Criticisms of Psychiatric Diagnosis: Why Engaging with Critique is Crucial for Progress

Conceptual complexities and controversies surrounding psychiatric diagnosis are depicted, highlighting the ongoing debate within the field of mental health.

I read with considerable interest Dr. Daniel Morehead’s article, “It’s Time for Us to Stop Waffling About Psychiatry,” especially given its engagement with my own contributions to Psychiatric Times‘s Conversations in Critical Psychiatry series. Dr. Morehead and I share common ground on several fundamental aspects: we both recognize psychiatry as a legitimate and essential branch of medicine, acknowledge its crucial role in addressing mental health challenges, and agree on the necessity to defend psychiatry against unfounded and excessive criticisms. We concur that it is important to effectively communicate the value of psychiatry to policymakers, insurance providers, and the public. Psychiatry boasts a rich intellectual heritage and embodies some of medicine’s most commendable attributes. Despite the limitations of its toolkit, psychiatry offers substantial relief to individuals grappling with psychiatric distress and functional impairment when applied judiciously. I am proud to identify as a psychiatrist and consider it a privilege to engage in this work, a profession I wouldn’t exchange for any other medical specialty.

However, despite this fundamental agreement on psychiatry’s standing, I diverge from Dr. Morehead’s depiction of critiques aimed at psychiatry as inherently destructive. My prolonged engagement with these criticisms has shaped a different perspective: I believe that Criticisms Of Psychiatric Diagnosis are not only necessary but also vital for the field’s advancement. Psychiatry’s tendency to dismiss these critiques does so at its own detriment. It is my firm conviction that we must redefine psychiatry’s relationship with critique, fostering a more constructive and productive dynamic.

Several factors understandably contribute to the heightened scrutiny psychiatry faces compared to other medical specialties. Notably, psychiatry exerts a degree of social control over individuals’ lives that is unparalleled in other medical fields. It navigates more frequent value conflicts and must integrate diverse disciplines and perspectives, a task inherently complex. Psychiatry also carries a troubled historical legacy, operates with a still-developing scientific foundation, and addresses conditions that are often stigmatized and poorly understood.

This amplified scrutiny, coupled with internal challenges within psychiatry, furnishes critics with ample material. Even issues prevalent across medicine, such as industry influence and the corruption of evidence-based practices, become more conspicuous within psychiatry due to this intensified observation. Furthermore, psychiatry encounters a significant number of “dissatisfied patients”—individuals who have experienced trauma, disillusionment, or even devastation within the psychiatric care system. The profession has historically shown a tendency to dismiss these accounts, often requiring external pressure to acknowledge their validity.

Psychiatry has demonstrated vulnerability to diagnostic trends, allowed itself to be unduly influenced by pharmaceutical corporations, and its theoretical frameworks have been susceptible to simplistic narratives and overly zealous reductionism. Leaders within the field have sometimes overlooked the structural determinants of mental health. While scientific progress cannot be forced, and humility is warranted given the current state of psychiatric science, many influential figures in psychiatry have, at times, made exaggerated claims and exhibited unwarranted arrogance.

It is crucial to acknowledge that psychiatry is not immune to unfair criticisms. Overt hostility, misinformation, and flawed arguments, as exemplified by groups like Scientology and figures like Szasz, are valid concerns to address and counter. However, there has been a tendency within psychiatry to prematurely label critiques as “antipsychiatry,” often indiscriminately grouping diverse critics under this label.

Psychiatry cannot circumvent this complex situation through mere rhetorical strategies, policing the tone of criticisms, or unilaterally deciding which critiques are permissible from within or outside the profession. Given psychiatry’s current social role, intense scrutiny is inevitable. The most effective response involves internal reform, actively challenging egregious misinformation akin to “anti-vaxx” narratives, and refuting inaccurate claims with evidence. Simultaneously, psychiatry must remain open to legitimate critique from academics, scientists, and, importantly, service users or patients. The term “service user” is employed alongside “patient” to promote inclusivity, reflecting the preference of some individuals with lived experience of psychiatric care for a more neutral descriptor.

It is readily apparent that systemic constraints contribute to adverse outcomes within psychiatry. In light of this, the psychiatric profession—represented by its leaders and organizations—bears a responsibility to actively strive for systemic change. Regrettably, it has often fallen short in this endeavor. By obstructing and dismissing critiques directed at psychiatric institutions, including those from bodies like the United Nations and the World Health Organization, psychiatry risks hindering progress and standing in the way of necessary reforms. Respectfully, psychiatry as a profession should actively participate in these reform efforts or, at the very least, not impede them.

