condition.1

Despite these cozy relationships, doctors and psychiatrists still “follow the science” and prescribe a range of drugs to treat mental disorders. The statistics bear out this activity: around 12 percent of adult Americans are taking an antidepressant. But despite their widespread use, the drugs help just 51 percent of patients, a major review of the evidence revealed.2

The true effectiveness could be lower still. Around 94 percent of published studies into antidepressants are positive—the drugs perform better than placebo—but the US drug regulator, the Food and Drug Administration (FDA), puts the total  at just 51 percent of studies, which suggests negative studies never see the light of day.

Despite the ongoing popularity of the drugs, the industry has lost its appetite for treating mental disorders. GlaxoSmithKline has closed its psychiatric laboratories, AstraZeneca has stopped all research on psychopharmacology, and Pfizer has dramatically cut its research budgets.

Perhaps they saw the writing on the wall, Scull surmises, and as the effectiveness of the drugs is slowly exposed, so the drug companies are turning to more lucrative, and less researched, fields. 

Whether drugs are taken or not, the vast majority of cases of depression resolve themselves in time, says Scull. In one study, depressed patients who were given a placebo still reported an 8.3-point improvement in their symptoms, according to a standard measure of depression, while those taking a drug reported scores that were only 1.8 points higher. 

Other studies have demonstrated the effectiveness of an antidepressant over a placebo has narrowed over the years, and today stands at just 3 points. If the unpublished studies were factored in, any difference could disappear, the researchers say.3   

With the drugs at their disposal not working, psychiatrists are turning back to ECT, a discredited technology that was the primary treatment of psychotic patients in the 1940s and ‘50s. Memory loss was common, and some patients in the throes of electroconvulsion broke femurs and even spines. 

Although it appears to be a retrograde step, Scull says that today broken bones almost never happen, and most patients benefit to some extent and aren’t reporting a loss of memory.

But even the keenest advocates of ECT admit that any improvements are short-lived. Around half of patients who are also taking antipsychotics relapse in a year, and the figure shoots up to around 80 percent if the patient doesn’t have further ECT treatments.

Back to the beginning

Modern psychiatry has been practiced for more than a century, and yet it feels as though the profession has gone right back to the start. It can’t find therapies that have long-lasting effects—in recent years, there’s been an 11 percent increase in people committing suicide while receiving psychiatric care—and the profession can’t pinpoint the origins of mental disease. It can’t even agree on whether these supposed diseases even exist at all.

As if to underline the possibility, James Davies believes that the epidemic of mental disorders is the result of social pressures, of people trapped in meaningless work or holding down several jobs just to keep their mountain of debt at bay.

The idea goes right back to the earliest days of psychiatry, when a weakness of mind and an inability to deal with life’s pressures were, along with syphilis, “degeneracy” and inherited characteristics, among the causes of insanity.

The recent lockdowns during the Covid-19 pandemic are expected to create an epidemic of their own—of mental disorders. Scientists are predicting a torrent of new cases, brought on by months of stress, social isolation and living in fear of a deadly virus. 

Sadly, those who will need help and support will find a psychiatric profession at odds with itself, and less confident than at any time in its history to have a meaningful response.





BMJ, 2008; 336: 1327


Curr Psychiatry Rev, 2010; 6(1): 1–10


CNS Neurosci Ther, 2010; 16(4): 217–26

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Article Topics: mental disorder, Psychiatry
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