It’s Time for Us to Stop Waffling About Psychiatry

Psychiatric Times, Vol 38, Issue 12,

Commonplace criticisms generate an image of psychiatry that is both wildly distorted and profoundly destructive.

  • You notice that a Harvard historian has published a book describing the history of psychiatry as a series of failures.1 This book receives praise from inside and outside psychiatry, garnering attention in major periodicals such as The Atlantic2 and
    The New Yorker.3
  • You see articles by prominent psychiatrists asserting that we should give up the idea that mental illness includes biological dysfunction, and either redefine mental illness or give up trying to define it altogether.4,5
  • You read articles by other prominent psychiatrists arguing that psychiatric treatment, including medications, should be decoupled from notions of biological dysfunction.6,7
  • You read an article by one of numerous psychiatrists and commentators who declare the field of psychiatry to be “in crisis,”1,8 and another discussing psychiatry’s particular vulnerability to “institutional corruption.”9
  • You notice a best-seller that makes a case that psychiatry is utterly corrupt, and that psychiatric diagnosis and treatment cannot be trusted. A quick internet search shows more than a dozen other recent books making the same argument.10
  • You read an opinion piece in the world’s most important medical journal stating that “something has gone wrong” in psychiatry, including the assertions that vast overprescribing and “trial and error ‘medication management’” have taken over the field.11 You note that psychiatrists are labeled pill-pushers and biological reductionists in psychiatric newspapers, general medical journals, and popular periodicals.12

Are you surprised by these assertions? Are you shocked? Do you get out your laptop to write a defiant letter to the editor? Do you consider giving up your psychiatric practice, since it may be misguided, corrupt, and unscientific? I doubt that you do any of these things. I suspect that, like me, you find these critical treatments of psychiatry to be interesting rather than shocking or even irritating. These sorts of criticisms of our field are, in fact, commonplace—so much so that they rarely generate much protest or sense of outrage among psychiatrists and other medical professionals.

And yet, such commonplace criticisms of our field generate an image of psychiatry that is both wildly distorted and profoundly destructive. They may not bother most of us as psychiatrists, but they confuse governmental bodies who might otherwise help us, arm insurance companies with arguments against paying for treatment, discourage nonpatients from seeking treatment, and add guilt and stigma to the lives of our scandalously under-supported patients, patients who are brave enough to seek treatment and face their own mental illness. As a result, millions of patients are harmed.

Such harms should no longer be ignored and tolerated. Because they are unjustifiable, the time has come for all psychiatrists to consistently speak out on behalf of our patients and the healing work we do for them, work that is mostly invisible to the public and routinely ignored in the media.13 In that spirit, I would like express what you and I both know but rarely articulate: These one-sided and destructive depictions of psychiatry need to come to an end. They should never again go unchallenged. Here is a list of the most common criticisms, and how each is decisively wrong:

Criticism 1: Psychiatric illnesses are not real illnesses in the conventional sense because they are not physically and biologically real.

Critics point out that (with the possible exception of Alzheimer disorder and other dementias) neurobiological research has failed to identify the precise biological mechanism for mental illnesses. That is, research has failed to produce the holy grail of a central pathology for even a single major mental illness. They also point out that our DSM diagnostic categories may not, and probably do not, correspond to actual disease entities.

Why is this criticism wrong? Because critics breezily ignore the massive array of medical and neurobiological research on the nature of mental illness that has accumulated in the last 50 years. Major mental illnesses are also physical illnesses, and the evidence for this is overwhelming. For instance, hundreds of structural imaging studies have shown significant grey matter losses for major mental illnesses.14 Microscopic studies have also shown abnormalities, including hippocampal and parahippocampal pathology in depression, posttraumatic stress disorder, and schizophrenia.15 Genetic studies have shown positive associations to all major mental illnesses, including addiction, schizophrenia, and attention-deficit/hyperactivity disorder.16 Hormonal abnormalities have been found across major psychiatric disorders,17 and inflammation has been documented as well.18 While the holy grail of central pathophysiology has not been located, there is more than enough evidence to know that major mental health disorders include physical, biological dysfunction.

