ÌÇÐÄVlog

I remember when textbooks of psychiatry had an introductory chapter describing the subject's history. Nowadays it seems the history of psychiatry has become too specialist to be left to psychiatrists, retired nurses, hospital chaplains and the like. While recently browsing the shelves in a bookshop, I found only one text with a historical introduction. Edward Shorter, professor in the history of medicine, University of Toronto, and the author of histories of the family as well as psychosomatic illness, would no doubt see his thesis confirmed in its title, Biological Psychiatry . In contrast to the last general histories of psychiatry, written 30 or more years ago, and which saw the culmination of the field as the "discovery" of the unconscious and the ascendancy of the psychoanalytic paradigm, this book ends with the triumph of the "second biological psychiatry".

Shorter's story starts at the end of the 18th century with the era of "moral therapy"; the insane could apparently respond to systematic, right-thinking treatment in therapeutic asylums. However, by the late 19th and early 20th centuries these dreams had died. Asylum populations had grown astonishingly, tenfold or more in some places, and moral therapies had become impossible. This growth, it is argued, followed a true increase in mental disorder as well as changes in family sentiment serving to diminish the acceptance of the seriously disturbed at home. The late 19th century saw the "first biological psychiatry", German-dominated because of state-supported asylums and university departments. It faded because of its detachment from patients and its failure to make useful discoveries. It also floundered in the dead-end doctrine of "degeneration" (the later consequences of which are not really examined). In parallel, lesser forms of mental illness remained the province of the "nerve doctors" in private spas and clinics. It was here that "psychotherapies" developed through a recognition of the power the person of the doctor could exert over patients. From the early 20th century to a peak in the 1960s, the lights of science were dimmed during a "psychoanalytic hiatus". Shorter discerns a variety of reasons, among which were the opportunity for psychiatrists to move out of the asylum to the respectability of the office, and the exercise of a medical monopoly. There remained alternative approaches during this period, resulting in new physical treatments - malarial treatment for neurosyphilis, chloral hydrate, bromides, sleep therapy, "shock" and lobotomy. After the 1960s the "second biological psychiatry", with its neurobiological paradigm, came "roaring back from the grave", resulting in breakthroughs in genetics and a "cornucopia" of new drugs. However, psychiatry remains prone to straying from the true path of science through its susceptibility to the interests of the pharmaceutical industry, and to popular values defining which psychological abnormalities deserve treatment.

The story is very well told in a lively and engaging manner. Many ideas demand attention and are often delivered with a punch (sometimes directed, without apology, at an opponent historian). The style can verge on the journalistic, with amusing or irreverent "sound-bites"; for example, the potency of the psychiatrist today apparently derives from the combination of "neurochem and neurochat". But I found the book, in the main, disappointing. It is breathtakingly partisan and, with some exceptions (the "nerve doctors" and psychotherapy; 19th-century German and French psychiatry), too superficial. Conceptual foundations of modern psychiatry are not presented with adequate subtlety - for example, disorders are either biologically or psychologically caused. Few in the field see it so simply. Shorter oversells recent developments in biological psychiatry; virtually everything he regards as well established can be contested. Major contributions from the social and behavioural sciences are ignored. There are significant gaps; for example, the number of patients in mental hospitals in this country has decreased by three-quarters from a peak of about 150,000 in the 1950s, now being roughly that of the mid-19th century. This deserves more emphasis than it receives here; "community psychiatry" is dismissed as a "grotesque joke". Because of such deficiencies, together with an unacceptable number of inaccuracies, the book fails to carry authority.

A general history of psychiatry is really a history of a society's aspirations and fears, and how these shape responses to behaviours that are difficult to understand. Changing values largely define what is regarded as a mental disorder and what can be done for, or to, sufferers, and by whom. Mental health practitioners are in danger of no longer being reminded of this, but perhaps the kind of synthesis attempted in this book is impossibly grand. Yes, we can welcome real progress in establishing psychiatry on a scientific basis; but my patients are probably as demonised today as they were in the past. Just listen to the media clamour for more controls in the name of securing "public confidence and safety".

George Szmukler is consultant psychiatrist and medical director, Maudsley Hospital, London.