At first glance, the new millennium has not been kind to psychiatry. The highly anticipated American Psychiatric Association's fifth edition of the Diagnostic and Statistical Manual (American Psychiatric Association, 2013) provoked unusually public rifts among leading psychiatrists, spilling out, for example, on the pages of the New York Times, the Wall Street Journal, and the Guardian, reminding the world that psychiatric classification remains rooted in the social and political world as much as in biology. At the same time, though the neurosciences have grown spectacularly over the last half century, these successes have not translated into a simple, biological reductionist understanding of psychiatric disease. If anything, advances in biological understanding have made biological reductionism appear increasingly chimerical. Even psychiatry's most cherished diagnostic categories, bipolar disorder and schizophrenia, appear increasingly fragile as genome-wide association studies have undermined their genetic distinctiveness.
At the beginning of the millennium, big pharma promised that the new generation of blockbuster drugs could not only treat core aspects of psychotic and depressive disorders, but also could make one ‘better than well’ (Kramer, Reference Kramer1993). By the second decade of the twenty-first century, it became increasingly evident that the new drugs were no more effective than those that had been discovered in the 1950s and early 1960s. A number of major civil and criminal rulings against the largest pharmaceutical companies for their illegal marketing and suppression of side effect data have added to the growing disillusionment over the effectiveness of what had been hailed as potentially revolutionary breakthroughs. Of course, pharmaceutical companies depend upon the generation of profit for their survival and so we should not be too surprised by their failures to adhere to the same ethical and evidentiary standards we hold to physicians. Nevertheless, for psychiatrists, who have become increasingly dependent upon prescribing psychotropic drugs as their main, often only, form of therapeutic intervention, the failure of the most recent drugs to live up to the hype has been particularly distressing to the profession (not to mention their patients). All of the above enumerated problems pale compared to the virtual collapse of the United States public mental health care system. Beginning in the late 1960s and early 1970s and accelerating at a distressingly rapid rate since the turn of the century, those with serious mental illness have become far more likely to become homeless, incarcerated, or die prematurely today than at any time over the last 150 years.
This is the history that Scull (Reference Scull2021) tackles in his essay, ‘American psychiatry in the new millennium: a critical appraisal.’ No other historian is more capable of providing an insightful and critical look at this recent history. He is the leading historian of Anglo–American Psychiatry. And for good reason. Not only is he the most productive historian of psychiatry alive, but he has also led the field with his incisive, thoughtful critiques that have had as much contemporary relevance as they have had for informing our understanding of the past.
His work also has provoked significant controversy as he has prodded psychiatrists to think more critically about their profession, their excesses, and their blind spots. In this essay, Scull looks critically at American psychiatry of the twenty-first century. He sees a profession in a deepening crisis. And, most importantly, it is largely a crisis of their own making. Driven by professional self-interest, psychiatrists abandoned psychodynamic psychiatry and threw their lot in with big pharma and biological reductionism. Similarly, psychiatrists embraced the 1980 DSM III largely out of professional expediency, adopting a system of categorization that satisfied insurance companies far more than either patients or the real nature of psychiatric disease. Scull writes: ‘As to the origins of mental pathology, where once the American professional elite embraced Freudian ideas, for nearly a half-century it has bet on biology, and the wager has mostly turned up snake's eyes.’
Scull's narrative has much to recommend. As a meticulous historian, few could argue with what he describes as the signs and symptoms of the new millennium's psychiatric ailments. And, psychiatry has much to account for, especially in the profession's near silence as unprecedented numbers of those with serious mental illness face incarceration and homelessness.