We do not have to know precisely how mental illness is physical to know beyond a reasonable doubt that it is physical. In light of current research, it is manifestly unreasonable to suggest otherwise. To put it another way, just because we do not know everything about the biology of mental illness does not mean that we don’t know anything about the biology of mental illness.

Criticism 2: Psychiatric medications make things worse. They are dangerous substances pushed by drug companies and greedy psychiatrists.

Psychiatric medications do indeed have serious risks. This is so because every medicine with actual medical effects has serious risks. As physicians, we know that common medications like aspirin and acetaminophen can be rapidly fatal, sedatives like diphenhydramine can cause delirium and contribute to dementia, and that the widespread use of antibiotics carries a heavy price for public health. No medicine is risk free.

Does that mean psychiatric medications are foolish and unwarranted risks? Not necessarily. Every good physician, and every well-informed patient, must weigh the risks of any treatment against potential benefits. Psychiatrists know that we cannot compare the use of psychiatric medications with zero risks, but with the risks of not taking a medication at all. What are the risks of inadequately treated mental illness? Mental illness is devastating to both mind and body. It speeds up the aging process, reduces the lifespan by an average of 10 years,19 and disables patients at rates higher than most other types of medical illness. Nine of the top 25 most disabling medical illnesses are mental illnesses.20 Mental illness is also deadly, accounting for an estimated 14% of all deaths worldwide.21

Meanwhile, there are well-proven psychiatric medications for all major mental disorders. What do I mean by well-proven? I mean proven by the same standards that apply to any other medical treatment, including multiple large, double-blind, placebo-controlled studies substantiating their use as reviewed by outside groups of experts and other interested parties. For instance, a review and meta-analysis of antipsychotic medications including 167 studies with 28,102 participants substantiated their use for schizophrenia.22 Although challenges have been made to the efficacy of antidepressants, one recent meta-analysis for acute treatment of depression included 522 studies with 116,477 subjects and found that “all antidepressants were more efficacious than placebo in adults with major depressive disorder.”23

If psychiatric medications are effective, they are widely regarded as significantly less effective than medications in other branches of medicine. Yet a meta-analysis directly comparing the efficacy of psychiatric with general medical drugs found otherwise. Leucht and colleagues24 compared medications for 20 common general medical conditions with medications for 8 major psychiatric disorders. They found no statistical difference between the effect sizes of the 2 groups of medications. Overall, psychiatric medications are comparable with those for chronic medical conditions such as hypertension, asthma, and rheumatoid arthritis. Imagine, then, the hand-wringing and furious debate that would ensue if other medical treatments were treated with the same hostility, suspicion, and bias as psychiatric medications.

Criticism 3: Psychiatrists are biological reductionists and pill pushers, who diagnose and prescribe everyone they see regardless of their condition.

As psychiatrists, we recognize that employers, insurance companies, and government agencies tend to pressure us to provide only medical diagnosis and biological therapies, leaving other aspects of mental health care to other professionals. But the element of truth in this criticism masks a host of distortions and false assumptions. For instance, it is incorrect to say that psychiatrists believe only in biological realities, or that psychiatrists want to diagnose disease and push pills on every hapless patient. Critics often forget that psychiatrists do not prescribe the majority of psychiatric medications in this country.25

Beyond this, the pill-pusher narrative completely misses the broader medical and social contexts in which psychiatrists practice. There is a massive shortage of psychiatrists in this country and the world as a whole. This means that it is difficult to get in to see a psychiatrist, even for those patients with an urgent need. Even patients who can pay for treatment out of pocket will have to be persistent and determined to get treatment from a psychiatrist. And this, in turn, means that most individuals who finally get to see a psychiatrist suffer from significant, chronic illness, and most have already tried and failed more readily available treatments (such as self-help books, psychotherapy, and medications prescribed by primary care physicians). Ask yourself: How often do you see a new patient who has not tried and failed multiple interventions already? How often do you see a new patient who has not suffered from mental symptoms for years before ever getting a psychiatric evaluation? Like other medical specialists, psychiatrists usually treat patients with moderate-to-severe, chronic, and complex illnesses. And more severe and chronic psychiatric illness usually requires multimodal treatment, including psychotherapy and medication.

