Desperate Remedies

1. Psychiatry's Turbulent Past: A Legacy of Desperate Remedies.

Periodically, as we shall see, enthusiasts have proclaimed that decisive breakthroughs are at hand or that miraculous cures have been discovered. To date, these supposed revolutions have proved evanescent and are often the harbinger of distinctly damaging interventions.

A history of harm. For centuries, psychiatry's quest to cure mental illness has often inflicted more suffering than it alleviated. Driven by desperation and a lack of understanding, practitioners embraced radical and often brutal interventions, frequently without scientific basis or patient consent. This pattern of "desperate remedies" repeatedly led to damaging outcomes.

Dubious interventions. The early 20th century saw a surge in physical treatments, many originating in Europe, that were enthusiastically adopted in the U.S. These included:

• Fever therapies: Deliberately infecting patients with malaria or inducing high fevers with horse serum or diathermy machines.
• Surgical removals: Excising teeth, tonsils, stomachs, spleens, and colons based on the "focal sepsis" theory.
• Shock therapies: Inducing comas with insulin or epileptic seizures with drugs (metrazol) and electricity (ECT).
• Brain surgery: Lobotomies, including the infamous "ice pick" method, to sever frontal lobe connections.

Patient vulnerability. The mentally ill were uniquely susceptible to these experiments. Deemed incapable of informed consent and often confined in isolated institutions, they became subjects for interventions that were often painful, mutilating, and sometimes fatal. The pressure on psychiatrists to "do something" for conditions they poorly understood, coupled with a lack of oversight, fueled this era of reckless therapeutic zeal.

2. The Asylum Era: From Utopian Hope to Custodial Despair.

Psychiatry emerged in the nineteenth century as a specialized branch of medicine claiming expertise in the management and cure of what was then called insanity or lunacy.

Utopian beginnings. American psychiatry was born from the asylum movement of the 19th century, fueled by an optimistic belief in "moral treatment" and high cure rates for insanity. Prominent figures like Samuel Woodward and Dorothea Dix championed the construction of a vast network of state asylums, promising to restore the mad to sanity.

Descent into custody. This early optimism quickly faded as asylums became overcrowded "mausoleums of the mad." By the late 19th century, they housed hundreds of thousands of chronic patients, many elderly, demented, or suffering from tertiary syphilis. The initial promises of cure proved "wildly off the mark," leading to widespread pessimism and a diminished reputation for the psychiatric profession.

Stigma and marginalization. Asylum doctors, increasingly isolated from mainstream medicine, faced scorn from neurologists who dismissed them as "boardinghouse keepers." The theory of "degeneration" gained traction, portraying mental illness as a sign of biological inferiority and justifying lifelong confinement rather than cure. This era also saw the entrenchment of racial segregation and discrimination within mental institutions, with Black patients receiving grossly inferior care.

3. The Rise and Fall of Psychoanalysis: A Fragile Hegemony.

Freud may have loathed America, but it was here that his ideas and approach enjoyed their greatest success.

Early influence. Despite Freud's personal disdain for America, his ideas gained significant traction among intellectuals and urban elites in the interwar years. Popularized versions of psychoanalysis, often stripped of their darker, pessimistic elements, promised liberation from neuroses and became staples in literature, theater, and eventually Hollywood. This cultural penetration, however, did not immediately translate into widespread acceptance within mainstream psychiatry.

Post-war dominance. World War II proved a turning point. The sheer scale of "war neuroses" among soldiers challenged the biological determinism of pre-war psychiatry, suggesting environmental and psychological factors played a crucial role. Military psychiatrists, many trained in simplified psychoanalytic techniques, returned from the war convinced of psychotherapy's power. This new generation, led by figures like William Menninger, rapidly ascended to leadership positions, transforming American psychiatry into a psychodynamically oriented profession.

A fragile reign. Psychoanalytic hegemony, though powerful in academia and private practice, was ultimately fragile. Its focus on lengthy, expensive "talk therapy" for neuroses had little relevance for the hundreds of thousands of severely psychotic patients in state hospitals. Furthermore, its resistance to empirical validation and its internal schisms left it vulnerable. The emergence of new biological treatments and the rise of clinical psychology as a competitor offering more standardized, quantifiable therapies would eventually lead to its dramatic decline by the 1980s.

4. The Accidental Revolution of Psychopharmacology.

No one planned the psychopharmacological revolution, and no one understood, in its early years, just how dramatic and far-reaching the effects of the new drug treatments would be.

