After finishing Jeffrey Lieberman’s new book, Shrinks: The Untold Story of Psychiatry, I was tempted to put it aside and not write anything, even though I had purchased the book with the intention of doing so. The reason was that I found it impossible to take the book seriously, and actually, I don’t think it is meant to be a serious book. Lieberman, who is a past president of the American Psychiatric Association, doesn’t present any scientific data to support his narrative, nor does it seem that he has relied on primary sources to document it. Much of what is told appears to be taken from secondary sources, and what is left is a kind of pop tale of psychiatry’s rise to glory. Even the publisher’s promotional copy basically acknowledges this, proclaiming it a “tale” that is populated by “true heroes . . . who dared to challenge the status quo.” That sounds like a blurb for an adventure story.
As for Lieberman having unearthed an untold tale, Shrinks relates a story that the American Psychiatric Association has been telling the American public ever since it published DSM III in 1980. The disorders in the DSM are real diseases of the brain; the drugs prescribed for them are quite safe and highly effective; and psychiatric researchers are making great advances in discovering the biology of mental disorders. Therapeutic and research progress are to be found at every turn.
But as I mulled over the book, it was the “heroes” reference, in both the publisher’s blurb and the text of Shrinks, that finally caught my interest. As part of my research for a new book I have coming out in April, Psychiatry Under the Influence: Institutional Corruption, Social Injury, and Prescriptions for Reform, which I co-wrote with Lisa Cosgrove, I reviewed all of the speeches given by presidents of the American Psychiatric Association at the organization’s annual meetings since 1980, and I was struck by how regularly they sounded this theme: Psychiatrists are true heroes. Which may or may not be true, but it is a bit unusual for a professional medical association to regularly remind its members of their own heroic specialness. And so it dawned on me: The revelatory aspect of Shrinks is that it serves as an institutional self-portrait. What you hear in this book is the story that the APA and its leaders have been telling to themselves for some time.
The cover of the book features a Freudian couch, inviting readers to sit back and listen. We can even play psychiatrist to Lieberman in his role as APA everyman, and ask this fanciful question: Is there reason, at book’s end, to make a DSM diagnosis?
The Doctor in the White Coat
Before reading Shrinks, it is useful to quickly view a video of Lieberman on YouTube in which he discusses his book. The words don’t really matter; what does is Lieberman’s presentation of himself. He is wearing a doctor’s white coat, complete with pen in the pocket. This is how he dressed for the camera. And with that visual in mind, we can turn to the introduction in Shrinks, where Lieberman recounts a story of a patient he calls Elena Conway.
Elena, 22 years old, had dropped out of Yale University a couple of years earlier when her grades mysteriously dropped. Thinking that their daughter suffered from “low self-confidence,” her parents, who were distrustful of psychiatry, hired “ life coaches and tutors,” and when that didn’t work, they turned to naturopaths, acupuncture and hypnosis, which also failed to help. Finally, Elena’s exasperated family doctor had this advice for her parents: “For Christ’s sake, take her to a real doctor!”
And so, Lieberman writes, they “came to me.”
What follows is an anecdote about a skilled doctor at work. Lieberman finds that Elena has grandiose ideas about saving the world, a symptom of schizophrenia. He orders Elena into the hospital, worried that she has gone untreated for so long, because untreated schizophrenia “gradually induces irreversible brain damage, like the engine of a car driven without an oil change.” Lieberman orders a battery of physical tests —blood tests, an EEG, MRI, and other neuropsychological exams—to rule out other possible causes of her grandiose thoughts and behavior, and then, with his diagnosis confirmed, he prescribes risperidone, “a very effective antipsychotic medication with only a modest potential for side effects.”
The reader knows what this anecdote of “real medicine” will bring: within weeks, Elena is much better. She is now “cheerful and intelligent, with a playful sense of humor,” and eager to return to Yale. Her parents, Lieberman reports, were “delighted to get their daughter back. “
At this point, the science-minded reader might recall how an anecdote is an “N of 1,” and thus can’t be taken as evidence of a therapy’s efficacy. What alert readers of Shrinks will also note, if they read the small print in the front of the book, is that this likely isn’t even a real anecdote. “In many cases I have created composites of multiple patients,” Lieberman writes. And so what we have in this introduction, along with the video of Lieberman, is a presentation of the psychiatrist as a skillful “doctor” in a white coat.
