Menand on Psychiatry

Louis Menand of Harvard University talks with EconTalk host Russ Roberts about the state of psychiatry. Drawing on a recent article of his in the New Yorker, Menand talks about the state of knowledge in psychiatry and the scientific basis for making conclusions about mental illness and various therapies. Menand argues that the research record shows little difference between the effectiveness of psychopharmacology and talk therapies of various kinds in fighting depression. Neither is particularly successful in any one case. Other topics that are discussed include the parallels between economics and psychiatry in assessing causation, the diminished role of Freudianism in modern psychiatry, and the range of issues involved in using medication to avoid pain and hardship.

Explore audio highlights, further reading that will help you delve deeper into this week’s episode, and vigorous conversations in the form of our comments section below.


May 31 2010 at 10:54pm

Your colleague Robin Hanson criticizes the conclusion of Menand’s article here.

Jun 1 2010 at 2:37am

Really enjoyed the change of topic Russ. It made me realise that ‘Brand Russ’ is as much about intellectual honesty as it is economics.

You’re probably one step ahead of me but how about a regular (say monthly) off topic podcast like this?

Don Kirk
Jun 1 2010 at 3:07am

Dr. William Epstein has a 2006 book, “Psychotherapy as Religion,” making the argument that the volumnous meta-studies of the research done in the discipline shows so little effectiveness in actually helping people because the discipline itself is merely a secular religion.

If seeking scientific treatment for depression is no more effective than going to the priest’s confessional–as a cathartic–then shouldn’t we all be very cautious about the claims of ‘science’ in psychotherapy?

Jun 1 2010 at 3:59am

I agree with you Paul. Brand Russ definitely seems to be as much about intellectual honesty or even epistemology as a whole as about economics.

Jun 1 2010 at 8:46am

I’m skeptical of prescribed drugs and always wonder of the long-term (10/20/30 years) effects and do they create chemical/cell alterations leading to arthritis/diabetes/other?

Drugging children, mainly boys, into complacent/compliant little classroom creatures seems to me as destroying their natural creativity and brilliance. And the cervical cancer vaccine urged by the drug maker a few years back for use on older pre-teens and teenager girls struck me a highly questionable and even irresponsible.

A few years ago I had a discussion with my primary physician stating that the medical community does not know those long-term implication, with no response. I suspect he too may have wondered but was without alternatives.

Jun 2 2010 at 9:38am

Every good South Park fan knows that the unfortunate side-effect of taking ritalin is developing a taste for Phil Collins’ music.

Jun 2 2010 at 3:37pm

There is a lot of misunderstanding on both sides of the mood drug issue. I thought this discussion was quite balanced and objective. My now, 21yr old daughter was helped markedly by the use of adderal but it was never prescribed as a cure but only something that could allow her to concentrate on school more effectively and it did. Just as there is no subsititue for school work regardless of medication maybe there should not be such a disconnect between medication and traditional psychotherapy but from what I read it sounds as though the HMO business model does not allow for such things. Yet another reason that model should be scrapped.

Michael Bishop
Jun 2 2010 at 6:11pm

I strongly recommend this recent blog post on the topic:

Jun 3 2010 at 1:18am

The following is off-topic:
I sometimes hear people (Arnold Kling & Pete Boettke, for instance) reference the macroeconomics of Axel Leijonhufvud. I’m not aware of Axel writing much popularization of his ideas for the general public, so maybe you could interview him.

Jun 3 2010 at 3:40am

On the subject of science. I’ve often heard the somewhat accusatory lament I heard in this podcast: that ‘science’ is limited, that it doesn’t know everything and so on.

When I hear that sort of thing, I feel compelled to make a few distinctions.

First, there’s a difference between the existing body of knowledge gained through scientific inquiry, and the method of scientific inquiry itself. Both are limited, but we should be clear about which one we’re talking about when we’re disparaging one or the other.

Second, any consideration of the limitations of scientific inquiry should be made in light of the alternatives. And when it comes to the objective acquisition of knowledge, there really are none. Just because it’s limited doesn’t mean it isn’t the best way forward.

Jun 3 2010 at 4:02am

Thank you for an interesting podcast. Menand seems knowledgeable about the topic, but I really wonder – is a professor in English qualified to make these opinions about psychiatry? I tried to see from his CV if he has any medical education or experience, but the education portion of his CV is extraordinarily vague. I’m surprised that you didn’t ask him about his experience and background, Russ.

In regards to drug companies hiding negative results, all clinical trials conducted in the U.S. (both publically and privately funded) are mandated by law to be registered on regardless of their outcome. See FDA Modernization Act of 1997. Trials are registered at start-up before the results are known and thereafter updated with results.

