Since the seventeenth century, Enlightenment thinkers have distinguished science from religion, and by at least one critical distinction, leading psychiatrists have unwittingly acknowledged that major constructs in contemporary psychiatry are religious ideas, not scientific ones.
Baruch Spinoza (1632-1677) is regarded by the eminent historian Jonathan Israel as a key member of the “radical Enlightenment” because he refused to compromise his thinking to appease religious authorities. Spinoza scholar Beth Lord notes that for Spinoza, “The aim of science, philosophy, and reason is to get at the truth,” but “the aim of religion is rather different . . . its aim is not to tell the truth or even to discover the truth, its aim is to make people behave better and to keep people obedient.” She adds, “The role of religion is really helping to manage people’s feelings and images when they’re in this irrational state.”
Such a religious role in psychiatry has been acknowledged by top insider psychiatrists with respect to two major constructs: (1) the DSM, psychiatry’s diagnostic manual published by the American Psychiatric Association (APA), the guild of American psychiatrists; (2) and the “chemical imbalance theory of mental illness,” which has long served as the rationale behind the use of selective serotonin reuptake inhibitor (SSRI) antidepressants for depression. Today, leading psychiatrists have acknowledged the scientific invalidity of both the DSM and the chemical imbalance theory, with some of them arguing that these constructs have been useful fictions.
The DSM and Religion
For the last decade, declaring that the DSM is scientifically invalid has not been a radical claim. The National Institute of Mental Health (NIMH) is the lead U.S. government institution that funds research on mental illness, and psychiatrist Thomas Insel was the NIMH director from 2002 to 2015. In 2013, Insel stated that the DSM’s diagnostic categories lack validity, and he announced that “NIMH will be re-orienting its research away from DSM categories.” More recently, in his 2022 book Healing, Insel stated: “The DSM had created a common language, but much of that language had not been validated by science.”
Even more bluntly than Insel, the chair of the DSM-IV (1994) task force, psychiatrist Allen Frances, stated in 2010 that “there is no definition of a mental disorder. It’s bullshit. I mean, you just can’t define it.” However, Frances argued (in Gary Greenburg’s 2013 book about the DSM-5, The Book of Woe) that these labels are still crucial to treatment, and he warned, “If you puncture that noble lie, you’ll be doing a disservice to our patients. . . . A lot of false beliefs help people cope with life.”
For Spinoza, religion is a fiction; however, he believed it can have utility for society if its stories inspire “justice and charity.” For Spinoza, Lord explains, “Useful fictions are those that promote tolerance and community.” However, there are also malevolent fictions, which Lord describes as “ones which people are controlled, oppressed, and enslaved.”
Frances’s argument that “A lot of false beliefs help people cope with life” is an argument that psychiatric diagnoses can be useful in a religious sense, not a scientific one. Religion can be useful in helping managing people’s emotions when they’re in an irrational state, and Frances is essentially arguing that psychiatry’s diagnoses function as a benevolent religion.
Just how unscientific is the DSM? Not only does it lack validity, DSM diagnoses lack reliability. The APA conducted field trials on its DSM-5 to assess the degree of agreement between clinicians diagnosing the same individuals. A standard statistic used to assess reliability is called kappa. A kappa value of 0 means zero agreement and no reliability; a kappa of 1.00 means perfect reliability; and a kappa of less than .59 considered weak reliability. DSM-III task force chair, Robert Spitzer, had proclaimed with respect to assessing the reliability of the DSM that a kappa of less than .40 indicated “poor” agreement and .70 was “only satisfactory.” For the DSM-5 field trials, here (reported in The Book of Woe) is a sample of kappa results: .20 for generalized anxiety disorder; .32 for major depressive disorder; .41 for oppositional defiant disorder; and .46 for schizophrenia.
If an instrument is either invalid or unreliable, it is not scientifically useful, and the DSM is neither valid nor reliable, and so it has no scientific value.
Another leading psychiatrist, Michael First, text editor for the DSM-IV, gives us a sense of how psychiatry, at its highest levels, thinks. “The good news about the DSM-5 is also the bad news,” states First in The Book of Woe, “[The DSM-5] relies on categories that facilitate clinician communication but have no firm basis in reality. So I think it’s an improvement, but it’s also an acknowledgment that psychiatry, especially in its understanding of mental illness, is still in its infancy.”
