How can the best insights of mainstream and critical psychiatry be brought together?
CONVERSATIONS IN CRITICAL PSYCHIATRY
Conversations in Critical Psychiatry is an interview series that explores critical and philosophical perspectives in psychiatry and engages with prominent commentators within and outside the profession who have made meaningful criticisms of the status quo.
Awais Aftab, MD
Joseph Pierre, MD is a health sciences clinical professor in the Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA. His clinical work focuses on the treatment of individuals with severe mental disorders, including schizophrenia. His research covers clinical trials in schizophrenia and early intervention for young individuals at high risk for psychosis. In 2005, he received Young Investigator Awards from both the International Congress of Schizophrenia Research and the American College of Neuropsychopharmacology. He has authored over 100 journal articles, abstracts, and book chapters. He also writes the Psych Unseen blog at Psychology Today, exploring the grey area between psychopathology and normality and the psychological underpinnings of everyday life.
Joseph Pierre, MD
My interest in highlighting critical perspectives extends to the way in which these critical perspectives are being received by thoughtful, well-meaning individuals from the mainstream psychiatric community. Joseph Pierre, MD is such a psychiatrist. He has engaged with the critical perspectives in his scholarly writings as well as in his online interactions. This interview focuses on the debates surrounding the DSM and psychiatry generally, delusion-like beliefs, social-epistemological conceptions of delusions, engaging with service users, and controversies relating to long-term outcomes with the use of antipsychotics. On most of these issues, Dr Pierre’s views are closer to prevailing psychiatric wisdom, but he also incorporates aspects of critical thought in productive ways that show the potential for common ground. My hope is that this interview will be informative for psychiatrists on both critical and conventional ends of the spectrum. For the critically minded, it highlights why many criticisms fail to persuade someone like Dr Pierre, and for the conventionally minded, it highlights what psychiatry stands to gain by engaging with the criticisms.
Aftab: In your contributions to the pluralogue on essential questions in psychiatric diagnosis,1 and in your chapter for the book Making the DSM-5,2 you have entered the conceptual debates surrounding definitions of mental disorder and the nature of psychiatric diagnoses. I am curious to know how your understanding of these issues has evolved over the course of your career. What has been the shape and form of your own critical engagement with the field, and what have you learned from it?
Pierre: My interest in critical psychiatry started at least a decade ago, sparked in large part by Allen Frances, MD’s series of critiques of the forthcoming DSM-5 in Psychiatric TimesTM. He highlighted the potential unintended consequences of premature revisions in the absence of a true paradigm shift. I was particularly interested in, and concerned about, the issue of diagnostic expansion, and how dimensional perspectives were going to be included in DSM-5. This resonated with my own academic work, which focuses on how we define psychotic disorders like schizophrenia, as well as individual symptoms of psychosis.3,4 In an attempt to work through these issues in my own head, I wrote a series of papers about the borders of mental illness in DSM.5,6 I also participated in several collaborations with Dr Frances and others like Ronald W. Pies, MD, with whom I had established a collegial kinship around this topic.
In addition to reviewing the academic literature for my writing, I also read books like Richard Bentall, PhD’s Madness Explained, Allan Horwitz, PhD’s Creating Mental Illness, and Robert Whitaker’s Anatomy of an Epidemic. In doing so, I began to see some flaws with approaches that were critical of the DSM. For example, the pre-DSM-5 criticism that each successive edition of the DSM resulted in the further proliferation of diagnoses could be explained by the development of finer distinctions of psychopathology, rather than necessarily reflecting more individuals being classified as mentally ill. Alternative definitional approaches, such as Jerome Wakefield, PhD’s harmful dysfunction model, did not seem to make it any easier to define mental illness operationally. My chapter in Making the DSM-5 was the culmination of my attempts to reconcile criticisms of the DSM with clinical pragmatism. I also advocated a broader mental health-mental illness continuum within psychiatry. Although I started my journey with a critical eye towards DSM-5, and have never felt that a new edition was justified, I nonetheless ended up becoming something of an apologist for the DSM as a good enough guide for clinical work, for which I have yet to see a better alternative.
