Mad Science: The Treatment of Mental Illness Fails to Progress [Excerpt] - Scientific American

As civilized human beings, we like to console ourselves with visions of progress, illusory as that concept often proves to be. Perhaps we have not seen progress in the realms of literature and art (though some would dispute that claim), but surely science moves forward, and medicine too, insofar as it is a science rather than an art. In the developed world, at least, we now enjoy longer, and certainly more materially abundant if not culturally richer and happier lives. Except if we are mad, that is. Modern psychiatry and its potions notwithstanding, one of the more sobering realities about serious mental illness in the twenty-first century is that its sufferers not only die at a much younger age on average than the rest of us (as much as twenty-five years sooner), but also that the incidence of serious illness and mortality in this population has accelerated in recent decades. On this most basic of levels we seem to be regressing.

Psychiatry seems to be in trouble too. The neo-Kraepelinian approach it adopted when DSM III was published in 1980 at first served it well. The reliability and replicability of psychiatric diagnoses increased, and embarrassing disputes about what was wrong with a particular patient receded into the past. Freudians lost the internecine professional war decisively, and psychiatrists embraced once more a biological account of mental disorders that superficially made sense to their medical brethren, however schematic it remained. And the new approach proved extraordinarily attractive to the drug companies, who underwrote the psychiatric research enterprise, and as the years went by, increasingly influenced the very terms in which mental illness was discussed, even the categories of illness that purportedly exist in the world.

Each successive edition of the manual, the revised third edition (III R) of 1987, the fourth edition (IV of 1994) and its ‘text revision’ (IV TR of 2000), adhered to the fundamental approach psychiatry had adopted in 1980, though new ‘illnesses’ were added on each occasion, the definitions of psychopathology were tweaked and the page count mounted. But as ‘illnesses’ proliferated in each revision, and the criteria for assigning a particular diagnosis were loosened, the very problem that had led to the invention of the new versions of the DSM recurred, and major new threats to psychiatric legitimacy surfaced.

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Those put in charge of the enterprise announced that the logic that had underpinned the two previous editions was deeply flawed, and they would fix things. Drawing on the findings of neuroscience and genetics, they would move away from the symptom-based system that they now acknowledged was inadequate, and build a manual that linked mental disorders to brain function. They would also take account of the fact that mental disorder is a dimensional, not a categorical kind of thing: a matter of being more or less sane, not a black and white world with sanity in this corner and mental illness in that. It was a grand ambition. The only problem was that it was an ambition impossible to fulfill. Having thrashed about in pursuit of this chimera, those running the project were ultimately forced to concede defeat, and by 2009 they were back to tinkering with the descriptive approach.

Mad Science: The Treatment of Mental Illness Fails to Progress [Excerpt] - Scientific American