Editor’s Note: In a recent MIA Report, psychiatrist James Phelps and Robert Whitaker each offered their opinions on this question raised by Phelps: Does MIA do more harm than good? Now, in this “dialogue,” each offers their perspective on a recent paper published by Nassir Ghaemi in Acta Psychiatrica Scandinavica. Ghaemi, a professor of psychiatry at Tufts Medical School, concluded that psychiatric drugs, except for lithium, do not provide a long-term benefit and thus should mostly be prescribed for short-term relief of symptoms.
Ghaemi’s Analysis Tells of a Failed Paradigm of Care
By Robert Whitaker
The understanding that has animated Mad in America since its inception has been this: Our society has organized its psychiatric care and use of psychiatric drugs around a false narrative, one out of sync with the scientific literature. In this paper, Nassir Ghaemi—even while viewing psychiatric disorders through a disease lens—has for the most part validated that understanding.
What gives his paper particular importance is that Ghaemi is a prominent academic psychiatrist, with notable standing within the profession. If his peers were to take his analysis to heart, American psychiatry would need to radically change its prescribing practices.
The conventional narrative tells of how the introduction of chlorpromazine into asylum medicine in 1955 launched a psychopharmacological revolution. Psychiatry now had disease-specific drugs to prescribe: antipsychotics, antidepressants, and anti-anxiety agents. After the American Psychiatric Association published the third edition of its Diagnostic and Statistical Manual in 1980, the public was informed that psychiatric disorders—schizophrenia, depression, bipolar, ADHD and so forth—were discrete illnesses of the brain, caused by chemical imbalances, with psychiatric drugs fixing those imbalances, like insulin for diabetes. A second generation of psychiatric drugs were touted as safer and more effective than the first generation.
When I first waded into reporting on psychiatry, nearly 25 years ago, I believed that narrative of progress. But when I dove into the scientific literature while writing Mad in America and Anatomy of an Epidemic, I came to see it as a historical delusion, one that had brought prestige to psychiatry as a guild and profits to pharmaceutical companies, but, ultimately, harm to our society and our public health.
For the past 10 years and counting, this website—with its reports on scientific findings, publication of blogs and personal stories, drug resource pages, podcasts and so forth—has sought to flesh-out that “counter-narrative.” Ghaemi’s paper tells of “truths” found in the scientific literature that are central to that counter-narrative.
- Psychiatric drugs are not antidotes to any known pathology; they do not fix chemical imbalances in the brain.
Ghaemi writes: “Biologically, antipsychotics are mainly dopamine blockers and standard antidepressants are mainly monoamine agonists. After their introduction in the 1960s, corresponding theories arose regarding the dopamine hypothesis of schizophrenia and the monoamine hypothesis for depression. Half a century of research has disproven these hypotheses: dopamine overactivity and monoamine depletion are not parts of the pathogenesis of schizophrenia and depression, respectively.”
2. The DSM does not tell of “validated” illnesses.
Ghaemi writes: “Another feature of the inability to develop drugs for psychiatric diseases, as opposed for purely symptomatic benefit, has to do with the poor validity of psychiatric diagnosis using the official nomenclature of the American Psychiatry Association (APA), the Diagnostic and Statistical Manual 5th edition (DSM-5). As discussed in more detail elsewhere, the process of defining DSM-5 definitions has been influenced heavily by non-scientific factors, and has not proven successful in biological and pharmacological research. However, the APA is fully committed to the DSM-5 ideology, and unwilling to allow more scientific approaches to diagnosis.”
3. Psychiatric drugs (other than lithium) do not provide a long-term benefit.
Ghaemi writes: “Most psychiatric drugs have not been proven, in properly designed randomized trials, to improve the course of any illnesses they are purported to treat; specifically they have not been shown to prevent hospitalization or extend life, as many clinicians believe.”
4. Drug-discontinuation trials, which are said to provide evidence for maintenance use of psychiatric drugs, are invalid and biased by design.
