Exactly how bogus is psychiatry?

Maybe incredibly.

“I’ve been practicing psychiatry for 38 years. I love my job, my peers, and my patients. But I’ve come to the conclusion that I’m participating in the biggest intellectual scam of this era.” – Paul Minot, MD

To answer the question of the title straightaway—psychiatry is incredibly bogus.

Before explaining why, I want to be clear that it is not my intention to convince people who are on psychiatric medication, and finding it helpful, to stop. Medication can be effective. Not as effective as therapy, or the combination of the two, but effective nonetheless.

The problem is that it’s unclear why it’s effective, and this is the Jenga tile that causes the whole tower to fall down.

Nobody Knows Why

When it comes to any kind of medication, most people assume that:

1. the properties of the drug will be responsible for any change that occurs, and

2. the drug works in a way that the professional prescribing it understands.

Believe it or not, neither of these is true for the antidepressants or anxiolytics that psychiatrists prescribe for depression and anxiety.¹

Let’s begin with the second assumption. Many readers will be familiar with the “chemical imbalance” theory of depression, which hypothesizes that depression results from having too little serotonin in the brain. Drugs that increase serotonin levels, such as selective serotonin reuptake inhibitors (SSRIs), should therefore fix the problem. However, as Harrington writes in Mind Fixers, “just as the public was embracing the ‘serotonin imbalance’ theory of depression, researchers were forming a new consensus that…the simplistic ‘chemical  imbalance’ theories of depression...were deeply flawed and probably outright wrong.”²

The time period Harrington is talking about is the 90s, probably the zenith for the public’s acceptance of serotonin (and other neurotransmitters) as culprits of mental illness—and medication as salvation. For example, the international best-seller, Listening to Prozac, was published in 1993.

Among researchers in 2024, however, the debate is over. As Irving Kirsch, a Harvard psychologist, writes: “The serotonin theory is as close as any theory in the history of science to having been proved wrong.” Ditto for theories based on other neurotransmitters such as norepinephrine (depression), GABA (anxiety), and dopamine (psychosis).

The bottom line is that if a drug claims to improve mental illness by adjusting neurotransmitter levels, it probably doesn’t. But does the average Joe know this? As mentioned before, one in six American adults takes psychiatric medication, a number that has increased even as the chemical imbalance theory on which these drugs were founded has been discredited.

The average Joe isn’t alone. A.I. appears to be clueless as well:

nope, try again

Part of the general confusion surely has to do with psychiatrists, who still believe—or at least pretend to believe—in this discredited theory.

“Psychiatrists [continue to] perpetuate the fiction,” Harrington says, “that the drugs they are prescribing are correcting biochemical deficiencies caused by disease, much as (say) a prescription of insulin corrects a biochemical deficiency caused by diabetes.”³

As for why psychiatrists would do that, the answer should be pretty obvious.

Placebo’s Role

If psychiatric medication isn’t correcting biochemical deficiencies, then what is responsible for its modest effectiveness?

It turns out, mostly placebo.

Kirsch again: “analyses of the published data and the unpublished data that were hidden by drug companies reveals that most (if not all) of the benefits [of antidepressants] are due to the placebo effect.”

Think about that for a moment. An industry worth tens of billions might be selling snake oil. The benefits of most (if not all) forms of psychiatric medication might have almost nothing to do with the pharmacological properties of the pill, and everything to do with the belief that the pill will work.⁴

The jury is still out on whether medication offers a benefit beyond placebo. As Tom Insel, former director of National Institute of Mental Health, notes in Healing: “After reviewing the results of over five hundred trials with more than 100,000 patients, [researchers] found that all twenty-one antidepressants were better than placebo.”⁵ On the other hand, Kirsch argues that placebo is responsible for at least 82% of antidepressants’ effect, and that “[e]ven the small statistical difference between antidepressants and placebos may be an enhanced placebo effect, due to the fact that most patients and doctors in clinical trials successfully break blind.”