That said, in my writing about the how we define mental disorders, I call for greater appreciation of contextual utility, whereby psychiatric diagnosis serves disparate purposes in different settings. DSM is a reasonable guide for clinical work and interventional research, but it is not as well-suited to other domains, such as etiological research or forensic work where it can be counter-productively confining. The biggest problem with the DSM’s contextual utility may be that it is primarily used not so much as a clinical guide but as a billing manual. It incentivizes over-diagnosis and over-estimates of severity based on reimbursement issues that demand unwarranted diagnostic confidence.
Aftab: Are there erroneous ways of thinking about psychiatry that you observe to be common among your psychiatric colleagues and trainees these days, and which you would like to correct?
Pierre: Although I can be a vocal defender of psychiatry against calls to abolish the DSM, psychiatric medications, or even our profession as we know it, I do see a variety of appropriate criticisms about the way psychiatry is sometimes practiced. These criticisms deserve greater attention.
As someone who did their residency training during the decade of the brain, at the height of optimism that neuroscientific discovery would result in both thorough understanding of mental illness as well as its cure, I have no doubt 20 years later that this was a vastly over-optimistic ambition. There is also little question that robotic 15-minute med checks that focus on symptom checklists and medication side effects represent bad psychiatry. In my work as an educator, I teach and advocate for a biopsychosocial perspective that views mental disorders as arising from interactions between environment and individual biology, similar to how we understand cardiovascular disease, diabetes, or even broken bones within the so-called medical model. Within this framework, psychotherapy and social interventions (eg, treating homelessness) are integrated with pharmacotherapy and sometimes used in lieu of somatic interventions. The systemic issues that relegate psychiatrists to mere prescribers (which you discussed with George Dawson, PhD, DFAPA), and have severely curtailed the duration of inpatient stays, has done our patients, and our profession, a disservice.
Over-prescription at the healthier end of the mental health-mental illness continuum is a valid concern about psychiatric care as it is practiced in some settings. I often see anecdotal evidence of treatment moving too readily to prescription, polypharmacy, and high-dose medication at the expense of watchful waiting, supportive care, psychotherapy, social interventions, treatment of substance use disorders, careful diagnostic re-assessment, and de-prescribing. That is partly due to psychiatrists over-identifying with their role as psychopharmacologists, but it is also driven by patients desperate for a pharmacologic quick fix. SSRIs and second-generation antipsychotics have thankfully reduced the risk-benefit ratio of psychiatric medications, but this has resulted in misperceptions that they are happy pills to be doled out like candy, often by primary care providers. These are important critical issues that deserve more attention in our profession. At the same time, however, they should not be used to argue against pharmacotherapy in toto, especially at the more severe end of the mental health-mental illness continuum.
Aftab: You have a long-standing interest in delusion-like beliefs (DLBs), conspiracy theories, and overvalued ideas, including the challenges these grey areas present in forensic settings. An important recognition, as you put it, is that “the formation and maintenance of beliefs and DLBs do not occur exclusively within the vacuum of an individual's mind, but are influenced by social forces.”7 Can you expand on your work in this area and some of the main conclusions that you have arrived at?
Pierre: Yes, psychosis has been a central interest of mine as a clinician and former early career researcher, especially with regard to the phenomenology of delusions and hallucinations and the grey area between pathology and normalcy. The DSM may be a good rough guide for diagnosing and treating disorders, but it falls far short of capturing the heterogeneity of individual symptoms or experiences like voice hearing and delusion-like beliefs. It does little to help clinicians decide what is or is not pathological. I do not see that as DSM’s fault though—clinical expertise and research discoveries are needed to move us forward in that regard.
In my academic work, I have been curious about how understanding pathological phenomena like delusions might contribute to a better understanding of more normative but potentially problematic phenomena, like political, religious, and false beliefs held with extreme conviction. The idea that a kind of subclinical psychopathology, including cognitive biases, underlies not only dysfunctional but also normal human behavior is the premise of my blog Psych Unseen.
