Joel Paris asserts that in order to practice evidence based medicine, “you have to give up certainty and embrace doubt”. Such gems of wisdom are based on his 40 years of clinical, research and editorial experience. In Fads and Fallacies in Psychiatry he casts a withering eye over the many areas of psychiatric practice where evidence does not support prevailing practices.
Fads are new ideas that are enthusiastically but incautiously adopted while fallacies are mistaken conclusions. The fundamental cognitive error shared by both is the assumption that you are wise and rational while others may be foolish and uncritical. Research demonstrates that most opinions are based on emotion rather than reason and that people then distort evidence to justify them. Surprisingly, this confirmation bias is as prevalent in research and clinical practice as it is in politics or religion. Paris quotes Thomas Huxley's aphorism; “many a beautiful theory is killed by an ugly fact but grimly adds that such theories linger on through inertia and “only change when old scientists die, and are replaced by younger ones”.
Paris gives many arresting examples of fads and fallacies, both historical and current. The attribution of change in a patient's condition to the most recent intervention is shared by many. Doctors and their patients are highly susceptible to groupthink and tend to favour simple causes and effects over the complex reality of the illnesses and behaviours that face them. Chronic fatigue syndrome, fibromyalgia, radical mastectomy and some modern treatments for multiple sclerosis, are used as examples from outside psychiatry. The role of the pharmaceutical companies and patient advocacy groups in the promotion of fads is also critically explored.
Psychiatry is more susceptible to fads than other branches of medicine due to the still rudimentary nature of our understanding of the mind. The mid twentieth century fads of insulin coma therapy and frontal lobotomies are telling examples. Paris sees ECT as an effective treatment that became a fad for a period before finding its proper place in the treatment of severe melancholic depression. He asks himself why he devoted years of his life to psychoanalysis and was so slow to see through it and can only conclude that he fell victim to this powerful fad that dominated American psychiatry during his training.
Paris goes on to detail current fads and fallacies in the aetiological theories, diagnostic systems, epidemiological research methods, prescribing practices, psychological therapies and preventative approaches currently popular in psychiatry. He argues that depression, bipolar spectrum disorders, ADHD, PTSD and autistic spectrum disorders are faddishly over-diagnosed today. The prescription of antipsychotics for conditions other than psychoses is seen as the most harmful fad in psychiatry today. Paris regards lack of regulation, poor attention to evidence and the ‘guru’ tradition, as responsible for the many fads, historical and current, in the field of psychotherapy. Recovered memory therapy is seen as a malignant example. Paris doesn't have any radical solutions but recommends that psychiatrists be sceptical and pay proper attention to evidence.
When I was training one of the texts that resonated most with me was Follies and Fallacies in Medicine by two of my professors, Petr Skrabanek and James McCormick. Like that book, Fads and Fallacies in Psychiatry is courageous, wise and necessary. Paris has a clear writing style, keeps to the point and doesn't feel the need to supply us with lengthy anecdotes from his own practice. His book is commendably brief but full of relevant, well referenced information. I hope that all psychiatrists will read it and that it might help us to withstand the fads and fallacies that relentlessly surge around us.
