Introduction to Special Issue: Geneses,organizations and transformations of psychiatric epidemiology

Abstract

Recent historiography has revealed a growing interest in the developments of psychiatric epidemiology. This volume aims to explicitly tackle the problem of transforming a diversity of knowledge into a structured scientific unit. Furthermore, it aims to answer this by bringing together historical studies that demonstrate how epistemic authority has led to the hierarchization of knowledge and the institutionalization of psychiatric epidemiology. Interdisciplinary research teams are traced back in history, and their organization is interrogated. Tracing the history of psychiatric epidemiology involves an exploration of disciplinary divisions of labour, such as how survey methods are based on theoretical frameworks, how research programmes are regulated with political and moral ideals, and how the wider public recognizes public health expertise.

A variety of interdisciplinary studies implemented within the scientific community

Psychiatric epidemiology – the study of the distribution of mental disorders within a population – emerged on the scientific scene during the second half of the twentieth century. However, unlike psychiatry, psychology and psychoanalysis, psychiatric epidemiology has not been studied by historians until recently, mainly because it was only professionalized much later. Several factors can explain the field’s relative ‘invisibility’: the still recent standardization of its methods, the diversity of local scientific traditions, nations’ varying public health policies, the range of different sites for observation (rural or urban studies, comparisons between neighbouring communities, insular populations, cohorts), as well as the varieties of disciplines (medicine, psychology, sociology, anthropology, biostatistics, etc.) implemented within the scientific research community.

These elements highlight the diversity of potential sources and thus pose the question: How should one write a history of this largely unrecognized field? By describing the institutional archives of large national and international agencies (the National Institute of Mental Health [NIMH] in the US; the Institut national de la santé et de la recherche médicale [INSERM] in France; the World Health Organization [WHO], etc.) and universities? By paying attention to the leading figures of the field in order to analyse international networks of psychiatric epidemiology? Or, instead, by piecing together the history of on-site data collection? Should the focus be on more extensive enquiries (e.g. The Stirling County Study directed by Alexander H Leighton, The Isle of Wight Study directed by Michael Rutter, etc.) as case studies? Or should it focus on the practice of adapting questionnaires derived from psychological studies (screening) and classic epidemiological indicators (prevalence, incidence, risk factors) to mental health issues?

These questions are central to this Special Issue. It is based on a conference organized by Emmanuel Delille and Samuel Lézé at the École Normale Supérieure de Lyon on 17 November 2019, with the support of the Lyon Institute for Advanced Study (Collegium de Lyon), entitled ‘Estimating, Locating, and Comparing Mental Disorders in the Second Part of the Twentieth Century: Psychiatric Epidemiology in Historical Perspective’. Bonnie Evans, Tiago Pires Marques, Emmanuel Delille, Steeves Demazeux, Gloria Frisone and David J Robertson presented their work, and Anne Lovell was the main discussant in the final panel discussion. She is an anthropologist trained in psychiatric epidemiology and has been responsible for two publications in the field of the history of psychiatry: one was a Special Issue with Ezra Susser (Lovell and Susser, 2014) and the other a book edited with Gerald Oppenheimer (Lovell and Oppenheimer, 2022). Of course, other significant works have marked milestones in the history of this field, such as Robert Castel (1983), Gerald N Grob (1985), Harry Yi-Jui Wu (2021) and Matthew Smith, whose new book on the history of social psychiatry (Smith, 2023) could not be read by most of the authors of this Special Issue, but who contributes directly to it with an article about the role played by the Chicago school. In addition, David J Robertson (2022) defended a doctoral thesis in history on mental health research and psychiatric epidemiology, the publication of which we eagerly await. Last but not least, a new case study has just been published on Finland (Myllykangas and Parhi, 2023).

The aim of this Special Issue is not to cover the entire history of psychiatric epidemiology, but we wish to emphasize that historiography showed a recent and growing interest in the formation of the epidemiology of mental disorders in the twentieth century which still continues. In this new landscape, two crucial methodological approaches are contributing to the historical reconstruction of this process, leading to the recognition of the emergence of a new epistemic object in the history of science: the mental health of populations.

