Socrates: Congratulations, Phaedrus, on your recent graduation.

Phaedrus: Please don’t mention it, Socrates. Graduating serves only myself—or, in fact, my parents. I have not yet done anything for the world.

Socrates: But you have, at least, seen through it. Now that you are a physician, what are you going to do?

Phaedrus: I am applying for a research post.

Socrates: In which specialty?

Phaedrus: Psychiatry, the healing of the soul—of course! I have my job interview tomorrow. Will you help me prepare for it?

Socrates: Very well, my young friend. I shall play the eminent professor of psychiatry. As you know, I have my own hierarchy of madness.

Phaedrus: What, with love being the highest form?

Socrates: Are you ready?

Phaedrus: I am!

Socrates: Mr Phaedrus, our university has a large and highly rated department of psychiatry. How much money do you suppose it spends on research each year?

Phaedrus: I really don’t know. Many millions, certainly.

Socrates: And how many comparable departments are there in this country?

Phaedrus: Dozens.

Socrates: And throughout the world?

Phaedrus: Hundreds, perhaps thousands.

Socrates: And for how many decades have they been conducting psychiatric research?

Phaedrus: Many decades.

Socrates: So it would be fair to say that, collectively, we have spent many billions on psychiatric research?

Phaedrus: Without question.

Socrates: Does that include the research budgets of pharmaceutical companies?

Phaedrus: No, not at all.

Socrates: Very well. Then name me one important breakthrough in psychiatry in all the decades since the Second World War.

Phaedrus: SSRI antidepressants. I heard one in six adults are now on them.

Socrates: Many perfectly competent people, including within psychiatry, argue that SSRIs are no more effective than a placebo.

Phaedrus: Some studies show that they work. Other studies show that they don’t. The consensus is that they are slightly more effective than a placebo.

Socrates: Who sponsored the studies?

Phaedrus: You raise a valid point, Socrates. We’d have to look at it carefully on a case-by-case basis.

Socrates: SSRIs have disturbing adverse effects, whereas inert placebos do not. Could it be that these adverse effects are increasing their placebo effect?

Phaedrus: OK, forget SSRIs. What about second-generation antipsychotics like risperidone and olanzapine? They have fewer disturbing adverse effects than first-generation antipsychotics like chlorpromazine. Surely, they must count as an important breakthrough.

Socrates: It has been argued that much of the difference between the old and the new is simply that the new are administered at much lower doses—though even they have disturbing adverse effects.

Phaedrus: Yes, they remain very dirty drugs. Theodorus says they only work insofar as they sedate you.

Socrates: Phaedrus, are you saying that, despite having spent many research billions, there has not been a single breakthrough in psychiatry in all these decades?

Phaedrus: What about mindfulness meditation?

Socrates: Phaedrus, you know that was invented in India, more than two thousand years ago.

Phaedrus: That was a long time before peer review.

Socrates: And yet, you wish to pursue a career in psychiatric research. Perhaps you fancy that you, of all people, will be the one to make the breakthrough?

Phaedrus: In the cold light of what we have said, my chances do seem rather slim. But perhaps medical science is more about making small steps than giant leaps, you know, working in a large team to make small steps.

Socrates: Small steps forwards or small steps backwards?

Phaedrus: How do you mean!

Socrates: When do researchers make small steps backwards rather than small steps forwards?

Phaedrus: When they publish misleading research. There is a saying, is there not, that to do the wrong thing is worse than to do nothing at all.

Socrates: Do the researchers put out misleading research because they are lacking in intelligence?

Phaedrus: No, it’s more that they are under a silent pressure to publish.

Socrates: In what way?

Phaedrus: Researchers need to publish results to appear successful and advance their careers—and perhaps also to justify themselves to themselves. Positive results are more likely to be published than negative results, and so there may be a tendency, however subconscious, to arrive at results that are slightly positive.

Socrates: If positive results are published while negative results are hidden from view, we may be deceived into thinking that a particular phenomenon is present when it is not, or that a particular treatment or intervention is effective when it is not.

Phaedrus: And that gives rise to false theories, false constructs, and false paradigms: blind alleys in which other researchers lose themselves.

Socrates: Not just other researchers, Phaedrus, but also physicians, science writers, journalists…

Phaedrus: Not to forget the patients themselves.

Socrates: Quite. Now tell me, Phaedrus, who pays for all this research?

Phaedrus: Universities, governments, charities…

Socrates: Anyone else?

Phaedrus: Pharmaceutical companies.

Socrates: And do pharmaceutical companies have any particular interest in the results?

Phaedrus: Well, naturally. They want to sell their drugs.

Socrates: Might that influence the research?

Phaedrus: It might.

Socrates: How?

Phaedrus: They might be more inclined to publish favourable results than unfavourable ones.

Socrates: How do you mean?

Phaedrus: Well, for example, there are pharmaceutical companies that have been known to selectively publish research with positive findings, while spinning, doctoring, or suppressing any research with negative findings. This creates the impression that their products are more effective than they are.

Socrates: Or even, that their products are effective when they are not.

Phaedrus: Yes, it misleads the research community, who create or adjust explanatory models to fit the ‘findings’.

Socrates: Which creates even more confusion.

Phaedrus: On top of all this, pharmaceutical companies spend large sums of money promoting their products to physicians and end consumers.

Socrates: How do they promote their products to physicians?

Phaedrus: By meeting with them and ‘educating’ them about a particular product or range of products, sponsoring their conferences, contracting them as speakers or consultants, and such like. They target the most influential physicians, so-called ‘key opinion leaders’.

Socrates: So the physicians they target are those in leadership positions.

Phaedrus: Yes, just those who are driving the research!

Socrates: Tell me, Phaedrus, when a researcher sets out to conduct a study, does he begin again from first principles?

Phaedrus: Of course not. He begins with what is already known.

Socrates: And how does he know what is already known?

Phaedrus: From the existing research.

Socrates: Including the research we have just been discussing?

Phaedrus: I see what you mean.

Socrates: Suppose an early finding is mistaken, but is accepted and built upon by other researchers. What happens to the mistake?

Phaedrus: I suppose it becomes embedded in the literature.

Socrates: And if enough further research is built upon it?

Phaedrus: It might eventually come to be regarded as established knowledge.

Socrates: Even though it was never knowledge in the first place?

Phaedrus: Yes.

Socrates: Well then, Phaedrus, if, after all this, you still wish to pursue a career in psychiatric research, you must take great care to avoid all these pitfalls and make small steps forwards rather than small steps backwards. Otherwise, you will have thrown away your education. You will have wasted your life. And you will leave this world, to which you owe so much, having done it more harm than good.

Phaedrus: Socrates, if I mention any of this in my interview, they won’t take me.

Socrates: No, they won’t.

Phaedrus: And if they take me, and I try to do the right thing, they will punish me.

Socrates: They will.

Phaedrus: Socrates, you meant to help me prepare for my interview.

Socrates: I have.

Phaedrus: What else can I do with myself, or for the world?

Socrates: Be brave.

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