Psychiatry is arguably the least science-based of the medical specialties. Because of that, it comes in for a lot of criticism. Much of the criticism is justified, but some critics make the mistake of dismissing even the possibility that psychiatry could be scientific. They throw the baby out with the bathwater. I agree that psychiatry has a lot of very dirty bathwater, but there is also a very healthy baby in there that should be kept, cherished, nourished, and helped to grow – scientifically.
Common criticisms in the media
- We are over-medicating our children, producing a generation of drugged zombies.
- We are using medication indiscriminately for people who don’t fit the diagnosis (i.e. antidepressants for people who only have normal mood fluctuations and life problems).
- Antidepressants lead to violence and suicide.
- Psychotropic medications all have terrible side effects.
- Antidepressants are no better than placebo.
- Psychotherapies are no better than talking to a friend.
- Electroconvulsive therapy (ECT) is a barbaric, damaging assault with no redeeming value.
- And we all remember how Tom Cruise attacked Brooke Shields on the issue of postpartum depression.
Thomas Szasz: Mental illness is a myth
Thomas Szasz goes even further: he rejects the whole concept of mental illness and considers it a plot to interfere with people’s human rights. He says:
- Psychiatric diagnoses are not valid because they are based on symptoms rather than on objective tests. (Steve Novella has pointed out that there are other well-established diagnoses like migraine that cannot be verified by any objective tests.)
- Mental illness is a myth: unusual behavior does not constitute a disease.
- Psychiatric diagnoses are an arbitrary construct of society to facilitate control of individuals whose behavior does not conform.
- Involuntary commitment is never justified even for the protection of the patient: patients always have the right to refuse treatment even if that means they will die.
The Citizens Commission on Human Rights
Szasz and Scientology (a marriage made in heaven?) joined forces to create the Citizens Commission on Human Rights. They have a slick website with a home page that proclaims its bias with a picture of a door labeled “Psychiatry: An Industry of Death.” They claim to be supporting human rights, but they appear to be engaged in a vendetta against psychiatry and psychotropic medicines. They do have some good points, but they go way overboard. And they systematically ignore any evidence showing that psychiatric care benefits patients.
A recent study
A recent study published in the New England Journal of Medicine helps bring several controversial psychiatric issues into focus. It was a randomized trial of 488 children age 7-17 with “substantial impairment” from anxiety disorders. It compared an SSRI drug (sertraline), a psychotherapy (cognitive behavioral therapy), a placebo medication, and a combination of sertraline and CBT. 23.7% of subjects improved with placebo, 59.7% improved with cognitive behavior therapy alone, 54.9% improved with sertraline alone, and 80.7% improved with combination therapy. Adverse events, including suicidal and homicidal ideation, were no more frequent in the sertraline group than in the placebo group; no child in the study attempted suicide. As would be expected, there were fewer side effects (insomnia, fatigue, sedation and restlessness) in the CBT group than in the sertraline group. An accompanying editorial suggested that many children are not being identified and treated appropriately, and that early treatment could reduce subsequent problems. Instead of “we are overmedicating our children” it suggests that “we are failing to treat all those who would benefit from treatment.”
This study is not perfect and can’t stand by itself, but it confirms previous studies showing that psychotherapy and SSRIs are both effective and the combination is even more effective.
SSRIs and suicide
In 2004 warnings inundated the media: studies had indicated an increase in suicidal ideation (from 2% to 4%) in children taking SSRIs for depression. The studies were flawed, and there was no increase in actual suicide rates, only in reported ideation. There were other clear data showing that SSRIs reduced suicide rates in depressed children. Nevertheless, the scare caused prescription rates to fall by 18-20%, and suicide rates promptly increased by 18%. The misguided attempt to prevent suicide instead led to an increase in suicides.
The Diagnostic and Statistical Manual of Mental Disorders
The Diagnostic and Statistical Manual of Mental Disorders or DSM is problematic. Diagnoses like homosexuality have come and gone depending on societal pressures. It is not very scientific. Neither was Freud, whose ideas have been largely discounted and whose diagnosis of “neurosis” is no longer used. The DSM is seriously flawed, but it’s better than any previous diagnostic system. It’s a noble effort, and the best we have at the moment. The real problem is when people misuse it and over-diagnose. Instead of discarding it, we can work to make it more reliable.
Mental illness does exist
It’s rejecting reality to think that mental illness doesn’t exist. Something is clearly wrong with an individual who is too depressed to get out of bed or eat, who is afraid to leave the house, or who believes he is Jesus Christ. These symptoms interfere with life and are usually distressing to the patient. One of my uncles developed paranoid schizophrenia: he lost contact with reality and was a danger to himself. In a previous century he might have spent the rest of his life warehoused in a locked ward. Medications allowed him to function: he married, had children and grandchildren, was loved, and led a relatively normal life in society. He had some side effects from the medications, but he and his loved ones felt that was a small price to pay.
Patients who clearly have a mental illness can be appropriately diagnosed and treated. Admittedly, a lot of not-so-clear cases end up with diagnoses and treatments they should not have. But that’s not a problem with psychiatry per se, but with the misapplication of psychiatry. We need to do better and we can do better. With science.
The mental health professions have made some stunning errors in recent decades, including the recovered memory craze, Satanic abuse confabulations, facilitated communication, multiple personality disorder with up to a hundred or more alters including animals, and Harvard psychiatrist John Mack’s gullible speculations about alien abductions. The good news is that science and reason have worked to identify these as errors and they have been largely avoided in mainstream practice.
Science is harder to apply to psychiatry than to other medical disciplines. Mental illness can’t be studied like pneumonia. We have no good animal models for most mental illnesses because animals don’t mentate the way humans do. We can’t do a blood test for depression like we do for diabetes. But we certainly can identify patients who are impaired by a recognizable constellation of symptoms, and we can test various treatments to see what relieves those constellations of symptoms. We can also look for underlying causes and ways to prevent illness.
Modern psychiatry, with its psychotropic medications and psychotherapies, is not as scientific or as effective as we would like, but it has undeniably saved lives and improved the quality of life of countless sufferers. Instead of bashing psychiatry for its faults, we should build on psychiatry’s successes and make it ever more science-based. Let’s put an end to psychiatry-bashing and stick to bashing specific practices that are not science-based and to bashing psychiatric malpractice like over-diagnosis and inappropriate prescribing. There is an excellent journal that tries to do exactly that: The Scientific Review of Mental Health Practice. It is far more credible than anything Szasz and Scientology have written.
This article was originally published in the Science-Based Medicine Blog