First’s acknowledgment that DSM categories “have no firm basis in reality” would be striking for Spinoza or for any modern scientist. However, apparently, First cared less about the implications of this acknowledgment than echoing the notion that psychiatry “is still in its infancy,” a variation of psychiatry’s shibboleth that it is a “young science with much to discover but making great progress.”
A shibboleth is a word or phrase used by adherents of a sect or tribe, but regarded by others as empty of real meaning. “A shibboleth,” notes linguist Suzanne Kemmer, “is a kind of linguistic password: A way of speaking . . . that is used by one set of people to identify another person as a member, or a non-member, of a particular group. The group making the identification has some kind of social power to set the standards for who belongs to their group: who is ‘in’ and who is ‘out.’”
Given that leading psychiatrists have termed the DSM, a fundamental construct of psychiatry, as “bullshit,” “false beliefs,” “invalid,” and having “no firm basis in reality,” the notion that psychiatry is a “young science” or a science “in its infancy” is empty of meaning. However, using such shibboleths identifies one as a member of a particular group with social power. While shibboleths have no value for scientists, shibboleths are important in religious and tribal organizations.
If the DSM is a type of fiction, the question is whether it is a useful fiction or a malevolent one? My experience is that for different types of personalities, psychiatric diagnoses produce different results. Some people believe that their DSM diagnoses provide them with a relieving explanation for their troubling emotions and behaviors; however, others believe that their DSM diagnoses have been stigmatizing and have resulted in them being controlled and oppressed. Religion is helpful to some people but not all people; and different religions are suited for different types of people.
The “Chemical Imbalance Theory of Mental Illness” and Religion
The second major construct in psychiatry now regarded as a fiction—or in the words of one leading psychiatrist, an “urban legend”—is the “chemical imbalance theory of mental illness,” which includes the serotonin deficiency theory of depression. This theory is not simply one more proposed hypothesis that was refuted by the research. Rather, it is a theory that, long after it was disproven, has functioned as a religious idea.
In July 2022, garnering mainstream media headlines, the journal Molecular Psychiatry published “The Serotonin Theory of Depression: A Systematic Umbrella Review of the Evidence.” In it, psychiatrist Joanna Moncrieff, co-chairperson of the Critical Psychiatry Network, and her co-researchers examined hundreds of different types of studies that attempted to detect a relationship between depression and serotonin, and concluded that there is no evidence of a link between low levels of serotonin and depression, stating: “We suggest it is time to acknowledge that the serotonin theory of depression is not empirically substantiated.”
In response to the review’s widespread attention, leading figures in psychiatry, rather than rebutting Moncrieff’s conclusions, attempted to convince the general public that her findings were not newsworthy, even belittling her. Psychiatrist David Hellerstein, professor of clinical psychiatry at Columbia University Medical Center and director of Columbia’s Depression Evaluation Service, stated: “Wow, next she’ll tackle the discrediting of the black bile theory of depression.”
However, the vast majority of society had heard nothing from psychiatry about the discarding of this serotonin deficiency theory of depression. In a 2007 survey, 84.7 percent of 262 undergraduates believed it “likely” that chemical imbalances cause depression. While I cannot locate a more recent survey, my experience—with patients, the media, and even many doctors—is that the majority of them have continued to believe in the serotonin deficiency theory of depression, and that is why Moncrieff’s findings were newsworthy.
Researchers had discarded the chemical imbalance theory of depression by the 1990s. In Blaming the Brain (1998), psychologist Elliot Valenstein detailed research showing that it is just as likely for people with normal serotonin levels to feel depressed as it is for people with abnormal serotonin levels, and that it is just as likely for people with abnormally high serotonin levels to feel depressed as it is for people with abnormally low serotonin levels.
The first unequivocal acknowledgment by a leading figure in psychiatry of the discarding of this theory that I am aware of was in 2011, when psychiatrist Ronald Pies, Editor-in-Chief Emeritus of the Psychiatric Times, stated: “In truth, the ‘chemical imbalance’ notion was always a kind of urban legend—never a theory seriously propounded by well-informed psychiatrists.” However, Pies’s statement was not widely publicized.
