Out of all the pseudoscience that are criticized on this website — from creationism and the anti-vaccine movement to anti-GM sentiments and alternative medicine — no subject has attracted more malicious attention from denialists trolls than the articles refuting anti-psychiatry. I often respond and end up in never-ending debates where they simply repeat the same arguments over and over again despite having had their errors explain to them in great detail with references to the scientific literature. When they fail their misguided war of attrition, they resort to verbal abuse by calling me fascist, pig, dickhead, Führer etc. and claim that I must consider individuals with mental conditions who receive evidence-based treatment to be “roadkill” (I do not). After a while this comes very tiresome, so those individuals have their comment privileges removed for violating the comment guidelines. However, they do not let this stop them from spouting their nonsense. They simply use proxies, new names and email addresses to continue with their behavior (while keeping the assertions exactly the same). Some even try to impersonate me. I ban the new identities or turn off comments. This makes things calm down for a while, but it starts back up again the next time I publish a post debunking anti-psychiatry.
Recently, a previously banned user now going by the name of Tin attempted to post an anti-psychiatry diatribe on an argument describing some common anti-psychiatry archetypes that scientific skeptics are likely to come across when they take on anti-psychiatry proponents online. Although using a new name and IP, he still used the same email address as he did when he was banned the first time, thereby giving it away and so the comment got caught by the spam filter. Usually I would not bother to write anything about it and just empty the spam queue, but some of the claims he made in that comment was absurdly wrong on so many different levels that it could be useful for other scientific skeptics to have access to a detail refutation of those assertions.
In his comment, Tin confuses a debate about the scientific details with a debate on the validity of the entire field and tosses in appeals to false balance. He also makes a number of other flawed arguments, such as calling Psychology Today an academic journal, when it is really just a magazine and blog website. He also asserts that antidepressants are not better than placebo despite the fact that meta-analyses taking publication bias into account show that they do outperform placebo in a clinically significant way. Tin even fails to understand that ICD-10 also has an ADHD diagnosis and that ADHD is diagnosed outside the U.S. Finally, the five papers that allegedly show that anti-psychiatry is based on evidence either do not support his position, directly contradicts his position or is irrelevant to the discussion. The rest of this article examines those anti-psychiatry claims in additional detail.
Psychiatry as a research field exists independently of DSM
Many anti-psychiatry proponents do not know this, but the Diagnostic and Statistical Manual (DSM) has a companion Sourcebook that discusses the development of DSM, evidence support ranging from reviews to field trials as well as references to the primary scientific literature for which the DSM is based on. For the DSM-IV, this Sourcebook came out in four separate volumes that together stretches over 4000 pages (American Psychiatric Association, 1994; 1995; 1997; 1998). In comparison, the text revision of the DSM-IV manual is only around 950 pages (American Psychiatric Association, 2000).
In sharp contrast to scientific reality, Tin makes the erroneous assertion that psychiatry is based on nothing else than the DSM. As we saw above, the DSM is based on a mountain of scientific research and this research exists independently from the DSM. A simple Pub Med search for psychiatry gives around 400 000 papers and for psychology it is close to 1 million. For depression it is around 300 000 papers and for anxeity it is about 150 000 papers. Far from being an ideological slave to the DSM, research performed in the context of psychiatry continues at a pace faster than ever, especially with fruitful interdisciplinary collaborations with neuroscience, genetics and social sciences.
The anti-psychiatry abuse of NIMH Director Thomas Insel
A couple of weeks before the release of DSM-5, Thomas Insel (the director of the National Institutes of Mental Health) wrote a blog post wherein he discussed classification systems of psychiatric conditions. The DSM is pragmatic and atheoretical and allows consistency and common language between psychiatrists. Insel writes about his dreams for a future where each psychiatric condition is characterized and defined after genetic risk factors, neural circuitry and brain chemistry related to specific aspects of cognition. This classifications system that the NIMH is developing is called Research Domain Criteria.