Jun 3 2010 at 7:42am

I agree with Christine’s comment on Menand’s qualifications to address the topic. He sounds like an interested observer, and his perspective is interesting, but I kept wondering throughout the interview what is his qualification to make “that observation” or if he had, perhaps, a stronger background in the subject area would he have been a little more definite. I even went to that Menand web site to see if there was some applicable qualification not mentioned by Russ… unfortunately no.

A good discussion, but perhaps not of the usual quality of EconTalk. My opinion.

Russ Roberts
Jun 3 2010 at 9:34am

Christine and Eric,

Menand is “only” an English professor. But he is drawing on the literature within psychiatry by psychiatrists to reach his conclusions. I suspect psychiatrists who advocate the use of drugs would dispute some of his conclusions. Other psychiatrists might think his conclusions aren’t strong enough. Who is a better judge of the state of knowledge–an insider or a well-read outsider?

Again, it is like economics. I’ve had many guests on EconTalk who claim authoritative knowledge that many authorities disagree with. Which word in the preceding sentence beginning with “auth” deserves the quotation marks of irony?

If you’re really in doubt (and you should always be, insider or outsider), read his article linked above and the books and articles he draws on for his conclusions.

Jun 3 2010 at 2:31pm

I hope that most of the times you said “science can’t figure out” you meant “science has yet to figure out”.
I see no reason why we will not be able to figure out everything about how the brain works given enough time and effort.
It is true as you said at the end that science cannot tell us whether to apply this knowledge to eliminating grief, though even then it can greatly inform the decision.

Jun 3 2010 at 2:56pm

I found this podcast very interesting. I’ve been a public defender in the federal courts for over ten years. During that time, I’ve grown increasingly skeptical about our criminal justice system, which (to my mind anyway) is best described as a feeding trough for lawyers, an ever-growing law enforcement bureaucracy, and the mental health profession. The argument over what to do about crime oscillates between two paradigms — rehabilitation and deterrence. In the meantime, the U.S. has succeeded in creating the largest prison population in the world, even though its overall crime rates are about the same as other rich countries (except in homicide where the US is a major outlier). I am as skeptical of the efficacy of “treatment” as I am “get tough on crime” laws.

Professor Roberts, there is a fairly recent study put together by several economist (I think two were from Harvard and one from Mercer, if I remember correctly). Their study sought to determine what economists know about the determinants of crime. Their conclusion was that economists know very little about the empirically relevant determinants of crime. This overall conclusion has one exception, however. According to the study, the hypothesis that drug prohibition generates violence is supported by both long-term series and cross-country facts.

I wonder if you could do a podcast sometime on crime, the statistical and economic models commonly used by economists to measure crime, and the effect of government policies on crime rates.

Thanks for all of your great podcasts.

Jun 3 2010 at 8:02pm


After I posted my comment and went on to work, I thought of the comment I heard on another podcast, and I think you used it as well quoting it yourself, that (was it Leamer? I’m not sure right now) had a disadvantage in commenting on macroeconomics that he knew nothing about macroeconomics, and that he had a great advantage over macro economists in that he knew nothing about macroeconomics. I thought about Menand, and saw the similarity. And I remembered that I did find the podcast interesting… I’ll put aside my bias and listen again. If I have another morning commute on the Beltway like this morning’s, I might even be done by work tomorrow morning.

Jun 5 2010 at 9:13am

The bit about people would rather go through the half year of suffering when losing a loved one reminds me of a classic story I read in a marketing book about how hard it was to sell Gerber’s baby food to mothers. Before Gerber’s most mothers spent a lot of time preparing food for their babies. They’d have to spend a lot of time boiling down veggies, straining them etc. They came to associate this large effort with their love for their baby. Giving them a jar they can just quickly open removed that “greater evidence” of their love for their baby.

So yeah in some relationships, people associate great efforts or great suffering as evidence to themselves and others about their commitment to the relationship. For example, I don’t feel like I’m a good friend until I help the person move.

Tom Vest
Jun 5 2010 at 11:05am

Re Christine & Eric’s comment: Menand “just an English professor”?

Those inclined to summarily dismiss the credibility of Menand’s views because he’s “just an English professor” might want to have a look at these publications:

To me at least, this record of inquiry looks a lot more like the general pursuit of “intellectual honesty” (c.f., Paul & NetSP’s remarks above) rather than a case of academic hubris or overreach. The Metaphysical Club in particular is one of the best books ever written on the American Pragmatic tradition (imo).

