Editor’s note: On July 29, Peter Sterling, a Professor of Neuroscience at the Perelman School of Medicine, published an essay on Mad in America that circulated widely within the neuroscience community. This is his response to a critique of his essay by Awais Aftab, which was published on Substack.
I welcome the opportunity to respond to Dr. Aftab’s critique of my essay, “Causality in Mental Disturbance: A Review of the Neuroscience.”
First, he objects correctly that my essay is not, as advertised, “an original research article” or “scientific paper.” Although the editor of Mad in America, Peter Simons, did run that line by me, I was distracted, and rather than pausing to consider, I simply assented. The fault is entirely mine.
Scientists are trained, by the way, to listen to our critics, try to grasp where we are wrong, and rectify. Accordingly, I have asked the editor to replace that introduction with the following:
“Here is one neuroscientist’s overview of what we don’t know about the brain regarding mental disturbance and what we should not be doing to the brain physically and chemically as ‘therapy’. Sterling’s perspective ‘follows the money’ to Big Pharma and Big Devices—corporations that dominate psychiatry’s current model of mental disturbance to sell their stuff. He continues down the money trail to Big Academy and Big Publishing who share the take, and he calls out some names.”
Dr. Aftab is also correct that my essay would never have been published in a conventional journal—because it is far too critical of the current story about mental “illness.” Only Robert Whitaker, the scientific journalist and publisher of Mad in America, would have the courage. Before submitting the article, as customary, I sought comments from nearly a dozen senior neuroscientists and neurologists. Not one challenged any of my neuroscientific assertions; not one asked me to tone it down. The published piece has been well-received by various senior neuroscientists and none, so far, have disputed its core points.
Dr. Aftab opens with a nod to taking me seriously because I am a “distinguished neuroscientist and Professor at UPenn School of Medicine.” But his next sentence casts doubt. So here I explain why readers should take me seriously. Not because I’m “distinguished,” but because I am well-informed.
Over the span of my career, now 60 years, I investigated the neural structure and function of the mammalian brain from the scale of synaptic vesicle release (nanometers) to the scale of local circuits (micrometers to millimeters), ultimately up to the scale of the whole brain, tracing the cortico-spinal connections (meter). Upon closing my laboratory, I integrated my knowledge across these levels to set out some broad conclusions in a book, written with Prof Simon Laughlin, Principles of Neural Design (2015). From there I stepped upward with a book on human evolution, What is Health: Allostasis and the Principles of Human Design (2020). This book integrates the science underlying human physiology and behavior as it emerged across 4 billion years, emphasizing especially the last 200,000 years, since we emerged as a species.
Although my laboratory studies were hyper-reductionistic, I claim creds to write broadly on human behavior and its disturbances. First, I have published articles across nearly five decades on society, stress, and the brain’s predictive control of physiology. Most of these articles were in conventional scientific journals, including eLife, Physiology and Behavior, Trends in Neurosciences, and JAMA Psychiatry. Second, I have worked outside the academy as a lifelong activist for civil rights and for building cooperative community life. Third, I have investigated the lives of indigenous peoples, visiting across four decades various indigenous communities in Central America. Fourth, for the past 20 years I have lived and farmed in the highlands of western Panama where my wife and I cooperate intimately with our neighbors—families of indigenous agricultural laborers and campesinos. Our small community governs itself without police, drug deaths, suicides, or shootings. No one in this community is unhoused.
Contrary to Dr. Aftab’s innuendo that I seek “deference,” I seek, as a committed scientist, challenges and alternative views based on serious study and thought. As a committed scientist, I reject “fake news” promoted by commercial interests. Dr. Aftab scorns my comments on ECT, saying “he [Sterling] is not a clinician.” But what does a young “clinician” in psychiatry really know these days? Mostly what they learned from the interns and residents just ahead of them. And what do they know? Mostly the story that mental disturbances are biological “disorders” that can be treated by interventions at the level of synapses and circuits. This story has been manufactured since the lobotomy days by neurosurgeons and psychiatrists (less so by neurologists) and promoted by Big Pharma and Big Devices through their “detail men.”
