I have over four decades of experience in psychiatry, most of it at the rough end of the scale, including prisons, military, isolated areas, minorities and post-traumatic states. I have also published extensively in the area of the application of the philosophy of science to psychiatry. This is a rather strange combination as philosophy is usually considered very erudite, quite the opposite of scrabbling around in the dirt and mud of Northern Australia, but it’s actually very important. It concerns the question of whether a topic is or is not science — essentially, how much credibility it should be given. Because that’s what science is about, credibility. So the question becomes: how much credibility should we give modern, mainstream psychiatry?
You will be aware that there are people who claim that there is no such thing as mental disorder; that anybody who claims to be mentally troubled is simply making it up. I don’t believe that. When people say they are in such terrible mental distress that they don’t believe they can go on, I believe them. Nobody, for example, willingly gives up a successful military career to become a lonely and miserable pensioner. Now mainstream psychiatry also claims that mental disorder is a reality, and all that counts is the nature and origin of that disorder. For modern, orthodox psychiatry, the answer is very clear: all mental disorder is just a variant of a brain disorder of some sort.
Specifically, mental disorder is a biological disturbance of brain function, presumed to be at the level of neurotransmitters and caused by genetic disorders. Thus, the treatment of all mental disorder, as a physical disorder of the brain, is necessarily physical in nature: chemicals to correct a chemical imbalance, you could say, or if that fails, electrical currents to induce seizures, implanted electrodes, powerful magnetic fields, hyperthermia and, in the extreme, neurosurgery to disconnect parts of the brain.
This is the standard view of psychiatry as it is taught in all medical schools in the world and adopted by all major professional psychiatric bodies throughout the world. Mental disorder, they say, is biology, and the correct approach to understanding all mental disturbance is via a detailed understanding of brain function. A full understanding of the brain will tell us all we need to know about mental disorder with no questions left unanswered. Practically the whole of the psychiatric research budget of something like $2.5 billion a year is directed at this end.
You can see this message a dozen times a day on TV, spread far and wide on the internet, in every newspaper and women’s magazine, even on posters in public toilets. This is true: you can stand at the urinals in Sydney Airport and be told that if you’re depressed, you should see your doctor. The subliminal message, of course, is that you will get drugs. Critics of this view don’t get much airtime these days. Mainstream psychiatry is very effective at shutting down alternate points of view, mainly because it claims to represent the “science of mental disorder.” All other explanations, they say, are not scientific and therefore shouldn’t be heard.
Essentially, biological psychiatrists deal with all criticism with a resounding blast of “We’ve got the science. Our view is supported by a wealth of scientific detail. Due to rapid advances in modern technology, we are on the verge of major breakthroughs in the diagnosis and treatment of mental disorder. We know what we’re talking about so don’t listen to anybody else, just line up and take your tablets.”
However, because it is such an important question, because people’s lives depend on this and psychiatry has a record of getting it seriously wrong, we need to be sure we can trust their claim. In practice, is it true that biological psychiatry has the science? Let’s look at some figures.
At present, 10% of the Australian adult population takes antidepressants. In the US, it is 13%. In the UK, the number of prescriptions of antidepressants doubled between 2005 and 2015, from 30 to 60 million. Yet 30 years ago, well within my career in psychiatry, that figure was about 1%. Are we any better off? Despite massive increases in the prescription of psychiatric drugs, there is no evidence to suggest it is effective. There is ample evidence to indicate the problem is actually getting worse.
In 1974, when I started psychiatry, the incidence of what was then called manic-depressive psychosis was 0.1-0.2% of population, meaning 1-2 per thousand. In 1980, with the advent of DSMIII, the name was changed to bipolar disorder and the diagnostic criteria were substantially loosened. In 1984, Nancy Andreassen, later editor of the American Journal of Psychiatry, said it was 1% of the population. In 2005, Lewis Judd, former president of the American Psychiatric Association said it was 5.4%. In 2008, Phillip Mitchell of Sydney University said it was about 11%. That is, the rate of diagnosis of this allegedly genetic disease increased 110 times, or 11,000%, in just one generation. That is not genetic diseases as I understand them.