General skepticism about the extent/credibility/legitimacy of institutionally conferred “expertise” (at least for all “non-market” institutions) seems to be an underlying theme of most if not all EconTalk podcasts. However, even if Russ’ intuitions about this question are on target, that should only serve to remind us all of the timeless maxim about people who live in glass houses…

[Tinyurl replaced by actual url. Our readers like to know where they are going.–Econlib Ed.]

Jun 5 2010 at 1:34pm

eric; that is a quote from boudreaux, in boudreaux on macroeconomics. I happen to have just re-listened to it the other day.

[ –Econlib Ed.]

Steven Bagley
Jun 5 2010 at 6:00pm

This podcast covered an interesting set of topics, a set unfortunately too broad for a single show. Menand’s choice as guest followed from his writing for The New Yorker a composite review of recent critiques of psychiatry, and for his considerable professional expertise on modern intellectual thought. He is not an expert in psychiatry (and admitted as much during the podcast), but I hope the reader/listener realize that neither Menand’s “I’ve read a few books about it” nor Robert’s stock-in-trade skepticism are authoritative. I found the show to contain a mixture of good insights and glaring errors, inconveniently mixed together. Here are few of the latter.

Menand comments weren’t consistent: at the beginning of the show he said that depression is not detectable in the brain, and later he mentioned shrinking hippocampi.

Roberts: “We don’t feel that way about a heart drug …. Somehow our brains are different.” Actually, many patients refuse to take medications (or even take tests for) all kinds of medical conditions, including high blood pressure and diabetes. The reasons are varied, but often include the same ones that apply to mental disorders: issues of stigma and labeling, a desire to avoid “depending” on a medication indefinitely, even the psychological defence of denial.

Menand: “You can give people serotonin and it doesn’t make them feel better.” Right. Serotonin doesn’t cross the blood-brain barrier. A serotonin precursor, tryptophan, is transported into the brain where serotonin is synthesized. Some early experiments did show antidepressant effects of tryptophan, but it hasn’t really worked out to be a reliable treatment. I realize that the larger point of his comment was that the brain is complicated. This is good example of that.

Menand: “Grief is the only exception to the rules for diagnosis depression in the DSM-IV.” (not an exact quote.) This is just false. The DSM-IV clearly lists drug abuse and medical conditions (e.g., hypothyroidism) as exceptions; that is, hypothyroidism can cause many symptoms of depression, but it wouldn’t be appropriate to diagnosis major depressive disorder in that case.

I haven’t conducted formal surveys, but I’m sure on the basis of many patients’ desire for quick pharmacologic relief (with medications or drugs of abuse) that a nontrivial fraction of the US population have very little romantic attachment to the idea of grief and would willingly take a pill that could resolve those feelings. I’m not encouraging such practice, only acknowledging the strong forces that patients bring to the exam room. Lazy and complicit clinicians make this problem worse.

Full disclosure: I am a practicing academic psychiatrist. I prescribe medications (and therapy) when I think they are warranted, and spend much of my time trying to fix incorrect diagnoses and improper treatments. I’d be the first to admit that psychiatry has many conceptual problems and weaknesses. I try to instill in the residents I teach some skepticism without nihilism. Most criticisms, though, are based on personal experience and simplistic reflexive rejection of current psychiatry, not on deep knowledge of either the underlying science or of clinical practice. I don’t see this as an inside/outsider issue so much as a debate often limited by lack of knowledge or relevant experience. You wouldn’t want to spend much time on my opinions on macroeconomics or Charles Peirce, in spite of my outsider status in both domains. As a footnote, I have written about the misuse of regression analysis in medical research and heartily echo Leamer’s comments in an earlier podcast about specification errors and lack of replication in such quantitative work.

Overall, I hope readers/listeners would bother to inform themselves BEFORE reaching strong conclusions; I caution such enthusiasts that the issues in the study of the mind and its failings are profoundly complicated and require considerable study beyond Menand’s essay and its sources.

Russ Roberts
Jun 5 2010 at 9:51pm

Eric (and Shawn),

Don Boudreaux may have said something like that about experts and macro but Leamer definitely said it and I quoted him–it’s from his paper on the business cycle that I referenced when speaking to him.

The Leamer podcast is here.

The Leamer paper is here.

Jun 7 2010 at 6:35am

I’m not dismissing Menand as “just an English professor”. I simply wanted to know more information about how he came to his opinions since it was not through formal education or his current position as an English professor. Has he read a couple of books or has he performed an extensive literature review? I don’t know. As I said, he seems knowledgeable. I simply would have liked to hear more about his methods since his education in psychiatry is non-traditional.

Jun 9 2010 at 2:21am

I’m a physician although psychiatry is outside my area of practice. I think Menand raises some valid points but I do feel he is too hard on psychiatry as a specialty.

