This is a very short, quasi-review of James Davies's book 'Cracked: Why Psychiatry is doing more harm than good'. It is already 'very short' regarding the fact that I could have written a thesis solely based on my opinions in response to those mentioned within. I used the prefix 'quasi-' since I intend as well to express my general comments regarding books written about medicine by non-medical professionals. I don't wish to be overly harsh, but I am born a blunt person and I don't intend to hold back when pointing out how James Davies has harmed psychiatry.
Earlier, I went to Amazon to check the ratings for the book. 4.6 out of 5.0. I was absolutely mortified. Utterly speechless, I started to wonder if I was the one with the problem. I do not wish to contaminate this entry with exorbitant detail regarding its contents so I'll just point out some of the major issues that I identified which are incorrigibly horrendous:
Over-focus on America;
Over-focus on Journals that just don't matter;
Over-focus on Pharmaceutical Industry;
Not having a clue of what psychiatry is about.
As a disclaimer, I have read this ghastly book in February. As I have a proclivity for intellectually-stimulating literature, I might have forgotten many of the minute details of this book. I welcome any manner of correction, as long as it's constructive.
This book is littered with references to the U S of A, despite its being published by a British publishing house, intended for a British audience. The interviews transcribed are mostly held with prominent figures in the American psychiatric industry. With all due respect, despite there being minimal differences in medicine between different geographical entities, these differences can be significant, especially in the field of psychiatry. It is well-known that the US has a serious problem with over-prescription. [1] My tutor, a leading psychiatrist in the department, once remarked that in the US, the myth of childhood bipolar disorder was created, due to two competing factors: (1) the reluctance of labelling young kids with issues such as conduct disorder and antisocial personality disorder due to envisaged prejudice, and (2) the pre-eminent role played by the pharmaceutical industry (or 'Big Pharma'). With such stark differences between the US and the rest of the world, bearing in mind that there are structural differences in healthcare provision and practices, I marvel at the way James Davies describes the US situation as if it is what the entire world is experiencing. Sure, this exists in the UK. However, with a nationalised healthcare system (our mighty NHS) where interference from private interests is reduced to a minimal level, can safe parallels be drawn?
This is not helped by the one big thing scientists should never do: associate, in any way, with journals of low impact factor. Impact factor is essentially a measure of the degree of 'importance' of a journal. It is determined by the number of times an article published by the journal is 'cited', or mentioned. [2] As a research student, I have been influenced by the age-old maxim 'publish or perish'. However, even that has a limit. Publishing on a journal that has low impact factor is often deemed as the last resort. In this case, James Davies has inadvertently based his book on knowledge synthesised by doubtful studies published by doubtful journals. Surely there can be useful information procured by such means, but as I said, this remains doubtful. Moreover, the lack of reference to more mainstream medical journals (such as The Lancet, New England Journal of Medicine, BMJ, JAMA, etc) puts Davies in an awkward position in two ways: (1) he is unwilling to engage in meaningful discussion by referencing mainstream medical opinion, (2) he lacks the fundamental skills in performing the most basic scientific research. Mainstream medical journals serve as the most authoritative voice in scientific affairs. They publish the grandest of trials, the most significant of studies. They are the sophisticated forums of the most rigorous and vigorous of academic debates. Information published by these journals represent the broad swathe of medical opinion that is well-respected amongst those who matter. Certainly one can dissent from the mainstream voice - dissent is, after all, the core of science and disruptive thinking. However, failure of engaging with the mainstream opinion to synthesise one's opinions comes across as a failure to conduct proper scientific research.
Hyper-focus on 'Big Pharma' is intrinsically connected to the lack of knowledge regarding what psychiatry and medicine are truly about. James Davies expended most of his book 'spilling the tea', talking about the ills of the pharmaceutical industry and how doctors are manipulated and enticed into submission. I have no doubt that this is happening every waking moment. However, to zoom into this issue is also to reject the core tenets of medicine. Doctors swear by the Hippocratic Oath. This is what every medical student did upon stepping into the medical school. We got dressed in immaculate suits and white coats. We swore to always abide by the Hippocratic Oath - to serve and help those in need. This is the standard of our profession. To suggest that doctors and other healthcare professionals are easily swayed by monetary considerations is to denigrate the profession itself. It is to suggest that most, if not all, doctors construe the Hippocratic Oath, as a blank piece of paper. Moreover, focusing too much on Big Pharma also brings forth a practical disadvantage to 'Dr' Davies (it transpires that he is a PhD holder): it is not specific to psychiatry. This is a common ill to medicine. All medical specialties are afflicted - since all medical specialties will, at some point, solicit the help of pharmaceuticals. Psychiatry might be seen as an easier target since a long-term problem of it is the lack of a solid biological basis. Researchers around the globe have endeavoured to unearth the pathophysiological mechanisms of different psychiatric illnesses, but to no avail. The use of drugs is therefore rather controversial on non-medical grounds - why do psychiatrists keep prescribing drugs when there is no particular biological basis? What are those drugs intended for? The benefit of Big Pharma or the benefit of the patient? This is precisely why the point is missed.
