Hans Pols, PhD

Psychotic episodes are  devastating for the individuals who have them, their friends, and families.  Wouldn’t it be wonderful if individuals could receive treatment before the  first psychotic episode strikes, so that it could be avoided altogether? After  all, “an ounce of prevention is worth a pound of cure.”[1 Unfortunately, in  psychiatry, we are a long way from achieving primary prevention-there is no  vaccine for psychosis, nor have clear genetic markers for severe and persistent  forms of mental illness been identified.

Throughout the 20th  century, psychiatrists have therefore focused their attention on the early  detection of signs and symptoms of mental ill health, assuming that early  treatment will stop conditions from becoming worse. However, the ideal of  secondary prevention can only be realized if these early signs and symptoms, or  a “pre-psychotic syndrome” can be identified successfully. During the 20th  century, psychiatrists have defined many of these “pre-mental illness  syndromes”; unfortunately, it has not always been demonstrated that they indeed  constitute the early phases of severe and persistent forms of mental illness.

In June 2011, a number  of Australian newspapers reported that a high-profile medical trial targeting  psychosis in young adults would not go ahead. It was to be conducted by Prof.  Patrick McGorry, who had been Australian of the year (an honorary and mostly  symbolic title bestowed by the Australian government on an unusually deserving  citizen advocating worthy causes). In the proposed trial, youths as young as  age 15 would receive Seroquel (quetapine) when they were first diagnosed, not  with psychosis but with attenuated psychosis syndrome (previously called  psychosis risk syndrome). Treating young adults with this syndrome would nip  the danger in the bud-their potential psychosis would be treated before it even  arose. The trial was to have been sponsored by the drug’s manufacturer,  AstraZenaca, which, like many pharmaceutical companies, was probably eager to  test its medication on a younger age group to expand the market for its  medications. What could be wrong with such a commendable initiative?

Attenuated psychosis  syndrome is proposed for inclusion in DSM-5 and has attracted an unusual amount  of discussion (and dissent). In particular, its relation to psychosis is  unclear. Emeritus professor Allen Frances, MD, who chaired the DSM-IV Task  Force, is a fierce critic of the concept. According to him, there is hardly any  evidence that attenuated psychosis syndrome, if left untreated, will ultimately  develop into a full-blown psychosis (current estimates state that this will  happen in merely 10% to 20% of cases). The number of “false positives” is  therefore staggering. Dr Frances warns that treating a group of individuals of  whom 90% would never become psychotic appears to be a waste of resources and a  rather risky proposition.

McGorry’s proposed  trial was widely criticized by psychiatrists world-wide, raising a number of  significant ethical problems. First, there is the high number of false  positives who would receive medication for a condition they would never develop  if left untreated. The trial would not target incipient psychosis but probably  address more or less unrelated conditions. This leads to the second ethical  problem: a great number of young people would therefore be put on a medication  they do not need. This would not matter so much if only aspirin or vitamins were  tested. Unfortunately, Seroquel has many highly undesirable side effects  including extreme weight gain and diabetes. One should only prescribe it when  it is absolutely necessary.

 by the United States government after allegations  it paid kickbacks to physicians while promoting the  drug for unapproved uses by children, the elderly, veterans and prisoners for  $525 million.[2 It has also settled, for $647 million, product liability cases  for misleading patients about the risks of diabetes and weight gain associated  with the use of the drug. Total expenses in legal fees associated with Seroquel  are now $1.9 billion, which constitutes less than 5 months of Seroquel sales. Not a great medication to prescribe to  individuals who do not need it.

Prof McGorry’s  proposed research has attracted (unfavorable) media attention (in Australia); I  highlight it here-not because it is exceptional or unusual in any way-but  because it illustrates ways of thinking that have been part and parcel of 20th  century psychiatry. The most important of these is the ideal of secondary  prevention in psychiatry: it is imperative to treat psychiatric conditions when  they first appear and when they are not as serious as they could become if left  untreated. This prevents them from becoming worse and less responsive to  treatment. This strategy is of course commendable when there is a proven link  between these less serious conditions and more serious ones. In most cases, it  has been assumed that such a link exists; it has hardly ever been demonstrated.