At the conclusion of his introduction, Lieberman writes that this is indeed the governing theme of Shrinks: “Over the course of this book, you’ll learn about a handful of renegades and visionaries who bravely challenged the prevailing convictions of their time in order to elevate their embattled profession. These heroes declared that psychiatrists were not doomed to be shrinks but destined to be a unique class of physicians . . . The world needs a compassionate and scientific psychiatry and I’m here to tell you, with little public fanfare, that such a psychiatry has arrived at last.”
In medicine, artful diagnosis is the foundation for effective treatment, and Lieberman structures his book to reflect that relationship: first the story of diagnosis, then treatment. Both narratives tell of a past when psychiatry wandered in the desert, and then found the Promised Land.
As a medical specialty, psychiatry got its start in the asylums that were built in the first half of the 19th century, and in those days, it had no diagnostic manual. Psychiatrists were caretakers of the “insane.” Then, in the late 1800s, psychiatry got its first glimpse of the guiding light of science in the work of German psychiatrist Emil Kraepelin. He separated psychotic patients into different diagnostic groups based on presenting symptoms and different clinical courses. But, Lieberman writes, the field soon lost its way, buffeted by the nonsensical ideas of various charlatans and, more ominously, the arrival of Freudians after World War II.
Psychoanalysis, Lieberman writes, became “a plague upon American medicine, infecting every institution of psychiatry with its dogmatic and unscientific mind-set.” Freudians came to dominate psychiatric departments at medical schools, and with their disdain of diagnosis and fanciful ideas about the unconscious, they opened the door to withering criticisms by antipsychiatry activists like Erving Goffman, R.D. Laing and Thomas Szasz, who mocked psychiatry as a pseudoscience. Psychiatry, it seemed, was headed to “extinction,” and it was then, at psychiatry’s darkest hour, that a small band of psychiatrists at Washington University in St. Louis, Eli Robins, Samuel Guze, and George Winokur, recalled the work of Emil Kraepelin and planted the intellectual seed that—as Lieberman writes—would “save psychiatry.”
As the Washington University group plotted their revolution, one person who took notice “was Robert Spitzer. Another,” Lieberman confesses, “was me.” The fight for “psychiatry’s soul” was on, with this small group of heroes taking on the powerful Freudians, and in Lieberman’s telling, it was this titanic struggle that gave rise to a new psychiatry. With Spitzer at the helm, the APA created a new edition of its Diagnostic and Statistical Manual, jettisoning old Freudian ideas and adopting a diagnostic approach modeled on Kraepelin’s work. This, Lieberman writes, “was the book that changed everything.”
In his YouTube video, Lieberman boasts that his book is the first ever to tell the “complete and unvarnished truth” of psychiatry’s history (a rather extravagant claim, one might think.) The problem with this history of the rise of scientific diagnosis is that the DSM III task force, as it created its diagnostic model, rejected the scientific framework that the St. Louis group had adopted for making diagnoses.
Robins, Guze, and Winokur, along with a psychiatric resident at Washington University, John Feighner, argued that in order for psychiatry to research mental disorders, it needed to identify individual illnesses based upon studies of presenting symptoms, the short and long-term course of the disorder, and genetic associations. After they reviewed the literature, they concluded that there was evidence of this sort for only 16 diagnoses, and even then, they considered these groupings of homogenous patients “tentative.” Guze wanted to apply this standard to DSM III, arguing that every diagnosis in the manual should be supported by this type of scientific information, but he was rebuffed.
“I couldn’t get that group to vote in favor of my suggestions,” Guze recalled. “The response that I was given was that they said we have enough trouble getting the legitimacy of psychiatric problems accepted by our colleagues, insurance companies, and other agencies. If we do what you are proposing, which makes sense to us scientifically, we think that not only will we weaken what we are trying to do but we will have given the insurance companies an excuse not to pay us.”
Having rejected the Guze model, the DSM III task force set about creating a manual that could provide a diagnosis—and thus insurance coverage—for everyone who came to psychiatrists seeking help. Psychiatry’s new “Bible” listed 265 disorders, with boundary lines for most drawn in an arbitrary fashion. Psychiatry told itself that it had followed Kraepelin, simply because it would make diagnoses based on “symptoms,” neatly forgetting the scientific details of his work.
