Medical Sociologist Details the Failures of American Psychiatry

A new article in Psychological Medicine argues that American psychiatry has ultimately failed those it is meant to serve.

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In a new article in Psychological Medicine, the medical sociologist Andrew Scull offers a critical look at the development of American psychiatry over the past 3 decades. He critiques American psychiatry’s reliance on biological understandings of mental illness, exploring how the Diagnostic and Statistical Manual of Mental Disorders (DSM), referred to as the “bible” of psychiatry, has yet to capture the phenomenon of ‘mental illness adequately.’ Scull also identifies concerns about future mental health research and psychiatry’s failure to address the high mortality rates of persons labeled as ‘mentally ill.’

Scull, a distinguished professor of sociology and science studies at the University of California, San Diego, writes:

“. . . the shortcomings of contemporary psychiatry undeniably must also shoulder a good deal of the blame for a situation where the life expectancy of someone with psychosis is decades shorter than that of the rest of us, and where that abbreviated life too often consists of an alternation between the jail, the flophouse, and the gutter − with all-too-brief psychiatric interventions largely confined to the prescription of antipsychotic medications.”

The DSM-5, published in 2013, is the latest edition of the American Psychiatric Association’s diagnostic manual. The contributors to the DSM-5 initially had hoped to radically change the approach to diagnosing mental illness, citing the failure of current research on mental illness to clearly identify the causal factors that contribute to distinct mental health disorders. Their hopes were based upon the belief that neuroscience and genetics research was close to identifying the biological causes of mental health disorders, beliefs which they used to justify moving towards a diagnostic system that did not rely solely on symptoms, as previous predecessors to the DSM-5 had.

The development of the DSM-5 was surrounded by controversy and widely critiqued. Some critics argued that the new DSM, like those before it, would continue to expand diagnostic categories and, as a result, pathologize normality. Other critics expressed concerns about eliminating the diagnosis for ‘Asperger’s syndrome’ and the Task Force’s plan to narrow the criteria for autism. Ultimately, the Task Force created the category ‘autism spectrum disorder,’ and what was previously conceptualized as Asperger’s syndrome fell underneath this umbrella.

In addition to criticism from both sides of the spectrum, the DSM-5 was heavily criticized by Robert Spitzer and Allen Frances, who were the primary developers of three previous editions of the DSM. Spencer was critical of the closed-door policy that the DSM-5 Task Force took to develop the new edition. However, the two taskforces he had facilitated were also held in secrecy. Frances, like other critics, voiced concerns about the expansion of the definitions of mental illness.

The controversy that accompanied the development of the newest edition of the DSM ultimately led to personal attacks and infighting in the psychiatric community. Although critiques by individuals like Spencer and Frances did not prevent the DSM-5 from being published, they did contribute to delaying publication and undermining its legitimacy.

The lack of leadership within the DSM-5 Task Force also led to differences in opinion among task force members themselves – with some promoting the loosening of criteria, like in removal of the bereavement exclusion in the diagnosis of major depressive disorders. In contrast, others argued for a tightening of criteria. As a result of the disorganization of the Task Force, an oversight committee was developed by the Board of Trustees of the APA, which was then followed up by a ‘Scientific Review Committee’ which reviewed all proposed changes and made suggestions to the APA President and Board of Trustees.

While the DSM-5 Task Force had hoped to move from symptom-based diagnoses to diagnoses grounded in biological understanding, they ultimately failed in their attempt:

“The ambitious plan to shift from a ‘tick the boxes’ approach to diagnosis to a system rooted in a biological understanding of mental illness quickly foundered because the necessary etiological understanding of the various forms of serious mental disorder simply did not exist.”

Further, the attempt to move from a symptoms-based to a more dimensional approach, which understands mental illness as ranging along a spectrum, was shut down by clinicians who were fearful that clients with mild forms of mental health issues would not be able to receive insurance reimbursement for their treatment.

Scull highlights how the move from a social focus in psychiatry to biological understandings can be traced back to the Reagan era, where societal factors like poverty, inequality, and migration were ignored in the service of a politically favorable biological approach to mental illness. The biological approach was also influenced by the pharmaceutical industry’s financial contributions, which led to a move away from psychoanalysis and a move toward psychopharmacology.