Serendipitous discoveries. The mid-20th century witnessed an unplanned revolution in psychiatry: the advent of psychotropic drugs. Chlorpromazine (Thorazine), initially explored for other medical uses, was serendipitously found to calm agitated psychiatric patients in France and Canada. Similarly, lithium's mood-stabilizing effects were discovered by chance in Australia. These discoveries, along with early antidepressants, marked a radical shift from previous somatic treatments.

Marketing-driven expansion. Pharmaceutical companies, particularly Smith, Kline & French (SK&F), aggressively marketed these new drugs. Recognizing the vast potential market in mental hospitals, they launched sophisticated campaigns to "educate" hospital administrators and state legislators about the drugs' ability to calm patients and reduce costs. This aggressive promotion, often bypassing rigorous scientific validation, rapidly integrated psychopharmacology into psychiatric practice.

Mixed legacy. While these drugs offered symptomatic relief—calming agitation, reducing hallucinations and delusions—they were far from "magic bullets." Many patients experienced severe side effects, including movement disorders like tardive dyskinesia, and the drugs often failed to address "negative" symptoms like apathy or social withdrawal. Despite these limitations, and often based on flawed research, the promise of a "chemical cure" profoundly reshaped public perception and professional practice, paving the way for a biologically focused psychiatry.

5. Deinstitutionalization: A Grand Reform Masking Neglect.

"Community care," it transpired, was a shell game with no peas. In place of forcible confinement in publicly run asylums, the chronically mentally ill were abandoned to their fate.

The emptying of asylums. Beginning in the mid-1950s, and accelerating dramatically in the 1960s and 70s, state mental hospital populations plummeted. This "deinstitutionalization" was widely hailed as a humane reform, promising a shift from isolated institutions to community-based care, supposedly enabled by the new psychotropic drugs.

Fiscal, not therapeutic, drivers. In reality, the primary impetus for deinstitutionalization was fiscal. Changes in federal welfare policies, particularly Medicare and Medicaid, allowed states to transfer the financial burden of mental patients from state budgets to the federal government, provided patients were discharged from state hospitals. This led to a mass exodus of elderly and younger patients into private nursing homes and other unregulated facilities.

A new nightmare. The promised "community care" largely failed to materialize. Patients were often discharged with little planning or support, leading to widespread homelessness, incarceration, and neglect. The "sidewalk psychotic" became a familiar urban sight, cycling between streets, shelters, and jails. This policy, supported by a curious alliance of anti-institutional leftists and fiscally conservative libertarians, effectively replaced public asylum neglect with privatized, often brutal, abandonment.

6. Psychiatric Diagnosis: A Shifting, Politicized Construct.

"On Being Sane in Insane Places" purported to report the results of an experiment involving eight subjects, one of whom was Rosenhan himself.

Crisis of reliability. By the 1960s, internal studies revealed a troubling lack of reliability in psychiatric diagnoses. Psychiatrists often disagreed on patient labels, and their theoretical orientations (e.g., psychoanalytic vs. biological) influenced their diagnoses more than patient symptoms. This undermined psychiatry's scientific credibility and its claims to expertise.

The Rosenhan bombshell. David Rosenhan's 1973 Science paper, "On Being Sane in Insane Places," exposed this diagnostic unreliability to a wide public. His study, which involved "pseudo-patients" feigning auditory hallucinations to gain admission to mental hospitals, claimed that psychiatrists could not distinguish the sane from the insane. Though later revealed to be largely fraudulent, the study caused a sensation and forced the profession to confront its diagnostic crisis.

The DSM revolution. In response, the American Psychiatric Association (APA) embarked on a radical revision of its Diagnostic and Statistical Manual (DSM). The DSM-III (1980), led by Robert Spitzer, aimed to create a "theory-neutral", symptom-based checklist approach to diagnosis, prioritizing reliability over validity. This move, while ostensibly scientific, was deeply political:

• It purged psychoanalytic language.
• It expanded diagnostic categories, often driven by clinical and commercial pressures.
• It facilitated the pharmaceutical industry's ability to market drugs for specific "diseases."

7. The Elusive Promise of Biological Psychiatry.

In the vast majority of cases, what materialized was a muddle. Crunching the data has shown that hundreds of genetic variants may (or may not) contribute to the diagnosis of a particular case.

