This raises some valid concerns about the foundations of modern psychiatry, especially around the chemical imbalance theory. It’s frustrating how outdated ideas can persist in public perception, but I agree that even if we don’t fully understand how medications work, their effectiveness for some individuals can’t be dismissed. The challenge is finding the right balance between skepticism and hope for those navigating mental health treatments. Thanks for putting this piece together!
Unfortunately, this article unintentionally illustrates how pop science operates. Trying to debunk such vast fields of research with anecdotal evidence and two pop science books written by journalists is futile and reveals a lack of scientific rigor in itself. Many of the claims in this article might have been somewhat true 20 years ago, but no longer. I’ll respond to the specific points in more detail when I have more time.
I'd be glad to hear your thoughts/read of the literature. Seriously, as someone who advises clients on this all the time, I want the most accurate picture possible.
As for your claim that I used pop science books for my argument, though, that's just not true. Harrington and Kirsch are academics and Ramos is a psychiatrist.
It´s so hard to navigate all this as a consumer. My inclination is to distrust the pharmaceutical industry and allopathic medicine in general, preferring to treat myself with lifestyle interventions and herbs, etc. But I know from experience that if my partner goes off his antipsychotic medication disaster will ensue. The meds don´t work as well as anyone would like though and his psychiatrist is now recommending ECT. I´m told it´s a "good therapy" and that the side effects are temporary. But I don´t care: ECT is my line in the sand. Despite his illness, my partner remains a smart guy. I know I couldn´t handle it if, on top of everything else, he had permanent cognitive deficits. It´s so easy for others to recommend therapies but my partner and I are the ones who have to live with the consequences.
I agree that all this is hard to navigate as a consumer and I think it's ultimately because nobody quite knows what's going on with mental illness. So, unlike researching other things, you never get to a hard and fast answer. Most people end up throwing a bunch of stuff at the wall and hoping some of it sticks. Anyway, I'm hoping the two of you find a good enough solution.
After more than a decade of consistent psychiatric medication and therapy, the best remedies I've found have been diet, sleep, and exercise. Therapy is great if you can find a good clinical psychologist, but in general, I've found navigating the various therapy options to be its own minefield. Great article! Thanks for sharing.
Very interesting. What do you think about the idea that while we don't know how these things work, and that OVERALL they work only slightly better than placebo, this effect is in fact clinically meaningful for some people, nonexistent for others and actively negative for yet another subsection of the suffering population?
Partially because psychiatric nosology is very wonky and for example the term "depression" can encompass clinical presentations varying from "mostly extremely low energy and motivation levels + fatigue" to "very dejected mood and anhedonia" to "guilt, self hatred and sense of personal worthlessness" plus combinations of all those; appearing put of the blue, in reaction to singular events, or as lifetime, ingrained. patterns of emoting and thinking. The idea that all those things would have a similar specific mechanism seems tad insane.
As to behavioural change being as effective or MORE effective than antidepressants (which is true). The thing is. Behavioural change is REALLY HARD. Look at obesity/overeating: for most people it's absolutely solvable by consistent behavioural change. Yet it's EXTREMELY hard for many chronic overeaters to maintain the change long term. Thus the success of semaglutide and other new anti overeating drugs. Obviously those drugs work much better than antidepressants and the mechanism is known.
Or look at antihypertensive drugs. A massive success story of pharma history. Life saving for millions. Yet the same results can be accomplished for many people by, again, behavioural change. And it's not even widely known.
You make many good points. I'm not sure what to make of the difference in effectiveness for psychiatric medication. It may be, as you say, that diagnoses are too vague and meaningless for research based on them to be anything but vague and meaningless. It could also be explained by people's varying susceptibilities to placebo, with the average benefit beyond placebo explained by experimental subjects' ability to break blind.
