CONVERSATIONS IN CRITICAL PSYCHIATRY
Conversations in Critical Psychiatry is an interview series aimed to engage prominent critics within and outside the profession who have made meaningful criticisms of psychiatry and have offered constructive alternative perspectives to the current status quo.
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.
I was first exposed to Dr Ghaemi’s ideas around seven years ago through his critical commentaries on the DSM in Psychiatric Times (See his author page here: https://www.psychiatrictimes.com/authors/s-nassir-ghaemi-md-mph). I subsequently discovered his wealth of writings on philosophical frameworks in psychiatry as well as how these conceptual issues have real world implications for the understanding, classification, and treatment of mood disorders. A common refrain in Dr Ghaemi’s work is that psychiatry has lost its way by pursuing a pragmatic, atheoretical framework for understanding mental illness in the form of DSM and that 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 arguments 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.
Awais Aftab, MD: In the book On Depression, you have 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.”1 From your perspective, what do you mean when you call something a disease? In cases when depression is not a disease, should it still be considered a disorder?
S. Nassir Ghaemi, MD, MPH: 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. In 1980, DSM-III leaders wanted to reject psychoanalytic interpretations, and they also did not want to commit to biological causes (diseases). They replaced the prior term reaction with the purposefully vague term disorder. Disorder means nothing and everything; anyone can interpret it as they like. That kind of anarchic eclecticism is exactly what DSM-III intended, and psychiatry has inherited for 40 years.2 The term disease refers to a biological cause of a physical illness.3 Sometimes depressive states have such causation, as in manic-depressive disease. Sometimes they do not. The term major depressive disorder vaguely combines many different depressive presentations and, thus, as a whole, means nothing scientifically.
Aftab: Some commentators have noted that the description of the natural history of depression espoused by psychiatry has changed dramatically over the decades, from an acute, rare, self-limiting illness with favorable prognosis to a chronic, common illness in which only a minority of people stay well. How do you make sense of this change in the conceptualization of depression’s natural history?
Ghaemi: I wouldn’t say that characterization is correct. Depression, if by that term is meant “melancholia” in older usage, was seen as severe and episodic and common in Kraepelin’s work. It did not have a good prognosis in the sense that it was recurrent. Each episode improved, but then recurred, with suicide common. Neurasthenia, which reflected what later was termed neurotic depression, was chronic and seen as rampant in late 19th century America.4 I think American psychiatry simply is ignorant of the history of mental illnesses.
Aftab: You have long crusaded against antidepressant use in bipolar disorder, arguing that these drugs lack efficacy and hinder recovery in bipolar.5-7 I think psychiatry’s official position has slowly shifted in that direction (at least for bipolar I), but antidepressants still remain widely prescribed for bipolar disorder. It is common to hear clinicians say, “I know what the research says but antidepressants are clearly helping my patients with bipolar disorder.” What explains this persistent notion of anecdotal efficacy in clinical practice?
Ghaemi: Clinicians often base their opinions on their experience, not realizing that—as the old saying goes—half of what they see is false, and they just do not know which half. The same reasoning was the basis for the medical profession’s wide acceptance for two millennia of the four-humor theory and of bleeding. What many clinicians do not understand is the importance of confounding bias, that all their experience is confounded by the influence of other factors that they cannot know or control, foremost among these being natural history of recovery in an episodic illness. Each bipolar depressive episode resolves naturally, usually within months. Randomized placebo-controlled data show that antidepressants and placebo both produce notable and equal improvement. Placebo is a stand-in for that natural history. Instead of giving nature the credit, as the randomized clinical trials prove, clinicians credit the drugs: a classic mistake of the unscientific practice of medicine.
Aftab: Even outside of bipolar disorder, you are not a huge fan of antidepressants.4 Recently, when Cipriani and colleagues'8 meta-analysis was published, you wrote an editorial9 commenting that the results actually confirmed what previous studies have shown: the benefit from antidepressants (over and above placebo) falls short of being clinically meaningful. It is hard to imagine a group of medications whose efficacy has been as closely scrutinized as that of antidepressants, and yet despite the largest meta-analysis ever conducted, doubts about efficacy remain. Why is this issue so controversial and divisive?
Ghaemi: The studies are replicated and clear: the effect size of benefit with antidepressants overall in major depressive disorder is small and short of the cut-off for clinically meaningful benefit. On the other hand, as previously noted, the natural history of depressive episodes is that they resolve, and so clinicians see improvement, not realizing that the benefit occurs almost equally with non-drug intervention (ie, placebo). The problem is, at root, an unwillingness to accept the verdict of science as opposed to one’s own wishes or beliefs. The psychiatric profession appears to identify its medical legitimacy with the claimed efficacy of its drugs. There is no reason to claim this equivalence. In fact, we hurt our legitimacy with the public, and with our medical colleagues, when we cling to our treatments excessively.
This process is no different now with drugs than it was half a century ago in American psychiatry with psychoanalytic extremism. The basic psychiatric attitude is the same, even though the treatments are opposite. We need to change our basic philosophy, accept a self-critical attitude that submits to scientific judgment with humanistic sensitivity. This basic philosophy is as old as Hippocrates and reflects being a good doctor, period. It is the right way to defend our medical and scientific legitimacy.
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. Baltomore, MD: The Johns Hopkins University Press; 2013.
2. Ghaemi SN. The 'pragmatic' secret of DSM revisions. Aust N Z J Psychiatry. 2014;48:196-197.
3. Ghaemi SN. Taking disease seriously in DSM. World Psychiatry. 2013 Oct;12:210-212.
4. Ghaemi SN. Why antidepressants are not antidepressants: STEP-BD, STAR*D, and the return of neurotic depression. Bipolar Disord. 2008;10:957-968.
5. Ghaemi. Antidepressants in bipolar depression: the clinical debate. Aust N Z J Psychiatry. 2012;46:298-301.
6. Ghaemi SN, Vohringer PA. Athanasios Koukopoulos' Psychiatry: The Primacy of Mania and the Limits of Antidepressants. Curr Neuropharmacol. 2017;15:402-408.
7. Ghaemi SN, Dalley S. The bipolar spectrum: conceptions and misconceptions. Aust N Z J Psychiatry. 2014 Apr;48:314-324.
8. 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.
9. Ghaemi SN. Antidepressants Work for Major Depression! Not so Fast. Medscape. June 13, 2018. https://www.medscape.com/viewarticle/897878. Accessed October 28, 2019.
10. Ghaemi SN. Clinical Psychopharmacology: Principles and Practice. New York: Oxford University Press; 2019.
11. Ghaemi SN. The rise and fall of the biopsychosocial model. Br J Psychiatry; 2009;195:3-4.
12. Kendell RE, Cooper JE, Gourlay AJ, et al. Diagnostic criteria of American and British psychiatrists. Arch Gen Psychiatry. 1971;25:123-130.
13. Robins E, Guze SB. Establishment of diagnostic validity in psychiatric illness: Its application to schizophrenia. Am J Psychiatry. 1970;126:983-987.
14. Ghaemi SN. Toward a Hippocratic psychopharmacology. Can J Psychiatry. 2008;53(3):189-196.
15. Ghaemi SN. After the failure of DSM: clinical research on psychiatric diagnosis. World Psychiatry. 2018;17:301-302.
16. Ghaemi SN. DSM-5 and the miracle that never happens. Acta Psychiatr Scand. 2014;129:410-412.
17. Ghaemi SN. Nosologomania: DSM & Karl Jaspers' critique of Kraepelin. Philos Ethics Humanit Med. 2009;4:10.