In some parts of the world, up to 40% of boys are taking stimulants for a disease called ADHD which didn’t exist when I began psychiatry. This so-called epidemic has only ever been reversed in Western Australia, just by making it more difficult for psychiatrists to write prescriptions for stimulants. One psychiatrist in Perth started 2000 people on the drugs in 20 months. Miraculously, by forcing psychiatrists and pediatricians to spend an extra five minutes getting an authorisation to start the drugs, suddenly, all these young people didn’t have the “disease” after all. It is now clear that something like half the prescribed drugs were leaking onto the black market, and a very high proportion of people started on them legitimately became addicted in adulthood.
Psychiatric drugs are held to be effective, safe, cost-effective and non-addictive. As a matter of empirical fact, nothing could be further from truth.
Are they effective? Psychiatric drugs are only marginally more effective than placebos, sugar pills. Over seven years, it has been shown that people with the diagnosis of schizophrenia do better without drugs.
Are they safe? They are most definitely not safe. In Australia, people taking psychotropic drugs in the long term die on average 19 years younger than undrugged controls. In the US, that figure is 25 years, mainly because they use larger doses and mix drugs more than we do. The drugs cause massive obesity and all its complications, but drug companies do everything they can to suppress this information. If people are given a list of the side effects of antidepressants, my experience is that they won’t take them.
Are they cost-effective? They most certainly are not — this is wholly a marketing ploy, but from the point of view of the drug companies, it is brilliantly successful. As prescription rates rise, so too do rates of pensions for psychiatric disorders. So-called second generation antipsychotic drugs are ridiculously expensive, sometimes costing hundreds per month when much cheaper alternatives are available.
Are they non-addictive? This is absolutely false, but mainstream psychiatrists believe it as an axiom of practice. By any definition of addiction, psychiatric drugs are among the most addictive chemicals known. Withdrawal symptoms are severe and can last two years. However, for the manufacturers, this is a godsend. Every time anybody tries to get off the drugs, he becomes disabled by symptoms. He will be told “Aha, that’s your mental illness coming back again, you need to stay on drugs for life.” So now you see why the consumption of psychiatric drugs doubles every ten years: nobody can get off them. Once you start, you’re hooked for life. But remember that the drugs were never tested for long term use. Practically all the trials that are used to test them are short term, very often six to eight weeks. I routinely see people who have been taking them 25-30 years. Massive weight gain of 30, 40 or 50 kg is inevitable for anybody taking these drugs more than two years but after two years, you’re addicted.
Let’s look at the science behind ECT, or electroshock treatment. In 40 years, practising psychiatry in the roughest and toughest parts of the country, most of it entirely alone, I have never used it. However, the Position Statement on ECT issued by the Royal Australian and New Zealand College of Psychiatrists (RANZCP) says it is “a valuable and essential form of treatment” which should not be withheld. The facts are quite clear. The state of Victoria uses as much ECT as the entire British National Health Service. In Queensland, from 2014 to 2015, use of ECT jumped from 16000 to 19000 episodes. Japan and Italy, of course, hardly use it. The two times I was appointed head of psychiatric units, it was used before I arrived. It was not used while I was in charge but as soon as I left, it started again. In both cases, during my tenure, the admission rate dropped, the duration of stay dropped and the bed occupancy rate in the units halved. In one hospital, we were able to close a ward. So the facts are crystal clear: ECT is most emphatically not essential. It is an option, and an expensive option at that.
