Psychiatry Finds Its Stride and Shows Potential for Making Progress
Former APA President Authors a New Book, “Shrinks”
Few fields of medicine are as misunderstood as psychiatry. The field predates the technology needed to truly understand the brain, so for decades psychiatry existed as an unscientific discipline, lacking an empirical foundation. Also, the definition of “mental illness” has been susceptible to cultural variability and has changed with time, revealing more about the prejudices of an era than the true nature of the illness. Homosexuality, for example, was defined as a mental disorder in the DSM until 1974. This combination of factors provided fertile ground for charlatans and purveyors of pseudoscience.
But psychiatry has since redeemed itself and now has a solid—and burgeoning—scientific foundation and a competent evidence-based clinical capability to treat mental illness and save lives. The many people who suffer from bipolar disorder, depression, schizophrenia, anxiety disorders, and other mental illnesses can now be effectively treated. But lack of awareness and stigmas prevent many from asking for help. Unlike a faulty heart or a bad liver, mental illness seems to say something about one’s character. As Jennifer Lawrence remarked in her Oscar acceptance speech: “It’s just so bizarre how in this world if you have asthma, you take asthma medication. If you have diabetes, you take diabetes medication. But as soon as you have to take medicine for your mind, it’s such a stigma behind it.” People don't want to think of themselves or their loved ones as fundamentally damaged. For this reason, many opt to endure the pain alone. Some opt not to endure at all.
Jeffrey Lieberman, MD, the Lieber Professor of Psychiatry, the Lawrence C. Kolb Professor of Psychiatry, and chair of psychiatry at P&S, is keenly aware of psychiatry’s reputation. As former president of the American Psychiatric Association, the most influential psychiatric organization in the country, he was responsible for introducing the world—media, politicians, fellow medical professionals, and the public at large—to the latest edition of the DSM, the “Bible of psychiatry.” In addition, during his tenure he contributed to important health care legislation such as the Mental Health Parity Addiction Equity Act’s Final Rule and the Patient Protection Affordable Care Act. Add to this Dr. Lieberman’s three decades of research on mental illness and clinical care with patients. Perhaps no one is better qualified to explain what psychiatry is and what it can do.
His new book, “Shrinks: The Untold Story of Psychiatry,” takes readers through the history of the field, from its unscientific genesis to its current state as a legitimate scientifically driven medical discipline. Featuring numerous case studies and portraits of such titans as Sigmund Freud and Eric Kandel, “Shrinks” frames the debacles and breakthroughs that have defined psychiatry, without whitewashing its past. Dr. Lieberman talks about his work and the field of psychiatry.
What was your goal in writing this book?
I had never written a book for general audiences. I was prompted to write this book because after 30 years of studying mental illness and caring for patients, I could no longer bear the idea that 25 percent of the population—90 million Americans, 1.5 billion people in the world—were at risk of suffering from mental illness because of lack of awareness, shame, or inability to find competent care. But that is the sobering reality. Too many people who develop a mental illness go untreated for no good reason. This simply cannot—and must not—continue.
I came up in an era that was an inflection point for psychiatry, when it became able, for the first time in history, to change the course of people’s lives for the better with genuinely effective treatment. After a career spent in research, when I became department chair and had to deal with many challenging administrative issues, I guess I got radicalized a little bit by the inefficiency and dysfunction of our health care system and decided to run for president of APA. I’ve never been particularly political, but I saw that it could be an effective platform to influence government policy and public opinion. Over the next two years, while I was in Washington, I worked with the administration and Congress on legislation and dealt with the media on issues ranging from explaining the new DSM to mental illness and violence in the wake of tragic events like Newtown, Conn., and Aurora, Colo. In the midst of this, a friend suggested that I write a book as an effective, very public way to set the record straight about what psychiatry is—and what it’s able to do.
Why do you think psychiatry is so distrusted?
Psychiatry has had somewhat of a checkered history. It has always been viewed with uncertainty—or, in some cases, suspicion—by the public and the media, as well as others in medicine. The main reasons are that it could not adequately explain what mental illness was and what caused it. If you couldn’t do that, how could you expect people to have confidence in its therapeutic capability.
Sometimes it seems like there is more mental illness now. For example, something like ADD wasn’t on anyone’s radar just a few decades ago; now it seems that every other child has it. Are we getting better at identifying mental illness or is it actually becoming more prevalent?
There are relatively few new medical conditions. AIDS was a new condition and chronic fatigue syndrome is new. But for the most part, human illnesses have been around for centuries. It’s the same with mental illnesses. They were simply hiding in plain sight. The best example is autism. It has been present in humankind for millennia but wasn’t described in medical literature until 1943. However, after it was described and could be diagnosed, there weren’t any treatments for it. Initially it was thought to be fairly rare. And then something happened in the 1990s: Several powerful people had children or grandchildren with autism, and suddenly it became more visible, eventually becoming an urgent public health program. Then the CDC says autism is increasing. All of a sudden there’s an epidemic. In fact, the vast majority of this “increase” came from greater awareness and identification. It’s the same with ADD: It’s always been there. But we do have more ADD here in the United States. Do we actually have a higher frequency? Probably not. The bar for diagnosis has been lowered, and the alacrity to write scripts has increased. Some parents are looking for an edge for their children, some kind of cognitive enhancer, so there’s a vogue to it. Unfortunately, kids may be exposed to medication they don’t need, which can have adverse consequences, including precipitating psychotic reactions. There’s not an epidemic with ADD. It’s just overdiagnosed.
So many people with mental illnesses keep it hidden. How do we reach them?
Anytime a movie star or a politician or a titan of industry has a psychiatric problem and is willing to talk about it, it helps decrease the stigma. Patrick Kennedy has been an important figure in this regard. He has candidly talked about his bipolar disorder and drug addiction. Robin Williams’ suicide was also an opportunity, though less felicitous, to help get people to take depression seriously. People aren’t sure how to regard mental illness. Is it a phase? Are you a freak? We need more awareness of what it looks like when someone is mentally ill. In terms of what you can do to help a friend or loved one: If you see them acting differently, strangely, or distressed, inquire about it. If there’s a real basis, maybe suggest they see someone. Err on the side of caution. So many people, after they lose a loved one, say, “I wish I would have known.”
People seem to want to talk about mental illness only after a tragedy. Though it does raise an important issue that needs to be addressed, doesn’t the discussion increase the stigma, making “mental illness” synonymous with “violent”?
The media do not do articles about mental illness, for the most part. And when they do, it’s the result of some tragedy or scandal, like the shooting of a Congresswoman Giffords in Arizona or the bizarre behavior of Amanda Bynes. What’s notable is that in both instances, it’s about someone with an untreated mental illness. Treatment could have changed everything. I have firsthand experience with people who have done terrible things while at the mercy of their symptoms, and after they are placed in jail or a hospital and finally receive the treatment they need, they become aware and insightful and experience real remorse.
Do you believe that we’ll eventually be able to not only treat symptoms, but actually cure mental illness?
Absolutely. It took a long time for psychiatry to find its stride, scientifically speaking. But now we’re really in a strong position and the momentum is building. The maturational process has been longer and slower for our field. We’re the late bloomers. It wasn’t that psychiatrists weren’t trying as hard as scientists in other medical specialties. It’s that the brain proved much more difficult to understand than the other organs. And the functions of the brain we’re studying are the most sophisticated and highly evolved in humankind. We didn’t have the technology before. It’s only now that psychiatrists have the neurobiology, neuroimaging, genetics, and pharmacology tools and approaches that we can begin to make adequate progress. After all, Galileo couldn’t prove heliocentrism without a telescope.