Marco Ramos on Misunderstanding Mental Illness
Feb 20 2023

brain-enigma-300x300.jpg When psychiatrist Marco Ramos of Yale University prescribes antidepressants to patients in distress and they ask him how they work, Ramos admits: We don't really know. And too often, they don't work at all. Despite decades of brain research and billions of dollars spent, psychiatry has made little progress in understanding mental illness. Listen as Ramos explains to EconTalk's Russ Roberts how the myth of the biological basis for mental illness began, why it stubbornly persists, and why honesty about what we know and don't know is the best policy.

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Gary Greenberg, psychologist and author of The Noble Lie and Manufacturing Depression, talks with EconTalk host Russ Roberts about the nature of addiction, depression and mental illness. Drawing on ideas in the two books, Greenberg argues that there are strong...
Louis 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...
Explore audio transcript, further reading that will help you delve deeper into this week’s episode, and vigorous conversations in the form of our comments section below.


Dr. Duru
Feb 20 2023 at 6:13pm

This was a VERY timely podcast for me! I recently joined the board of a start-up charity that will raise money for scholarships for 1) students pursuing fields related to mental health, and 2) providing free counseling sessions. We hosted our launch party just last week.

This discussion covered so much ground and the associated Boston Review article so much more! I don’t even know where to begin in commenting on how much I appreciate all this work. I am holding closest to heart the summarizing comment at the end from Ramos: “We need to start think of mental illness as something that is a relationship with a broader cultural, social, and political world. Until we start doing that we’re going to continue to perpetuate this psycho pharmaceutical system that we’ve been critiquing…”

I am also going to pay closer attention to how offering more counseling services may only treat the symptoms of critical political, social, and/or cultural issues. Those issue threaten to constantly undermine treatment efforts.

Finally, like Russ, I would caution blaming “capitalism” for the pressures people feel in life. Such blame seems like an easy foil given we live in a capitalist system. Show me a different economic system where large numbers of people do not struggle to make a living. Chasing utopian systems of living seems like a mirror to the escapism offered by psychedelics. Instead, I prefer Russ’s approach would be to get creative about how incentives and free market principles can unleash the kind of innovative thinking and effective methods we so desperately need on issues of mental health.

Barbara Ann Johnson
Feb 20 2023 at 6:28pm

I’m an RN, retired. Again and again, I see doctors relying heavily on “tests”. I’ve had Rheumatoid Arthritis for more than forty years, but never had a positive result test result for RA and only a slightly elevated Sed rate. I was a palliative care specialist in a hospital and a young woman with stomach cancer had an abrupt change of condition. Her oncologist though she had a reaction to an opioid. I was asked to see her in the ICU. She was dying. I saw all the signs. I told her oncologist and he said that all her tumor markers showed she was improving. She died two days later. Labs are not the answer. I attend a day program two days a week for depression. The saddest part is to see so many unloved people and chronically ill people. It’s love and caring that we all need first, even with drugs.

Feb 20 2023 at 7:28pm

I’m a psychiatrist with 10 years of experience and have come to appreciate Paul McCue’s answer to this question of where mental illness resides more with each patient that I see. He highlights the interplay of four perspectives the biological, psychological, life story and Behavioral. For anyone looking for foundation from which to understand mental illness. Paul McCue’s perspectives of psychiatry is a great place to start building.

Shalom Freedman
Feb 21 2023 at 6:14am

There is a very large claim at the center of this conversation. It is that we have no real understanding of the way anti-depression medicine works. The claim also leads to another claim regarding the falseness of Neuroscience’s and Pharma’s claims of understanding how the drugs are effective.

The fact that according to Marco Ramos the drugs do work in thirty percent of the cases does not he maintains change the truth that we really do not understand how that is the case.

While I share the view that drugs cannot cure all Depression and that much Depression can be contended with only by changing the person’s life, I am also skeptical of the absoluteness of denying any neurological understanding of Depression.

No doubt there are ways of understanding Depression through consideration of Social and Cultural factors also. But my guess is each individual story must be considered and treated on its own and that the way to help those of the seventy percent that can be helped is not through any single correct analysis or understanding.

Feb 21 2023 at 11:01am

I think Ramos is off regarding a point about suicides and mass shootings being a mental health issue. He assumes that when people point to these problems as mental health issues that they are also implying mental health experts to be the solution.

Maybe being at Yale, he is around more people who think experts are the solution to everything, but I think when most people point out the underlying mental health issue, they understand it is a result of societal/spiritual issues and they don’t mean that more mental healthcare in the form of experts is the answer. More people agree with him that there are social issues at work here then he gives credit for, I think. Maybe I’m just in my own bubble.

Mark Crady
Feb 21 2023 at 1:38pm

I was hoping for more a deeper discussion of capitalism’s challenges when it comes to depression.

The fundamental problem is that what we “want” and what we need are two different things and capitalism does such a good job of giving us what we “want” that we don’t end up getting what we need.

Take food. Getting a burger delivered to my door for less than $10 is truly amazing.

Pre-ground beef so I don’t even have to struggle with a fork and knife.
Special sauce, engineered to give my taste buds exactly what they want.
Delivered to my door so I don’t have to bother to go outside
Dropped off at my doorstep so I don’t have to interact with people.

But struggle, eating healthy, going outdoors, and social interactions are how we evolved and they’re all necessary parts of a full life.

Similarly, capitalism has done an impressive job of giving depressed people what they “want“. A simple pill they can swallow that might make them somewhat happier.

But what they need is to struggle with exercise and to eat healthier and to spend time outdoors and to build social connections with neighbors, friends or loved ones.

Jonas Koblin
Feb 22 2023 at 2:03am

The fundamental problem is that what we “want” and what we need are two different things and capitalism does such a good job of giving us what we “want” that we don’t end up getting what we need.

Excellent point Marc!

Jonas Koblin
Feb 22 2023 at 1:59am

Very timely for me too. I was just reading David Foster Wallace’s Planet Trillaphon:

“there were two general kinds of antidepressants: tricyclics and M.A.O. inhibitors… Apparently both kinds worked well, but Mr. Kablumbus said that there were certain things you couldn’t eat and drink with M.A.O. inhibitors, like beer, and certain kinds of sausage. My Mom was afraid I would forget and maybe eat and drink some of these things, so we all conferred and decided to go with a tricyclic. Dr. Kablumbus thought this was a very good choice. Just as with a long trip you don’t reach your destination right away, so with antidepressants you have to “go up” on them; i.e., you start with a very tiny little dose and work your way up to a full-size dose in order to get your blood level accustomed and all that. So in one way my trip to the planet Trillaphon took over a week. But in another way, it was like being off Earth and on the planet Trillaphon right from the very first morning after I started. The big difference between the Earth and the planet Trillaphon, of course, is distance: the planet Trillaphon is very very far away. But there are other differences that are sort of more immediate and intrinsic. I think the air on the planet Trillaphon must not be as rich in oxygen or nutrition or something, because you get a lot tireder a lot faster there. Just shoveling snow off a sidewalk or running to catch a bus or shooting a couple baskets or walking up a hill to sled down gets you very, very tired.”

Doug Iliff, MD
Feb 23 2023 at 8:02pm

Minor points:

I did an internship in psychiatry, three years of residency in family medicine, six years of emergency room, and now 36 years of active family practice.  I’m old enough to have experienced the age of MAO inhibitors and tricyclic antidepressants.  They were virtually useless for depression, but I did spend too many nights after overdoses sitting in the ICU watching a monitor for fatal arrhythmias.

SNRIs (e.g., fluoxetine, sertraline, escitalopram) were a godsend.  Overdose deaths are virtually nonexistent, and they are remarkably, though not universally, effective.  Dr. Ramos, being a relative youngster, missed this experience,  I’m happy to hear that the explanation for their method of action is unknown, and that I’ve been deceiving myself all these years; however, being a pragmatist, I don’t care.

Since 1980 I have practiced in the home of the Menninger Foundation— at least until it departed for Houston because insurance companies would no  longer pay the bill for many months of expensive psychoanalysis.  My dad grew up next door, so he had the experience of meeting movie stars of the 1930s.  Cognitive behavioral therapy matches psychoanalysis in its human connection, but adds practical exercises directed at confronting and conquering emotional blocks.  As noted, CBT and drugs work better together than either alone.

