A dance to the music of the century

Modern psychiatry began in the early 19th century from a social psychiatric seed. The early alienists, Pinel and Tuke, Esquirol and Connolly believed that managing the social milieu of the patient could contribute significantly to their changes of recovery. These physicians produced the first classificatory systems in the discipline. At the turn of the century, university psychiatry, which was biologically oriented, began to impact on psychiatry, especially in Germany. This is seen most clearly in the work and classificatory system of Emil Kraepelin (Healy, 1997). At the same time, a new psychodynamic approach to the management of nervous problems in the community was pioneered most notably by Sigmund Freud. This led to yet another classification of nervous problems.

In the first half of the century, unlike German and French psychiatry, British psychiatry remained largely aloof from the influences of both university and psychodynamic approaches. It became famously pragmatic and eclectic. Edward Mapother, the first director of the Maudsley Hospital typified the approach. Aubrey Lewis who succeeded him, as well as David Henderson in Edinburgh, both of whom trained with Adolf Meyer in the USA, were committed to Meyer's biopsychosocial approach (Gelder, 1991). The social psychiatry that stemmed from this was to gain a decisive say in European and world psychiatry in the decades immediately following the Second World War.

Things at first unfolded no differently in that other bastion of English-speaking psychiatry - America. In the first decade of the 20th century, Meyer introduced Kraepelin's work to North America, where it had a modest impact, failing to supplant Meyer's own biopsychosocial formulations. In 1909, Freud visited the USA. He appears to have regarded it as an outpost of the civilised world, one particularly prone to enthusiasms. At this point, Freudian analysis restricted itself to handling personalities and their discontents. It initially made little headway in the USA.

There was another development in the USA that was to have a decisive impact on British and world psychiatry in due course. In 1912, the USA legislature passed the Harrison's Narcotics Act, the world's first piece of legislation which made drugs available on prescription only, in this case, opiates and cocaine. While substance misuse was not at the time a part of psychiatry, which confined itself worldwide almost exclusively to the management of the psychoses, this move to prescription-only status by involving medical practitioners in managing the problem almost by necessity meant that the issue of personalities and their disorders would at some point become part of psychiatry.

The years before the Second World War led to two sets of developments. First, there was a migration of psychoanalysts from Europe to North America, so that by the 1940s a majority of the world's analysts lived there. In America, what had been a pessimistic worldview was recast with an optimistic turn, in part perhaps because the War demonstrated that nervous disorders could be environmentally induced and at the same time genetic research was temporarily eclipsed. This new remodelled psychoanalysis abandoned Freud's reserve about treating psychosis. It triumphed and drove American psychiatry to a view that everyone was at least latently ill, that everyone was in need of treatment and that the way to put the world's wrongs right was not just to treat mental illness, but to resculpt personalities and promote mental health (Menninger, 1959).

Second, sulphonamides were discovered and the War stimulated research, which made penicillin commercially available. The success that stemmed from these led to explosive growth in the pharmaceutical sector. The search for other antibiotics led to the discovery in France of antihistamines, one of which turned out to be chlorpromazine. The Food and Drug Administration in the USA responded to these new drugs by making all new drugs available on prescription only. European countries followed suit. This was to bring not only problems of personality but also the vast pool of community nervousness within the remit of non-analytic psychiatry.

The psychoanalysts gained control of American psychiatry in the decade before the introduction of the psychotropic drugs. By 1962, 59 of 82 psychiatric departments were headed by analysts, all graduate programmes were based on analytical principles and 13 of the 17 most recommended texts were psychoanalytical (Shorter, 1996). As a director of the National Institute of Mental Health put it:

“From 1945 to 1955, it was nearly impossible for a non-psychoanalyst to become a chairman of a department or professor of psychiatry” (Brown, 1976).

As early as 1948, three-quarters of all committee posts in the American Psychiatric Association (APA) were held by analysts (Shorter, 1996).

One of the features of these developments was that a rootless patois of dynamic terms seeped out into the popular culture to create a psychobabble, with untold consequences for how we view ourselves. Another feature, that is regularly cited was the way the analytical totalitarianism that resulted handled failures of patients to get well or of critics to come on side. These were turned around and viewed as further indicators of the psychopathology afflicting patients and critics respectively (Dolnick, 1998).

Walter Reich (1982) argued that this style was a defence against pessimism that stemmed at least in part from America's peculiar needs for solutions to complexity. He was writing at a time of change, just after the publication of DSM-III (American Psychiatric Association, 1980) DSM-III, which is commonly cited as marking the triumph of a neo-Kraepelinian revolution in American psychiatry, was widely seen as changing the rules to favour a newly emerging biological psychiatry. Its message that psychiatry's business was to treat diseases, was a counter to perceptions that the analytical agenda had become a crusade that had taken “psychiatrists on a mission to change the world which had brought the profession to the verge of extinction” (Bayer & Spitzer, 1985).

