In case you were wondering: After you crack a knuckle it’s about 20 minutes before you can crack it again. This was established by a series of experiments in 1947 at a research hospital in London. According to the researchers, “the minimum time was 17 minutes… but never more than 22.”

Eureka!

This may seem like menial work, but efforts to understand knuckle cracking pepper more than a hundred years of scientific literature, and continued into the 2000s. Then, in 2015, Canadian researchers watched knuckles cracking on MRI and were able to document ‘cavitation’, bubbles that pop open to fill space where a knuckle joint is stretched. Soon after, mathematical work confirmed those tiny bubbles can fully account for the impressive sound of a knuckle crack.

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The modern quest to explain knuckle cracking is a useful reminder that, even today, physicians stand on a tiny island of knowledge, surrounded by a nearly endless sea of unknowns. Until just recently, that sea included knuckle cracking. But the single greatest unknown remains. That, ironically, is the great repository of knowledge itself, the human brain. How it works and what’s happening in it is the holy grail of unknowns.

One reflection of our ignorance about the brain is the DSM-V, a book that defines and classifies mental illness. It is an important and broadly helpful book that codifies a universal language for psychiatry. But name any condition in it, and you’ve spoken a word with absolutely no anatomic or physiologic explanation. Depression? Don’t know where it is, don’t know what it is, don’t know how it happens. Schizophrenia? OCD? Bipolar? Addiction? Same.

This means there is not one pill, procedure, or treatment for mental illness that targets the underlying problem, a fact that makes psychiatry special in modern medicine. The biomedical model—identifying pathology at the anatomic or cellular level, then curing or improving it—simply does not apply.

Which may be one reason why a Nobel Prize was awarded in 1949 for the advent of the frontal lobotomy, a procedure for psychiatric patients in which an ice pick-like instrument was inserted through the forehead or eye socket, into the brain. The tip then pierced, and irreversibly damaged, the frontal lobe. This often led to a permanent loss of personality, lifelong apathy and listlessness. Even some of the procedure’s proponents referred to it as 'soul surgery’.

Today, frontal lobotomy is broadly recognized as unethical, and largely banned. But it arose from the hubris of scientists who believed so firmly in the power of their small island that they ignored the sea around them. Despite knowing nothing of the underlying disease or the inner workings of the brain, they developed a ‘treatment’ designed to permanently alter brain anatomy and physiology. It is a very different approach to medical treatment than the biomedical model, and it is one to avoid.

Incredibly, to this day, the Nobel Prize website defends the 1949 award, saying “at that time there were no other alternatives!” This is flagrantly untrue, and betrays a profound misunderstanding of psychiatric treatment. While antipsychotic drugs were not yet available, there were many alternatives to lobotomy. Options like talk and group therapy, institutionalization, safety measures in periods of danger, assisted living, social support and guidance, and more, are crucial measures that still help psychiatric patients every day, and through periods of crisis.

Yet the Nobel language implies that like lobotomy, drugs are somehow uniquely directed at the underlying problem in psychiatric illness. In reality, they are no more targeted than a rubber room.

To be clear, for many people psychiatric drugs are a godsend, making life livable, safe, and productive. But while they may change thinking and behavior, they don’t even attempt to correct the underlying condition. Like lobotomy, they simply go into the brain and muck around.

Confusion on this point is intentional. For decades pharmaceutical campaigns used the misleading phrase ‘chemical imbalance’ to describe mental illnesses, as if this is a part of any known pathology. It is not.

But that did not stop the makers of dopamine blocking drugs from advancing the theory that ‘overactive’ dopamine causes schizophrenia. Nor did it stop advocates of the ‘monoamine theory’, who suggested neurotransmitter imbalances caused mood disorders and monoamine drugs could fix them. And then came the greatest bamboozle of all, the idea that serotonin deficiency causes depression, which made serotonin drugs among the most prescribed in the world.

But the joke’s on us. Today, the serotonin theory is thoroughly debunked, but serotonin drug sales continue to soar. The illustration below, from the current website of a high profile research lab, is typical. It is based entirely on an advertising campaign, and has no basis in scientific fact.

Obviously, serotonin drugs don’t target any known disease. And yet they are commonly used not just for depression, but for anxiety, OCD, phobias, bulimia, premature ejaculation, PMS, fibromyalgia, irritable bowel syndrome, sleep, pain, and more.

Why else would they be prescribed for such a mind-boggling array of conditions? As one of my instructors in med school used to say: a drug that works for everything, doesn’t work for anything.

Again, some psychiatric drugs can be life saving (not the serotonin ones—mostly lithium and the antipsychotics), and there are many who need them to function. But if we’re being careful with our terminology ‘psychiatric drugs’ are not psychiatric. Like lobotomy, they simply have effects in the brain. Some may be desirable, others may not.

To be fair, using a pill to treat a symptom, rather than cure a disease, is common. Ibuprofen for a headache is one example. But when people and their families agree to long term medicines for mental health, they and their families often believe the pills are specific to their illness, or at least based on knowledge of the underlying problem. That belief is buttressed by white coats, framed degrees on the wall, and misleading illustrations like the one above.

For safety, island dwellers must respect the sea. To avoid disasters like bloodletting and frontal lobotomy we must recognize and acknowledge what we do not know.

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