Psychotherapy and Psychosomatics: End of an Era for Independent Journals? An Interview With Giovanni Fava

Welcome to Mad In America Radio. My name is Bob Whitaker, and today my guest is Italian psychiatrist, Giovanni Fava. Before we begin, I’d like to take a few moments and explain the context of this interview. From 1992 to 2022, Dr. Fava edited the journal Psychotherapy and Psychosomatics. We will be talking about the importance of that journal and what may be lost now that the publisher, Karger, may be taking it in a new direction.

Here’s why this journal, under Dr. Fava’s leadership, was so important to us all. When psychiatry talks about how its drug treatments are evidence-based, it points to RCTs and meta-analyses of those RCTs as proof that its drugs are more effective than placebo.

However, Psychotherapy and Psychosomatics under Dr. Fava’s guidance presented a very different evidence base to its readers. First, his journal told of how clinical experiences should govern our understanding of the impact of psychiatric treatments, particularly over longer periods of time. Second, his journal told of how RCTs and meta-analyses when used to direct clinical practices can lead to harm. Third, his journal told of the corrupting influence of pharmaceutical money on the creation of psychiatric diagnoses and drug trials.

When Dr. Fava became editor of Psychotherapy and Psychosomatics in 1992, it had a low impact factor. When he resigned as editor in 2022, it had an impact factor that made it one of the most influential journals in psychiatry and psychology. He left the journal in good hands in 2022 and he remained involved as an honorary editor. However, in December, Karger fired one of the two editors in chief, Dr. Fava then resigned as honorary editor, and most of the editorial board resigned as well. The future of this journal, which had been so essential to our understanding of the impact of psychiatric treatments is now unclear.

Editor’s note: Also see Robert Whitaker’s MIA Report: The Editorial Demise of Psychotherapy and Psychosomatics Is Bad News For Us All

The transcript below has been edited for length and clarity. Listen to the audio of the interview here.

Robert Whitaker: Welcome to Mad In America Radio, Dr. Fava.

Giovanni Fava: Thank you.

Whitaker: The title of your journal was Psychotherapy and Psychosomatics. I’m not sure everybody understands what the term psychosomatics means. Can you explain that?

Fava: Psychosomatic medicine is a movement that originated in medicine about 50 or 60 years ago. It tries to consider the person as a body-mind unity, using the scientific methods that apply to medical research. It has always been a field of pioneers, and independent thinkers. One of the most important people in American psychosomatic medicine was George Engel, who, by the way, was also my teacher. I spent a summer with him while a medical student. This model, which is known as the biopsychosocial model, is recognized all over the world.

Whitaker: Now, you became editor in of Psychotherapy and Psychosomatics in 1992, and you bring to that position years of clinical experience, in particular, working with patients with mood disorders. How did that clinical experience inform your thinking about what you would like to see in your journal?

Fava: When I became an editor of this journal, I didn’t know exactly what I was going to face in the following years. If we go back 30 years, a very long time being an editor, there is pretty much a story of the changes in research and publishing. Going back to your question, something that I realized very soon is that in the 1990s, the number of investigators who had familiarity with the clinical process was limited.

In other words, you can find people who publish about clinical methods, who give lectures, who teach, but these people wouldn’t know how to treat a patient in practice. They don’t have access to clinical practice, which is exactly the contrary of what I’ve been doing. I always had a busy clinical practice, so I could see what was going on in the real world.

Whitaker: Research that is divorced from patient contact or patient knowledge seems like it’s destined to be blind to the real world if you don’t have that clinical experience.

Fava: Right, and remember that the number of researchers who have no familiarity with the clinical process has increased tremendously over the years. All the research aspects that I’ve been dealing with in my career as an investigator, the source came from clinical practice. The ideas and the hypothesis were rooted in my clinical practice. If you don’t have that, you end up doing studies that may be elegant and may be rigorous, but they have no relevance to what the clinicians do.

Whitaker: Now, in 1994 you write an editorial suggesting that it is possible that antidepressants might worsen the long-term course of depression. At the same time here, at least in the United States, and I think this is somewhat globally true, we were hearing of SSRI antidepressants that fixed chemical imbalances, that were breakthrough medications and could even make you feel better than well.

Now this is an example where we see two contrasting narratives around a class of drugs. Can you explain how you came up with that and why there’s this incredible difference between the story [of chemical imbalances] and the question you’re raising at this time?

