Does Psychiatry Work?
A Review of 'Desperate Remedies' by Andrew Scull
© photo by Dani Bregman
This book review appears in the November issue of Commentary Magazine. Click here to read it on the Commentary website and to check out some great articles - including one by Barton Swain, The War On Work, which explores some of the same issues around the meaning and purpose of work that I touched on in my July post, Right Work.
When I was a young medical student and it came time to pick a specialty, the landscape was alarmingly broad. At one extreme was psychiatry. The noble goal was to alleviate the deepest and most profound kind of human suffering, but it had the downside of being more talk than action. At the other extreme was surgery, which had plenty of action but not enough talk.
In the end, I split the difference and chose family medicine, a generalist field with plenty of both talk and action. The goal in family medicine is to see the patient and their illness in the full context of their life. And after more than 25 years of practice, I feel entitled to generalize: As good as we are at fixing the body, a lot of what’s broken lies in the mind. In other words, psychiatry matters. And that is why Desperate Remedies, Andrew Scull’s tour-de-force history of psychiatry from the birth of the asylum in the 1830s to today, is an essential book for our times.
Scull, a distinguished historian at the University of California at San Diego who has been studying and writing about mental illness and treatment for more than four decades, begins with the massive institutions of the 19th century that housed thousands, and eventually hundreds of thousands, of American unfortunates with intractable conditions such as tertiary syphilis, dementia, alcoholism, and schizophrenia. Presided over by doctors known as alienists—men who considered themselves experts in mental illness but who were mostly dismissed by the rest of the medical profession—these “living tombs” grew to immense proportions, with budgets that often came to represent the largest item in state ledgers. They ate up as much as a third of a state’s revenue in some cases.
The carcasses of former insane asylums litter the national landscape. For a great example in New York City, visit Randall’s Island, where enormous brick buildings with caged windows loom over the grass and turf playing fields used by the city’s schools and sports leagues. My kids play soccer, so I’m on Randall’s a lot, and for years I’ve wondered about these buildings. Turns out the largest one is the Manhattan Psychiatric Center, formerly known as the New York City Asylum for the Insane. It once housed 4,400 patients and was the largest such institution in the world. It still has about 200 beds. To read Scull’s book and be made aware of the neglect and abuse that occurred behind those walls is hard enough, but the juxtaposition of children playing in their shadow and blithely unaware of their dark history makes it harder still.
And so it is with the rest of Desperate Remedies. Scull describes the past in a way that makes us see the present in a new and jaundiced light. He surveys the celebrated doctors and scientists of the asylum age and describes the procedures they performed on their mentally ill patients. They deliberately infected their charges with malaria or induced meningitis by injecting horse serum directly into the spinal canal. They surgically removed healthy teeth, tonsils, stomachs, spleens, cervixes and colons. They induced life-threatening hypoglycemic coma with insulin overdose. They electrocuted people to cause seizures and lobotomized them with ice picks through the eye socket directly into the brain.
Needless to say, consent was not an issue. The unwilling subjects often represented the most vulnerable persons in society—indigent, black, or female (never mind that they were all, by definition, the mentally ill), who had no one to advocate for them and who were in no position to advocate for themselves.
In the later parts of the book, Scull leaves the 19th century behind to discuss two 20th-century developments that revolutionized psychiatry: psychoanalysis and psychopharmacology, or therapy and drugs. In each case, Scull balances intellectual history with absorbing and entertaining accounts of the politics and personalities behind it. He is at his best in describing the story of Sigmund Freud’s one and only visit to America in 1909, for example, where he was accompanied by his friends and colleagues, Carl Jung and Sandor Ferenczi, and found himself traveling on in the same ship as his main critic, William Stern.
While Freud’s trip set the stage for a level of influence in America that far surpassed anything he ever achieved in Europe—at one point more than 70 percent of American psychiatric patients were receiving some version of Freudian-based psychoanalytic care—it almost didn’t happen. The timing was bad and, more to the point, the $400 honorarium was too low.
Jung urged Freud to reconsider. Think of all those rich American potential patients, he said, some of whom Jung himself had begun treating for astronomical fees. Eventually the stars aligned, the dates were changed, and most important, the honorarium was increased to $750. Freud accepted.