Big point: our society is in real trouble.  It’s not just privileged adolescents at Yale.  I live in the middle of the Midwest, God’s country.  If you want to be shocked, look at the pictures by young artists displayed in today’s paper:

I wrote to the author that he needs to put these kids on suicide watch.  This is, at root, a culture of death— coming from social media, Hollywood, and bad philosophy.  There’s the basic problem.  It’s not an issue of economic or political philosophy.  Culture, cell phones, and religion are the battlefield.

Doug Iliff
Feb 24 2023 at 8:01am

I failed to proofread: should be SSRIs, not SNRIs.  Sorry!

Comments are closed.


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TimePodcast Episode Highlights

Intro. [Recording date: January 24, 2023.]

Russ Roberts: Today is January 24th, 2023, and my guest is Marco Ramos, M.D., Ph.D., historian of medicine, and psychiatrist at Yale University. Marco, welcome to EconTalk.

Marco Ramos: Thank you so much for inviting me, Russ. I'm delighted to be here.


Russ Roberts: Our topic for today is an article you wrote last spring for the Boston Review, and you were reviewing two histories of psychiatry, and the title of the article really grabbed my attention: "Mental Illness Is Not in Your Head."

Now, you may not have written that title. Usually authors don't get to write their own titles. But, that's what your article is about. And, for interested listeners, we've done a bunch of related EconTalk episodes on this topic with Gary Greenberg, Louis Menand, and more recently Johann Hari, and you can find those in our archive. We'll link to them with this episode.

So, I want to start with a quote. You said the following, quote:

In 1990 President George Bush announced that "a new era of discovery" was "dawning in brain research." Over the next several decades the U.S. government poured billions of dollars into science that promised to revolutionize our understanding of psychiatric disorders, from depression and bipolar disorder to schizophrenia. Scientists imagine that mental illnesses in the future might be diagnosed with genetic tests, a simple blood draw, or perhaps a scan of your brain. New pharmaceuticals would target specific neurochemical imbalances, resulting in more effective treatments. The 1990s, Bush declared, would be remembered as "The Decade of the Brain."

Marco, how did that turn out?

Marco Ramos: Yeah. Thanks again so much for having me, Russ, to discuss this important topic.

It didn't turn out, is the truth. And in many ways, exactly that hope for a biological future for psychiatry is what drove me personally into the profession itself.

You know, I grew up in the 1990s, and I was looking at all of the promises that were coming with some of the drugs that were coming out to treat depression, as well as schizophrenia. There were sort of neuro--shiny, colorful pictures of the brain that were coming out on TV and sort of educational programs, as well as from our President, as you just outlined. And that's part of what pushed me, my interest, into mental health.

Actually in college I was doing neuroimaging research on aging. But, unfortunately now that I'm sort of on the other side of training, I've really found that biology has very little to do with my day-to-day practice.

So, when I treat patients every week and I prescribe an antidepressant, for example, for depression, and a patient asks me a very simple and reasonable question about how does this drug actually work in the brain--why do we think biologically it's going to help my depression that I'm experiencing? I don't have good answers and we don't really have good answers.

We do know some of the things that those drugs do in your brain, but the things that they do in your brain has not been linked to an improvement in a given patient's mood. Really, a lot of what we know, particularly with respect to pharmaceuticals, is trial and error.

And, that's the case, as I was just saying for antidepressants, but really for pharmaceuticals across the board. We're not really sure why they help people.

But the myth that the reason that they're helping people is because they're targeting some underlying biological reality that undergirds mental illnesses continues to get propagated, has made pharmaceutical companies lots of money, has made academic researchers careers.

And so, the piece in many ways was actually leaning on these two books to take a step back and say, 'What do we actually know about the biological reality of mental disorders?' And, it turns out we know very little.


Russ Roberts: And you write about this. It's certainly--I'm older than you; I've watched this field evolve over time, and there is a desperate desire to treat mental illness like physical illness. They both share the word 'illness.' And, physical illness, we can see a tumor, we can find a parasite, we can find a bacteria, and we often have a mechanism for fighting those.

The hope was that this would also happen here. And, as you say, and as other guests have come on and said, there is this, I'd call it--I think Gary Greenberg calls it a 'noble lie,' or you could call it a piece of folklore. 'Well, there's a chemical imbalance in the brain.' The problem is we have not been able to link any measured chemical imbalance with the disorders we're trying to treat. Correct?

Marco Ramos: Correct. Yeah, that's exactly the issue. It would be great. And, again, part of the reason that drove me into psychiatry originally was the hope for a biological test: that, if you came in and told me you were suffering depressive symptoms, I could measure, perhaps, something in your blood; we could send you for a scan. Any sort of what's in the literature called a biomarker. Then we could have a biomarker that we could use to say definitively, 'You have this condition.'

And because, just like we have biomarkers, for example, for diabetes, as you've suggested, or we have sort of genetic markers for different kinds of cancer that determine what treatment we're going to use, we could have something similar for mental illness. And, the truth is we just don't have that.

But, we keep trying to shove mental illness into this biomedical frame, into this biomedical box, despite the lack of progress on this front in many ways, over the course of the last half century. We suffer, I think in many ways, in academic psychiatry from a lack of imagination. From being able to see a frame for psychiatry that's not this sort of very narrow and rigid biomedical structure that we're sort of just continually trying to shove psychiatry into.


Russ Roberts: And, we'll come back later and talk about some alternative perspectives that you've outlined, which are very provocative. Because once you have a title, "Mental Illness Is Not in Your Brain," the next question is going to be: Well, where the heck is it? And, we'll talk about that.

But, I want to continue to talk a little bit about more of what we might call this--it's tempting to call it meta-science. It's not meta, though. It's not science. It's fake science, or I don't know, a narrative to help people, but it also helps make people rich so they have an incentive to lie about it. This idea that there's an imbalance or an inadequate amount of some chemical and that a pharmaceutical drug might correct that is deeply appealing for all kinds of reasons.

And, when I have spoken about this before with guests, many listeners will angrily--angrily--write in: _fill the blank_--some pharmaceutical they've been taking for some time--'saved my life. I was depressed. I was suicidal. But since I've been taking _blank_, I'm much better.'

So, on one level, and certainly for certain people, these drugs that, even though we don't understand how they work, they seem to work.

Now, some of it could be a placebo effect. Some of it could be if you're prescribed nothing over some period of time, the symptoms would have abated anyway. But, there are many, many people and many doctors will tell you, all that is true--what we've been saying for the first few minutes of this conversation--but that does not change the fact that these pharmaceuticals help people. Do you agree or disagree?

Marco Ramos: I, no--

Russ Roberts: And, what kind numbers are we talking about?

Marco Ramos: Yeah. That's great. And, I'm really glad you sort of brought this point up, Russ, because I think it's an important distinction between does a drug work?--in other words, when we give a pharmaceutical for depression, does it help someone's depression? That's one question. And, then on the other side of the question of how does the drug work?

What we've been talking up to this point is all about how does the drug work? It's been touted, as we've been saying, that it works biologically, but we really don't know the answer to that.

And so, you've brought up the question of: Do these drugs work? And, I absolutely believe these drugs work for certain people. I think the data show-- the best data that we have--shows that it's about 30% of people who take them, who meet criteria for depression as we define it, will have some sort of benefit on their mood, because of the drug. If you add placebo on top of that, it's approaching like 60%.

Now, when I'm treating a patient in front of me, I don't really care if they're getting better because of placebo or because it's, quote-unquote, "really the drug." I just care that they're getting better. So, I also share that with my patient. So, that patient who is sitting in front of me and saying, 'How does this drug work?' I'm very open. I said, 'You know what? We really don't know exactly how or why this drug helps certain people. We do know it helps about 60%.' And, then I break it down for them, just like I just did for you here. So, I use these drugs on a weekly basis with my patients because I found that I think they do help them.

Now, it's frustrating because I think we need to divorce these two ideas. Just because we're saying we don't know how this drug works biologically does not mean we need to throw out the drugs altogether. Right? So, I think there's plenty of middle ground between those two positions.

The problem I have, I think, is that this myth--or this noble lie, as Gary Greenberg put it--keeps getting touted instead of academic psychiatrists as well as pharmaceutical companies taking a more humble and honest position and just leveling with people and saying, 'We don't know how these drugs work, but they seem to work for this percentage of people and we have good evidence that they do, and so we should continue to use them.'


