IN YOUR MIND, NOT YOUR BRAIN:

In 1990 President George Bush announced that "a new era of discovery" was "dawning in brain research." Over the next several decades the U.S. government poured billions of dollars into science that promised to revolutionize our understanding of psychiatric disorders, from depression and bipolar disorder to schizophrenia. Scientists imagined that mental illnesses in the future might be diagnosed with genetic tests, a simple blood draw, or perhaps a scan of your brain. New pharmaceuticals would target specific neurochemical imbalances, resulting in more effective treatments. The 1990s, Bush declared, would be remembered as "The Decade of the Brain."

This brave new world of brain research also promised to free us of the stigma and discrimination attached to mental illness and addiction for centuries. Localizing psychiatric disorders in the brain would make them chronic medical diseases--like diabetes and high cholesterol--instead of individual moral failings or deficiencies in character. While it was impossible to predict exactly what the future would bring, there was an overwhelming sense that psychiatric science was going to crack the "mystery" and "wonder" of this "incredible organ," as Bush called it.

Looking back as a psychiatrist and historian today, I find that these hopes feel quaint. They remind me of other misplaced visions of technological futures from the twentieth century: flying cars, pills for a whole day's nutrition. The reality of psychiatric practice is far less glamorous than the visions of its future that I grew up with. Thirty years later we still have no biological tests for psychiatric disorders, and none is in the pipeline. Instead our diagnoses are based on criteria in a book, the Diagnostic and Statistical Manual of Mental Disorders (often called, derisively, the "bible" of American psychiatry). It has gone through five editions in the last 70 years, and while the latest edition is almost 100 pages longer than the last, there is no evidence that it is any better than the version it replaced. None of the diagnoses is defined in terms of the brain.

We also have not had any significant breakthroughs in treatment. For decades the pharmaceutical industry has churned out dozens of antidepressants and antipsychotics, but there is no evidence that they are more effective than the drugs that emerged between 1950 and 1990. People with serious mental illness today are more likely to be homeless or die prematurely than at any point in the last 150 years, with lifespans that are 10 to 20 years less than the general population. Biological research has also failed to reveal why psychiatric drugs help some patients but not others. When a patient asks me how an antidepressant works, I have to shrug my shoulders. "We just don't know, but we do have evidence that there's about a 30 percent chance that it will help your mood." Perplexed, one patient responded, "Doesn't it have to do with neurotransmitters or something?" I sighed, "Yes, that was the theory for a while, but it didn't pan out."

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