The emphasis on  prevention is not unique to psychiatry but characterizes developments in  several (if not all) medical specialties. In days long since gone, one would  see a dentist when one’s toothache became unbearable-today, dentists fill  cavities and polish our teeth so that we will never end up in this situation.  They also whiten and straighten our teeth although this prevents neither  toothaches nor tooth decay. Today, the demands we make of physicians (and  dentists) far exceed those of average patients a hundred years ago. Today,  physicians do a lot more than treat serious illness-and we expect them to do  that.

Most historians of  psychiatry have discerned two themes in the history of 20th century psychiatry.  First, there has been a broadening of the definition of what constitutes mental  ill-health. A wide range of conditions in between mental health and severe and  persistent forms of mental illness have been identified and investigated. The  formerly almost absolute distinction between mental health and mental illness  has been replaced by a wide spectrum of conditions, which has led to the  blurring of the distinction between the normal and the abnormal.

Second, conditions on  this spectrum have increasingly become the target of psychiatric intervention;  psychiatrists now treat a variety conditions less serious than severe and  persistent forms of mental illness but definitely in need of treatment. During  the 20th century, prevention has been the most important argument to hold both  themes together: treating less serious psychiatric conditions prevents these  from becoming worse-because it has been assumed these conditions will  inevitably become more serious over time. It was well into the 20th century  before any effective medical treatments for severe and persistent forms of  mental illness were developed. Mental hospitals were severely overcrowded while  little could be done for their inmates. Therapeutic nihilism reigned. Any type  of intervention that promised to prevent mental illness from developing or  becoming worse was therefore worth considering.

The blurring of the  distinction between normal and abnormal is generally associated with Sigmund  Freud: according to psychoanalysis, nobody is entirely normal, although some  individuals are better in keeping their unconscious desires in check than  others, thereby maintaining an appearance of mental health and normality.  Despite differences in appearance, we are all to a certain extent mad. Views  like these open up unexpected vistas for psychiatric attention: behind the  everyday veils of normality, happiness, and adjustment hide psychopathology,  lust, and perversion.

Nevertheless, the  blurring of the distinctions between the normal and the abnormal is not unique  to psychoanalysis. The historian of psychiatry Elizabeth Lunbeck has analyzed  how, in the 1910s, American psychiatrists proposed psychopathy as a category to  designate forms of psychopathology that had previously been unrecognized  because they had been able to pass as normal.[3 No longer would mental illness,  as insanity, be limited to insane asylums, where it could be contained  successfully. On the contrary, the widespread presence of psychopaths  everywhere, hiding under the veil of normality, threatened the social fabric of  American society. These views made psychiatric intervention even more  compelling: not only would it remove sick individuals from public life, it  could also protect the social order.

In my own work on the  history of the mental hygiene movement, similar themes appear. In the 1920s,  mental hygienists launched a major project on the treatment of juvenile  delinquency to prevent children from developing life-long criminal careers. The  concept of adjustment as an essential marker of mental health, central to the  philosophy of mental hygiene, brought a great range of human behavior under the  purview of psychiatry. Instead of treating maladjustment in adults (for  example, adults with mental illness), mental hygienists argued that treating  maladjustment in children (for example, children with enuresis or temper  tantrums) would prevent serious forms of mental illness from arising later in  life.