Russ Roberts: It reminds me a little bit of the story--I heard it told about Enrico Fermi. It's told about Niels Bohr. I think it's probably told about Einstein. A student comes into this great scientist's office and there's a horseshoe over the door and student says, 'Professor Fermi, you don't believe in that, do you?' And, he said, 'Oh, of course not. But, they say it works even if you don't believe in it.' And, there's an aspect of this that captures.

But, the part that's disturbing is, of course, that for some people--say, 60%, or 30% if you take out the placebo effect--it works for a while; and it doesn't work for very long and it requires that you change the dose or you add a different cocktail or you substitute.

And, then the second, of course, equally worrisome problem is that there's serious side effects to many of these drugs, and they're not small. It's not like the ads you hear on TV, 'could include indigestion or discomfort.' There's some terrible side effects for some people on these drugs. So, talk about those two issues.

Marco Ramos: Absolutely. Yeah. Absolutely. And, I'm going to talk about the side effects at the individual level, but then I'm also going to back up and just reflect on how this myth has affected how we understand our mental health just more broadly, which I think is in some ways the larger damage that it's caused in our society.

But, you're absolutely right. These drugs have some tremendous side effects. For example, certain, what are called second generation antipsychotics, which are often used either for schizophrenia, but they can also be used for--in conjunction with antidepressants for mood--they can cause diabetes. And in fact, if you use them long enough, they inevitably will cause diabetes. It's not really a question: it's just a matter of how long you use them. And, sure, the guidelines say we should measure for it and we should track if someone's developing diabetes and all these certain things. But, we know that it's going to give the person diabetes if we continue to use these drugs in the long term.

And, you really have to have a conversation with the patient about these longer term side effects that they may have, and you really have to take a step back and wonder: Is it worth it? Is it worth giving this patient a condition--a medical condition--that they did not have before so that we can address[?] this particular issue?

And this feeds into that larger point that I was making, is: really what pharmaceutical companies capitalized on with this myth of the biological reality of mental illness, is that the solution to our subjective psychic distress in society is a pill.

The reason that you are not--and this is exactly what all the ads--so, I'm teaching a course on the history of drugs right now at the undergraduate level here at Yale and we're talking about how in the 1980s as direct-to-consumer advertising for pharmaceuticals became legal for the first time in the United States, pharma capitalized on that by saying, 'We can create demand for psychopharmaceuticals by convincing people--with television ads, with print ads--that the subjective distress that you're feeling in your everyday life: You think it has to do with your job, you think it has to do with your relationships. It doesn't have to do with any of that. It has to do with your brain. It has to do with the neurochemical imbalances that you're suffering from. And, the only solution to that is a pill.'

And, that heavy advertising, and then the market that developed along it, has in many ways created a society--particularly for people, I think in many ways who have privilege, who have access to doctors, etc.--where when you're not feeling well, one of the first things you ask yourself is, like, 'Should I be on a drug?'

And, that sort of individualized approach, biological, if you will--in scare quotes--quote, "approach" to our mental health is in many ways I think the larger legacy of this myth of the biological reality of mental illness. That, the way that we need to approach our emotional and psychological problems in our everyday life is to go to a doctor and to get a pill. And, that approach forecloses a lot of other questions, a lot of other ways of understanding mental health, and that in many ways is I think the larger result of this myth.


Russ Roberts: Well, you said, It's not your job, it's not your relationship: it's in your brain.' And Gary Greenberg would say, 'Yeah, of course it's in your brain. Where else would it be?' But the question is: where does it come from and what's the best way to cope with it?

And, the pill idea--I think of it as sort of--one of my favorite cartoons is the person whose car is by side of the road and the hood is up, and I think it's one of the passengers is looking under the hood and the second one comes out to check on it, and the person looking under the hood says, 'I think I know the problem.' And, under the hood is a giant On/Off switch and it's set to Off. So, it's easy to fix, just put it back on On. And, you're depressed or you're unhappy or you have anxiety or you're stressed out or you're sad: Just give me the pill. I don't like to suffer.

And, I think--I've never really spoken about this on the program, but I suspect some of the cultural sympathy that we have for this idea that a pill is better to deal with this is a reaction to the pre-Enlightenment Age view of suffering, which was: It's a punishment from God, say. Or, you have bad luck. Or some, quote, "non-scientific" explanation. And, the idea that it's actually in the brain and it's a chemical thing somehow is seen as an advance.

And, I think that one of the deep aspects of the way you write about this is a realization for me--even though I've thought about this for a long time; we'll come back and talk about this later. But, a realization for me that actually that's not helpful. It's not an advance. Yeah. Now it could be, right? Could be. But so, far, it's actually an illusion, or a lie--at least so far. And that is shocking, at a certain level. And, I'm sure your patients go like--and Johann Hari has written about this--like, 'What do you mean it's not a chemical? You don't know how it works.' I mean, of course: 'It's science. It's a pill. It's the switch. You found the switch that was on the wrong setting and you fixed it. It just fixes it.'

Marco Ramos: That's right. Oh, absolutely. Yeah, and absolutely. But, what I will say is that I've found that people really actually appreciate the honesty and the education. And, I think there's a pressure on the professional side to--particularly in psychiatry, which always has felt sort of, 'Is it a part of mainstream medicine or is it not?' It's always occupied this kind of marginal relationship.

Well, that's not true. I'm an historian. So, there were moments where psychiatry was more mainstream. But at least now, especially, and certainly for the last, I would say, half century, it has occupied this somewhat marginal position that has pushed academic psychiatrists and psychiatry as a profession to act like we're just doctors like everyone else. In some ways to peddle these lies or lean on them when we can to make ourselves feel like we're specialists, just like if you were to see a kidney doctor.

But, I found that that that sort of openness and honesty, while it is--without a doubt patients are coming to mind who are just look at me incredulously and are like, 'Is it that you don't know how they work and other psychiatrists do, or do we really just not know?' And, then we have a conversation about it. But, then I'm also very honest about the data on efficacy and how I really do feel like it's going to help them.

I also, as a historian, want to take a little bit of a step back about: When is it--because we often think of the 1980s and 1990s as when pharmaceutical companies started pushing out the first antidepressants. But, really the first blockbuster psychopharmaceutical was in the 1950s. And, it was a drug that now really doesn't exist, at least under this trade name, called Miltown Meprobamate. And, it was a drug that came out, and in the 1950s was a huge blockbuster drug. And it's specifically the first time that pharmaceutical companies started to realize--and this is in the wake of very effective medical drugs coming out, so, like, penicillin, the Salk vaccine for polio.

All of a sudden you have this moment where pharmas are realizing prescription drug markets are where the money's at, not over-the-counter stuff. Like, 'We have these effective drugs now.'

But, it's with Miltown that they start to think, 'We can have a drug that doesn't just treat a disease in their body. We don't have to wait for people to get sick to make money from the drugs they take. Instead, we can use this drug Miltown that treats people's anxiety, particularly upper middle class, white collar professionals and their families.'

So, the image that they had of Miltown specifically--we're sort of familiar with 'Mother's Little Helper' perhaps, and Valium, in the 1970s. But, Miltown in the 1950s was really targeting the white collar businessman and professional who's got high demands for productivity. Right? Like, going to his job--it's super stressful. The solution, right, that the pharmaceutical company offers you at this time is not to say, 'Do I need a new job?' Or not to say, 'Do I need to sit down and talk with my boss?'

No, none of those things. If you take this pill, you'll feel better and you'll continue to be as productive as you need to be.

And, I think that underlying--which is the sort of origin of what has been called in the literature 'lifestyle drugs.' Right? These drugs that are designed not to treat a sickness or illness medically in your body, but are designed to sort of optimize your life in a particular way. These lifestyle drugs that were designed really in many ways--and this is as American as it gets--to make us productive as possible--right?--in sort of business settings still undergirds the ethos of a lot of sort of the drug culture, if you will, in the United States. Where we think about drugs as ways to make a life that sort of sometimes makes us suffer, but we feel like we need to do it to be productive, to continue to thrive, what have you. It makes that life possible. Right? Taking this drug makes the life possible. And, I see this a lot with, particularly my undergraduate students, at a sort of the pressure cooker that is a university like Yale.