Psychiatry is not the only area of medicine where there are glorious arguments over statistical methods. Because there are disagreements does not mean a particular therapy is unwarranted. It does mean we need to continue to study the subject so that we may resolve controversial issues.

One of the readers commented about the vaccine for cervical cancer. Every treatment has its downsides and the medical field always tries its best to identify those downsides before a therapy is brought to market. It is impossible to give 100% assurance that all risks have been identified. A drug might be tested on 10 000 volunteers before coming to market. That means a side effect that is seen in 1 in 20 000 patients might not be immediately recognized. However, based on the initial 10 000 patients we can reach reasonable conclusions about the risks versus the benefits. The side effects of any therapy are often discussed in the media. However, what about the other side? I have watched mothers sit beside their twenty something daughters as they died from cervical cancer.

Psychiatry is no different. Psychiatrists make decisions on the best information they have. As psychiatrists learn more about any particular therapy, they modify their practice accordingly. Sometimes some therapies engender more discussion within the profession than others but ultimately those debates will be resolved and treatment adjusted accordingly.

The negative aspects of psychiatry are often emphasized in the media. However, I have seen both sides…the young man who enters the ER depressed but a year latter is happy and enjoying life. And yes I have seen the young man who didn’t receive help in time and shot himself in the head or hung himself from a rafter.

I have seen the successes and the failures. Psychiatrists do great work and the controversies within their specialty do not reflect a lack of ability but rather a desire to continue to improve the care that they provide.

Russ Roberts
Jun 9 2010 at 6:14pm


For me, the critical question is whether knowledge progresses. Do things get resolved? In economics, it was resolved around 1980 that Keynesian economics was fatally flawed. Mainstream economists stopped teaching it at the graduate level. Now it’s back. Yet, nothing was resolved empirically to re-establish the relevance of Keynes. We still have little or no consensus on the sign of the so-called Keynesian multiplier. That doesn’t mean economics is worthless. It does mean it is limited.

I have the same issues with psychiatry. Why was Freudianism rejected? Could it come back? Do we understand better than before how drugs work? When they work and when they don’t? Those are the key questions.

Jun 10 2010 at 12:46am

Hi Russ,

The arguments about statistics and validity of data that I hear from your fellow economists are the same ones that abound in the medical literature. Yet despite all the controversies we eventually come to a resolution.

15 years ago there was a big debate in cardiology about whether a person having a heart attack should receive a drug (e.g. thrombolytic) or an intervention (e.g. angioplasty). In centers that have interventional cardiologists, angioplasty is now considered superior. However, along the way there were many studies and arguments over statistics and the relevance of many data sets. Yet we managed to muddle through it all and find the right answers.

In psychiatry it is no different and all these issues will be resolved with time. Furthermore, psychiatry is more than just the treatment of depression. Depression has huge environmental influences with organic predispositions. In contrast, schizophrenia has a huge organic basis with environmental influences. Psychiatric treatment of schizophrenia still has lots of room for improvement. However, when one compares the treatment of schizophrenia now with what was available 100 years ago, the advances are impressive.

Psychiatry is a science. However, it is a science with enormous complexity. Therefore, it takes longer to find the answers and along the way it is not surprising to find such controversies as described in your podcast.

Personally, I think Keynes is useful in a liquidity trap. However, economies don’t spend much time in liquidity traps and that is why I think it was dismissed. Now I know you think I’m crazy for saying Keynes has relevance but I’ll keep listening to your podcasts and maybe someday I’ll join the choir. So don’t give up on me Russ!!!

About this week's guest: About ideas and people mentioned in this podcast:

Podcast Episode Highlights
0:36Intro. [Recording date: May 26, 2010.] Article for the New Yorker on the state of psychiatry. Can psychiatry be a science resonates with Can economics be a science. Do we know what depression is? Is it different from being really sad in response to a life challenge? Is there such a thing as clinical depression? Center of a lot of debates about psychiatry and at the center of debates about the Diagnostic and Statistical Manual of Mental Disorders (DSM), first created 1952, now in 4th edition. Impossible to distinguish empirically sadness over some life event--death, divorce, losing job--and clinical depression--depression that doesn't seem to have an exogenous reason. If you look at the brains of people who have been laid off or had some life event that has made them sad and the brains of those who just have the same symptoms, you see the same kind of brains. Raises the question of when patients are diagnosed as depressed by psychiatrists and prescribed some form of therapy, sometimes medication, whether we are medicalizing just normal life mood changes, and whether we should be in the business of that or not. Isn't there an argument to be made that, we can't see it in the brain but we know it when we see it in people's behavior? People who can't get out of bed in the morning, but nothing bad has happened to them--haven't been laid off, simply can't behave normally? Something clinically wrong with them? Absolutely. The question arises in cases where it is a little more ambiguous. No question that there are cases of endogenous or apparently endogenous depression where medical intervention, talk therapy or medication, would be appropriate. The question has to do with whether we are defining the category down to include all kinds of other things that are either only marginally connected. If you can't get out of bed--you lost your job--or you can't get out of bed--you don't know why, you still can't get out of bed. Efficacy of treatment in those two different cases? Whole range of psychiatric treatments available to people, increase all the time. There have been a lot of studies comparing the efficacy of different forms of treatment; for example, talk therapy and psychopharmacology medications; medication and cognitive behavioral therapy--a different form of non-medicated treatment; psychoanalysis with other kinds of talk therapy, with drugs, and so forth. Cases comparing drugs with placebos. Many studies. Most conclude that they are all about equally effective, or equally ineffective. This was noted back the 1930s by an American psychiatrist, Saul Rosenzweig, who called it the "dodo bird effect"--from Alice in Wonderland's "Everybody has won and all must have prizes." For any kind of psychiatric treatment, pretty much all come out the same. Might take three or four to find the one that works for any individual. One interesting study with better type of test--these all go back into the 1940s--that seems to be repeatable: people do equally well either just talking to sympathetic professors or talking to licensed psychotherapists. There is something for a depressed or anxious person or somebody with a mood disorder in talking to somebody who seems to care, who sympathizes, that makes them feel better. The particular training the person may have doesn't seem to be important. Russ: great grandmother on father's side used to say, according to dad: "If you don't feel good, go out and talk to a rock." Probably in Yiddish. Folk wisdom from Eastern Europe: don't even need a sympathetic person, just need to talk.
7:40When you say they do equally well, is the glass half full or half empty? Historical treatment, think of insane a little like bit like depressed--we tried shock therapy; now we use medication, which is to some extent talking and listening. All work equally well, but how well do they work? Not too well. Effectiveness rates about 50%-60%, not pulling that out of a specific study. They are relatively effective but not 100% effective. Shock therapy: one of the most effective for people with major depression. ECT--not used prominently any more because it got very bad press. One Flew Over the Cuckoo's Nest made people feel that there was some Frankenstein monster effect to it. For major depression, very effective. Nobody even knows why or exactly what it does but it seems to work. All these things are effective at the margin. Despite the fact that for some individuals pharmaceuticals or talk therapy can change their lives for the better. We don't know who should get what; we don't understand the process. Article lists at great length all the criticisms people have made of psychiatry as a medical science, but in the end it's like most medical science--it deals with a lot of black boxes, hard to understand what's going on. Certain things seems to work better than other things. Psychiatry: what you are treating is people's conscious life, much trickier to figure out what's going on and try to fix it. Dealing with a patient consciously involved in repairing her own conscious life. The fact that all these treatments are only more or less effective doesn't mean they are not worth pursuing. Like economics--society, brain. Can't hold everything constant that you'd like to to assess the impact of one thing. Self-fulfilling prophecy aspect: if people feel they are going to get better, they get better. A lot has to do with the patient buying into the effectiveness of the treatment. That's been shown by the effectiveness of placebos. People think they are taking an anti-depressant even if it's a sugar pill, they will feel better.