Fava: In my clinical practice, I observed a number of phenomena which were intriguing. Withdrawal syndromes were part of this phenomena, but there were also other clinical aspects, such as loss of clinical effect and so on. I decided to write an editorial where I didn’t have any conclusion or any firm statement to share, but I was raising doubts about certain issues. What was present in those days was something that is the one of the most important ingredients of scientific research, that is intellectual freedom, which many researchers do not have. They’ve lost it because of industry ties and so on. I wrote that editorial, but in most of the journals, I must say, those issues were forbidden.

Bob, I was very happy to see that in your breakthrough book, Anatomy of an Epidemic, you dedicated one chapter to the questions that I raised, because it’s important to have those discussions. In those days, I must say that I had total intellectual freedom.

Whitaker: For me, reading that editorial legitimized something I was trying to do with Anatomy of an Epidemic, which was to investigate whether classes of psychiatric drugs, on the whole, might be worsening aggregate outcomes. Then when I came upon your editorial, first of all, it legitimized the question. Then, of course, we also saw among the American psychiatrist’s efforts to silence that question. At this time, in the United States, if you looked at mood disorder experts in academic psychiatry, they were nearly all taking consulting money from the pharmaceutical industry, which, of course, compromised their intellectual freedom, which you were not compromised by.

You raised this question, but you didn’t let it drop, even though I think Donald Klein said to stop investigating it. You kept going at it, and as you did, you brought more evidence of clinical observations to support your suspicion that this was happening. Finally, you came forth with a biological explanation or hypothesis as to why this might be. Can you explain what that hypothesis was, and what is the possible biological mechanism for this worsening of outcomes?

Fava: As a clinician, there were things which I was observing. One was the withdrawal effects of SSRI antidepressants. I saw these withdrawal reactions. In the beginning, those reactions were called withdrawal. But then, as you describe, big pharma intervened, and said, “Okay, you have to call them discontinuation syndromes”.

Then there was the fact that in certain patients, these symptoms did not fade away after a few weeks, but became chronic, and persistent. Then I put together this with a phenomena related to antidepressants that had been reported in the literature. One thing is that if you give an antidepressant, for instance, to a young woman who’s suffering from an anxiety disorder and never had a history of bipolar disorder, then she might become hypomanic or manic. At that point, you think, Okay, I made a mistake. Let’s stop the antidepressant, everything will go back to the point it was. But in many cases, it doesn’t go back.

Then the loss of clinical effects. At the beginning of the millennium, we published two very important papers by psychopharmacologists in a drug trial where it was shown that in about one-third of cases of patients on long-term treatment develop a loss of clinical effect.

The patient had taken the antidepressant, but it stopped working. In other patients, you stop the antidepressant, it works. After a few months, you prescribe it again, and it no longer works. What is going on here? You have all these phenomena. Then I use a theory which had been outlined in another field, which is the oppositional model of tolerance.

Tolerance is a word that you’re not supposed to use in respected journals. What does it mean? It is the fact that with a treatment, whatever treatment, it has some effects, but as treatment goes on, after a few months, it may trigger other effects which counteract the initial ones and produce certain side effects. When you stop treatment, these counteracting effects become predominant. You have withdrawal, you have persistent symptoms, and you have a number of clinical phenomena.

This, of course, was just a theory. But another teaching of George Engel was the fact that a theory is important not in itself, but to the extent that it may explain something that you encounter clinically. My model could explain all these different issues.

I started with the editorial, and then we kept on publishing important papers. We published the first paper by David Healy on SSRIs and suicide. We published the first report on persistent sexual side effects. This was a time when I could actually do whatever it felt ethically right to do.

Whitaker: As you know, Martin Harrow, when he did his long-term outcome study of schizophrenia patients and was looking to explain why outcomes were better for those off medication long-term, he began looking at oppositional tolerance as an example of why it may make some patients, psychotic patients, more psychotic over the long-term. You see that explanation. Maybe it’s just a hypothesis, but it is one that  provides a possible explanation for what you’re clinically seeing.

I have to say the other interesting thing here is I’m obviously not a clinician, but as a reporter, I would talk to a lot of people who took these medications. The story that you are telling here was very close to what they were telling me. “I can’t get off these drugs. I can’t get my sexual function back. I’m depressed all the time”. It’s interesting that even just listening to the patient stories, which is a little bit like clinical experience, you get this other narrative that comes out.