By labeling all forms  of undesirable conduct as “maladjustment,” it became self-evident to expect  relatively innocent forms of the behavior to become serious later on. Rather  than punish delinquency, the therapeutic treatment of children with  “pre-delinquent syndrome” could be expected to bear fruit. Unfortunately, the  central assumptions of this approach were never put to the test, and would most  certainly not hold up when investigated properly. Led by their convictions,  psychiatrists and mental hygienists were not bothered by this. They focused on  lesser complaints, while neglecting the plight of the mentally ill in  increasingly overcrowded mental hospitals (leaving them to somatic  psychiatrists who experimented with insulin therapy, metrazol shock therapy,  ECT, and lobotomy).

The mistaken  impression could arise that the two themes in the history of psychiatry  identified thus far (blurring the distinction between normal and abnormal, and  targeting less serious states for psychiatric intervention) were characteristic  of psychoanalysis or other psychiatric approaches focusing on mental and  behavioral factors. It would be too easy to dismiss them because, with  psychiatry becoming increasingly biological and scientific, such trends have  been reversed today.

Nothing could be  farther from the truth, however. During the last 20 years or so, we see these  trends developed in an unprecedented way in psychopharmacological psychiatry.  In the 1950s, only individuals with severe and persistent forms of mental  illness received medication such as Thorazine. Today, fidgety and distracted  kids as well as shy adults are portrayed as individuals who could benefit from  psychopharmacology. Increasingly, a wider range of psychiatric medications are  prescribed to young children, with the idea that early intervention will  prevent problems from getting worse. It is this mind-set, now more than a  century old, that made McGorry’s research project appear innovative and cutting  edge.

Dr McGorry has  introduced a slight modification to his study, which will now go ahead. Instead  of Seroquel, he will now test the efficacy of fish oil.

Franklin B.  Protection of towns from fire (Letter). 

 Wilson D. AstraZeneca settles most Seroquel suits. 

http://prescriptions.blogs.nytimes.com/2011/07/28/astrazeneca-settles-most-seroquel-suits/

The Psychiatric Persuasion: Knowledge,  Gender, and Power in Modern America

 Princeton, NJ: Princeton University  Press; 1994.

Articles

Psychotic episodes are devastating for the individuals who have them, their friends, and families. Wouldn’t it be wonderful if individuals could receive treatment before the first psychotic episode strikes, so that it could be avoided altogether? 

Treating Mental Illness Before it Strikes

In the sixth edition of his famous 2-volume textbook 

, which appeared in 1899, Emil Kraepelin introduced the by now well-known distinction between dementia praecox (soon to be called schizophrenia) and manic-depressive illness. Exhausted after finishing the manuscript and checking the page proofs, he decided to take a sabbatical with his older brother, the botanist Karl Kraepelin. One of their destinations was Buitenzorg (today’s Bogor), near Batavia (Jakarta), the capital of the Dutch East Indies, since it boasted both a large mental hospital and a botanical research station, located near the famous botanical gardens.

After their arrival in early 1904, Emil occupied himself with the classification and categorization of mental illness in the tropical zone, while Karl did the same with tropical flora. (He also collected a great number of ants as a favor to Auguste Forel, who used them in a monograph on Javanese ants.) Emil Kraepelin was eager to determine the environmental, social, cultural, and ethnic factors that influenced the types, prevalence, and expression of mental illness-in other words, he wanted to know the extent to which the famed categories of his 

 applied outside of Europe (some of his conclusions were published in the 

Zentralblad fr Nervenheilkunde und Psychiatrie 

in 1904). This was the basis for his title as the founder of comparative psychiatry.

The establishment of the Buitenzorg mental hospital had a long history: planning had lasted over 40 years and it took 2 decades after construction had commenced before the first patients were admitted. It proved to be very hard to ascertain the prevalence of mental illness among the Javanese and, consequently, how many beds were needed. Many colonial physicians argued that the Indonesians were more akin to noble savages and far behind the social and mental development of Europeans. Since they viewed mental illness as an inevitable accompaniment of advanced civilization, they believed that the incidence of Javanese mental illness would be very low. Others argued that the contact with a much more advanced civilization was causing widespread social dislocation and individual turmoil, leading to a much higher incidence of mental illness. These inner tensions and ambiguities in the discourse of colonial psychiatry provided great interpretive flexibility as well as few reliable estimates about mental illness.