Part of the stimulus to DSM-III had come from participation in the International Pilot Study of Schizophrenia, where American psychiatrists had felt keenly the disdain with which their diagnostic views were regarded by their European counterparts, who were British or who, like Norman Sartorius, Assen Jablensky and others, had close links with the Maudsley (Spitzer, 2000). The DSM-III was fiercely resisted in the UK, whose leading authorities had been the key figures behind the international system of classification (ICD) for several decades. The new system was dismissed - “serious students of nosology will continue to use the ICD” (Shepherd, 1981). But an empire was slipping from British hands (Spitzer, 2000). The World Psychiatric Association took as its banner for its 1996 meeting the slogan “One World, One Language”. Few people, attending the meeting at least, thought this language was anything other than biological or neo-Kraepelinian.

Reich (1982) commented on the change in American psychiatry from analysis to a more biologically-based discipline but this change, he suggested, was likely to be governed by similar dynamics to those that drove the earlier turn to psychoanalysis. By the 1990s, the rise of psychopharmacology and biological psychiatry was complete. The chances of a non-neuroscientist becoming a head of a psychiatric department in the USA was highly unlikely and not much more likely in the UK. The standard textbooks were heavily neuroscientific in their emphasis. Where once the APA was controlled by analysts, annual meetings now generated millions of dollars - largely from pharmaceutical company sponsored satellite symposia, of which there were 40 in 1999, at approximately $250 000 per symposium in addition to fees for exhibition space and registration fees for several thousand delegates brought to the meeting by pharmaceutical companies, as well as several million dollars per annum from sales of successive versions of the DSM.

The UK, which had once stood dismissive of American trends and diagnoses, increasingly followed American leads. Fashions in recovered memory therapies or fluoxetine-taking rapidly crossed the Atlantic, influenced in part perhaps by the ever-increasing attendance of British psychiatrists at APA meetings. By 1999, it was possible that greater numbers of British psychiatrists, sponsored largely by pharmaceutical companies, attended the APA meeting than the annual meeting of the Royal College of Psychiatrists, a development that would have been incredible a decade before.

Biological psychiatry, meanwhile, had not restricted itself to the psychoses from whence it came. By the end of the century, the complete transformation of personality rather than simply the treatment of disease was becoming the goal. This was most clearly articulated in Peter Kramer's Listening to Prozac (Kramer, 1993). Where once the psychiatric concern had been for symptoms as these reflected diseases, the emphasis was increasingly on the management of problems by biological means. The extent to which community nervousness stems from social arrangements rather than diseases is clearly uncertain, but where the best estimates of annual prevalence rates of depressive disease stood at between 50 and 100 per million in 1950, by the mid-1990s they had risen to 100 000 per million for depressive disorders as defined by the DSM, with even higher rates for depressive symptoms (Healy, 1997).

Despite the neo-Kraepelinian revolution, some American opinion leaders were beginning to argue that the profession faced disaster if it did not stop offering to solve social ills and if it did not pull back to a medical focus (Detre & McDonald, 1997). Where once blame had been put on families, or mothers in particular, the 1990s became the decade of blaming the brain (Valenstein, 1998). By the end of the decade, the psychobabble of yesteryear was fast being replaced by a newly minted biobabble. The Guardian newspaper ran a feature on “Oh no! We're not really getting more depressed are we?” in which a psychologist, Oliver James, pondered whether the British have become a low-serotonin people (James, 1997). Finally, an ever increasing emphasis on long-term treatment with psychotropic agents, along with difficulties with withdrawal from them (a perennial British concern), inevitably recalls Karl Kraus' quip about analysis becoming the illness it purported to cure.

The mass treatment of problems with psychotropic drugs could not but in itself run into problems. Reports of suicides, homicides and other events while taking fluoxetine (Healy et al, 1999) led Eli Lilly to devise a strategy to manage criticism which involved blaming the disease, not the drug (Cornwell, 1996). On 20 April 1999, two students took firearms into a high school in Littleton, Colorado, killing 12 students, one staff member and then themselves. Within days of suggestions that one of the teenagers had an antidepressant in their blood stream, the APA Website carried a statement from the Association's president:

“Despite a decade of research, there is little valid evidence to prove a causal relationship between the use of antidepressant medications and destructive behavior. On the other hand, their [sic] is ample evidence that undiagnosed and untreated mental illness exacts a heavy toll on those who suffer from these disorders as well as those around them” (American Psychiatric Association, 1999).

Many of those who take up psychiatry as a career might be thought to do so for fairytale or romantic reasons. At some point they will have nourished fantasies of helping patients with neuroses or psychoses to recover to the point of being invited to participate in the ball of life once more. In the course of a century, psychiatrists attending the ball have elegantly changed partners on a number of occasions. It is less clear that those who are not invited to the ball have seen much difference as a consequence of changes on the dance floor. When the clock strikes for the new millennium, are any of the dancers likely to be bothered by a stray glass slipper or does that just happen in fairytales?