The rates of involuntary treatment and incarceration vary dramatically from state to state, Qld being among the worst in Australia. Mental health acts are acts for incarceration, not treatment. In the Kimberley Health Region of Western Australia, I had no authority to detain people but just by being there, I was able to reduce the numbers of people sent south to the mental hospitals by 96%. There is absolutely no reason to believe that having quasi-judicial hearings before tribunals to determine involuntary treatment has led to any change or improvement, or anything except dramatic deterioration in efficiency, endless delays, and massive additional costs. The Qld Mental Health Review Tribunal costs about $11 million a year, not including all the time people spend sitting around while it deliberates. It achieves nothing except to spread responsibility around the bureaucracy until patients feel they are caught in a legalistic limbo. Many patients, if not most, don’t bother attending their hearings because they know the outcome in advance. The money would be better spent on public housing.
The costs of biological psychiatry are completely out of control. There is a government mental health clinic in the working class suburb where I work in my practice. Anybody referred there will face a 4-6 week delay in getting an appointment and a great deal of inconvenience. Patients mostly seen by nurses, psychologists or junior medical officers. Using Qld MHS figures, it costs $275 per half hour consultation. In my practice, which is 400m down along the road, new referrals face a 2-4 day delay but are sometimes seen on the same day. A half hour consultation with a very experienced psychiatrist costs a grand total of $73.50. That is, the public system takes 10-25 times as long to get a quarter of the service at four times the cost. But if they see me, it is extremely unlikely they will get any drugs. I prescribe antidepressants for no more than about 2% of my new referrals, yet I know my working class, public patients have exactly the same demographic profile as the public clinic along the road.
Is biological psychiatry cutting edge science? At the security units 2 km from my office, patients are admitted for many years at a cost of $4-6 million but routine search of their files reveals no history, no plan, no nothing. Certainly, they have no hope. There have been patients on that site for 150 years — it was once the biggest mental hospital in the country, with 2500 inmates, but there are no occupational therapy facilities. Patients simply lie on chairs under the trees or pace up and down. All of these figures have been handed to chief psychiatrist of Qld and to the Qld Mental Health Commissioner but they were totally ignored.
Finally, I recently had a contract with a government department to provide care for their “customers.” The average costs among other psychiatrists seeing their patients was about $5-10000 per patient, although this is a guess based on other reports because the actual figures are a closely guarded secret. Over two years, my costs for 311 patients amounted to $1012 per patient, or 80-90% cheaper. However, my contract was abruptly terminated with no audit of any sort, no warning and certainly no thanks, apparently because I didn’t admit them to private hospitals. I had cost the private hospitals in that city anything up to $3 million over two years and they didn’t like it. But if treated properly, there is little or no need to admit people to private mental hospitals. We could close almost all private hospitals in the country and the standard of mental health would go up.
So let’s go back to the claim that modern mainstream psychiatry is a valid scientific field. I deny this. I have argued at great length that orthodox psychiatry breaches all standards of what constitutes a science. In particular, it fails the essential test of not having a model of its field of study. That is correct. In an extensive survey of eleven years of the 13 major English-language psychiatric journals, I looked at something like 18,000 original papers, reviews, editorials and the like, covering some 175,000 pages. Believe me, it wasn’t fun. But it showed that no psychiatrist in the world has ever referred to or provided a justification of the claim that mental disorder is a biological disorder of the brain. Nothing. It doesn’t exist. In this case, absence of proof definitely amounts to proof of absence, because if they had it, they would flaunt it — they would shove it down your throats, maybe even put it on posters in public toilets. Modern psychiatry is not a science of mental disorder, it is an ideology of mental disorder.
When I see medical students or registrars in training (residents), I ask them the following question. “On your first day in psychiatry, your first lecture, when the professor came in and began his lecture, what was the name of the model of mental disorder he said he would be addressing?” Invariably, the answer is something like “He didn’t. He just came in and started talking about genes and neurotransmitters.” That, ladies and gentlemen, is not an education in mental disorder, it is an indoctrination in an ideology of mental disorder.