11:37Critique of Irving Kirsch's, book reviewed: placebo effect. As the patient, you know that if you've got the real thing, you've got side-effects. So if you experience these side effects, you are then convinced you are not on the placebo; you're on the real drug. That is the real impact, the self-fulfilling prophecy makes you better, not the drug itself. Clever. Is it plausible that the magnitudes are explained? Empirical support for that? How do the defenders of psychopharmacology respond? Emperor's New Drugs. Kirsch has been doing what are called meta-analyses of multiple different drug tests. When he first started doing this his methods were severely criticized by people within the profession for statistical errors and unreliability. He claims he has perfected his statistical methods; and meta-analyses, which were uncommon and dismissed 12-13 years ago are more common now. His claim is that in drug trials testing a new anti-depressant against a placebo, most of the time the placebo will do as well as the antidepressant. In the cases where the placebo outperforms the antidepressant that means that having an outcome which is statistically greater than could be attributed to chance, he thinks that is a similar placebo effect to the one Russ described: the patient in the trial taking the real medication experienced side effects and feels he is taking the real medication, and therefore feels better. The conclusions have been criticized a lot. Does seem to be a bit of a stretch to claim that in every case in which a medication out-performs a sugar pill, it's just a placebo effect. He does talk about other cases where patients have been made to feel better because they've been persuaded that the drugs they are taking will be effective, besides anti-depressants. There was a recent meta-analysis published in the JAMA, last fall or maybe January of this year: conclusion that for mild depression, placebos just as effective as mild anti-depressants. For patients with major depression, anti-depressants had a significantly better effect than placebos. Odd study: only test Paxil, but there are about 25 anti-depressants on the market. Small sample size, though meta-analysis, about 700 patients. Claim that it works on severely depressed patients but not mildly depressed ones is very hard to square, because the claim would have to be that affecting brain chemistry doesn't really do anything for you, but if it does it for you, then obviously affecting brain chemistry works. Black box, complex problem. The point about patients responding positively if they think they are getting something that works--apocryphal story about Enrique Fermi, probably about other professors as well: student comes into Fermi's office, surprised to see that Fermi's got a horseshoe over his door and says, "Professor, you don't believe in that, do you?" Fermi replies, "Of course not! But they say it works even if you don't believe in it." Idea that if you had something really debilitating, you can take a sugar pill, but if someone gives you fancy explanation and gives you something totally bogus it will make you better. Very few people accept the premises of Freudian psychoanalysis, but it was used for years. Sure there are famous cases where it didn't do any good. The black box theory has been totally discarded, but seems to make people feel better.
18:02Turn to Freud. Talk about what happened to Freud within the profession, the clinical aspect of it. Want to make an analogy to economics. What happened to Freud's presence in the discipline? Delayed reaction. In the 1950s, Freudianism was very well-established in medical schools, so that medical training was run by psychoanalysts. Psychoanalysts mainly had smaller private practices, not in the big mental hospitals. Dominant presence in medical schools; finally went out in the 1960s-1970s. Joel Paris book, transformation of medical training in psychiatry. In the 1950s, psychoanalysis had cultural cache; Freud was thought to be the person that unlocked secrets of the mind. This was the period when the first major mood-disorder drugs went on the market--Miltown, anti-anxiety drugs--then in the 1960s, Librium and Valium, very popular. Did what anti-depressants do now--change brain chemistry. By changing brain chemistry, a lot of people got rid of the symptoms of anxiety. Acceptance of drugs like Miltown was not considered at odds with Freudian theory. With Freudian theory, it's not brain chemistry that is causing you to be anxious--it's inner psychic conflict--childhood, way you were raised. Has to be brought to the surface to deal with it. Contradicted by the idea you could take a pill to do the same thing. By the late 1960s, people in the profession started pointing out the disjunction. By 1980, Donald Klein article, "Anxiety Reconceptualized," profession weaned itself from Freud. First two editions of the DSM were influenced by Freud; by 1980, 3rd edition, Freud was almost out of the manual, and today almost none left. Biologizing of psychiatry, but also the idea of what forms of pop therapy would be effective. There are psychoanalysts around, but in general the profession has tried to distance itself from Freud. Like economics--Freud a little touchy-feely: no surgeon has found the id or the super-ego. Brain chemistry is "much more scientific"--has that appeal. Like making economics more mathematical. There must be some people working on that black box. It's true that psychoanalysis now looks rather fuzzy as a science, but Freud thought of it as a science. Describing stuff that goes on in the mind as a scientist. Now we think there is nothing in the mind that corresponds to the categories Freud created or how patients behave. Most people have the rough idea that depression is caused by a lack of serotonin, and if you take a Selective Serotonin Reuptake Inhibitor (SSRI) you are freeing up more serotonin in your neurotransmitters and you'll feel better. But most medical scientists don't think that's what causes or fixes depression. You can give people serotonin and it doesn't make them feel any better. Horseshoe. Some kind of cascade effect created in the brain when you use chemicals like Prozac. Not that alone that causes people to feel better; but triggers some other series of events in the brain. A lot of black boxes even in the medical model. Can now do brain scans.
