A fair response from The Human Condition Revisited on our Psychiatry article from a year ago. A few points:

1. I agree that calling psychiatry incredibly bogus is too harsh (I’ve added a note at the beginning of the old article indicating this). However, I am still mulling whether I think the field is more helpful or harmful.

2. There’s no doubt that medication helps some people more than others and some conditions more reliably than other conditions. Medication’s track record for the positive symptoms of psychosis, for example, is much better than its track record for depression. As I stated in the article, my intention is not to dissuade anyone from taking or trying medication. My intention is to 1) temper client expectations, 2) encourage alternatives, and 3) hold psychiatry as a discipline accountable. I’ve made the same arguments about my own field, psychotherapy.

3. I’m open to the idea that the neurotransmitter model has been completely abandoned by psychiatrists, but if so, the public messaging hasn’t caught up. I’ve now asked Gemini and ChatGPT “How do antidepressants work?” and both cite the neurotransmitter model. Also, just type the question into Google. The average person, who doesn’t spend their days poring through research articles, will come away believing the neurotransmitter model is alive and well.

4. Fair point on effect sizes. Still, placebo plays a significant role—by some estimates, the majority role. Should psychiatrists acknowledge this more directly? If so, how? And given that placebo could be harnessed by a number of other interventions with fewer side effects than psychiatric medication, how should we think about medication’s opportunity cost?

5. Speaking of alternatives, I do think we need to ask: What’s the end goal? I’d like to see more psychiatrists discuss this openly. Are clients supposed to be on medication for the rest of their lives? If so, let’s be upfront about it. If not, let’s talk about off-ramps that square with known (or at least hypothesized) mechanisms. This is one of the primary concerns of my clients—that if they start, they’ll never be able to stop.

6. I was initially annoyed that someone critiqued my article. That’s human. But I took some time, and went back to read my old article, and came across the quote about “professional courage” from Anne Harrington. I think psychiatrists need to have more professional courage in admitting the limits of their knowledge, the power of placebo, the presence of alternatives, and the conflicting incentives of the field. I must do the same. First, because I am not a practitioner or researcher in this space, my knowledge is limited to what I read, what I hear secondhand from clients, and what my intuition says. Second, using “incredibly bogus” was an attention grab, a rhetorical device. It made the issue appear simpler than it is. I apologize for that and—ultimately—want to thank The Human Condition Revisited for presenting a more accurate portrayal of the problem and promise.