In 2012, the invalidity of the chemical imbalance theory of depression was news to National Public Radio correspondent Alix Spiegel, who is the granddaughter of psychiatrist John Spiegel, a former president of the APA. Her 2012 NPR story provides us with the explanation as to why—even after the research had clearly disproven the theory—most of the general public have continued to be unaware that it had been discarded. What Spiegel discovered was that the theory was maintained by psychiatry so as to manage patients’ feelings and make them more comfortable accepting treatment.
Spiegel began her story by recounting how as a depressed teenager, she and her parents were told the following by a Johns Hopkins Hospital psychiatrist about her depression: “It’s biological, just like diabetes, but it’s in your brain. This chemical in your brain called serotonin is too, too low. There’s not enough of it, and that’s what’s causing the chemical imbalance. We need to give you medication to correct that.” Then, Spiegel tells us, the psychiatrist handed her mother a prescription for Prozac.
As a journalist, Spiegel discovered the truth about the serotonin imbalance theory, and she tried to discover why psychiatry had not made greater efforts at publicizing that it had been disproven and discarded. Spiegel sought explanations from Alan Frazer, professor of pharmacology and psychiatry and chairman of the pharmacology department at the University of Texas Health Sciences Center, as well as from Pedro Delgado, chairman of the psychiatry department at the University of Texas, who had actually helped debunk the serotonin deficiency theory of depression in the 1990s. In Delgado’s 1999 review of the research, “Antidepressants and the Brain,” he and his co-author detailed how, in serotonin depletion studies, “depletion in unmedicated patients with depression did not worsen the depressive symptoms, neither did it cause depression in healthy subjects with no history of mental illness.”
Frazer told Spiegel that by framing depression as a deficiency—something that needs to be returned to normal—patients feel more comfortable taking antidepressants. Frazer stated, “If there was this biological reason for them being depressed, some deficiency that the drug was correcting, then taking a drug was OK.”
Delgado told Spiegel that the fiction of the chemical imbalance theory has benefits, pointing to research showing that uncertainty can be harmful; and so simple and clear explanations, regardless of how inaccurate, can be more helpful than complex truthful explanations.
Similarly, following the 2022 publication of Moncrieff’s review, psychiatrist Daniel Carlat, chair of psychiatry at Melrose Wakefield hospital, told NPR that doctors don’t know exactly how antidepressants work but “Patients do want to know that there is an explanation out there. And there are times when we do have to give them a shorthand explanation, even if it’s not entirely accurate.”
Prior to Prozac—the first of the SSRIs, entering the market in 1988—a poll in 1986 revealed that “only 12 percent of respondents were willing to take medication for depression and that 78 percent of people would be willing to live with the depression until it passed,” according to the Psychiatric News in 2002. However, this reluctance to take antidepressants changed dramatically; the rate of antidepressant use in the United States increased nearly 400 percent between 1988 and 2008. The chemical imbalance theory resulted in many people, such as Alix Spiegel and her parents, believing that SSRIs could correct the serotonin deficit that was causing depression.
The chemical imbalance theory of depression, long known by researchers to be untrue, is a fiction that has been retained by psychiatry to make people more comfortable taking antidepressants. Some people believe strongly it is simply unethical for doctors to use any disproven and discarded theory to persuade patients to accept treatments; however, others, including leading psychiatrists, believe that doctors should be able to employ useful fiction. The case for the usefulness of this fiction rests in large part on the answer to this question: Exactly how effective are antidepressant medications?
Antidepressants and Faith
Ironically, the effectiveness of antidepressants has much to do with another religious construct, faith—or what scientists call “expectations” and “the placebo effect.” The power of expectations with respect to the effectiveness of all substances used as antidepressants is uncontroversial—which is why, in drug studies, scientists use a placebo control group to tease out how much of a positive outcome is due simply to expectations and not the drug itself. While the placebo effect is uncontroversial, what is controversial is just how powerful the placebo effect is.