Interest in the genetics behind mental illness faltered following World War II due to its associations with the Nazi regimes’ murders of those determined to be ‘mentally ill.’ Still, a resurgence in interest occurred in the 1970s and 1980s with new technologies in the study of genetics and DNA. Although the profession believed that these technologies would lead to discovering the genes behind mental health disorders, such discoveries never occurred.

While there have been claims that the genetic basis of schizophrenia has been discovered, these claims have time and time again failed to be replicated, which is crucial in proving the validity of the research.  Scull writes:

“Genes, it seems, are not fate, and the thousands of alleles that contribute a small additional risk of illness do not operate ‘in a simple deterministic manner.’ Developmental and environmental factors must play a crucial role in whether the ‘nudge’ of these alleles manifests itself in mental disorder, which suggests that the over-emphasis on the biology of mental disorder has been a strategic mistake.”

Additionally, while there have been major advances in neuroscience, they have not contributed to any further understanding of mental illness. Yet, this has not stopped recent National Institute of Mental Health (NIMH) directors from pouring funds into biological research.

One former director, Thomas Insel, spoke of his regret:

“I spent 13 years at NIMH really pushing on the neuroscience and genetics of mental disorders, and when I look back on that, I realize that while I think I succeeded in getting lots of really cool papers published by cool scientists at fairly large cost − I think $20 billion − I don’t think we moved the needle in reducing suicide, reducing hospitalizations, improving recovery for the tens of millions of people who have mental illness.”

Presently, the major causes of mental illness are unknown, although it is increasingly understood that it is the result of a complex combination of both social and biological factors. Moreover, doubt has been cast on whether certain groups of diagnoses, such as schizophrenia and major depressive disorders, should actually be bound together, calling the current diagnostic system into further question.

Moreover, despite its push to move away from a symptom-based understanding of mental illness, the DSM-5 ultimately resigned itself to a symptom-based approach due to lack of biological evidence and major support for the symptom-based approach by the insurance and pharmaceutical industries. This support was furthered by the NIMH and FDA, which in turn backed clinicians into a corner – to get paid, they had to support and use the DSM, despite its major flaws.

The DSM-5 has been critiqued for lacking validity, with critics arguing against a symptom-based approach and pointing to a lack of consistency, as the categories are symptom-based and dependent on the subjectivity of the clinician to determine.

Examining how psychiatry has fared in relation to identifying successful treatments, Scull accuses the profession of falling short in its reliance on antidepressants, tranquilizers, and antipsychotics as ‘cures.’ He points to inconsistencies in symptom-relief, the ineffectiveness of these drugs, and highlights damaging and dangerous long-term side effects such as weight gain, risk of diabetes and heart disease, and movement disorders like tardive dyskinesia. Research elsewhere has found that those who are able to slowly stop using antipsychotic drugs may be more likely to recover.

The data on clinical trials of antipsychotics is largely held by drug companies, who selectively determine what findings to release and suppress. Pharmaceutical companies also use academic researchers to support their “research” by lending their names to ghost-written papers that are, in actuality, written by individuals employed by the drug companies. Drug company misconduct is well-known, as seen in the various lawsuits and the resulting fines imposed upon them.

In addition, the deinstitutionalization movement has affected the current mistreatment of those deemed ‘mentally ill.’ Although psychiatric hospitals were supposed to be replaced with community care, such care is sorely lacking, which in turn has contributed to the imprisonment and homelessness of those struggling with mental health issues.

Along with deinstitutionalization, psychiatrists’ move away from institutional practice to the more profitable private practice has resulted in a profession that lacks interest in the care of those who are impoverished or labeled as “difficult” clients. This, coupled with a political focus on ‘welfare reform,’ has resulted in a lack of adequate resources available to treat those in need.

Scull powerfully concludes his critique of the development of American psychiatry over the past 30 years:

“From the patient’s point of view, all these developments have occurred alongside the collapse of public psychiatry and the consignment of many of the mentally ill to the squalor of the streets and the terrors of American jails. For those retaining any lingering disposition to embrace a narrative of psychiatric progress, there is the brutal reality that those suffering from serious mental illness have a lifespan of 20 to 30 years less on average than the rest of us – and this is a mortality gap, moreover, that is increasing, not diminishing.”

