Ideas·IDEAS AFTERNOON

What psychiatrists still don't know about mental illness

How can it be that psychiatry still doesn’t know what causes major mental problems such as depression, bipolar disorder, and schizophrenia? Historian Anne Harrington and writer Marya Hornbacher explore psychiatry’s messy medical past and surprisingly uncertain present.

'We don't understand any major mental disorder biologically,' says Harvard historian of science

According to Anne Harrington, psychiatrists predict it will take 40 years to truly understand mental disorders biologically. (Shutterstock / SeanidStudio)
Listen to the full episode53:59

* Originally published on October 28, 2019.

Anne Harrington puts it plainly: "We don't understand any major mental disorder biologically."  

The Harvard historian of science takes no pleasure in relating this surprising fact. She knows that people with depression, schizophrenia and bipolar conditions want better treatments for their symptoms. She also acknowledges that psychiatrists and researchers ARE "working hard to change that situation."

But her book, Mind Fixers: Psychiatry's Troubled Search for the Biology of Mental Illness, surveys a flawed medical field that has been unable to come to any clear consensus around the causes of — or cures for — mental illness. 

Patients still wait

Her observations may be news to outsiders, but to not to writer, Marya Hornbacher. For her forthcoming book, she spoke to some 1500 people who, like her, are living with major mental disorders.

"We're aware that we're the lab rats, and that's uncomfortable," Hombacher told IDEAS. 

Anne Harrington is the author of 'Mind Fixers: Psychiatry's Troubled Search for the Biology of Mental Illness.' (Daniel Nedelcu)

The reasons for this situation are many.  Anne Harrington feels there has been a central challenge for the profession in grappling with the enormous range of mental suffering, which spans from conditions like anxiety and depression, to mania and psychosis.

But there's also been a problem inside the profession, she says, in that psychiatry as a medical field has often been more "tribal" than most. That insularity has led to more rivalry than collaboration and, she argues, has stalled progress.

A divided approach

Psychoanalytic psychiatry grew out of Freudian thinking around the patient: childhood trauma, the family, and social factors. But biological psychiatry, which emerged from neuroanatomy, argued the answers were hidden somewhere inside the body. 

In the 19th century, the biological approach meant postmortem brain examinations of patients who died in asylums and mental hospitals. Infection was also suspected as a source. Proof that syphilis was behind at least one disorder encouraged the biological hypothesis.

Extreme cures in the 20th century

Treatments could be brutal, and were often conducted without consent. ECT, insulin shock therapy, and malarial fever therapy were reported to work for some patients. Sterilization was permitted in Virginia, and that eugenicist-informed law was referenced later by the Nazi regime in their sterilization program of the 1930s.

Some doctors successfully promoted frontal lobe lobotomy in the mid-20th century. The experimental surgery indeed stopped disruptive or socially unacceptable behaviours, but at the enormous expense of the patient's memory, personality, and agency. 

Sigmund Freud founded psychoanalysis, based on bringing unconscious emotions and experiences into consciousness. But biologically-based psychiatry examines mental disorders through the lens of the nervous system. (Hans Casparius/Hulton Archive/Getty Images)

Limits of pharmaceutical era

When the so-called "major tranquilizer" chlorpromazine was used to control symptoms of psychosis in the late 1960s, a new era of pharmaceutical treatments dawned. 

By the 1980s, Anne Harrington says, psychiatry as a field embraced the biological project, and made a premature "declaration of victory… [leading the public to believe] insights were also on hand and new treatments were on hand." 

With the general public adopting drugs from Valium in the 1950s to Prozac in the 1990s and various others since, the fortunes of pharmaceutical companies also rose higher.

Psychiatry left talk therapy to other professions, and became centred on diagnosis and prescription.

Writer and journalist Marya Hornbacher is the author of Madness: A Bipolar Life. Her new book set to be released is called, We've Been Healing All Along: Stories of Hope on the Road to Mental Health. (maryahornbacher.com)

Making psychiatry better

Historian Anne Harrington acknowledges that there are well-intentioned psychiatrists and good research and treatment. But she also believes that overall the field needs a more collaborative, "patient-centred" approach.  She has been told that more effective treatments are still decades away.

Writer Marya Hornbacher also calls for a less top-down approach, saying many people with mental illness feel that "psychiatry is way, way way out of touch... they don't know what it is like to live with a mental health disorder... to take the meds, or deal with the side effects.

"They don't know, really what we're capable of."


Guests in this episode:

  • Anne Harrington is the Franklin L. Ford Professor of the History of Science at Harvard University, and the author of Mind Fixers: Psychiatry's Troubled Search for the Biology of Mental Illness, among other books.
  • Marya Hornbacher is a writer, journalist, and professor. She's the author of Madness: A Bipolar Life, and the forthcoming title, We've Been Healing All Along: Stories of Hope on the Road to Mental Health.

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