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To see Dr Morehead's original article, check out It’s Time for Us to Stop Waffling About Psychiatry.
Then read Dr Morehead's response to this article, It’s Time for Us to Realize We Are All on the Same Side.
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Does psychiatry need criticism in order to improve?
I read the article “It’s Time for Us to Stop Waffling About Psychiatry”2 by Daniel Morehead, MD, with great interest, particularly since it makes frequent references to some of my work in Psychiatric Times from the Conversations in Critical Psychiatry series. Dr Morehead and I agree about a lot of things: the fundamental legitimacy of psychiatry as a branch of medicine; the essential role psychiatry has to play in the treatment of mental health problems; that a defense of psychiatry is warranted against egregious and misplaced criticisms; and that the value of psychiatry must be conveyed to legislators, insurers, and the general public. Psychiatry is a profession with a rich intellectual history that exemplifies some of the best of what medicine has to offer. The tools it has at its disposal are limited, but when used appropriately, offer tremendous relief to individuals with psychiatric distress and impairment. I am proud to be a psychiatrist, consider myself privileged to do the work that I do, and would not trade it with any other medical specialty.
Despite these core agreements on the status of psychiatry, I am not entirely in agreement with Morehead’s characterization of critiques of psychiatry as destructive and harmful. My own view is different, shaped by my longstanding engagement with these critiques. Critiques of psychiatry are necessary and important, and will continue to be so, and psychiatry can only dismiss them at its own peril. It is my opinion that we need to reconceptualize psychiatry’s relationship with critique in a more productive manner.
There are understandable reasons psychiatry is scrutinized way more than other medical specialties. It, for instance, exercises social control over the lives of individuals under its care to a degree exercised by no other specialty; it is subject to more value disagreements; it has to work across multiple disciplines and perspectives that are difficult to integrate; it has a tumultuous historical legacy; the state of scientific development is still comparatively rudimentary; and it deals with conditions that are stigmatized and poorly understood, etc.
To see Dr Morehead's original article, check out It’s Time for Us to Stop Waffling About Psychiatry.
Then read Dr Morehead's response to this article, It’s Time for Us to Realize We Are All on the Same Side.
These and other factors ensure that psychiatry will be under the spotlight (just as we can expect that the police force will almost always be more scrutinized than the postal service). This additional scrutiny intersects with disorder within psychiatry’s own house, giving critics plenty of flammable material to work with. Even problems that are pervasive across all of medicine—such as industry influence and corruption of evidence-based medicine—become more noticeable in the context of psychiatry thanks to the additional scrutiny.3 There are also too many “unhappy customers” when it comes to psychiatry, so to speak: recipients of psychiatric care who have been left traumatized, disenchanted, even devastated by their experiences. There has been tendency within the profession to not take such individuals seriously, at least not without being forced to do so.
Psychiatry has been vulnerable to diagnostic fads. The profession has allowed itself to be exploited by pharmaceutical companies. Psychiatric theory has been vulnerable to “single-message mythologies” and zealous reductionism.4 Its leaders have neglected structural determinants of health. The state of science is what it is; we can make conditions conducive to scientific research, but discoveries and breakthroughs cannot be rushed or forced. While acknowledging the state of psychiatric science should lead to an attitude of humility, many psychiatrists in positions of power and influence have often made grandiose claims—and at times have displayed stunning arrogance.
This is not to say that psychiatry does not face unfair criticisms. There is rampant hostility, misinformation, misguided arguments, etc, exemplified well by Scientology, Szasz, and other actors. It is right to be wary of them and to push back against them, but at the same time, many psychiatrists have been too trigger-happy with allegations of “antipsychiatry” and have lumped all sorts of critics under the same banner.5
In my opinion, psychiatry cannot wriggle its way out of this dilemma by rhetorical appeals, tone-policing of criticisms, and becoming self-assigned arbiter of what sort of critiques are allowed from inside or outside the profession. As I have mentioned, based on the social role that psychiatry currently occupies, excessive scrutiny is inevitable. The best response to this state of affairs is to actually put the house in order, push back against egregious “anti-vaxx” style misinformation, and counter inaccurate claims when such claims are made, but to otherwise remain receptive to critique from scholars, scientists, and service users/patients. (I use the term “service user” in addition to patient in the spirit of inclusiveness, as it is preferred as a more neutral term by some individuals with experience of psychiatric care).