Will Carpenter, Chair of the DSM-5 Psychosis Work Group, followed up with Scull’s critiques in a commentary. Carpenter agreed with most of Scull’s criticisms, especially broadly, that American psychiatry has failed those that need the most help. Carpenter also offers potential steps, based on Scull’s criticisms, that can be taken to improve the understanding and treatment of mental illness.

 

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Scull, A. (2021). American psychiatry in the new millennium: a critical appraisal. Psychological Medicine, 1–9. https:// doi.org/10.1017/S0033291721001975 (Link)

17 COMMENTS

  1. “… the necessary etiological understanding of the various forms of serious mental disorder simply did not exist.” Actually, I beg to differ. Robert Whitaker’s “Anatomy of an Epidemic,” which credibly pointed out that the ADHD drugs and antidepressants can create the “bipolar” symptoms, was published in 2010.

    This means that the etiology of a lot of “bipolar,” is related to the “mental health” clinicians’ inability to read, and abide by, this disclaimer in their DSM-IV-TR:

    “Note: Manic-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar I Disorder.”

    And instead of adding the ADHD drugs to that disclaimer, as should have been done. That disclaimer was completely removed from the DSM5.

    But what this means is that the etiology of likely much of the so called “bipolar epidemic” is the misdiagnosis of the common adverse effects of the ADHD drugs and antidepressants. Which means much, or all, of the “bipolar” has an iatrogenic etiology, not a “genetic” one.

    And I know I’d found the medical proof that the antipsychotics could create “psychosis,” via anticholinergic toxidrome, by 2009. But this is also true of the antidepressants.

    https://en.wikipedia.org/wiki/Toxidrome

    I will admit, I don’t think I’d researched into what “schizophrenia” was well enough to look for and find, the medical evidence that the antipsychotics could also create the negative symptoms of “schizophrenia,” until 2015. But once I looked, it didn’t take me long to find the medical proof that the antipsychotics could also create the negative symptoms of “schizophrenia,” via neuroleptic induced deficit syndrome.

    https://en.wikipedia.org/wiki/Neuroleptic-induced_deficit_syndrome

    This means that the etiology of much of the “schizophrenia” is the “schizophrenia treatments.” So, not only does “bipolar” likely have a primarily iatrogenic – not “genetic” – etiology, but so does “schizophrenia.”

    This means that “… the necessary etiological understanding of the various forms of serious mental disorder [DO] exist.” It’s just that the psychiatric and psychological industries don’t want to admit to the truth.

  2. Psychiatry does one thing. They push dangerous, deadly pills they augment with therapy to convince you that you’re doing the right thing by obeying the psychiatrist and taking these pills until you nearly die and like Lady Macbeth; they try to wash their hands of it. This is not failure; it is criminal abuse. This is evil; very evil. Thank you.

  3. jumping in too late to say anything brilliant and/or unique, but…

    Psychiatry is evil. I think because I am a Christian, I feel more comfortable saying that now than I did in years pre-faith. Not that others cannot say it and mean it, not that people in other belief systems cannot call psychiatry evil with the same level of clarity and such, just…

    yeah. for me, church-free Christianity has freed my mind to see the evil in all things mental health-related. pop psychology, self help, personality tests, counseling, “Biblical” counseling, psychotherapy, and of course…

    Psychiatry. ugh. I find it difficult to understand how a sociologist could, somehow, view over 3 decades of rampant, socially- and legally-enforced wholesale destruction as a “failure.” Clearly, if psychiatry has been on a nationwide killing spree for 3 decades, this is not a “failure,” it is — as other posters have rightly pointed out, already — quite the success story. ugh.