Back in 2001, I wrote a paper about distinguishing between religious and delusional beliefs in which I noted, “even the most bizarre delusional idea might find a match in an average episode of the X-Files.”8 In recent years, while focusing on conspiracy theories, I have paid more attention to how historically unprecedented access to information, misinformation, and deliberate disinformation shapes our beliefs and how we, as psychiatrists, sort out whether a belief is a delusion in that context. These days, the vexing part of that challenge is that both pathological delusions and normative delusion-like beliefs are typically drawn from pre-existing cultural ideas and memes with fringe ideas increasingly shared in the internet era. With delusion-like beliefs such as conspiracy theories, the evidence to support them is usually found while searching for answers online. Misinformation is so easy to find not only because individuals believe and propagate it as a form of social affiliation, but also because peddling disinformation can be profitable, as well as a tool of political propaganda. In that sense, delusion-like beliefs, not unlike like psychiatric disorders, are very much a byproduct of interactions between individuals and their social environments.
Aftab: Similar to the way you emphasize how DLBs are formed and maintained by social forces, there is an emerging social epistemological conception of delusion that sees delusions as characterized not merely by individual epistemic deficits but also social epistemic deficits.9 Has your engagement with the conceptual literature on DLBs had any influence on your understanding of delusions?
Pierre: My recent work on conspiracy theories is based on a similar argument, that existing research has focused too much on individual psychology and that common belief in conspiracy theories can be better understood within a socio-epistemic model, whereby mistrust of authoritative sources of information leaves individuals vulnerable to misinformation in the form of conspiratorial counter-narratives.10 I would agree that such social perspectives have been given short shrift in understanding delusions proper as Kengo Miyazono, PhD et al9 and more recently Vaughn Bell, PhD and colleagues11 have argued, but overreliance on social theories fails to adequately account for delusions. For example, Miyazono et al hypothesize that “testimonial isolation” and “testimonial discounting” (being sheltered from or otherwise ignoring alternative explanations) can explain delusion formation and maintenance in schizophrenia, but a quick look at the world around us reveals that neither is specific to psychotic disorders. Most of us are shielded from views that contradict our own within social echo chambers and online filter bubbles and we routinely discount the dissenting testimonies of others (shouting “fake news”) when they are encountered.
In my experience, the key to distinguishing between pathological delusions and normative delusion-like beliefs lies within exploring their evidential justifications. We do not hold beliefs only due to epistemic trust in the testimony of those who tell us or teach us things, as Miyazono et al suggest, but also based on folk intuitions and subjective experience. Phenomenologically, subjective experience, and in particular anomalous experience, figures more heavily into clinical delusions than it does in delusion-like beliefs. Conspiracy theories, for example, are out there, waiting to be found and shared, whereas delusions have been traditionally regarded as unshareable, echoing what Jaspers wrote about delusions lying beyond intersubjective understanding. The unshareability of delusions often hinges on their idiosyncratic and self-referential content, based on anomalous subjective experiences that are prioritized over other types of evidence. In that sense, I see individual psychopathology as indeed central to understanding delusions in a way that is not as relevant to delusion-like beliefs.
As I suggested earlier however, the internet has thrown a fascinating wrench into efforts to distinguish delusions from delusion-like beliefs. Bell et al11 suggest that unlike shared delusion-like beliefs, idiosyncratic delusions are socially maladaptive, but it is now possible for subjective anomalous experiences and their delusional misinterpretations to be validated and reinforced within social spaces online. This can provide a false normalization of psychotic symptoms, whether we are talking about voice-hearing or paranoia in the form of so-called “gangstalking.” This might be de-stigmatizing within those online spaces, but can also steer individuals away from the potential benefits of psychiatric treatment. DSM-5 all but did away with folie á deux or shared psychotic disorder, leaving little guidance for clinicians grappling with seemingly delusional beliefs that are supported by testimonial validation in the internet era.
As with mental disorders more broadly, what we really need to understand delusions and delusion-like beliefs are truly integrative models that do not point to individual biology or social/environmental exposure as a reductionistic either/or. Psychiatric disorders are not merely normal responses to difficult life circumstances and trauma, just as they are not inevitable byproducts of genetics or chemical imbalances. We should also bear in mind that while experiences like delusions and delusion-like beliefs can be modeled as existing on a continuum, they may yet be important categorical distinctions, not only between delusions and delusion-like beliefs, but also between different types of delusions.