Kraepelin investigated 100 European, 100 indigenous patients, and 25 patients of Chinese descent at the Buitenzorg mental hospital. One wonders how these interviews were conducted and the impression Kraepelin made on these patients. Kraepelin, already a rather intimidating presence for his own students and colleagues, would have needed at least 2 interpreters to interview Indonesian patients: an Indonesian physician to translate Javanese (or Sundanese, or whatever was the patient’s first language) into Dutch, and a second one to provide a translation into German. This would naturally make it more difficult to establish rapport with patients and influence the outcome of his investigations. Nevertheless, concerns like these did not deter Kraepelin who went about his business as methodically as ever.

Kraepelin’s conclusions are interesting. He discovered that paresis or tertiary syphilis was virtually absent among Java’s indigenous population. The rates among European patients were equal to those found in the Western world. Interestingly, he explained this difference by assuming that Eastern brains were less susceptible to syphilis (rather than, for example, assuming that the moral standards of Europeans were significantly looser). He also concluded that alcohol-related mental disease was virtually absent among the Javanese. This was easily explained by the absence of the consumption of alcohol among the Javanese, most of whom are Muslim.

With respect to manic-depressive illness, Kraepelin thought that it was really striking that the depressive episodes were of rather short duration in Javanese patients, who tended to have prolonged and highly expressive manic episodes (one form of which was running amok). With respect to dementia praecox, visual and auditory hallucinations were much less prevalent among the Javanese, and their delusions were less systematized. The prognosis of Javanese patients was significantly better than that of Europeans. Following Kraepelin’s lead, P.H.M. Travaglino, a Dutch colonial psychiatrist used a simple analogy to explain this finding (probably following a more Bleulerian interpretation of schizophrenia): In a poor man’s house, one only finds a few chairs and one table. It would thus take considerable effort to create a confused mess. Similarly, the primitive mind contains only a few elements, which are therefore much harder to become disorganized. Apparently, cultural biases common to colonial societies made their influence felt in psychiatric diagnosis as well.

Kraepelin did not investigate how the different ethnic groups became institutionalized. For Europeans with serious forms of mental illness, a medical certificate generally sufficed. Indigenous patients were only admitted if they had created a public nuisance or after they had broken the law (and were not considered rational). In particular, men who had run amok were commonly institutionalized (if they survived). Depressed patients, on the contrary, were almost never admitted, since they were highly unlikely to break the law. Kraepelin’s conclusions were limited because his study population was a highly selected group. Basing conclusions on the nature of mental illness on an analysis of mental hospital populations however, was not unusual at the time.

Kraepelin asked a number of questions that still occupy informed psychiatrists today. Are there forms of mental illness unique to specific cultures? To what extent is the expression of mental illness shaped by social and cultural factors? In addition, Kraepelin was inspired by the project of his senior colleague Wilhelm Wundt, who was formulating a 

 (folk psychology or anthropological psychology). On the basis of his clinical observations, he concluded that the normal Javanese mind was primitive, primarily emotional, childish, and highly suggestible (even though he did not conclude that Europeans were alcoholic philanderers lacking in impulse control).

These conclusions corresponded with those of the anthropologist Lucien Lvy-Bruhl in his writings on the primitive mind. They also corresponded with biases held by the European population in the Indies. One could therefore conclude that Kraepelin asked a number of interesting and intriguing questions but was limited in the ways he sought to answer them by anthropological, psychological, and psychiatric views that were common in his time.

In the sixth edition of his famous 2-volume textbook Psychiatrie, which appeared in 1899, Emil Kraepelin introduced the by now well-known distinction between dementia praecox (soon to be called schizophrenia) and manic-depressive illness.

