The history of psychiatry is frankly embarrassing, but do we need yet another critical account? Well, Scull is one of the best commentators and the counsel of the years has brought him to acknowledge that ‘some progress’ has been made. Refreshingly, he has no time for social labelling theory and avows the very real misery of much mental illness. He is also as critical of psychoanalysis and the current vogue of cognitive–behavioural therapy for everything as he is of drug treatments. Further, Scull is wise enough to briefly acknowledge that much of medicine has an ignoble past and that modern practice is often palliative rather than curative.

The early chapters of this generally impressive tome re-tread some old ground, but Scull writes very well, with an eye for telling details. He revisits Henry Cotton's ridiculously overzealous application of Billroth's surgical bacteriology to patients, as he covered before in horrifying detail in Madhouse: A Tragic Tale of Megalomania and Modern Medicine (2005). Psychiatry has arguably been particularly prey to an all too recurrent theme of desperate novel treatments oversold and adverse effects ignored, before being dropped when something new comes along. Scull may well be right that asylum doctors could get away with even more than those running physical hospitals because of the stigmatisation of people with mental illness – even if many denizens were quite wealthy. He clearly identifies the periodic oscillations between an overreliance on biomedical treatments for people who are severely ill and psychosocial approaches for the less unwell. Scull is also rightly scathing, in a chapter updating his radical account of Decarceration (1977), about how we have moved from ‘confinement and cruelty in jails’ to ‘total institutions akin to prison and concentration camps’ and more recently to ‘an alternative version of malign neglect’ in the community. He asserts more than demonstrates that this was a political initiative to save money rather than (as psychiatrists tend to believe) a direct result of drug discoveries. Perhaps all citizens of democracies share some responsibility for allowing the ‘neoliberal dismantling of the welfare state’ and doctors particularly so. Scull cannot, however, resist the occasional ill-aimed swipe at psychiatry, stating baldly that we were particularly slow to adopt randomised controlled trials – whereas Archie Cochrane, for example, writing in Effectiveness and Efficiency (1972) was more critical of other specialties.

It is almost 300 pages before we get to the contemporary practice of psychiatry and these last few chapters feel a bit rushed, particularly in comparison with the rest of the book. Scull seems conflicted about whether the drugs we use have ‘miraculous’ and ‘dramatic benefits’ (like lithium) or merely afford ‘at best, some … symptomatic relief’. He rightly attributes the underuse of lithium to a lack of Big Pharma promotional activity but incorrectly states that antipsychotics reduce quality of life. The section on the dopamine hypothesis of schizophrenia neglects to mention virtually all the best evidence to support it. That on genetics is a bit dismissive and confused – there are many reasons why risk genes overlap across disorders and this does not pose any more threat to our diagnostic system than, say, the notable genetic overlap between schizophrenia and multiple sclerosis. Scull is on firmer ground highlighting DSM-III as being driven by a very necessary desire to enhance diagnostic reliability, and he is right that Big Pharma have exploited successive DSMs rather than been in league with psychiatry as some conspiracy theorists would like to believe. To say, however, that there are no diagnostic tests for psychiatric disorders is to ignore all the known causes of intellectual disabilities (known as learning disabilities in the UK health services) and the dementias. Not to compare this with the rest of medicine is to avoid the fact that many diagnoses such as migraine, Parkinson's disease and most epilepsies remain clinical – generally with a 10% misdiagnosis rate. To state that the causes of major mental illness ‘remain as enigmatic as ever’ is simply wrong, even if that knowledge has not translated into patient benefits.

The last chapter is a particular disappointment, being all too reminiscent of some Mad in America polemic and falling back on tired, misplaced calls for a ‘paradigm shift’ away from the perennial purported ‘crisis’ in psychiatry. Yes, at its worst, psychiatric diagnosis could be a DSM tick-box exercise, and out-patient reviews little more than medication checks, but none of my colleagues practise that way. Yes, the general (but not entire) lack of validating biological tests in psychiatry leaves us open to ever increasing numbers of diagnoses but this is not ‘18th century practice’; indeed, it allows for the emergence of novel conditions such as pathological gambling. There is no doubt, however, that the numbers of American children diagnosed and treated for attention-deficit hyperactivity disorder far exceeds the 1% or so likely to benefit – even worse, arguably, are the numbers of children diagnosed with bipolar and treated with lithium.

The bottom-line is that most people who present to psychiatric services get evidence-based interventions and are satisfied with their treatment. To help more, better, we principally need better funded mental health and social services. Increased research funding could allow us to target existing therapeutics and develop better interventions for people with histories of childhood adversity and ongoing disadvantage. That would certainly be more useful than repetitively criticising psychiatry – or indeed bemoaning the death of socialism as a political force. One may as well howl into the wind. With the Wellcome Trust and others spending billions on mental health research over the next decade we can expect notable progress, but it takes time – and that does not lend itself to dramatic copy.