Fava: Right. Many researchers subscribe to an idealistic theory that really makes no sense. The fact that you give a medication, you do something, you take it away and everything goes back to normal, to the pre-intervention. What I’ve always been trying to explain to my patients is that there is no way back. You cannot go back, but you can go forward. Recovery is a one-way street where you need to get a better balance, but not thinking of going back.

Whitaker: In 2011, you wrote maybe one of your final papers about this. Then Rif El-Mallakh wrote a similar paper in, I think it was Medical Hypotheses. He labels it Drug-Induced Tardive Dysphoria and also says it may be a mechanism similar to other psychiatric drugs. My question to you is now, you have become an impactful journal.  Did this idea enter the larger consciousness of prescribers?

Fava: It did, but it took a very long time for people to recognize certain phenomena. The journal became also a psychopharmacology journal because we were willing to publish papers and studies that other journals would never publish.

Let me give you an example. In the late 1990s, I was in Buffalo, New York. I was in a bookstore, and I was looking at a magazine where there was a journalist writing about conflicts of interest and mentioning a study done by a professor of social sciences in Boston, Sheldon Krimsky. I looked at the various databases and couldn’t find that study.

I wrote to Krimsky saying, “I cannot find the study. Could you send it to me?” He wrote a very nice letter back and said that I couldn’t find the study because no one wanted to publish it. This was a major investigation that started the issue of conflicts of interest. They took the Boston authors and their disclosure of conflicts of interest in their papers and checked more like a journalist checking the facts. They found that one-third of the authors in major scientific journals had important conflicts of interest.

I said, “Submit it to me. It will be peer-reviewed, of course, but if the methodology is fine, we’ll publish it”. Which we did. That paper should have been published in Nature or Science, not in Psychotherapy and Psychosomatics.

Whitaker: I happen to know a little bit about the background of that paper. Lisa Cosgrove was one of the co-authors, and they submitted it to other journals, and of course, it didn’t find a home. This is one of the reasons that if Psychotherapy and Psychosomatics takes a different direction, it’ll be such a loss.

Fava: Let me just mention the attitude of the publisher, Thomas Karger, who was this publisher in Switzerland. He told me, “I’d like to see if the paper gets mentioned in magazines or newspapers”. That paper by Krimsky and Cosgrove got an entire page in The Washington Post. Today it would no longer be possible of course, but we’re talking about 20 years ago. I sent the page to Thomas Karger, and he wrote me a very brief note saying, “I’m proud to be your publisher”.

Whitaker: Wow.

Fava: Those were the days. Going back to your question, we continued publishing papers on this issue of antidepressants and other psychotropic drugs, and the journal became sort of a reference to investigators not being tied to the industry, and had trouble publishing their papers. One of these is Guy Chouinard. Chouinard is one of the most important clinical psychopharmacologists. He is the author of the Theory of Supersensitivity Psychosis, which again is not a very popular theory relating to antipsychotics.

We started this collaboration together, and in 2015 we published the first systematic review on withdrawal effects of SSRIs. There was an editorial by Guy Chouinard commenting on the findings. Michael Hengartner commented on that review, noting that it comes after 200 systematic reviews on the benefits of antidepressant drugs. 200 against one. But that one review had an effect, and people started considering these effects.

For instance, I was pleasantly surprised to see that in the UK, the updated NICE guidelines started talking about withdrawal again, citing our systematic reviews. It means that you publish certain things, and after a while, you can see an effect.

Whitaker: I first came upon Guy Chouinard when he was writing about dopamine supersensitivity in the early 1980s. When I saw that he was on your editorial board, it showed how it was a home for this type of thinking. It made it so valuable.
You said there were 200 RCTs, in essence, saying these drugs worked, and now you have this contrary line. Can you just summarize why RCTs, in essence, can lead clinical practice astray?

Fava: Randomized controlled trials are a very important part of clinical science, but we should not forget that the results of randomized control trials apply to the average patient, and they may not apply to all clinical cases.

Let me just mention a fantastic study that was done about 30 years ago by Yale investigators. This study was looking at beta blockers after myocardial infarction. They found that treatment can induce improvement in a subgroup of patients, create no change in another subgroup, and make things worse in another small subgroup. What is the problem? You just talk about the average and don’t hear about the third subgroup. This applies also to psychotherapy. We had major problems in disclosing the side effects of psychotherapy, which was another major aspect of the journal’s activities, randomized controlled trials concerned with psychotherapy.