Aftab: As you are well aware, there is considerable anger directed at psychiatry from consumers/survivors/ex-patients and the self-described “harmed patient” community. I personally was not aware of the intensity and magnitude of this until I became active on social media. I am interested in your thoughts on this phenomenon and how it is changing the nature of public psychiatric discourse. This also taps into the larger issue of service-user involvement in psychiatry. As Nev Jones, PhD, emphasized in her recent interview with me,12 there is an immense need for diverse service users to be invited to the table as epistemic agents and interlocutors. I see that as an admirable and essential goal, although it is not without its challenges when it comes to implementation. The historical attitude of the field toward such an undertaking has been one of reluctance, perhaps because mental health consumerism has been viewed by many with some degree of suspicion and as an extension of the antipsychiatry movement.13 What is your opinion on the involvement of service users in psychiatry as epistemic agents and how should the field navigate the associated challenges?
Pierre: Yes, the internet has profoundly affected social discourse and even epistemology itself by providing a platform for previously unheard voices to be heard. Some have reasonably argued that this democratization of knowledge has led to the death of expertise, such that encountering dissenting opinions is par for the course within online spaces whether we are experts or not. During my career, there is always been a picket line of protesters at American Psychiatric Association meetings, but now that picket line shows up on my Twitter feed. Navigating such interactions and deciding how to engage, or not, is fraught with challenges, especially given that we are often talking about patients or ex-patients outside of the doctor-patient relationship
Generally speaking, there is potential for dialogue around improving psychiatric care, with medication side effects like akathisia or phenomena like benzodiazepine and antidepressant withdrawal in mind, but accounts of more idiopathic experiences (eg, withdrawal symptoms associated with being bed-ridden for years on end) and the use of polemical language (eg, “prescribed harm,” “brain damage,” “torture”) can provoke defensiveness on the part of clinicians and render common ground elusive. And unfortunately, online group processes often foster fractious discord, splitting, and projective identification rather than facilitating the kind of face validation that such patients are often looking for.
Like so much online discourse these days, there is also a dialogical impasse created by competing epistemologies. Self-identified “harmed psychiatric patients” are typically speaking from individual experience, whereas clinicians see things based on clinical experience with our own patients as well as the published literature. The idea of validating service users as epistemic agents is not novel, however; it is a fundamental part of our clinical work with patients, albeit with an eye out for potential cognitive distortions and false beliefs based on subjective experience. I maintain that many who identify as “harmed patients” would be best served by finding an empathic clinician who can listen to their stories and work with them in a therapeutic setting, but I understand that some have given up on that possibility and see it as anathema.
My work on conspiracy theories, and especially following the anti-vaccine movement, has led me to appreciate that offering consumers a seat at the table is a necessity for authoritative institutions (such as science, medicine, and psychiatry) to mend the kind of mistrust that can underlie belief in misinformation. But how to best listen to, learn from, and dialogue with patients outside of clinical spaces—and just what table we are referring to—is far from clear. As with so many polarized debates these days, a good start might be to steer clear of polemics in favor of finding middle ground, but that is often not what individuals want and is better achieved offline. We should also avoid the pitfall of framing the dialogue as between an “us” and a “them,” or as necessarily a dichotomy between subjective lived experience vs objective clinical experience and evidence, bearing in mind that psychiatrists (and other mental health professionals) and patients are not mutually exclusive groups, as Dr Jones exemplifies. Historically, lying on the couch was a core part of psychiatric training and many of us have done so as real patients as well.
Aftab: The view that individuals with schizophrenia who stay on antipsychotic medications do worse over the long-term than those who discontinue them has generated a lot of controversy, and you have also commented on this issue.14 I do not think there is any conclusive evidence that this is the case and I certainly am well-aware of the therapeutic potential of antipsychotic medications and the immense relief they bring to many, but I also do not think that the issue is quite that clear-cut.
