1. Assess real clinical practices in terms of:
a) patterns of antipsychotic drug use and how they changed over time
b) physicians' determinations of the nature of treatable psychiatric disease and effective outcome as shaped by cultural and scientific values and beliefs and how these changed over time

2. Assess clinical science in terms of:
a) its scientific evolution as illustrated by the development of causal inference, generalizability, and research design
b) its meaning to researchers as reflected by their claims of its clinical and scientific value compared to the actual strength of the scientific evidence
c) its social and cultural values as expressed in the scientific and textbook literature, professional newsletters, and pharmaceutical company publications regarding antipsychotic drugs

METHODS:

1. Assessment of clinical practices: This has been the core of the project. The primary method used has been medical record chart abstraction on patient records in three California state hospitals and the UCLA Neuropsychiatric Institute. This research has focused on psychiatric records of patients hospitalized 1940 and 1999, using a sample that consists of 928 individual patients with approximately 2,000 hospital episodes. The sex distribution of the sample is approximately 52% women and 48% men, with a diagnostic distribution that is approximately 40% schizophrenia, 20% other psychotic illnesses, and 40% non-psychotic illnesses. These data are entered into a customized FileMaker Pro relational database, which gives me great flexibility in assessing the inter-relationships between demographics, therapeutics (e.g. medication dosages), diagnoses, and physician-perceived clinical status, as well as how these relationships changed over the course of our study period. With this data, we are characterizing changes in clinical practice over time (Aim 1a) by assessing all diagnostic and treatment decisions over the course of an individual's hospitalization, linking treatment prescription to diagnosis and clinical status for all treatments and psychotropic drugs used (with a focus on antipsychotic drugs). For assessing physician-decision making (Aim 1b), I am using a mixed method approach.

2. Assessment of scientific practices: This work has focused on published and archival work from the twentieth century. The methods have consisted primarily of literature synthesis, meta-analysis, and traditional historical narrative analysis. This work has been used to contextualize the clinical practice in Aim 1 as well as examining scientific practices in their own right, focusing on the development of clinical trial methods in psychiatry.

STATUS: For the main portion of the project, we have finished the data collection and are in the process of analyzing both the qualitative and quantitative data. While a number of articles have been published from this work and several manuscripts are in preparation, the main aim is to finish a monograph on the history of schizophrenia in the context of the psychopharmacological era. This book project is in its middle stages with all the data collected and we are now in the midst of the qualitative and quantitative analysis.

IMPACT: This project asks three fundamental and inter-related questions: First, what factors shape the ways in which ordinary practitioners determine whether a patient has schizophrenia? Second, how do these assessments shape therapeutic decisions? And, lastly, how do these treatment decisions in turn shape how psychiatrists understand illness? I am answering these questions by way by way of an historical analysis of ordinary psychiatrists' diagnostic and therapeutic decisions from the 1900s to 2000. While perhaps counter intuitive, a historical analysis of contemporary clinical practices is urgently needed in this current era of rapid change in both clinical science and practice. While our common sense notion of science is that it is value free and independent of history, it is, to the contrary, deeply imbedded in a historically determined social and cultural world. The same holds true for clinical practice, both in its ideal form (in terms of what constitutes best practices) and in its everyday reality. In a manner analogous to evolutionary science, understanding of the form and function of contemporary clinical science and practice requires historical analysis as well as non-historical approaches. Such an approach is especially important in the case of schizophrenia. From its very origins as an object of medical scrutiny in the modern era, the understanding and treatment of severe mental illness has been deeply influenced by social, cultural, and historical factors. As a recognized disease, schizophrenia is barely 100 years old. However, despite its relatively short history, the therapeutics and scientific understanding of the illness has undergone dramatic upheavals and, though less apparent when viewed from our present vantage point, this history continues to shape the ways in which physicians understand and care for patients suffering from this "most solitary of afflictions."

PUBLICATIONS:

Braslow JT. 1999. Therapeutic Effectiveness and 
   Social Context: The Case of Lobotomy in a 
   California State Hospital, 1947-1954. Western 
   Journal of Medicine, 170, 45-48. 
Braslow JT. 1999. History and Evidence-Based 
   Medicine: Lessons from the History of Somatic 
   Treatments from the 1900s to the 1950s. Mental 
   Health Services Research Journal 1, 231-240. 
Braslow JT. 2000. Therapeutics and the History of 
   Psychiatry. Bulletin of the History of Medicine 74, 
   794-802. 
Braslow JT. 2001. Does Sex Make a Difference? 
   Trials and Tribulations of Late Nineteenth-Century 
   Gynecological Surgery. Reviews in American 
   History 29, 403-409.
Braslow JT and Starks SL. 2003. Psychiatric 
   Science and Therapeutics in the Second Half 
   of the Twentieth Century. Paper prepared for 
   the Institute of Medicine Committee on 
   Incorporation of Research into Psychiatry 
   Residency Training.
Braslow JT and Starks SL. 2004. "Psychology and 
   Psychiatry". In New Dictionary of the History of 
   Ideas, edited by Maryanne Cline Horowitz. 
   New York: Charles Scribner's Sons. 
Duan N, Braslow JT, Brown AH, Kaptchuk TJ, 
   Tallen LE. 2004. "Expanding Methodological 
   Tools for the Production of Clinical Evidence". 
   Paper prepared for the Institute of Medicine 
   Committee on the Use of Complimentary and 
    Alternative Medicine.
Kravitz RL, Duan N, Braslow JT. 2004. Evidence 
   Based Medicine, Heterogeneity of Treatment 
   Effects, and the Trouble with Averages. 
   Milbank Quarterly 82, 661-687.
Sherman SE, Chapman A, Garcia D, Braslow JT. 
   2004. Improving Recognition of Depression in 
   Primary Care: A Study of Evidence-Based Quality 
   Improvement. The Joint Commission Journal on 
   Quality and Safety 30(2), 80-88.
Braslow JT. 2005. "Timeless Desperation and Timely 
   Measures". In Clio in the Clinic: History in Medical 
   Practice, edited by Jacalyn Duffin. New York: 
   Oxford University Press.
Starks SL and Braslow JT. 2005. "The Making of 
   Contemporary American Psychiatry, Part 1: 
   Patients, Treatments, and Therapeutic Rationales 
   Before and After World War II". History of 
   Psychology 8, 176-193.
Braslow JT and Starks SL. 2005. "The Making of 
   Contemporary American Psychiatry, Part 2: 
   Therapeutics and Gender Before and After World 
   War II". History of Psychology 8, 271-288.
Braslow JT, Duan N, Wells KB, Starks SL, Polo A, 
   Korraa H, BromleyE. 2005. "How Generalizable 
   Were Mental Health Treatment-Outcome Studies 
   Prior to the NIMH "Bridging Science and Services" 
   Report? External Validity, 1981-1996." 
   Psychiatric Services 5, 1261- 1268.
Braslow JT, Duan N, Wells KB. 2006. "Enhancing 
   Generalizability: Stepping up to the Plate. Reply to 
   Susan Essock." Psychiatric Services 57, 141-142.

Principal Investigators:
Joel Tupper Braslow, MD, PhD

Sponsored by:
National Institute of Mental Health