Understanding Psychiatry: Navigating Skepticism and Science

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COMMENTARY

The public discourse around psychiatry is becoming increasingly shaped by skepticism—not only toward medications, but toward the very foundations of the field. A growing number of voices, including some within our own ranks, question whether psychiatric diagnoses are valid, whether psychotropic medications work, and whether psychiatry itself should continue to operate under a medical model at all.

In many cases, these critiques stem from valid concerns: the historical overreach of institutional psychiatry, the commercialization of care, the role of pharmaceutical marketing, or the unequal quality of mental health treatment. But what begins as warranted criticism has increasingly veered into dangerous territory: the outright dismissal of psychiatry as a science and profession.

As a practicing psychiatrist, I believe we are not responding to this movement with enough clarity—or courage. What is too often absent from these conversations is a grounding in clinical reality. A single day spent on an acute inpatient psychiatric unit offers a perspective that no amount of theory or online discourse can replicate. There, one encounters individuals in the grip of psychotic disorders—patients with schizophrenia responding to voices commanding self-harm, or deeply paranoid and unable to distinguish reality from delusion. One sees patients with bipolar I disorder in manic episodes—grandiose, sleepless, impulsive, and utterly unaware of their condition. These are not simply cases of existential distress or the struggles of the “worried well.” These are clear neuropsychiatric syndromes that impair insight, judgment, and self-regulation. To suggest that these conditions are purely social constructs, or that they can be resolved with talk therapy and kale smoothies, is to profoundly misunderstand—and trivialize—what our patients live through.

That is not to say psychotherapy, nutrition, exercise, and social support are unimportant. They are essential to comprehensive care. But when used as primary treatments for severe psychiatric illness in lieu of medication, they are not only insufficient—they can be dangerously inadequate. In acute psychosis or mania, the brain is in a state of profound dysregulation. Medication is not optional; It is lifesaving. And yet, many in today’s discourse argue otherwise. Antidepressants and antipsychotics are increasingly portrayed as inherently harmful, or even as tools of social control. There is a growing tendency to view all pharmacologic treatment with suspicion, and by extension, to view those of us who prescribe it as misguided or complicit. We are asked to justify interventions that are standard in every other field of medicine.

Much of this backlash stems from distrust of the pharmaceutical industry. That skepticism is not unwarranted—drug companies have at times prioritized profit over transparency. But the appropriate response is not to discard pharmacologic treatments altogether. Every branch of medicine operates within the same commercial reality. No one argues that the existence of Big Pharma invalidates the use of insulin for diabetes or chemotherapy for cancer. We can hold industry accountable without throwing out the evidence base that supports our tools.

What concerns me most is how binary the discussion has become. Many who advocate for “nonbiological” approaches seem to feel that acknowledging any biological basis for psychiatric illness undermines the importance of trauma, social determinants, or meaning making. But this is a false dichotomy. The biological and psychosocial are not mutually exclusive—they are inseparable. The mind is not distinct from the brain. Environment and biology interact in dynamic, reciprocal ways. We can and must treat both.

Personally, I find this debate exhausting because it distracts from the work that really matters taking care of people. I believe in the power of talk therapy. I also believe in clozapine. I believe in addressing adverse childhood experiences, systemic inequity, and food insecurity—and I also believe in lithium. We are not forced to choose between the soul and the synapse. Our patients deserve both.

Perhaps the most dangerous claim in the antipsychiatry narrative is that mental illness itself does not exist—that diagnoses like schizophrenia or bipolar disorder are simply labels imposed by society. This view may appeal to certain political or philosophical instincts, but it does not hold up against the empirical weight of decades of research. Psychiatric disorders show heritability, biological correlates, and predictable longitudinal courses. We can argue about the limitations of our current diagnostic system—and indeed we should—but denying the existence of severe mental illness is not a progressive stance. It is a form of erasure.

Ironically, many of the most vocal critics of psychiatry would likely not want to live with the consequences of their own rhetoric. I have yet to meet someone who would feel comfortable inviting an acutely psychotic individual into their home without treatment. Even the most strident critics instinctively understand that something real and deeply disorganizing is taking place in these conditions—something that requires more than conversation and community support.

If we as psychiatrists do not defend the legitimacy of our field, we risk allowing ideology to overtake evidence. We owe our patients more than silence. We must speak clearly, unapologetically, and compassionately: psychiatric illness is real. Medication is not a cure-all, but it is often essential. And psychiatry, despite its imperfections, remains a critical part of medicine.

To our colleagues in the broader mental health community: let us strive for nuance. Let us remain open to criticism and reform but not retreat from science. Let us acknowledge the limits of our knowledge while defending the legitimacy of our work. Because in the end, this is not just about psychiatry—it is about the individuals we serve. And they deserve care that is grounded in both evidence and empathy, not ideology.

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.