Agency, Uncertainty, and Flexibility in Psychiatric Care: Q&A with Awais Aftab
Awais Aftab is a psychiatrist whose work focuses on conceptual and critical issues in psychiatry
I’m so excited to start a Q&A series here at Surface Level, where we’ll get the perspective of writers, thinkers, professionals, and those with lived experience related to questions I’m asking and essays I’m writing. First up is Awais Aftab, who writes and speaks extensively about psychiatry and its challenges. I learned so much from his work for my In and Out of Control essay, and I’m sure you will too.
[This Q&A was conducted via email.]
SL: I came across your work as I was researching my recent piece about hormonal birth control and psychiatric medication, where I examined how both types of medication are under explicit scrutiny by health and human services secretary Robert F. Kennedy and the MAHA cultural movement. Your essay in The New York Times was instrumental in my thinking. What have the responses been to the premise of your piece, where you acknowledge that harm from antidepressants is a real, under-researched concern? How do those reactions differ between psychiatry professionals and lay people?
AA: I am glad to hear that, Sophia, and thank you for reaching out to me. Overall, and reassuringly, the response was fairly positive, both from professionals and lay people. I had made an effort to present a sensible rather than a controversial or polarizing thesis, and I think readers appreciated that. That said, there was also a range of negative reactions. Some people were unhappy that I made a sort of public concession, minimal though it was, to RFK Jr’s comments. Some staunch critics of psychiatry, the sort who believe that antidepressants are ineffective and dangerous and unsuitable for clinical use, were unhappy that I didn’t go far enough in recognizing the harms. Some psychiatrists have this rather ridiculous belief that the New York Times is an antipsychiatry publication (eyeroll; I imagine such psychiatrists are insulated from actual “antipsychiatry” platforms) and they thought that I should have been more assertive in proclaiming the legitimacy of psychiatric profession when I made the case that there are real and under-researched harms. Some thought that my piece may make people reluctant to seek care and I should feel responsible for that. This is the kind of mindset I find quite irksome and infuriating. Physicians trying to preserve the public's eagerness to seek care at all costs has no doubt contributed to the erosion of public trust in medicine. The New York Times also published 5 letters in response to my piece, illustrating some of this diversity. The letter by Daniel Smith was my favorite and I ended up writing a post in response to it, The Medication Life and the Moral Career.
SL: I have been thinking a lot about what makes psychotropic drugs different from other medications, in a cultural context. It seems to me that patients are more likely to hear about potential side effects and variable effectiveness in, say, drugs to treat cancer versus drugs to treat mental mental illness. It has made me wonder whether historic (and current) stigma, and the relative newness of modern psychiatry as a field, creates an environment where psychiatric medication and treatment is fighting for legitimacy in a way that other treatments are not. How do you think the tension between stigma and legitimacy plays a role in talking about psychiatric medication’s potential harm and variability?
AA: I am inclined to think that this has something to do with the messy metaphysical status of mental disorders. Because the issue is philosophically difficult, there is a tendency to either reduce mental disorders to physiological disorders to give them legitimacy or to simply think of them as problems of living or deviant behaviors that don’t really belong in the medical realm [For an academic treatment of these issues, see our 2024 paper in World Psychiatry]. This also influences the public perception of psychiatric medications. What exactly are medications doing? One way to make it concrete is by saying something like, “they correct a chemical imbalance, like insulin in diabetes mellitus.” And many in the medical community said things like that for decades, and many still do, and because the statement is misleading at best and an outright lie at worst, it generates predictable distrust and backlash. On the other hand, those who don’t believe in the reality of mental illness try to make sense of psychiatric medications as something akin to alcohol or cocaine. Medications that can sedate you, stimulate you, numb you, disinhibit you, but that’s all they can do. This leads to all kinds of stigmatizing attitudes towards psychiatric meds [see my discussion of models of action of psychiatric meds]. I think a better approach is to focus on the experience of suffering and impairment that accompanies mental illness, seeing psychiatric conditions as maladaptive and harmful behavioral statements that are nonetheless embodied, and because they are embodied, the bodily mechanisms provide opportunities for medical interventions to reduce, relieve, or modify that suffering.
