Our Psychiatric Future, by Nikolas Rose

Books critical of psychiatry generally follow a format. We hear about over-diagnosis and the medicalisation of everyday life, the excessive prescription of antidepressants and antipsychotics (and their ineffectiveness) and then the narrowness of biomedicine. Add to this the ever-controversial use of compulsion and professional highhandedness and, more recently, a rejection of diagnosis altogether.

Nikolas Rose’s book covers all these areas but also has chapters on global mental health and the user movement, “Experts by Experience”. The latter is worth the price alone as Rose forensically dissects the intricacies of the conflict between professionals and patients. (And it is a conflict.)

The almost visceral quality of this chapter throws the rest of the book into sharp relief. We move from the trenches to remotely garrisoned generals arguing over the finer points of military strategy. Rose makes some very telling hits, though. He quotes the outrageous hubris of Thomas Insel. During 13 years heading the National Institute of Mental Health in the US, he required research applications to be structured around neuroscience and genetics, not diagnoses. He confessed that “all I succeeded at was getting really cool papers published by cool scientists at fairly large costs – I think $20 billion – I don’t think we moved the needle in reducing suicide, reducing hospitalisations or improving recovery for the tens of millions of people who have mental illness”.

Rose concludes from this the futility of the “tyranny of diagnoses” and later comments (with no clear justification): “We have already seen that the existing categories have not proved particularly helpful.” The remoteness of these debates is at its most extreme in chapter seven, “Who Needs Global Mental Health?” Here a handful of academics (all based in Harvard or London) debate with each other about how to square the circle of exporting Western biomedicine while respecting local customs and wisdom.

Ordinary practical psychiatry gets only the briefest walk-on part in this book. “It is easy to think”, writes Rose, “that the main purpose of making a diagnosis is to identify the nature of the condition…and…treat its causes and mitigate its harmful consequences.” Quite. That is what psychiatrists do. As a quotation from psychiatrist Anthony Clare makes clear, we treat these categories as hypotheses, not eternal certainties. They are useful, but fuzzy at the edges. This, rather than the evil machinations of Big Pharma, explains why antidepressants are overprescribed. When antidepressants work, it is obvious to all concerned. So doctors try them when unsure. The same happens with antibiotics, but nobody denounces penicillin.

If you want a scholarly and thought-provoking critique of current psychiatry, then this is the book for you. But you may wonder why psychiatry is so easy to criticise but shows no signs of going away. If so, read it along with a book that describes what psychiatrists actually do, perhaps Clare’s Psychiatry in Dissent: Controversial Issues in Thought and Practice.

The last chapter considers the possible future of psychiatry. In this Rose and I finally come together. Neither of us really has a clue. When change does come, it will be utterly unexpected. Rose is absolutely right, however, that relentlessly ploughing the same furrow is getting us nowhere.

Tom Burns is professor emeritus of social psychiatry at the University of Oxford and the author of Our Necessary Shadow: The Nature and Meaning of Psychiatry (2013).

Our Psychiatric Future
By Nikolas Rose
Polity, 248pp, £55.00 and £17.99
ISBN 9780745689111 and 9780745689128
Published 5 October 2018