A study that describes the progress of psychiatry and examines the choices before practitioners today has invited some opinionated reviews. Anne Harrington, the Franklin L Ford Professor of the History of Science at Harvard University, the author of Mind Fixers Psychiatrys Troubled Search for the Biology of Mental Illness, in a letter to the journal, Nature, responds to one of them.
The progress of medical science traces a path from early ideas of “humours” or the “disposition” of the organs, as if they were sentient objects, to understanding the structure of the body in physical terms, by observation and dissection. This was first undertaken by Galen in the 2nd century AD, and continued energetically in the second millennium. What followed was the discovery of the circulation of the blood, vaccines, chemistry, pharmacology, microbiology and genetics, and we are now able to effectively deal with a great many physical ailments of the human body.
The same, however, cannot be said about diseases of the mind. While the role of the counsellor, or the confessor, was there to manage levels of anxiety, overt imbalance was labelled “insanity” and considered to be possession by spirits. Affected persons were usually excluded from society and confined to asylums, if not subjected to torture and methods of exorcism. As there had been similar beliefs about the reasons for physical disease, until they were replaced by the study of anatomy and scientific medicine, efforts were made to find physical reasons for mental disease as well. Those attempts, however, during the 19th century, were largely the dissection of the brains of deranged persons, after they died, to see if there were gross changes in brain tissue, which could be related to the mental condition
The attempts, naturally, did not lead anywhere and a reaction was the rise of Sigmund Freud, who sought the reasons for neurosis, obsessions, and even hysteria in childhood experiences or memories, formed before the child had learnt to articulate or which the grown person did not recollect. Freud considered the early stages of life — the oral, where a child’s need is mainly food; the anal, when she becomes aware of excretion, with the reactions of parental figures to oral or anal needs, and finally the sexual, all of which influence future relationships.
Freudian and other theories gave rise to psychoanalysis, where a trained practitioner probes into a patient’s recollection of past events, the influence of associates, the images or voices in the patient’s mind, and dreams, to unravel the causes of the patient’s current maladjustment. Psychoanalysis grew in popularity and did report many successes and Freud-based analysis is the basis of most behavioural therapy or analysis. The methods, however, are either ineffective or impractical in cases of schizophrenia, bipolar disorder or where the patient is incapable of communication.
There was also evidence of biological reasons for mental illness. The first instances were the association of insanity with syphilis, that schizophrenia could keep away epilepsy, and the use of electroconvulsive therapy (shock treatment) for severe depression. Although the psychoanalytic approach dominated in the middle years of the 20th century, Harrington writes that this practice, and stateaided psychiatric hospitals, ran into disrepute. Drugs were also discovered that could control schizophrenia or manic-depression, and severe behavioural problems in children, and the need for hospitals where patients had to be admitted was questioned.
Drugs, however, were the answer for only some of the diseases and even then, they often needed to be stopped because of side effects. Without the support of institutions, patients were abandoned and many ended up in prison. Harrington notes that the places with the most mental health patients in the US are jails.
The definitions of mental health and illness also began to be questioned. Mental illness, it was suggested, was a sign of mental health, it was the social environment that was diseased! Apart from even the cures being questionable, the very diagnoses by the professionals were found to be, in many cases, contradictory.
For all this, the discovery of a number of preparations that alleviate conditions of schizophrenia or depression, and the science of drugs that affect specific portions, or even specific classes of nerve endings of the brain, to relieve symptoms, have put biological psychiatry in a promising light in recent times. “The brain is also an organ”, is a slogan that psychiatrists of this conviction use and drugs form an important part of most hospital-based mental health programmes.
Harrington, however, points out the great complexity of how the brain functions, and that the mechanism of the action of most drugs is still not known. In a number of cases, pharmaceutical companies that market new drugs make claims that are not realised, or only with unacceptable side effects. Overall, Harrington says that psychiatry is in a state of crisis and leading practitioners need to take stock, to make the best of the directions — some drug based, others interventional, like electroconvulsive therapy, and then the psychoanalytical — for the alleviation of suffering.
Alison Abbot, science writer and Nature’s senior correspondent at Munich, in her review of Mind Fixers, starts by citing an article in the journal, Science, where the writer describes an experiment that shows many hospitals to be “unable to distinguish the sane from the insane.” This, Abbot says, exemplifies the burden of the book, but adds that Ms Harrington has reached a pessimistic conclusion, because she believes “psychiatrists should devote themselves…serious psychoses, and leave mental suffering that is not a true illness to therapists and social workers.”
This, in fact, is scarcely the position that Harrington has taken. What we need, she says in her letter to Nature, in response to the review, is “to know how to engage constructively with the distrust, and how to balance the relationship between immediate patient needs and long-term scientific insights.”
Abbot also says Harrington “fails to acknowledge promising approaches in biological psychiatry, particularly very new insights about brain circuitry as a potential target for treatment.”
On one hand, Harrington’s book is not a survey of current research. On the other, our knowledge of how the brain works is quite rudimentary. The best, so far, is that we can use a light signal to reset a neuron in a mouse brain to reverse a “fear” memory. Not really “new insight” to give us confidence while dealing, in the near future, with the psychological turmoil the world will be going through.