Is Psychiatry More Mindful Or Brainier Than It Was a Decade Ago?

BRITISH JOURNAL OF PSYCHIATRY (2000), 176, 1^5 EDITORIAL Is psychiatry more mindful or brainier measures. More than 20 000 patients were subjected to psychosurgery in the USA than it was a decade ago?** between 1935 and 1950. The procedure was carried out in private as well as public hospitals, and it was endorsed by leading LEON EISENBERG academics because it sometimes `worked'. What brought about the demise of psychosurgery was neither science nor compassion but the introduction in 1954 of chlorpro- mazine, the first in a series of drugs that made psychosurgery redundant (Pressman, 1998).1998). Academic psychiatry in the USA in the experience (Doll, 1991). Not until 1948 Good as they are, psychotropic drugs decade after the Second World War was was the first double-blind randomised con- were vastly overvalued then, as they are dominated by psychoanalytic theory. trolled trial (RCT) in medicine carried now. They were credited with emptying Psychotherapy, most of it psychodynamic out ± the Medical Research Council trial the mental hospitals, although the onset of in orientation, was the principal activity of streptomycin for treating tuberculosis de-institutionalisation had preceded the in- of clinicians in office practice. Critics like (Medical Research Council, 1948). With troduction of the drugs. In catchment areas myself who pointed out the lack of empiri- the advent of psychotropic drugs, RCTs en- where `open hospital' and `community psy- cal validation for the theory or the practice tered psychiatric research. They undoubt- chiatry' policies had been implemented, were unavailing (Eisenberg, 1962). edly improved matters, but they have not drugs had relatively little additional effect This is less surprising when considered quite taken us to the promised land. Thorn- on length of hospital stay (Shepherd et aletal,, in context: there were nono treatments of ley &ley&Adams (1998) reviewed for the 1961), but they werewere decisive in hospitals demonstrated effectiveness. Psychiatric CochraneCochraneCollaboration the first 2000 con- where patients continued to be warehoused diagnosis had low interrater reliability. trolled treatment trials in schizophrenia. (Odegaard, 1964). De-institutionalisation The `brain sciences' were largely irrelevant Most trials were substantially flawed: they in the USA was driven more powerfully to clinical practice. To its credit, psychiatry had inadequate sample size, or too short a by economic forces (cost-shifting from state made a virtue of the failure of its biomedi- duration, uncertain blinding, inconsistent to federal budgets) than by theory or data. cal science by remaining the one medical methods of evaluation, or poor reporting. The decline of the mental hospital census speciality with a persistent interest in the Only 20 (1% of the 2000) were rated at 5 was celebrated without finding out where patient as a person in an era increasingly on a 1±5 scale of quality. Clearly, we still the former patients were. Elderly patients dominated by organ-based medical sub- have a long way to go. were `trans-institutionalised' to nursing specialities.specialities. Psychoanalysis, despite its inadequacies homes; many long-stay patients were The chance discoveries of effective as science, made a powerful contribution discharged to home addresses that no psychotropic drugs transformed the field to psychiatry. It taught trainees to listen longer existed, and became street people. in the mid-1950s. Because the new agents to patients and to try to understand their Calls to evaluate the community mental were relatively syndrome-specific, diagnos- distress ± not simply to classify them, or health movement (Eisenberg, 1968) were tic categories were defined operationally shock them, or lock them up. It made psy- as unavailing as earlier critiques of and gained reliability. The search for an chiatrists aware of the importance of mem- psychoanalysis. understanding of drug action stimulated ory, its vulnerability to distortion, and its Given the above background, is psy- research in neurobiology. Welcome as these central role in patients' stories about them- chiatry `more mindful' or `brainier' than it developments were, they embodied a peril: selves. Such narratives can be self-defeating, was a decade ago? In an immediate sense, psychiatry began to focus exclusively on and a key task of therapy was defined as the answer is a self-evident `yes'. A decade the brain as an organ. Psychiatrists found helping patients to reconstruct their auto- of imaginative research has taught us very it useful to emphasise their medical identity biographies in such a way as to foster much more about both brain and mind; for purely economic reasons. Prescribing growth. That task, no less important today, the