Emil Kraepelin on Cultural and Ethnic Factors in Mental Illness

The Politics of War Trauma: The Aftermath of World War II in Eleven European Countries

 by Jolande Withuis and Annet Mooij (eds). Amsterdam: Aksant; 2010.

By now the story of the origin of posttraumatic stress disorder (PTSD) is fairly well known: the diagnosis was the surprising outcome of an unusual set of political circumstances during the 1970s in the United States. At that time, a somewhat unlikely coalition was formed between psychiatrists who treated disgruntled Vietnam War veterans, advocates for Holocaust survivors, and representatives of the feminist movement who demanded public attention for the long-lasting psychological effect of physical and sexual abuse of women.

These 3 groups had observed similar sets of symptoms in the traumatized individuals under treatment. And in all three groups symptoms at times appeared many years after the original event. In all 3 groups, the PTSD diagnosis provided medical recognition of their suffering, opened up avenues for treatment, and presented a justification for compensation claims.

Accounts on the origins of PTSD generally emphasize the originality and novelty of the diagnosis. 

The Politics of War Trauma: The Aftermath of World War II in Eleven European Countries 

dispels this notion thoroughly. Unusually rich and extensive medical and political debates on the 

 of extraordinary suffering of World War II took place in many European countries after 1945. Physicians who themselves had experienced deportation and life in Nazi concentration camps played a key role in these debates.

In all European countries, the public recognition of these horrifying experiences depended on a variety of social, political, cultural, and medical factors, which all changed over time. The essays in 

analyze the unlikely political coalitions that made the recognition of war-related suffering possible; which groups were included and which were excluded; and how changes in medical, social, cultural, and political thinking influenced this process.

Central to the formation of medical theories on the health effects of war as well as their social recognition (in the form of pensions, entitlement to compensation, or health care) were the way European nations came to terms with World War II. Politicians, religious leaders, and other opinion makers engaged in extensive efforts to frame the memory of the war in ways that positioned themselves (and their nations) favorably and that downplayed culpability, guilt, and collaboration.

The collective memory of any war is inherently fraught with myths about widespread and heroic resistance and martyrdom at its core (rather than banal collaboration and innocently looking the other way, which was much more common). These myths consist of more or less deliberate acts of forgetting, falsification, obfuscation, fabrication, and confabulation. In many countries, the ranks of the Resistance swelled enormously immediately after the armistice. At the same time, government bureaucracies and the armed forces were symbolically purged of a small number of collaborators (while most others remained in their position). Presenting a favorable image of one’s past during the war was particularly necessary for those European countries which sought to hide their official allegiance to Nazi Germany and many acts of collaboration, including Austria, Italy, Vichy France, Denmark, and Spain (which is unfortunately missing in this volume).

Austria, as the alleged first victim of Nazi aggression, has always denied any responsibility for its complicity in Nazi atrocities. It referred claims from Austrian survivors of concentration camps to Germany while it paid pensions to all Austrians who had served in the German 

 Denmark celebrated a very small and select group of resistance fighters to deflect attention from its less-than-admirable war record (it surrendered without a fight and its government accommodated the Germans without too much friction). Luxembourg made much of the “pupils of the nation,” a group of orphaned children of killed resistance fighters.

Questions of which individuals were entitled to compensation or war pensions (for suffering, lost income, incapacity, or health problems) were resolved within the context of these sets of narratives to remember the war, commemorate its heroes, and vilify the villains. According to many, resistance fighters and soldiers who resisted the invading Nazi powers deserved recognition. Yet many post-war regimes were loath to acknowledge the contribution of communist resistance fighters and were not eager to include them as potential recipients of pensions.

In France, for example, an influential bureaucrat was proud that he personally had made sure that 75% of applications by Communists were rejected (p 89). In Belgium, Flemish Catholics (who had not been unsympathetic to the Nazis) were upset that the proposed pension legislation would benefit more Walloon than Flemish individuals (because there had been far more Walloon resistance fighters) and insisted on emendations. In West Germany, Communist resistance fighters were written out of the historical record and hardly received any recognition and compensation.