But although Freud may have impressed America, the feeling was not mutual. “America,” he would later remark, “is gigantic—a gigantic mistake.” It was, he informed Arnold Zweig, an “anti-Paradise” populated by “savages” and swindlers, and it ought to be renamed “Dollaria.” So Freud came to America for the money, only to attack it for being all about the money? Sounds like classic projection.
Scull also excels in his account of the highly subjective forces behind ostensibly objective psychiatric science, particularly as it involves the DSM, or Diagnostic and Statistical Manual, which was designed to formalize and systematize the practice of psychiatry. When I was a resident, the fourth edition, or DSM-4, was the bible of psychiatry. A diagnosis did not exist unless it was included in the volume, and a patient could not be given that diagnosis unless their symptoms and presentation satisfied the checklist required to meet it.
Like any rule-based system, the DSM could be gamed. But Scull masterfully shows how it was a game from the start, the product of a bit of science and a lot of politics, personality, and financial interest. With each subsequent edition of the DSM, the number and variety of official psychiatric conditions ballooned to the point where something could be found for practically anyone. This was a boon for the pharmaceutical industry. Meanwhile, the basis for all these new mental illnesses became ever more removed from both common sense and scientific evidence. The DSM revision process has become a disastrous one, full of backbiting, recriminations, and accusation.
Scull caps the book with a devastating critique of contemporary psychiatry, which likes to congratulate itself, as does the rest of medicine, that evidence-based medicine and clinical trials have freed it from the quackery of the past. Now at least we know what works, right? Not so fast. Scull convincingly argues that between industry-sponsored trials, cherry-picking of data, and a publishing bias for positive results, not to mention the usual venal influences of money and corruption, the system has “often produced evidence-biased medicine rather than evidence-based medicine.”
Worse yet, a meticulous review of the evidence, biased as it is in favor of positive results, leads him to two damning conclusions. First, when it comes to devastating psychiatric illnesses such as schizophrenia and bipolar disease, the new drugs are no better than the old. Second, when it comes to more ubiquitous illnesses such as anxiety, depression, eating disorders, post-traumatic stress disorder, and substance abuse, even the best drugs we have are barely better than placebos.
Of course, it’s only fair to ask, could Scull himself be biased? After all, it stands to reason that just as a medical journal prefers a study proving that a drug works to one proving that it doesn’t, an author may prefer to sound alarm bells rather than an all clear.
So allow me to share, from the trenches of clinical medicine, my perspective as a doctor who is not a psychiatrist but for whom, as for all primary-care docs, mental illness is a significant part of what I see daily.
The good news is that the tools we have—therapy and drugs—often help, sometimes a lot. The neutral news is that there’s a big placebo effect. In many cases, the patient would likely have improved anyway. The bad news is that many patients don’t respond, and things are getting worse, especially in the wake of Covid and especially in young people, with not much else to offer.
What keeps me up at night are the parents of troubled, often functionally disabled, sometimes suicidal kids. Many families have nowhere to turn; medications cause intolerable side effects or just don’t work; good psychiatrists who take insurance are impossible to find; residential treatment programs have long waiting lists despite charging a fortune.
So if Scull is overstating his critique, I can’t see it from my perch. The state of mental health care today can best be compared to the mediocre Catskill resort in the old Jewish joke: The food is terrible, and such small portions!
I like to teach medical students that when a disease has lots of treatments, it means that none of them really works. In the case of psychiatry, Scull makes a strong argument that one root cause is the lack of a unifying theory of mental illness.
Over the course of Desperate Remedies, Scull traces two oscillating schools of thought that parallel the old nature vs. nurture debate. Is mental illness due to chemistry or culture? Is the culprit neurological or psychological? Biology or society?
It’s a dichotomy that originated centuries ago. Today we have mostly called a truce and agree that when it comes to mental illness, both nature and nurture play a role. But a truce is not a peace. The conventional treatment of therapy and drugs suggests that we remain stuck in the mold, covering our bases while missing something fundamental.
In fin-de-siècle Vienna, while the 38-year-old Freud was developing his theory of the unconscious, the 15-year-old Einstein was sitting in his room in Munich conducting thought experiments. The story goes that young Einstein posed himself a question: If I were traveling on a beam of light, what would I see? It was a question that unlocked the door to 20th-century physics. When it comes to mental illness, Scull’s extraordinary book leaves me with the unsettling thought that not only do we lack good answers, but we are still waiting for an Einstein to ask the right questions.
