Influenced like many of my generation by the writings of Laing, Szasz, Illich, Jung and Freud, I studied medicine to do psychiatry. At the time research was becoming mandatory for anyone hoping to engage with the field. I chose to work on the serotonin system. But this was working on the mind as much as the brain; this was the serotonin system brought into view by LSD rather than the one that Prozac would later usher in. This was biology as a source of variation and individuality rather than standardization. This background made me acutely aware of emerging biobabble, biomythologies, and the rhetoric in claims made by what later came to be called biological psychiatry.
I was newly perched at a laboratory bench in 1980, when the controversy blew up about whether schizophrenia increased in frequency in the nineteenth century. Faced with a clear increase in hospitalizations for insanity, Fuller Torrey in 1980 and Edward Hare in 1983 argued that an infectious or other trigger must have been at work. I instinctively took the opposite side – schizophrenia didn’t suddenly appear in the nineteenth century; surely we have always had it. German Berrios’ cautionary note about the changing meaning of mania rang true and I’ve spent a great deal of my career since dealing with the shifting meanings of terms like neurosis, psychosis, depression and mania (See Mania).
I have spent even more time supporting an argument put forward by Andrew Scull in 1984 in response to Torrey and Hare to account for the increase in hospitalizations, namely that health systems attend to our ailments to secure their own health.
But even the biological psychiatrists who displaced social psychiatry in the 1980s were inclined to see schizophrenia as emblematic of the human condition rather than a disease that might rise and fall. Tim Crowe argued the genes responsible for language gave rise to schizophrenia. Geneticists and neuroscientists have not been inclined to think schizophrenia could have recently appeared and might as soon disappear.
But for doctors and historians the rise and fall of diseases is almost central to the definition of a disease – or should be. When it comes to mental illnesses the rules seem to change.
In the 1980s, prior to working on the history of psychopharmacology, I looked at annual reports from the superintendents of Irish asylums who, facing a tide of insanity that rose higher in Ireland than anywhere else in the world, for the most part dismissed claims that there was a real increase in insanity. Asylums were an experiment invented by the English. They thought it a prudent idea to try it out on the Irish first, and built the first asylums in Ireland and more there than anywhere else. Never a people to miss a chance, the Irish at least in part took to wintering in facilities put in place by the British. This all made sense to me. There had to be a mundane explanation like this to account for the fact that in the face of the highest rates of incarceration ever recorded, mental illness was never featured in Irish literature, one of the richest in the world. Against this background it was clear there was no true increase in insanity or no way to tell if there was a true increase or not.
The Madness of North Wales
In 1996 in North Wales we began working on a project that has turned all my ideas upside down. This research led to a series of articles demonstrating a disappearance of classic postpartum psychosis, showing that severe social dislocation can trigger schizophrenia like psychoses that in general have a very good outcome, that hospitalizations for severe mood disorders (melancholia) are declining in frequency and then the findings for schizophrenia. We hope to feature the research on a forthcoming website – The Madness of North Wales – along with hundreds of records, music, literature, art and other material aimed at making North Wales live and allowing us to outline a series of dramatic and universal accounts of madness in all its varieties through some intensely dramatic personal and local stories. (See The North Wales Mental Health Research Project).
All was going well with our research and publications, until we attempted to publish papers on schizophrenia. Over the same two decades I have published articles on the hazards of psychotropics drugs, with journals scared to publish for legal reasons, and companies possibly finding other ways to sabotage publication, but I have never had reviews as vituperative as some of the reviews for these schizophrenia articles.
The first of two papers offer the best figures yet on the issue of whether schizophrenia did in fact rise in frequency during the nineteenth century or not. The message in the paper is very much a good news message – as I will lay out in the next post – but one of the reviewers, a medical historian, was adamant that nothing we could do would permit him to recommend publication. The paper would have been rejected had the editor not suggested disregarding this review – something that no editor had ever done for an article of mine before.
We sent a second paper to another of medicine’s most prestigious journals which usually has an open review system but in this case the reviewers chose to remain anonymous. One of the reviewers argued that because some black males were incarcerated in US hospitals in the 1960s, we could never be sure any historical diagnoses from case records were correct. This might sound reasonable but was in fact lunatic in that we were not relying on the diagnoses in the records to make our diagnoses as the paper made clear. But the editor sided with the reviewers.
The question is whether the reviewers and editor were exceedingly twitched because of the paper’s findings which make it clear that compared to any other medical disease, uniquely patients with schizophrenia in many ways fare far worse now than a century ago. Faced with an absence of suicide in schizophrenia a century ago, an absence we can be very confident about, one reviewer suggested that this could have only come about because patients were permanently strait-jacketed and secluded. This self-evidently was not the case – the patients demonstrably spent 99% of their time on hospital farms or in sewing rooms or kitchens. But this cut no ice with editors or reviewers.
Such has been the resistance to the findings that like them or not, it would seem that the responses to the findings must be telling us something important. There is resistance to any undermining of the idea of progress. There is a fundamental disagreement about the nature of disease and in particular mental disease. When many hear the message that schizophrenia is rapidly declining in frequency it seems they in fact hear that insanity is vanishing. It is as though the message that tuberculosis is declining in frequency were heard as respiratory disorders are vanishing, when the only way respiratory disorders will ever vanish is if we no longer have respiratory systems. Even though schizophrenia may have risen and might now be falling, as long as we have brains we are almost certain to create new and perhaps equally as bad mental diseases in the future.
The rise and fall of schizophrenia that will be outlined in the next post may give some clues as to how we produce insanities – and some of the steps we can take to prevent them. As long as we refuse to concede a disorder like this might rise and fall in frequency, we are never going to look for the things we could change that might make a difference. This is why the issue counts.