25:08People have a romance about science, sometimes social science, certainly about medicine, that we are making progress, results of careful study. A lot of other stuff going on, not as scientific as we like: fads, issue of mathematics, pharmaceutical part making it feel more scientific. Also a parallel--money, self-interest, the benefits people get from belief there is a relationship between x and y. Gary Greenberg's work: role that pharmaceutical profits play in distorting received wisdom. Work of Thomas Szasz, critical of psycho-pharmacology because it's been used by the state, not just in communist countries, to control its citizens. Fake science. Greenberg's critique: deeply skeptical of the claims of psychiatry to be a science; attributes the popularity and proliferation of those claims to a desire to make money. Elegant writer; pretty straight-forward diagnosis of the problem: people figured out that if you could persuade people that their moods were diseases and use some chemical you'd put into a pill to make them feel better, you could make a lot of money. Greenberg's book is about depression; claim is that we have lots of good reason to feel depressed about the state of the world. Industry and capitalism have tried to persuade us that it's just brain chemistry. Take pills and we'll be able to ignore the problems of pollution and politics. The Szasz thing is different: use of diagnosing as a way of categorizing and marginalizing, controlling people, certain personality types. People are being manipulated through their lack of knowledge, through the system, whether it's people in power or people profiting from it--distorting the culture and the norms and the incentives people are facing. Fascinating and depressing. The use of pharmaceuticals on children has exploded; school children who have some sort of Attention Deficit Disorder (ADD). Hard to pay attention to stuff that's boring; matter of degree as to who is having an ADD problem and the medicating of those children has had a large effect, good and bad, on the children and a large effect on the profits of those companies. The bar for diagnosis is much lower; the medications are easily available. The reason we have the DSM is that it provides clinical categories for diagnosis. If you can show your insurer that a doctor has prescribed a medication based on one of the diagnoses in the DSM, then your insurance company will like pay for some or all of it. If the insurance companies backed out of that business, you'd see a lot less diagnosis. Part of the cycle of this whole thing. In turn, the legal environment. The DSM is a very attractive way for doctors and insurance companies to insulate themselves because they are "following best practices." Whole thing is driven by every entity basically supporting each other. Hard to break out of the system because everybody has a stake in it. Russ: The one person we might want to focus on is the person putting the pill in their mouth. Four kids, wife a schoolteacher: we hear about issues that come up with forms of behavioral challenges for kids. Not only get dumbing down of the category, but a multiplication of the number of subsets within the category. Not just ADD, but ADHD; various syndromes, etc. If you are a parent whose kids are struggling, you are pretty desperate. You'd like to believe your doctor knows, has evidence. But it's not scientific. Fascinating how willing people are to give up their autonomy and the autonomy of their kids to people who don't know very much. It's subsidized which makes it easier to follow. Menand: The patient does have a stake in it, to the extent the remedy is available and insurance will cover it, might as well try it. Secondly, it is a science, it's just that science is not much better than anything else that we use. Going on with the medication and the symptoms: don't know how it works.
34:08Disconnect between the way scientists discuss their work, the way it appears in the media, and the way people perceive it. Romance about science that is not really justified. Nobody has a bigger romance than the critics of medical science, because they think if we call it science it has to have all the answers. It's not science unless the symptoms that a patient reports in psychiatric treatment can be traced to an underlying organic cause. We can't do that we shouldn't treat them: it's just making the best guess. Greenberg's book: expects too much of science, particularly medical science dealing with people's minds. Good for people to be aware of that. Based on earlier points: Probably better to be fooled! Economic behavior as well: a lot of it people think it's going to happen. Not so sure, but there is a belief out there. Darker side to this. Have to be realistic about what science can and cannot do. But there is also a negative side. Sometimes it doesn't just not work: it makes the problem worse. Subtler effects. First focus on the outright negative. What evidence that some of these things are not just ineffective, but dangerous? Not qualified. David Healy, books on history of psychiatry: come to believe there are bad side effects of anti-depressants, particularly Paxil, that are being suppressed; can cause suicide. Been around since Prozac was licensed in 1997-8; Listening to Prozac, started to explore the ramifications of these kinds of medications. Healy, crusade to expose the suppression of evidence. Industry does its own drug tests, and even the ones done by the FDA are paid for by the industry. The industry does not have to report negative outcomes in their trials for a new medication--only have to come up with two positive trials for the medication to be licensed. Area of great controversy. Thalidomide was actually prescribed as a sedative. Other anxiety reducers--Valium, Librium--turned out to be addictive. Might say: what is the harm of being addicted to something that makes you feel good? Does it really make you feel good or do you have to take it or you suffer withdrawal? Most drugs like this have limited effectiveness, stop working; but if you stop taking them, and have withdrawal pains, you are addicted. People think addictive, bad. People don't like the idea they are dependent, or hostage to a medicine. We don't feel that way about a heart drug. If it were a financial backbreaker, might be upset. Our brains are different. Menand: I take the generic Lipitor, statin, every day; don't think I'm dependent on the drug. Not addictive in the sense of suffering withdrawal.
