Psychiatrists Do Not Know What They Are Treating

The mysteries of the mind are harder to unravel than psychiatrists pretend.

Schizophrenia: An Unfinished History, by Orna Ophir, Polity Books, 224 pages, $35

Desperate Remedies: Psychiatry's Turbulent Quest to Cure Mental Illness, by Andrew Scull, Belknap Press, 512 pages, $35

The Mind and the Moon: My Brother's Story, the Science of Our Brains, and the Search for Our Psyches, by Daniel Bergner, Ecco/HarperCollins, 320 pages, $28.99

As a boy, especially while lying in bed or suffering a fever, I was periodically troubled by harshly critical voices that vaguely charged me with misconduct and failures of character. As I grew up, the murmuring Greek chorus was replaced by a single voice, which by then I recognized as my own.

If those seemingly external voices had persisted into adolescence and adulthood, I might have qualified for a diagnosis of schizophrenia. Instead, I became a garden-variety neurotic, assailed by self-recriminations that undermined my confidence and interfered with my happiness.

Are these two states of mind categorically distinct, or do they occupy different spots on a continuum of mental health? Is one properly classified as a brain disease requiring biomedical treatment while the other is a psychological condition amenable to talk therapy? Or are we talking about a difference in degree rather than kind?

The renegade psychiatrist Thomas Szasz, a longtime Reason contributing editor, argued that "mental illness" was a metaphor that should not be taken literally. In his view, the patterns of speech and behavior that are seen as symptoms of schizophrenia, like less severe and more common disturbances of thought and emotion, could be traced to "problems in living" rather than an identifiable neurological lesion or biochemical defect.

Less radical critics of psychiatry's scientific pretensions tend to dismiss Szasz's take as implausible, clinically naive, and cruelly indifferent to the suffering of people diagnosed with schizophrenia. At the same time, they emphasize that psychiatry has never managed a satisfactory account of what schizophrenia is, let alone what causes it or why the treatments du jour can be expected to work. That ongoing failure with regard to schizophrenia, which Szasz called "the sacred symbol of psychiatry," epitomizes the field's broader crisis of credibility, which extends to the medicalization of nearly every human folly and foible.

In Schizophrenia: An Unfinished History, psychoanalyst Orna Ophir traces the concept's evolution since the 19th century, culminating in contemporary debates about its validity and usefulness. Swiss psychiatrist Paul Eugen Bleuler, who introduced the term schizophrenia, perceived a group of diseases characterized by "the four As": autism, ambivalence, and abnormal affect and associations. DSM-5, the latest version of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, defines schizophrenia based on a list of symptoms: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, and "negative symptoms" such as flat affect. A diagnosis requires just two of those symptoms, including at least one of the first three, persisting for a month or longer, plus impairment of a major life function and one or more signs lasting for at least six months.

Prior to the 2013 publication of DSM-5, Ophir notes, members of what was then known as the International Society for the Psychological Treatments of the Schizophrenias and Other Psychoses argued that schizophrenia was "an idea whose very essence is equivocal," a "category without natural boundaries, a barren hypothesis." They "condemned it [as] 'yesterday's diagnosis,' 'a construct with little reliability or predictive validity,' precisely because the symptoms used to diagnose it can be understood as extreme versions of normal human experience." Even critics who saw value in Bleuler's original concept agreed that the existing diagnostic criteria were "arbitrary and pseudoscientific."

As sociologist Andrew Scull notes in Desperate Remedies, that dissent came from a faction of mental health specialists who had dominated organized psychiatry for decades before losing control to academics and clinicians with a biomedical orientation. But if objections from once-regnant psychoanalysts don't give you pause, the blunt observations of Thomas R. Insel, a neuroscientist and psychiatrist who directed the National Institute of Mental Health (NIMH) from 2002 to 2015, really should.

In 2013, Insel dismissed the DSM's symptom-based framework as "equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever." Although most psychiatrists "actually believe" that the disorders they diagnose "are real," he said, "there's no reality. These are just constructs. There is no reality to schizophrenia or depression."

