At the dawn of the 20th century, it was not unreasonable to think that the cause of mental illness might be a bacterial infection, lurking somewhere in the body. Germ theory had revolutionised general medicine, and the discovery of a blood test for syphilis had revealed the root cause of the fatal condition formerly known as “general paralysis of the insane”, which may have afflicted up to a quarter of asylum patients. One of the key proponents of the theory that madness was caused by an undiagnosed bacterial infection – or “focal sepsis” – was the American psychiatrist Henry Cotton, the superintendent of Trenton asylum in New Jersey. In 1916 he began testing his theory. He removed the teeth of 50 of his patients, suspecting that some inner dental rot might be addling their minds. They seemed no better, so he pushed things further. He removed the teeth and tonsils of 25 patients next and deemed 24 of them recovered enough to be discharged. Almost anywhere in the body could harbour harmful germs, and soon Cotton was also removing spleens and stomachs, colons, cervixes, ovaries, wombs and fallopian tubes.
Cotton claimed that his surgical techniques could increase recovery rates among asylum patients from 37 per cent to 85 per cent, and his reputation soared. He secured prestigious lectureships and glowing newspaper write-ups. He was invited to visit Britain to share his techniques. Wealthy families descended on Trenton, willing to pay any price to have their mentally ill relatives operated on. Finally, some long overdue progress for psychiatry seemed at hand, some hope for long-suffering patients.
The problem was, by his own estimate, around a third of the people Cotton operated on died. He was transparent with his colleagues about this mortality rate, which he attributed to his patients’ poor physical condition, an explanation his peers initially accepted. Two reports that cast doubt on his success rates and probed the shocking number of fatalities (in fact, almost half of Cotton’s patients died due to their surgery or related complications) were suppressed by Cotton’s mentor, the eminent psychiatrist Adolf Meyer. When Cotton died of a heart attack in 1933 he was described in his obituary as a “great pioneer whose humanitarian influence was, and will continue to be, of such monumental proportions”.
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One would hope that Cotton’s story is an aberration, but it sets a fitting tone for Andrew Scull’s dense and harrowing history of psychiatry, Desperate Remedies: Psychiatry and the Mysteries of Mental Illness. Scull begins in the 1820s, where he identifies a newfound optimism that insanity could be cured if the sick were cared for in an appropriate moral and physical environment: the asylum. As these institutions spread across the US and Europe, the men in charge of them championed tortuous new treatments. These psychiatrists – or “alienists” as they were initially known – were motivated in part by a desire to alleviate terrible suffering, but often by ego and blinding ambition, too. Scull describes in horrifying detail the use of insulin comas, malarial fevers, bone-breaking electric shock treatments and crude lobotomies, the latter performed on conscious patients, who received an ice pick to the back of their eye sockets.
Psychoanalysts and other proponents of “talking cures” at least listened to their patients, Scull observes, but they too were prone to professional overreach and drastic measures. Some believed that many physical illnesses were psychosomatic, among them asthma: “the asthmatic wheeze was the ‘suppressed cry’ of a patient suffocated by an over-attentive mother”, the psychoanalyst Helen Flanders Dunbar argued (it’s usually the mother’s fault). In the 1950s residential schools for asthmatics were established to sever these supposedly harmful parental bonds.
Scull, a professor of sociology at the University of San Diego in California, is the author of around a dozen cultural histories of madness and psychiatry. Desperate Remedies is one of the broadest. The history is in many ways a build-up to a blistering critique of contemporary psychiatry, a profession he describes as in “crisis”. He believes the field has made some progress over the past two centuries – but not much. The public conversation on mental health has shifted in recent years. There is much greater awareness of the importance of seeking support, and the stigma attached to some conditions has partially lifted (it’s much easier to talk about struggles with anxiety or depression, for example, than about experiencing psychosis). But many members of the public still overestimate how much psychiatry can help, particularly if their symptoms are severe. A substantial proportion of people diagnosed with conditions such as schizophrenia, bipolar disorder and depression will not be helped by the available medications, and psychiatrists still have no way of knowing in advance who will respond well to the drug treatments – which can come with substantial and sometimes life-shortening side-effects.
We’re lucky to live in an era of evidence-based medicine: a psychiatrist can no longer remove a patient’s internal organs on a hunch. But Scull believes that psychiatry is better thought of as producing “evidence-biased medicine”: pharmaceutical companies routinely cherry-pick which studies they make public, covering up trials that have produced unfavourable results. Only 30 per cent of clinical drug trials are published, and lawsuits in the US have revealed that drug companies have even suppressed evidence of fatal side-effects.
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A literature review of the trials that have been published suggests that anti-depressants produce a 10-15 per cent improvement in symptoms over a placebo. Scull doesn’t deny that any alleviation of suffering, however slight, is worthwhile. But he’s sceptical: if pharmaceutical companies were compelled to disclose all of their results, the drugs would be shown to be even less effective. The picture for antipsychotic medication is bleaker, not least because on average between 66 and 80 per cent of trial participants drop out, either because the drugs aren’t working or because the side-effects are intolerable. Literature reviews suggest that the improvement in symptoms produced by antipsychotic medication is so marginal that it is close to clinically insignificant.
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Scull believes that it’s not only the pharmaceutical industry that is failing patients, but the medical model underpinning modern psychiatry. Criticism has been growing for years of psychiatry’s diagnostic system, enshrined in the Diagnostic and Statistical Manual of Mental Disorders, with opponents arguing that the distinctions between different psychiatric conditions are so blurred and arbitrary as to be meaningless. In 2016 one of the world’s leading experts on schizophrenia, the psychiatrist Robin Murray, wrote that the evidence that schizophrenia was a “discrete entity”, rather than the severe end of psychosis, had been “fatally undermined”, and he expected the term to fall out of use.
There hasn’t been a pharmaceutical breakthrough for mental illness in decades, and the billions poured into neuroscientific and genetic research have done little to improve the lives of patients. Scull argues that there will always be limits to what medication or medical science alone can achieve because mental illness is not purely biological: our brains are shaped by developmental and environmental factors, and our thoughts and feelings are shaped by our social and cultural context.
His arguments are passionately delivered and while some might sound radical, they also have common sense. Psychiatry is indeed in turmoil over whether (and how) to abandon its diagnostic system and disease model, but few practitioners still argue that mental illness is entirely biological. Almost everyone recognises that mental illness involves an interplay between biological, psychological and social factors: the challenge (and controversy) lies in how much emphasis to place on each, and where to look for underlying causes or potential solutions. To make real progress in addressing mental illness, Scull believes we need to invest much more in understanding the psychological and social causes of mental distress – but there is little political will to do so. “Psychiatry faces a difficult way forward. So do we,” he concludes.
Desperate Remedies: Psychiatry and the Mysteries of Mental Illness
Allen Lane, 512pp, £25
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This article appears in the 08 Jun 2022 issue of the New Statesman, Marked Man