In East Germany, the opposite happened. Only those individuals who had furthered the international interests of the Soviet Union were honored. All the others had to wait until after the wall came down.

Questions remained about individuals who were conscripted to work in German ammunitions factories. They were forced to become collaborators and did not fit the image of heroic resistance fighters. Recognition for them was slow in the coming. During the first 2 decades after World War II, Jews returning from the concentration camps found it very difficult to get any claims acknowledged (the few who survived the extermination camps felt positively unwelcome upon their return).

Before World War II, many Jews did not have the nationality of the country they were living in-which initially excluded them from any consideration for compensation. Veterans’ organizations and other pressure groups were essential in formulating the terms under which recognition for the traumas of war could be gained-conscripted workers had to form their own associations to make their demands known before they were recognized.

Until 1965, most countries emphasized the resistance when remembering the war. More recently, the Holocaust and the fate of European Jews have become central to the recollection of the war. That shift had far-reaching consequences for bureaucratic recognition and compensation regimes.

It is one thing for post-war governments to outline who is entitled to compensation and pensions and what conditions have to be met to receive these. It is quite another thing how these rules were interpreted and applied by faceless bureaucrats. And here, some striking events occurred.

For example, Italian bureaucrats repeatedly asked a Jewish Auschwitz survivor for her medical records during her time there to substantiate that her current incapacity was related to her war-time experiences. I already mentioned the pride of a French bureaucrat in making sure Communists would not receive any compensation. In Germany and Austria, former Nazi physicians often wrote dismissive medical reports of Jewish concentration camp inmates. Laws formulated with the best intentions meant little in the face of bureaucratic obstructionism, which was the exception rather than the rule.

This richly documented volume summarizes many historical points about the early beginnings of PTSD: 
•The cleansing (or whitewashing) of national reputations, the activities of various pressure groups, and the evolving state of medical knowledge contributed to the recognition of war as trauma which constituted grounds for recognition, support, and compensation. 
•European physicians had already formulated the diagnosis the KZ-syndrome (KZ refers to Konzentrationslager, German for concentration camp). 
•When PTSD arrived in 1980, it became yet another element in these discussions without fundamentally altering them. These discussions accelerated in the 1970s. At that time, historical perspectives on the war years became considerably more nuanced while the number of individuals claiming war-related impairments did not diminish, as had been widely expected, but only increased. 
•Also in the 1970x, attention to the fate of the European Jews increased. No longer were the heroic fighters of the underground resistance central to the recollection of the war but the horrifying images of the extermination camps. It appears that a greater acceptance of a psychological approach to life problems-accompanied by a greater acceptance of the public expression of emotions-was a factor in the increasing number of people who claimed to suffer from war-related trauma. 
•In addition, it seems that the waning of the Cold War and the lesser relevance of a number of national myths about heroes and villains during the war were important factors.

Interestingly, the distinction between organic versus psychological disorder-so central in many histories of psychiatry and in psychiatric discussions today-appears to be more or less irrelevant in the medical discussions covered in this book. Critical instead was the issue of causality: could one prove that one’s current level of incapacity was related one’s war-time experiences?

This issue became more difficult to assess as the years passed by. Yet, in some countries and for some categories of individuals (those who spent more than 6 months in prison or concentration camps, for example), this causality was assumed. In other countries, the burden of proof was with the compensation authorities (that is, only if they could prove that reasonable grounds existed that an applicant’s current condition was 

 related to the war could compensation be refused).

Whether complaints or incapacity were purely psychological or based on physical injury was hardly important. This makes the approach originally espoused by the editors of the volume (to trace the history of the recognition of psychiatric complaints related to World War II) somewhat irrelevant-but it, correctly in my opinion, broadens that question to include a variety of unexplained medical symptoms related to war experiences.