I also agree that the pharmaceutical industry has been successful in a number of areas for which we should be grateful. It's just that psychiatric medication by and large isn't one of them. And yeah, behavioral change is hard, especially in the modern world. People would be much more successful in losing weight if they weren't constantly presented with delicious, cheap, and unhealthy food options, or if they were forced to exercise in order to survive.
You endorse Minot's claim that psychiatry is "the greatest intellectual fraud". This is a striking and provocative statement, but it is neither accurate nor constructive. Criticism of a complex medical field requires nuance and precision. While psychiatry, like all areas of medicine, faces challenges and limitations, dismissing the entire field as a fraud is neither helpful nor grounded in reality, as I'll explain below.
2. The serotonin hypothesis and the placebo effect
It is true that the classic serotonin hypothesis for depression has been largely debunked, and most psychiatrists are fully aware of this. But that doesn't mean we don't know anything. As you mentioned, Irving Kirsch's work points to the important role of the placebo effect in the efficacy of antidepressants. However, Kirsch's conclusions are themselves controversial. For example, Alexander Scott argues in his article "All Medications Are Insignificant" that Kirsch's threshold for clinical significance is too high and that effect sizes such as those of antidepressants cannot be interpreted out of context (https://www.astralcodexten.com/p/all-medications-are-insignificant).
Furthermore, Awais Aftab's 2024 article provides an updated view of hypotheses about why antidepressants work, illustrating that serious, scientifically based thinking is very much alive in psychiatry (https://www.psychiatrymargins.com/p/how-antidepressants-work). The current state of research may show that older hypotheses are flawed, but that's the nature of science: it evolves as we learn. This doesn't mean that psychiatry is making 'wrong' claims, but rather that it is progressing towards better models for understanding the brain and mental health.
3. Antipsychotics and the dopamine theory
The link between dopamine D2 receptors and delusions is relatively well established, and drugs that target this pathway have shown efficacy in treating symptoms of conditions such as schizophrenia. This is not to say that these drugs are without their challenges, but to suggest that psychiatry knows nothing or is fraudulent ignores these advances. Consider the relationship between dopamine and conditions such as Parkinson's disease, where similar neurochemical mechanisms are at work.
4. Problems with clinical trials and drug approvals
It is well documented that there are systemic problems with clinical trials and drug approval processes. However, these problems are not limited to psychiatry; they affect the entire field of medicine. Regulatory standards are constantly evolving, and the field does not passively accept these shortcomings, but works to improve them. These challenges don't justify labelling psychiatry as fraudulent or dismissing psychiatric medicines altogether.
5. DSM’s flaws
Yes, the DSM has its limitations, and many would agree that it doesn't meet the highest scientific standards. It's a practical tool for clinicians, not a perfect reflection of scientific reality. The syndromes described in the DSM are indeed arbitrary clusters of symptoms, not diseases in the biological sense. However, psychiatry is aware of these limitations and is actively working on better diagnostic models, such as the HiTOP system, which aims for a dimensional and scientifically based approach. The move away from categorical diagnoses recognises the significant overlap between different disorders.
5. Evolutionary psychiatry
Although evolutionary psychiatry is a relatively new term, its core principles have long been incorporated into psychotherapeutic practice. CBT for example, incorporates evolutionary insights by focusing on the adaptive origins of certain behaviours. Randolph Nesse's "smoke detector principle", a key concept in evolutionary psychiatry, is used in CBT. In my opinion, Randolph Nesse is operating within the realm of psychiatry and CBT, not outside of it. Similarly, Öhman and Ekman's research on fear conditioning emphasises how certain fear responses are rooted in evolutionary survival mechanisms, a fact that is often explained to patients in therapeutic settings.
6. Conclusion
Rather than dismissing psychiatry altogether, I would suggest taking a more cautious and critical, but not cynical, view. While the efficacy of psychiatric drugs may often be confounded by placebo effects, this doesn't detract from the real benefits that many patients experience—even if placebo is a significant factor. Rather than seeing psychiatry as a fraud, see it as an evolving field—one that acknowledges its past mistakes and is actively working towards a better understanding of mental health.
