In Defense of Biological Psychiatry
Biological psychiatry has come under attack, but what does history teach us?
Posted Apr 06, 2019
Biological psychiatry has come under attack in recent years. Antidepressant drugs, for instance, have been criticized on various fronts and have become particularly contentious (see, for example, Kirsch, 2009). The popular media is flooded with articles on the supposed widespread dangers and ineffectiveness of psychiatric medication.
As a psychoanalytically-trained psychotherapist and as a former adherent to a purely psychosocial approach to mental disorder, I am well aware of the arguments made against biological psychiatry. I feel compelled to address this popular controversy, not only as a practicing clinician but also as a student of psychiatric history.
A mere 70 years ago, there existed not a single effective treatment (with the notable exception of electroconvulsive therapy) for any serious mental disorder—no antidepressants, no mood stabilizers, no antipsychotics. In the United States, more than 600,000 seriously mentally ill were confined to state asylums, which functioned more as warehouses than hospitals. The only thing that could be done for schizophrenia, for example, was simple confinement and an attempt at fostering a decent social environment in the hospital setting. Notoriously, lobotomy and insulin shock therapy were common, as were other medically dubious and oft-harmful attempts at biological intervention. Hospitals were grossly overcrowded, psychiatrists had caseloads of hundreds of patients, and psychiatric care lagged miserably behind the rest of medicine.
Psychoanalysis offered help for the mildly ill and the personality disordered, but the seriously disturbed were without recourse. Many lived out their entire lives within the four walls of a state mental hospital. Unable to work, marry, or have children, hospitalized patients were isolated from the rest of society—locked up and forgotten.
This all began to change in the 1950s with the development of three drugs that forever altered the course of global psychiatry: chlorpromazine, imipramine, and lithium. Within a few years, psychiatrists finally had effective treatments for the field's three flagship disorders, i.e., schizophrenia, manic-depression (bipolar disorder), and depression. A tide began to shift in the conceptualization and the treatment of serious mental illness. The psychiatric journals, which had led with articles on transference reactions and unconscious processes, began instead publishing papers on neurobiology and psychopharmacology. Discovery of the benzodiazepines in the 1960s further broadened the range of biologically treatable psychiatric conditions.
For the first time in human history, something could be done in the outpatient setting for severe mental illness. The state hospitals gradually closed and were replaced with (a grossly underfunded) community mental health system. Patients who had been committed for years could finally live alongside family and friends in the community. The birth of psychopharmacology also marked the birth of freedom for hundreds of thousands of mental patients.
Critics of biological psychiatry have short memories. If it were not for the pioneers of psychopharmacology in the 1950s and 60s—people like Nathan S. Kline, M.D.—psychiatric patients would likely still be condemned to the same dismal conditions with little hope for anything approaching a normal life.
Modern criticism of biopsychiatry is almost always based on the logical fallacy that mental illness is not genuine disease (see my 2018 article with psychiatrist Ronald Pies addressing this and other myths here). The idea that contemporary psychiatrists see mental illness as simple "chemical imbalance"—an argument frequently leveled by those opposed to psychiatric medication—is another grossly inaccurate characterization. Most psychiatrists today subscribe to the biopsychosocial model as pioneered by George Engel.
Even psychologically-minded theorists have historically recognized the need for a medical psychiatry. Carl Jung famously admitted that some cases of schizophrenia appear to be purely organic in origin. The psychiatrist-psychoanalyst Silvano Arieti, a pioneer in the psychotherapy of schizophrenia, advocated for a unified biological and psychodynamic approach to the disorder, noting that medications have an important place in schizophrenia treatment.
Attempts to explain serious mental illness in purely psychosocial terms notwithstanding, biological interventions represent the most effective means of treating serious mental disorder. While psychiatric drugs may occasionally be overprescribed and misused—for instance, for mild cases of depression and anxiety, or in the treatment of personality disorder—as a whole they have been one of the most significant advances in the history of medicine. When psychiatry is done right, it has results that are on par or superior to those in all other medical specialties.
Every day, those of us in the field see patients get better on psychiatric medication, many of whom would have been deemed, in the not-so-distant past, to be beyond help. While a dose of skepticism can be healthy for any field, an outright disavowal of biological psychiatry is to throw the baby out with the bath water.
Author's note: The title of this article was borrowed from a letter written many years ago by Emil Kraepelin, widely considered the father of modern psychiatry.
Kirsch, I. (2009). The emperor's new drugs: Exploding the antidepressant myth. London: The Bodley Head.