Are patients less likely to hear about potential side effects and varied effectiveness of psychiatric meds compared to other meds in other areas of medicine? I don’t know. It was probably the case 10 or 20 years or so, but in recent years these issues have gotten a tremendous amount of media attention. And if you look at millennials and Gen Z, so many of them are on psychiatric meds that varied effectiveness and harms are plain for anyone to see. It is common to hear jokes about SSRIs decreasing sexual desire, impairing ability to orgasm, or causing emotional blunting. A lot of my patients are looking up information about their meds on Google and browsing through discussions on Reddit forums. Many people are asking ChatGPT, etc. So the information is out there and easily accessible. And on social media, there are prominent accounts with large followings, and all they do is talk about medication harms. And yet, despite all this, there are still people out there who are clueless about these issues around efficacy and adverse effects, which means that clinicians also can’t just assume that their patients understand these things.
SL: I’m curious where, if at all, you see an intersection between hormonal birth control and psychiatric symptoms. My understanding is that in terms of side effects, depression and other mental health impacts are the least understood when it comes to hormonal birth control—research has been mixed, and there haven’t been any randomized controlled studies on it. How, if at all, does birth control show up in the field of psychiatry and mental health? For example, is birth control something you consider in a patient’s history when they come to you for treatment?
AA: Considerations of birth control are not infrequent. Some psychiatric medications have well-recognized risks on fetal development (depakote, lithium, etc.) so it is best practice to advise women of reproductive age who need to use them to be on birth control. Premenstrual dysphoric disorder or premenstrual worsening of depression and anxiety are also quite common, and combined oral contraceptives are a treatment for that. Some women also experience worsening of depression, anxiety, irritability, etc. with oral contraceptives, and unless psychiatrists are also paying attention to hormonal birth control, they can miss that connection. Hormonal birth control is another treatment, like antidepressants, that is simultaneously celebrated, feared, condemned, and misunderstood by the public. Medical treatments are available to us and offered to us based on average effects but people differ in how they react to medical treatments, and in order for this process to go well, an incredible amount of personalization and causal inference at the individual levels needs to happen.
SL: In your NYT essay and in your Substack work, you write with an empathetic balance between big, philosophical questions, rigorous science, and empathy for the patient experience. I’d love to hear more about your thoughts on improving that patient experience. You’ve written about changes you hope to see from the psychiatric community, but for an individual patient, what do you want those seeking or in the midst of psychiatric care to know? What are some questions you wish you got asked more?
AA: I have written two patient-oriented pieces in the past that I’d mention here, an article for Psyche, What a psychiatric diagnosis means – and what it doesn’t mean, and an article for Asylum magazine, A Psychopharmacology Fit for Mad Liberation?. A realistic understanding of the nature of mental health problems and their treatment is quite important. I’d say to patients: use the resources at your disposal. Read about other people’s experiences. Advocate for your needs. I think a lot of people don’t appreciate that the mental health care an average person receives is quite impoverished and inadequate.
I wish more patients would ask me about the limitations of treatments: what can this treatment realistically accomplish for me and what kind of expectations are unreasonable? Patients can feel a tremendous amount of uncertainty and ambivalence about psychiatric meds, and when present, it’s important to explore in clinical settings. I really enjoy working with patients who can critically analyze their own symptoms and their own responses to treatments, and who can direct their own care in innovative ways. For an illustration of this kind of thing, I recommend this interview with David Mordecai.
SL: Let’s get a little philosophical here! Looking at these issues through the lens of my own experience with hormonal birth control and a mood stabilizer, I found that so much of my questions, hesitation, and desire for information come from a desire for control. That theme echoed in many of the first person accounts I read, and many of the anecdotes that populate social media. In the articles I’ve read about Laura Delano, including your review of her memoir, I’ve specifically noticed the tension between the psychiatric patient who feels defined by their diagnosis and, in this context, the deprescribing patient who becomes free of labels and medication. I can understand how important that shift in a control locus is for someone’s sense of self, especially with an illness and/or treatment that makes them feel out of control. How do you think about personal agency and will in the context of psychiatry?