Russ Roberts: Which is weird because they all get As. But, it doesn't matter. Some get A-minuses and that's--

Marco Ramos: Yes. Oh, they find ways to be competitive. It's just like them. Yeah.

Russ Roberts: Yeah, they'll find it.


Russ Roberts: This is a crazy speculation. I've never read or heard this. I don't know if there's anything to it. But, you know, my dad worked an office job's life. He worked in air defense, and I think he was under a lot of stress in that job. And, there was a long period of time where he smoked two to three packs of cigarettes a day. And, at some point I asked him, as a kid--I just will mention as an aside, people say you should model things for your kids. There's modeling and then there's anti-modeling. After watching my dad smoke, I have never smoked a cigarette in my life of any kind--just for the record--because I was so turned off by his habit. And, it had health consequences for him down the road. He lived to 89, thank God, but still some of those years were unpleasant because of his smoking.

But, I asked him something about why, what was good about it? He said, 'Well, it calms me down,' or it helps him.

And, I'm wondering--there are two things that are obviously true, one of which is: Pharmaceutical companies have been very good at getting the government to cover the out-of-pocket costs for consumers. So, part of the reason that they can be so successful with their drugs is because they're reaching into the pockets of taxpayers rather than the people who are taking the drugs. And, I've talked about that many times on this program. I'll stop there.

But, the question I'm thinking about is the following. You give a number, like one out of six Americans is on some sort psychotherapeutic drug. And, I'm certainly aware of the rise, especially among young people of drugs for anxiety, ADHD [Attention Deficit Hyperactivity Disorder], you name it--various things that before were just treated as difficulties that are now treated as illnesses to be cured.

And, I'm wondering if the reduction in smoking, which was a palliative effect for some of the stress that we're talking about, encouraged the demand for some of these alternatives. Have you--do you ever think about that, read about that?

Marco Ramos: Not that question in particular, but I like that kind of question. And, I'm going to speak a little bit about it, which is that we often separate--and this is also a function of this biomedical lies, myth, about the biological reality of these illnesses--we often separate exactly what you're bringing together. We separate drugs like cigarettes, which are not, obviously we don't--physicians don't prescribe them. You don't go to a pharmacy to get them. You get them at a gas station or whatever. We separate drugs like that from prescription drugs that you go to your doctor to get. And, we act like these two things are totally separate and distinct. Right? One is for recreation. Sometimes they're illegal if they're too much fun or too dangerous or what have you. And, that's the sort of recreational drug market. And then we have the sort of medicalized market, and in that context, the drugs are used specifically to treat an illness, and you're a patient in that context, not like a drug user or a consumer.

And, in many ways, this division is altogetherr--well, it has real consequences for people. In terms of the substances, it's false. In my History of Drugs class, I talk about how the same biochemical substance often crosses this line back and forth and back and forth. Tobacco--I mean, we got to go a little bit farther back for tobacco--but, in the sort of early modern period was thought of as a cure-all even for things like cancer. And in fact, the first-line intervention in France to resuscitate someone who was unconscious was to actually blow tobacco smoke through an enema through their rectum into their intestines. And, there were all sorts of medical treatments written about tobacco. Obviously it's crossed the line into recreational for a variety of important reasons.

But, we can see this with opiates. Right? Opiates for in many contexts have been used as prescriptions, but they're also used recreationally. Over the course of the last 200 years, opiates have pinged-pong back and forth many, many times with dramatic consequences on people.

So, we need to see the boundary between this medicalized market and this recreational drug market as extremely porous, and we should be suspicious of it. And, I think your contention that we should see a history of cigarette use as a way for people to deal with the anxiety and stress of their everyday life and a history of Miltown, or Valium or other benzos as a way to deal with anxiety, as part of the same history.

What's happening is people are anxious in their lives, and they're turning to substances in different ways. Sometimes that happens through these recreational markets; sometimes that happens through the medicalized market. But, what pharmaceutical companies realize, for some of the reasons you were just saying, is that if they can medicalize things that people are targeting with their recreational drug use. So, like if I'm drinking alcohol because, to take the edge off after work every day. If I can medicalize that, then there's a lot of money to be made there, and there's a big market there that you can create and that you can continue to tap into.

Russ Roberts: And of course, the idea that a glass of wine is--one, not two, not 1.7--but one glass of red wine could be good for your heart, is the wine industry's counterpoint to the 'cigarettes cause cancer: you should be taking Valium instead.'

I can't help but think about Noah in the Book of Genesis who, after watching the entire world destroyed and everyone's dead except for his immediate family--which, it beats the alternative probably, but it's a jarring reality to face. The first thing he does is he plants a vineyard and passes out from alcohol--and why? Because there are no antidepressants for him. The pharmaceutical company, the pharmaceutical industry hasn't come along yet.


Russ Roberts: Anyway, before we move on to the alternative ways to think about this, which we'll turn to next, I want to ask one thing about CBT [Cognitive Behavioral Therapy]. Now, CBT, often gets abbreviated that way as CBT, it stands for I think cognitive behavioral therapy, which is a fancy word for talking. It's the old school of psychoanalysis. You mention Freud in your article.

For a while, there was an idea that we could talk to people. And, if I remember correctly from Gary Greenberg, there is some evidence--maybe a lot of evidence--that CBT--talking to a thoughtful person who can help you explore the sources of your anxiety or stress or depression or sadness--can work as well as some psychopharmaceuticals. So, where are we on that?

Marco Ramos: Yeah, I'm glad you brought that up. And, yeah, first of all, to that last point, that's absolutely the case. Many psychotherapy modalities, their efficacy is just as high, if not higher than pharmaceuticals.

One case, for example, where it's almost certainly higher is with PTSD [Post-traumatic stress disorder]. Cognitive processing therapy, which is a particular flavor of CBT, which stands for cognitive behavioral therapy, has better data than pharmaceuticals for the same condition. There, psycho-pharmaceuticals can help, as well.

So, it's undoubtedly extremely effective. The reason it's effective, I think is not a mystery. There's been quite a lot of good--like, people in the psychotherapy world can--I don't want to say 'tripped up,' but I'll say you can get tripped up about the differences between different flavors of psychotherapy. From psychoanalysis, which is more Freudian, to CBT, which is a different approach, and saying these are incompatible and completely different ways of looking at psychotherapy.

But, most people, many people in their daily practice sort of weave them together. And, the reason they work across the different modalities is largely the same. It's what you just emphasized, which the fancy term for it is called 'therapeutic alliance.' But, the idea is that when you feel connected with another human being--which is, again, therapeutic alliance--and you feel like that person is appreciating you in a wholistic way, is listening to you and cares about you, you feel better. And, that's it right there; and that goes a long way for people, that connection.

In terms of where are we now with it, it's with the advent of pharmaceuticals and that being the mainstay of treatment for many psychiatrists, because of a lot of structural factors. These factors have to do with, for example, if you have an outpatient practice, you're incentivized by pharmaceutical companies, by insurance companies, by your own desire to make a living, to see patients for a very short period of time, usually 15- to 20-minute visits. And, if you're seeing a patient for that short a period of time, it can be hard to connect in a psycho-therapeutically beneficial way. And so, what do you turn to in those cases? You turn to drugs: you turn to psycho-pharmaceuticals.

And so, there's an immense structural pressure for your practicing psychiatrist to use drugs--because they can see more patients, have higher volume, make more money--than providing hour-long or 45-minute-long cognitive behavioral or psychodynamic psychotherapy sessions. And so, there's a lot of pressure.

As a result, there's been a big push in American psychiatry as a whole to emphasize drug prescription over psychotherapy. And in addition to that, psychotherapy--and partly as a result of this phenomenon over the last half century--psychotherapy increasingly has become the domain of psychologists and social workers who have either Ph.D.s or social work licenses certification versus someone with a medical degree who is seen as a medical doctor prescribing medical--and these are scare quotes here--"medical" interventions like psychopharmaceuticals.

Yeah, so that's more or less the picture.

Russ Roberts: I just want to mention Thomas Szasz--S-Z-A-S-Z, for those Googling at home--who has written many thoughtful things about the way we treat people who are labeled abnormal, insane, crazy, whatever phrase we've historically used--now we say mentally ill. But Szasz had a lot of provocative and interesting things to say about this, and I encourage people to read them and see if they find him of interest.