A very thoughtful reply and one that I'll internalize. (Also, some good stuff to follow up on.) I agree with most of what you say, so perhaps the main difference comes down to how cynical a person is justified in being at the current moment.
Big picture, you're right that psychiatry is making advances and will eventually get there. It's possible within this big-picture view to tolerate some of the current inadequacies and struggles. However, my opinion is that psychiatry (and clinical psychology) have mainly bumbled along from incorrect theory to incorrect theory, at each stage puffing their chests out as if they've finally found the answer. This makes me skeptical that right around now they're going to turn things around.
I don't doubt that there are good psychiatrists out there and promising research being done. But I do doubt that the average psychiatric experience is "worth it" given that placebo accounts for much of the gain and the costs are significant. However, you make many fair points and I'm glad people like you are in the field. I am skeptical toward my own field and trying to change it from within, too. I'll try being a bit more cautious and critical, rather than cynical, toward psychiatry. Fwiw, I do take a very even-handed approach with clients.
A huge and glaring problem with this narrative: in talking about “psychiatric medication” you’re painting a ridiculously broad brush, and oversimplifying what should really be a drug and disorder-specific conversation. The overprescribing of stimulants for ADHD and benzodiazepines for anxiety disorders is a vastly different issue than the questions of mechanism and placebo re SSRI’s.
And more critically: in the case of bipolar and psychotic disorders, the right medication can be an absolute godsend. I’ve seen rapid success stories play out countless times at the inpatient psych hospitals I interned at during my training (I’m not a physician). It is nonsense to chock the effect of antipsychotics and mood stabilizers up to placebo. I doubt the author would actually endorse this claim, but the fact that the original post was written in such a way as to imply this possibility is a huge issue. This isn’t a pedantic point; these are some of the worst off and most vulnerable patients we see in the helping professions. It’s worth keeping these folks in mind before you dismiss the umbrella category “medication” altogether.
Awais Aftab has a great post on the question of SSRI mechanisms. Worth a read by the author and others interested in this topic.
I do mention that psych medication tends to be successful for the positive symptoms of psychosis and the manic side of bipolar disorder. And I will admit that I have limited exposure to what happens in psychiatric hospitals, so I take your point. Perhaps what we could say is that for the ~1% of people with severe mental illness, medication can be a godsend. But far more people than that are taking or considering taking medication. I'll have a look Aftab's article.
Perfect, now let's talk about psychotherapy...what is its mechanism of action? does each psychotherapy work because of what its practitioners say it works or because of general factors or common elements? how much of the effect of psychotherapy is a placebo effect?
Ramos's quote about GWAS is dead wrong. GWAS has been a major success for finding genes related to mental disorders, including schizophrenia. Every year we see larger studies and find more relevant genes.
> One after another…[they] abandoned the field of psychiatry altogether.
But... that's a bad thing, isn't it? There were promising developments and then we just… Ended them on a whim? Wow.
> Psychiatrists charge more and are harder to find and book.
You don’t have to book them every week. The costs of one-time appointment and medication is minuscule compared to the cost of weekly therapy.
Also, anxiolytics have a very real effect: they make people sleep. People are much better equipped to make decisions when they rested compared to when they are not.
It could be a good or bad thing. If there are fewer medications, people might be more persuaded to rely on solutions that are cheaper, have fewer side effects, and so on, like exercise.
True, you see your psychiatrist less and the cost may end up being less overall because of that.
Yes, sleep is incredibly important, so however you can get it, good. But I doubt anxiolytics want to hang their hat on being a sleep medication.
Robert Whitaker's "Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America" opened my eyes to this reality. Thank you for this post!
This raises some valid concerns about the foundations of modern psychiatry, especially around the chemical imbalance theory. It’s frustrating how outdated ideas can persist in public perception, but I agree that even if we don’t fully understand how medications work, their effectiveness for some individuals can’t be dismissed. The challenge is finding the right balance between skepticism and hope for those navigating mental health treatments. Thanks for putting this piece together!
