PSYCHIATRY

PSYCHIATRY. Psychiatry, a branch of medicine, is a discipline that takes the full range of human behaviors, from severe mental illness to everyday worries and concerns, as its study. In the nineteenth century the discipline was largely concerned with the insane, with the mentally ill sequestered in large custodial asylums located largely in rural areas; as a result, psychiatrists were cut off from medicine's main currents. In the early twentieth century, under the leadership of such men as Adolf Meyer and E. E. Southard, psychiatry expanded to address both the pathological and the normal, with questions associated with schizophrenia at the one extreme and problems in living at the other. Psychiatrists aligned their specialty more closely with scientific medicine and argued for its relevance in solving a range of social problems, including poverty and industrial unrest, as well as mental illness. Psychiatry's expanded scope brought it greater social authority and prestige, while at the same time intermittently spawning popular denunciations of its "imperialist" ambitions. The discipline's standards were tightened, and, in 1921, its professional organization, formerly the American Medico-Psychological Association, was refounded as the American Psychiatric Association. In 1934, the American Board of Psychiatry and Neurology was established to provide certification for practitioners in both fields.

Over the course of the twentieth century, psychiatry was not only criticized from without but also split from within. Psychiatrists debated whether the origins of mental illness were to be found in the structure and chemistry of the brain or in the twists and turns of the mind. They divided themselves into competing, often warring, biological and psychodynamic camps. Psychodymanic psychiatry, an amalgam of Sigmund Freud's new science of psychoanalysis and homegrown American interest in a range of healing therapies, was largely dominant through the early 1950s. From the moment of its introduction following Freud's 1909 visit to Clark University, psychoanalysis enjoyed a warm reception in America. By 1920, scores of books and articles explaining its principles had appeared, and Freudian concepts such as the unconscious, repression, and displacement entered popular discourse. The dramatic growth of private-office based psychiatry in the 1930s and 1940s went hand in hand with psychoanalysis's growing importance; by the early 1950s, 40 percent of American psychiatrists practiced in private settings, and 25 percent of them practiced psychotherapy exclusively. The scope and authority of dynamic psychiatry were further expanded in World War II. Nearly two million American recruits were rejected from the services on neuropsychiatric grounds, and the experience of combat produced more than one million psychiatric casualties— young men suffering from combat neuroses. Only one hundred of the nations' three thousand psychiatrists were psychoanalysts, yet they were appointed to many of the top service posts. The prominent psychoanalyst William Menninger, for example, was made chief psychiatrist to the army in 1943, and he appointed four psychoanalysts to his staff. The immediate postwar period was psychodynamic psychiatry's heyday, with major departments of psychiatry headed by analysts and talk of the unconscious and repression the common coin of the educated middle class.

The cultural cachet of psychoanalysis notwithstanding, most psychiatric patients were institutional inmates, diagnosed as seriously disturbed psychotics. The numbers of persons admitted nationwide to state hospitals increased by 67 percent between 1922 and 1944, from fiftytwo thousand to seventy-nine thousand. Critics charged psychiatrists with incompetence, neglect, callousness, and abuse. Both desperation and therapeutic optimism led psychiatrists to experiment with biological therapies, among them electroconvulsive shock therapy (ECT) and lobotomy. ECT was introduced to enthusiastic acclaim by the Italian psychiatrists Ugo Cerletti and Lucio Bini in 1938. Within several years it was in use in 40 percent of American psychiatric hospitals. Prefrontal lobotomy, first performed by the Portuguese neurologist Egas Moniz in 1935, involved drilling holes in patients' heads and severing the connections between the prefrontal lobes and other parts of the brain. More than eighteen thousand patients were lobotomized in the United States between 1936 and 1957. Psychosurgery promised to bring psychiatrists status and respect, offering the hope of a cure to the five hundred thousand chronically ill patients housed in overcrowded, dilapidated institutions. Instead, it was instrumental in sparking, in the 1960s and 1970s, a popular antipsychiatry movement that criticized psychiatry as an insidious form of social control based on a pseudomedical model.

Biological psychiatry entered the modern era with the discovery of the first of the antipsychotic drugs, chlorpromazine, in 1952. For the first time, psychiatrists had a means to treat the debilitating symptoms of schizophrenia—hallucinations, delusions, and thought disorders. Pharmacological treatments for mania and depression soon followed, and psychiatrists heralded the dawn of a new "psychopharmacological era" that continues to this day. The introduction, in the 1990s, of Prozac ®, used to treat depression as well as personality disorders, brought renewed attention to biological psychiatry. The oncedominant psychodynamic model, based on the efficacy of talk, fell into disrepute, even though studies showed that the best outcomes were obtained through a combination of drug and talk therapies. The profession, divided for much of the century, united around the 1980 publication of the third edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-III), psychiatry's official manual of nomenclature that endorsed a descriptive, nondynamic orientation, thus signaling psychiatry's remedicalization.

Psychiatry has had to constantly establish its legitimacy within and beyond medicine. Despite enormous advances in the understanding and treatment of mental illness, in the mid-1990s psychiatry was one of the three lowest-paid medical specialties (along with primary care and pediatrics). Psychiatry's success has spurred increased demand for services. But with increasing pressure on healthcare costs, and with the widespread adoption of managed care, psychiatry—that part of it organized around talk—has seemed expendable, a form of self-indulgence for the worried well that society cannot afford. Insurers have cut coverage for mental health, and psychologists and social workers have argued that they can offer psychotherapy as ably as, and more cheaply than, psychiatrists, putting pressure on psychiatrists to argue for the legitimacy of their domination of the mental health provider hierarchy. In this, psychopharmacological treatments have been critical, for only psychiatrists, who are medical doctors, among the therapeutic specialties have the authority to prescribe drugs. Advances in the understanding of the severe psychoses that afflict the chronically mentally ill continue to unfold, fueling optimism about psychiatry's future and insuring its continuing relevance.

BIBLIOGRAPHY

Grob, Gerald N. Mental Illness and American Society, 1875–1940.Princeton, N.J.: Princeton University Press, 1983.

Healy, David. The Antidepressant Era. Cambridge, Mass.: Harvard University Press, 1997.

Valenstein, Elliot S. Great and Desperate Cures: The Rise and Decline of Psychosurgery and Other Radical Treatments for Mental Illness. New York: Basic Books, 1986.

Elizabeth A. Lunbeck

See also Mental Illness; Psychology.