It's also worth asking what “effective” means. Kirsch once again:  

…the mean difference between drug and placebo was less than two points on the HAM-D. The HAM-D is a 17-item scale on which people can score from 0 to 53 points, depending on how depressed they are. A six-point difference can be obtained just by changes in sleep patterns, with no change in any other symptom of depression. So the 1.8 difference that we found between drug and placebo was very small indeed – small enough to be clinically insignificant.⁶

You might be wondering, by the way, why there’s so much research on whether psychiatric medication outperforms placebo. The answer is that this was once the hurdle to clear before bringing a new drug to market. However, although new products had to outperform placebo, they did not have to be novel, which is why the market is currently dominated by second- and third-generation antidepressants and anxiolytics. (If you’re taking medication, it’s likely to be one of these.) Yet the difference between these and the first-generation medications of the 1950s is incredibly minor. A good way to think about them is that they make a slightly different dish using the same ingredients.

In the 2000s, the European Medical Agency mandated that new drugs would have to outperform existing drugs on the market, and this changed everything. Harrington summarizes the effect: “When [pharma] companies were told they had to compare new drugs not only to placebo but to an existing drug known to be efficacious…their response was: ‘we don't know how to do that.’ One after another…[they] abandoned the field of psychiatry altogether.”⁷

In other words, pharmaceutical companies were well aware that they had no idea why their medications were working, and this prevented them from making—or wanting to make—new ones once the standards were raised.

So here’s how I see it. Psychiatrists who maintain that medication works for a known reason are like financial advisors who tell you they have a beat on the market: either they are severely misinformed or actively fraudulent. Neither is acceptable.

In League with their Own

I’ve been frank about my belief that therapy, too, works for reasons that science doesn’t understand. It certainly doesn’t work for the reasons that the various therapeutic orientations, from psychoanalysis to cognitive-behavioral therapy, suggest. But I tend to think psychiatry’s hubris is more dangerous for two reasons. First, psychiatry costs more. Second, it has more power to shape cultural conceptions of mental health.

The costs of therapy beyond the session fee don’t get much attention. I’ve tried to articulate some of those costs in The Art of Suffering Well and Returning to Ivan Illich, but the best source might be Bad Therapy by Abigail Shrier. In any case, these costs exist because therapists and clients don’t always have the same incentives. By and large, clients want quick recovery and therapists want a stable practice.⁸

However, the costs of therapy are small compared to those of psychiatry. For one, it is still commonplace to think of therapy as a short- to medium-term solution—as something a client can “graduate” from. It might take a while, but it isn’t supposed to be permanent. Medication, on the other hand, often is. For example, if a client goes to therapy for help with ADHD, the goal is for them to develop tools and techniques—I hate this phrase, but we’ll let it slide for now—and be on their merry way. If that same client goes to a psychiatrist, they will likely be prescribed Ritalin or Adderall. Problem solved, right? But what’s the end game? Medication is a quicker solution requiring a longer commitment.

Other costs are higher, too. Psychiatrists charge more and are harder to find and book. And the side-effects of medication—e.g., weight gain, sexual dysfunction, insomnia—are usually more severe than the side-effects of therapy. So, I tend to see therapy as a better option because the costs are smaller and the benefits similar.

My main beef with psychiatry, though, is that in conjunction with Big Pharma, it has incredible power to shape cultural conceptions of mental health. We saw above how it continues to conveniently perpetuate the chemical imbalance theory of mental illness, which, despite ample evidence to the contrary, is still firmly entrenched in the layperson’s mind. But the best example of psychiatry’s unfortunate sway might be the Diagnostic and Statistical Manual of Mental Disorders (DSM). No other book influences our culture’s ideas about mental health and illness more than “psychiatry’s bible.”  