Unfortunately, this article unintentionally illustrates how pop science operates. Trying to debunk such vast fields of research with anecdotal evidence and two pop science books written by journalists is futile and reveals a lack of scientific rigor in itself. Many of the claims in this article might have been somewhat true 20 years ago, but no longer. I’ll respond to the specific points in more detail when I have more time.
I'd be glad to hear your thoughts/read of the literature. Seriously, as someone who advises clients on this all the time, I want the most accurate picture possible.
As for your claim that I used pop science books for my argument, though, that's just not true. Harrington and Kirsch are academics and Ramos is a psychiatrist.
Thank you for your thoughtful response, which motivates me to write the more detailed reply to your essay.
It´s so hard to navigate all this as a consumer. My inclination is to distrust the pharmaceutical industry and allopathic medicine in general, preferring to treat myself with lifestyle interventions and herbs, etc. But I know from experience that if my partner goes off his antipsychotic medication disaster will ensue. The meds don´t work as well as anyone would like though and his psychiatrist is now recommending ECT. I´m told it´s a "good therapy" and that the side effects are temporary. But I don´t care: ECT is my line in the sand. Despite his illness, my partner remains a smart guy. I know I couldn´t handle it if, on top of everything else, he had permanent cognitive deficits. It´s so easy for others to recommend therapies but my partner and I are the ones who have to live with the consequences.
I agree that all this is hard to navigate as a consumer and I think it's ultimately because nobody quite knows what's going on with mental illness. So, unlike researching other things, you never get to a hard and fast answer. Most people end up throwing a bunch of stuff at the wall and hoping some of it sticks. Anyway, I'm hoping the two of you find a good enough solution.
After more than a decade of consistent psychiatric medication and therapy, the best remedies I've found have been diet, sleep, and exercise. Therapy is great if you can find a good clinical psychologist, but in general, I've found navigating the various therapy options to be its own minefield. Great article! Thanks for sharing.
Totally agree and glad to hear it. Thank you for reading and commenting.
Very interesting. What do you think about the idea that while we don't know how these things work, and that OVERALL they work only slightly better than placebo, this effect is in fact clinically meaningful for some people, nonexistent for others and actively negative for yet another subsection of the suffering population?
Partially because psychiatric nosology is very wonky and for example the term "depression" can encompass clinical presentations varying from "mostly extremely low energy and motivation levels + fatigue" to "very dejected mood and anhedonia" to "guilt, self hatred and sense of personal worthlessness" plus combinations of all those; appearing put of the blue, in reaction to singular events, or as lifetime, ingrained. patterns of emoting and thinking. The idea that all those things would have a similar specific mechanism seems tad insane.
As to behavioural change being as effective or MORE effective than antidepressants (which is true). The thing is. Behavioural change is REALLY HARD. Look at obesity/overeating: for most people it's absolutely solvable by consistent behavioural change. Yet it's EXTREMELY hard for many chronic overeaters to maintain the change long term. Thus the success of semaglutide and other new anti overeating drugs. Obviously those drugs work much better than antidepressants and the mechanism is known.
Or look at antihypertensive drugs. A massive success story of pharma history. Life saving for millions. Yet the same results can be accomplished for many people by, again, behavioural change. And it's not even widely known.
You make many good points. I'm not sure what to make of the difference in effectiveness for psychiatric medication. It may be, as you say, that diagnoses are too vague and meaningless for research based on them to be anything but vague and meaningless. It could also be explained by people's varying susceptibilities to placebo, with the average benefit beyond placebo explained by experimental subjects' ability to break blind.
I also agree that the pharmaceutical industry has been successful in a number of areas for which we should be grateful. It's just that psychiatric medication by and large isn't one of them. And yeah, behavioral change is hard, especially in the modern world. People would be much more successful in losing weight if they weren't constantly presented with delicious, cheap, and unhealthy food options, or if they were forced to exercise in order to survive.