The evidence for long-term maintenance use of psychiatric drugs comes from randomized “discontinuation” trials. Patients who are good responders to the drug are randomized to either continued use of the drug or are withdrawn from the drug, with the latter group said to be a placebo group.
Ghaemi writes: “Non-responders to the acute treatment are not included in the maintenance phase. Hence this design is biased from the start by excluding acute symptomatic non-responders . . . A final feature of relevance is that the randomized discontinuation design almost never has failed to show benefit for any drug in which it is used. A design which provides efficacy for any drug under any condition is not a scientifically valid design, since it cannot falsify its hypothesis.”
- Psychiatry needs to rethink its use of psychiatric drugs.
Ghaemi writes: “Short-term symptomatic benefit should not be presumed to provide long-term disease-modifying benefits in psychiatry. Since most psychiatric drugs are symptomatic, they should be used mostly short-term rather than long-term, and at lower doses.”
As can be seen, his paper tells of pathologies that remain unknown; of a diagnostic manual that is invalid; and of drugs that do not provide a long-term benefit. In short, his paper tells of how our society, for the past 65 years, has organized its care around a false narrative, which told of drugs that were antidotes to discrete illnesses and provided a long-term benefit, as they reduced the risk of relapse.
I am sure that many MIA readers and critics of psychiatry will disagree with some elements of Ghaemi’s paper. For instance, Ghaemi doubles down on the belief that there are discrete underlying pathologies to major psychiatric disorders that remain to be discovered and thus could be targeted by new drugs. I also think that his assertion that lithium provides disease-modifying benefits over the long term can be questioned, given that bipolar illness today runs a much more chronic course than manic-depressive illness did in the pre-lithium years. But those disagreements are not the point here. Ghaemi’s paper tells of a failed paradigm of care, and in so doing, it echoes MIA’s mission statement:
“We believe that the current drug-based paradigm of care has failed our society, and that scientific research, as well as the lived experience of those who have been diagnosed with a psychiatric disorder, calls for profound change.”
One final note. This is part of a “dialogue” about responding to published articles in the scientific literature, and given that Ghaemi has asserted findings that I believe to be true, I could be said to be suffering from “confirmatory bias” in my response. That is indeed an element that is going to be present in any dialogue about differing responses to findings published in scientific journals.
Agreeing on 90% Yet Portrayed So Negatively: Time for a Shift in Emphasis
By Jim Phelps
Astounding, breaking news: two psychiatrists in 90% agreement with Robert Whitaker. No wait, lots of psychiatrists. Wait, wait: the majority of psychiatrists?
Right. Most of us agree that the DSM definitions of depression are not based on biology. We recognize that DSM diagnoses sound like diseases but they’re not the same as diagnoses like appendicitis or pneumonia.
Most psychiatrists would agree that we don’t fully understand what’s different in the brain of someone who is severely depressed; or someone who is having extremely disturbing thoughts, out of their control; or someone who is so anxious that they cannot leave their home.
Likewise, we would agree that because we don’t fully understand what’s different in the brains of people with a mental illness, we don’t fully understand how our treatments work either. We know that neurotransmitters are affected, but then what happens? The downstream effects quickly disappear into the unknown.
Many actually agree with Dr. Ghaemi and Mr. Whitaker that it’s not clear whether long-term use psychiatric medications is clearly better than not using those medications beyond a short-term intervention. (The story for lithium is different, for people who can take it without daily or dangerous side effects, and there are many such people).
Some of us are even thankful for Robert Whitaker’s sustained efforts to increase awareness of the risks of some psychiatric medications—e.g., that severe antidepressant withdrawal is common and often more extreme than recognized 10 years ago.
At the same time: I began this exchange with Mr. Whitaker because I fear he overstates psychiatry’s problems. Terms like “historical delusions”, “false narratives”, and a “failed paradigm of care” reflect passionate concerns—understood. And… this inflammatory language stirs others’ passions, potentially interfering with decisions readers and their loved ones may face, now or soon: what are they to do when they are experiencing severe mental distress?