The dominant approach focuses on case studies, revealing the diversity of the origins and sources of psychiatric epidemiology in the period when the major field surveys of communities began, before the 1980s and the development of the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III): the geography of the survey sites, the succession of surveys based on divergent political and scientific objectives, and the significant role of interdisciplinarity and qualitative methods such as sociology and anthropology (Lovell and Oppenheimer, 2022; Lovell, Oppenheimer and Susser, 2023; Lovell and Susser, 2014). The theoretical aim of this multi-site historiography is to reconstruct the circuits of knowledge production by highlighting the role of scientific sociability at the heart of frontier fields such as transcultural psychiatry or medical anthropology (Delille, 2017). It explores the sociology of the Chicago School and its complex relationship with social psychiatry (Smith, 2023). As such, this historiography of epistemic and genetic pluralism is an essential contribution to a history that reveals how science always retains the marks of its places of production (Livingstone, 2003).

This account of psychiatric epidemiology from a global perspective contrasts with a longer-term historiography focusing on the disciplinary frontiers of epidemiology (Amsterdamska, 2005) and the internal evolution of the methods and concepts of an epidemiological specialty put to the test by the specificities of mental illness (Susser and Morabia, 2006). From this perspective, the aim is to identify the successive stages leading to the transformation of a field of research that gradually gained autonomy as a scientific specialty and academic discipline supported by a community of researchers and professors, and reproduced through training programmes, textbooks and journals, mainly in the USA (Grob, 1985; Horwitz and Grob, 2011).

In retrospect, it seems easy to judge the epistemological ‘ruptures’ while at the same time declaring that psychiatric epidemiology was always moving towards ‘modernity’ via the transition from psychiatric institution statistics to population statistics, the search for the ‘true’ prevalence of mental illnesses, the interest in less severe mental disorders, the use of the concept of ‘exposure risk’ and the cohort method, the development of the DSM-III in the 1980s, and so on. In this respect, it is significant that most medical textbooks acknowledge the role of community studies without considering their results. For example, depressive and anxiety disorders were only aggregated from the 1980s onwards after the practical application of DSM-III (Tsuang, Tohen and Zahner, 2003).

The first historiographical trend was interested in the genesis, or rather the geneses, of a specialized field of research (i.e. specialization through collaboration). In contrast, the second historiographical approach takes the point of view of the history of institutions and professions to focus on the demarcation stages of a legitimate ‘academic discipline’. Historiography slides from one direction to the other once both have been determined. This opposition indicates a tension that goes well beyond this historiography of psychiatric epidemiology. Indeed, a recurring difficulty in the history of science stems from the unreflective use of the term ‘discipline’, which covers at least two realities. Historiography, including that of psychiatric epidemiology, slides from one meaning to the other without formulating the theoretical problem. The first meaning refers to ‘specialized knowledge’, while the second refers to the ‘political institution, a way of structuring scientists’ behaviour’ (Kohler, 1985; Stichweh, 1992).

While the merit of the first historiographical trend is that it avoids essentializing the institutional consensus, it does not historicize the epistemic, methodological, moral and political value judgements that actors project onto their past in order to unify research into an academic discipline. From a global history perspective, the first approach demonstrates that there are moral, political and epistemic value judgements based on geographical locations and their local dimensions. The second approach bases its account on epistemic value judgements, sanctioned retrospectively without taking account of their interaction with moral and political value judgements, as if the true naturally met the good. This does not take into account how idealizations of the good may impact what is reported as true in epidemiological judgements on mental illness and the mental health of populations.

The problem of transforming a new field of research into an academic discipline

An important epistemological issue in the history of science is to explain the transformation of a specialized field of knowledge into an institution of academic reproduction: how is a fundamentally diverse and fragmented set of sources gradually transformed into a scientific unit structured by a hierarchy and authority? The classic answer, at the heart of the second historiography, is that the transformation occurred through successive demarcations. The discipline’s ‘work on the boundaries’ leads to a precise scientific identity (Gieryn, 1999). The discipline is presented as the result the division of legitimate sciences within an epistemic hierarchy. In this respect, the processes of disciplinary segmentation (i.e. the division of a particular and specialized science from a more general science) are much more studied than the processes of assimilation of disciplinary segments (i.e. the division of a particular and specialized science by fusion or combination of epistemic elements from several general disciplines).