In his book, Lieberman does not discuss whether DSM III and subsequent DSM iterations provide the reliability and validity that make a diagnostic manual useful in medicine. However, he does make this claim, which appears to be telling readers of its validity: “The Manual’s greatest impact is on the lives of tens of millions of men and women who long for relief from the anguish of mental disorder, since first and foremost the book precisely defines every known mental illness. It is these detailed definitions that empower the DSM’s unparalleled medical influence over society.”
Here is the scientific story of DSM III’s reliability. When it was published, Spitzer and the APA claimed that field trials had proven it to be vastly more reliable than DSM I and DSM II (meaning that two psychiatrists, when confronted with the same patient, would make the same diagnosis.) That is still an assertion made in conventional narratives of psychiatry. However, the reliability trials of DSM III that were conducted after its publication, including a large one funded by the NIMH, found that its reliability was in fact fair to poor, with NIMH investigators concluding that there was hardly any more agreement between psychiatrists “beyond what is expected by chance.” As for the field tests of DSM 5, the reliability scores were even worse.
As for the DSM’s validity, Spitzer and his co-authors acknowledged in their introduction to DSM III that the diagnoses should be considered “hypotheses,” and their thought was that future research would “validate” these constructs. But as any number of prominent psychiatrists have now publicly acknowledged, this has not turned out to be the case. Allen Frances, chair of the DSM IV task force, Tom Insel, director of the NIMH, and Nancy Andreasen, former editor-in-chief of the American Journal of Psychiatry, have all noted that the DSM diagnoses lack “validity.” Indeed, at a 2012 roundtable discussion of the DSM, which involved more than 20 experts in psychiatric diagnoses, the moderator, Yale Medical School psychiatrist James Phillips, concluded that “virtually all discussants” agreed that “most of the diagnoses fail the test of the original Robins and Guze . . . validators.”
Thus, we see the propagandistic aspect of part one of Lieberman’s book. He touts the creation of DSM III as a great leap forward for psychiatry, with the profession now having adopted a scientific mindset for diagnosing disorders, based on the work of Robins and Guze, and with that claim having been made, he subsequently relates, in every anecdote in the book, a tale of his making an artful diagnosis, which leads to the proper treatment for the disease. The anecdotes tell of a profession skilled in distinguishing between a myriad of disorders listed in the DSM, while a review of science, which is absent from his book, tells of a profession lost in a diagnostic wilderness, its “Bible” neither reliable nor valid.
The narrative that Lieberman tells about “treatment” follows a trajectory similar to his narrative about diagnosis. First, he relates how psychiatry spent a long time wandering in a therapeutic desert. In the 1800s, Lieberman states, there were “no effective treatments for mental illnesses.” Then, in the first half of the 20th century, as asylums became ever more crowded with chronic patients, psychiatrists tried any number of desperate cures. Insulin coma therapy, metrazole convulsive therapy, and surgical lobotomy—all were popularized, but none stood the test of time. Serious mental illnesses—schizophrenia, manic depressive illness, and major depression—ran a chronic course, and there was little that asylum doctors could do to change that.
“Spontaneous remission—the only ray of hope for the mentally ill from the 1800s through the 1950s—was in most cases about as likely as stumbling upon a four-leaf clover in a snowstorm,” Lieberman writes.
But then comes the miracle of chlorpromazine. First developed for use as an anesthetic in surgery, chlorpromazine was introduced into asylum medicine after French surgeon Henri Laborit noticed that it induced a notable emotional lethargy in his patients. Chlorpromazine took European psychiatry by storm, but according to Lieberman, the American Freudians, with their psychoanalytic nonsense, had no use for this drug, deriding it as psychiatric aspirin. Finally, Smith, Kline and French bypassed the psychoanalysts and got the state officials that administered mental hospitals to try the new drug, which was marketed as Thorazine in the U.S.
“The results were breathtaking,” Lieberman writes. “All but the most hopeless cases improved, and many long-institutionalized patients were sent home . . . Like a bolt from the blue, here was a medication that could relieve the madness that disabled tens of millions of men and women—souls who had so very often been relegated to permanent institutionalization. Now they could return home and, incredibly, begin to live stable and even purposeful lives. They had a chance to work, to love, and – possibly—to have a family.”