Russ Roberts: But, I want to raise a question: that--whether we should be making a distinction here. So, Thoreau, in the 19th century, said, 'The mass of men lead lives of quiet desperation.' So, life is hard, even in our wealthy times: compared to the past, seems to be that people are not really much happier or maybe a lot less happy. And, to be cynical about it, I feel like the culture, driven by pharmaceutical industry, has moved the goalposts for mental illness to include not just schizophrenia, but unhappiness, sadness. And, then getting closer to more serious conditions, I would say the word I would use is despair.

And, obviously none of those are pleasant. None of them. And, many people would like alleviation from any of those symptoms. You call them moods.

But, would you make a distinction between somebody who struggles to get by day-to-day in a good mood with somebody who we would label schizophrenic, even if we can't medically determine it? In other words, if you've ever visited a psych ward--and I have as a exercise, once--the people there are not just sad. They are struggling in ways--you see them on the street in American cities now. You see them: they're talking to themselves--I talk to myself and I don't think I have these problems--they're talking to themselves in ways that are deeply disturbing. They're shouting, often. They're not functional, in the literal sense that they can't hold a job and interact with people in a normal way. But, they're deeply troubled.

And I would argue that that condition, which--we used to lock those people up, for better, for worse, we don't anymore. We, quote, "let them go." And, I think it's better and worse.

But, there's a difference, it seems to me, between the person on the street who is schizophrenic--even if we can't define that objectively or with a bio-marker--and somebody who is struggling to get by day to day and finds cigarettes, alcohol, Valium, you name it, a comfort.

Would you make that distinction? And, if so, how should we think about those more extreme cases?

Marco Ramos: Yeah. No, I think another really significant point is the medicalization of everyday suffering versus perhaps--which we've been talking about, the pharmaceutical industry exploiting, etc.--versus these more intense cases of psychological distress that certain people have. And, I agree and believe in that.

And, I think if you just look with humility about what have we learned in psychiatry over the last 150 years, and without being crazy optimistic or inflating our knowledge, just really: What have we learned? We've learned in many ways through just observation of people that certain people periodically will have certain states over the course of their lives that are very distressing. These states can be what we call, like, mania, for example. And then, we call people who have mania, we say have bipolar disorder.

But, it's a very particular state that has been observed consistently over time in many different settings by mental health professionals in certain populations. Right? And, we know some things about it because we've observed it for so many years. We know that if you've had one, you're likely to have another one. That they tend to become more intense over time, these manic states.

And, we could say something similar I think, as you've been suggesting, for psychosis; and people who have episodes of psychosis, we would say have schizophrenia now.

But, we know some things, that there are these certain states that people become extremely distressed in. They become less functional. They're unable to do the things in their life that they want to accomplish. In many ways, you can see mental illness really as: Someone's on a particular life trajectory, and then once one of these states happens, usually all of a sudden things start going in a drastically different direction. And, because we've observed it for so many years, we know some of the characteristics of what usually plays out when we've seen this given state.

So, I think that's undoubtedly the case; and I think it is important to distinguish those two things because we can also--people who are going through these experiences, whether it's psychosis or whether it's mania--we can confidently tell them some of what they might expect for the rest of their lives, some of what might help them in the shorter term. Sometimes it'll involve medication, sometimes it won't.

Yeah, so I just think that's a really, and yeah, I'm glad you brought it up. Because I think it's a really significant point, and I think it is something that is an important role for psychiatrists trying to suss out and distinguish these different things.

Now, the issue is--I've said all this about there are these different conditions that we've observed over time. It's a completely different question: Does the mental health system as it's currently constructed or as it has in the past--does it actually help those people who I've been describing? Does it help the situation? Does it make them worse?

And in many ways, if we look at the history of psychiatric confinement, the goal in most cases was not for the sake of the patient. Right? It wasn't for the care of the patient, even if it was sometimes put in those terms, if you look at it socially, going back to the 16th century, but all through the 19th century. It wasn't for the care of the patient that people were confined. It was the care of society at large, the, quote-unquote, "normal people" who didn't want to be walking down the street and see someone who was mumbling or what have you. Right?

And so, because of that social function of the mental health system itself, it leads to a lot of problems where, yes, we know that these sort of conditioning exist and they repeat in a certain way and we potentially can help these groups of people. But, the sociopolitical function of psychiatry--and this is what Thomas Szasz talks a lot about--over time--and this is the part of Szasz that I really think is useful--has been to label people who don't fit into society in a particular way as being pathological and then to confine that group of people and separate them from society.

And, that for me is where you start to get into problematic territory. It's the social and political function of psychiatry as a way of separating marginalized and labeling people.

For example, you might ask--and we have noticed these states over time, mania and that psychosis that you mentioned--can we imagine a society where, like, people who were occasionally manic and psychotic would, it would be fine? There would be a way for society outside of confining them to treat them, interact with them, care for them? Might it also--and this is, a lot of the: Szasz was writing in the 1970s, and there's a lot of other writers at the time who were asking these sorts of questions--in other societies, are these psychotic states actually seen as something that's beneficial?

And, increasingly, some of the research that's happening on auditory hallucinations--which for a long time in psychiatry was seen as a telltale marker of psychosis--it's increasingly coming out that a lot of people hear voices and a lot of people hear voices and don't have a lot of the other symptoms we associate with schizophrenia. And in fact, their hearing voices for them is a rich part of their life that helps them cope with what's going on in the world. And they also, in many cases, believe[?] can help others through a variety of mechanisms.

So, while I do feel like particularly mania and psychosis are things that we've observed over time in people and we know some things about, that does not mean necessarily that we should treat them as pathological and worthy of confinement, even though that's the way that psychiatry has approached them in the past.

Russ Roberts: Szasz writes about lots of interesting things related to this, including, in the Soviet Union, the use of medical diagnosis to medicalize dissidents and to confine them in tragic and cruel ways.


Russ Roberts: But I think the fundamental question that you raise is the--which is unanswerable--Do the people who suffer from these manias and these psychoses, what do they want? And of course: Which 'they' are you talking about, the ones that are manic or the ones when they're not manic? And, if you read A Beautiful Mind, by Sylvia Nasar or seen the movie, you know John Nash turned down--I think [when?] offered to be Chair of a Department of Mathematics--because he said he was busy being Emperor of Antarctica--and he meant it very seriously. And, he is one of the greatest minds of his time.

So, he was living in an alternative reality to the people around him, and they were very uncomfortable with it; and as they tried to cope with it in ways that you referred to earlier, they drew the line at shock treatments. They did not want his brain damaged to make him more pleasant to be around, or, quote, "more realistic." And then he had a period where he was not suffering from those symptoms.

And so, how we should deal with that--how we as families should deal with that, we as a community, as a society, as a nation--those are really, really hard questions. But, it seems to be those are the questions we ought to be talking about and thinking about.

Marco Ramos: Absolutely. Can I just push back on one point just a little?

Russ Roberts: Sure. Yeah.

Marco Ramos: Which is, it was just the notion that it's unknowable. Because, I think in some ways you're right: you're sort of pointing toward the difficulty with these big-big-picture questions.

But, in another way, there are plenty of people with schizophrenia who have a lot to say about how we should be treating schizophrenia.

And we should--that perspective has not been represented in the sort of structures that we've made to handle mental illness in our country throughout its history, precisely because of all this social marginalization we've been talking about.

And, because they've been so marginalized, this population and this community, people with lived experience of mental illness, that it never occurred to the, quote-unquote, "experts" to actually talk to them about what sorts of modalities they might actually find to be healing.

And so, you know, I would encourage, and I have got--and this is a genuine offer. I know people with lived experience in mental illness who have a lot to say about how they would like to be treated, and I'd be happy to connect you with them because I work with some of them. Some of them are community organizers here in Connecticut who are working with, like, the Department of Mental Health Services in Connecticut, to reimagine how mental health is delivered specifically in this state.

But, that's a concrete first step: Is, bringing that community into the conversation. Centering people who have lived experience of this, so that we can know how should we be doing this differently.

Russ Roberts: Yeah, I'm very sympathetic to that, and at the same time, I don't think we should--I don't want to romantic romanticize mental illness, which there's a strong cultural thread that does that. One of my favorite movies used to be the King of Hearts, which is, you could argue as a fable about insanity, and the theme of that fable is that the insane are the sane ones and the sane ones are the insane ones because they think the world we live in is normal.