However, I believe that Scull gives far too much credit to psychiatrists as the authors of their own fate. I also think Scull overplays his claim that American psychiatry is in crisis. For better and for worse, there is little evidence that psychiatry faces an existential crisis. For example, in a 2017 meta-analysis of 162 papers reporting on public attitudes toward psychiatrists, the authors concluded: ‘From a global perspective, our results suggest that the help provided by psychiatrists is held in high esteem by the public. The public's readiness to recommend seeking help from a psychiatrist has increased over the past 25 years. Thus, our findings do not support the notion that psychiatry is currently exposed to strong discrimination and, as a consequence, shunned by the public’ (Reference Angermeyer, van der Auwera, Carta and SchomerusAngermeyer, van der Auwera, Carta, & Schomerus, 2017, p. 57). From the perspective of graduating senior US medical students, psychiatry is far from crisis. Between 2011 and 2021, the number of US graduates matching in psychiatry almost doubled from 640 to 1205, an increase that has outstripped all other medical specialties (Moran, Reference Moran2021).
Even if the profession of psychiatry is not in crisis, nevertheless, Scull is correct that psychiatry has yet to adequately come to grips with the social, subjective, and biological nature of psychiatric disease (Braslow, Brekke, & Levenson, Reference Braslow, Brekke and Levenson2021). However, to describe a psychiatric profession as rationally placing self-interested bets on how best shore up the discipline, ignores the fact that psychiatrists and the profession are as much a victim of contingent historical circumstances as are their patients. It is true that psychiatry, more than any other medical specialty, has continually remade itself in terms of what psychiatrists deem as acceptable explanations of psychiatric disease (swinging wildly from psychoanalysis in the 1950s to biological psychiatry in the 1990s and 2000s) and legitimate treatments.
I think we need to dig deeper than professional self-interest to better understand the vicissitudes of psychiatry and to address the very real failures of psychiatric science that, at least for now, has placed an unrealistic faith in biological reductionism, and a clinical practice that has largely abandoned those most disabled by psychiatric disease. By definition, psychiatry is charged with policing the boundaries between normal and pathological behaviors, thoughts, feelings, and activities. As such, just as psychiatric disease itself operates on multiple levels, psychiatric science and practice is inherently bound up with historically contingent cultural values, social structures, and systems of care. The fact that, despite the profession's painfully apparent failures, psychiatry is as healthy as it has ever been suggests a different diagnosis. In other words, the recent history that Scull recounts urges us to ask why psychiatry is so vulnerable to major epistemological and therapeutic shifts. Though not explicit in the current essay, Scull has given us the tools and conceptual framework to begin answering this question in a way that goes beyond professional interests. In 1993, Scull reflected on his first book, Museums of Madness, which he had begun to research as his dissertation project 20 years before (Scull, Reference Scull1993). He notes that ‘[I]n the eyes of some members of the psychiatric establishment and of adherents to various versions of the liberal public relations school of psychiatric history, my early work marked me as a sort of Marxist enfant terrible of the discipline’ (p. 4). While I think Scull might not have wholeheartedly embraced the label of Marxist, he has consistently situated psychiatric practices within larger social, political, and economic contexts. Reflecting on the origins of psychiatry in the late eighteen and early nineteenth centuries, Scull writes in the same essay, ‘efforts by physicians to define madness as a uniquely and exclusively medical problem and province were aided by and dependent upon the larger changes.’
Scull's essay has provocatively sketched out the current ‘crisis’ of psychiatry. However, not to entirely absolve psychiatry, I think we need consider what precisely are those larger forces that psychiatry is ‘aided by and dependent upon’ that has made psychiatry so vulnerable to both overly exuberant embraces of particular theories (be they biological or social) and therapeutics, only to repudiate them under a new set of circumstances. To understand our current ‘crisis,’ I hope Scull's essay encourages us to look further and to ask not why the profession is in crisis but, rather, what are the forces that keep psychiatry from crisis when the profession has abandoned its sickest patients to homelessness, jails, and premature deaths.
Returning to Scull's, Reference Scull1993 essay, he quotes Michael MacDonald that insanity is ‘the most solitary afflictions to the people who experience it; but…the most social of maladies to those who observe its effects’ (p. 3). Arguably, what makes psychiatry appear to be in continual crisis is the profession's inability to come to grips with the fundamental nature of psychiatric disease as simultaneously social, psychological and biological.
