Progress and Change in Psychiatry Coming Too Slowly

The book Desperate Remedies: Psychiatry’s Turbulent Quest to Cure Mental Illness by Andrew Scull, Ph.D., is being published this month. The book, based on a carefully researched history of psychiatry, provides a critical assessment of the psychiatric enterprise. In the rush to find cures for psychiatric illnesses, Scull believes that there has been a disappointing lack of focus on patients. Rather, the profession has been gnawed away from within by various self-interested factions and subjected to multipronged attacks from without.

It is important to remember psychiatry’s beginnings. Even in 1886, Pliny Earle, M.D. (a superintendent of several asylums and a founder of APA and the AMA), lamented that “in the present state of our knowledge, no classification of insanity can be erected on a pathological basis, for the simple reason that, with but slight exceptions, the pathology of the disease is unknown. …” Furthermore, he noted that there was an overwhelming reliance on reporting of symptoms (Pliny Earle Papers, 1886, box 1, folder 3, American Antiquarian Society, Worcester, Mass.).

Nearly a century and a half later, nothing, it seems, has substantially changed. The connection between the general lack of progress in psychiatry may reflect that previous research may not have included “all of us.”

Steven Hyman, M.D., a former director of the National Institute of Mental Health who did much to support shifting psychiatric research to focus on biology, neuroscience, and genetics, had by 2007 concluded that “it is probably premature to bring neurobiology into the formal classification of mental disorders” (Nature Reviews Neuroscience, September 2007).

The Beth Israel Deaconess Medical Center Grand Rounds recently presented highlights from the 2021 American College of Neuropsychopharmacology meeting. Although many advances have been made in understanding complicated plastic brain functions, almost none were clinically applicable, and when they were, the therapeutic mechanism was poorly understood. The summary of the conference was a validation of Scull’s treatise and Earle’s lamentation that nothing has significantly changed; however, it was noted that the quest of big pharma over the last several decades to develop drugs and thereby earn huge profits is gradually being replaced by new, radiologically based interventions into the brain. As a result, prior optimism over the prospect of highly specific drug-based cures is changing to pessimism over the current state of affairs using nonspecific pharmacologic “blunt instruments” and a return to physical treatment instruments.

Few patients and their families escape the ravaging effects of mental illness; however, nobody escapes its social burdens. Just as Black patients were once segregated in separate wards or in entirely separate institutions, marginalization, discrimination, and exclusion persist in psychiatry to this day. The form is different, but the premise is the same. Racism, sexism, and other forms of discrimination continue to impact individuals in all sectors of society, including the economy, housing, education, and the criminal justice system. And with respect to physical and mental health, the cumulative disadvantages of poverty and prejudice are vividly demonstrated by high rates of maternal mortality and lower life expectancy. Unsurprisingly, during the COVID-19 pandemic, racial and ethnic communities had less access to medical and mental health care than Whites. The lack of correcting the effect of bias on contemporary research on racial disparities in psychiatric treatment is dismaying. Even organized psychiatry did not come forth with an apology for its support of structural racism until January 2021. We are now working on righting our wrongs by taking systematic steps to eliminate racism within our organization.

If research in genetics, neuroscience, and microbiomics do not show signs of producing practical advances for all of humanity, supporting programs may tire of funding such endeavors.

A renewed focus on the prevention of traumatic life experiences such as living in poverty and witnessing violence would provide a welcome shift in the psychiatric paradigm. Rather than exclusively seeking more biological cures for downstream psychiatric illness that are socially driven, patients and the public may benefit from less prescribing and more listening to the desperate voices that can be heard if one pays attention.

Incidentally, this is my last column as your president, and you will be in good hands under the leadership of incoming President Rebecca Brendel, M.D., J.D. While my term may be ending, I will never stop fighting to ensure that all patients—regardless of background and ability to pay—have access to high-quality care and are treated with the dignity and respect they deserve. It is incumbent on all psychiatrists to do the same. ■

“Can Neuroscience Be Integrated Into the DSM-V?”