It is easy to recognize that psychiatry is working under systemic constraints that lead to many poor outcomes, but in such a situation, the psychiatric profession (represented by its leaders and organizations) has a responsibility to actively try to change the system. It has prominently fallen short in this regard. By blocking and dismissing criticisms aimed at psychiatric institutions (for instance, criticisms from the United Nations and the World Health Organization), it may very well be standing in the way of those who are actually trying to change it. With respect, psychiatry as a profession should join the effort or get out of the way.
When I say psychiatry, I mean myself and others like me who are included in it. We are not external to the profession—we are a part of it, we embody it, we represent it. We do not criticize psychiatry from some external vantage point, but as active participants within it. There has been an unfortunate tradition that many who critique dominant aspects of psychiatric theory and practice do so by framing it as a critique “of psychiatry,” giving the illusion of an external critique directed at a monolithic institution. That picture is obviously incorrect; psychiatry is a diverse discipline with many traditions, critiques of psychiatry are typically critiques of certain (dominant) practices within psychiatry, and these critiques often arise from within psychiatry. It is easy to be distracted by this framing of criticisms, but it is a mistake not to engage with the criticisms because of it.
The space of psychiatric critique is populated by diverse arguments. Here is an incomplete list:
-Critiques of DSM, its limitation, and its misapplications, and the dominant role it plays in current practice6
-Critiques of the links between psychiatric professionals and pharmaceutical industries7
-Critiques of the medicalization of everyday distress8
-Critiques that originate from a philosophical analysis of psychiatric concepts9
-Critiques that originate from relevant social sciences, such as anthropology, history, and sociology10
-Critiques that originate from a tradition of evidence-based medicine and question the efficacy of psychotropics such as antidepressants11
-Critiques of the long-term use of medications12
-Critiques that originate from human rights discourse and the use of psychiatric coercion13,14
-Critiques from harmed patients, individuals with lived experience, and the consumer/survivor/ex-patient movement15,16
For every sort of critique above, one can point to examples of criticism that are scholarly, academic, rigorous, and well-intentioned, even if one disagrees with them. Critiques from patients and service users are particularly important. Within our academic and clinical bubble, it is easy to develop the impression that all is well, but if we go outside the bubble, engage with individuals in the community where the clinical power differential no longer exists in the same way, and engage with individuals on social media and the blogosphere, I can assure you that we will encounter large numbers of patients whose encounters with psychiatric care have left them dissatisfied and traumatized.
Morehead says that “the time has come for all psychiatrists to consistently speak out on behalf of our patients.” Indeed, it has, and I would add that we can only do so genuinely and meaningfully if we also speak out on behalf of our patients who have been harmed by psychiatric care. Not only that, but we should go a step further and facilitate the process of empowering our patients to speak for themselves—as is the goal of the service user and lived-experience communities, as well as movements such as neurodiversity and mad pride.
It is important to note that the examples of criticisms with which Morehead opens his article do not correspond to the “common criticisms” that he subsequently addresses, giving a misleading impression. For example, Morehead cites Anne Harrington’s Mind Fixers in the beginning.17 The book is a history of psychiatry’s efforts to understand the biological basis of mental illness, especially in the context of grandiose ambitions and reductionistic claims of biological psychiatry during the 1980s, 1990s, and 2000s.18 Harrington’s book is a scholarly work by a reputable historian that every psychiatrist should read. In fact, Anne Harrington, DPhil was recently invited to speak by the Royal College of Psychiatrists19 and had an excellent online dialogue with the British psychiatrist Matthew Broome, MD, PhD, which illustrates well how we can benefit from historical critique and engage productively in response.
Morehead references the 2012 paper by Phillips et al on conceptual and definitional issues in psychiatric diagnosis.20 This article highlights some of the most prominent names in philosophy of psychiatry and reveals the philosophical difficulties that surround the notion of mental illness and the elusiveness of a satisfactory definition. This has been a topic of interest to me for many years, and my own philosophical work in this area reflects the conceptual inadequacies of our notion of mental illness.21 If Morehead believes that there is no need for such philosophical analysis and we already have an adequate definition at our disposal, he is welcome to disagree with me and engage with the philosophy of psychiatry literature, but it is unclear to me why this should be seen as an example of problematic and irresponsible critique of psychiatry.