Given this context, it would be surprising if psychiatrists did not prescribe medications to the vast majority of their patients. Do you think that endocrinologists and rheumatologists prescribe medications to most of their patients? No one suggests that these specialists are greedy pill-pushers. Yet most critics of psychiatry reason in this very fashion.

Furthermore, I do not personally know a single psychiatrist who claims that mental illness is only biological, or who insists that psychiatric medications are the only legitimate form of treatment.26 Instead, this criticism of psychiatry seems to be a compelling narrative that reflects divisions in our field, which were present in the 20th century, when biological psychiatrists and Freudians fought over psychiatric turf and legitimacy. Thanks to progress in scientific research, those days are long gone. Both medications and psychotherapy are well proven, with hundreds of studies legitimating the medical use of cognitive behavioral therapy, psychodynamic therapy, interpersonal therapy, dialectical behavioral therapy, mindfulness-based therapies, and many more.27 Every psychiatrist I have ever met supports the use of psychotherapy and other psychosocial treatments, and they recognize that psychosocial treatments are woefully underfunded for those with moderate-to-severe mental illness.

Concluding Thoughts

We live in an intellectual culture that has habituated the public to think of psychiatry as flawed, failed, corrupted, and lost. The stereotypical picture of our field focuses relentlessly on the influence of drug companies, the weaknesses of the DSM-5, and the dangers of overprescribing. But when this picture of our field dominates, the public loses sight of the authentic healing work that we and other mental health professionals perform on a daily basis. They forget the scientific realities that ground our field in something besides self-interest and profit, and they forget the array of scientifically substantiated treatments that makes our gratifying work possible. And when we as psychiatrists forget to confront and correct such one-sided distortions, the results are disastrous.

Before you finish this article, consider trying a thought experiment. Reflect for a moment and see if you can think of well-known intellectuals who are famous for being gadflies and critics of psychiatry. I would bet that a little effort would bring up a wide variety of names associated with everything from outright antipsychiatry to legitimate and constructive criticism: Tom Cruise; Thomas Szasz, MD; Robert Whitaker; Peter Breggin, MD; Allen Frances, MD.

But who, on the other hand, is a well-known proponent of psychiatry? Ask yourself whether you can name a similar list of individuals who are well-known defenders of our work. And if several names do not spring immediately to mind, what does this tell you about our profession? What does this tell you about the state of our culture in regard to our profession? What does this tell you about our intellectual habits and assumptions about mental health care by physicians? And finally, what does this realization call you to do in response to such a sad and twisted state of affairs?

Dr Morehead is the director of training for the general psychiatry residency at Tufts Medical Center. His new book, Science Over Stigma, promotes a defense of mental health treatment and a call for advocacy. Dr Morehead would like to thank Ronald Pies, MD, for his generous assistance with this article.

References

1. Harrington A. Mind Fixers: Psychiatry’s Troubled Search for the Biology of Mental Illness. W.W. Norton & Co; 2019.

2. Greenberg G. Psychiatry’s incurable hubris. The Atlantic. 2019:30-32.

3. Szalai J. Mental illness is all in your brain – or is it? New York Times. April 24, 2019. Accessed September 22, 2021. https://www.nytimes.com/2019/04/24/books/review-mind-fixers-psychiatry-biology-mental-illness-anne-harrington.html

4. Aftab A. Psychiatry and the shores of social construction: Sami Timimi, MD. Psychiatric Times. March 12, 2021. Accessed September 22, 2021. https://www.psychiatrictimes.com/view/psychiatry-social-construction-sami-timimi

5. 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.

6. Moncrieff J. Research on a ‘drug-centred’ approach to psychiatric drug treatment: assessing the impact of mental and behavioural alterations produced by psychiatric drugs. Epidemiol Psychiatr Sci. 2018;27(2):133-140. 