Your view seems to be that the only thing that can really resolve this is a randomized-controlled trial (RCT) of antipsychotics in the long-term treatment of schizophrenia. Using RCTs to look at outcomes at, say, the 5-year mark (let alone 10 years or 15 years) is extremely challenging. The expected dropouts alone would probably render the results inconclusive, and the difficulty of recruitment would bring up limitations of generalizability. So I am not confident that an RCT of such duration, even if it is somehow conducted, will inevitably satisfy critics on either side. Furthermore, I want to push back against the idea that only RCTs can settle questions such as this. Henrik Ohlsson, PhD, and Kenneth Kendler, MD, made a similar point in a different context (psychiatric epidemiology) when they wrote, “The view that causation can be definitively resolved only with RCTs and that no other method can provide potentially useful inferences is simplistic . . .We need to avoid the extremes of overzealous causal claims and the cynical view that potential causal information is unattainable when RCTs are infeasible.”15 Obviously, observational studies always have inherent limitations, but it does not mean that they cannot offer us meaningful information with a certain degree of confidence.
Secondly, one of your arguments against the observational studies, such as by Martin Harrow, PhD (and there are at least 8 observational studies which have looked at this)16 is that the unmedicated patients who did better likely had schizophrenia of lesser severity or better prognosis to begin with. But that is not really consistent with the data from Harrow’s study, in which the results remain unchanged even when data is analyzed separately for good-prognosis and poor-prognosis patients.16 Again, I do not want to give the impression that these data are conclusive or are not subject to limitations or confounding, but I also think it is about time we start taking observational data a bit more seriously and move beyond the position that in the absence of RCTs the only reasonable option for us is to stick to our guns (as a reminder, the causal association between cigarette smoking and lung cancer was established based on non-RCT data). At the very least we can openly acknowledge uncertainty both in communication with the public as well as with our individual patients, that when it comes to long-term outcomes (3 years or more) of antipsychotic treatment in schizophrenia, we do not quite know with certainty whether antipsychotics on average improve them or worsen them, so that our patients and their families can make informed decisions taking into account this uncertainty. Your thoughts?
Pierre: RCTs are often the best way to establish causal relationships between clinical interventions and associated events, but they are obviously not the only way. For example, we do not have RCTs to prove that cannabis causes schizophrenia, but we do have longitudinal cohort studies that support the hypothesis. Note that the idea that cannabis use over time, particularly at an early age, can trigger or increase the risk of developing a chronic psychotic disorder like schizophrenia matches observations that cannabinoids can also cause psychotic symptoms more acutely.
With antipsychotics and psychosis, RCTs have resulted in consensus that antipsychotics can reduce psychotic symptoms in the short term. There is also support for antipsychotic effectiveness in relapse prevention from both longer-term RCTs as well as discontinuation studies.17,18 And anecdotally, in my clinical practice as an inpatient psychiatrist, psychotic relapses are almost always preceded by discontinuation of antipsychotic therapy (and/or illicit drug use) in the weeks to months before rehospitalization. That should be the starting point for making sense of non-randomized longitudinal studies in schizophrenia with the seemingly paradoxical finding that those who continue on antipsychotic treatment have a worse course of illness than those that do not. While it is theoretically possible that antipsychotics could cause that worsening (eg according to the unproven “dopamine super-sensitivity psychosis” hypothesis), especially when we consider that side effects like extrapyramidal toxicity can result in poorer outcomes, it makes more sense to suspect that this is a disease severity effect within a naturalistic, non-randomized study design. If we imagined similar long-term studies of medications like anti-hypertensives or sulfonylureas, I do not think we would be surprised if illness morbidity was greater among those who had to remain on medication due to illness severity, without invoking a medication toxicity effect.
In Anatomy of an Epidemic, Robert Whitaker quotes Martin Harrow as explaining the paradoxical finding of his 2007 study as follows: “It’s not that those who went off medications did better, but rather it was those who did better [initially] who then went off medications.” Subsequently however, both Dr. Harrow19 and Whitaker (in his writing for the Mad in America blog), have noted that that explanation does not seem to match estimates of prognosis at baseline. But baseline estimates of prognosis are not a great proxy for whether patients were actually doing better over time and do not explain why antipsychotics were deprescribed or discontinued. In fact, Harrow’s 2017 study19 demonstrated that better work functioning was associated with not being prescribed antipsychotic medication in their 20-year follow-up study. While we are still left with a potential chicken and egg debate about the arrow of causality, this could be interpreted as validation of Harrow’s original disease severity explanation: that those who were functioning better were able to stop and stay off medications.