The psychopharmacological revolution was underway. Next, the Swiss pharmaceutical company Geigy developed a derivative of chlorpromazine, imipramine, that proved—in Lieberman’s telling—as curative for depression as chlorpromazine was for the mad. “The entire profession was utterly transmogrified,” Lieberman writes. “Two of the three flagship illnesses, schizophrenia and depression, were reclassified from ‘wholly untreatable’ to ‘largely manageable.’” These were “miracle medications,” Lieberman writes, and then lithium arrived, and in the space of less than 15 years, all thee of the major serious illnesses in psychiatry had been tamed.
These drugs, Lieberman tells readers, were specific antidotes to these disorders. “What made chlorpromazine, imipramine, and lithium so different from the sedatives and tranquilizers before was they directly targeted psychiatric symptoms in a kind of lock-and-key relationship,” Lieberman writes. “Sedatives and tranquilizers produced the same broad mental changes in everyone, whether or not a person was suffering from a mental disorder, whereas antipsychotics, antidepressants and mood stabilizers reduced the symptoms of illness without producing much of an effect on healthy people.”
With these new miracle drugs in their toolbox, the stature of the psychiatrist changed. Lieberman and his colleagues “became receptive to the unexpected new role of psychiatrists as psychopharmacologists, as empathic prescribers of medication.”
In so many ways, this is the core of the narrative that the American Psychiatric Association has told to the public for the past 50 years, which has been embraced in its broad outlines by the public. The arrival of Thorazine in asylum medicine kicked off a “psychopharmacological revolution,” and today the profession has an array of effective therapies for the brain diseases it treats.
Although it would take a book-length treatise to fully deconstruct that governing story of psychiatry, even a fairly quick review can reveal that it is quite unmoored from science and history. The story that Lieberman tells is built on three assertions: spontaneous remissions are rare; the arrival of Thorazine and other antipsychotics made deinstitutionalization possible; and psychiatric drugs have dramatically improved long-term outcomes for schizophrenia, depression, and bipolar illness.
The natural course of major mental disorders can be difficult to assess precisely because societal treatment of the mentally ill has often been so abysmal, and thus treatment hindered the likelihood of “spontaneous remission.” But if we go back in history to the first half of the 19th century, we find that asylums practiced a form of care known as moral therapy, and historians who have studied the patient records of those early asylums have determined that “spontaneous remission” occurred rather frequently.
Moral therapy was introduced into the United States by Quakers, and their belief was that while they didn’t know what caused madness, they could treat their mad “brethren” with kindness and provide them with shelter, good food and daily walks in the countryside, and in this way “assist nature” in helping them to get well. Historians have determined that 35 to 80 percent of all first-episode patients in those early asylums were discharged within a year, and the majority were discharged as having been cured (which meant that their disturbing behavior and psychotic thoughts had largely disappeared.) In addition, a long-term follow-up study of 984 patients discharged from Worcester asylum in Massachusetts from 1833 to 1846, which was conducted in the 1880s, found that 58 percent had remained well throughout their lives. Another seven percent had relapsed but had subsequently recovered and returned to the community. Only 35 percent had become chronically ill or had died while still mentally ill.
This history of therapeutic success, and of the possibility of spontaneous remission, was forgotten in the second half of the 19th century, as communities began dumping all sorts of people—those struck by neurological disorders, end-stage dementia from syphilis, and senility in the elderly—into the asylums. Discharge rates plummeted, and moral therapy came to be seen as a failed therapy. Then, in the first decades of the 20th century, the United States fell under the sway of eugenic ideas about the “mentally ill,” which called for people so diagnosed to be segregated in asylums and kept there through their breeding years, lest they spread their bad genes. This social policy led to a buildup of the asylum population during the first 50 years of the 20th century, and the belief that these patients, since they were now spending decades in the hospital, were chronically ill.
Even so, studies by Kraepelin and others during this period of first-episode patients found that spontaneous remission was fairly common, at least for those ill with mania or depression. In fact, Kraepelin separated his psychotic patients into two types. Those psychotic patients who presented with a lack of affect (and difficulty in making willed movements), tended to deteriorate into early dementia, and thus were his dementia praecox group. Those who presented with affect, either mania or depression, could be expected to recover, with their illness running an “episodic course” over the long-term. This was Kraepelin’s manic-depressive group. “Usually all morbid manifestations completely disappear,” he wrote in 1921, “but where that is exceptionally not the case, only a rather slight, peculiar psychic weaknesses develops.”