7. Aftab A. Integrating academic inquiry and reformist activism in psychiatry. Psychiatric Times. January 4, 2020. Accessed September 22, 2021. https://www.psychiatrictimes.com/view/integrating-academic-inquiry-and-reformist-activism-psychiatry

8. Aftab A. The impoverishment of psychiatric knowledge. Psychiatric Times. March 30, 2020. Accessed September 22, 2021. https://www.psychiatrictimes.com/view/impoverishment-psychiatric-knowledge

9. Aftab A. Institutional corruption and social justice in psychiatry. Psychiatric Times. March 9, 2020. Accessed September 22, 2021. https://www.psychiatrictimes.com/view/institutional-corruption-and-social-justice-psychiatry

10. Whitaker R. Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs and the Astonishing Rise of Mental Illness. Crown; 2010.

11. Gardner C, Kleinman A. Medicine and the mind – the consequences of psychiatry’s identity crisis. N Engl J Med. 2019;381(18):1697-1699.

12. Khouzam H. The 21st century psychiatrists need to reestablish their identity as healers of the human psyche and not just pill pushers. Contemp Behav Health Care. 2016;2(1):44-47.

13. McGinty EE, Kennedy-Hendricks A, Choksy S, Barry CL. Trends in news media coverage of mental illness in the United States: 1995-2014. Health Aff (Millwood). 2016;35(6):1121-1129.

14. Goodkind M, Eickhoff SB, Oathes DJ, et al. Identification of a common neurobiological substrate for mental illness. JAMA Psychiatry. 2015;72(4):305-315.

15. DeCarolis NA, Eisch AJ. Hippocampal neurogenesis as a target for the treatment of mental illness: a critical evaluation. Neuropharmacology. 2010;58(6):884-893.

16. Glatt SJ, Faraone SV, Tsuang MT. Genetic risk factors for mental disorders: general principles and state of the science. In: Tsuang MT, Stone WS, Lyons MJ, eds. Recognition and Prevention of Major Mental and Substance Use Disorders. American Psychiatric Publishing; 2007:3-20.

17. Zorn JV, Schür RR, Boks MP, et al. Cortisol stress reactivity across psychiatric disorders: a systematic review and meta-analysis. Psychoneuroendocrinology. 2017;77:25-36.

18. Yuan N, Chen Y, Xia Y, et al. Inflammation-related biomarkers in major psychiatric disorders: a cross-disorder assessment of reproducibility and specificity in 43 meta-analyses. Transl Psychiatry. 2019;9(1):233.

19. Chesney E, Goodwin GM, Fazel S. Risks of all-cause and suicide mortality in mental disorders: a meta-review. World Psychiatry. 2014;13(2):153-160.

20. US Burden of Disease Collaborators; Mokdad AH, Ballestros K, et al. The state of US health, 1990-2016: burden of diseases, injuries, and risk factors among US states. JAMA. 2018;319(14):1444-1472.

21. Reisinger Walker E, McGee RE, Druss BG. Mortality in mental disorders and global disease burden implications: a systematic review and meta-analysis. JAMA Psychiatry. 2015;72(4):334-341.

22. Leucht S, Leucht C, Huhn M, et al. Sixty years of placebo-controlled antipsychotic drug trials in acute schizophrenia: systematic review, Bayesian meta-analysis, and meta-regression of efficacy predictors. Am J Psychiatry. 2017;174(10):927-942. 

23. 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.

24. Leucht S, Hierl S, Kissling W, et al. Putting the efficacy of psychiatric and general medicine medication into perspective: review of meta-analyses. Br J Psychiatry. 2012;200(2):97-106.

25. Mark TL, Levit KR, Buck JA. Datapoints: psychotropic drug prescriptions by medical specialty. Psychiatr Serv. 2009;60(9):1167.

26. Aftab A. Psychiatry and its critics. October 28, 2020. Accessed September 22, 2021. https://awaisaftab.blogspot.com/2020/10/psychiatry-and-its-critics.html

27. Psychological treatments. Society of Clinical Psychology – Division 12, American Psychological Association. 2016. Accessed September 22, 2021. https://www.div12.org/treatments/