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…You invest a ton of money. You invest- … $20 billion– More than $20 billion in a particular approach. And at the time you’re constructing this you say finally because of all the work that’s being done in genetics we now have decoded the human genome. We have PCR so we can chop it up and we can look at bits of it. We have a lot more understanding of the role of neurotransmission in the brain. Surely we’re going to be able to recast our diagnostic system based on underlying pathology so that we won’t be worrying about symptoms anymore. We’ll be looking at the actual underlying pathological changes that have taken place. But in the event, it turned out they couldn’t do that. By about 2008 they had thrown up their hands and said, no, we’re going to have to continue to refine, rely upon the same basic approach that we developed in 1980. And when that document came out, and there’d been a lot of criticism, some of it from Robert Spitzer, who had been largely in control of DSM-III and DSM-IIIR, and then his successor Allen Frances, who’d run DSM-IV, they both were fiercely critical about what was going on and said it was being done in the dark and it was done in secrecy and it wasn’t scientific. And when it was about to come out, Thomas Insel and Steven Hyman, the two then existing at the preceding director of the National Institute of Mental Health, denounced the document as unscientific and useless. So if you’re talking about a crisis, that’s a crisis for the field. If its diagnostic system is being dissed by leading figures like that, what else was a problem? The difficulties with the drug existing therapies particularly had become more and more manifest. To make matters worse, partly because Big Pharma had sometimes behaved, shall we say, rather unethically. Sometimes with these drugs it had hidden things that undercut their claims, it had manufactured studies, it had manipulated data, and it got caught out and it paid billions of dollars in damages for some of the tricks it had got up to. Not just in psychiatry—I mean Vioxx, for example, the painkiller, was another huge scandal and it was a five billion dollar settlement—but the drug companies had suffered some reputational damage. Beyond that, they didn’t have any real clues. Unfortunately neuroscience hadn’t thrown up new targets for different forms of drug development, and they decided they could make ome reputational damage. Beyond that, they didn’t have any real clues. Unfortunately neuroscience hadn’t thrown up new targets for different forms of drug development, and they decided they could make more money with spending their money on research on other diseases, not mental illness. A crisis was you were stuck with a set of drugs that Steve Hyman says aren’t really any advance on the ones by accident we found in the fifties, mm-hmm, and there isn’t new research, unless it’s small startups, going on to develop new ones. So, you have an increasing sense your diagnostic process is falling apart, your drug treatments’ limitations are becoming more manifest, and as well, for people with serious mental illness, public policy has screwed things up badly. So, if you, a person with serious mental illness, you will die, on average, fifteen to twenty-five years before the rest of us. That gap has been growing rather than diminishing. So, that’s not a good thing. It’s not something I want to lay entirely at the door of psychiatry, so Don’t get me wrong. I think a lot of this is public policy that has really abandoned treatment for the seriously mentally ill, and you see it on the streets of our cities. You see the sidewalk psychotics. You see people who are cycling between brief periods of inpatient care, the gutter, or the flop house, and the jail. So the three largest centers of inpatient psychiatric care, if you can call it that, in the United States today are the Los Angeles County Jail, Cook County Jail in Chicago, and Rikers Island in New York. That’s shockingly because, by their very nature, of course, prisons aren’t equipped to deal with serious mental illness. Some dark ways to return to the asylum era.…

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