A busy week for critical psychiatry.

Another week, another couple of books criticising psychiatry. Fortunately, they dovetail neatly to address the central problem in the field. The first is not by a psychiatrist but by a physician who is as well-qualified as any psychiatrist to analyse psychiatric methodology. Prof. Peter Gøtzsche, of the Institute for Scientific Freedom, in Copenhagen, raises the vitally important question: Is Psychiatry a Crime Against Humanity? His answer is published as a free ebook at https://www.scientificfreedom.dk/books/.

Prof. Gøtzsche was co-founder and, for years, director of the Nordic Cochrane Centre in Copenhagen, until the Centre’s new director decided to take it in a different direction and pushed him out. The Cochrane Collaboration is a UK-based charity with centres in different parts of the world which was set up to provide an independent assessment of medical research so physicians could have the best available evidence-base for their practice. As a methodological analyst, Prof. Gøtzsche published extensive reviews and studies of mainstream medical fields such as mammography (2012), and then became interested in psychiatry. He quickly saw through the fog of statistics and became highly critical of the psychiatric drug industry and the entire biological orientation of psychiatry, including the DSM diagnostic system.

In 2017, he was appointed to the Governing Board of Cochrane but, after numerous disputes with the new director (not a physician) over his critical attitude to psychiatric research, was abruptly turfed out. Undeterred, he set up the Institute for Scientific Freedom, retired from practice and got busy on shredding psychiatry’s fig leaf of scientific respectability. This is his fourth book on psychiatry, all of which I’ve read and recommend. With just over a thousand citations from his encyclopaedic knowledge of the field, his latest is typical of his highly-detailed and no-holds-barred approach. I believe it should be compulsory reading for all medical students and trainees in psychiatry, and anybody else in the mental health field who takes their work seriously. In particular, it should be essential for general practitioners as they are now the main prescribers of psychiatric drugs. For non-medical readers, it will probably be heavy going as it presumes a fair bit of knowledge of psychiatry, but it’s definitely worth reading Chapters 1 (Psychiatry is in crisis), 9 (Forced treatment: a licence to kill)  and 11 (Censorship, denial and lies: How the psychiatric guild protects their falsehoods).

Chapter 1 opens with the blunt warning: “We have a mental health crisis.” He describes how he started studying psychiatric research and quickly realised large parts of it are wildly misleading at best, frankly deceitful at worst. Above all, the research works for psychiatrists and drug companies rather than patients. The more closely he looked at the scientific basis of psychiatry, the worse it seemed. However, the psychiatric response to criticism was unlike anything seen in medicine as a whole: psychiatrists became inflamed and attacked him as a person, rather than focus on the research failings he had uncovered. Psychiatry, he concluded, is a deadly racket; since that was published in 2013, he has seen nothing to cause him to change his mind. The time has now come, he says, to ask whether it is a crime. Good question, and it is one mainstream psychiatry needs to answer very quickly, except we know they won’t. If Gøtzsche is lucky, they will attack him, otherwise they’ll ignore him, but the one thing they won’t do is respond directly to his criticism.

Chapter 2 covers what he calls “depression pills,” because they are not “antidepressants” in the sense penicillin is an “antibiotic.” If you are taking these drugs, prepare to be frightened but, as he makes crystal clear, do not under any circumstances stop them abruptly otherwise you are most likely to go into a severe and potentially dangerous withdrawal state. In particular, he emphasises the danger these drugs represent for children and adolescents. Chapter 3, on anxiety, is relatively short, which is a bit of a disappointment for me as I see anxiety as the root cause of most mental disorder. However, I totally agree with his focus on how depression pills can only make anxiety worse. Chapter 4, on ADHD, is again mainly on children although in Australia, and probably many other places, the drug industry is doing its utmost to throw its net over as many adults as it can. Basic rule of marketing: if your market is saturated, open a new one. And so we come to Chapter 5, on psychosis, which really ought to be a book on its own. There is very little skullduggery that hasn’t been tried (usually successfully) in convincing the world that madness is spreading rapidly and needs heaps of drugs. What psychiatry doesn’t reveal is how horrible the drugs are to take, how they shorten people’s lives and, once started, how difficult it is to stop them. And how expensive.

In the remaining chapters he looks at dementia (don’t believe all that hype about drugs delaying Alzheimer’s Disease), ECT (there are plenty of places in the world where it is either banned or severely restricted, or simply unavailable), psychosocial interventions and finally, asks whether there can be a better psychiatry. On the evidence he presents, that isn’t very likely:

I have often wondered why it is fruitless to appeal to psychiatrists’ inner moral compass. I guess many don’t have one and that this is why they became psychiatrists, as they will not be held to account in this specialty (p78).