So, I think you have to be careful. And I don't like that movie anymore. I think that romanticizes mental illness. And I don't want to criticize the creators of it. It's fable--it's a metaphor--it's okay.

But, at the same time, it's a tricky--it's a very challenging thing to think about who the real you is in various states and what you want in different states.

But my default is certainly to agree with you: That, the people who suffer in these situations should be the first person who we listen to. And, it's not just that weren't the first. Most of the time they were never listened to. So, I'm very sympathetic to that encouragement.

Before we leave this topic, I just want to mention one thing in your article, your essay that I found surprising. And just for my ignorance. Which is: I assumed that schizophrenia was one thing that, 'Well, maybe depression,' and other things that we might struggle to objectively measure with a biomarker.

But, surely schizophrenia is a genetic disease--quote, "it runs in families." And yet you suggest that it's so much more complicated than that. So, just say something brief about that; and then I want to turn to a different question.

Marco Ramos: Yeah. And, that that's very common, to see, sort of schizophrenia as a hard, like, biological disease in a way that some of these others aren't.

I will point out that right as my article was coming out, there was some research into the genetics of schizophrenia that looks somewhat promising. And I got a lot of tweets from that community when my article came out-- which I welcome, obviously.

I'm not against biological breakthroughs by any means. But I am interested in the question of what constitutes a breakthrough. And, even with these somewhat recent, still-tentative advances from my understanding of sort of being able to use these GWAS [Genome-Wide Association Study] technologies. Which basically--and again, I'm no geneticist, but just to break it down--there was a hope for a while that we would just find a gene associated with a particular condition. Right? That would be very clean.

There's other medical illnesses that follow that model. We can say: there's this genetic mutation; it results in this change in phenotype; which is the illness.

That has not panned out in terms of schizophrenia or bipolar disorder.

So then we turn to this GWAS strategy, which is basically a way, as far as I understand it--and again, my understanding somewhat limited--of looking at a variety of genes, sometimes in the case hundreds and thousands, and showing how across all of those genes particular changes can increase or decrease your risk for a particular condition.

So, there has been some advancement along those lines, I'm told by the genetics community.

But still--and this is after going back and forth with some of them--we are miles away from that resulting in any kind of biomarker. And, I will state, again, as I brought up before--and again, I hope we get biomarkers. I would love to have biomarkers. But, this thing has happened many, many times across history where there's some advance--right? There's some promising thing that happens. And then there's this big reaction to it: 'Oh, this is the breakthrough, this is the turning point,' etc. And, it just doesn't pan out.

And at some point--I like a lot of your references to art and film, and I think of, like, "Waiting for Godot." It feels like we're waiting for this sort of biological Godot. And at some point we need to stop, just, waiting. I think there should still be research on this front, but at some point, if we have a limited number of research dollars, then we need to start diversifying, and we need to stop putting all of our eggs in this one basket and stop just sort of waiting for this biological Godot that may never show up.

Russ Roberts: Yeah, we should put it all in for psychedelics, right?

Marco Ramos: Yeah, exactly.

Russ Roberts: Because that's the latest. Magic.

Marco Ramos: Yeah. That's another. That is the latest magic, without a doubt.

And it is--the enthusiasm that I'm seeing around it--here at Yale in particular, there's research on psilocybin. There's research that's coming out in certain corners on drugs like ayahuasca, on DMT [N,N-Dimethyltryptamine], which is the active ingredient in peyote, in MDMA [3,4-methylenedioxy-methamphetamine] for a variety of conditions, which is commonly recreationally called ecstasy.

Again, we should note, I was talking about recreational versus medical. This is another example of that sort of boundary-crossing. And I think in many ways, this is the same story we've been talking about; and this is what I worry about. People talk about this being a massive breakthrough and a turning point. And, yes, these drugs may help people. As they have in the recreational setting for a long time, for certain people who have enjoyed using them and feel like they give them insight into their life.

But, what we're really seeing here in many ways is the same story that we saw in the 1950s with Miltown, where you have pharmaceutical companies realizing that they can capitalize on this enthusiasm for psychedelics, and creating markets. And, with that comes all the problems that we've been talking about before, with lack of access to care, etc.

And, the other thing that I just noticed with this recent psychedelic boom--and this is what I talk a lot about in the article--is that psychiatry has just been so susceptible to hype over time. It's just unbelievable to me. If you look at now with psychedelics, in the 1980s with the biological turn, in the 1920s with these new psychosomatic interventions that were extremely violent, but won Nobel Prizes in the 1920s and 1930s. At each of these moments, there's just this overwhelming, unabashed, unscientific in many ways, hype around these substances without us just taking a pause and just saying, 'Okay, these are substances just like any others. Let's see what they do.'

But, the reason this hype keeps repeating itself is for a lot of reasons. But, I think if you look at the interest it serves, it serves the interest of pharmaceutical companies who are now going to be able to profit on these substances. Many of which have been used by indigenous communities for thousands of years, but now they're able to patent through various means, that I can talk more about, and profit from. And, it's also helping academic psychiatrists who are going to be able to build careers on this hype.

And so, that's why the hype, I think, keeps repeating itself. But I think it is time to try not to get swept in the hype quite as much.

Russ Roberts: Yeah, I'm 68. It's taken me a long time to reduce my susceptibility to hype. I'm not there yet, but I'm making some progress. And, when you talk about that--the psychedelics--I realize, 'Oh yeah, this is just like those other things.' You give examples from psychiatry. For me, it's more like Theranos, driverless cars.

There's a, I would call it messianic--and I say that with respect, as a religious person--but human beings have a messianic desire for redemption: 'We're going to solve this. The idea that it can't be solved is unbearable. That's out of the question. Of course, if we haven't solved it yet it's just a matter of time. And, you, Dr. Ramos, with your pessimism and cynicism, shame on you. We should always be hoping that this is the turning point.' And, of course, you're a human being. You realize that it could be. But, let's reserve judgment probably, at least for now.

Marco Ramos: Yeah. Absolutely.


Russ Roberts: Let's turn to the title of your piece, because I confessed recently that: this recent interview--it hasn't aired yet--on peer review, that I've always thought, 'Sure, peer review is awful. But we just have to fix it,' and then it suddenly, thanks to Adam Mastroianni, we should imagine maybe it's not fixable. And, your piece reminds me of that kind of outside-the-box-thinking, which is surprisingly difficult.

So, here's an area where--enormous amount of human suffering and enormous potential to help people--the idea that it's not in your brain is so jarring. And, certainly the episode with Johann Hari, he takes a similar approach to his own suffering and to these quick kind of questions, and it's a radical idea. The radical idea is that maybe--and a thoughtful scientific person has to entertain this radical idea because at least the crude evidence is that many societies don't suffer from these problems. Many of these problems appear to be what we would call first-world or modern problems.

Depression does not--it could be a definitional problem, diagnostic problem--but depression does not seem to be common among people who are not of the modern era, whether they're currently living now or in the past. And again, I don't want to romanticize those communities. They had other problems.

But, it does make you wonder why it is that in one of the richest societies, in one of the richest times, depression is on the rise. And, you can say, 'Well, that's just a diagnostic change.' Suicide is on the rise among young people, as far as I understand it.

Something has gone wrong. It's untenable--when you think about it, when you step outside all the cultural baggage we have around mental illness--it's untenable that it's just the fact that brains aren't working as well as they used to. That is literally a non-scientific hypothesis. It cannot be maintained.

So, you have an explanation. I'm going to disagree with it, but give us your explanation.

Marco Ramos: Yes. Because this is such a big-picture conversation, I'm going to bring it down to a particular case. Which is: here at the university where I teach--at Yale--and the very serious matter of suicide, which is something that has happened among students here, obviously. But also, it's an issue, as you've been saying, in young people generally. Particularly--and this tends to get more media attention--but it's an issue more broadly at these elite academic institutions. And, this question emerges, like: 'How could someone who has got everything to look forward to turn to something like that? There must be something wrong with them,' right? That is the underlying assumption.

And then next position is: Why couldn't they get access to mental health care?

So, that's sort of our reflexive script that we run down. There's suicide: there was something wrong with them. Why didn't they get access to mental healthcare?