These are what Morehead calls the 3 most common criticisms:
Criticism 1: Psychiatric illnesses are not real illnesses in the conventional sense because they are not physically and biologically real.
Criticism 2: Psychiatric medications make things worse. They are dangerous substances pushed by drug companies and greedy psychiatrists.
Criticism 3: Psychiatrists are biological reductionists and pill pushers who diagnose and prescribe everyone they see regardless of their condition.
These criticisms as stated are frequent enough in layperson, Szaszian, and Scientology critiques of psychiatry, and they are worth rebutting in their own right. However, these criticisms have very little to do with the sophisticated critiques offered by respected scholars and psychiatrists such as Dr Harrington, Dr Frances, Dr Steingard, Dr Waterman, Dr Fava, Dr Cosgrove, and Dr Kleinman, all of whom are included in the list at the beginning of the article. If these authors have not made these criticisms—and they have not—then why use them as prefatory examples? By doing so, Morehead risks conveying an inaccurate portrayal of the nature of their criticisms.
Furthermore, for each of the common critiques Morehead brings up, there are related critiques that are indeed worth taking seriously. For instance, it is indeed the case that research studies have reported a wide variety of associations between psychiatric disorders and various biological factors, but these tend to be at the group level, often of small magnitude, and they tend to be neither sensitive nor specific, neither necessary nor sufficient. They are better understood as biological risk factors. At the same time, research has also reported a wide variety of associations of psychiatric disorders with psychological and social risk factors, and these associations are of a magnitude equal to, if not greater than, the associations with biological factors. Even for conditions with high heritability such as schizophrenia, identified genetic associations, captured in aggregate by polygenic risk score, account for a woefully small percentage of risk, while risk factors such as trauma are far more potent and far more neglected.22 This raises the question: Why should biological risk factors be privileged over psychosocial risk factors when it comes to understanding psychiatric disorders? This privileging of biological over psychosocial is, in a sense, what we do when we characterize psychiatric disorders as brain diseases and brain disorders.23
Consider Morehead’s second criticism. Psychiatric medications do indeed have legitimate clinical uses. Even critics such as Dr Moncrieff, who otherwise adopts a Szaszian view of mental illness, accept that antipsychotic medications have therapeutic utility in acute psychosis. Acknowledging this does not mean we can look away from the evidence that the efficacy of these medications has been systematically exaggerated and their harms downplayed through problems with the design, conduct, and reporting of clinical trials.3 To bring up 1 example of neglected risks, it took years of protests by harmed patients and concerned clinicians for the profession to even begin to acknowledge the severity and burden of antidepressant withdrawal syndrome.24-26 With regards to antidepressant efficacy, the Cipriani et al meta-analysis27 cited by Morehead indeed shows that antidepressants outperform placebo by a statistically significant margin, but the magnitude of average difference between antidepressants and placebo is so small at face value that its clinical relevance is unclear.28 The situation is even worse for children and adolescents. A 2021 Cochrane review and meta-analysis29 concluded that antidepressants “reduce depression symptoms in a small and unimportant way compared with placebo.” While this does not by itself prove that antidepressants have no clinical utility—we have decades of clinical experience to rely on, and there are analyses that suggest that selective serotonin reuptake inhibitors may have more specific actions on depression mood rather than aggregate rating scale scores30—this does however indicate deeper problems with our reliance on standard “evidence-based” strategies of randomized controlled trials, systemic reviews, and meta-analyses. This is something we can only begin to tackle if we take the critiques seriously. It also highlights that the efficacy of antidepressants is not robust enough to justify the astonishingly high levels of prescribing we currently see—13.2% of US adults had used antidepressant medications in the past 30 days during 2015 to 2018, according to the Centers for Disease Control and Prevention.31
Morehead states that mental illness speeds up the aging process and reduces the lifespan by an average of 10 years, without seemingly stopping to ask whether this accelerated aging and shortened lifespan could be facilitated in part by the use of psychiatric medications. Psychiatric medications, such as antipsychotic medications, confer high risk of obesity, diabetes, and hyperlipidemia, all of which are well-recognized factors associated with increased aging and mortality. A recent editorial in JAMA Psychiatry has hypothesized that long-term exposure to antipsychotics increases the risk of premature dementia in individuals with psychosis.32 In my view, complacency in the face of such evidence is alarming. It is easy for psychiatric professionals to focus on the harms of under-diagnosis and under-treatment, but these gestures ring hollow and insincere if the profession also does not adequately address the harms of over-diagnosis and over-treatment.