1. Is psychiatry really "incredibly bogus"?
You endorse Minot's claim that psychiatry is "the greatest intellectual fraud". This is a striking and provocative statement, but it is neither accurate nor constructive. Criticism of a complex medical field requires nuance and precision. While psychiatry, like all areas of medicine, faces challenges and limitations, dismissing the entire field as a fraud is neither helpful nor grounded in reality, as I'll explain below.
2. The serotonin hypothesis and the placebo effect
It is true that the classic serotonin hypothesis for depression has been largely debunked, and most psychiatrists are fully aware of this. But that doesn't mean we don't know anything. As you mentioned, Irving Kirsch's work points to the important role of the placebo effect in the efficacy of antidepressants. However, Kirsch's conclusions are themselves controversial. For example, Alexander Scott argues in his article "All Medications Are Insignificant" that Kirsch's threshold for clinical significance is too high and that effect sizes such as those of antidepressants cannot be interpreted out of context (https://www.astralcodexten.com/p/all-medications-are-insignificant).
Furthermore, Awais Aftab's 2024 article provides an updated view of hypotheses about why antidepressants work, illustrating that serious, scientifically based thinking is very much alive in psychiatry (https://www.psychiatrymargins.com/p/how-antidepressants-work). The current state of research may show that older hypotheses are flawed, but that's the nature of science: it evolves as we learn. This doesn't mean that psychiatry is making 'wrong' claims, but rather that it is progressing towards better models for understanding the brain and mental health.
3. Antipsychotics and the dopamine theory
The link between dopamine D2 receptors and delusions is relatively well established, and drugs that target this pathway have shown efficacy in treating symptoms of conditions such as schizophrenia. This is not to say that these drugs are without their challenges, but to suggest that psychiatry knows nothing or is fraudulent ignores these advances. Consider the relationship between dopamine and conditions such as Parkinson's disease, where similar neurochemical mechanisms are at work.
4. Problems with clinical trials and drug approvals
It is well documented that there are systemic problems with clinical trials and drug approval processes. However, these problems are not limited to psychiatry; they affect the entire field of medicine. Regulatory standards are constantly evolving, and the field does not passively accept these shortcomings, but works to improve them. These challenges don't justify labelling psychiatry as fraudulent or dismissing psychiatric medicines altogether.
5. DSM’s flaws
Yes, the DSM has its limitations, and many would agree that it doesn't meet the highest scientific standards. It's a practical tool for clinicians, not a perfect reflection of scientific reality. The syndromes described in the DSM are indeed arbitrary clusters of symptoms, not diseases in the biological sense. However, psychiatry is aware of these limitations and is actively working on better diagnostic models, such as the HiTOP system, which aims for a dimensional and scientifically based approach. The move away from categorical diagnoses recognises the significant overlap between different disorders.
5. Evolutionary psychiatry
Although evolutionary psychiatry is a relatively new term, its core principles have long been incorporated into psychotherapeutic practice. CBT for example, incorporates evolutionary insights by focusing on the adaptive origins of certain behaviours. Randolph Nesse's "smoke detector principle", a key concept in evolutionary psychiatry, is used in CBT. In my opinion, Randolph Nesse is operating within the realm of psychiatry and CBT, not outside of it. Similarly, Öhman and Ekman's research on fear conditioning emphasises how certain fear responses are rooted in evolutionary survival mechanisms, a fact that is often explained to patients in therapeutic settings.
6. Conclusion
Rather than dismissing psychiatry altogether, I would suggest taking a more cautious and critical, but not cynical, view. While the efficacy of psychiatric drugs may often be confounded by placebo effects, this doesn't detract from the real benefits that many patients experience—even if placebo is a significant factor. Rather than seeing psychiatry as a fraud, see it as an evolving field—one that acknowledges its past mistakes and is actively working towards a better understanding of mental health.