There are actually two hugely complex but inter-related issues here which would fill several books. The first is the entrenched dishonesty of the psychiatric industry as it exists today, and the second is psychiatry’s brutality. There are many reasons medical graduates choose psychiatry, some worthy, some not so worthy, but I doubt that cheating the system and brutalising people are among them. That just happens, it evolves along the way, as the career of the Nazi psychiatrist, Ernst Rüdin, shows. Rüdin was the architect of the program to murder hundreds of thousands of mental patients, firstly in Germany and later in the occupied countries. This was so successful that it was adopted as the “Final Solution” to exterminate the Jewish, Romany and other ethnic minorities in Europe. I don’t think Rüdin started psychiatry rubbing his hands with glee at the thought of all the people he could murder, that just grew. It grew and mutated and metastasised until it became the crime of the century. The reason is very simple: there is nothing in their theory of psychiatry to stop it happening. Nothing to stop it happening again.

Modern psychiatrists are brought up believing that mental disorder is wholly physical (with a bob in the direction of psychosocial influences); that only psychiatrists know what is right; that their treatment is based in science and therefore can’t be faulted; that all those mental people have no idea what is wrong with them; that their resistance to treatment comes from their mental disorders and must be overcome by force if necessary so the psychiatrists can do their healing job; that critics are malicious and antipsychiatry (which, like pornography, they can’t define but can recognise when they see it); and that psychiatry is on the verge of massive breakthroughs so people who try to hold it back are doubly malicious.

When I say “brought up believing,” that is what I mean: indoctrinated. Told what to believe and actively discouraged from/penalised for questioning or criticising the received view. Brainwashed if you like although, for a lot of them, a quick rinse would do. Given these mental factors, it is a matter of statistics that, eventually, a dishonest and brutalising psychiatry will emerge. It’s like what’s called stochastic terrorism: if you demonise a section of humanity as an omnipresent threat that must be crushed, sooner or later some unhinged individuals will decide to do something violent against them. Then the people who were shrieking about immigrants or different religions or races will say it had nothing to do with them.

I’m not saying there are no psychopaths in psychiatry – Joseph Biederman of Harvard was certainly one, see pp 60, 70 – but given the mix of personalities who start the training, and given the pressures within the profession, very few psychiatrists are prepared to go against the flow by demanding to see the evidence. It’s so much easier, and so much more profitable in so many ways, to copy what the professor says and recite it back in the exams, to soak up the drug company propaganda and to pour scorn on the Peter Gøtzsche’s of this world (and Joanna Moncrieff, and Peter Breggin, and so on). Out of that comes a deeply dishonest, brutal and anti-humanist psychiatry.

This point is probably no clearer than in the question of incarceration and involuntary treatment. The World Health Organisation and the UN Human Rights Commission call for it to be phased out; the Convention on the Rights of People with Disability (CRPD) and various other bodies and treaties all say it has to go, but psychiatrists simply ignore these developments and get on with banging people up. However, as Gøtzsche points out, “ … forced treatment is not evidence-based but culture-based” (p99). This is absolutely correct. Just as the use of ECT varies enormously from one city to another, so too does the use of detention and involuntary treatment. Don’t worry about the “evidence base” of involuntary treatment, there isn’t one. Simply, if involuntary treatment is available, people in positions of power will use it on the basis they are doing it for the patient’s good. That is the first step on the slippery slope to brutalism.

However, none of that explains why psychiatry, unique among medical specialties, and probably unique in science, has an established record of scandalous deceit in its research record. Given all this, the question is: “Why?” That’s where we come to the second book published this week. Theories in Psychiatry: building a post-positivist psychiatry (here) provides the intellectual background to the generally abysmal performance of the psychiatric profession: in a few words, they don’t know what they’re doing. The nice, considerate psychiatrists (they exist) have no way of drawing the lines and telling the money-hungry adventurers and power-mad ratbags “No more.” When they do manage belatedly to draw lines (e.g. insulin coma therapy, psychosurgery, deep sleep therapy), the “key opinion leaders” laugh and say “But that’s all so yesterday, we’ve moved on. Bye bye, stick in the muds.” Sure, they blather on about chemical imbalances and dysfunctional neuronal circuits and genome-wide association studies and PET scans and drugs and so forth, but the simple fact remains: psychiatry has no theory of mind and no model of mental disorder, nor does it have a theory of personality or a model of personality disorder. It is therefore not a science and should most definitely not be granted the status of a medical specialty based in an articulated science of mental life. In the absence of a model of mental disorder, the idea of an “evidence-based psychiatry” is a hollow joke. Without a guiding model, people will simply select the evidence that supports their prejudices. For this reason alone, psychiatry is not fit to hold power of life and death over patients (as Gøtzsche makes so clear).

In his final chapter, Peter Gøtzsche throws down the gauntlet: “A new paradigm is needed for psychiatry” (p170) to replace the grotesquely inadequate “biological approach.” That is exactly what physician George Engel said nearly fifty years ago. He said we need to get away from the “biomedical model” and move toward a “biopsychosocial model.” He didn’t write one, he couldn’t have done at that stage but fortunately, there is now an integrative model of mind and body waiting wings. Waiting for psychiatry to listen to the critics instead of abusing them.

The two books complement each other. Peter Gøtzsche gives the hard facts of how psychiatry cheats and misleads and generally breaches the most basic rules of science – and humanity – while my little effort strips away the intellectual pretensions of the wannabe “clinical neuroscientists” who are calling the tune in psychiatry. Meantime, tough about the patients.