Mental Illness, The Trouble With Medicating
7 min readThe standard of care for Mental illness in the United States has drastically changed since the 1950s, when more than half a million patients resided in enormous state hospitals. As pharmaceutical firms developed new antipsychotic medications, national policy shifted such that most of the old hospitals have now closed. Today, the majority of U.S. patients, even those with serious mental illnesses such as schizophrenia, bipolar syndrome, and major depression, receive only short-term, in-patient medical treatment to quell symptoms before being sent home.
The old asylums were the scenes of some well-publicized abuses and poor conditions. Yet their closures and the parallel embrace of medications did not solve the issue of how to best care for people. The current mental health system leaves many mentally ill patients no better off, says Joel Braslow, a historian and psychiatrist at the University of California, Los Angeles. In some cases, the situation has grown worse.
In the 2019 Annual Review of Clinical Psychology, Braslow and UCLA colleague Stephen Marder argue that our current “age of psychopharmacology” has shrunk society’s sense of responsibility toward the mentally ill. Whereas most psychiatrists once viewed mental illness as a complex interaction between a patient’s biology and social context, Braslow and Marder contend, it is now often seen more narrowly as merely symptoms to be medicated.
Braslow blames this shift for what he calls our society’s “total failure” in caring for its most vulnerable members: Roughly 140,000 seriously mentally ill people are now homeless on city streets, while 350,000 others are serving time in prisons and jails, where their illnesses get little treatment.
Knowable Magazine spoke with Braslow about the history of this transformation and what it would take to better serve the multitudes of people living with psychiatric problems.
Why do you call this the “age of psychopharmacology”?
I think about it in two different but interrelated ways. First, it underlines our growing reliance on drugs to treat disorders of the mind. Today, one in six Americans takes a psychoactive drug. This has reinforced the idea that the drugs treat specific diseases, much like insulin treats diabetes. For example, Tipper Gore (the ex-wife of former Vice President Al Gore) has explained her own depression as a chemical imbalance, with her brain running out of serotonin like a car runs out of gas. This description implies that depression has both a specific cause — in her case, depleted serotonin — and a specific cure, a drug.
Secondly, there’s our shrinking vision of what causes psychiatric disease and what we can do clinically for those who suffer from it. Prior to the late 1960s and 1970s, American psychiatrists tended to take a more expansive view. Today’s greater focus on the individual and a simple model of disease has helped justify the belief that drugs or psychotherapies hold the key to alleviating psychiatric disease. However, this view ignores the fundamental nature of psychiatric disease as simultaneously biological, psychological, and social.
What accounts for this shift?
Psychoactive drugs have been used since the 19th century, but they were generally regarded as little more than sedatives — referred to as “chemical straitjackets.” The chance discovery of the major classes of psychotropic drugs in the 1950s changed the status of psychopharmacology. These new compounds did more than simply sedate; they actually treated many of the symptoms of psychiatric disease, such as hallucinations, depressed mood, and disordered thoughts.
However — and this is a crucial point — throughout the 1950s and much of the 1960s, psychiatrists largely saw psychotropic drugs as just one part of an overall regimen, a part that neither dominated nor defined the nature of the disease and its treatment. Psychiatrists continued to see psychiatric disease in a holistic manner, in which symptoms could involve an individual’s failure to function in the social world and their inner torment. Treatment remained similarly expansive, especially when the illness warranted state hospitalization.
Things changed dramatically from the 1970s onward. It’s tempting to attribute this to the drugs’ effectiveness, but this is simply not the case. There has been little change in the actual efficacy of antidepressants, antipsychotics, and anti-anxiety drugs over the last half-century. Social, economic, and cultural circumstances did far more to bring on the age of psychopharmacology than did the effectiveness of the drugs themselves.
For one thing, psychiatric hospital administrators came under increasing pressure to decrease their hospitalized patient population. Hospital records from the 1970s show doctors under pressure to discharge patients earlier and earlier. So physicians, understandably, focused on symptoms that could be quickly and easily treated, and relied increasingly on drugs as their primary intervention. Under such circumstances, it became more and more impossible to address the thornier problems of how the patients functioned in the world.