problem that continues to bedevil us drugs and monitoring drug therapy require is being squeezed out of clinical practice conceptually is how to integrate the two a medical licence, whereas psychologists, and residency training. domains into what, for lack of a suitable social workers and counsellors can compete word, I shall have to call `brain/minded- in the psychotherapy market in the USA. ness'. The very elegance of neurobiology Mindlessness had begun to replace brain- THE EMPTYING OF MENTAL and the power of genetics dazzle us: knock lessness (Eisenberg, 1986). HOSPITALS out a gene and the effect stares you in the In the 1940s and 1950s, just about all face; study a psychosocial phenomenon medical therapeutics was based on the In the 1940s and 1950s, increasing num- and the relevant variables require sophisti- claims of expert opinion and clinical bers of severely disturbed patients were cated statistical analysis before the meaning warehoused in understaffed mental hospi- is clear. The psychosocial findings in a tals (Deutsch, 1948). No treatments given case may be more important for patient *Plenary Session Address originally presented atthe worked; Freud himself saw no role for ana- care than finesse with genes in the labora- Royal Australian and New Zealand Congress of lysis in treating the psychoses. Desperate tory, but they do not seem as `real'. Add Psychiatry,Perth, Australia,12 April1999. times were thought to justify desperate to the medical bias in favour of the tangible 11 Downloaded from https://www.cambridge.org/core. 30 Sep 2021 at 09:31:44, subject to the Cambridge Core terms of use. EISENBERG a market that understands doctors who pre- less time with each patient, providing psy- embryogenesis, axons from both eyes mi- scribe pills but not those who listen (and chotherapy less often, and prescribing grate to, and intermingle in, the geniculate talk) to patients and it is evident why the drugs more often than they did ten years nuclei. The segregation of separate layers `neurologising tautology' ± that only those ago (Olfson et aletal, 1999). Residency training results from bursts of electrical activity aris- facts that can be reduced to terms of nerve programmes are narrowing their focus to ing in unstable retinal ganglion cells. cells are scientific ± is growing apace DSM±IV (American Psychiatric Associa- Neither the genes governing the retina nor (Eisenberg, 1986). tion, 1994) diagnosis and algorithms for the genes governing the geniculate specify drug prescribing; much less emphasis is the ocular alternation layers; they result placed on learning how to elicit the pa- fromfrom interactioninteraction between neurons in the MANAGERIAL FETTERS tient's story and how to do psychotherapy; course of development (Penn et aletal, 1998).,1998). ON EFFECTIVE CARE psychological care in mental health `carve- At the next relay, the precise targeting of outs' is being farmed out to social workers projections from the lateral geniculate to As a clinical discipline, psychiatry is thriv- and counsellors in order to save on costs. occipital cortex in turn depends on genicu- ing as it never has. Clinicians now com- Just as the intellectual underpinnings of late activity. Abolishing geniculate action mand a range of therapeutic interventions our field are becoming brainier and more potentials leads axons to project to cortical whose efficacy has been demonstrated mindful, practitioners are being pressed to areas that they ordinarily bypass, and leads through RCTs. We have an array of proven reify DSM±IV categories and employ drugs many fewer axons to project to the striate psychosocial interventions: cognitive± as panaceas ± strategies that are neither cortex (Catalano & Shatz, 1998). Finally, behavioural therapy, interpersonal psycho- brainy nor mindful! I will not say more post-natal stimulation is required for the therapy and problem-solving therapy; and, on this matter here, as I have addressed it formation of ocular dominance columns to reduce relapse in schizophrenia, family elsewhere (Eisenberg, 1999bb).). in the occipital cortex (Wiesel, 1982). Both intervention, social skills training and re- I now turn to the expanding science eyes of the newborn must receive precisely habilitation. To the standard neuroleptic base of psychiatry and what it portends focused stimulation from the visual envir- drugs have been added the `atypical' anti- for understanding the relationship between onment during the early months of post- psychotic agents which are effective in con- mind and brain. I will highlight three natal life in order to produce a fine-tuned trolling negative symptoms. The existing research areas: the role of experience in cortical structure. stock of tricyclics and monoamine oxidase constructing the anatomy

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