    Reagan was called by some a “friendly fascist,” something similar…and they were -not- wrong. My best guess (keep in mind; I’m only 2 cups of coffee in, lol) is that the “trickle down,” no such thing as “society,” up by your boot straps! – mentality did not radically change psychiatry, so much as it took off the softer, more seemingly humane fuzzy edges that had been put in place in decades past, back when the psychiatric guild thought it best to pretend to care about the common good and individuals caught in their clutches. and then…

    yeah, Reagan, apparently. Thatcher, too. Clinton’s Orwellian “welfare reform,” etc. Thing is…

    Psychiatry was already evil. Psychiatry has been evil since day -1- . Psychiatry cannot be “reformed” because it is -evil- . I once thought that the talking people in the mental health industry were not evil, possibly even occasionally good, mostly just useless. No…no, no, no. The whole industry is -evil- , and psychiatry is so unbelievably, nauseatingly -evil- that the latest epidemic of mental health is probably going to end -very badly- , not just for the US, but for the whole, wide world. Starts out with the psych guilds gaining popularity as a band aid for faltering, sometimes failing societies…

    predictably, the psych guilds will then use their power to damage the individuals, families, communities, and whole societies they claim to “help.” ugh. 🙁

  4. I wonder, will the information about psychiatry, psych drugs and iatrogenic harm lead to offers of palliative care for those who have been severely harmed? My timing was bad. I was in high school when Reagan was president (my suicide attempts were chalked up to my being a spoiled brat looking for attention), then came Prozac, the atypical antipsychotics, the ADD drugs and all the other “miracle” drugs. When I didn’t respond to those I got ECT then more drugs than TMS then more drugs as I was consistently blamed for not getting better after all the “help”/spit out of the system/denied treatment for my increasingly severe physical problems. Psychiatric treatment was like a tsunami over my life… It left nothing untouched, nothing unharmed. At 55, I wonder how much longer I will live, and how bad things will get before the end. I want and believe I deserve palliative care. But so far no doctor or treatment provider has taken me seriously when I say that. When I dared voice my desire for euthanasia I was told to stop being ridiculous and provocative. I live in fear of what will happen. I have no one in my life, no friends or family, no emergency contact. I often think that the silent message is that I should actually kill myself rather than become a bigger burden on the system and spend the rest of my life warehoused somewhere, from the moment I can’t take care of myself. People who have been harmed by the system deserve to be heard, believed and offered whatever help they need so that they might have some quality of life and not have to live in fear. I won’t hold my breath but that is what should happen if there were any justice.

    • I agree 100%. If a plumber promised to fix your leaky pipe, then ended up flooding your basement, and “fixed” that by burning down your house, they would owe you the cost of replacing everything they ruined, plus additional for the inconvenience and emotional turmoil you experienced as a result. Why would this NOT apply to psychiatrists? If you are paying them to improve your “mental health,” and it observably gets worse, and your physical health deteriorates as well due to their “treatments,” at what point are they responsible for damages? Seems like simple breach of contract to me for starters, with aggravating factors involved with worsening instead of improving your condition. I guess normal rules of contract don’t apply to psychiatrists?

      • Although, you are right; unfortunately, it would be very difficult by the standards of the legal system, for most of those abused by psychiatry to list who, what, where, etc. as to abused them. I could not list all the drugs that have been prescribed me. I can not remember all the psychiatrists, therapists, etc. who have “treated” me. I can not tell you which year what happened. I have some memory of some incidents particularly between the years of 2002/2003 and 2013 to 2015. But, even off the drugs since 2013/2015, I have gaps in my memory. I also would need a lawyer who would be and the finances to pay for the lawyer. Although, there might be vindication, in the end, what would I get for it—maybe more money; but more than likely the process of living through all that terror again. It would be like living through a never ending tornado and it might not lengthen my life, but shorten it. I know that many who post here might not agree to my decision as to how I have handled this—but, I leave this all to the judgement of God and Jesus. It is in their hands, not the hands of mere mortal humans. Thank you.

        • I agree, it’s not feasible or practical and I don’t really expect any form of reparations or justice. What I do want and also need is palliative care, but I don’t think I’ll get that either. My life would be bearable if there was some acknowledgment that the damage I have suffered has left me with severe disability and chronic pain. It sure would be nice if there were a doctor anywhere who would believe me about all the harm that I suffered and the degree of my disability and pain and then provide medical treatment based on that. Based on the idea that I have suffered severe damage and need help now for the rest of my life. I don’t believe I can recover from the damage certainly not with out a great deal of help and it doesn’t seem there is any help. What I would like is some of treatment and support that acknowledges the damage so that I can survive and not live in fear every day of what is going to happen to me. But I guess I won’t even get that and if it comes to it that I am afraid of winding up in a nursing home or some kind of residential care for the rest of my life I’ll definitely think about killing myself.

