American psychiatry in the new millennium: a critical appraisal

Abstract

This article casts a critical eye over the development of American psychiatry from 1980 to the present. It notes the rapid decline of psychoanalysis that followed the publication of DSM III; the rising influence of genetics and neuroscience; the re-emphasis on the biology of mental illness; and the collapse of public psychiatry that accompanied deinstitutionalization. It argues that while genetics and neuroscience have made scientific progress, the clinical utility of their findings to date has been very limited. The fifth edition of the DSM was supposed to base itself on this new science but that proved impossible. Diagnosis remains purely phenomenological and controversial. One of the ironies of research on psychiatric genetics is that has failed to find either a Mendelian origin of schizophrenia and depression or to validate the importance of hypothesized candidate genes. Genome-wide association studies have instead uncovered risk factors for major mental illnesses, but these overlap considerably, and the genetic associations are not dispositive. Most of those who carry these genetic variants do not develop mental illness. The status of psychopharmacology since the mid-1950s is scrutinized, as is the influence of the pharmaceutical industry on contemporary psychiatry, and the implications of its recent decision to abandon work in this arena. The paper concludes with an assessment of the crisis that it contends confronts contemporary American psychiatry: its overemphasis on biology; the urgent questions that persist about diagnosis and therapeutics; concerns about the directions of future research; and its inability to reduce the excess mortality that plagues the mentally ill.

Teachers With Special Needs. De-Psychiatrization of Children in Schools

“…. .to believe that whatever received a name must be an entity or being, having an independent existence of its own", is strongly reinforced by the nowadays dominant biomedical paradigm (Scull, 2021), in which the main focus of research, communication and education around disorders is on their supposed biological underpinnings. Despite decennia of expensive brain research with ever better equipment and technologies, no single biomarker has been established for any of the disorders defined in the DSM (Scull,2021).…”

Studying mental health problems as systems, not syndromes

“…Some of these changes, such as the transition from a categorical to a dimensional model of personality disorders in DSM-5, were supported by data. But most diagnostic categories and thresholds have been shaped predominantly by historical forces, not empirical evidence (Lilienfeld, 2014;Lux et al, 2010;Scull, 2021;Zimmerman et al, 2006). If Wernicke, a rival of Kraepelin, had not died prematurely in a bicycle accident, today's DSM may well have looked somewhat (Kendler, 2016).…”

“…One of many examples of a lack of integration is biological reductionism, a framework that has dominated our research landscape since the 1980s, and constrained research funds, health-care policy, and clinical service delivery (Borsboom et al, 2019;Miller, 2010;Scull, 2021). While I don't know if individual researchers or organizations hold the view that mental disorders can be reduced to biology-reduced in the sense that they are nothing more than biology (van Riel & van Gulick, 2019)-research and funding priorities have often progressed as if this position as endorsed.…”

“…Fried 7 (First et al, 2018). Genome-wide association studies have identified hundreds of hits for common mental disorders, but variants are often related to multiple psychiatric and medical diagnoses, other variables such as personality traits or smoking (Cai et al, 2019), and have little clinical utility given the very small amount of explained variance (Kapur et al, 2012;Kendler, 2012Kendler, , 2019Scull, 2021). Celebrated breakthroughs in the field, such as blood tests for depression, have quickly and quietly disappeared (Bilello et al, 2015).…”

Commentary in response to Andrew Scull's ‘American psychiatry in the new millennium: a critical appraisal’

“…In this issue of Psychological Medicine, he addresses modern American psychiatry. He begins by noting the past 50 years as described by Jeffrey Lieberman (Scull, 2021). Here, American psychiatry leaves the unfortunate psychoanalytic era and now arrives as a scientific medical field with very substantial advances in knowledge and therapeutics.…”