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Psychiatry
Answering Antipsychiatry
A Q&A on psychiatric medications and other criticisms of psychiatry.
Posted July 2, 2019
Dear Dr. Pierre,
I read your piece “What Do You Mean, I Don’t Have Schizophrenia?” in Psychiatric Times with pleasure and surprise. I am afraid that, despite your disclaimer, you have been hopelessly infected with my views, a.k.a. common sense or the obvious.
Best regards,
Thomas Szasz
—Personal communication from Thomas Szasz, 2009
Some time ago, I was interviewed for a story about the risks and benefits of psychiatric medications and some of the critiques of psychiatry by "antipsychiatrists." Here's my perspective on psychiatry and common critiques of the field.
What are some of the major positive impacts of taking psychiatric drugs?
The short answer is that based on thousands upon thousands of clinical trials, psychiatric medications have been shown to reduce the symptoms of a wide range of psychiatric disorders. Since these are placebo-controlled trials, we can be confident that the observed effects are specific to the medications. Results vary across disorders and across individuals, but in some cases, the amount of improvement can be substantial and life-saving.
What are some of the major negative impacts of taking psychiatric drugs?
Like any medication, the major negative impact of taking psychiatric drugs involves side effects. At worst, those side effects can be life-threatening.
You’ve seen first hand the impact psychiatric drugs can have on saving or changing patients lives — can you tell me what you see on a day-to-day basis?
I work primarily in an inpatient hospital setting where people are admitted with significant, functionally impairing symptoms. In this setting, unlike in outpatient work, there's rarely any question about whether a patient has a mental illness or not. And, since many of my patients have chronic mental illness like schizophrenia, one of the most common reasons for a relapse or exacerbation of symptoms is that a patient has stopped taking their medications. In most cases, when patients with severe mental illness are started or restarted on medications, they experience a clinically significant reduction in symptoms. This might translate to a substantial reduction in psychotic symptoms like paranoia or auditory hallucinations, or for depressed patients, the resolution of severe “neurovegetative” systems (lack of energy, insomnia, poor appetite, etc.) and suicidal thoughts. In hospital work, these improvements allow people to return to their lives outside of the hospital. In the outpatient world, they allow people to return to work or other meaningful life activities.
Why might psychiatric drugs be essential for some patients?
Contrary to some popular myths, serious mental illnesses are not simply “problems of living” or reactions to stress. Accordingly, they don't improve by adopting a “pull oneself up by one’s bootstraps” approach and often don't get better through psychotherapeutic interventions alone. For many disorders, like major depression or obsessive-compulsive disorder, clinical trials have demonstrated that the best outcomes are achieved with a combination of both medications and psychotherapy.
Does the science behind psychiatric drugs (i.e. the “chemical imbalance theory”) hold up? If not, what do the alternative theories say?
The “chemical imbalance theory” is a straw-man argument by “anti-psychiatrists.” It’s not something that’s been seriously taught in medical school or psychiatry residency for 20 years. That said, we know that antipsychotic medications help with psychotic symptoms, and so far as we can tell, these medications work by blocking dopamine receptors in the brain. Conversely, we know that illicit drugs like cocaine or methamphetamine, which are “pro-dopaminergic,” can cause psychotic symptoms. It’s therefore reasonable to suggest that psychotic symptoms might be linked to dopamine in some fashion. But we know that schizophrenia is not just a disorder of too much dopamine. The same is true of depression. Antidepressants appear to work by increasing serotonin and other catecholamines, which suggests that these neurotransmitters are relevant, but no one thinks that depression is fundamentally a disorder of too little serotonin. In fact, neurotransmitters are probably just one part of the puzzle. For example, there’s reasonable evidence that schizophrenia is a developmental disorder with a strong genetic component that is also associated with observable structural brain changes. For a long time now, depression has been investigated as an inflammatory disease. The bottom line is that we don’t really know what causes these disorders, but that doesn’t mean that they don’t exist. Syphilis was a real disease long before we discovered that infection with Treponema pallidum was the cause and long before we discovered that penicillin was the key to treatment.
Do you consider the anti-psychiatry movement to be dangerous? Why or why not?
I consider misinformation, in general, to always be potentially dangerous. In the case of “anti-psychiatry,” I think it's dangerous to be sending a message that psychiatric treatment doesn’t work or is more harmful than helpful. That can steer some people away from treatment when issues of stigma already mean that many psychiatric conditions are often under-treated. In that way, anti-psychiatry is similar to the anti-vaccine movement, which was started based on faulty information and seems to be resulting in the re-emergence of diseases that we haven’t seen on a large scale in many years.
Are any of the anti-psychiatry movement’s critiques of psychiatric drug use and psychiatry as a whole valid?
As I see it, the anti-psychiatry movement is essentially a “consumer movement.” I’m certainly sympathetic to some of the critiques I’ve read. No doubt, some people have had bad experiences in psychiatric treatment. Sometimes psychiatrists “get it wrong” in terms of diagnosis or treatment. Over-diagnosis and over-treatment can be a problem. And some patients have not been helped, or have suffered serious side effects, from psychiatric medications. The same is true in the rest of medicine. Sometimes a surgeon operates on the wrong limb. Sometimes people die from medication allergies. Sometimes people are seriously misdiagnosed. Those are valid problems that are not to be trivialized, but they don’t mean that we should condemn medicine or psychiatry or psychiatric medications as a whole, throwing out the baby with the bathwater.
Some of the critiques about psychiatry relate to the fact that it is sometimes coercive (i.e. involuntary treatment). This sets it apart from the rest of medicine (though occasionally general medicine is coercive as well, such as with mandated treatment for tuberculosis). There’s no question that psychiatry as an institution plays a central role in this paternalism, but the power to treat people involuntarily has been placed into psychiatry by people/government. If you don’t support involuntary treatment, you should take that argument to your local government. But before you do, think about how to get help to your friend or family member who is suicidal and refuses to seek mental health care.
Beyond those issues, I believe many of the other critiques I’ve heard about psychiatry — that it is a slave to biological explanations of disease/disorder and pharmacotherapeutic interventions only, for example — are false, straw man characterizations. The toxicity of psychiatric medications is, in my opinion, often overstated. But that certainty doesn't mean it's a non-issue — both psychiatrists and our patients would love to have more effective medications with fewer side effects.
When it comes to psychiatrists' attitudes towards medications, the relationship between organizations like the American Psychiatric Association and the pharmaceutical industry is sometimes raised as a problematic conflict of interest. That is a valid concern that no doubt has eroded trust in the profession. However, at the risk of "whataboutism," it’s also worth noting that some “voices” in the anti-psychiatry movement have their own potential conflicts of interest since they're competing to be mental health providers. We see this with Scientology here in the US as well as with “Critical Psychologists” in the UK.
How would you respond to the anti-psychiatry movement’s arguments?
A common problem with debates emerges when one side ends up arguing with itself and presumes that the “other side” is monolithic. So I won't presume to know all the arguments of all anti-psychiatrists. I’ve responded to some of the arguments I’ve heard here. I'm sure there are many more left unanswered.
