Perspectives
Book
Biological psychiatry’s decline and fall
As the 20th century drew to a close,
there was an air of optimism among
psychiatrists. Long gone were the
days when mental disorder and
distress were attributed to childhood
trauma or “refrigerator mothers” to be
treated—if the patient could afford it—
by psychoanalysis. Rather, they were
manifestations of a biological disease,
a malfunctioning of brain processes,
either genetically or developmentally
Mind Fixers: Psychiatry’s caused. The psychiatrists’ bible was
Troubled Search for the Biology the monumental US Diagnostic and
of Mental Illness
Statistical Manual of Mental Disorders
Anne Harrington
W W Norton, 2019 (DSM) or WHO’s equivalent, the Inter­
pp 384, US$ 27·95 national Classification of Diseases. The
ISBN 9780393071221
DSM, by then in its fourth edition,
provided a checklist against which
psychiatrists could tick off patients’
symptoms and assign them to one of
a multitude of diagnostic categories
and hence appropriate therapy. Hand
in glove with the DSM, the burgeoning
psychopharmaceutical industry offered
a range of drugs, prescribed in their
hundreds of million across high-
income countries. It seemed that even
the most intractable conditions like
schizophrenia would yield their genetic
and biochemical secrets and thereby
offer targets for drug intervention.
Fast forward two decades, and, as
historian Anne Harrington affirms,
“it has become increasingly clear to
the general public that it [biological
psychiatry] overreached, overpromised,
overdiagnosed, overmedicated and
compromised its principles”. Having
announced her conclusion so bluntly
in the opening pages of Mind Fixers:
Psychiatry’s Troubled Search for the
Biology of Mental Illness, she then takes
the reader on a brisk journey through
the history of western attempts to
understand, classify, and treat the
shape-changing forms that mental
disorder and distress have taken.
Although Mind Fixers is primarily a
history of US psychiatry, it initially looks
at theories and therapies from Europe.
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Harrington’s account begins in the
19th century with Munich psychiatrist
Emil Kraepelin’s classification of mental
disorders, including two broad types,
“manic depression” and “dementia
praecox”, and his search for a biological
base for these diagnoses. By the
early 20th century, both Kraepelinian
classification and Freudian psycho­
analysis—in a sense both its successor
and rival—had crossed the Atlantic.
“...as historian Anne Harrington
affirms, ‘it has become
increasingly clear to the general
public that it {biological
psychiatry} overreached,
overpromised, overdiagnosed,
overmedicated and
compromised its principles.’”
Harrington’s emphasis is on
psychiatry’s biological claims—by
which she largely means neurological;
genetics, which has so permeated
psychiatric history, only gets a fairly
brief look in, largely in the context of
1930s eugenics.
The emphasis on biology was integral
to American psychiatry’s long and still
contested struggle to establish itself as
a branch of scientific medicine, with its
target organ, “the mind”, regarded as
no different in kind than the kidneys
or the heart. By the 1990s, and despite
vigorous attempts at pushback both
from patients and rebel voices within
the profession, biological psychiatry’s
colonisation of increasing numbers of
human discontents seemed secure. This
is the story that occupies the first part
of Mind Fixers.
As Harrington tells it, the early
attempts to biologise mental disor­
ders sought explanation in faulty
neuroanatomy, brain abnormalities
that could be detected post mortem.
Undeterred by the failure to find such
faults, and to the lasting detriment
of their willing or unwilling subjects,
by the 1920s some psychiatrists
were opting for “heroic” empirical
treatments, ranging from insulin coma
therapy and electroconvulsive the­
rapy to lobotomy. Other psychiatrists
temporarily abandoned such assaults
on the brain in favour of Freudian
and post-Freudian analysis, which
achieved what Harrington calls a
“fragile triumph”. However, neither
approach, whether in Europe or the
USA, was well equipped to understand
or treat the throngs of soldiers invalided
out of the trenches, suffering from
what became known as shell shock.
Two related events sparked the
resurgence of biological psychiatry
during the 1950s: the identification
of the first of the many chemical
neurotransmitters that carry signals
from neuron to neuron across
the synapses; and the accidental
discovery of the calming effects of
chlorpromazine (originally developed
for treating post-surgical shock) on
distressed patients. At this point in
her account, Harrington switches from
what she calls “doctors’ stories” to
the “disease stories” of schizophrenia,
depression, and bipolar disorder. Over
the next decades, as more and more
neurotransmitters were identified,
confidence grew that the cause(s) of
these mental disorders lay in faulty
chemistry. Indeed, I recall how during
my PhD at London’s then Institute of
Psychiatry, half the biochemistry lab
was devoted to the hunt for abnormal
metabolites in “schizophrenic blood”
and “schizophrenic urine”. I was told
that one such substance, hailed with
enthusiasm, was later found to be a
product of the excessive amount of
tea drunk by the patients. Each newly
identified transmitter in turn became
the molecule of the moment, from
glutamate and GABA to serotonin.