AA: People develop complicated relationships with diagnoses and treatments in many other areas of medicine as well but the degree to which it happens in psychiatry is striking. Some of these are based on a misunderstanding of the nature of diagnoses and treatments as well as our tendency to essentialize diagnostic categories, but it is also related to the fact that when it comes to psychological suffering, we have a choice. We can look at the distress and disability through a medical lens but we can also choose to look at it through a different lens, and there is nothing in the nature of the phenomena that compels us or obliges us to do that (see more about this here and here). When a certain narrative is imposed on a patient or when it is presented as the only legitimate choice, many patients feel that something valuable has been taken from them. As a clinician, I am astounded by the power of person-centered care (when it is truly person-centered and not just some vacuous buzzword). Two clinicians can offer the same treatment to a person and get wildly different results because of how the diagnosis and treatment are framed. I have written about how even a stigmatizing diagnostic label such as borderline personality can be perceived as enhancing agency and bringing control depending on the context and the framing. For some people, the only time they get to take control over their relationship to medical care is when they decide to reject diagnoses and come off psychiatric medications. When that happens, it is easy to conclude that the problem was diagnosis and treatment to begin with, when in reality the problem was a lack of agency they experienced in clinical care and a system of treatment that often feeds off on it. When people do get the opportunity to engage with diagnoses and treatments in an informed manner and on their own terms, the outcomes are quite different. This is all additionally complicated because agency is at times diminished or impaired in psychiatric disorders. I don’t mean that simply in the sense of decision-making capacity, but in its fullest sense, as it relates to a person’s sense of self, their relationship to the world, the locus of control, and their ability to create meaning for themselves. Part of the task of psychological treatment is to enhance a person’s agency, and one of the ways in which this agency can sometimes manifest is by the person deciding that they don’t need medical treatment anymore.
SL: If you could change public perception tomorrow, what shift would you want to see in attitudes toward psychiatric medication? What is the most important conversation we can have now, in this political era, to ensure accessible information and care for all?
AA: The psychologist Paul Bloom writes at one point in his book Psych, “I cannot stress this enough—if you are in distress, seek treatment. It works. But, and I can’t stress this enough either, the treatment of mental illness is at a primitive stage.” (see my review here) I admire this kind of honesty and we need a lot more of it. Psychiatry is an immature clinical scientific discipline, and comes with all the uncertainty, confusion, and imperfections of immature science. It’s better than nothing, and for many it can be lifesaving, but it still leaves a lot to be desired. I think the public should approach psychiatric treatment with realistic expectations. It has a decent chance of helping you to some degree, a meaningful chance of helping you tremendously, but also a significant chance of hurting you in some ways.
We are in this weird social moment where blind trust in medicine co-exists with a great deal of ill-informed or ill-motivated distrust of medical authority. The public needs reliable sources of information and critical thinking skills to navigate this. People have a right to make informed decisions about their treatment and to have access to care. They also have a right to understand the limitations of treatments and the potential for harm. Medical treatment isn’t just a matter of personal preference. It’s shaped by clinical evidence, risk-benefit analysis, public safety concerns, cost-effectiveness, and the availability of public healthcare resources, including healthcare insurance. Still, within these broader constraints, there remains considerable room for individual preference and flexibility, and I anticipate social media and AI will expand this room even more.
SL: Thank you, Awais!
Awais Aftab, MD, is a psychiatrist in Cleveland, Ohio, and clinical assistant professor of psychiatry at Case Western Reserve University. His academic, educational, and public-facing work focuses on conceptual and critical issues in psychiatry. His first book, “Conversations in Critical Psychiatry,” is an edited volume of interviews published by Oxford University Press (2024). He is a senior editor for the journal Philosophy, Psychiatry, & Psychology. His academic work has been published in top psychiatric journals such as JAMA Psychiatry, American Journal of Psychiatry, and World Psychiatry. He has written for the New York Times and has been quoted in publications such as the Washington Post, LA Times, VICE News, and Rolling Stones Magazine. He writes online on his Substack newsletter Psychiatry at the Margins.