The question, “Does psychiatry work?” is like the question, “Does medicine work?” The answer is rather Talmudic: it depends. It depends on the problem (or “diagnosis”), on various external circumstances, on the patient and on the doctor. And it depends on how you define success. Unfortunately, while Desperate Remedies is an entertaining compendium of scandals and scoundrels in the history of psychiatry, it is too burdened with authorial outrage to offer a serious discussion of historical efforts to help people with what we now call psychiatric disorders.
Andrew Scull, whose professional career has apparently been devoted to summarizing various atrocities among practitioners of mental healing over the centuries, has not set himself a difficult task. Physical interventions to cure or reverse mental or spiritual maladies over the ages have been numerous and brutal enough to attract the Madame Tussaud's clientele in droves. Of course surgery without anesthesia or antisepsis, copious blood-letting, and ingestion of various noxious and/or disgusting substances characterized management of all kinds of ills of the flesh.
The nineteenth century saw significant progress in many areas of medicine, as a corollary to the general advances in science and technology that accelerated during that period. Scull's view, however, is that “alienists” and their ilk either took no notice of this or perverted it into justification for more barbarity. Philippe Pinel's reforms, celebrated in the classic mural of him removing the chains of the inmates of the Salpetriere, and his efforts to introduce a system of humane asylums where the severely disturbed could be protected and, hopefully, cured do not fit Desperate Remedies consistently outraged tone and are omitted, in favor of a pointlessly condescending discussion of the futility of phrenology, and later, of recording behavioral symptoms in “obsessive detail.” This is the viewpoint of the non-scientist who disdains the work of all of the people – most actual investigators -- who pursue plausible lines of inquiry that turn out not to be useful.
In Scull's highly personalized telling, psychiatry's leading lights (as he sees them) are invariably arrogant, personally obnoxious, sadistic or at least hypocritical, venal liars. He can quote from their writings to prove it. Money, power and glory are the only motivators. Kraepelin and Freud and Big Pharma may all disagree and offer different approaches, but they are all cut from the same cloth which has nothing to do with helping people.
As for the present and future, analytic therapy is finished, drugs are being sold relentlessly, there is lots of well-funded research (though Scull, interestingly, fails to mention neural networks), but there is little cause for hope.
What is this all about? Are things really as bad as that?
We can quite reliably treat severe depressions—what used to be called endogenous or psychotic depressions—often without hospitalization. using various antidepressant medication or even ECT (which as currently practiced is not brutal if perhaps unesthetic) and supportive psychotherapy.
Many of the ills that used to be called neurotic (anxiety, phobias, less severe depressions) often respond to psychotherapy, although this is the area where medication use and overuse is an issue.
We can rapidly abort most acute psychotic episodes with medication and supportive care without resort to hospitalization (if people have an accepting living situation). About a third of these often young patients recover fully within six months, and about half of the rest can be well stabilized and lead essentially normal lives. There remains an unfortunate group who are chronically severely incapacitated, though we do have the knowledge and skills to make them quite comfortable. While Scull dismisses the early asylum managers as “innkeepers”--betraying his ignorance of the challenges of managing any residential program, even an inn—some of the physician leaders of these institutions have made heroic and successful efforts to improve the lives of very impaired patients who cannot be cured. Unfortunately, except for the very wealthy, the resources for this effort, never generous, have been severely curtailed for political reasons. Scull says the psychiatric profession has accepted the dumping of state hospital patients without protest because they are not financially rewarding, ignoring even prominent doctors like John Talbott who have tried eloquently to raise the issue.
So it's obvious that the author of Desperate Remedies is driven by more than academic interest as a historian. Taking a leaf from his book, one might suspect simply that he believes a popular expose will sell better than a scholarly review, and he simply wants the money. But that may be doing him an injustice. I could not help noting that he drops his usual sardonic tone and become frankly enraged describing Bruno Bettleheim (whom he neglects to note was actually not a psychiatrist but a psychologist) as a “charlatan” who abused his patients. The context is his discussion of psychoanalytic speculation about the role of parents in development of schizophrenic or autistic children. Bettleheim was a leader in this school of thought. And Desperate Remedies is dedicated to Andrew Scull's late son. I apologize for thinking like an “analytically oriented” psychiatrist, but it does not seem unduly far-fetched to speculate that Scull may have strong personal reasons for disparaging psychiatry and psychiatrists.
Great review. Thanks.