A very thoughtful reply and one that I'll internalize. (Also, some good stuff to follow up on.) I agree with most of what you say, so perhaps the main difference comes down to how cynical a person is justified in being at the current moment.
Big picture, you're right that psychiatry is making advances and will eventually get there. It's possible within this big-picture view to tolerate some of the current inadequacies and struggles. However, my opinion is that psychiatry (and clinical psychology) have mainly bumbled along from incorrect theory to incorrect theory, at each stage puffing their chests out as if they've finally found the answer. This makes me skeptical that right around now they're going to turn things around.
I don't doubt that there are good psychiatrists out there and promising research being done. But I do doubt that the average psychiatric experience is "worth it" given that placebo accounts for much of the gain and the costs are significant. However, you make many fair points and I'm glad people like you are in the field. I am skeptical toward my own field and trying to change it from within, too. I'll try being a bit more cautious and critical, rather than cynical, toward psychiatry. Fwiw, I do take a very even-handed approach with clients.
Thanks for taking the time to comment.
A huge and glaring problem with this narrative: in talking about “psychiatric medication” you’re painting a ridiculously broad brush, and oversimplifying what should really be a drug and disorder-specific conversation. The overprescribing of stimulants for ADHD and benzodiazepines for anxiety disorders is a vastly different issue than the questions of mechanism and placebo re SSRI’s.
And more critically: in the case of bipolar and psychotic disorders, the right medication can be an absolute godsend. I’ve seen rapid success stories play out countless times at the inpatient psych hospitals I interned at during my training (I’m not a physician). It is nonsense to chock the effect of antipsychotics and mood stabilizers up to placebo. I doubt the author would actually endorse this claim, but the fact that the original post was written in such a way as to imply this possibility is a huge issue. This isn’t a pedantic point; these are some of the worst off and most vulnerable patients we see in the helping professions. It’s worth keeping these folks in mind before you dismiss the umbrella category “medication” altogether.
Awais Aftab has a great post on the question of SSRI mechanisms. Worth a read by the author and others interested in this topic.
I do mention that psych medication tends to be successful for the positive symptoms of psychosis and the manic side of bipolar disorder. And I will admit that I have limited exposure to what happens in psychiatric hospitals, so I take your point. Perhaps what we could say is that for the ~1% of people with severe mental illness, medication can be a godsend. But far more people than that are taking or considering taking medication. I'll have a look Aftab's article.
Perfect, now let's talk about psychotherapy...what is its mechanism of action? does each psychotherapy work because of what its practitioners say it works or because of general factors or common elements? how much of the effect of psychotherapy is a placebo effect?
Psychotherapists are the secular versions of priests. Psychotherapy is the secular confessional.
Great questions that I'll address in another post soon.
Ramos's quote about GWAS is dead wrong. GWAS has been a major success for finding genes related to mental disorders, including schizophrenia. Every year we see larger studies and find more relevant genes.
Hm, okay, I'll look a bit more into this then.
> One after another…[they] abandoned the field of psychiatry altogether.
But... that's a bad thing, isn't it? There were promising developments and then we just… Ended them on a whim? Wow.
> Psychiatrists charge more and are harder to find and book.
You don’t have to book them every week. The costs of one-time appointment and medication is minuscule compared to the cost of weekly therapy.
Also, anxiolytics have a very real effect: they make people sleep. People are much better equipped to make decisions when they rested compared to when they are not.
It could be a good or bad thing. If there are fewer medications, people might be more persuaded to rely on solutions that are cheaper, have fewer side effects, and so on, like exercise.
True, you see your psychiatrist less and the cost may end up being less overall because of that.
Yes, sleep is incredibly important, so however you can get it, good. But I doubt anxiolytics want to hang their hat on being a sleep medication.
Thanks for reading and commenting!
Robert Whitaker's "Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America" opened my eyes to this reality. Thank you for this post!
Ah, something to put on my list. Thank you!