Monday, November 27, 2017

Psychiatry or Anti-Psychiatry Blog How Do You Tell?

I was recently e-mailed a graphic that declared "Top 100 Psychiatry Blog" and encouraged me to display it on my blog.  I was contacted again a week later and asked why I was not displaying the graphic.  My first question was whether there really were 100 psychiatry blogs on the Internet.  My second question was whether there was any advertising hype associated with this offer.  The Internet seems like one big ad these days.  What appears to be a reasonable site often degenerates into more mouse clicks than an electronic health record in order to get viewers close to ads so that they count as advertising revenue.  There are plenty of sites out there that just link to other sites and try to get advertising revenue without producing any original content.

I visited the list of blogs and several were familiar.   I have a number of blogs written by the psychiatrists who I follow attached to this web site in my profile - along with a number of scientific blogs.  I don't think that ranking them serves any useful purpose, but I will say that they seem very reasonable to me.  At the same time there were also blogs listed there that were more antipsychiatry than anything.  Are antipsychiatry blogs psychiatry blogs?  What if they are implicitly rather than explicitly antipsychiatry blogs?  Does that make a difference?  I think that if you are writing from a strictly or even loosely antipsychiatry vantage point it probably has very little to do with psychiatry.  These sites exist and you can certainly go there.  You can read them exclusively.  But I would not equate them to a psychiatry blog that is written by someone who knows the field and is interested in scientific discussions about the field.   

So what are the red flags if you are wondering about a psychiatric blog that you might be reading? Here are a few guideposts:

1.  They are not written by psychiatrists -

Believe it or not there are a multitude of people on the Internet writing about subjects that they have no knowledge of at all.  It turns out that psychiatry is a complex subject that requires a great deal of scholarship in training and on an ongoing basis.  It is not generally amenable to lay interpretations of the meaning of brain imaging studies or clinical trials.  Some of the top viewed posts on this blog are excellent examples.  Some of the major Internet sites have writers that clearly do not know the subject material but do not hesitate to provide a heavy handed analysis that is often miles away from reality.  Fake news is an overused term that can't easily be applied to opinion.  I had a couple of readers ask the question: "Well - aren't we entitled to our opinion?"  Of course you are entitled to your opinion - but your opinion really does not apply to the real treatment of psychiatric illnesses or what is really happening in psychiatry.  There are blogs out there who bombastically target about "reforming" psychiatry when the opinions expressed on those sites clearly indicate that none of the authors knows anything about the practice of psychiatry or the influence of business and government on the care of mental illnesses.         

2.   They are written by psychiatrists -

Curiously - psychiatry itself has produced some world class antipsychiatrists who in some cases affiliated themselves with more notorious antipsychiatry organizations.  For me Thomas Szasz is a clear case in point.  In fact, some of his antipsychiatry rhetoric has become so mainstream that it is even used by psychiatrists when they wax rhetorical.  I recommend a skeptical approach to any blog - even if it is written by a psychiatrist that is a blanket condemnation of the field or that makes it seem like every conceivable problem with mental health diagnosis and treatment can be blamed on psychiatry or psychiatrists.  There is generally an air of superiority in the writing as in "Most other psychiatrists have these problems but I don't, because either I am intellectually superior or my methods are superior."  To my knowledge that condition has never existed in the history of the field.

3.  They may be the remnants of the newspaper business selling the news -

Every week I get one and sometimes two large newspapers in my driveway whether I want them or not.  The newspaper business is so desperate that they have to give papers away. They have stopped cold calling every week with some promotion that everyone knows these days is just a scheme to rapidly escalate the charges to the point that you cancel the subscription and start over.  It is obvious that nobody wants to buy a newspaper anymore.  I don't even want it littering my driveway for free.  I feel badly for another industry gone obsolete - but not bad enough to buy a newspaper.  That unhealthy atmosphere drives all manner of provocative headlines.  What used to be a discussed and edited product is now like anything else on the Internet - provocative and looking for mouse clicks and advertising revenue. The spin offs of these newspapers are generally as bad.  Some of them are "Top 100" sites. Not the best sources to consider for unbiased news about psychiatry - especially in the context of a well documented pre-existing media bias against psychiatry.

4.  They are uniformly negative about psychiatry and psychiatric practice-

One of the main reasons for this blog is to simply point out that most media is biased against psychiatry and psychiatrists - if anything the blogs are much worse.  I wrote an early post on this blog about how a writer has to adopt an overly negative view of psychiatry in combination with an overly positive view of the rest of medicine to be that negative about psychiatry.  In the real world, the demand for psychiatry has greatly exceeded the supply.  Non-physician specialists are now being hired en masse to fill unfilled psychiatric positions.  Psychiatrists are consulting in collaborative care models with primary care physicians to enable them to treat more psychiatric problems and prevent closed practices that occur when psychiatrists provide individualized care.  All of this hiring is being done by organizations that would just as soon not hire any psychiatrists if they could get away with it.  That is strong economic proof that psychiatrists and psychiatry has a lot to offer tens of thousands of patients in these health plans. 

5.  They are basically fronts for antipsychiatry cults-

As a psychiatrist with limited resources I am not about to name names and end up in some endless cycle of ridiculous litigation.  You really have to do your homework on this one, because nobody can afford to stick their neck out and name names.  Sites on the Internet that were set up to follow and characterize these groups have been intimidated into removing material or in some cases just shutting down.   These sites are often obvious by over the top rhetoric about psychiatry or psychiatrists, but many are now taking a more subtle approach.  They can give the appearance of being legitimate - right up to the point that they may offer services or request donations.  The services often cost very large amounts of money.  The legitimate psychiatry blogs I read are not looking for patients or funds.  They also point out they are not handing out medical advice and that they are generally for educational or scientific purposes.  One of the best ways to investigate questionable clinical services or requests for donations is to make sure that they have appropriate site licenses and professional licenses by state regulatory agencies.   

