CONVERSATIONS IN CRITICAL PSYCHIATRY
S. Nassir Ghaemi, MD, MPH is a psychiatrist with clinical and research expertise in mood disorders and training in philosophy and public health. He is Professor of Psychiatry at Tufts University, Lecturer on Psychiatry at Harvard Medical School, and directs clinical drug discovery research in psychiatry at Novartis Institutes for Biomedical Research in Cambridge, Mass. He is the author of the new textbook Clinical Psychopharmacology (Oxford; 2019), and multiple other books including The Concepts of Psychiatry (Johns Hopkins; 2003), The Rise and Fall of the Biopsychosocial Model (Johns Hopkins; 2009), and the New York Times bestseller A First-Rate Madness: Uncovering the Links Between Leadership and Mental Illness (Penguin, 2011). He also shares his insights on his website www.psychiatryletter.net.
The aim of Conversations in Critical Psychiatry is to engage prominent individuals within and outside psychiatry who have made meaningful critiques of psychiatry and have offered constructive alternative perspectives to the current status quo.
I first got exposed to Dr Ghaemi’s ideas about 7 years ago through his critical commentaries on DSM in Psychiatric Times, I subsequently discovered his wealth of writings on philosophical frameworks in psychiatry as well as how these conceptual issues have “real world” implications when it comes to the understanding, classification, and treatment of mood disorders.
A common refrain in Dr Ghaemi’s work has been that psychiatry has lost its way by pursuing a pragmatic, atheoretical framework of understanding mental illness (ie, progress requires going beyond pragmatism in search of truth). Over the years I have found his ideas to be highly thought provoking and engaging and his opinions have been instrumental in shaping my own views on psychiatry. Dr Ghaemi exemplifies the spirit of a maverick thinker and wields his nuanced understanding of history, philosophy, and research methodology to challenge conceptual errors rampant in the field.
Dr Aftab: In On Depression, you’ve argued that sometimes depression is a medical disease but often it is not. You write: “It has become de riguer to state that depression is a disease. I would say the opposite: most depression is not a disease. The part of it that is recurrent and episodic, or due to a specific medical cause, is disease. But the part that is not episodic, that is chronic and admixed with anxiety, becomes indistinguishable from personality.”1p14 From your perspective, what do you mean when you call something a “disease”? In cases when depression is not a disease, should it be considered a “disorder”?
Dr Ghaemi: The word “disorder” is meaningless. It is purposefully vague, introduced by DSM-III for every one of its 292 diagnoses in an attempt to be atheoretical about the causes or nature of those diagnoses. DSM-III leaders in 1980 wanted to reject psychoanalytic interpretations, and they did not want to commit to biological causes (diseases), so they replaced the earlier term “reaction” with the purposefully vague term “disorder.”
Dr Aftab has no relevant disclosures or conflicts of interest. Dr Ghaemi discloses that he is an employee of Novartis Institutes for Biomedical Research. The views expressed here are his own and do not reflect those of his employers.
1. Ghaemi SN. On Depression: Drugs, Diagnosis, and Despair in the Modern World. Baltimore, MD: Johns Hopkins University Press; 2013.
2. Cipriani A, Furukawa TA, Salanti G, et al. Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: a systematic review and network meta-analysis. Lancet. 2018;391:1357-1366.
3. Ghaemi SN. Antidepressants Work for Major Depression! Not so Fast. Medscape. June 13, 2018.
4. Ghaemi SN. Clinical Psychopharmacology: Principles and Practice. New York: Oxford University Press; 2019
5. Kendell RE, Cooper JE, Gourlay AJ, et al. Diagnostic criteria of American and British psychiatrists. Arch Gen Psychiatry. 1971;25:123-130.
6. Robins E, Guze SB. Establishment of diagnostic validity in psychiatric illness: Its application to schizophrenia. Am J Psychiatry. 1970;126:983-987.