When I refer to “psychiatry,” I am speaking of myself and my colleagues within the field. We are integral to the profession, not external observers. Our critiques originate from within psychiatry, as active participants. It is inaccurate to portray critique as solely coming from external sources directed at a monolithic entity. Psychiatry is a diverse field encompassing various perspectives. Critiques “of” psychiatry often target specific, dominant practices within the field and frequently emerge from within its own ranks. Focusing on the framing of criticisms can be a distraction, and it is a mistake to disregard valid concerns simply due to their perceived origin.

The landscape of psychiatric critique is rich and varied, encompassing numerous arguments, including but not limited to:

• Critiques of the DSM (Diagnostic and Statistical Manual of Mental Disorders): Examining its limitations, misuse, and dominant influence on contemporary practice.
• Critiques of Pharmaceutical Industry Ties: Investigating the connections between psychiatric professionals and pharmaceutical companies.
• Critiques of Medicalization of Distress: Questioning the increasing tendency to medicalize everyday human suffering.
• Philosophical Critiques: Analyzing psychiatric concepts through philosophical lenses.
• Social Science Critiques: Drawing on insights from anthropology, history, and sociology to critique psychiatric practices.
• Evidence-Based Medicine Critiques: Questioning the efficacy of psychotropic medications, particularly antidepressants, based on rigorous evidence evaluation.
• Critiques of Long-Term Medication Use: Examining the potential harms and limited benefits of prolonged medication regimens.
• Human Rights Critiques: Addressing concerns about coercion and human rights violations within psychiatric care.
• Patient and Service User Critiques: Giving voice to the experiences of harmed patients, individuals with lived experience, and the consumer/survivor/ex-patient movement.

Each category of critique includes examples of scholarly, rigorous, and well-intentioned arguments, even if disagreements exist. Critiques from patients and service users are particularly salient. Within the confines of academic and clinical settings, it is easy to develop a sense of complacency. However, engaging with individuals in community settings, where power dynamics are different, and in online spaces like social media and blogs, reveals a significant number of patients who are dissatisfied and traumatized by their encounters with psychiatric care.

Dr. Morehead advocates for psychiatrists to consistently advocate for their patients. I wholeheartedly agree and would add that genuine and meaningful advocacy must also include speaking out on behalf of patients who have been harmed by psychiatric care. Furthermore, we should actively empower patients to voice their own experiences, aligning with the goals of service user and lived-experience communities, as well as movements like neurodiversity and mad pride.

It’s important to note that the examples of criticisms Dr. Morehead initially presents in his article do not accurately reflect the “common criticisms” he subsequently addresses, creating a misleading impression. For instance, he references Anne Harrington’s Mind Fixers, a historical analysis of psychiatry’s pursuit of biological explanations for mental illness, especially during the era of biological psychiatry in the 1980s, 1990s, and 2000s. Harrington’s book is a respected scholarly work that offers valuable insights for psychiatrists. Her recent invitation to speak at the Royal College of Psychiatrists, followed by a productive online dialogue with psychiatrist Matthew Broome, exemplifies how historical critique can be beneficial and generate constructive responses.

Dr. Morehead also mentions the 2012 paper by Phillips et al., which addresses conceptual and definitional challenges in psychiatric diagnosis. This article, authored by prominent figures in the philosophy of psychiatry, highlights the philosophical complexities inherent in the concept of mental illness and the ongoing struggle to achieve a satisfactory definition. This topic has long been a focus of my own philosophical work, reflecting the conceptual shortcomings in our understanding of mental illness. While Dr. Morehead may disagree with the necessity of philosophical analysis and believe our current definitions are adequate, it is unclear why such scholarly inquiry should be considered problematic or irresponsible criticism.

Dr. Morehead identifies the following as the three most common criticisms:

• Criticism 1: Psychiatric illnesses are not genuine illnesses in the conventional sense because they lack physical and biological reality.
• Criticism 2: Psychiatric medications worsen conditions. They are harmful substances promoted by pharmaceutical companies and self-serving psychiatrists.
• Criticism 3: Psychiatrists are biological reductionists and over-prescribers who diagnose and medicate indiscriminately.