One of the major problems with the DSM, as psychiatrist Marcos Ramos notes, is that “some 69 percent of the members of the Task Force of the current DSM-5 disclosed financial ties to the pharmaceutical industry—a 21 percent jump from disclosures reported by the Task Force for DSM-IV.” It’s not hard to see how one hand washes the other. The more “disorders” the DSM has, the more drugs can be developed to target them.⁹ Oppositionally defiant? Paranoid? Intermittently explosive? Let’s get you something for that.

hm…

As the DSM grows, the demand for therapy and medication—the DSM’s standard recommended treatments—grows with it. Although therapists have been lifted by this rising tide, they aren’t really driving the bus. The symbiotic relationship between psychiatrists and pharmaceutical companies is.

Wooly Eyes

I don’t mean to sound too conspiratorial, but I’m convinced the public is having the wool pulled over its eyes here. As Ramos writes, “Research conducted by scientists with ties to the pharmaceutical industry were 22 times less likely to report negative side effects [of psychiatric medication] than researchers without those ties.”

With too little protection for the average Joe and too many resources for Big Pharma, it's hard to stop the creation of new disorders and the marketing of more medications that may be no more effective than a sugar pill. Kirsch provides an example of this imbalance at work:

How is it possible that medications with such weak efficacy data were approved by the FDA? The answer lies in an understanding of the approval criteria used by the FDA. The FDA requires two adequately conducted clinical trials showing a significant difference between drug and placebo. But there is a loophole: There is no limit to the number of trials that can be conducted in search of these two significant trials. Trials showing negative results simply do not count.

So, the mandate that new medication must outperform existing options—while a step in the right direction—is not enough.

Another form of protecting the public would be to tie DSM disorders to biomarkers—reliable physical cues—as is done with medical conditions such as diabetes or gout. That way, diagnoses would be subject to less manipulation. Related, it would help if we could identify a genetic basis for mental illness.

The DSM-V was supposed to follow through on these promises, but it didn’t. This wasn’t a due to a lack of effort, though. As Harrington points out:

...current brain science still has little understanding of the biological foundations of many—indeed most—everyday mental activities. This being the case, how could current psychiatry possibly expect to have a mature understanding of how such activities become disordered—and may possibly be reordered?¹⁰

As for uncovering genetic bases, genome-wide association studies (GWAS) generated a ton of excitement, but likewise fell flat. Ramos writes:

The oft-cited claim, for example, that schizophrenia has a genetic basis has failed to pass scientific muster…GWAS studies have not revealed a clear genetic basis for schizophrenia (or bipolar disorder, for that matter) … In fact, in the era of genome-wide association studies, psychiatric disorders have distinguished themselves from most types of physical illness by the absence of strong genetic associations.

The way I see it, then, the DSM is not and has never been a scientific document. I mean, homosexuality counted as a disorder 50 years ago. Then, under political pressure, the American Psychiatric Association voted for it to be taken out. Real scientific endeavors don’t vote things out; they let evidence decide. We didn’t have evidence then, and we don’t have it now.

Rather than the standard assumption of the layperson, which is that psychiatric medications “fix” imbalances in the brain, let me offer another: Medications created under the auspices of since-disproven theories target bogus disorders for the profit of vested stakeholders.

Should you, your partner, or your kids take medication?

Before offering some advice, let me admit my bias. Through my work with colleagues and clients, I just haven’t gotten the best impression of psychiatrists. I’ve heard my fair share of horror stories about therapists, too, but not nearly as many, percentage-wise. The feedback on psychiatrists is pretty consistent. Brusque, absent, brief. Many of my clients have left the appointment more demoralized than before.

There are exceptions, of course. And, honestly, I honestly don’t much blame psychiatrists. Look at the condition they are in. 15 minute appts. Half a mil in debt. Working with the most complicated thing in the universe. What else do we expect?

Plus, plenty of friends and clients have sworn by their medication. So what’s a person to conclude?