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At first glance, the new millennium has not been kind to psychiatry. The highly anticipated American Psychiatric Association's fifth edition of the Diagnostic and Statistical Manual (American Psychiatric Association, 2013) provoked unusually public rifts among leading psychiatrists, spilling out, for example, on the pages of the New York Times, the Wall Street Journal, and the Guardian, reminding the world that psychiatric classification remains rooted in the social and political world as much as in biology. At the same time, though the neurosciences have grown spectacularly over the last half century, these successes have not translated into a simple, biological reductionist understanding of psychiatric disease. If anything, advances in biological understanding have made biological reductionism appear increasingly chimerical. Even psychiatry's most cherished diagnostic categories, bipolar disorder and schizophrenia, appear increasingly fragile as genome-wide association studies have undermined their genetic distinctiveness.
At the beginning of the millennium, big pharma promised that the new generation of blockbuster drugs could not only treat core aspects of psychotic and depressive disorders, but also could make one ‘better than well’ (Kramer, Reference Kramer1993). By the second decade of the twenty-first century, it became increasingly evident that the new drugs were no more effective than those that had been discovered in the 1950s and early 1960s. A number of major civil and criminal rulings against the largest pharmaceutical companies for their illegal marketing and suppression of side effect data have added to the growing disillusionment over the effectiveness of what had been hailed as potentially revolutionary breakthroughs. Of course, pharmaceutical companies depend upon the generation of profit for their survival and so we should not be too surprised by their failures to adhere to the same ethical and evidentiary standards we hold to physicians. Nevertheless, for psychiatrists, who have become increasingly dependent upon prescribing psychotropic drugs as their main, often only, form of therapeutic intervention, the failure of the most recent drugs to live up to the hype has been particularly distressing to the profession (not to mention their patients). All of the above enumerated problems pale compared to the virtual collapse of the United States public mental health care system. Beginning in the late 1960s and early 1970s and accelerating at a distressingly rapid rate since the turn of the century, those with serious mental illness have become far more likely to become homeless, incarcerated, or die prematurely today than at any time over the last 150 years.
This is the history that Scull (Reference Scull2021) tackles in his essay, ‘American psychiatry in the new millennium: a critical appraisal.’ No other historian is more capable of providing an insightful and critical look at this recent history. He is the leading historian of Anglo–American Psychiatry. And for good reason. Not only is he the most productive historian of psychiatry alive, but he has also led the field with his incisive, thoughtful critiques that have had as much contemporary relevance as they have had for informing our understanding of the past.
His work also has provoked significant controversy as he has prodded psychiatrists to think more critically about their profession, their excesses, and their blind spots. In this essay, Scull looks critically at American psychiatry of the twenty-first century. He sees a profession in a deepening crisis. And, most importantly, it is largely a crisis of their own making. Driven by professional self-interest, psychiatrists abandoned psychodynamic psychiatry and threw their lot in with big pharma and biological reductionism. Similarly, psychiatrists embraced the 1980 DSM III largely out of professional expediency, adopting a system of categorization that satisfied insurance companies far more than either patients or the real nature of psychiatric disease. Scull writes: ‘As to the origins of mental pathology, where once the American professional elite embraced Freudian ideas, for nearly a half-century it has bet on biology, and the wager has mostly turned up snake's eyes.’
Scull's narrative has much to recommend. As a meticulous historian, few could argue with what he describes as the signs and symptoms of the new millennium's psychiatric ailments. And, psychiatry has much to account for, especially in the profession's near silence as unprecedented numbers of those with serious mental illness face incarceration and homelessness.