Many proponents of anti-psychiatry (including Tin) and bad science journalists have falsely concluded that this means that Insel and the NIMH have “abandoned” or “put the kill shot” to DSM-5. In reality, Insel is trying to improve diagnosis classification by focusing on genetic risk factors, neuroimaging and cognitive psychology. Essentially, Insel wants a long-term transition from pragmatic and atheoretical to biological psychiatry. He does not reject the DSM as a useful tool and he certainly does not reject psychiatry as a research field (Novella, 2013; Grohol, 2013).
Also, it is quite ironic that anti-psychiatry proponents appeal to a strong defender of biological psychiatry, when they themselves either deny the existence of psychiatric conditions outright or just the biological risk factors.
Psychology Today is not an “academic journal”
Psychology Today is a popular bimonthly magazine about psychology. Their websites feature a number of individual blogs discussing various topics related to psychology, but some also promote alternative medicine, neuro-linguistic programming (NLP) and anti-psychiatry (Psychology Today Therapists, 2013, Borigini, 2012; Wen, 2013; Greenfeld, 2013). Tin incorrectly claim that this is an academic journal. This is of course nonsense. Psychology Today is just a popular psychology magazine. Trying to make it appear as if it was a prominent, peer-reviewed scientific journal is ludicrous.
Tin appeals to a blog post by psychologist Michael W. Kraus that he selectively quotes to make it appear as if Kraus claims that psychiatry/psychology is not scientific. In reality, Kraus is arguing for the exact opposite position as the blog post in question is a blazing defense of psychology as a scientific field (Krauss, 2013). Sure, Kraus does mention some criticisms of DSM-5, but that criticisms was about the complexity of the classification system and what kind of typal classification was better (Frances, 2012). That criticism was not a defense of anti-psychiatry or an attack on psychiatry itself. Instead, it was a debate about scientific details far removed from the fanaticism of anti-psychiatry.
Antidepressants have a clinically significant beneficial effect above placebo
Turner and colleagues (2008) performed a meta-analysis antidepressant efficacy data from published studies and FDA reviews. While they did detect evidence of publication bias, the standardized effect size of antidepressants when taking publication bias into account was 0.31 (0.27-0.35 95% CI). Each of the 12 individual antidepressants they investigated was superior to placebo. A second meta-analysis carried out by Kirsch et al. (2008), looking at four of those 12 antidepressants, came to roughly the same effect size (0.32). However, because they used an arbitrary and outdated cut-off criteria for clinical significance (0.5), Kirsch and colleagues falsely concluded that antidepressants were not superior to placebo. Essentially, their argument was akin to saying that since the glass is less than half full, it must be empty (Turner and Rosenthal, 2008).
To sum up, two independently performed meta-analyses carried out by two groups with widely different positions on the efficacy of antidepressants found the same results: antidepressants do outperform placebo. In contrast to this consensus, anti-psychiatry proponent like Tin ignore the meta-analysis by Turner and the problems with the interpretation provided by Kirsch. In his misguided crusade against antidepressants, Tin cherry-picks data interpretation to suit his own ideological goals.
Misusing the scientific literature to further the ideological goals of anti-psychiatry
Tin lists five papers he believes support anti-psychiatry beliefs regarding the efficacy of antidepressants. In reality, these either does not support anti-psychiatry, directly contradict anti-psychiatry or are completely irrelevant to the discussion.
The first paper referenced was Khin et al. (2011) and it looked at the apparent decline in treatment effect for clinical depression by analyzing data from over 80 double-blind randomized controlled trials. Their general conclusion is not that antidepressants lack efficacy compared with placebo, but rather than declining baseline severity was the strongest predictor for study outcome. Strike one.
Carpenter and colleges (2011) looked at the efficacy of the antidepressant paroxetine and the incidence of suicidality and suicide behavior. Their general conclusion was that paroxetine had a higher efficacy than placebo across all psychiatric conditions they studied (including clinical depression) and that those given paroxetine had a comparable incidence of suicidality and suicidal behavior to those given placebo. This paper does claim that there is a higher incidence of suicidal behavior specifically for paroxetine treatment in a very specific age-group, but this is probably due to an erroneously carried out subgroup analysis. There is sometimes a tendency for researchers who do not find any statistically significant results when looking at their entire dataset to start analyzing subgroups in an effort to find some difference that appear statistically significant. This leads to the problem of multiple comparisons: if you perform a large number of comparisons, a small number of them will turn out to be statistically significant by chance. Reading the results section of Carpenter et al. (2011) shows that this was indeed the case. They carried out 31 different comparisons between paroxetine and placebo treatments. The alleged higher incidence of suicidal behavior of individuals with clinical depression given paroxetine has a 95% confidence interval with the lower boundary being 1.1 (i.e. just outside the null hypothesis of no difference) and the confidence interval is unacceptably large (the corresponding p value was 0.493. The method section even states point-blank that “no adjustment of P values was made for multiple comparisons”. It is therefore clear that these researchers capitalized on chance from multiple comparisons and that this study cannot be considered evidence that paroxetine increases the incidence of suicidal behavior. Strike two.