When the single molecule story proved
insufficient, attention turned to the
possible interactions of several. At a

meeting for patients and carers in the
1970s, I shared a panel with a euphoric
neuropharmacologist who proclaimed
our task was to elucidate the pathway
by which “a disordered molecule leads
to a diseased mind”.
These were also the decades of
deinstitutionalisation—the emptying
out of the psychiatric hospitals in favour
of “care in the community”, often
hailed as an indication of the success of
the psychopharmaceutical revolution.
But this is a misleading correlation;
psychiatry was under attack from a new
generation of radicals and the hospitals
had been emptying across Europe
irrespective of the arrival of the drugs.
Because of her US focus, Harrington’s
account of the kickback against the
medicalisation of madness slightly
overlooks this international dimen­
sion. She discusses David Rosenhan’s
inspired experiment of sending
“pseudopatients” claiming to hear
voices into hospitals in California—
once inside, the volunteers behaved
“normally”, only for their behaviours
to be dismissed as symptoms of
their disorder—and Thomas Szasz’s
critique of psychiatry as social control.
From the UK, R D Laing’s Philadelphia
Association with its enthusiasm
for lysergic acid diethylamide (LSD)
and antipsychiatric argument that
psychiatric patients were responding
sanely to insane situations gets a look-
in, but Michel Foucault’s influential
perspective of patients as an oppressed
group warrants barely a paragraph and
Franco Basaglia’s 1978 Law 180 that
directed the closure of Italy’s psychiatric
hospitals gets no mention. But as we
have become all too aware in austerity
Britain, care in the community in the
absence of adequate state provision
can throw the responsibility of caring
for people with mental illness back
onto the family, especially women.
Meanwhile, drugs or no drugs,
hospitalised or (inadequately) cared
for in the community, the numbers
of those diagnosed with a mental
disorder continued to increase. As
Harrington describes, the list of
www.thelancet.com Vol 394 August 24, 2019 629
specific conditions listed in the DSM
grew longer with each edition. By
the millennium, she highlights how
children as young as 4 years were
being diagnosed with conditions
ranging from autism to attention
deficit hyperactivity disorder, and
WHO had declared depression to be a
global concern. Despite the high global
burden of mental disorders, the latest
generations of pharmaceuticals, such as
the antidepressant selective serotonin-
reuptake inhibitors— including Eli Lilly’s
fluoxetine formulation Prozac which
was supposed to make a person “better
than well”, as Peter Kramer wrote in
his book Listening to Prozac—were
proving no better than antidepres­
sants developed back in the 1970s
and 1980s. And with patents running
out of time, there was nothing new on
the pharmaceutical horizon.
Many years in the making, DSM-
5 appeared in 2013, to a chorus of
criticism; Harrington summarises this
crisply (Gary Greenberg’s 2013 Book
of Woe gives a painful blow-by-blow
account). Harrington suggests that
the proliferating symptom categories
ceased to carry conviction; in the USA,
the leadership of the US National
Institutes of Health pivoted away from
the DSM approach—“100% reliability
0% validity”, as Harrington writes—
stating they would only fund projects
with clearly defined biological
hypotheses. The big players in the
pharmaceutical industry folded their
tents and withdrew from the field,
turning to more tractable targets,
notably cancer. For some mental health
Perspectives
problems, psychological therapies, such
as cognitive behaviour therapy (CBT),
are becoming more popular, sometimes
in combination with pharmaco­therapy;
as Harrington points out, even as far
back as the 1970s, trials had shown
that CBT outperformed imipramine as
a treatment for depression.
Together with this rich history
of mainly American psychiatry,
Harrington is prepared to step out
of her role as historian and look to a
possible future for psychiatry, opening
up debate about these issues. She
offers a three-fold prescription. First,
stop medicalising so much of life;
recognise that the range of so-called
normal human thought, emotion,
and behaviour is much wider than the
tight normative limits set by current
diagnoses. Second, reject reductionist
thinking and engage a broader range
of professionals including social
scientists in the research and treatment
of mental illness. Third, establish a
patient-oriented research ethic. She’s
right, of course. But there’s also a wider
sociopolitical context of poverty and
exclusion in the midst of wealth in what
to many of us feels to be an increasingly
precarious social and natural world.
And in too many countries, the crisis in
the provision of mental health services
is acute—a failure of society, not the
psychiatric profession alone. The extent
to which inequality breeds ill-health—
including mental health—warrants
wider discussion.
Steven Rose
steven.rose@open.ac.uk
Turtle Rock Scientific/Science Source/Science Photo Library