As a result of this interest in demarcation and public opinion, a decisive dimension of the historiography of the epidemiology of mental illness is under-investigated: the analysis of the often quieter ‘work on the hierarchy’ of the internal organization of the field of research leading to specialization through the assimilation of disciplinary segments such as psychiatry, psychology, anthropology, sociology and so on. Despite this, historians of science who examine specialization by assimilation of disciplinary segments (e.g. biology and chemistry to form biochemistry; geology and physics to form geophysics) place much more emphasis on unification by assembling elements of equal or equivalent epistemic value than on assembly by hierarchization or the division of scientific work involving a structure and an authority structuring the epistemic elements:

In assembly, scientists bring together disjoint elements to order them within frameworks of higher organization. These elements may be conceptual, methodological, practical, or institutional. They include theories, instruments, and research problems. The builders of frameworks, motivated by curiosity or ambition, organize individual activity and collective activity in somewhat restricted settings such as a lab or agency and larger settings of several types. They emphasize congruencies and utilities, convince themselves and their colleagues of the assembly’s legitimacy, and produce larger frameworks. Individuals or teams at multiple sites might investigate a single research problem. Alternatively, previously separate research problems might be brought under one heading for a limited purpose. Phenomena are converted to research problems, research problems are treated collectively in a research school or tradition, and research schools or traditions are brought together as a larger framework, often called disciplines. (Good, 2000: 263)

For this reason, it is a good methodological practice to insist not only on the concrete work of putting things in order at the moment of genesis of the history of a field of research, but also on the transformation of disciplinary arrangements over the long term that can align moral, political and epistemic authorities in the history of science (Brown, 2015: 270–1) and in the history of psychiatry (Lézé, 2010). Consensus is an ‘agreement’ that is all the more provisional in that it implies a hierarchy of revisable norms and values and a subordination of more or less tacit disagreements. Indeed, the integration of the multiplicity of elements is a consequence of selections to include or exclude subordinate elements into an epistemic order. Even in the name of an ideal of interdisciplinarity or collaboration, inclusion is achieved in practice by giving rank and status through specialization, complementarity or stratification in the concrete division of research work (Griesemer and Gerson, 1993: 203). On the one hand, attempts at exclusion are just as significant in relativizing the ideal of interdisciplinarity in the relationship between the epidemiology of mental illness and clinical psychiatry. On the other hand, deference to the epistemic authority of expertise organizes the entire knowledge production circuit, from the composition of the team, the development of instruments, the interpretation of results, and their use in the form of expertise in public health policies. As a result, the work of consensus can only be fully explained by exploring the history of the judgement criteria at the heart of the epistemic authority that generates the hierarchies of the research field.

In the end, consensus only erases the history of diversity (of places and conflicts), and also the criteria of arrangement and rearrangement, not to mention the ‘petty arrangements’, of actors pursuing a legitimization strategy. Such actors then allow themselves to be overtaken by the involuntary effects of institutional arrangements that constrain the renewal of legitimization strategies. With this in mind, this thematic issue aims to historicize the forms of epistemic authority to explain better their effects on institutionalizing and stabilizing psychiatric epidemiology. The historical analysis of epistemic authority thus makes it possible to re-articulate the two historiographies of psychiatric epidemiology on the transformations of epistemic authority and the effects of this on the formation and transformations of the hierarchy and division of knowledge.

The hierarchization of knowledge in the history of psychiatric epidemiology

The articles in this issue contribute to the history of the hierarchization of knowledge in psychiatric epidemiology and of the reception and transformation of epistemic authority that ensued. Three dimensions reveal the effects of epistemic hierarchies, whether negotiated explicitly or not: the status of disciplines as a basis for the hierarchy of members of an interdisciplinary research team; the theoretical and methodological selections as a basis for the construction of survey instruments and their practical application; and the moral and political ideals regulating research programmes, and the recognition of their expertise in public health.

The first five articles cross three epistemic dimensions in order to contribute to in-depth studies of the work of prioritizing knowledge in psychiatric epidemiology; and finally there is a Classic Text.

