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Psychiatry
A New Socratic Dialogue on Psychiatric Research
Socrates comes back to life to shed light on modern models of mental disorder.
Posted December 6, 2013
Socrates: Congratulations, Phaedrus, on your recent graduation.
Phaedrus: Please don’t mention it, Socrates.
Socrates: Now that you are a physician, what are you going to do?
Phaedrus: I am applying for a research post.
Socrates: In what specialty?
Phaedrus: Psychiatry, the healing of the soul—of course! I have my job interview tomorrow. Will you help me prepare for it?
Socrates: Very well, my good friend. I shall interview you as though I were an eminent professor of psychiatry. Are you ready?
Phaedrus: I am!
Socrates: Our university has a large and highly rated department of psychiatry. How many people do you think it employs?
Phaedrus: You mean the research department and not the hospital?
Socrates: Yes, just the research department. Forget about the clinical services.
Phaedrus: I’d guess about 50.
Socrates: Are you counting just principal investigators? Or are you also including senior researchers, junior researchers, course organizers, personal assistants, receptionists, cleaners, and so on?
Phaedrus: OK, well maybe about 200 then.
Socrates: Let’s go with 200. What’s their average annual salary?
Phaedrus: Before or after tax?
Socrates: Before tax.
Phaedrus: Well, I suppose an eminent professor could make perhaps $500,000 per year…
Socrates: Don’t include payments from pharmaceutical companies.
Phaedrus: Then maybe $250,000. At the other extreme, some staff may be paid no more than $20,000. So maybe, what, $50,000 on average?
Socrates: Yes, that sounds reasonable. Let’s stick with that. So, in total, how much is spent on salaries every year?
Phaedrus: 200 staff multiplied by an average salary of $50,000. Give me just a moment… $10,000,000.
Socrates: $10,000,000, just on salaries. How much do you suppose is spent on the actual research? More or less?
Phaedrus: I would assume that most of the money in a typical research grant is spent on research rather than on salaries.
Socrates: How much more do you think?
Phaedrus: Maybe twice as much.
Socrates: So twice $10,000,000, or $20,000,000, on research projects. Do you agree?
Phaedrus: Yes, that seems fair.
Socrates: So how much is spent in total, on both salaries and research projects?
Phaedrus: $10,000,000 plus $20,000,000: $30,000,000.
Socrates: So, according to you, our department spends $30,000,000 a year. Assuming that our budget has remained constant over the years, how much have we spent since 1960?
Phaedrus: Do you mean in today’s dollars.
Socrates: Yes.
Phaedrus: Well, 53 years multiplied by $30,000,000, which is, what, about $1,600,000,000?
Socrates: Yes, $1.59 billion to be exact.
Phaedrus: Amazing.
Socrates: Right. Now tell me: what was our most significant discovery in these past fifty-three years?
Phaedrus: Let me think.
Socrates: Or any one of our more significant discoveries.
Phaedrus: I’m ashamed to say that I cannot name any.
Socrates: Why are you applying for a position in our department when you cannot even name any of our breakthroughs?
Phaedrus: I wish I could!
Socrates: Fret not, it’s not your fault.
Phaedrus: How do you mean?
Socrates: I mean, there have been no breakthroughs to speak of.
Phaedrus: Oh dear!
Socrates: If, since 1960, we have spent $1.6 billion in one single psychiatry research department, how much do you think we have spent in every psychiatry research department in the country?
Phaedrus: It must be several times that, maybe $50 billion.
Socrates: Yes, or more than that. And how much have we spent in every psychiatry research department in the world?
Phaedrus: Several hundred billion, no doubt.
Socrates: Does that include the research budgets of pharmaceutical companies?
Phaedrus: No, not at all.
Socrates: Now, can you name me one important breakthrough in psychiatry since 1960?
Phaedrus: SSRI antidepressants.
Socrates: Many intelligent people, including within psychiatry, argue that SSRIs are no more effective than a placebo.
Phaedrus: Yes, and they seem to have the figures to prove it.
Socrates: What’s more, SSRIs have disturbing side effects, whereas placebos do not.
Phaedrus: What about second-generation antipsychotics? They have fewer disturbing side effects than first-generation antipsychotics. Surely they must count as an important breakthrough.
Socrates: Some people argue that the only difference between the one and the other is that second-generation antipsychotics are administered at considerably lower doses—which explains why they have fewer disturbing side effects.
Phaedrus: Yes, and, in any case, they remain very dirty drugs. I heard someone argue that they only work because they knock you out.
Socrates: Phaedrus, are you saying that, despite having spent hundreds of billions on research, there has not been a single breakthrough in psychiatry in these past fifty or sixty years?
Phaedrus: You have given me no choice but to say it.
Socrates: And yet, you wish to pursue a career in psychiatric research. Perhaps you fancy that you, of all people, will be the one to make the breakthrough?
Phaedrus: In the cold light of what has just been said, my chances do indeed seem very slim. But perhaps medical science is more about making small steps than giant leaps.
Socrates: Small steps forwards or small steps backwards?
Phaedrus: How do you mean!
Socrates: When do researchers make small steps backwards rather than small steps forwards?
Phaedrus: When they publish research that misleads. There is a saying, is there not, that to do the wrong thing is worse than to do nothing at all.
Socrates: Do they put out misleading research because they are lacking in intelligence?
Phaedrus: No, it’s more that they are under a silent pressure to publish.
Socrates: In what way?
Phaedrus: Researchers need to publish results to appear successful and advance their careers, and, more subtly, to justify themselves to themselves. Positive results are more likely to be published than negative results, and so there may be a tendency, however subconscious, to arrive at results that are slightly positive.
Socrates: If only positive results are ever published, then negative results are hidden from view, deceiving us into thinking that a particular phenomenon is present when it is not, or that a particular treatment or intervention is effective when it is not.
Phaedrus: And that gives rise to false theories, false constructs, and false paradigms: blind alleys in which other researchers lose themselves.
Socrates: Not just other researchers, Phaedrus, but also physicians, science writers, journalists, and so on.
Phaedrus: Not to forget the patients themselves.
Socrates: That’s absolutely right. How else might we be misled?
Phaedrus: Commercial interests.
Socrates: How do you mean?
Phaedrus: Well, for example, there are pharmaceutical companies that have been known to selectively publish research with positive findings, while spinning, doctoring, or suppressing any research with negative findings. This creates the impression that their products are more effective than they are.
Socrates: Or that their products are effective when they are not.
Phaedrus: Yes, it misleads the research community, who create or adjust explanatory models to fit the “findings”.
Socrates: Which creates even more confusion.
Phaedrus: On top of all this, pharmaceutical companies spend large sums of money promoting their products to physicians and end consumers.
Socrates: How do they promote their products to physicians?
Phaedrus: By meeting with them and “educating” them about a particular product or range of products, sponsoring their conferences, contracting them as speakers or consultants, and such like. They target the most influential physicians, so-called ‘key opinion leaders’.
Socrates: So the physicians they target are those in leadership positions.
Phaedrus: Yes, just those who are driving the research!
Socrates: Well then, Phaedrus, if, after all this, you still wish to pursue a career in psychiatric research, you must take great care to avoid all these pitfalls and make small steps forwards rather than small steps backwards. Otherwise, you will have thrown away your education. You will have wasted your life. And you will leave this world, to which you owe so much, having done it more harm than good.
Neel Burton is author of The Meaning of Madness, The Art of Failure: The Anti Self-Help Guide, Hide and Seek: The Psychology of Self-Deception, and other books. Watch his latest TED Talk, In Praise of Idleness.