Dr. Aftab responds to my essay with a “meta-essay,” chiding me for incorrectly analyzing Dr. Siddiqi’s essay and for straying beyond its boundaries. Dr. Aftab objects to my “broad-sweeping conclusions,” my lack of “humility,” my “grievances against psychiatry,” and my “tirade against psychiatric neuroscience.”
To be clear: I hold no general grievance against psychiatry. To the contrary, I have sought psychotherapy at various crisis points in my life and benefited enormously from two wise and empathic psychiatrists. My so-called lack of humility simply reflects clarity and confidence. Confidence emerging appropriately from my broad knowledge and my rich experience across two cultures with families, neighbors, close colleagues (several intermittently psychotic) and students (ditto)—plus my own children and grandchildren. Should an old man apologize for writing based on his integrated experience? I offer this now as a sort of public gift. I expressed no “tirade” against “psychiatric neuroscience”—although I do regard that expression as an oxymoron.
What Dr. Aftab does not do is address any of my substantive conclusions—here summarized with links to supporting publications:
(1) Current medicalization of all social and psychological suffering is unjustified by the currently known neurobiology.
Psychiatry’s diagnostic manual lists hundreds of behaviors, deviating from the mean by 1-2 standard deviations. It calls them “disorders” and designates them with numbers and names: “schizophrenia,” “major depression,” “bipolar disorder,” “obsessive-compulsive disorder,” and “attention-deficit/hyperactive disorder.” These are said to be “just like” genuine brain disorders, such as Parkinson’s. But recent large-scale imaging studies fail to identify brain correlates with any of these behaviors. Earlier such claims, often published in high profile journals, are now proven to be bogus (Sterling 2022, 2023).
Nor do recent genetic studies support the story of multiple, distinct brain disorders. Rather, they find genes associated with mental disturbance to number in the 100s to 1000s. Moreover, genes associated with one “disorder” overlap strongly with those associated with the other disorders, suggesting that they are not distinct “diseases” but rather different manifestations of a shared mental/behavioral trait. This hypothesis receives support from a four-decade longitudinal study showing that most individuals who express one type of disturbance eventually express them all, either successively or simultaneously (Caspi et al 2020). Finally, here is Daniel Geschwind (UCLA Professor of Human Genetics, Neurology and Psychiatry) summarizing the neuroscience of mental disturbance in his 2017 talk at the Allen Institute:
“Psychiatric disorders are syndromes… What we call psychiatric diseases are just levels of impairment… The threshold is not scientific but a clinical/practical threshold for when individuals are unable to function in the world. These syndromic diagnoses are not etiologically defined… just one end of a continuum of normal variability… For most disorders it’s the common variants that move an individual toward that threshold, and sometimes a rare variant can push the person over.” (My emphasis)
Geschwind, a world-class researcher (and clinician), is a core figure in the search to identify the normal function of the trait that can involve mental disturbance. Here he denies the stories concocted around the “syndromic diagnoses”: he denies that they are “diseases.” Notice that the genetic and the longitudinal studies cited here combine to support the view of Dr. Thomas Szasz—that mental “illness” is a myth. Szasz, long scorned, now proves to have been prescient.
(2) Absent any identified neural pathology there is zero rationale for interfering with brain circuitry either mechanically or chemically. This is simple logic: if you haven’t identified anything as “broken,” there can no rationale for “fixing.” Dopamine and serotonin are not “just like insulin”—as the Big Pharma story goes—so there is zero scientifically based rationale for administering any of the brain drugs marketed over 70 years, nor for psychosurgery, ECT, TMS, or DBS.
