Loren Mosher

BMJ 2004; 329 doi: (Published 19 August 2004) Cite this as: BMJ 2004;329:463

Psychiatrist who espoused drug-free treatment for schizophrenia

The US psychiatrist Loren Mosher spent his entire professional career seeking more humane and effective treatment for people with a diagnosis of schizophrenia. This caused him to be cast as a maverick and to be marginalised by mainstream psychiatry.

As an advocate for patients' rights Mosher took an approach that was derived from the “moral treatment” of mentally ill people, a tradition characterised by Philippe Pinel when he removed the chains from the men held in the Bicêtre Hospital in Paris in 1797.

Mosher started a heated debate when he publicly resigned in 1998 from the American Psychiatric Association (APA)—which he called the American Psychopharmaceutical Association—charging that “psychiatry has been almost completely bought out by the drug companies.”

An honours graduate of Harvard University, Mosher served from 1968 to 1980 as the first chief of the Center for Studies of Schizophrenia of the National Institutes of Mental Health. He was the founder and first editor in chief of Schizophrenia Bulletin, and he coauthored the textbook Community Mental Health: Principles and Practice, which has been translated into five languages, and wrote or edited numerous scientific articles.

The consequences of his opposition to the influence of drug companies over medicine and his insistence on non-drug measures to help patients took a toll. In a 2003 interview with the San Diego Weekly Reader he said, “I am completely marginalized in American psychiatry. I am never invited to give grand rounds. I am never invited to give presentations… in the United States.”

Dr Mosher's early research into identical twins and schizophrenia convinced him that genes alone could not explain the onset of schizophrenia. By ignoring environmental and psychosocial factors, the psychiatric establishment was guilty, he said, of reducing schizophrenia to a “mechanistic” brain disease model. The result, he said, is that, “We're so busy with drugs that you can't find a nickel being spent on [non-drug] research.”

While doing research training at the Tavistock Clinic in London from 1966 to 1967 Mosher developed an interest in alternative treatments for schizophrenia. He visited Anna Freud and R D Laing and was influenced by Laing's view that schizophrenia was a reaction to an unbearable situation.

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Mosher worked closely for years with many advocacy groups, including the “psychiatric survivor” group MindFreedom International. Its director, David Oaks, said, “There are a number of psychiatrists who support our work, but few who simply liked hanging out with survivors the way Loren did. Loren was a real hero. He was willing to confront the mental health system, and he always did it with great humour and wit and intelligence.”

In the early 1970s Mosher founded an innovative home-like treatment programme for patients with newly diagnosed schizophrenia called the Soteria (Greek for deliverance) Project. He believed that the violent atmosphere of mental hospitals and the routine use of “toxic” drugs were counter to a healthy recovery. Staff members at the project were encouraged to treat residents as peers and to share household chores. The programme was designed to create “an environment that respected and tolerated individual differences and autonomy.” The Soteria Project closed in 1983 when funding dried up.

Mosher had a far more nuanced view of the use of drugs than is generally admitted. Though he often emphasised environmental factors, his writings indicate that he believed a delicate interplay between inherent “vulnerability” and environmental challenges could tip a patient over into schizophrenia or what he preferred to call “disturbed and disturbing” behaviour. Far from rejecting drugs altogether, he insisted that they be used as a last resort—and then in far lower doses than currently is usual in the United States.

More important, perhaps, than his resistance to drug use was his interest in non-drug treatments. Residents at the Soteria Project were treated with a quiet, calming environment. Neuroleptic drugs were used only when the patient became violent or suicidal. If the patient made no progress after six weeks and consented to drug treatment neuroleptics could be prescribed at low doses. Overall, 58% of Soteria patients were treated at some point with antipsychotic drugs, but only 19% were continuously maintained on the drugs, compared with 94% of patients who receive the usual care.

A 2003 report on outcomes among patients who were randomised to usual care or to the Soteria treatment, written by Mosher and Dr J R Bola, concluded that overall the Soteria patients did as well as or better than patients assigned to usual care. Critics immediately raised questions about possible study biases and its statistical analyses.

If there is one measure of his work, however, that transcends statistical argument, it is that surveys of patients treated at Soteria show that they simply felt better. They liked how they were treated better than in hospital. And if the mind is something that has value beyond its ability to function in a way that allows its owner to work or live independently, then feeling better is as good a goal—perhaps as moral a goal—as any.

Loren Mosher leaves his second wife of 16 years, Judith Schreiber; three children, Hal, Tim, and Missy Galanida; and two brothers, Roger and Harold.

Loren Richard Mosher, clinical professor of psychiatry University of California at San Diego Medical School (b Monterey, California, 1933; q Harvard University Medical School, Boston, United States, 1961), died from liver cancer in Berlin on 10 July.

[Jeanne Lenzer]