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Psychiatry on the Couch

Arthur Kleinman

The Unbalanced Mind. Julian Leff. viii + 168 pp. Columbia University Press, 2001. $23.95.

Creating Mental Illness. Allan V. Horwitz. xii + 289 pp. University of Chicago Press, 2002. $32.50.

Mad in America: Bad Science, Bad Medicine, and the Enduring Mistreatment of the Mentally Ill. Robert Whitaker. xviii + 334 pp. Perseus Publishing, 2002. $27.

Out of Its Mind: Psychiatry in Crisis. A Call for Reform. J. Allan Hobson and Jonathan A. Leonard. xii + 292 pp. Perseus Publishing, 2001. Paper, $17.

Mental health is an increasingly significant issue worldwide. Globally, 5 of the 10 leading causes of disability in people 15 to 44 years of age are psychiatric disorders. Depression is among the five most costly diseases in the world, in terms of morbidity. In the United States, suicides outnumber homicides by about three to two. Substance abuse and violence-related trauma are cynosures of our era. And psychopharmacologic agents are enormously popular. One could argue from all this that psychiatry is more relevant today than ever. Yet there is a widespread sense both within and without the profession that all is not well.

The fundamental problem is that although we know a lot about the biomedical etiology of neurological disorders, we still fathom embarrassingly little about the biology of the major mental illnesses. And even the burgeoning understanding of genetic and metabolic risk factors has not translated into clinically useful tests or cures. Modern technology has not produced a single blood test or brain scan that can be routinely used to diagnose depression, bipolar disease, schizophrenia or other common mental illnesses. Admittedly, biomedical science has made real progress on Alzheimer's disease—a disorder often used to make the case that mental illness has a biological basis—but this affliction is, after all, a neurological disease rather than a psychiatric one. So the recent advances provide no justification for hyping the relevance of such biological findings to the key questions in mental health, a practice that only provokes popular skepticism and professional cynicism.

At the same time, psychoanalysts who once asserted that they understood the psychology of mental disorders have had their claims so thoroughly debunked that the members of the general public, and even well-educated people, now have the incorrect impression that psychiatrists know nothing at all about the psychology of mental illness. And indeed, the profession of psychiatry has largely turned its back on empirical psychology, as if data on emotions and cognition could have little serious effect on the practice of psychiatry.

So the discipline is in modest disarray. But the mentally ill are in an even worse state. Mental illness is still a serious source of negative stereotyping and discrimination even in the United States and Europe; in China, India and Africa, the stigma is so severe that patients are feared, rejected and routinely mistreated. In the poorest countries, to enter an ordinary mental hospital is to visit a hell where patients are chained, beaten, starved and kept for years, even when they are symptom-free. In the non-Western world, most mentally ill patients never receive an accurate diagnosis, appropriate treatment or high-quality professional care.

In America, arguably the most important development in the mental health field has been the organization of the mentally ill, their families and supporters into an effective political force. They have fought stigma with improved knowledge and awareness, and have successfully lobbied for more research funding, better health insurance coverage and more effective treatment and rehabilitation programs.

Julian Leff, a leading British psychiatric researcher, argues in The Unbalanced Mind that what is known about social and interpersonal factors in mental illnesses has greater applicability in patient care than do basic biological research findings. Only psychopharmacology, in his view, should be given the same level of clinical importance. Yet knowledge about such factors as stressful life events, negative emotions, cultural differences and racism is simply not translated into therapies, programs and policies to near the extent that drug-treatment findings are. The imbalance must be corrected, Leff avers, if progress is to occur. Research on "relationships between people" in different social contexts can make the biggest difference in improving prevention and care.

And yet Allan V. Horwitz, an authority on the sociology of mental illness, cautions in Creating Mental Illness that psychiatry has been medicalizing social problems to such an extent that most of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, 4th edition, is filled with social behaviors—for example, so-called "personality disorders," school problems and criminal behaviors. For these, the disease concept does not seem applicable and treatment of the individual is not especially helpful. Patients and families may nonetheless seek out medical diagnoses to legitimize experiences that might otherwise taint their reputations and threaten their social status.

In Mad in America, science writer Robert Whitaker carefully charts the disappointing history of the treatment of the most seriously mentally ill in America. Writing about "medical failure," he actually accuses the psychiatric profession—and particularly, organized health services, abetted by society as a whole—of being "toxic" to the clinically mentally ill. Whitaker does not employ the exaggerated prose of the antipsychiatry movement, which has ignorantly and indiscriminately bashed psychiatry for several decades. Serious and well documented, his account is characterized by a sense of sadness about the truly appalling experiences of the mentally ill and the lost opportunity for humane practice, rather than by heated rhetoric about professional abuse. He does paint a picture of bad values, bad treatment and bad policies—as well as bad science. His account is too simplistic to do justice to the multiplicity of professional orientations and programs, and he is perhaps overly romantic about the World Health Organization's findings of better outcomes for schizophrenia in less developed societies. But his work has the healthy overall effect of underlining the importance of honesty and humility about the real limits of knowledge and practices.

Whitaker cites troubling instances of psychiatric data being distorted for commercial ends. For example, the pharmaceutical industry markets selective serotonin reuptake inhibitors (such as Prozac) as magic bullets, despite data showing that only about 65 percent of patients with major depressive disorder who are given the drugs experience any significant benefit (compared with 40 to 45 percent of those given a placebo). Atypical antipsychotic agents for chronic mental disorders are being hyped in the media, and psychiatric diagnoses are being applied to every problematic human experience from bereavement to conflicted relationships.

Whitaker overdoes his critique by failing to acknowledge the important gains for patients and families from drugs that reduce the pain and disability of depression, prevent suicide and offer at least partial control of greatly disabling psychotic symptoms. Nonetheless, his emphasis on the limitations of science, psychiatry and public policies, and on the persistence of inhumane care, challenges the accounts of unflagging progress found in conventional publications. In the story of mental illness, human tragedy is still as strong a theme as professional achievement.

A more exaggerated language of crisis and reform is employed by Allan Hobson—a distinguished Harvard psychiatrist and influential sleep researcher—and medical writer Jonathan Leonard in Out of Its Mind. They describe psychiatry in the United States as having a "split personality" caused by the decline of psychoanalysis and the fact that psychiatrists have been turned into drug pushers by health maintenance organizations and insurance companies uninterested in the human suffering of their patients. In the final part of their book, following useful sections on the neuroscience of sleep and dreams and the neurobiology of mental illness, they immodestly propose a new neurodynamic psychology that unites brain science with the "good" aspects of Freudian psychology. Little substantive evidence is provided for what such a "new" psychology would look like, and what is said about the neuroscience underpinning psychology is either trivial or so remote from real clinical practice that it seems gratuitous.

In fact, as T. M. Luhrmann shows in her ethnographic study of American psychiatric training and practice, Of Two Minds (Knopf, 2000), most psychiatrists seem in practice to be able to bridge psychopharmacological and psychotherapeutic approaches. There is a real crisis in the financing and delivery of mental health care, but it's an exaggeration to claim that a crisis in psychiatry's intellectual content is fracturing the field. The important issue for psychiatry today is the need to come to terms with its limits rather than continuing to expand utopian visions about the help it can offer.—Arthur Kleinman, Social Medicine, Harvard Medical School

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