However, I believe that Scull gives far too much credit to psychiatrists as the authors of their own fate. I also think Scull overplays his claim that American psychiatry is in crisis. For better and for worse, there is little evidence that psychiatry faces an existential crisis. For example, in a 2017 meta-analysis of 162 papers reporting on public attitudes toward psychiatrists, the authors concluded: ‘From a global perspective, our results suggest that the help provided by psychiatrists is held in high esteem by the public. The public's readiness to recommend seeking help from a psychiatrist has increased over the past 25 years. Thus, our findings do not support the notion that psychiatry is currently exposed to strong discrimination and, as a consequence, shunned by the public’ (Reference Angermeyer, van der Auwera, Carta and SchomerusAngermeyer, van der Auwera, Carta, & Schomerus, 2017, p. 57). From the perspective of graduating senior US medical students, psychiatry is far from crisis. Between 2011 and 2021, the number of US graduates matching in psychiatry almost doubled from 640 to 1205, an increase that has outstripped all other medical specialties (Moran, Reference Moran2021).
Even if the profession of psychiatry is not in crisis, nevertheless, Scull is correct that psychiatry has yet to adequately come to grips with the social, subjective, and biological nature of psychiatric disease (Braslow, Brekke, & Levenson, Reference Braslow, Brekke and Levenson2021). However, to describe a psychiatric profession as rationally placing self-interested bets on how best shore up the discipline, ignores the fact that psychiatrists and the profession are as much a victim of contingent historical circumstances as are their patients. It is true that psychiatry, more than any other medical specialty, has continually remade itself in terms of what psychiatrists deem as acceptable explanations of psychiatric disease (swinging wildly from psychoanalysis in the 1950s to biological psychiatry in the 1990s and 2000s) and legitimate treatments.
I think we need to dig deeper than professional self-interest to better understand the vicissitudes of psychiatry and to address the very real failures of psychiatric science that, at least for now, has placed an unrealistic faith in biological reductionism, and a clinical practice that has largely abandoned those most disabled by psychiatric disease. By definition, psychiatry is charged with policing the boundaries between normal and pathological behaviors, thoughts, feelings, and activities. As such, just as psychiatric disease itself operates on multiple levels, psychiatric science and practice is inherently bound up with historically contingent cultural values, social structures, and systems of care. The fact that, despite the profession's painfully apparent failures, psychiatry is as healthy as it has ever been suggests a different diagnosis. In other words, the recent history that Scull recounts urges us to ask why psychiatry is so vulnerable to major epistemological and therapeutic shifts. Though not explicit in the current essay, Scull has given us the tools and conceptual framework to begin answering this question in a way that goes beyond professional interests. In 1993, Scull reflected on his first book, Museums of Madness, which he had begun to research as his dissertation project 20 years before (Scull, Reference Scull1993). He notes that ‘[I]n the eyes of some members of the psychiatric establishment and of adherents to various versions of the liberal public relations school of psychiatric history, my early work marked me as a sort of Marxist enfant terrible of the discipline’ (p. 4). While I think Scull might not have wholeheartedly embraced the label of Marxist, he has consistently situated psychiatric practices within larger social, political, and economic contexts. Reflecting on the origins of psychiatry in the late eighteen and early nineteenth centuries, Scull writes in the same essay, ‘efforts by physicians to define madness as a uniquely and exclusively medical problem and province were aided by and dependent upon the larger changes.’
Scull's essay has provocatively sketched out the current ‘crisis’ of psychiatry. However, not to entirely absolve psychiatry, I think we need consider what precisely are those larger forces that psychiatry is ‘aided by and dependent upon’ that has made psychiatry so vulnerable to both overly exuberant embraces of particular theories (be they biological or social) and therapeutics, only to repudiate them under a new set of circumstances. To understand our current ‘crisis,’ I hope Scull's essay encourages us to look further and to ask not why the profession is in crisis but, rather, what are the forces that keep psychiatry from crisis when the profession has abandoned its sickest patients to homelessness, jails, and premature deaths.
Returning to Scull's, Reference Scull1993 essay, he quotes Michael MacDonald that insanity is ‘the most solitary afflictions to the people who experience it; but…the most social of maladies to those who observe its effects’ (p. 3). Arguably, what makes psychiatry appear to be in continual crisis is the profession's inability to come to grips with the fundamental nature of psychiatric disease as simultaneously social, psychological and biological.
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I have no financial interests to declare, and have received no financial support for this paper