Harrow and Thomas Jobe, MD’s16 commentary was one of many responses to a review article about the risk-benefit of long-term antipsychotic treatment in schizophrenia, which collectively demonstrate that psychiatry recognizes different explanatory hypotheses and that there is room for healthy academic debate on this issue (as well as many others, such as antidepressant effectiveness). In the spirit of seeking middle ground, we should acknowledge the take home message of the longitudinal studies in schizophrenia by Harrow and others—that lower doses of antipsychotic medication that minimize side effects are usually best and that some individuals diagnosed under the umbrella of schizophrenia may be able to stop and stay off antipsychotic medications. In my practice, I often deprescribe antipsychotics and revise chart diagnoses of schizophrenia. What we need to clarify based on well-designed clinical trials is when that is most appropriate and when it is not.
It is said that tolerating uncertainty and ambiguity is a requisite for practicing psychiatry. The challenge with acknowledging areas of uncertainty within a public sphere is that doing so can be weaponized to reinforce a post-truth view of the world in which everything is debatable, and any counter-position is just as valid. Although I like to think of myself as a middle of the road kind of individual, it is important to keep in mind that the truth does not always lie in the middle of a debate, whether we are talking about climate change, vaccines, or antipsychotic medications.
Aftab: There seems to be an implicit hint in your response that individuals diagnosed with schizophrenia who are able to stop and stay off antipsychotic medications may not really have had schizophrenia to begin with. Is this something you wanted to imply or perhaps I am misreading? While misdiagnosis certainly happens, I think it is commonly accepted–for instance, by psychiatrists such as E. Fuller Torrey, MD20–that a subset of patients with schizophrenia (a minority but could be as much as 20%) are able to recover and stay well off antipsychotic medications. Would you agree?
Pierre: The conundrum of schizophrenia is that even Bleuler conceptualized the term to account for a heterogeneous group of superficially similar disorders. So, it makes sense, almost tautologically, that those who benefit from or need long-term medication and those that can safely stop and stay off them (something that has been reported as far back as the 1950s) might at the very least have different types of schizophrenia. In retrospect, that might also mean that a patient did not have schizophrenia in the first place (eg, perhaps they had a substance-induced psychosis or voice-hearing experiences inappropriately labeled as a psychotic disorder) or it might reflect a variant of spontaneous recovery (eg, schizophreniform disorder or simple schizophrenia). It goes back to thinking of DSM diagnoses within a particle and wave model: both as a continuum but also with meaningful categorical distinctions within a spectrum. Personally, I think both conceptualizations are useful for understanding schizophrenia.
Aftab: I definitely share your clinical experience that psychotic relapses in individuals with schizophrenia are very commonly preceded by discontinuation of antipsychotic therapy. However, some psychiatrists are beginning to wonder to what extent such relapses may be precipitated by abrupt rather than gradual discontinuation. An interesting on-going RCT investigating this question is the RADAR trial by Joanna Moncrieff, MD, et al.21 In this RCT individuals with schizophrenia and related disorders (who have had more than 1 episode) are randomized to either a clinically supervised, gradual reduction of antipsychotic medication, leading to discontinuation when possible, or to continued maintenance treatment. Investigators will look at social functioning and relapses, with the primary outcome being social functioning at 24 months. Now this trial will not end until 2022, so we will not get to see the results any time soon, but hypothetically speaking, if the trial were to demonstrate that a large number of individuals are able to gradually discontinue antipsychotic medication with superior social functioning at 24 months—would that have any impact on your confidence that the results of long-term observational studies are adequately and sufficiently explained by disease severity confounding?
Pierre: I would certainly welcome a well-designed RCT that might help to resolve any debate there is about the association between poorer outcome and antipsychotic treatment in naturalistic studies. However, the more important question to answer is how to predict who can and cannot safely discontinue antipsychotic medications. Inclusion criteria that allow entities like “other non-affective psychosis” as proposed in Moncrieff et al20 mean that the study population may end up being farther away from the true schizophrenia side of the psychotic spectrum, which has presented a problem in interpreting recent studies of first-episode psychosis.22 What we really need are clinical trials that explore the risk-benefit of antipsychotic medications and non-antipsychotic interventions within more narrowly-defined psychotic disorder subtypes.
