Psychiatry: A Graveyard of Dumb Ideas

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There are a lot of dumb ideas in psychiatry. I have thought of some of them myself. True, it is hard to top whoppers from the history of mental health, like removing vital organs to try to cure mental illness¹ or injecting malaria into people with schizophrenia.² But our own time has its share of bad ideas. Not to be outdone by our misguided forebears, recent years have seen our culture “treat” those with severe illness with jail time instead of hospital care while keeping the anachronistic antipsychiatry movement alive, if only on life support. Reflecting on such tragedies should give us all reasons for circumspection and humility. For beyond doubt, some of the things all of us say and do in the name of mental health today will one day seem bizarre and barbaric to those who come after us.

What Is the Dumbest Idea in Psychiatry?

In a spirit of sympathetic humility, I would like to point out an especially dumb idea that many educated individuals readily endorse whenever they hear it. It makes them immediately believe that mental health treatment does not work despite any evidence they have otherwise encountered. The big argument goes something like this: More and more people in our society get mental health treatment, and yet rates of mental illness continue to go up. Complications of mental illness like suicide remain stubbornly elevated. Therefore, mental health treatment is not working. If anything, it is making things worse. If it were helping, we would see less mental illness rather than more. Our treatments for mental illness are failing.

The idea goes back at least as far as Hillman’s and Ventura’s memorable book title, We’ve Had a Hundred Years of Psychotherapy—and the World’s Getting Worse.³ But to this day, we also find it in such mainstream periodicals as Time (“America Has Reached Peak Therapy. Why Is Our Mental Health Getting Worse?”).⁴ Meanwhile, over at Axios, New York University’s dean of the public service school opined, “We’ve expanded access to care enormously over time, and we’ve got a lot more mental health practitioners than we ever did before, and that does not show up in any measures of people’s well-being.”⁵ No less a figure than Thomas Insel, MD, former director of the National Institute of Mental Health, told Time that such a failure to make an impact on public mental health was out of step with the rest of medicine: “That’s not true for cancer [survival], it’s not true for heart disease [survival], it’s not true for diabetes [diagnosis], or almost any other area of medicine.”⁴

The centerpiece for this idea’s popularity should probably be Abigail Schrier’s bestseller, Bad Therapy.⁶ The book was reportedly the No. 1 worldwide bestseller when it debuted on Amazon in early 2024 and quickly became a New York Times Best Seller.⁷ Admittedly, Schrier (a former Wall Street Journal columnist) is not claiming that all psychotherapy is bad. She endorses psychotherapy for individuals who have true mental illnesses. But she also makes this misleading argument forcefully in interview after interview. As she put it in her book: “As early detection and treatment for breast cancer improved since 1989, rates of death from breast cancer plummeted. Or maternal mortality: as antibiotics became more readily available, rates of maternal death in childbirth collapsed. Better and more widely available dental care has meant fewer toothless Americans.… And yet as treatments for anxiety and depression have become more sophisticated and more readily available, adolescent anxiety and depression have ballooned.”⁶

Psychiatry is failing because more treatment is not leading to better mental health among the public. Case closed. Treatment does not work. It makes things worse. Our mental health is getting worse as individuals get more treatment.

Debunking a Dumb Idea

What is wrong with this argument? Quite a few things, which is why it is a dumb argument. Here are a few of them:

The causes of mental illness are different from the treatments for mental illness: If rates of diabetes go up in our country (as they did for decades), no one assumes this is due to bad treatment. Everyone intuitively grasps that rates of diabetes go up because of factors such as poor diet and lack of physical activity. The fact that more individuals get diabetes has little or nothing to do with the effectiveness of our treatments for diabetes. In the case of mental health, we do not know the precise reason rates are increasing nationally. But we do know that proven risk factors such as trauma, stress, and social isolation are part of the picture rather than some problem with treatment. Treatments can be failures or successes after someone contracts an illness, but they have nothing to do with whether someone gets the illness in the first place.

We are treating chronic illnesses, not curing acute ones: As I have detailed elsewhere, we do not have cures for most of the chronic illnesses that constitute our public health problems. We do not cure diabetes, and we do not cure hypertension. We have good treatments for these illnesses but controlling someone’s blood pressure or blood glucose does not mean we have cured their illness. The rates of such illnesses stay the same, even if treatment is successful. This applies to psychiatry as well. We have well-proven, effective treatments, but most illnesses we treat are chronic, even when they respond to treatment.⁸ We should not expect rates of mental illness to melt away due to widespread treatment.

