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Book Forum: History of Psychiatry   |    
The Invisible Plague: The Rise of Mental Illness From 1750 to the Present
HOWARD S. SUDAK, M.D.
Am J Psychiatry 2003;160:1017-1018. doi:10.1176/appi.ajp.160.5.1017
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Philadelphia, Pa.

By E. Fuller Torrey, M.D., and Judy Miller. New Brunswick, N.J., Rutgers University Press, 2001, 416 pp., $28.00.

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E. Fuller Torrey, indefatigable champion of better treatment for the severely mentally ill, has written another book on their behalf. This is a remarkable work: remarkably strong and weak in alternating spurts. If the intent of Torrey and coauthor Judy Miller was to convince the reader that there is an epidemic of insanity that is being ignored, unrecognized, or dismissed as irrelevant, they have failed (at least for me). If, however, their aim was to present a highly literate, poignant, historical review of the absolutely shameful ways in which we have treated the mentally ill for the last 250 years in North America and the British Isles, they have done a smashing job—and, at the same time, raised pertinent and provocative challenges to the way we view schizophrenia. We are too prone to think that the way things are is the way they were and always will be. Lacing their work with references to literature contemporaneous to the period reviewed does little or nothing to buttress the authors’ contention but helps provide a historical review that can stand on its own merit.

The authors note that the rate of insanity, primarily schizophrenia, rose from less than 0.1% to more than 0.5% in North America and the British Isles between 1750 and 2000. They feel that this "plague," this "epidemic," has been ignored for political and economic reasons (e.g., public and private mental hospital administrators don’t want to look bad; it is expensive to provide adequate facilities). They state that the rise of mental illness has been covered up by means of specious statistics understating the prevalence or by glib explanations, such as, "Lumber-yards generate lumber; hospitals generate patients." "It’s all due to those defective immigrants we allow in." "It’s due to readmissions." "There are so many cases out there waiting for admission that the ‘increase’ is really just due to the backlog."

The authors are critical of other theories—indicating that the theorists stoop to using only the data that suit their biased positions—while they ignore their own doing much the same. For instance, the authors cite sources such as the following: "William Perfect, owner of a private madhouse in Kent, in 1778 published his Select Cases in the Different Species of Insanity…claiming that ‘instances of insanity are at this day more numerous in this kingdom than they were at any former period.’ " The authors further note that "a majority of Perfect’s 61 cases appear to have had a medical origin (e.g., syphilis, mercury poisoning, encephalitis) but others appear to be consistent with a modern diagnosis of schizophrenia or manic-depressive illness." Of course, there are no simple truths here, but Torrey and Miller would have us believe that there is a multifaceted conspiracy extending from Colonial times through the present and blinding most of us. The authors reveal this insidious epidemic, insisting on "the biological reality of insanity" as though this were still in contention.

The authors are not entirely wrong. Mental hospital superintendents, politicians, and taxpayers are all human and, therefore, undoubtedly influenced by conscious or unconscious motives that others may read as base (particularly if they are in conflict with their own). The authors may be entirely correct in stating that there is (or has been) an unacknowledged "plague" of mental illness here. However, this book does not answer the question to my satisfaction—it reads as more polemical than neutral or objective.

Much of the data and the figures appear convincing—but I am familiar enough with such data to know how open these are to willful or unintentional distortion or selectivity. Even aside from issues such as age-adjusted versus non-age-adjusted data, controls for urban versus rural residence, sample sizes, and appropriate statistical measures, the enormous complexity of diagnostic variability over time and changes in societal mores regarding the treatment of the mentally ill across 250 years makes disentangling this knot formidable. Severely mentally ill patients get shuffled from place to place all the time; consequently, they are potentially miscounted all the time. For example, as I write this, a front-page headline in today’s New York Times (Nov. 17, 2002) is "New York State Hospital Patients Transferred to Nursing Homes in New Jersey." Will this change the prevalence in both states?

If, as Torrey and Miller suggest, mental illness is an epidemic, what slowed it down? Are we now in the midst of a related epidemic of autism? Why haven’t the overall suicide rates increased significantly over the last 100 years concomitantly with this epidemic? May we safely rely on inpatient head-counts to establish incidence and prevalence rates? If this is the most valid index, we must have undergone a massive disepidemic in the last 50 years as a result of the deinstitutionalization of the mentally ill and the attendant decrease in the number of mental hospital beds (from 50% of all U.S. hospital beds to less than 10% currently). Also, why confine the study to North America and the British Isles—one would assume that an epidemic would be worldwide and certainly not confined to those speaking the English language. The authors, of course, do not suggest this, but European and Asian comparisons would be of great interest.

To return to this work as a wonderful historical, political, and literary treatise, I found the history of the earliest U.S. hospitals and mental institutions laudably comprehensive—especially since my own, The Pennsylvania Hospital and its Institute, were so even-handedly dealt with. There are three appendixes, each excellent (the last being detailed notes) plus a very good list of selected references and an index. Among the jacket endorsements is an amusingly nice quote from the noted mental historian Gerald Grob, which seems especially gracious in view of the fact that Grob is repeatedly taken to task by the authors in the text.

In the preface, Torrey writes that 30 years ago he submitted a paper suggesting that epidemic insanity was a recent phenomenon that was "summarily rejected as fanciful by all journals to which it was submitted and it was never published. One anonymous reviewer even commented, ‘I cannot grant a thing to this paper.’ This book is in part a very belated and detailed response to those critics, in the hope that they are still alive to read it." I, however, can grant many a positive thing to this book.

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