The Crack-Up of Psychiatry

By Paul Raeburn


Psychiatry in Crisis: A Call for Reform

By J. Allan Hobson and Jonathan A. Leonard

Perseus 292pp $26

Each year, about 1,200 slots are available at U.S. hospitals for medical students who want to train as psychiatrists. Once, those positions attracted the best and brightest medical graduates. Now, only a third of those places are filled by American medical students--most of them drawn from the bottom quarter of their class.

The decline in psychiatry has been matched by a deterioration in the availability of mental-health care: The number of patients in public mental hospitals has fallen from a peak of 558,000 in 1955 to 60,000 today. Meanwhile, an estimated 5 million Americans suffer from such illnesses as schizophrenia, manic-depression, autism, depression, or obsessive-compulsive disorder. Many of those who would once have been treated, however badly, in mental hospitals are now on the streets, in homeless shelters, or in prison. Some receive no treatment at all.

In Out of Its Mind, J. Allan Hobson, a psychiatrist at Harvard Medical School, and Jonathan A. Leonard, a writer, paint a terrifying picture of the collapse of American psychiatry and the toll it has taken on the mentally ill. The book--likely to provoke outrage even among those who have never thought about these questions--is all the more disturbing because the decline in care has occurred during a period when scientific advances have led to a variety of new psychiatric drugs. The drugs, Hobson and Leonard write, provide "a real chance for large numbers of severely afflicted mental patients to have at least a semblance of normal life."

Out of Its Mind begins with a history of American psychiatry, showing how and why it has fallen so far. The authors next provide a long section detailing recent advances in brain science, including Hobson's own work on dreams. And they conclude with a series of proposals to rejuvenate psychiatry and transform the care of the mentally ill in the U.S. Their indictment of the present system is so devastating, however, that their optimism about the future sounds hollow.

Psychiatry arose in the 19th century, when its main role was to provide custodial care for the mentally ill. Little was known about the causes of mental illness, and even less about treatment. In the early 1900s, researchers made some progress in understanding delirium tremens and the neurological complications of syphilis, which was then responsible for 10% of U.S. mental-hospital admissions. But care remained primitive.

In the 1930s and '40s, U.S. psychiatry underwent a revolution, triggered by the arrival and widespread acceptance of the work of Sigmund Freud. Freudian psychoanalysis "often explained mental ills in ways that were bizarre, erroneous, misdirected, confusing, and sometimes harmful," Hobson and Leonard write, but "its theories were based on keen observations of human behavior that seemed at least as good as any others available at the time."

Freud's ideas ruled American psychiatry until the 1950s, but then the Freudian dynasty began to fall apart. Tranquilizers, led by Miltown, and then Librium and Valium, appeared in the 1950s and '60s, just as several landmark studies were showing that Freudian psychoanalysis was of little help to mental patients. American psychiatry then underwent its second revolution, this time deserting Freudian theory for an unholy devotion to the new medicines. Psychotherapy was largely abandoned, and many mental hospitals were emptied and shuttered.

It is now widely accepted that the best treatment for mental illness is a combination of drugs, which alleviate symptoms, and current forms of non-Freudian psychotherapy, which get at the social and psychological elements of the disorders. Yet drugs began to replace therapy. By the 1980s and '90s, that trend accelerated as insurance companies and health-maintenance organizations, aiming to reduce costs, seized on drugs as a cheaper alternative to therapy. The care of the mentally ill was fractured: Psychiatrists prescribed pills, and psychotherapy, if provided at all, was done by psychologists or social workers, whose hourly rate undercut that of psychiatrists. Communication between the two is often sporadic, and, as a result, most patients receive inadequate care. And Hobson and Leonard estimate that there are 2 million Americans with severe mental illness receiving no treatment whatsoever.

This tragic breakdown in care has paralleled an explosion in scientific understanding of mental illness. Hobson and Leonard provide a neat summary of recent progress in brain science and the treatments it has led to. In a concluding section, they also call for a rebuilding of the mental-health-care system so as to give patients access to drugs, psychotherapy, and long-term coordinated care. "While such programs would cost money, they would probably cost less than what HMOs, insurance companies, families of the mentally ill, and a broad array of government institutions from jails to homeless shelters are now paying to provide low-quality, underfinanced, and fragmented services," they write.

It's hard to know exactly what their rational, humane system might cost. What is clear is the high social cost of doing nothing: Many of the mentally ill are cast adrift, without treatment, until they end up broke, homeless, or in prison. Surely America owes them more than that.

Senior Writer Raeburn covers science and medicine.

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