In a new editorial in the journal Psychotherapy and Psychosomatics, psychiatrist Giovanni Fava of the State University of New York at Buffalo writes a scathing critique of the demise of pluralism and dissent in medicine.
Fava lists several ways that dissent is crushed in medical research and practice, especially through industry influence, bias in publishing, and over-dependence on randomized controlled trials. He remarks that there are several commonplace industry practices, undertaken by researchers and clinicians, that support the status quo, squash disagreement, and reward mediocrity.
“True talent is threatening because it is frequently associated with independent thinking, which undermines the power structure, while mediocrity assures lifetime commitment. Fighting the cult of mediocrity is the ultimate pathway to fostering pluralism in clinical research,” he writes.
The traditional narrative about the history of medicine and psychiatry is rooted in ideas of progress. Many have claimed that there is better awareness of ‘mental illness,’ reduced stigma, and better medicines to treat them. Despite these claims, numerous studies have come forth challenging these stories of linear progress. Some have undermined the field’s claim to objectivity by showing that diagnosis and treatment are subject to racial and class-based bias, while others revealed that the bio-medical model’s contention that “mental illness is like any other” can increase social distance and perception of dangerousness about the individual.
The most consistent criticism of the discipline has come from service users and psychiatric survivors who have long questioned the use of antipsychotic drugs long term, arguing that it inhibits recovery and functioning. These groups have also fought against the deliberate silencing of their voices in the psychiatric debate and called for the inclusion of client input in the formulation of psychiatric diagnosis and treatment.
Despite these criticisms, dissent has not always been welcome and, in this editorial, Fava points to the numerous ways it is quieted in the field of medicine, resulting in intellectual stagnation, and more dangerously, the dissemination of propaganda.
He first exposes the various ways academic publishing hides disagreement and the plurality of viewpoints on any given issue. Since the financial burden of open access publishing falls on the author(s), it ensures that research funded by grants, industry, or other big institutions gets published. This creates a situation where researchers with conflicts of interest are more likely to get published. At the same time, independent researchers with innovative findings, especially those who duly report the side effects of drugs, are unlikely to be published or funded.
The commercialization of academic journals has led to a reduction in correspondence sections that host different viewpoints and debates. Additionally, there is a trend to include a number of renowned authors, not because they have contributed to an article but because they provide consensus. This inflates the author’s ‘h index,’ which measures their citations and productivity. In effect, many studies, especially psychiatric drug trials, are essentially ghostwritten.
Other studies have similarly pointed to bias in publishing. For example, psychology and psychiatry research abstracts are manipulated to imply significance when none exists. This has dangerous implications for clinical practice as it was found that clinicians often base their decisions on what they read in the abstracts.
Fava goes on to show how powerful special interest groups, often backed by corporate interests, block the distribution of information they find unappealing. They censor this information by sometimes intervening as editors or reviewers, picking and choosing literature that benefits them, and by spinning results of clinical trials. Sometimes the investigator him/herself/themselves censors their results because they fear ostracism by the academic community. Others have similarly shared experiences where reviewers often reject articles based on what threatens their personal orientations.
Fava further asserts that overdependence on randomized control trials (RCTs), and more recently meta-analyses, is another way pluralism is discouraged. RCTs often only show the efficacy of a treatment for the average patient without considering the individual clinical presentations of different patients. This is in line with a new review which found that “empirically supported treatments” (also known as evidence-based therapies) might not be built on sound evidence after all.
Even systematic reviews are prone to issues as many have no authors with clinical experience and thus little grounding in actual practice. Fava considers this disconnect between researchers and clinical practitioners as the central cause of the intellectual crisis in medicine. He uses the example of the expulsion of Peter Goetzche from Cochrane to show how evidence-based medicine often erroneously forces the idea that there is only one treatment available and punishes any dissenting voices.
He further writes that meta-analyses can often homogenize the results of studies that were conducted based on vastly different criteria and protocols, and in effect can be useless when it comes to individual patient care. Thus, although meta-analyses are considered the “platinum standard” of research, they often produce conflicting results and are equally vulnerable to researcher bias.
Fava further suggests that meta-analyses can also overestimate benefits without paying serious acknowledgment to side effects, and this is often guided by commercial interests. Citing psychiatry as a field replete with such problems, he gives the example of a study that found industry influence, and thus conflicts of interests, in two-thirds of the meta-analyses on antidepressant drugs. Other studies have similarly problematized widespread industry influence in the healthcare sector. Findings suggest that the pharmaceutical industry is trying to use the euphemistic phrase “discontinuation syndrome” instead of “withdrawal” to smooth over the adverse effects of anti-depressants. Fava writes:
“Iatrogenic manifestations of behavioral toxicity, such as withdrawal syndrome and persistent post-withdrawal disorders, have been censored and denied funding and attention.”
In the end, Fava offers some ways that pluralism of viewpoints can be introduced and dissent against hegemonic practices appreciated in the field of medicine. He suggests that medical journals must welcome debate and dissent and base their publication criteria on sound methodologies and not popular theories. The content of a journal should be autonomous from its financial source.
Further, over-dependence on evidence-based medicine must be restricted and these trials should be integrated with clinical practice and knowledge. Instead of conducting bigger trials with wide inclusion criteria, it might benefit patients more if smaller trials with more specific clinical criteria were conducted by, for example, working with sub-types of depression or according to the medication history of a patient. Often researchers overlook the fact that current symptom presentation could be a result of patients’ past treatments which had severe adverse effects (called iatrogenic co-morbidity).
A recent positive development in the field is medicine-based evidence (MBE) which evaluates efficacy based on biological and biographical criteria. Fava writes:
“It builds on the archive of patient profiles using data sources, including both clinical and socio-behavioral information. The clinical seeking guidance for the management of the individual patient will start with the patient’s longitudinal profile and find matches in the archive, which provides an important source of therapeutic pluralism.”
Additionally, public funding sources should prioritize innovative research and academic promotions should value independent thinking and original contributions over the quantity of articles produced. Given the rampant industry influence in not only research but also education, it is all the more essential to give voice to disparate and disagreeing sources. Until now, only a few in the discipline of psychiatry have responded positively to any form of dissent.
Fava, G.A. (2019). The decline of pluralism in medicine: Dissent is welcome. Psychotherapy and Psychosomatics, 89, 1-5. (Link)