Davies also acted as a 'pioneer' and discussed at length the ills of the lack of a rational basis when constructing the DSM (Diagnostic and Statistical Manual of Mental Disorders, published by American Psychiatric Association [APA], also known as the 'bible' of psychiatry; it is rivalled only by WHO's International Classification of Diseases). This perhaps can be illustrated by the numericisation of diseases. For instance, he did not understand why 5 instead of 4 criteria were required (provided that the symptoms lasted for > 2 weeks) for the diagnosis of major depressive disorder. He questioned about the precise technicalities of the operation of such diagnostic criteria, demanding 100% accuracy. However, it is vital to clear the ground.
Psychiatry and Medicine are about healing, the former being incorporated as a specialty of the latter in the past two centuries. Sigmund Freud's psychoanalytical theories were proven to be no more than hogwash due to the lack of a sound scientific basis. [3] The contemporary focus of psychiatry aligns closely with that of Medicine - healing. We as medical professionals are faced with living, breathing people, trying their best to survive. We as doctors are encountering numerous patients with psychiatric issues, all unable to sleep or find joy in their lives. What is our role? Our role is to help them. We try our best to give them what they truly need - reintegration into society. Ultimately, having a normal life. As medical professionals, honestly, we don't care about politics. We don't care about the encroachment of Big Pharma into the medical industry. We don't care about the discussions behind the doors of the APA committee. This might be a bold statement but to be frank, every medical student opts to study medicine because of the overarching desire to serve those in need. Pandering to the public opinion that medicine should be purely scientific is to deny what medicine is about. It is conceded that clinical diagnosis for schizophrenia, for instance, should not be fully replaced by blood tests. [4] Why's that? The answer is simple - even if the blood tests are normal, the suffering can be immense. The blood test does not show us the person. The person sits in front of the doctor in the consultation room, striving hard to relay all he or she has experienced for the past few months. The difficulty of engaging with others, the toxic thoughts eroding their minds, the racing hallucinations and incapacitating delusions...A blood test is a number. It doesn't show us the full picture. The drugs given to the patient are for the patient's benefit. Yes, we concede that we don't know enough about psychiatry. Nobody does. Neuroscientists are doing their best to unearth new correlates and pathways of communication between various brain structures every minute. For example, UCL has recently published a paper on the neural circuitry of anxiety and fear, and how it informs therapeutic options for patients with anxiety disorders. [5] But then, pharmacotherapy is the only way we know which can help these tormented souls. They are the least invasive yet most efficacious options put before us. These drugs may fail to introduce any permanent benefit, but at least the patient can sleep well that night. These drugs may not even address the core pathophysiology, but the symptomatic relief yielded is already sufficient in introducing a slight amount of normality in their lives. This is what we are aiming for. Similarly, what difference does meeting 4 or 5 criteria make in terms of management and follow-up? Does meeting 4 instead of 5 criteria mean that the patient's suffering is dismissible? It is only a guide for the physician. It merely gives us a general idea of the suffering of the patient, which potentially impacts our decision over finer matters such as dosage and treatment period. In medicine, at certain times, we are not aiming for 100% scientific accuracy. No. We serve our patients. We act on their behalf for their best interests.
In Chapter 13, I witnessed the full-blown confrontation between Professor Sue Bailey, the head of the Royal College of Psychiatrists, and James Davies. Davies's responses given in his book betrayed his lack of understanding whatsoever to what Professor Bailey was getting at. Nor were his responses sophisticated enough to warrant any of our serious attention. They do come across as a rant resultant from an injured ego. Professor Sue Bailey summarised the role of the psychiatrist in her responses to James Davies's absurd questions. I quote them here in full:
'So let's focus back on the critical psychiatrists - they are saying that many problems are not medical issues. They may be right, but does it actually make any difference to the person who is in distress? The person is in distress for some reason, and that may be because they have had a bad day, it may be that they have been traumatised and abused by Jimmy Savile, for instance. And it's now in the newspapers and they are worried about it. Now, it may not need medical treatment but they need some support, to be listened to. I have no problem with that... (p 263)
'You've got a human in front of you who has come to you for a reason, who wants help. And the job is to listen to them and to try and disentangle it, and some of it will be about social support, some will be about advice about how they are living their life, and some of them temporarily will have a distress - however that is diagnosed in the new classification system...(p 264)'
And Professor Bailey did not hold back (and rightfully so):
'Look, I think there are frankly better things people should be doing with their time. I haven't actually got a lot of truck with these discussions if I am honest with you. The majority of people I look after are living in poverty, with inequality, and have experienced abuse - they've got undiagnosed, unrecognised mental illnesses. So I actually think that we should focus on the reality of what we can do as doctors, rather than having erudite discussions about what the various situations of what DSM should have done. (p 266)'
Enough said.