Various long-term studies of patients hospitalized for a first episode of mania or depression prior to 1950 found that perhaps 50% would be discharged and never again be hospitalized, another 30 percent would suffer periodic episodes, but would recover to euthymia (e.g. an absence of symptoms) in between those episodes, and only 20 percent or so would become chronically ill. This understanding of the course of affective disorders—and thus the possibility of spontaneous remission—was oft repeated by leaders in the field during the 1950s and 1960s. For instance:
- In 1964, Jonathan Cole, head of the NIMH’s Psychopharmacology Service Center, wrote that “depression is, on the whole, one of the psychiatric conditions with the best prognosis for eventual recovery with or without treatment. Most depressions are self-limited.”
- That same year, Nathan Kline wrote that “one always has as an ally the fact that most depressions terminate in spontaneous remissions. That means that in many cases regardless of what one does the patient will begin to get better.”
- In a 1969 textbook on manic-depressive illness, George Winokur wrote that “assurance can be given to a patient and to his family that subsequent episodes of illness after a first mania or even a first depression will not tend toward a more chronic course.
Although schizophrenia is typically seen as running a chronic course, studies of first-episode patients from 1945 to 1955 found that at least 60 percent of the patients were discharged within one year, and at longer-term follow-ups, 65% or more of the initial cohorts were living in the community. The diagnosis of schizophrenia was being applied to a diverse group of psychotic patients during that period, but, at the very least, this data shows that “spontaneous remission” was fairly common for this larger pool of psychotic patients.
As for the assertion that antipsychotics made it possible to discharge chronic patients from mental hospitals and thus enabled deinstitutionalization, this too is belied by the facts. In 1955, there were 267,000 schizophrenia patients in state and county mental hospitals, and eight years later, during which time Thorazine was regularly prescribed, there were still 253,000 patients with this diagnosis in the hospitals. Deinstitutionalization was made possible by the enactment of Medicare and Medicaid legislation in 1965. It provided federal subsidies for nursing home care but no such subsidy for care in state mental hospitals, and so the states, seeking to save money, began shipping their chronic patients to nursing homes and other residential homes. Social policy, rather than a miracle new drug, prompted the discharge of chronic patients from state hospitals.
Lieberman’s third assertion is that psychiatric drugs dramatically improved long-term outcomes for major mental disorders, This was the very question that I investigated in Anatomy of an Epidemic, and a thorough review of the scientific literature reveals that, if anything, drug treatment increases the likelihood that major mental disorders will run a chronic course. That history of long-term outcomes took a book to document, but in order to provide a check on Lieberman’s claims, we need only cite a few quick facts.
In a 1994 study titled One Hundred Years of Schizophrenia, Ross Baldessarini and his colleagues at Harvard Medical School reported that 35% of schizophrenia patients had favorable outcomes during the first third of the 20th century. They determined that a similar percentage had favorable outcomes in the post DSM-III era; outcomes today were no better than they had been a century earlier. Meanwhile, in the best long-term study of schizophrenia patients in the modern era, Martin Harrow and Thomas Jobe found that those off antipsychotics were eight times more likely to be in recovery at the end of fifteen years.
Depression is now understood to run a chronic course (as opposed to an episodic course,) and there are a small number of researchers writing about whether antidepressants have a depressogenic effect of the long-term. One who has done so is Rif El-Mallakh, an expert in mood disorders at the University of Illinois. He writes: “A chronic and treatment-resistant depressive state is proposed to occur in individuals who are exposed to potent antagonists of serotonin reuptake pumps (i.e. SSRIs) for prolonged time periods. Due to the delay in the onset of this chronic depressive state, it is labeled tardive dysphoria. Tardive dysphoria manifests as a chronic dysphoric state that is initially transiently relieved by — but ultimately becomes unresponsive to — antidepressant medication. Serotonergic antidepressants may be of particular importance in the development of tardive dysphoria.”
The same is true with bipolar disorder. This disorder now runs a much more chronic course that it did in the pre-lithium era, with patients so diagnosed showing much greater functional impairment. In a 2000 paper, Carlos Zarate and Mauricio Tohen wrote about this surprising downturn in outcomes: “In the era prior to pharmacotherapy, poor outcome in mania was considered a relatively rare occurrence. However modern outcome studies have found that a majority of bipolar patients evidence high rates of functional impairment.”