The genetic quest. Following the decline of psychoanalysis, psychiatry firmly re-embraced biological reductionism, pouring vast resources into genetic and neuroscientific research. Early twin and family studies suggested a hereditary component to mental illness, leading to hopes that specific genes for schizophrenia or depression would soon be identified, akin to Huntington's chorea.

Disappointing returns. Despite decades of intensive research and billions of dollars invested, the "Holy Grail" of specific genetic markers for major mental illnesses remains elusive. Genome-wide association studies (GWAS) have identified hundreds of genetic variants associated with disorders like schizophrenia, but each has a tiny effect, and collectively they account for only a small fraction of the risk.

• For schizophrenia, 270 genetic loci account for only ~7.7% of variance.
• For major depressive disorder, robust and replicable findings are largely absent.

Neuroscience's limitations. Similarly, advances in neuroscience, particularly brain imaging (fMRI), have provided insights into brain activity but have yielded little clinical utility for diagnosis or treatment. Observed brain "abnormalities" in psychiatric patients have often been found to be artifacts of long-term drug treatment, rather than underlying causes of the illness. The promise of a "biological psychiatry" has largely remained a promissory note.

8. The Perilous Alliance: Psychiatry and Big Pharma.

The deeper scandal of psychiatry’s incestuous relationship with the pharmaceutical industry lies elsewhere, however. We live in an era that purports to be governed by something called evidence-based medicine.

Commercial imperative. The rise of psychopharmacology forged an increasingly close and financially lucrative alliance between psychiatry and the pharmaceutical industry. Drug companies heavily influenced research agendas, marketing strategies, and even diagnostic categories, often prioritizing profit over patient well-being. This relationship has led to widespread ethical concerns and legal battles.

Evidence-biased medicine. While "evidence-based medicine" became the mantra, industry-sponsored trials often produced "evidence-biased medicine."

• Suppression of negative data: Unfavorable trial results and serious side effects were routinely suppressed or downplayed.
• Ghostwriting: Academic papers touting drug benefits were often ghostwritten by industry, with prominent academics lending their names for legitimacy.
• Marketing over science: Drugs were promoted for "off-label" uses (not FDA-approved) through "thought leaders" and direct-to-consumer advertising, often based on flimsy or fabricated science (e.g., the "chemical imbalance" theory of depression).

Consequences of corruption. This pervasive influence led to:

• Over-prescription: Antipsychotics and antidepressants became blockbuster drugs, often prescribed for mild conditions or to vulnerable populations (children, elderly) with little evidence of benefit and significant risk of harm.
• Serious side effects: The long-term consequences of these powerful drugs, such as tardive dyskinesia and metabolic disorders, were often minimized or ignored until public outcry forced acknowledgment.
• Erosion of trust: Scandals involving concealed financial ties and research misconduct by leading academic psychiatrists further damaged the profession's credibility.

9. The Enduring Crisis: A Call for Honesty and Integrated Care.

Madness remains, as it has for millennia, a mystery that stubbornly refuses to bend itself to the rule of reason.

A profession in crisis. Contemporary psychiatry faces an existential crisis. Its diagnostic system (DSM) is increasingly seen as an artificial construct, lacking biological validity and prone to over-pathologizing normal human experience. The promised breakthroughs from genetics and neuroscience have not materialized into effective treatments, and the pharmaceutical industry is now retreating from psychiatric drug development.

Limitations of current remedies. While psychopharmacology offers symptomatic relief for some, it is far from a panacea. Many patients do not respond to drugs, or experience intolerable side effects. Psychological therapies like CBT offer some help for milder conditions but are largely ineffective for severe mental illness. The "progress" achieved is limited, and often comes at a high cost to patients.

Towards a holistic future. The current "bio-bio-bio" model of mental illness is deeply misguided. Mental disorders are complex phenomena, shaped by an intricate interplay of biological, psychological, and social factors. A truly effective psychiatry must:

• Embrace humility: Acknowledge the limits of current knowledge and treatments.
• Integrate approaches: Move beyond monistic views (mind-only or brain-only) to a comprehensive bio-psycho-social understanding.
• Prioritize patient well-being: Focus on functional outcomes and quality of life, not just symptom reduction.
• Demand societal responsibility: Recognize that addressing serious mental illness requires major public investment in housing, support services, and a compassionate social safety net, rather than abandoning the afflicted to the streets and jails.

Last updated: August 15, 2025