Diagnosing in the dark: the continuing relevance of Thomas Szasz's assault on psychiatric pretensions.

• Author: Sullum, Jacob
• Position: The Myth of Mental Illness: Foundations of a Theory of Personal Conduct - Manufacturing Depression: The Secret History of a Modem Disease - The Protest Psychosis: How Schizophrenia Became a Black Disease - Book review

The Myth of Mental Illness: Foundations of a Theory of Personal Conduct, 50th anniversary edition, by Thomas Szasz, Harper Perennial, 329 pages, $14.99 paper

Manufacturing Depression: The Secret History of a Modem Disease, by Gary Greenberg, Simon & Schuster, 432 pages, $27

The Protest Psychosis: How Schizophrenia Became a Black Disease, by Jonathan M. Metzl, Beacon Press, 246 pages, $24.95

HALF A CENTURY after Thomas Szasz first declared "there is no such thing as 'mental illness,'" his radical critique of psychiatry is widely viewed as outmoded and simplistic at best, cruelly dogmatic at worst. "The opinion of official American psychiatry," Szasz writes in the preface to the 50th anniversary edition of The Myth of Mental Illness, "contains the imprimatur of the federal and state governments. There is no legally valid nonmedical approach to 'mental illness,' just as there is no such approach to measles or melanoma ... . Debate about what counts as mental illness has been replaced by legislation about the medicalization and demedicalization of behavior."

Yet psychiatry's lack of scientific rigor is so obvious today that the profession's leading lights openly complain about it. In a January Wired article about the ongoing revision of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM), Gary Greenberg, a psychotherapist and journalist, recounts an interview with Allen Frances, lead editor of the manual's current (fourth) edition.

"There is no definition of a mental disorder," Frances tells him. "It's bullshit. I mean, you just can't define it."

Since mental disorders officially exist in the United States only if they are listed in the DSM, which is the bible for mental health professionals and the key to insurance coverage, this is a pretty significant concession. It reinforces Szasz's point that psychiatrists invent mental illnesses by voting on whether to recognize them. "Old diseases such as homosexuality and hysteria disappear," he writes, "while new diseases such as gambling and smoking appear, as if to replace them."

The perils of this approach are evident in Greenberg's eloquently honest book Manufacturing Depression: The Secret History of a Modern Disease, which questions psychiatrists' authority to medicalize our moods even as it sympathizes with the suffering of depressed people and describes the author's own bouts of melancholy. Although his book has a Szaszian title (recalling the heretical psychiatrist's 1970 book The Manufacture of Madness), Greenberg mentions Szasz only once in passing. Jonathan Metzl, a professor of psychiatry and women's studies at the University of Michigan, has a bit more to say about Szasz in The Protest Psychosis: How Schizophrenia Became a Black Disease. Metzl implicitly criticizes Szasz and other opponents of forced treatment for inspiring the deinstitutionalization that began in the 1960s, which he says often left former mental patients with "nowhere to go and no one to turn to for help." Yet by tracking the shifting, politically driven definition of schizophrenia, commonly viewed as the mental disorder most clearly established as a disease, Metzl's eye-opening book casts doubt on psychiatry's status as a field of medicine, let alone one with a strong enough basis to justify coercively treating unwilling patients. Together he and Greenberg show that Szasz's objections to psychiatry's role in stripping people of their freedom and relieving them of their responsibility, no matter how often they are dismissed as quaint or simpleminded, remain logically and morally compelling.

As Greenberg makes clear in his Wired article and his book, mental disorders are defined by patterns of behavior, without regard to what causes them. By listing these criteria in the DSM, psychiatrists have achieved a high degree of diagnostic agreement, but they simply assume that people who are given the same label have the same underlying problem. In Manufacturing Depression, Greenberg quotes Thomas Insel, director of the National Institute of Mental Health, who told psychiatrists at the American Psychiatric Association's 2005 convention that the DSM "has 100 percent reliability and zero percent validity."

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In Szasz's view, this lack of validity is...