First, if you’re taking medication and it’s helpful, by all means keep using it. It’s entirely possible these drugs are doing something that we can’t explain yet. Even if they aren’t—even if they are entirely placebo—placebo is incredibly powerful. I count the steps up to my office each day not because it does anything, but because it calms my mind. Highly educated people in particular, I have found, are far too dismissive of the healing power of things we cannot yet explain…things that do not make sense from our current scientific perch.

If you’re considering using medication or recommending it to someone you care about, try exhausting simpler options first. For example, a good rule of thumb is: before medicating, try exercising three times a week.

It’s also important to remember that pain is a signal. Sometimes it’s an inaccurate signal—especially in the modern world—but sometimes it’s not. As Weinstein and Heying note in A Hunter-Gatherer’s Guide to the 21st Century: “Muting pain with medication interferes with the feedback system in our bodies, making it much harder for us to know what we should, or should not, do.”¹¹ If pain is medicated away, potentially valuable information goes with it.

If you decide to move forward, consider going through your primary care physician. PCPs are supposed to prescribe medication while you look for a psychiatrist. Because of the shortage and high cost of psychiatrists, PCPs will often let you look for as long as you’d like.

Disciplined?

Finally, what should be done with psychiatry as a discipline? Here’s what Harrington says at the end of her book:

Psychiatry has at least one possible alternative, but it would require an act of great professional and ethical courage. It could decide to return to a less hierarchical understanding of its place in the mental health and medical systems; one that...would acknowledge that mental suffering is a larger category than mental illness, and that even disorders with a likely or possible biological basis are not just medical, because the experiences of all human beings, ill or otherwise, are shaped by their cultural, social, and familial circumstances.¹²

Paul Minot and Marco Ramos have done that, and I admire them for standing out and speaking up. But people like them are rare.

So, with the majority of medication’s effectiveness caused by placebo, no consensus on whether (or how) medication provides benefit beyond placebo, and no biological reality underpinning the diagnoses toward which medications are aimed, I think the discipline of psychiatry should be taken with a huge grain of salt.

It is not lost on me, by the way, that the more prestige we grant psychiatry, the greater the placebo effect for the medication it prescribes.¹³ Hell, if you’re on medication, I could have improved its effectiveness by, say, providing a compelling evolutionary reason for why we all need a little chemical adjustment. This missed opportunity for greater healing is but one cost of truth.

But truth tends to have upsides, as well. In fact, in a few weeks I’ll be hosting our first podcast with guest Dr. Randy Nesse, who became so frustrated with psychiatry that he started evolutionary psychiatry. I’ve found many of Nesse’s insights compelling, and I suspect that’s because they’re simple, inexpensive, and true. Sort of the opposite of psychiatric prescription in general.

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References

Harrington, A. (2019). Mind fixers: Psychiatry’s troubled search for the biology of mental illness. W. W. Norton & Company.

Kirsch, I. (2014). Antidepressants and the placebo effect. Journal of Psychotherapy and Psychosomatics, 83(1), 1-7. https://doi.org/10.1027/2151-2604/a000176

Ramos, M. (2022, May 17). Mental illness is not in your head. Boston Review. https://www.bostonreview.net/articles/mental-illness-is-not-in-your-head/.  

1. One in six Americans takes psychiatric medication; antidepressants and anxiolytics are by far the most common types.

2. p. 215

3. p. 273

4. For more on this powerful and hardly understood effect, see The Placebo Effect edited by Harrington. And stay tuned for an article on the placebo effect of therapy.

5. p. 45

6. Kirsch is juxtaposing clinical significance with statistical significance here.

7. p. 266

8. I hope I’ve made it clear that most therapists are not consciously manipulating their clients. It's just that misaligned incentives can operate in many subtle ways.

9. As Harrington says: “The strategy of repurposing old drugs for new disorders (that, in many cases, people had not known they had) was highly successful.” - p. 257.

10. p. 276

11. p. 70

12. p. 273-274

13. The same can be said for psychotherapy.