In this blog, Dr Pols reviews The Politics of War Trauma: The Aftermath of World War II in Eleven European Countries, by Jolande Withuis and Annet Mooij (eds).

PTSD Before PTSD: A Review

This book aims to demonstrate how, regrettably, over the last twenty years or so, typically American conceptions of mental illness have been exported successfully to the rest of the world. According to Watters, the often enthusiastic international reception of DSM-III and IV with its standardized descriptions of typical American forms of mental anguish, has homogenized human suffering all over the world. Psychiatry appears to be following the example of McDonald’s, which successfully homogenized (and worsened) the daily diet of humankind.

Watters presents his argument with four case studies. The first one focuses on the tragic death of an emaciated 14-year old woman in Hong Kong, who fainted and fell to her death in broad daylight in 1994. When journalists wanted to report on the case, they quickly found out, using Google, about the symptoms and causes of anorexia nervosa. Soon after, awareness campaigns and prevention programs were organized based on Western insights-and lo and behold, the number of young women in Hong Kong suffering from anorexia nervosa increased dramatically. By way of contrast, Watters describes the research and ideas of Dr. Sing Lee, who had studied a small number of women patients who had deliberately starved themselves. Interestingly, they did not display the symptoms of anorexia nervosa. They did not have a morbid fear of becoming overweight, did not have body image issues, and did not starve themselves to look thin and attractive. It appeared that Dr. Lee had found a rare form of mental illness which might be unique to Asia, and which resembled anorexia nervosa, but was a distinct disease entity. Unfortunately, he was not able to cure this condition with the aid of traditional Chinese medicine and other approaches based on local culture. His only patient with this condition died of starvation.

The second case focuses on the effort to relieve the trauma of the inhabitants of Sri Lanka after the tsunami. The descriptions of NGOs falling over each other and investing significant resources in turf wars are familiar by now. The conclusion that construction materials were needed more urgently than trauma counsellors can come as no surprise. Nevertheless, Watters judges the influence of these counsellors to be relatively benign-ending his chapter with the bemused smiles of young children drawing and painting, not having the faintest idea of what the art therapist who gave the material to them was up to. The third case study focuses on the way an individual with schizophrenia was maintained by his family in Zanzibar. The narrative is moving but because it only involves one individual, it is hard to make any generalizations.

The last study deals with the mega-marketing of depression in Japan. It details the successful efforts of GlaxoSmithKline, the producers of Paxil, to introduce new conceptions of sadness and depression to Japan. Previously, Japanese psychiatry and popular thinking only acknowledged a rare and very severe form of depression, which required institutionalization. Medical anthropologists and open-minded psychiatrists were feted in exclusive holiday resorts and received generous honoraria for their willingness to share their insights with CEOs and marketing experts. A smart marketing campaign then presented new images of depression-after all, experience in the Western world had demonstrated that marketing disease leads to much higher sales that marketing specific cures. The image of depression that was presented to the Japanese public was left deliberately vague, but it was one that could affect almost everyone, in particular the young, the smart, the aspiring, and the successful. Ask-your-doctor commercials appeared everywhere, de-stigmatizing depression and encouraging individuals to take charge of their own condition by requesting prescriptions. At the same time (around the year 2000), as we now know, the evidence in favour of Paxil (and many other SSRIs) remained flimsy, incomplete, and inconclusive. Undesirable side-effects (including, possibly, akathisia, violent behaviour and increased risk of suicide) had been deliberately swept under the carpet. Nevertheless, marketing campaigns do not let questionable science stand in the way of good sales figures.

Of course, it should be emphasized that the pharmaceutical industry is very interested in Japan, because it is a wealthy country. This contrasts with its complete lack of interest in many developing nations, which are often deprived of much-needed medications. The chapter on the mega-marketing of SSRIs in Sri Lanka, for example, would be remarkably brief.

