What if Mental Illness Isn't All In Your Head?

Mind Fixers: Psychiatry’s Troubled Search for the Biology of Mental Illness
Anne Harrington
W. W. Norton, $17.95 (paper)

Desperate Remedies: Psychiatry’s Turbulent Quest to Cure Mental Illness
Andrew Scull
University of Chicago Press, $35 (cloth)

In 1990 President George Bush announced that “a new era of discovery” was “dawning in brain research.” Over the next several decades the U.S. government poured billions of dollars into science that promised to revolutionize our understanding of psychiatric disorders, from depression and bipolar disorder to schizophrenia. Scientists imagined that mental illnesses in the future might be diagnosed with genetic tests, a simple blood draw, or perhaps a scan of your brain. New pharmaceuticals would target specific neurochemical imbalances, resulting in more effective treatments. The 1990s, Bush declared, would be remembered as “The Decade of the Brain.”

This brave new world of brain research also promised to free us of the stigma and discrimination attached to mental illness and addiction for centuries. Localizing psychiatric disorders in the brain would make them chronic medical diseases—like diabetes and high cholesterol—instead of individual moral failings or deficiencies in character. While it was impossible to predict exactly what the future would bring, there was an overwhelming sense that psychiatric science was going to crack the “mystery” and “wonder” of this “incredible organ,” as Bush called it.

Looking back as a psychiatrist and historian today, I find that these hopes feel quaint. They remind me of other misplaced visions of technological futures from the twentieth century: flying cars, pills for a whole day’s nutrition. The reality of psychiatric practice is far less glamorous than the visions of its future that I grew up with. Thirty years later we still have no biological tests for psychiatric disorders, and none is in the pipeline. Instead our diagnoses are based on criteria in a book, the Diagnostic and Statistical Manual of Mental Disorders (often called, derisively, the “bible” of American psychiatry). It has gone through five editions in the last 70 years, and while the latest edition is almost 100 pages longer than the last, there is no evidence that it is any better than the version it replaced. None of the diagnoses is defined in terms of the brain.

We also have not had any significant breakthroughs in treatment. For decades the pharmaceutical industry has churned out dozens of antidepressants and antipsychotics, but there is no evidence that they are more effective than the drugs that emerged between 1950 and 1990. People with serious mental illness today are more likely to be homeless or die prematurely than at any point in the last 150 years, with lifespans that are 10 to 20 years less than the general population. Biological research has also failed to reveal why psychiatric drugs help some patients but not others. When a patient asks me how an antidepressant works, I have to shrug my shoulders. “We just don’t know, but we do have evidence that there’s about a thirty percent chance that it will help your mood.” Perplexed, one patient responded, “Doesn’t it have to do with neurotransmitters or something?” I sighed, “Yes, that was the theory for a while, but it didn’t pan out.”

And how about stigma? As anthropologist Helena Hansen has argued, the neuroscience of addiction has often reinforced stigma by reducing substance use to an individual problem, instead of the result of structural factors rooted in longer histories of racial violence. American psychiatrists also diagnose Black and Brown patients with disproportionate rates of schizophrenia compared to white patients—a disparity that psychiatrist-sociologist Jonathan Metzl traces to psychiatrists in the 1970s who pathologized Black activism as “psychosis.” Finally, Black patients experiencing mental health crises, including children, are more likely to experience the violence of being physically restrained, tied to their beds in ways that resemble the experiences of asylum patients over a century ago.

In 2015 the former director of the National Institute of Mental Health (NIMH), Thomas Insel, crystallized this disillusionment:

I spent 13 years at [NIMH] pushing on the neuroscience and genetics of mental disorders, and when I look back . . . I realize that while . . . I succeeded at getting lots of really cool papers published by cool scientists at fairly large costs—I think $20 billion—I don’t think we moved the needle in reducing suicide, reducing hospitalizations, improving recovery for the tens of millions of people who have mental illness.

It does not help that academic psychiatry today feels out of touch. Many people have underscored the profound importance of mental health amid the social isolation of the pandemic, racial violence in our society, and the increasingly hyper-competitive culture of schools, sports, and the market. But academic psychiatry’s almost singular focus on brain-based research has meant that the profession has been largely absent from these conversations. And for what? All the “cool papers” on neurobiology have won academic grants and helped professors get promoted, but they have not meaningfully impacted the diagnosis and care of the millions of people suffering psychic distress.

How did we end up here? If we have failed to understand psychiatric disorders biologically, what happens when we examine them historically? Two recent books by historians explore the crisis in biological psychiatry, tracing the political, economic, social, and professional factors that led psychiatrists to attempt to pin the reality of mental illness—and the legitimacy of the profession—on the brain. Written by leading historians in the field, these are big books, in heft and scope, that cover two hundred years of the profession’s failures. They reveal that U.S. psychiatry, across its history, has been dangerously susceptible to hype and “cool,” ranging from enthusiasm for brain dissection in the 1890s to the fanfare surrounding neurotransmitters and genetics a century later.

Understanding the undulating history of psychiatric hype and crisis is crucial today as the profession builds toward its next trend: psychedelics, already heralded as a “renaissance” and psychiatry’s “next frontier.” These two histories demonstrate that the academic and corporate pursuit of such hype has neglected the perspectives of communities most affected by psychiatric research and care, resulting in significant psychological and bodily harm. The strengths and limitations of these important books push academic psychiatrists to reexamine our priorities. They challenge us to envision a future world where the billions of dollars invested in biological research are instead redistributed to the communities who need it most—in order to provide the resources necessary for radically reimagined forms of care that center whole humans instead of just brains.