  5. Though this paper apparently conveys a robust criticism of one of our more protected professions, it seems more like a game of kids throwing rocks at each other than a serious scholarly work.

    In 1980 my psychologist warned me about psychiatry. From that and other data I can assume that the two fields have been in a state of civil war for some time now. To trace back the dehumanization of psychiatry to the Reagan era is totally preposterous. How about the two world wars? Psychiatry was deeply involved in both of them!

    By believing the lie that “Presently, the major causes of mental illness are unknown” the paper leads the reader into believing that we will have to invest yet millions more of tax dollars into research that will help no one except maybe some vested interest’s bottom line.

    For me, this has been the great tragedy of my lifetime. That great strides WERE made in these fields, but were ignored because they threatened vested interests. That was the most obvious evidence that the “mental health system” was constructed for political purposes, and not to help anyone or solve any problems. Since the system became better-funded in the 1960s, societal problems have only been getting worse. Looks a lot more like a protection racket to me!

    Even most readers of this website don’t have any clue that the problem of mental health has largely been solved. Well, I’m not going to be the one to force the solutions down anyone’s throat, but to continue to act like they don’t even exist seems at best a bit negligent. At some point we should get to the point of realizing that some good work has been done on this and is worth discussing. How much longer do you all want to play this game of blind man’s bluff?

    • Psychiatry and psychology have not been in a state of civil war. In fact they’ve been in bed together for decades. If I had a dollar for every time I was told, well you need therapy but you need to be medicated so that the medication will get you in enough shape to be able to do the therapy. The psychiatrist would send me to the therapist and the therapist would send me back to the psychiatrist and they all made a good bit of money off of me and then tossed me away. Borderline personality disorder, a diagnosis made up by psychiatrists. The treatment for borderline personality, DBT, a treatment made up by psychologists. Oh yeah you need to be mindful but that doesn’t mean you should stop taking the antipsychotics antidepressants and mood stabilizers your doctor is prescribing. Use your wise mind! It’s nothing but a good cop bad cop routine at best.

      • Katel, What you state here has been similar to my experience, too. Most of the time, I have had this type of experience in a “community mental health center” where they had the psychiatrist and a therapist (usually a licensed social worker.) The tragic joke is always “take this drug” so we can understand why you feel the way you do. I guess, it should have been a tip-off, but I was blinded, partly by the fact I had a psych degree and was overly trusting. I also say “be
        careful” who you turn to after you leave what I call “psych world.” It sounds real great to be involved in things like meditation, mindfulness, and even some New Age type stuff; but, beware they are all the same devil in different disguises. Also, if you can, stay as far away from any therapy (even if they claim they want try to ply you with drugs.) After “psych world” it is very important to take care of yourself to the best of your ability. This means be kind and gentle and forgiving to yourself and others. Live life as peacefully and as calmly as possible. And take note of what you can do and should not do, what you can eat and should not eat, and a whole bunch of etc. Remember no doctor or anyone on Earth knows you as well as you know you. Only God knows you better. Therefore, prayer does always help, too. Thank you.

        • In my memory, I think I had only one “therapist” who did not refer me to a “psychiatrist” for drugs; but, she was independent and not tied to any specific medical-type clinic. Of course, I think, many of these “clinics” the “patient” now really does see an actual M.D. psychiatrist, but some sort of health care provider who receives his or her approval to prescribe from the authority of an M.D. psychiatrist. Sometimes, this happens in the millions of urgent care clinics that have popped up across the US for the many minor ills we get that are just below the emergency room level. So, many times nowadays, we are not getting our prescription for many dangerous drugs from M.D.s of all specialties but from health care providers that when we hurt or in pain, we are unable to actually see their real credentials. It might save money; but does it really save lives? Thank you

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