The psychiatric publishing industry is a story of its own. One of the most important features of any field claiming to be scientific is that criticism of the status quo, of the mainstream theories and ideas, is mandatory. There is no choice in this — if you don’t criticise your field, you have a political party, or a religion, or a football club, anything but a science. Yet orthodox psychiatry is violently allergic to criticism. Some years ago, I surveyed ten years of the Australian and New Zealand Journal of Psychiatry. Of 1184 papers, reviews, editorials and commentaries, only seven could be deemed critical. Four of these were trivial. Of the remaining three, two were by overseas authors and only one by a member of the College. That was my paper, which showed that the widely-revered biopsychosocial model didn’t exist. It was never written. So that amounts to somewhat less than one critical word per member per year, which is hardly in keeping with the spirit of the injunction to criticise your professors. That’s lucky for the professors, because they react very, very badly to criticism.
While we’re on the spurious biopsychosocial model, I should point out that mainstream psychiatry has assiduously ignored my paper showing that it is a fantasy. These days, there are about 150 papers published each year on something that doesn’t exist, which must be some sort of record for self-deception. How the editors manage to excuse themselves we don’t know because they are immune to criticism.
You have heard many references to the DSM system, the Diagnostic and Statistical Manual of the American Psychiatric Association. While this is sometimes described as the “bible” of psychiatry, I should point out that science doesn’t have bibles, only religions do. The current version, DSM-5, hasn’t had quite the impact its authors hoped. I say that this is because it is based on a false model of mental disorder, the notion that there are separate and distinct categories of mental disorder. There is no truth in this — even the APA itself experimented with an alternative model but it became too threatening so they dropped it. When you consider how much money they make from their DSM, you can understand, but I certainly don’t sympathise with their plight.
The DSM is based on the idea that all mental disorders can be mapped to specific “chemical imbalances in the brain.” You will hear this trope all the time but there is no evidence to support it. The only “chemical imbalance” in the brains of mentally-troubled people are caused by the drugs they take because that’s what psychiatric drugs do, that’s their role, that’s their function. Any chemical that doesn’t affect neurotransmission at some level doesn’t have an effect. However, we don’t know what those changes mean except for one thing: those changes cause the addiction. If there are no brain changes, there’s no addiction.
Finally, psychiatrists are now deskilled. Modern psychiatrists have practically no training or practice in taking proper history or in psychotherapy. This is why they have to resort to drugs for everything, because they don’t know what else to do. Anybody who uses ECT is only saying he has reached the limit of his skill set, mostly because he hasn’t taken a proper history. As a living, breathing, functioning human being, the distressed patient is a closed book.
My conclusion is that the widely-trumpeted claim that orthodox psychiatry is justified by science is false.
If you say to a person, “You have a mental disorder,” without yourself having a model of mental disorder, that is not science.
If you say to a person, “You must take these drugs,” knowing they are dangerous and will shorten his life, that is not science.
If you say, “It is essential you have ECT,” knowing full well that other psychiatrists manage identical patients without using it, that is not science.
If you lock people up on the basis of an alleged “chemical imbalance of the brain,” for which there is zero evidence, and then give them drugs that produce unknown chemical imbalances and addiction, that is not science.
If you don’t criticise what you are doing and you actively suppress criticism, that is not science.
If you indoctrinate your students and trainees, and don’t educate them to criticise the status quo, that is a disgrace.
I will no doubt get lots of criticism from other psychiatrists for daring to air these matters in public. I have been told by a president of the RANZCP that it is inappropriate to discuss them in public, that they should only be seen in the College journals. However, he was on safe ground there as he knew his close friend, the editor, never publishes anything critical. But they’ll have to wear the criticism because modern psychiatry is now beyond the point where normal courtesies apply. In plain language, if you have mental problems these days, you live in dangerous times.
So we can go back to my original question, of how much credibility we should give modern, orthodox psychiatry. The question of whether psychiatry has a rational basis is now settled. It doesn’t. But don’t wait for psychiatrists to suddenly develop a conscience and start a process of critical self-examination. After waiting 43 years for the day, I can tell you it won’t happen.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.