In April 2002, the Journal of the American Medical Association (JAMA) published a study that investigated whether the herb St. John’s wort, purported to be an antidepressant, was more effective than a placebo. In this study, in addition to one group given St. John’s wort and a second group given a placebo, there was a third group that received the SSRI Zoloft. The results? The placebo worked better than both St. John’s wort and Zoloft. Specifically, a positive “full response” occurred in 32 percent of the placebo-treated patients, 25 percent of the Zoloft-treated patients, and 24 percent of the St. John’s wort-treated patients.
A leading researcher of the placebo effect is psychologist Irving Kirsch. In 2002, Kirsch examined forty-seven drug company studies on various SSRIs and other antidepressants. These studies included published and unpublished trials, but all had been submitted to the Food and Drug Administration (FDA), so Kirsch used the Freedom of Information Act to gain access to all data. He discovered that in the majority of the trials, antidepressants failed to outperform placebos, and he reported that “all antidepressants, including the well-known SSRIs . . . had no clinically significant benefit over a placebo.” While in aggregate, antidepressants slightly edged out placebos, the difference is so unremarkable that Kirsch and others describe it as “clinically negligible.”
Moreover, drug companies are not required to do long-term outcome studies to acquire FDA approval. The FDA’s “Major Depressive Disorder: Developing Drugs for Treatment Guidance for Industry” states the following: “Antidepressants in established classes (e.g., SSRIs, SNRIs) typically need studies of 6 to 8 weeks duration to demonstrate efficacy.” Thus, the general public is unaware of studies that show antidepressants, over the long term, may result in more, not less, depression. In 2017, “Poorer Long-Term Outcomes among Persons with Major Depressive Disorder Treated with Medication,” published in Psychotherapy and Psychosomatics, reported that, after controlling for depression severity, the outcomes of 3,294 subjects over a nine-year period showed that antidepressants may have had an immediate, short-term benefit for some people, but at the nine-year follow-up, antidepressant users had significantly more severe symptoms than those individuals not using antidepressants.
Useful and Malevolent Fictions
So, where does this leave us? Leading figures in psychiatry acknowledge that DSM psychiatric diagnoses and the chemical imbalance theory of mental illness are not scientifically valid, but are useful fictions that help people manage their emotions and comply with their medication treatments. However, we have a great deal of evidence that casts doubt on the scientific value of antidepressants, especially in the long term; and even drug companies, in their antidepressant ads, acknowledge the adverse effects of these drugs, while there is now little controversy that there are debilitating withdrawal reactions for many individuals who stop taking their antidepressants.
For Spinoza, as Lord explains, fictions such as religion can be “hugely useful in structuring our experience and helping us to decide how to behave and how to live our lives.” She notes, “Spinoza’s aim is always for people to become more rational and to be able to govern themselves through their own true knowledge about the world. But he’s kind of realistic about the prospects of that happening, and since he doesn’t see humanity becoming enormously rational any time soon, he tends to think that structures like religion are necessary to keep people in line.”
Reason informed Spinoza and his radical Enlightenment friends of the value—both for an individual and for society—of justice and charity; and so to the extent that some Bible stories inspire people not inclined to rationality to act with justice and charity, these stories are useful fictions. However, as Lord points out, “Spinoza certainly thinks that there is potential for these fictions, whether they be political or religious fictions, to be used in negative ways.” Spinoza saw the idea of afterlife rewards and punishments from an anthropomorphic deity as a fiction that was necessary for those not ruled by reason to act with justice and charity; however, it was also clear to him that the fictions of heaven and hell were used by some clergy authorities as a means to control and exploit their congregants.
Some leading psychiatrists believe that that DSM diagnostic manual and the chemical imbalance theory of mental illness have functioned as useful fictions that help promote wellbeing. However, many patients have experienced damage from these constructs, which they see as malevolent fictions. People differ in their opinion on the usefulness or malevolence of all organized religions, and so it should be no surprise that there are differences of opinions about psychiatry.
Once we recognize the religious nature of psychiatry—unwittingly acknowledged even by leading psychiatrists—the following concerns about psychiatry become clear and compelling: (1) if a society does not distinguish science from religion, this subverts critical thinking and scientific inquiry; and (2) if a society declares any religion to have the authority of science, this results in oppressive intolerance for individuals who reject that religion.