An MSW colleague of mine lent me this. Here is my note to her after I started reading it.
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Dear _______,
I read the book you lent me about suitcases in an asylum’s attic, or at least I read about half of it. Unfortunately that was all I could stand. In case you are considering lending the book to others, especially students, I would like to share my thoughts on the book.
The authors have a stridently anti-psychiatry worldview, and do not admit their own biases. To give one example, after going on for pages about how the hospital was warehousing this guy against his will, they admit the hospital had repeatedly offered to place him out for over a decade and he had continually refused. Another example is saying that none of the patients had tried to kill themselves or others, but even in the stories I read there were patients who struck out at others, had the cops called for threats they made, etc., and they admit one person did try to starve himself. The authors do admit in one spot that there is inherent selection bias in choosing as they did to look at people whose luggage was left there—e.g. it selects for those without families, those who stayed until they died, etc.—but do not appreciate in the rest of the book that this bias could explain a lot of the things that they point out as recurrent themes in these patients. There are a lot of similar examples that I’m not quoting here, but I can bring in my notes if you’re interested.
More importantly, there are numerous factual errors, like saying that there is no evidence that antipsychotics reduce emotional symptoms in people with schizophrenia. That’s just silly—there are many dozens of randomized controlled trials that prove that very point. The authors appear to assume that if one would just talk to the patients, they would get better. They supply no details of how this would be done, and no evidence for the effectiveness of this approach, yet it seems this is one of their main complaints about how the patients were treated. Ironically this also directs attention away from the non-medication intervention that is most proven to work in schizophrenia: family education.
Plus there are repeated insinuations that psychiatrists are motivated mostly by greed and ignorance and paternalism. I’m sure this describes some psychiatrists some of the time, and it does appear that mistakes were made in the care of some of these patients and that some of them could have been sent home (if they had a home). But it is not only factually wrong but also mean-spirited to assume that’s always what is going on. This is frequently accompanied by “scare quotes,” like saying that hospitals wouldn’t release names of patients at their death ‘due to “confidentiality” concerns.’ Additionally, the authors are upset that patients seemed to get no useful treatment, but the book covers only the first half of the 20th Century, and in fact there were no useful treatments for schizophrenia at that point in time, and only one really useful treatment for major depression, and that after about the 30's. The repeated implication is that patients still get no useful treatments today. Similar comments could be made about the authors’ description of unmodified ECT, which hasn’t been used in America for decades now.
Finally the authors endorse some really wacky, out-there stuff, like saying explicitly that hallucinations are to be welcomed not treated. The book repeatedly implies that the patients’ symptoms—which, when described, are often quite serious—would not really be a problem for the patients if the psychiatrists would just stay out of the way.
The stories are actually interesting, and the authors obviously invested a lot of work in researching the patients’ lives, so it is a shame that the book is full of dangerous misinformation and hateful innuendo.
Thanks,
Kevin
Sunday, January 04, 2009 1:08 AM
Kevin Black wrote:
About my comment that there were no effective treatments in the early 1900s . . . it's not quite accurate, though it is true that the first effective specific treatment for schizophrenia was not discovered until the late 1950's. Actually, leaving aside belladonna, opium, magnesium salts, and other naturally occurring pharmaceuticals, chloral hydrate was synthesized as early as 1869. Apomorphine was synthesized in the same year and soon thereafter was tried as a treatment for schizophrenia (marketed today in the U.S. for treating Parkinson disease; it has no pharmacologic similarity to morphine despite the name). Barbiturates were first sold for medical use in 1903-1904. The psychiatrist Wagner von Jauregg received the Nobel Prize for physiology or medicine in 1927 for his fever therapy for neurosyphilis--actually giving people malaria on purpose to provoke bouts of fever, then giving quinine to kill off the malaria. (That may sound nuts now, but if you read the Nobel speeches, available online, quantitative response data were available, and at the time this was dramatically more effective than previously available therapy for this [then] major cause of psychiatric illness. Still, his public health work with iodine therapy for dementia due to dietary hypothyroidism is generally felt to be a more long-lasting contribution.) ECT (for schizophrenia), lithium salts (for mania) and amphetamine (for what we now call ADHD) were all introduced in about 1937. They are all still important mainstays of treatment, though ECT's efficacy for schizophrenia is quite limited and it is now used primarily for treating mood disorders. It is still the most effective known treatment for major depression.