A. Do nothing and hope it resolves. It might. Physical illnesses, even broken bones, occasionally heal on their own. With 86 billion neurons, something will “break” from time to time. It might get better on its own. But just as for some bone fractures, medical help may be needed.
B. Rely on social support: love from understanding family and close friends; strong personal connections, like church, colleagues at work, or friends at school; online groups; and community resources (e.g., mental health centers with peer counseling, social workers, supported housing and work opportunities).
C. Begin psychotherapy. Choosing the right kind, and finding a good therapist, can be challenging, but done well, therapy is better than pills for some forms of mental distress and equally good—with fewer risks—for many other forms. And… there are some forms of mental distress that very few professional therapists would take on by themselves: delusions that are potentially dangerous or significantly interfering with a person’s ability to function; the fully manic phase of bipolar illness; depressions with such low energy that participation in therapy is not possible; or suicidal thinking with a plan and means at hand.
D. Find a psychiatrist. Good luck with that, unless you’re in a large eastern U.S. city, or abroad in a country with an excellent health care system. Even if you can find one, without being hospitalized, there are still many choices to be made: which medications should be considered? How long to take them?
Evaluating these options requires learning more about them, and careful comparisons of potential outcomes—not emotionally driven decision-making. To be truly helpful, Mad in America should help readers with these kinds of decisions, not fan flames. Consider two common examples.
First, depression. There are many kinds. The DSM is supposed to help sort them, but can confuse rather than clarify the picture. What is a “Mixed State,” for example? The simple answer: it’s depression, with some over-energized symptoms at the same time (agitation, irritability, anxiety, weird insomnia, can’t concentrate because thoughts are all over the place). Doing nothing, or relying on good social support, might be enough for a mixed depression—sometimes. Some forms of psychotherapy, like “Social Rhythm Therapy” would help, if you can find a therapist who knows this technique. (That is so rare, I made a video to help people with the core ingredient, Sleep Control for Mood Stability). If one must add a medication, should it be an antidepressant or a mood stabilizer?
For mild to moderate depressions, forget the medications, amen. (Together we could work on convincing primary care providers about this). Even for severe depression, if safety is not an issue and therapy can be fully utilized, Options B and C may be sufficient. When to use an antidepressant, and for how long, requires careful, personalized decision-making—which many psychiatrists do (granted, not enough. Find a young one if you can).
Second, delusions. First: is this a delusion or could it actually be true? Next: a belief in something like mental quantum tele-transport does not necessarily require treatment. Thoughts like “oh, don’t worry, I can give away all my savings because I can make it all back anytime I want in just a few days” might be managed with aggressive social interventions. But delusions that significantly affect a loved one’s function or safety, right now: what is a family supposed to do? If they have been reading Mad in America, they might be very hesitant to take steps that could protect lives. Starting a dopamine-blocking medication doesn’t mean committing to use it for years.
Mad in America’s blogpost regarding Dr. Ghaemi’s article declares “Psychiatric Drugs Do Not Improve Disease or Reduce Mortality.” It reached my national newsfeed, so presumably reached thousands of eyeballs. For people who face difficult decisions about a loved one with severe depression or dangerous delusional thoughts, this may have been confusing and frightening.
Many psychiatrists—I hope it could be most of us—are not like the psychiatrists described in many MIA posts. We understand that there are huge gaps in our knowledge. We’re listening, looking at outcomes short and long, and actively re-thinking our approaches as we go.
We and MIA could chorus together: psychiatry is not needed for the majority of mental problems, amen. But we are needed, sometimes. Don’t increase stigma toward all of us. Shift the emphasis from what we don’t know and have gotten wrong to what needs to be gotten right: helping people for whom waiting it out, or good social support, perhaps with the right psychotherapy as well, is not enough. What are they supposed to do? Let’s talk about that.