The third paper, Mosholder and Willy (2006), examined suicidality in pediatric antidepressant RCTs. They claim that the “active drug treatment was associated with a rate of serious suicidal events almost twice that of placebo.” However, there are a couple of problems with this study that obscures this interpretation: (1) trials with zero events in a treatment arm were excluded (essentially biasing the study selection towards studies that included suicidality) and (2) no individual psychiatric medication was associated with an increased risk (the trend only emerged when data was aggregated; a version pf the Simpson’s paradox). This suggests that the sample was not representative and that the conclusion depends if you look at individual or aggregated data. Strike three.
The fourth paper by Cuestas and Cuestas (2010) is an article in Spanish published in an obscure journal. Using Google Translate to examine the full text paper shows that the claim that antidepressants do not outperform placebo is entirely based on the Kirsch et al. (2008) paper discussed earlier in this blog post. No original data related to this issue is described in this paper. Instead, it discusses variability in placebo response. Strike four.
The fifth and final paper, Preda et al. (2001) looked at the incidence of mania or psychosis associated with the use of antidepressants. They found that during a 14-month period, around 8% of admissions to a university-based psychiatric unit was related to “antidepressant-associated mania or psychosis”. But what exactly did the study authors determine an episode of mania or psychosis to be associated with antidepressants? Reading the paper itself shows that their inclusion criteria for “association” was that the individual was taking antidepressants at the time of admission and that they had started it within 16 weeks. In other words, when they write “antidepressant-associated mania or psychosis”, we should read that as “mania or psychosis in individuals who happen to be on antidepressants at the same time”. In other words, they are measuring a correlation. They do have another inclusion criteria as well: “rapid improvement following discontinuation of antidepressants with addition of a neuroleptic or mood-stabilizing regiment when clinically indicated”. Of course manic or psychotic symptoms will rapidly improve if you treat with neuroleptics or mood-stabilizers (they mention that the majority of individuals in the study were given these substances). Curiously, one exclusion criteria included “stable medication regiment prior to admission”. That means that they really looked at the correlation between initiation of antidepressants and admission of manic or psychotic symptoms, not long-term use. In their discussion section, the researchers point out that “most cases meeting inclusion criteria were known to have a psychotic/manic diathesis [i.e. family history of psychosis/mania – E. K.] by history.” and “a past history of psychosis was found in 61% (N = 26) of our group”. Finally, the point out that “it is difficult to ensure that the emergence of psychotic or manic symptoms was due to the initiation of antidepressant treatment and not intrinsic to the disease course” and that their paper is not meant to study the incidence of antidepressant-association psychosis or mania (because they did not include a control group). Strike five.
ICD-10 does have an ADHD-like diagnosis and ADHD is diagnosed outside the U. S.
In psychiatry, there are two diagnostic manuals that are most commonly used around the world. These are the DSM (published by the American Psychiatric Association and focuses exclusively on psychiatric conditions) and the ICD (published by the WHO and covers all medical conditions). The equivalent of the DSM diagnosis ADHD is called “hyperkinetic disorder” in ICD. In the U.S. DSM is used more often than ICD and ICD is more often used than DSM in Europe.