With regard to antipsychotic discontinuation and the explanatory value of super-sensitivity psychosis, it is important to note that psychotic exacerbations often do not come immediately as a rebound effect—they often take weeks to months. This challenges the notion that relapse is best attributed to the effects of acute antipsychotic withdrawal.23 In a meta-analysis of placebo-controlled RCTs for relapse prevention in schizophrenia, antipsychotic medications were favored over placebo regardless of abrupt discontinuation or gradual tapering.16 Note also that in individual studies like that of Gitlin and colleagues,24 where depot antipsychotic medication was discontinued (amounting to a slow taper), the vast majority of patients still experienced a psychotic relapse months later. Anecdotally, I once discontinued antipsychotic medication in a patient who I did not think had schizophrenia and I am sorry to say that after several months of a slow taper, I was proven wrong. I still regret that clinical error.
Aftab: In conversations with you (and with some of the other respected colleagues, such as Ronald Pies, MD), I get this impression that even when you acknowledge limitations or accept criticisms related to psychiatry, you do so from a place of security, as if you are standing on secure, solid ground. My sense is quite different when it comes to myself: I feel as if I am standing on shaky ground most of the time. If there was one circumscribed area of psychiatry that was subject to controversy, I would overall feel quite secure, but when I survey the state of affairs, I see problems almost everywhere: the traditional classification system struggling in terms of reliability and validity, justifying itself mainly by utility; neurobiological research failing to deliver clinically meaningful advances; the ways in which the practices of pharmaceutical companies have negatively impacted the integrity of evidence-based psychopharmacology; how antidepressant prescribing far outpaces the marginal evidence of efficacy, and how the burden of antidepressant withdrawal has long been minimized; the ways in which diagnoses have become blunt instruments in service of reductionistic narratives; the discontent both physicians and patients experience with the current system. Beneath it all, I do think psychiatry as a profession has a solid core, worth defending, worth preserving, but on the surface, I find constant upheaval. My goal is not to argue that you should feel about all this as I do – it is an impression after all – but I wonder if you have anything to say to psychiatrists such as myself who feel, so to speak, bogged down?
Pierre: As I suggested earlier, tolerating shaky ground is something of a requisite for practicing psychiatry. The brain is the most complex organ in the body, and we are still trying to emerge from the Middle Ages of understanding human behavior. There is no doubt that pathophysiology, diagnosis, and evidence-based treatment guidelines are much firmer in other specialties like infectious disease or auto mechanics. But for me, the mystery of psychiatry and the pluralistic approaches to address it are what make our profession so interesting and intellectually challenging. At the same time, the privilege of intimate human connection and the opportunity to relieve suffering validate that what we are doing is worthwhile.
I should also concede that despite my academic interest in the grey area between mental health and mental illness, I have spent my career thus far as an inpatient psychiatrist working within a multidisciplinary team at the more severe end of that continuum, where diagnostic uncertainty and debates about whether someone is mentally ill or not are less common, and decisional thresholds guiding when to treat or not are often relatively clear. I have been lucky to find the right niche to give me a feeling of foundational security despite the agnosticism that goes with our profession. So, to you and any other psychiatrist whose faith might be shaken, I say find the niche where you feel like you can make a difference. That is what is most important.
Aftab: Thank you!
The opinions expressed in the interviews are those of the participants and do not necessarily reflect the opinions of Psychiatric TimesTM.
Dr Aftab is a psychiatrist in Cleveland, Ohio, and clinical assistant professor of psychiatry at Case Western Reserve University. 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 Times Advisory Board. He can be reached at firstname.lastname@example.org or on twitter @awaisaftab.
Dr Aftab and Dr Pierre have no relevant financial disclosures or conflicts of interest.
1. 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.
2. Pierre JM. Overdiagnosis, underdiagnosis, synthesis: A dialectic for psychiatry and the DSM. In: Paris J, Philips J, eds. Making the DSM-5: Concepts and Controversies. Springer;2013:105-125.
3. Pierre JM. Deconstructing schizophrenia for DSM-V: challenges for clinical and research agendas. Clin Schizophrenia Related Psychoses. 2008;2:166-174.
