Evidence Over Dogma: Practicing Psychiatry in the Age of Gurus and Hot Takes

tirachard/Adobe Stock

If you are a psychiatrist who shares educational content online, the backlash will eventually arrive. It usually sounds something like: “This guy doesn’t know anything—he just pushes pills and benzos.” It’s a familiar charge, and it misses the mark.

Most clinicians I know are not ideologues. We do not swear allegiance to a drug, a diagnostic manual, a lab, or a single theory of mind. We care about what works, for whom, at what cost, and with what trade-offs. Some patients thrive with psychotherapy and lifestyle changes alone. Some benefit from medication. Many need both. A few find value in adjunctive nutraceuticals with credible data (eg, S-adenosyl-L-methionine [SAMe] for depressive symptoms). None of this is heresy. It is just clinical judgment aligned with science and patient values.

What Critics Miss About Good Psychiatry

There is an exaggeration of psychiatry as a conveyor belt of prescriptions. There is also a misrepresentation of holistic care that rejects pharmacology entirely. Neither caricature helps patients. Good psychiatry is pragmatic:

• If diet, exercise, sleep regulation, psychotherapy, and social connection are sufficient—great.
• If medications are indicated—we discuss expected benefits, side effects, and alternatives, then decide together.
• If a credible adjunct exists—we consider it, set goals, and monitor outcomes.
• If something has no evidence or contradicts it—we say so, explain why, and decline to recommend it.

This is not dogma, it’s humility. It is the discipline of changing our minds when the data change and being honest when the available data is poor.

Why Pseudoscience Sells (and Why Psychiatry Is a Target)

Snake oil rarely advertises itself as snake oil. It markets certainty, identity, and hope—especially to people who have been dismissed or harmed by the healthcare system. Psychiatry, with its heterogenous conditions, subjective outcomes, and slow-moving evidence base, is especially vulnerable to confident answers wrapped in sleek branding.

Common red flags include absolute claims (“cures,” “root cause solved for everyone”); unvalidated tests marketed to “personalize” care without showing improved outcomes; proprietary secret sauces (protocols, supplements, or scans) with high price tags and sparse peer review; and a cult of personality where the messenger eclipses the method.

Meanwhile, legitimate debate within psychiatry—on diagnostic boundaries, overreliance on medications, and the influence of industry—gets flattened into “all meds bad” or “just follow guidelines” buckets. We can hold 2 truths: (1) our field has real problems worth fixing, and (2) those problems do not justify abandoning standards of evidence.

The Standard: Plausibility, Evidence, Outcomes

Patients don’t want ideology; they want to get better. Our job is to make transparent, testable recommendations.

A simple hierarchy helps when assessing options. Have patients check:

1. Plausibility: Does the mechanism make sense, or is it hand-waving?
2. Evidence quality: Are there randomized trials? Replication? Effect sizes that matter?
3. Patient-centered outcomes: Does it improve functioning, symptoms, and quality of life—not just biomarkers?
4. Harms and costs: What are the side effects, opportunity costs, and financial burdens?
5. Equity and access: Can this be used outside boutique clinics or cash-only models?

By walking patients through this framework, we replace internet certainty with collaborative clarity.

SAMe, CBT, SSRIs, and Squishy Narratives

Take depression as a practical example. Reasonable options include psychotherapy (eg, CBT), exercise, sleep interventions, and antidepressants. Some adjuncts—like SAMe—have encouraging evidence for certain patients. Reasonable clinicians can disagree about sequencing and combinations. That is fine. Disagreement does not equal corruption.

Where I draw the line is marketing masquerading as medicine—protocols or products sold with sweeping promises and no meaningful data. Patients deserve better than confident claims built on testimonials, selection bias, and glossy reels.

As such, clinicians can employ mini tests to assess the claims made (Table).

Having the Conversation Without the Food Fight

You do not have to win comment sections. You do have to talk with patients who are reading them. There are a few strategies that help to accomplish this goal:

• Lead with validation, not victory. “You’ve been through a lot, and you’re doing your homework. Let’s review what we know and what we don’t.”
• Name the trade-offs. Every option has costs. Make them explicit so the patient is not surprised later.
• Translate evidence to lived experience. “Here’s what a 20% response rate means for you over the next 4 to 6 weeks.”
• Use time-boxed trials. Agree on measurable goals and a timeline. If it is not helping, pivot.
• Invite second opinions. Confidence without control. “If you want another perspective, I’ll help you find one.”

Imperfect Science, Honest Practice

Psychiatry is not oncology; our biomarkers are fewer, our heterogeneity greater, and our tools imperfect. That does not mean anything goes. It means honest, iterative care: set goals, measure, adjust, repeat. It means being comfortable saying, “I don’t know yet,” and just as comfortable saying, “This doesn’t work—and here’s why.”

To the critics: You are right to be wary of overprescription, sloppy diagnosis, and industry spin. Many of us are, too. Hold us to high standards. But hold everyone else—the gurus, the brands, the boutique labs—to the same standards. Skepticism is a virtue only when it is applied consistently.

The Ask

Do not just take my word for it. Read the studies. Ask for effect sizes, not slogans. Expect transparency about uncertainty and trade-offs. And when someone—doctor or influencer—promises certainty in a field defined by nuance, take a breath and ask: Where’s the evidence, what are the risks, and what’s the plan if this doesn’t work?

That’s not cynicism. That’s care.

Dr Rossi is an inpatient and consultation liaison psychiatrist who also performs electroconvulsive therapy services at AtlantiCare Regional Medical Center in Pomona, New Jersey. He currently serves on the board of the New Jersey Psychiatric Association, where he has worked on advocacy projects, including enhancing access to collaborative care in the state.

Table. A Clinician’s Mini-Checklist for Claims That ‘Sound Right’

• Specificity test: Can they say who it helps, how much, and by when?
• Transparency test: Are the methods and data available for scrutiny?
• Proportionality test: Do the claims match the quality of evidence—or are they two steps ahead?
• Falsifiability test: What result would convince them they’re wrong?
• Conflict-of-interest check: Who profits, and how?

If a claim fails 2 or more of these, slow down.