Psychiatry is at a crossroads. The medical model has been dominant in mental health, and while it has an essential place, its dominance is being challenged by many forces and is no longer guaranteed in the future. Clinical psychology is maturing as a discipline, tackling the “theory crisis,” developing its own classification systems such as HiTOP, rediscovering psychoanalysis, and developing innovative treatments for serious mental illness.33-36 There is also a new energy in social work, and service user movements grow stronger every day. Institutions such as the United Nations and the World Health Organization have challenged psychiatry to improve its record in terms of human rights.37 The world is changing, and along with it, psychiatry’s place in the order of things. Navigating this changing landscape requires a vulnerability and humility that does not come easily. It requires appreciating and defending our foundations within medicine, but it also requires appreciating the pluralistic nature of mental healthcare, to learn from our critics, and to take ownership of the problems that confront us.
Dr Aftab is a psychiatrist in Cleveland, Ohio, and clinical assistant professor of psychiatry at Case Western Reserve University. He leads the interview series “Conversations in Critical Psychiatry” for Psychiatric Times. He is a member of the executive council of Association for the Advancement of Philosophy and Psychiatry and has been actively involved in initiatives to educate psychiatrists and trainees on the intersection of philosophy and psychiatry. He is also a member of the Psychiatric TimesTM Editorial Board. He can be reached at email@example.com or on Twitter (@awaisaftab).
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2. Morehead D. It’s time for us to stop waffling about psychiatry. Psychiatric Times. December 2, 2021. https://www.psychiatrictimes.com/view/its-time-for-us-to-stop-waffling-about-psychiatry
3. Healy D. Pharmageddon. University of California Press; 2012.
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5. Davies J. Calling someone ‘anti-psychiatry’ is not an argument – and for many it feels abusive. Mad in the UK. February 22, 2020. Accessed January 3, 2022. https://www.madintheuk.com/2020/02/calling-someone-antipsychiatry-is-not-an-argument-feels-abusive/
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9. Zachar P. A Metaphysics of Psychopathology. MIT Press; 2014.
10. Kleinman A. Rethinking Psychiatry. Simon and Schuster; 2008.
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19. RCPsych. How will current psychiatric practice be seen in the future? 2021. Accessed January 3, 2022. https://www.rcpsych.ac.uk/events/conferences/detail/2021/12/09/default-calendar/how-will-current-psychiatric-practice-be-seen-in-the-future
20. Phillips J, Frances A, Cerullo MA, et al. The six most essential questions in psychiatric diagnosis: a pluralogue. part 1: conceptual and definitional issues in psychiatric diagnosis. Philos Ethics Humanit Med. 2012;7:3.
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22. Marsman A, Pries LK, Ten Have M, et al. Do current measures of polygenic risk for mental disorders contribute to population variance in mental health? Schizophr Bull. 2020;46(6):1353-1362.
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24. Hengartner MP, Davies J, Read J. Antidepressant withdrawal-the tide is finally turning. Epidemiol Psychiatr Sci. 2019;29:e52.
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27. 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(10128):1357-1366.
28. Ghaemi N. Antidepressants work for major depression! Not so fast. Medscape. June 13, 2018. Accessed January 3, 2022. https://www.medscape.com/viewarticle/897878
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35. Aftab A. Psychoanalysis and the Re-Enchantment of Psychiatry: Jonathan Shedler, PhD. Psychiatric Times. July 29, 2020. https://www.psychiatrictimes.com/view/psychoanalysis-re-enchantment-psychiatry-jonathan-shedler-phd
36. Morrison AP, Law H, Carter L, et al. Antipsychotic drugs versus cognitive behavioural therapy versus a combination of both in people with psychosis: a randomised controlled pilot and feasibility study. Lancet Psychiatry. 2018;5(5):411-423.
37. New WHO guidance seeks to put an end to human rights violations in mental health care. World Health Organization. June 10, 2021. Accessed January 3, 2022. https://www.who.int/news/item/10-06-2021-new-who-guidance-seeks-to-put-an-end-to-human-rights-violations-in-mental-health-care