We cannot judge the success of mental health treatment for those who never receive it: In any given year, half of those with mental illness do not receive treatment for it.⁹ Of those who receive treatment, one-third to half do not follow up with it reliably.^10,11 So how can we judge the large-scale effects of treatment on community mental health when most of our community is not getting adequate treatment for mental illness? Successful treatment should indeed reduce the consequences of mental illness, like rates of suicide and disability. However, we can only judge the success of those treatments for individuals who get them.

Mental health treatment is proven to work: I am not sure how many times psychiatrists need to explain to the rest of the world that our treatments work, but apparently, more explanations are in order. If we want to know whether psychiatric treatment is helping, then we should review all the studies that have been done to find out whether psychiatric treatments help. What do these studies show? Psychiatric treatment has been proven to work in hundreds of studies. Psychiatric medications are proven to be effective treatments for all the major mental illnesses. Psychotherapy is proven to be an effective treatment for all the major mental illnesses.¹² A host of other biopsychosocial approaches also have proven benefits.⁸ This does not mean we can cure most mental illnesses, of course. But our treatments are proven to work, and this is not a matter of scientific debate. Compared with rigorous and controlled scientific studies, inferences about the association between treatment rates and illness rates in the general population are worthless guesses. Intellectuals and public health experts ought to know better.

Concluding Thoughts

There is, of course, a kernel of truth hidden in the argument that large-scale treatment is not working. We should care whether public mental health is getting better or worse as a whole. The goal of psychiatry is not just to treat mental illness but to improve our community’s mental health. So, if we see that rates of mental illness and its complications are going up rather than down, we should all be concerned and ready to do something about it. But none of this means that treatment does not work. It works. So, let’s put this particular dumb idea to rest once and for all.

Dr Morehead is a psychiatrist and director of training for the general psychiatry residency at Tufts Medical Center in Boston. He frequently speaks as an advocate for mental health and is the author of Science Over Stigma: Education and Advocacy for Mental Health, published by the American Psychiatric Association. He can be reached at dmorehead@tuftsmedicalcenter.org.

References

1. Davidson J. Bayard Holmes (1852–1924) and Henry Cotton (1869–1933): surgeon–psychiatrists and their tragic quest to cure schizophrenia. J Med Biogr. 2016;24(4):550-559.

2. Freitas DRC, Santos JB, Castro CN. Healing with malaria: a brief historical review of malariotherapy for neurosyphilis, mental disorders and other infectious diseases. Rev Soc Bras Med Trop. 2014;47(2):260-261.

3. Hillman J, Ventura M. We’ve Had a Hundred Years of Psychotherapy—and the World’s Getting Worse. HarperSanFrancisco; 1992.

4. Ducharme J. America has reached peak therapy. Why is our mental health getting worse? Time. August 28, 2023. Accessed November 22, 2024. https://time.com/6308096/therapy-mental-health-worse-us/

5. Owens C. Why the mental health crisis feels stuck. Axios. May 24, 2024. Accessed November 22, 2024. https://www.axios.com/2024/05/24/mental-health-pandemic

6. Shrier A. Bad Therapy: Why the Kids Aren’t Growing Up. Sentinel; 2024.

7. Gillespie N. Abigail Shrier: stop obsessing over our children’s happiness. Reason. April 10, 2024. Accessed November 22, 2024. https://reason.com/podcast/2024/04/10/abigail-shrier-stop-obsessing-over-our-childrens-happiness/

8. Morehead D. Science Over Stigma: Education and Advocacy for Mental Health. American Psychiatric Association Publishing; 2021.

9. Key Substance Use and Mental Health Indicators in the United States: Results From the 2022 National Survey on Drug Use and Health. Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration; 2023. HHS publication PEP23-07-01-006, NSDUH series H-58. 2023. Accessed November 22, 2024. https://www.samhsa.gov/data/report/2022-nsduh-annual-national-report

10. Fernández D, Vigo D, Sampson NA, et al. Patterns of care and dropout rates from outpatient mental healthcare in low-, middle-and high-income countries from the World Health Organization’s World Mental Health Survey Initiative. Psychol Med. 2021;51(12):2104-2116.

11. Semahegn A, Torpey K, Manu A, et al. Psychotropic medication non-adherence and its associated factors among patients with major psychiatric disorders: a systematic review and meta-analysis. Syst Rev. 2020;9(1):17.

12. Morehead D. The unheralded revolution in psychotherapy research. Psychiatric Times. August 22, 2023. https://www.psychiatrictimes.com/view/the-unheralded-revolution-in-psychotherapy-research