However, as Davies's book gained popularity in literary circles, this is alarming. Professor Bailey was branded as a traitor to modern medicine. Her beliefs were used as evidence by James Davies as sheer obstinacy for medicine and psychiatry - the lack of refusal for both to move forward. It perpetuates the toxic belief that 'doctors know best and do not concede to criticism'. This is, on the first ground, damaging to the doctor-patient relationship. On the second ground, it perpetuates beliefs pertinent to psychiatry which are neither helpful to the current situation, nor beneficial to the patients. What if we do have very accurate tests to diagnose traditional psychiatric disorders such as depression and schizophrenia? Does it mean the clinician's expertise can be replaced by a mere machine which generates results? As I explored above, no. Test results and the suffering of the patient may not be proportionate. However, the proliferation of such books reinforces the opposite. The general public think that medicine is merely about science. A subject in pursuit of 100% accuracy, when in fact this ideal has never existed. Many have caught the wrong drift. A similar book, 'The Great Pretender' by Susan Cahalan, runs along the same lines. While I have sympathy for Ms Cahalan's autoimmune encephalitis and the relatively long time it took for her doctors to make the proper diagnosis (which I think is totally normal, considering that autoimmune encephalitis is very low in any differential list unless there is corresponding family history or other observations), it does not automatically give her the right to fire a baseless and venomous tirade of abuse towards an established medical specialty. It amuses me that many people seem to think psychiatry is a relatively easy target for their uneducated diatribes. Mistruths perpetuate mistruths. Hearsay perpetuates hearsay. The generation of this air of toxicity soon drives people who genuinely need psychiatric help away from the system, convinced that modern psychiatry cannot help them with their issues. They head towards less established lines of treatment, or worse, suffer from more stigmatisation since the public are more and more convinced that psychiatry is merely a clown show with no fundamental basis. Whose fault is this? Psychiatrists? No. It is the fault of all these so-called 'writers' who have received no medical training whatsoever, writing about psychiatry without even the slightest clue of what psychiatry and medicine are about. The positive attention mental health illnesses has received throughout the years is easily pulverised by the ignorance and selfishness of these people.
I am not denying the issues psychiatry is facing. Big Pharma's looming into the scene is certainly a big worry. What is happening in the US can also engulf the entire globe, seeing the lucrativeness of the pharmaceutical industry. We can have constructive academic debate regarding the ways to ameliorate the situation, e.g. reduction of pharmaceutical influence in clinical decision-making. However, to write about this topic without any pre-knowledge of what medicine and psychiatry are about is simply ludicrous and blasphemous. To discredit psychiatry wholly with such a ridiculous book title without caring to listen to what the head of the Royal College of Psychiatrists, the one responsible for the training of future psychiatrists, had to say, is nothing short of risible.
James Davies is the only person, in virtue of writing this book, causing more harm than good to psychiatry and the world that depends on it.
[1] Smith B. (2012). Inappropriate prescribing. American Psychological Association. Retrieved 10 November 2020, from https://www.apa.org/monitor/2012/06/prescribing.
[2] Sharma M, Sarin A, Gupta P, Sachdeva S, Desai AV. (2014). Journal impact factor: its use, significance and limitations. World J Nucl Med. 13(2):146. doi:10.4103/1450-1147.139151
[3] Cox S. (2020). What Sigmund Freud Got Wrong About Psychology (And Your Mother). All That's Interesting. Retrieved 10 November 2020, from https://allthatsinteresting.com/sigmund-freud-psychology#:~:text=While%20Takooshian%20says%20the%20%E2%80%9Cjury,affirms%20that%20humans%20develop%20through.
[4] Korth C, & Fangerau H. (2020). Blood tests to diagnose schizophrenia: self-imposed limits in psychiatry. The Lancet Psychiatry, 7(10), 911-914. https://doi.org/10.1016/s2215-0366(20)30058-4
[5] Robinson O, Pike A, Cornwell B, & Grillon C. (2019). The translational neural circuitry of anxiety. Journal Of Neurology, Neurosurgery & Psychiatry, jnnp-2019-321400. https://doi.org/10.1136/jnnp-2019-321400
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