6.  They are written by somebody who claims they have been wronged by a psychiatrist-

I am always skeptical of this approach, basically because if you have been wronged by physicians in American society there are generally more remedies than there are in any place in the world.  I have repeatedly pointed out that the boards of medical practice in any state have a very low threshold for investigating physicians and assigning punishment that can include license forfeiture.  Practically all physicians these days are employees in healthcare organizations and there are administrators in those organizations who may be even more eager than medical boards to discipline physicians right up to firing them.  All three of these entities - medical boards, employers, and malpractice attorneys have very strong incentives for going after physicians.  In fact, any physician caught in that cross fire does not stand a chance - even if they have done nothing wrong.  American society is renowned for being litigious and medical malpractice is one of the cash cows.  There are 3 ready solutions for people who feel they have been wronged by any physician.  When I compare the time it takes to write a vituperative blog for no real gain to these cash, justice, or revenge solutions - the logical questions is why?  There are not many good answers to that question.  I can think of maybe one or two - but even then extrapolating from an isolated case to thousands of doctors requires an illogical leap - especially while maintaining an equal level of contempt.

Keep all of this in mind.  A "Top 100" site may include sites that are there to bash psychiatrists or the profession.  It may be written by someone with absolutely no knowledge of psychiatry or (potentially worse) a psychiatrist who thinks that they know more than any other psychiatrist who was ever born.

Like most things on the Internet - let the reader beware.

George Dawson, MD, DFAPA


  1. Blogs are basically opinion sites, and we know what opinions are analogous to, so, I guess one has to weigh if he/she can wander in and tolerate a potential stench, or random chance pleasant potpourri...

    My concern is we tolerate too many of our colleagues saying and doing things that don't truly measure up to reasonable and fair standards of care, or responsible principles, and the worst, focusing on an agenda and not an appropriate goal for the public.

    And I think that is not a surprise to read, but, I honestly and genuinely ask you, do you really think our profession as a whole practices and preaches healthy, functional care assessment and interventions as of 2017? As someone who has been a Locum Temp guy the past 7 years, I can say with limited experience in 3 Northeastern states, I have not been either impressed or pleased with what I have had to follow in these travels.

    Our "colleagues" who practice active clinical care in mostly community mental health care out patient sites are often sell outs or, while not frequent but still too often to see, honestly believe it is better to give people what they want than what they need, for more likely the simple fear that the provider will be seen as someone "who doesn't care" or "won't do the 'right' thing".

    And then these "physicians" conveniently bolt, either in retirement, or find the hasty exit elsewhere to practice more mayhem before legitimate consequences can be implemented. And what is most pathetic, is most states have this PDMP (Prescription Drug Monitoring Programs) to not only catch the patients who are drug seeking, but, allegedly to catch the nefarious providers as well.

    And yet, I know of physicians who continue to be the real life "Mayhem" character from that insurance commercial, who seems to elude these monitoring programs for the several years some have been in existence now? Just curious, have you ever tried to take down an impaired colleague?

    My answer to readers interested in this comment is such: I have tried, and frankly, medicine, and I think Psychiatry even more so, is truly a fraternity system, and policing our own is not a joke, but an insult to the public we truly serve. And to bring it back to your post here, blogs sometimes are clueless or reckless, but, sometimes trying to educate and empower in a somewhat elusive and behind the scenes manner.

    Hey, I know I am not read much, but, it is an outlet. And with that analogy, I don't mind shocking some people at times. Who knows, maybe we all need an ECT intervention once in a while. Rebooting as a metaphor?...

    Joel Hassman, MD

  2. "Hey, I know I am not read much, but, it is an outlet. And with that analogy, I don't mind shocking some people at times."

    Not read much either and frankly - I don't know how you can tell if a human is reading the site or a bot looking for reverse hits on a clickbait site. My guess is that the number of hits may overestimate human readers by as much as 80%.

    Like you - I don't mind because it is an outlet. I get to present my interests and criticisms in the field to the few people who may be interested and I encounter them in real life. At a recent conference, a resident introduced himself and told me that he was a reader. That has happened a handful of times. Interesting and appreciated - but not enough to keep me going in itself.

    I like the idea that there is nothing commercial about what I write. I am not trying to sell a book or T-shirts. I am not sponsored by Big Pharma or Big Managed Care.

    I have been more fortunate in working with good to excellent colleagues. Early in my career I did witness a tragedy where a psychiatric lost his life due to impairment. But the people I work with generally get better and better.

    I have had a lot of personal experience with misdiagnosis and problematic treatment by physicians from many specialties and some of that is included in this blog to point out that mistakes happen and medicine/psychiatry is not a zero risk endeavor. (I almost bled out from questionably indicated lymph node biopsy before I went to medical school.)

    The other issue that I made explicit in the most recent post is the post Orwellian nature of medicine. This is really a parallel and worse environment than I started training in - in 1982. The environment has become so blighted that most MDs were totally clueless about how bad EHRs were and have only recently started complaining. They are still quiet on MCOs. I know some of them look at what I write and say - he is just a cranky old guy.

    That level of cluelessness and process I have witnessed all along is another reason to keep typing.