4. Pierre JM. Hallucinations in nonpsychotic disorders: toward a differential diagnosis of "hearing voices". Harv Rev Psychiatry. 2010;18(1):22-35.
5. Pierre JM. The borders of mental disorder in psychiatry and the DSM: Past, present, and future. J Psychiatric Practice. 2010;16:375-386.
6. Pierre JM. Mental illness and mental health: is the glass half empty or half full? Can J Psychiatry. 2012;57(11):651-8.
7. Pierre JM. Integrating non-psychiatric models of delusion-like beliefs into forensic psychiatric assessment. J Am Acad Psychiatry Law. 2019;47(2):171-179.
8. Pierre JM. Faith or delusion? At the crossroads of religion and psychosis. J Psychiatr Pract. 2001;7(3):163-72.
9. Miyazono K, Salice A. Social epistemological conception of delusion. Synthese. 2020:1-21.
10. Pierre JM. Mistrust and misinformation: A two-component, socio-epistemic model of belief in conspiracy theories. J Soc Polit Psychol. 2020;8:617-641.
11. Bell V, Raihani N, Wilkinson S. Derationalizing delusions. Clin Psychol Sci. 2020.
12. Aftab A, Jones N. Phenomenology, Power, Polarization, and the Discourse on Psychosis: Nev Jones, PhD. Psychiatric TimesTM. October 8, 2020. Accessed January 5, 2021. https://www.psychiatrictimes.com/view/phenomenology-power-polarization-psychosis
13. Rissmiller DJ, Rissmiller JH. Evolution of the antipsychiatry movement into mental health consumerism. Psychiatr Serv. 2006;57(6):863-836.
14. Pierre. Do antipsychotics worsen schizophrenia in the long-run? Psych Unseen blog. Psychology Today. August 8, 2014. Accessed January 5, 2021. https://www.psychologytoday.com/gb/blog/psych-unseen/201408/do-antipsychotics-worsen-schizophrenia-in-the-long-run
15. Ohlsson H, Kendler KS. Applying causal inference methods in psychiatric epidemiology: a review. JAMA Psychiatry. 2020;77(6):637-644.
16. Harrow M, Jobe TH. Long-term antipsychotic treatment of schizophrenia: does it help or hurt over a 20-year period? World Psychiatry. 2018;17(2):162-163.
17. Leucht S, Tardy M, Komossa K, et al. Antipsychotic drugs versus placebo for relapse prevention in schizophrenia: a systematic review and meta-analysis. Lancet. 2012;379(9831):2063-71.
18. Gilbert PL, Harris MJ, McAdams LA, Jeste DV. Neuroleptic withdrawal in schizophrenic patients. A review of the literature. Arch Gen Psychiatry. 1995;52(3):173-88.
19. Harrow M, Jobe TH, Faull RN, Yang J. A 20-Year multi-followup longitudinal study assessing whether antipsychotic medications contribute to work functioning in schizophrenia. Psychiatry Res. 2017;256:267-274.
20. Torrey EF. Better off without antipsychotic drugs? Psychiatric Times. June 18, 2014. Accessed January 5, 2020. https://www.psychiatrictimes.com/view/better-without-antipsychotic-drugs
21. Moncrieff J, Lewis G, Freemantle N, et al. Randomised controlled trial of gradual antipsychotic reduction and discontinuation in people with schizophrenia and related disorders: the RADAR trial (Research into Antipsychotic Discontinuation and Reduction). BMJ Open. 2019;9(11):e030912.
22. Pierre JM. Diagnostic uncertainty, antipsychotic dosing, and optimal psychosocial interventions: unanswered questions in first-episode psychosis. Schizophr Res. 2020 (in press).
23. Emsley R, Nuamah I, Gopal S, et al. Relapse after antipsychotic discontinuation in schizophrenia as a withdrawal phenomenon vs illness recurrence: a post hoc analysis of a randomized placebo-controlled study. J Clin Psychiatry. 2018;79(4):17m11874.
24. Gitlin M, Neuchterlein K, Subotnik KL, et al. Clinical outcome following neuroleptic discontinuation in patients with remitted recent-onset schizophrenia. Am J Psychiatry. 2001;158:1835-1842.