Despite that assessment, Insel hoped research would illuminate the biological sources of the mental problems clumsily cataloged by the DSM. But by the time he retired from the NIMH, he confessed that, despite spending some $20 billion on such studies, "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." In his 2022 memoir, he reiterated that "advances in neuroscience have yet to benefit patients," as The New York Times put it.

Scull, who suggests that schizophrenia is "a label that lumps together a variety of heterogeneous phenomena," notes that "the clinical utility" of brain research based on functional magnetic resonance imaging "has been essentially nonexistent." And while twin studies suggest that schizophrenia is at least partly heritable, extensive research has failed to identify genetic markers that play more than a minimal role in the odds of receiving such a diagnosis.

Historically, Scull reminds us, the noble-sounding goal of "benefit[ing] patients" has resulted in supposedly enlightened and humane interventions that horrify us today. In the name of helping people with mental illness, psychiatrists used insulin and other drugs to induce comas, infected people with malaria parasites in the hope that the resulting fevers would prove therapeutic, extracted teeth and excised internal organs that were thought to harbor mind-altering microorganisms, blindly slashed frontal lobes with ice picks hammered through eye sockets, and used electricity to trigger bone-fracturing, discombobulating, and memory- erasing seizures.

Physicians won Nobel Prizes for that sort of thing. The treatments were effective in the sense that they often made psychiatric patients less disruptive and more manageable. Whether such indiscriminate assaults on brain function left those patients better off is a different question.

The drugs that supplanted such crude and brutal methods posed a similar conundrum. Scull notes that Thorazine, which psychiatrists viewed as a godsend, also improved symptoms, but at the cost of debilitating side effects such as tardive dyskinesia, a potentially permanent condition that "involves facial tics, grimacing, grunting, protrusion of the tongue, smacking of the lips, rapid jerking and spasmodic movements, or sometimes slow writhing of the limbs, torso, and fingers." Scull cites research indicating that the next generation of antipsychotic drugs, although supposedly safer and more effective, were not, on balance, much of an improvement.

The cost-benefit ratio for more commonly prescribed psychiatric drugs is likewise open to question. The studies that won approval for selective serotonin reuptake inhibitors (SSRIs) like Prozac, Scull notes, showed modest effects on depression that were statistically significant but may not have been clinically meaningful.

In fact, as journalist Daniel Bergner explains in The Mind and the Moon, those studies suggested that SSRIs may be only slightly more effective than placebos, if that. Lithium, which Scull describes as a frequently useful treatment for what is now known as bipolar disorder, has side effects that many patients find intolerable, a point that Bergner illustrates with the story of his brother's resistance to treatment.

Even when drugs seem to work, psychiatrists cannot explain why. As Scull and Bergner both emphasize, the "chemical imbalance" story that was used to sell SSRIs was no more than a convenient fairy tale, unmoored from scientific evidence. And while lithium has been used to treat mental illness since the 1940s, its mechanism of action remains unclear.

Such uncertainty is inevitable given the tentative, empirically impoverished nature of psychiatric taxonomy, which no less an authority than Allen Frances, who oversaw the team that produced the fourth edition of the DSM, has described as "bullshit." When psychiatrists diagnose in the dark, it is no surprise that they prescribe in the dark too.

The title of Bergner's book alludes to President John F. Kennedy's dual goals of reaching the moon and using "scientific achievement" to make "the remote reaches of the mind accessible." Bergner notes that Kennedy—who "was haunted by the story of his intellectually disabled, lobotomized sister, long confined, concealed, and unvisited in a midwestern institution"—was especially excited about new antipsychotic medications that he thought would enable "the mentally ill to be successfully and quickly treated in their own communities and returned to a useful place in society."

That did not happen. While Scull pins the failure of deinstitutionalization on neglect by tightfisted politicians, pervasive and persistent ignorance about the problems that sent people to sprawling state mental hospitals surely bears some of the blame. As ambitious mental health specialists ranging from 19th century alienists to Insel have discovered, the mysteries of the mind are harder to unravel than psychiatrists pretend.