In sum, Lieberman recounts a story of miracle drugs arriving in psychiatry in the 1950s and 1960s, which brought hope to the hopeless and enabled people struck by serious mental illnesses to live fairly normal lives. That is a story that of course provides great comfort to the psychiatric profession. But, alas, it is belied by the science that can be dug out from psychiatry’s own journals.
In his book, Lieberman tells of other types of therapies in psychiatry, such as ECT and cognitive behavioral therapy, and of how the field is now embracing a more “pluralistic” approach to treating various disorders. All of these therapies are said to work well, with Lieberman waxing particularly enthusiastic about electroshock therapy. “I’ve seen patients nearly comatose with depression joyfully bound off their cot within minutes of completing their ECT.”
I read that line and my mind couldn’t help itself: Here was a modern-day story of Jesus, curing the lame, who could now throw away their crutches and walk.
Psychiatry’s Glorious Present and Future
In the last third of his book, Lieberman writes of a “Psychiatry Reborn.” He tells of research into the biology of mental disorders, and how imaging studies are finding all sorts of abnormalities in the brains of the mentally ill, and of advances in understanding the genetics of mental illnesses. This is familiar stuff, and there is no point in putting it under review, although there was one paragraph in particular that stuck out for me. Thanks to brain imaging studies, Lieberman writes, “we’ve learned that schizophrenic brains exhibit a progressive decline in the amount of gray matter in their cerebral cortex over the course of the illness, reflecting a reduction in the number of neural synapses . . . In other words, if schizophrenics are not treated, their brains get smaller and smaller.”
The implication here is that antipsychotics arrest this loss of grey matter, and thus preserve a more normal functioning. Lieberman, of course, knows this isn’t true. Although it may be that there is a decline in brain volumes of people diagnosed with schizophrenia that occurs independently of these drugs, there is abundant evidence, starting with Nancy Andreasen’s large study of this question, that antipsychotics induce a decrease in brain volumes. Lieberman even did a study of this type, finding a decline in volumes in patients treated with either haloperidol or olanzapine. More recently, German investigators, conducting a thorough review of this literature, concluded that it called for rethinking the use of antipsychotics, because the brain shrinkage appears to be associated with functional declines. But in Lieberman’s narrative, the image of the drugs as miracle agents must be preserved, and so he tells a story about how they arrest this pathological process.
And I have to confess, I found that sad.
Wearing the Black Hat
I should note that I make a one-sentence appearance in Lieberman’s book, as one of a modern group of antipsychiatry activists, and of course Lieberman lumps me together with the Scientologists, which has been psychiatry’s response to critiques of its narrative for some time now. The critics are anti-science cultish fanatics! I have to say though that even here Lieberman’s scholarship is rather poor, for he misspells my name and accuses me of taking a swipe at the creation of DSM 5, which is something I did not personally write about. But such mistakes are of no account; truth is, I was rather flattered to be wearing a black hat in this particular “untold story of the history of psychiatry.”
Through the Lens of the DSM
As I wrote in the beginning of this post, I think Shrinks ultimately provides a revealing self-portrait of psychiatry as an institution. Lieberman is a past president of the APA and he has reiterated the story that the APA has been telling to the public ever since DSM-III was published. And it is this narrative, quite unmoored from science and history, that drives our societal understanding of mental disorders and how best to treat them.
In Shrinks, Lieberman at one point diagnoses the Freudians, writing that if the psychoanalytic movement “had been able to lie upon its own therapeutic couch, [it] would have been diagnosed with all the classic symptoms of mania: extravagant behaviors, grandiose beliefs, and irrational faith in its world-changing powers.” Now we have in this book a story told by the biological successors to the Freudians, and it seems to me that turnabout is fair play. So what diagnosis can be made?
The symptoms that Lieberman saw in the Freudians—extravagant behaviors, grandiose beliefs, and irrational faith in its world-changing powers—seem present in this narrative, and I would think we might add that there is evidence of an institutional “delusion” too, the profession unaware of it own science. Psychiatry has a word for this lack of insight into one’s illness, but rather than spell it out here, I will simply note that anyone who has ever objected to taking antipsychotic medications will know it quite well, with psychiatry explaining this is why patients don’t like their drugs.