Interdisciplinary research teams carry out epidemiological investigations

All collaborations are organized around interdisciplinary divisions of labour, even if studies of the history of science sometimes emphasize the role of the leader while neglecting the constitution of the group and, in this case, the origin and subsequent trajectory of the anonymous investigators (Russell, Tansey and Lear, 2000). Like the concept of ‘assembly’, the observation of ‘collaboration’ (Hackett, 2005) does not lead to a history of the production of a scientific ‘stratification of authority’. However, ‘science is not an undifferentiated network of social relations’ (Griesemer and Gerson, 1993: 186, 190). Thus, studying the composition of the team makes it possible to understand the production of knowledge beyond the observation of interdisciplinarity, which is, above all, a value of materialized scientificity whose rhetoric erases the hierarchy of the social status of agents as well as the epistemic hierarchy of scholarly norms. The articles by Matthew Smith, Emmanuel Delille, and Bonnie Evans show particularly well the effects of hierarchies between disciplines by investigating disciplines, such as psychometry, and investigators who are forgotten or at the margins of knowledge production because they produce films and photographs rather than written material.

Survey methods are based on theoretical frameworks

Research teams do not naturally merge research instruments, in this case questionnaires; nor merge ‘questions’ without applying eclectic reasoning to choose what is considered operational and trustworthy. A rivalry between methods may persist. As Steeves Demazeux’s study on the gradual domination of mechanical objectivity shows, the focus on symptomatology and the standardization of questionnaires through the inclusion and exclusion of questions and ‘value judgements’ rely on specific criteria for selecting questions, the inclusion of questions from past surveys, the transformation of a type of clinical judgement into a type of statistical judgement, and even attempts to oust some investigators, ethnographers and, above all, clinicians. Furthermore, specific surveys became ‘reference models’ to be replicated or included in the introductions to textbooks recounting the glorious past of the discipline, as shown by Matthew Smith’s article on the sociology of mental illness in the Chicago School.

Political and moral ideals, such as the ‘healthy society’, govern research programmes and the recognition of epidemiologists’ expertise

Interdisciplinarity is thus an epistemic virtue that is politically imperative during the formative period of psychiatric epidemiology and the struggle to define the possible meaning of the politico-administrative category of health or the militant category of the ‘mental health movement’ in tension with psychiatric interpretations. The objective of serving public health through population surveys erases the moral concerns of the time for a target population such as the military, as Steeves Demazeux reminds us. As all five articles demonstrate, young people are often judged with the contemporary standards of a good worker or functioning citizen. These political and moral values interfere, reducing the polysemy of epidemiological concepts (such as ‘acculturation’ or ‘social environment’ – see articles by Emmanuel Delille and Tiago Pires Marques) and their concrete applications by investigators who can, in turn, create traditions of investigative practice and preferences for a style of data collection and quantification (Tiago Pires Marques). Epistemic norms, therefore, imply not only a hierarchy of these norms, but also a hierarchy of political and moral norms that translate locally the great epistemic virtues of the moment. This thematic volume thus opens the door to a history of science programmes analysing the formation and transformation of the norms and values underlying epidemiological judgements about mental illness and the mental health of populations.

Classic Text

For this, Emmanuel Delille has chosen an outline of a scientific project by the psychiatrist and anthropologist Alexander H Leighton (1908–2007). This short presentation at a conference in 1949 shows the epistemic hierarchy of psychiatric epidemiology at one of the most significant events to bring together all the American researchers in this field of research just after World War II. In his frame of reference, Leighton subordinated the study of mental disorders to the methods of the human and social sciences, and specifically to applied anthropology. His role as head of the collective enquiry made him an ambitious ‘entrepreneur’ in a dynamic field of research, but one in which there was as yet no agreement. As pathology cannot be based on physiology in psychiatry, he chose questionnaires as research instruments to assess the symptomatology of a population. However, the survey is presented in the lexicon of scientific experimentation, integrating researchers from a wide range of scientific backgrounds. The removal of all references to psychoanalysis also shows the internal negotiation within the same survey. Leighton’s use of the concept of stress indicates that he borrowed an ecological framework by focusing on minor or reactive pathologies (such as depression and anxiety) rather than major pathologies (such as schizophrenia). At that time, American philanthropic foundations supported the functionalist model in social sciences and the ideal of interdisciplinary research in mental health: psychiatric epidemiology is just one area of research illustrating this epistemic regulation. More broadly, the conservative ideal of functionalist integration also appears in the concept of ‘socio-economic disintegration’ borrowed from the Chicago School when choosing a community to study.