There is much to commend about Watters’ book. It is a page-turner which hardly ever fails to engage its reader. It is significant that recent developments in the history of psychiatry are discussed-after all, we know an awful lot about the asylum by now, but not much about what happened after the 1960s. Studies focusing on the post-World War II world are still relatively rare, even though significant developments in psychiatry and mental health care have taken place over the last sixty years (deinstitutionalization and the development of psychopharmacology, to mention only two). Also appealing is Watters’ discussion of the “rest of the world.” Thus far, most historians of psychiatry have focused on psychiatry in the Western world. Over the past twenty years, colonial psychiatry has received ample scholarly attention, but studies on this topic have often focused on the activities of Western psychiatrists in far-away places (articulating theories in which “race” took the place of “class”). Unfortunately, the reactions, ideas, initiatives, and theories of the original inhabitants of these far-away places are rarely taken into account.  This is exactly what Watters does-although he presents Western (or, more accurately, American) psychiatry as decisively hegemonic. As a consequence, psychiatrists, other mental health care workers, and media types concerned about mental illness in the rest of the world appear almost exclusively reactive. The flow of ideas, however pernicious in its effect, moves from the United States to the rest of the world-and, strangely enough, the rest of the world enthusiastically embraces it, discarding much more refined and interesting indigenous approaches (even though they do not actually work in the examples given in the book-and many more examples of traditional healing methods in the developing world could be mentioned that are inhumane and cruel). The four case studies are sufficiently diverse to compare and contrast responses to mental illness and Western psychiatry.

Nevertheless, a feeling remains that the story fits together too well. Criticizing American initiatives has been a favourite activity of academics for some time now-Watters’ analysis therefore has a familiar feel.  Nevertheless, one could imagine countless scenarios in which psychiatrists and other mental health care workers in the non-Western world maintain a more level-headed approach to the patients they see (in all fairness, Watters’ ire is mostly reserved for uncritical media types and pharmaceutical corporations, rather than for physicians). After all, many American mental health care practitioners often view picking a DSM-diagnosis as a bureaucratic exercise after which the real treatment can begin. The importance of DSM in many developing countries appears to be somewhat overstated.

If the influence of American psychiatric ideas could be diminished, psychiatric anthropologists would be able to conduct more interesting research projects. At least that appears to be Watters’ opinion. His interest in the rest of the world is laudable. Nevertheless, he completely overlooks the fact that in most developing countries, there are hardly any psychiatrists and access to psychotropic drugs is very difficult. As a consequence, many individuals do not receive the care they need and suffer unnecessarily. If Watters’ caution were widely heeded, this situation would likely only worsen.

Lastly, why should we be particularly concerned about the disappearance of various culturally-specific forms of mental suffering? Watters compares the disappearance of exotic forms of mental illness (often described as culture-bound syndromes) to the increasing extinction of plant and animal species, which is impoverishing the bio-sphere. The metaphor of disappearing species is not altogether convincing-who would, after all, advocate preserving the current diversity in suffering? Because Watters often appears to be critical of American psychiatry, his descriptions of reactions to mental illness in the rest of the world are often empathic, generous, and positive, while American approaches only appear in a negative light. Seen that way, the pervasive influence of American psychiatric thinking is easily regarded as pernicious-in particular if it is a poor fit with the experiential world of non-American patients. The often cruel and pointless treatment methods that are still widespread in the non-Western world do not find a place within this book.

This book aims to demonstrate how, regrettably, over the last twenty years or so, typically American conceptions of mental illness have been exported successfully to the rest of the world. According to Watters, the often enthusiastic international reception of DSM-III and IV has homogenized human suffering all over the world. 

Hans Pols, PhD

Articles

Treating Mental Illness Before it Strikes

Emil Kraepelin on Cultural and Ethnic Factors in Mental Illness

PTSD Before PTSD: A Review

Review – Crazy Like Us: The Globalization of the American Psyche