40:56Science question: great point that we shouldn't ask too much of science. Have to be realistic. Deeper issue: whether the data or our understanding is being distorted, either by profit motive distorted by the way we've set up the incentives, paying for the drugs with other people's money; or legal environment; can be a friend or enemy of capitalism and still see this as a not-so-healthy thing. Issue: big underlying psychological issue; 2001 book, The Metaphysical Club, talk about Charles Peirce, pragmatist, American philosopher skeptical about the role of reason. Biases, self-deception part of the way we perceive the world around us. See it in economics all the time. In psychiatry? In economics, people convince themselves that their statistical analysis is right. Econometric analysis oversold for sake of reputation, ideological bias, pure self-interest. Cognitive behavioral therapy: one author thinks it's the greatest thing since sliced bread; the other thinks it's a total waste of time. Harmful even, mind control. Does Peirce have some relevance? Yes, and also William James and John Dewey. Does assume that human beings pursue knowledge for interested reasons--materialistic or idealistic, but there is a reason. True of empirical studies as much as for literary criticism or anything else we try to figure out. We have a reason, a bias, an idea of what we are looking for, what we expect to find. Peirce: No single individual therefore can possibly have anything like an objective view of any subject he studies, including things like knowing the position of a star. Everyone is going to perceive that position slightly differently, even using the same instrumentation. But in the aggregate if you take the average, you can have a rough idea. Want to have enough studies of each relationship, each with its own biased view. Want to have lots of input; no single input is going to be the answer. But the average is also not quite right. Hayekian; Richard Smyth, U. of North Carolina: have you ever read any Hayek? Of course; wisdom is not in any one person's brain very Hayekian. Problem, as Leamer has pointed out: you can take the same data set but different specifications; if you are trying to determine whether the death penalty deters murder, if you favor that argument you can show for every execution you deter 30 murders; if you don't favor it, you can show with the same data set that it actually causes 12 murders. Don't take the average: some kind of consensus might emerge; but he concludes the data don't let us answer this question. State of knowledge does not permit us to infer the right answer to the questions we are asking. Science is never going to answer the fundamental questions about our autonomy and our authenticity and what we should do in life. Not questions science is going to answer or even want it to answer.
47:48Imagine a person who lives with grief, loss of a loved one; and imagine you created a grief pill. If you take the pill and instead of going through six-month period of not being able to get up in the morning or focus on your job, instead you just get over it in a day. Would you take the pill? Plusses and minuses? Idea would be in six months you are going to feel better anyway. Doesn't mean you didn't love the person; won't feel the physical symptoms, insomnia, hollow in stomach. Most people say they wouldn't take the pill. But why? People feel in general we are creatures that grieve; something wrong to short-circuit that. We do try to get over it; we do get over it; but there is some reason why we are creatures who do this. There are other people who have more specific reasons for not wanting to take a pill such as this: period of bereavement is still a period of connection with the person; in thinking about the person, even though you are unhappy, that person is still a part of your life. If you take the pill, you would be losing that person again. There is a way in which it's not obvious why that is out of bounds for people but people would use all kinds of other chemical enhancers, from caffeine to SSRIs to deal with real life problems. Grief is the only category in the DSM that's excluded from the diagnosis of depression. Not supposed to be clinically depressed. In the DSM-V, coming out in a couple of years, they have gotten rid of that exception, so that you can be diagnosed as depressed even if in period of grieving. Good time to buy stock in Lily and Merck. Not a lot of new drugs in the pipeline. They tweak the molecule, give it a new brand name; then have a copyright for a certain amount of time. Goes generic, have to tweak it again. In spite of claims of all the money the pharmaceutical industry pours into development, there doesn't actually seem to be that much in terms of research and development recently. What's the future of that industry? They spend a lot; what they choose to spend on depends on what's subsidized. Analogous story, Nozick podcast, the Experience Machine: hook yourself up, could fulfill any fantasy you wanted: be a great athlete, cure cancer, surfing dude; feels real. Only on the machine for a few minutes; but then they unplug you and you not only didn't actually accomplish the thing, but you are dead. Some people would hook themselves up; some wouldn't. Natural element; religious element as well. Feeling that God has a certain path for you, and by hooking yourself up to a machine you are not only cheating yourself, but betraying your purpose in life. Whether informed with a God view or natural feeling, something about the inauthenticity that is troubling to people. We do cheat in lots of areas. Death, purpose of life, sex--we cheat there too--areas we have a lot of emotional, spiritual baggage. Tricky part is figuring out where the line is. Can feel that God made us in a certain way; but God made me with very bad eyes; don't feel any compunction about wearing glasses. Michael Sandel, bioethics: meaning of life is to accept the limitations of your life. What constitutes authenticity, autonomy, is a matter for religion, culture--not science. Sylvia Nasar, A Beautiful Mind, John Nash a couple of times refuses shock therapy because he and his family had a certain respect for his brain. He had a gift; would be wrong or immoral for him to lead a more placid life if it meant cutting off some of his creativity. That is what some people feel about some of these chemical interventions. A lot of associations between depressions, bi-polar disorder, and creativity. It's not clear that people who have been medicated are less creative. They sometimes value the manic part of bipolar disorder as part of their creative aspect, but they can't do it when they are manic.

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