And, I want to push back on that script, and I want to suggest that in many ways--and there's been this big push at this university in response to some of the high-profile suicides--and I don't know if you saw the Washington Post piece on how depression is treated here at Yale. In any case, your listeners can look if they want more information.

But, there's been this big push to expand access to mental health services for the student, and for students. And, again, who couldn't agree with that? Who couldn't agree with more mental health services?

But, what I really feel--and this is something that I actually unpack with students in my seminar on madness, on the History of Madness--is that this immediate push to increase access to mental health services is also a way of ignoring the actual reasons--structurally, socially, culturally--that people are feeling sick at an institution that is supposed to be so privileged, like Yale.

And so, what if, instead of just demanding access to individualized care, where you're likely going to get a psycho-pharmaceutical and you're likely going to get some therapy in the most ideal circumstances, what if in addition to that--I'm not saying we shouldn't provide individuals with care. What if in addition to that, we had a serious conversation about what is it in this culture that is making people ill? How can we move beyond the question of access to start to ask, collectively, what is happening in our micro-society here that people are feeling so sick that sometimes they feel the only way out is suicide? Right?

And, those same dynamics are affecting all sorts of other people in less dramatic ways that don't necessarily result in that--right?--but are still affecting people, nevertheless.

And, the issue that I have with this focus on access to mental healthcare, and then this focus--which is built into that with 'the illness is in that person's brain who took their life'--is that it forecloses a deeper examination of what is it about this place that is, to put it technically, pathogenic? What is it about this larger culture that we're sitting in that is making us ill, and what might we do about it?

Russ Roberts: Yeah, it's incredibly sad to me. I think economists don't like to talk about this. They would say, 'Oh, this is outside economics. It's not relevant.' We talk about incentives. We talk about wellbeing, though we pretend to, and we pretend to talk about people maximizing their wellbeing, and we assume it's connected to their access to material goods. Certainly people at both ends of the material wellbeing spectrum--the top, let's say 20%, 10%, 5% at one end, versus the people at the bottom who are facing a despair of a different kind--both groups are in despair, to me. And I think your insight is profound.

I feel the same way about the tragedy of mass shootings. We have a conversation about gun control: it's very formulaic. But for some reason, we cannot have a conversation about why it is that someone finds it compelling to kill strangers. Something has gone deeply wrong. You could imagine it happening once, twice. But, for it to happen occasionally, as it does now in America, is not a statement about gun control.

You could argue--it's very similar, by the way, to the pharmaceutical point for me. And this may offend people; I don't know. But, whether we understand brain chemistry or not, we understand that some pharmaceuticals can help some people. Similarly, whatever causes mass shootings, we could debate whether gun control of various kinds could mitigate the consequences of these events.

But, it does not ask what to me is the real question, which is not, 'How do we keep guns out of the hands of people while maintaining our First Amendment rights--Second Amendment rights, excuse me.' But rather, 'What has come to the world that this is considered normal?'

And for me, it's not much different from asking: Why is it we can debate what should be done about people living in tents on the sidewalks of American cities. But, you do have to think about--a thoughtful person should be thinking about--how do we get to this point where someone thinks that's a reasonable lifestyle?

And, you could argue--and again, I'm never going to romanticize that--but you can argue there's something beautiful about the fact that we let people live that lifestyle. We don't arrest them like we used to. Not only do we not arrest them, we don't put them in mental institutions where we put drugs into them against their will or give them shock treatment.

But, the idea that we don't look at the underlying problem, it is bizarre.

Marco Ramos: Yeah, it is. It is. And increasingly--and just to build on your example of gun control and mass shootings--mental health always emerges in these conversations. And that, to me, is the most absurd of the uses of mental health. I feel like I have to state this explicitly, even though it should be obvious, but psychiatrists cannot predict when someone is going to commit suicide or when someone is going to kill someone.

We have tried over many, many years to figure that out, and we are nowhere closer. They have done rigorous studies that have shown that we are just unable to do it. And, part of the reason is these are just such rare events that they're very difficult to predict. They're so contingent, etc. And, our science isn't that great--as we've been discussing--in the first place.

But, nevertheless--and this happens on, across the political divide, of liberals asking for more mental healthcare to conservatives--and it's a similar gut reaction, this cultural script, that there's this larger social issue: there needs to be more mental health.

And, to me, that forecloses the conversation that you are trying to get at, which is: What is more broadly going on here? What is happening as a society that's making this response--whether it's mass shootings or homelessness or suicide--possible, sensible, the thing that someone feels like they need to do? What's happening at a broader level?

And, mental health just gets sort of slapped on there. It's like, 'Oh, we hire some more psychiatrists, hire some more psychologists, and we're good.'

And, the problem is--and this is one of the issues I think that is unfortunate--is that psychiatrists and psychologists often don't get up and say: We can't fix that problem.

Russ Roberts: Why would they?

Marco Ramos: Exactly.

Russ Roberts: Better not to.

Marco Ramos: Exactly. Because it's more money, it's more jobs, etc.

And, this is no knock on a lot of practitioners who are feeling like they don't have the capacity to treat all the patients that they want to treat, so they welcome more resources, etc. So, I'm not trying to demonize anyone.

What I'm trying to do is just explain how this system perpetuates itself: where it's politically expeditious for politicians, as well as administrators and universities, to instead of doing a deep dive into the culture, to say, 'Okay, I can just hire some more psychiatrists and psychologists. I can just expand access to mental healthcare.' And then, on the other side with the practitioners, it's good on their end.

And so, it just becomes this script that's gotten so embedded where people just assume that mental health is going to fix things when access to mental health services is just not.


Russ Roberts: All these examples we're talking about are where I would suggest the solution to a social problem is palliative. It's: Let's reduce the consequences of this rather than get at the root cause. And I think you have to ask: Why are we so uncomfortable thinking about the root cause? And, I think you and I have different answers.

You want to put, I think, some of the burden on capitalism, and I want you to defend that. I don't agree with you, but why don't you make that case and then I'll give it an alternative view and we'll see if we have any common ground. But what we share, clearly, view that although palliative care is better than no care at all, it's not the effective or holistic way of getting at the problem.

Marco Ramos: Yeah. And I think that--I like the way you're framing that, is that sort of palliative care--that we can see mental health in many ways as palliative.

But, we need to be honest in framing it in those terms. That's really what it is. It's helping people cope with something that they are grappling with in their life in a particular way to provide some ease of suffering. But, it's not, on its own or at least as it's conceived of currently in the United States.

There are other ways of looking at mental illness from the past and through history in other settings outside of the United States--like in Latin America as well as Africa in post-colonial context--where mental health has specifically been linked to political and social mobilization, and in certain contexts they would consider it liberation. And so, part of my research, and the book that I'm writing, is sort of looking at the history of what was called Liberation Psychiatry in Latin America in the 1970s.

And, it starts with a very simple idea, which is that: You cannot be mentally--you can't have mental health unless you're liberated from the social structures that are making you sick. And, if that's the case, then there needs to be this palliative work, as you put it, that you're talking where you support the person who's being made ill by these larger social structures. But, there also needs to be political work on the part of the practitioner with their patients, to resist--to liberate them from--the things that are making them sick in society.

And, this still happens. I talk about them in the 1970s. But, part of the reason I'm interested in it is because it's still happening in certain groups today, and I can give a variety of examples.

But one, for example, was a train crash that happened in Argentina, where a lot of my research occurs, in 2014. And, it was essentially a product of the fact that the new government was disinvesting from state resources and so the trains became very unsafe and the trains tend to mostly be commuter rails for the poor.

And so, there was this horrible train accident. And, after the fact, the mental health professionals who I work with had these group therapy sessions with the families who had been effective[affected?], where they provided this support--palliative care--for what had happened.

But then these group therapy sessions built into political action--that not everyone participated in, but many people did. And, they came from this therapeutic setting where they organized and actually demanded that the trains-- that there be reinvestment in the train system, etc.--and that there would be reparations to these families who had lost a lot of income from having wage earners who were killed in the train accident. Etc.

And, not only that: The last, sort of--the way this loop completes, I think in many ways, is that: not only was the political action in many ways effective unevenly so, but in many ways effective in getting certain services for this community that had been affected. But also, psychologically, the process of politically organizing to speak back to the thing that had hurt you was psychologically therapeutic.