The term “ADHD” is used in DSM whereas the ICD-10 equivalent is called hyperkinetic disorder (Balaguru, 2012). However, the eighteen diagnostic symptoms are almost identical (Swanson, 1998; CDC, 2005; WHO, 1993;). There are, however, two key difference between the two as it related to this discussion (Swanson et al. 1998). The first difference is that ICD-10 requires symptoms in all three categories of inattention, hyperactivity and impulsivity, but DSM does not. In n clinical practice, this has meant that the ICD-10 tends to underdiagnose the condition (Lahey et al. 2006). The second key difference is that the ICD-10 excludes comorbid conditions, so if you fulfill the diagnostic criteria for hyperkinetic disorder as well as e. g. anxiety and depression, you can not be diagnosed with hyperkinetic disorder. This means that hyperkinetic disorder is considered to be a subset of ADHD.
Anti-psychiatry proponents like Tin wrongly claim that ICD does not even have a diagnosis for ADHD. In reality, there is an ICD-10 equivalent of ADHD and the diagnostic criteria are strongly overlapping. For a similar reason, the claim that ADHD does not exist outside the U.S. is false. Studies such as Faraone et al. (2003) and Polanczyk et al. (2007) show that ADHD is not a uniquely American psychiatric condition, that the incidence ranges are comparable and that the variability between continents is partially due to methodological differences between studies (e. g. diagnostic system used and other factors).
ADHD diagnosis is based on clinical assessment, rating scales and interviews
A diagnosis of ADHD (whether the clinician is using ICD or DSM) requires a clinical evaluation based on medical exams, information regarding medical history and school records, interviews with parents, teachers etc. and the use of multiple rating scales. An ADHD diagnosis should not be made unless the symptoms cause considerable and long-term functional impairment in multiple locations (Mayo Clinic, 2013).
In contrast, anti-psychiatry proponents like Tin dismiss all of this and assert that diagnosis is completely subjective. As we have seen, this is erroneous because a clinical evaluation by a professional is carried out and that evaluation is based on evidence.
ADHD is not treated with psycho-surgery or electroconvulsive therapy
Treatment for ADHD includes psychiatric medication and cognitive behavioral therapy. Tin falsely claim that psycho-surgery and electroconvulsive therapy (ECT) is used for ADHD. It is not. Psycho-surgery is almost never used anymore for any condition, has never been used to treat ADHD and there is an ongoing transition to deep brain stimulation for those rare cases were it is considered. ECT (also never used for ADHD) is mostly used as a treatment for severe cases of treatment-resistant depression and other conditions.
The fallacy of false balance
Throughout his anti-psychiatry diatribe, Tin repeatedly appeal to false balance, calling my refutations “one-sided” and “black and white” while suggesting that I give equal exposure to anti-psychiatry claims. However, that would amount to giving pseudoscience a platform, which does not interest me. It is precisely the same reason why I do not give equal time to creationism, Holocaust denial or race trolls. As a final attempt, Tin appeals to my “other blogger friends” and claims that I should accept anti-psychiatry because those “other blogger friends” also criticize psychiatry. However, this notion is based on two distinct fallacies: (1) criticizing details and suggesting improvements based on science is not the same as a complete rejection of the entire field (i.e. anti-psychiatry) and (2) just because some scientific skeptics are selective in their commitment to critical thinking and the defense of good science does not mean that I should compromise my scientific skepticism stance and also embrace pseudoscience. In fact, I have written several posts on this website criticizing other skeptics and individuals with skepticism-related positions for their problematic promotion of anti-psychiatry.
There are literally millions of scientific research papers and reviews on the topic of psychiatry and psychology. These fields cannot be reducible to the DSM. The anti-psychiatry abuse of NIMH Director Thomas Insel is misguided because he is a strong proponent of biological psychiatry and his blog post expressed a desire for a future classification system containing genetic risk factors, neural circuitry and brain chemistry related to specific aspects of cognition. Insel is not anti-psychiatry and he has not abandoned the DSM. Tin falsely claim that the popular magazine Psychology Today is an academic journal and links to a blog post defending psychology as a science (apparently not having read the post).
Antidepressants have been shown to be superior to placebo by large-scale meta-analyses that have taken publication bias into account. Tin misused five separate published papers in his misguided crusade against psychiatry: some of them did not support his position, some contradicted it outright and some were completely irrelevant to the question under discussion. He also falsely claim that the ICD does not have an ADHD diagnosis (it does) and that ADHD does not exist outside the U.S. (it does).
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