Dr. Aftab apparently accepts at face value the so-called “randomized clinical trials” as evidence for efficacy and safety. Such trials serve to bamboozle the FDA. But of course, they are designed by Big Pharma and Big Devices to slip across the “p” line in small, short-term trials with rudimentary evaluations of mental functioning—such as “rating scales” which themselves wither under scientific scrutiny (Fried et al 2022). As richly documented in Whitaker’s and my publications, such weak studies are not confirmed by subsequent larger and longer evaluations (Whitaker 2023; Sterling 2020, 2022, 2023). Consequently, all the jiggering with human brains from childhood through old age are simply bizarre manipulations promoted for commercial reasons and for reasons of social control. Two generations of physicians trained on these stories—myths—simply don’t know any better.
Consider, for example, a trait that affects activity level and attention to external authority. Most children—those near the mean of a normal distribution—can sit quietly for 45 minutes and attend to a “teacher.” But the idea of distribution implies other children off the mean, including some (~10%) off by 1-2 standard deviations. There is no neuroscience to suggest that children within two SD of the mean have abnormal brains. There is simply a story—children with a certain score on a checklist have a brain disorder—concocted by Big Pharma and its associated academics, to legally sell amphetamines as “medicine.” Long-term follow-ups regarding success and stability in career, family, mood, and so on show no advantage for those treated with stimulants during childhood. On average, however, they are several inches shorter (Hecht et al 2016).
My essay terms all brain manipulations to “treat” mental disturbance (surgery, drugs, electrical and magnetic stimulation) as Ponzi schemes. They are not like Ponzis—they are actual Ponzis, as defined by Oxford: a form of fraud in which belief in the success of a nonexistent enterprise is fostered by the payment of quick returns to the first investors from money invested by later investors. Ex: “a classic Ponzi scheme built on treachery and lies.”
Dr. Aftab objects, saying “These are quite strong claims.” Yes, for sure! I have studied such claims for half a century—that mental disturbance arises from pathology in neural circuits and warrants some new physical intervention. These have always proved to be “nonexistent enterprises” that earned quick returns. Since there was never a rationale, of course they couldn’t help over the long term. They did, however, cause all sorts of chronic brain damage. By then the enterprise had always moved on to the next story. Here I am playing the old man’s role: to recognize the same old Ponzis and call them out. New generations of neuroscientists and psychiatrists need to abandon these bogus stories and move forward to invest in honest projects.
Some colleagues respond: your points are true, they say, but someday we might really understand these circuits, and that is a positive goal. Of course! What could be deeper than to discover the differences between sane thoughts and disturbed thoughts, between a steady mood and its extreme highs and lows. But right now we do not understand, and so there is no rationale for any physical/chemical tinkering. None of it works over time, and it generally retards recovery (Whitaker, 2023). Meanwhile, it enriches Big Pharma and Big Devices, Big Publishing, and select corners of the Academy—while damaging the brain.
Caspi A, Houts RM, Ambler A, et al. (2020) Longitudinal Assessment of Mental Health Disorders and Comorbidities Across 4 Decades Among Participants in the Dunedin Birth Cohort Study. JAMA Network Open. 3:e203221.
Fried EI, Flake JK, and Robinaugh DJ. (2022) Revisiting the theoretical and methodological foundations of depression measurement. Nature Reviews Psychology, 1: 358–368.
Sterling P (2020) What is Health? Allostasis and the Evolution of Human Design. MIT Press.
Sterling P (2022) A Neuroscientist Evaluates the Standard Biological Model of Depression madinamerica.com/2022/10/neuroscientist-evaluates-depression/
Sterling P (2023) Causality in mental disturbance. https://www.madinamerica.com/2023/07/causality-mental-disturbance/
Sterling P, Platt ML.( 2022) Why Deaths of Despair Are Increasing in the US and Not Other Industrial Nations—Insights From Neuroscience and Anthropology. JAMA Psychiatry. 2022 Apr 1;79(4):368-374.
Hechtman L et al. (2016) Functional Adult Outcomes 16 Years After Childhood Diagnosis of Attention-Deficit/ Hyperactivity Disorder: MTA Results. J Am Acad Child Adolesc Psychiatry 2016;55(11):945–952.
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.
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