These criticisms, as stated, are indeed prevalent in lay discourse, as well as in Szaszian and Scientology-aligned critiques of psychiatry. They warrant rebuttal. However, they bear little resemblance to the nuanced critiques offered by respected scholars and psychiatrists like Dr. Harrington, Dr. Frances, Dr. Steingard, Dr. Waterman, Dr. Fava, Dr. Cosgrove, and Dr. Kleinman, all mentioned at the beginning of Dr. Morehead’s article. If these scholars have not made these simplistic criticisms—and they have not—then why use them as preliminary examples? This approach risks misrepresenting the nature of their actual critiques.

Moreover, for each of the “common criticisms” Dr. Morehead raises, there are related, more sophisticated critiques that deserve serious consideration. For example, research does indicate associations between psychiatric disorders and biological factors, but these are often at the group level, of modest magnitude, and lack sensitivity and specificity—better understood as biological risk factors. Psychosocial risk factors, such as trauma, show associations of equal or greater magnitude and are often comparatively neglected. Even in conditions with high heritability like schizophrenia, identified genetic associations explain a small proportion of risk, while factors like trauma are more potent and under-addressed. This raises a crucial question: why prioritize biological risk factors over psychosocial factors in understanding psychiatric disorders? Characterizing psychiatric disorders as primarily brain diseases or brain disorders implicitly reinforces this privileging of the biological perspective.

Consider Dr. Morehead’s second “common criticism” regarding medication. While psychiatric medications have valid clinical applications, even critics like Dr. Moncrieff, who adopts a Szaszian perspective on mental illness, acknowledge the therapeutic role of antipsychotics in acute psychosis. However, this acknowledgment should not obscure the evidence suggesting that the efficacy of these medications has been overstated, and their harms minimized, due to issues in clinical trial design, conduct, and reporting. For instance, the profession was slow to acknowledge the severity of antidepressant withdrawal syndrome, requiring sustained patient advocacy and clinician concern to initiate recognition. Regarding antidepressant efficacy, the Cipriani et al meta-analysis cited by Dr. Morehead does show statistical superiority over placebo, but the small magnitude of this difference raises questions about its clinical significance. The situation is even less clear for children and adolescents, with a 2021 Cochrane review suggesting antidepressants offer only a “small and unimportant” benefit compared to placebo in this population. While this doesn’t negate the clinical utility of antidepressants entirely—clinical experience and analyses suggesting specific effects of SSRIs on mood exist—it points to deeper problems with our reliance on standard evidence-based methodologies like RCTs, systematic reviews, and meta-analyses. Addressing these issues requires engaging seriously with critiques. Furthermore, the efficacy of antidepressants does not justify their widespread prescription rates—13.2% of US adults used antidepressants between 2015 and 2018, according to the CDC.

Dr. Morehead notes that mental illness accelerates aging and reduces lifespan by approximately 10 years, but seemingly overlooks the possibility that psychiatric medications might contribute to this. Antipsychotics, for example, carry significant risks of obesity, diabetes, and hyperlipidemia, all linked to increased aging and mortality. A recent JAMA Psychiatry editorial even hypothesized that long-term antipsychotic exposure may increase premature dementia risk in individuals with psychosis. Complacency in the face of such evidence is concerning. While focusing on the harms of under-diagnosis and under-treatment is common in psychiatry, these concerns appear disingenuous if the profession does not equally address the harms of over-diagnosis and over-treatment.

Concluding Thoughts

Psychiatry is at a critical juncture. The medical model, while essential, faces increasing challenges and its dominance is no longer assured. Clinical psychology is evolving, addressing theoretical limitations, developing alternative classification systems like HiTOP, re-exploring psychoanalysis, and innovating treatments for severe mental illness. Social work is gaining renewed momentum, and service user movements are growing stronger. Organizations like the UN and WHO are urging psychiatry to improve its human rights record. The changing global landscape necessitates that psychiatry adapt. Navigating this evolution requires vulnerability and humility, embracing both the defense of its medical foundations and an appreciation for the pluralistic nature of mental healthcare. Learning from critiques and taking ownership of existing problems are vital for psychiatry’s continued relevance and progress.

Dr. Aftab is a psychiatrist in Cleveland, Ohio, and Clinical Assistant Professor of Psychiatry at Case Western Reserve University. He leads the interview series “Conversations in Critical Psychiatry” for Psychiatric Times. He is a member of the executive council of the Association for the Advancement of Philosophy and Psychiatry and has been actively involved in initiatives to educate psychiatrists and trainees on the intersection of philosophy and psychiatry. He is also a member of the Psychiatric TimesTM Editorial Board. He can be reached at [email protected] or on Twitter (@awaisaftab).

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