Book Review

Out of Its Mind: Psychiatry in Crisis — A Call for Reform

N Engl J Med 2001; 345:300July 26, 2001

Article

Out of Its Mind: Psychiatry in Crisis — A Call for Reform
By J. Allan Hobson and Jonathan A. Leonard. 292 pp., illustrated. Cambridge, Mass., Perseus, 2001. $26. ISBN: 0-7382-0251-7

In Out of Its Mind: Psychiatry in Crisis, Hobson, a psychiatrist and neurophysiologist, and Leonard, a freelance science writer, have created the equivalent of a medieval triptych depicting hell, purgatory, and heaven. As in all such paintings, hell is the most interesting.

Hobson and Leonard's hell is the present state of psychiatry. The authors describe the fate of patients with severe psychiatric disorders who were “unceremoniously decanted out of America's mental hospitals,” how laws governing involuntary hospitalization have become “more deranged than the behavior” of those requiring treatment, and the swing of psychiatry's pendulum “from the brainless mind of Freud to the mindless brain of biomedicine.” Contemporary psychiatric services, contend the authors, are “like the croquet game in Alice in Wonderland, where the flamingoes, soldiers, and hedgehogs ordered to serve as mallets, wickets, and croquet balls spend a lot of time getting in the way and doing the wrong thing.” The situation is so dire that “psychiatry doesn't need a minor tuneup. It needs resuscitation. Psychiatry is dying.”

The purgatorial road leading out of hell, according to Hobson and Leonard, goes through a fusion of neuroscience and psychotherapy that the authors dub “neurodynamics.” This road through neurodynamics, claim the authors, will lead to a new psychiatry that integrates neuroscience with the best aspects of psychotherapy. They argue, however, that “much or even most of Freud's psychology has been discredited.” In a world of neurodynamics, persons with minor psychiatric disorders, such as some anxiety disorders or lesser degrees of depression, would be treated with psychotherapy alone. Major disorders, such as bipolar disorder and schizophrenia, would be treated with medications and psychotherapy. The current practice of using drugs to treat minor disorders is, say the authors, like shooting “pheasants with elephant guns.”

As in the medieval triptychs, however, the heaven created by the authors is full of hope but vague on many details. The authors acknowledge that our present knowledge of the neuroscience of psychiatric disorders is limited — “we lack general agreement on anything but a very muddy picture” — yet claim that “brain science has advanced enough to provide a foundation capable of uniting the two halves of psychiatry's split personality.” They advocate the creation of “a hundred or so regional mental health centers for diagnosis, treatment, and research,” describing almost precisely the more than 800 community mental health centers (CMHCs) created with federal funds in the 1960s, but they fail to mention the CMHCs as such or why they failed to do the job that Hobson and Leonard are now proposing should be done again.

The authors' largest omission is their failure to do more than mention briefly the present funding system, which is the single largest cause of the contemporary disaster called psychiatric services. It is Medicaid regulations, and especially federal restrictions on funding institutions for mental diseases, that are driving the system. These regulations have led to managed care, the closing of needed state hospitals, and the transfer of patients to other institutions such as nursing homes, shelters, and jails. All the present fiscal incentives encourage states to dump patients onto the streets in order to shift the cost of their care from the states to the federal government; there are no fiscal incentives to follow patients or to provide good care. Hobson and Leonard call for improved continuity of care but fail to recognize that the present funding system virtually guarantees that such continuity will not occur.

Despite this limitation, they should be commended for even attempting to paint a future for psychiatry. They bravely “encourage the new trend toward outpatient commitment” and discuss frankly the failure of psychiatry to recruit the best medical students into the profession. For a profession in which the various schools of neuroscience and psychotherapy are barricaded in their individual fortresses, talking only to themselves, the authors preach dialogue and understanding. Even if the hinges holding the triptych together are loose, the fact that the three canvases even exist side by side is, in itself, no small accomplishment.

E. Fuller Torrey, M.D.
Stanley Foundation, Bethesda, MD 20814