And, it seems very obvious. But it's not something--I was not trained to do that as a psychiatrist, you know, here in this country. I had to go to a different--completely different--place to even understand how I might connect the care that I provide to an individual patient to these broader social and political factors through my work as a practitioner. To even to be able to conceptualize that, I had to go to a different place, because it's so far outside the way that at least psychiatry is taught in this country.


Russ Roberts: Again, I think that, if I remember correctly, that's a theme in Johann Hari's book. And, my pushback there is similar to my pushback here, especially if you made a more broad critique of, say, any modern society and its reliance on market processes or other situations that we might call capitalism.

It seems the alternative is simpler--although I don't want to say it's therefore true. It's not: I'm not going to use Occam's Razor here.

But, a more--a simple--we don't have more capitalism than we had 50 years ago. You could argue we have less. We could dispute that. That's not what I want to talk about.

But, I think what we do have more of is loneliness.

And, we have--at our heart of our popular culture today--a device that I used to celebrate and I still love using, which is my phone. And, I see--you don't have to be a deep social critic or a deep social observer to see what the smartphone has done to human interaction in wealthy countries. There's less.

And, I think back to your comment about cognitive behavioral therapy, to interact with another human being is healthy. We're social creatures. We're social creatures who like meaning and purpose.

And the beauty of that post-train-wreck set of actions is that it combined, combining with a group of people to achieve something that was meaningful and purposeful and deeply empowering--I'm sure to the people involved.

And, for whatever reason, there's less of that in the modern world, it seems to me.

And, two obvious things that have changed are: God is dead, and the family seems to be dying. And those are the two things that through most of human history gave people meaning and purpose. A family, their children, their grandparents, whatever it was, and their religion. If those things go away, it might be hard to keep mental health for human beings that evolved under different set of circumstances.

So, I'm open to the reality that, say, globalization caused despair in certain parts of the world, and that people can't cope with it or don't want to cope with it, and they've turned to other things.

But, it seems pretty clear to me, and I'm a pretty big fan of personal choice, so I don't really want to restrict choice. I don't want to ban phones and I don't want to constrain them in certain ways. But, we have a problem.

It seems to me to be so obvious, and maybe when I say these things my younger listeners say, 'Oh, you're just old. You don't understand.' But, I think human beings don't connect with each other as much as they used to.

Now one--the optimistic take on that--is that: Well, we'll figure out new ways to do that. And we do connect in--I mean, I connect to people on Twitter in wonderful ways. You and I are two strangers; we're connecting over a podcast and people are listening and relating to us in imperfect, but pretty cool ways. But, it seems to me we have a loneliness problem. Do you agree?

Marco Ramos: Yeah. I mean, I think there's a lot of what you said--and I'm torn because I want to address the capitalism bit, but I also want to--

Russ Roberts: Go ahead. Take a shot at it.

Marco Ramos: Yeah, yeah, yeah. And speak to the loneliness. I just don't want to forget.

So, I'll start with the loneliness, though. And, what is sort of embedded in that question, which is our evolving relationship to technology, and how technology has changed the way that we relate to ourselves and the way that we relate to each other. And that we need to pay attention to and track how it's making new connections possible. But also, the ways in which it might be foreclosing certain kinds of, like, meaningful action.

And, this--I don't have much more to say on that than this is something we need to be paying particular attention to right now.

Specifically, you're seeing, with the advent of artificial intelligence and, like, ChatGPT--which is blowing up--whether the notion that, like, artificial intelligence could, for example, provide therapy. Right?

And, there's now been a study--this just popped up on my Twitter feed--where they blinded people to whether they were talking to a real person or they were talking to a robot in--not a robot, sorry, in ChatGPT; and ChatGPT was instructed to sort of provide empathy, etc. The ChatGPT responses were supervised by a human, versus a human; and they compared the two and they found that ChatGPT was faster and that the users tended to rate the ChatGPT responses--supervised by a human being--as being more effective, more empathetic than the actual human responses. Well, they would find that or it wouldn't be publishable. Let's remember, there's some publication bias here probably.

Marco Ramos: Yeah. Yeah--

Russ Roberts: But, it's provocative--

Marco Ramos:It's provocative. And, I don't mean to say that this is a sort of fact.

But, the one other sort of intriguing--I'm more interested in this as sort of a cultural phenomenon: that I think increasingly these are the sorts of questions that people are asking and this is the direction I think that a lot of research is going to be pushing.

But, when people found out that the responses were actually coming from AI [Artificial Intelligence], obviously they--or perhaps not obviously--they no longer felt like they could continue to receive care through the ChatGPT.

So, this is something that we're going to need to look at. Because there's a lot of financial interest in deepening our relationship--our social relationship--to the technologies that we have, and increasingly finding more and more meaning in those spaces than in connection with the human beings around us. There's a lot of financial pressure there. Ranging from sort of the mental health realm where I practice, to everyday life, as you're saying, and we need to be critical of that. Absolutely.

Russ Roberts: Yeah. Now, I have used ChatGPT a little bit. It's really interesting and fascinating. We had a recent conversation with Ian Leslie about it, listeners can check out.

But, I find myself saying, 'Please,' which is funny, right? I say, 'Please tell me--blah, blah, blah.' And, I can imagine an avatar on screen that when I was telling my troubles to that being--not sentient in my view, but some would argue it could become sentient--that it could be programmed to cry and show empathy, show what I would take as empathy. Wouldn't be empathy in my view, but maybe it'll work, quote, "just as well," or almost as well. Or it's a placebo: it'll fool me. I want to be fooled. It's cheaper. Blah, blah, blah.

Yeah, you're right, though, that it's really important for people to keep in mind the financial stakes that are involved between real people and not real people in this area.

But, now, do you want to say something about capitalism?

Marco Ramos: Yeah. And, it just gets to that point. And I feel like in this entire conversation, we've been talking about how the financial pressure exerts itself on our overall desire as human beings to find wellbeing in our life, and the way that it can alienate us from that.

And, just as a psychiatric practitioner, it's talking about how being constrained to have short visits where we're prescribing medication instead of meaningfully connecting with people leads to high, high rates of burnout. Where people come into this profession to try to help people, and then as they start to practice, they're finding that they're not having the meaningful connection that they assumed. And then they look at their bank account and they're hundreds of thousands of dollars in debt, and they don't feel like there's a way out. They're sort of trapped into this particular situation. And, this is a product of, in many ways, all of these financial interests that we're talking about.

So, I'm less interested in sort of the counterfactual[?]--I think it is important to ask what the alternatives there might be. But, I don't think we should just use that as an excuse. There's no alternative in this sort of, like, Tina, you know, Margaret Thatcher mode to say, 'There's no alternative so this is the way things must be.' And, I think if you go down that route, that's just the way of justifying an unsavory status quo.

I think we need to be asking how things can be better. I think we need to be pushing on the financial interests that are constraining our wellbeing. And, if we're not doing that, we're just going to continue to pump people full of pharmaceuticals instead of actually looking at the broader cultures that's making people sick.


Russ Roberts: Yeah, actually, I think we don't have enough capitalism. And I mean that very seriously. I think the dysfunctionality of a lot of what we observe around us is partly--not completely--due to the way we have distorted the market signals of profit and loss.

Just take the simplest of examples: the idea that Medicare can't negotiate a pharmaceutical price. That they're legislatively forbidden to negotiate price is--I don't know. I don't know what to say about it. I call that crony capitalism. But you--it might be a labeling difference. But it's--where we agree, I think, is that I think it's really powerful to remember that the status quo is not the only choice and--

Marco Ramos: Right. Yeah. No, I think that's right.

And, in many ways it might be a labeling difference, perhaps. But I think the broader point for me--and this conversation has been really helpful for sort of clarifying this for me--is that we need to start thinking about our mental--and this gets back to the title that you keep coming back to, which was not mine. It was actually Matt Lorde, the editor's, which is a brilliant title--but, that "Mental Illness Is Not in Your Head." So then: Where is it?

We need to start thinking about mental illness as something that is a relationship with our broader social, political, and cultural world. And, until we start doing that, we're going to continue to sort of just perpetuate this psychopharmaceutical system that we've been critiquing throughout this conversation.

Russ Roberts: My guest today has been Marco Ramos. Marco, thanks for being part of EconTalk.

Marco Ramos: Thank you so much for having me, Russ. Really enjoyed it.