Whitaker: I think especially with psychological and psychiatric disorders, that’s what you see. You see some people do well with the treatment, some people not so well and then some people worsen, but as you say, RCTs lead to one practice for everybody.

Fava: Right. In a way, evidence-based medicine has degraded clinical practice. What I mean is that with this idea that you have guidelines that apply to everyone, whereas it is the clinical judgment of the clinician who has to interpret those guidelines. But clinical judgment means independence, it means not following orders, not following guidelines, and it’s very dangerous.

Whitaker: In 2022, you write an editorial looking back at your 30 years of guiding the journal and in that editorial, you divided it into three periods. Can you tell us a little bit about how you saw the journal evolving over time?

Fava: Over the years, we collected a number of clinical investigators who were very independent and who had ideas that were important but didn’t find room in mainstream journals. We continued to do that to the point that a few years ago we reached an impact factor which was above the American Journal of Psychiatry. This was really a paradox because the American Journal of Psychiatry is extremely powerful in terms of investment and so on. We were this small group of people.

But things were changing in the world of publishing because the open access issue became more and more prevalent. Then we had Thomas Karger’s retirement, and everything changed in the company. In my opinion, it changed for the worse.

Three years ago, I decided that, well, I had been an editor for 30 years, and yes, I could have continued. Everyone was saying, “Please stay, because the time you resign, everything will be over” in a way. Which was true, I must say. But I decided, why don’t we try to continue with the two associate editors who were working with me, and this is what we did, and I remained an honorary editor. But there was a big difference in that we no longer had a publisher who was proud of what we were doing. We had a publisher who was concerned about other matters and didn’t care about the impact factor.

Whitaker: What were the other factors that the publisher was concerned about now?

Fava: In general, publishers now want to have a say in the editorial line of a journal. For instance, inviting papers. The field has changed so dramatically. When I started in the 1990s, there were some ghost-written papers, but we could really recognize those and they were limited. Now you have a tremendous number of papers that are totally ghost-written.

Let me give you just an example. I acted as a reviewer, not as an editor, to a respectful pharmacology journal and in my review I objected that this paper was commissioned by a drug firm, written by a medical editor, and approved by the authors who had major conflicts of interest concerned with the product that was discussed in the paper. The response of the editor was that they had disclosed all these issues.

Whitaker: As if that removes the conflict.

Fava: Yes. Thomas Karger’s philosophy was that of the subscription-based journal, which is the best form.

Whitaker: There are those two funding sources, open access where people have to pay, or journals where they’re basically funded by pharmaceutical advertisements. With a subscription basis, it’s basically funded by the readers.

Fava: Right, and the libraries. A couple of decades ago, publishers found out that libraries were not willing to accept subscriptions to new journals. So there was this idea, let’s have the authors pay for the journal. It’s like if we go to a restaurant, we bring our food, we go to the kitchen, we cook the food, we bring it to our table, we eat it, and we pay the bill. That’s open access. The point is to make a financial threshold for reporting certain things.

Let me give you a personal example. In my career, I reported for the first time certain side effects, for instance withdrawal effect with Sertraline, anterograde amnesia with Zopiclone, and other things. Of course, I don’t have any grant. In fact, I could probably get the grant for not publishing. I know of psychopharmacology investigators who were paid for not publishing certain findings.

It’s important that we don’t have that financial threshold. Things change in the world of publishing and Thomas Karger was for subscription. The new management is leaning toward open access. In open access, you publish anything. Then there was the next step, predatory journals.

Whitaker: With this switch in publications, it wasn’t so much necessarily that they were against some of the content, but it just wasn’t a model that produced the revenue they wanted to see.

Fava: Yes. What happened is that there were problems between the editors and the publishing house and suddenly the two editors left. Actually, one had decided to leave, and the other was fired. At that point, I was not even informed what was going on. I wrote to the editorial board and said, “Okay, this is what’s going on. I’m resigning. What are you going to do?” Most of the editorial board resigned, and then Retraction Watch reported that this added to many other events that occurred in the world of publishing in the past years.

Whitaker: I have three quick questions. Since you had such a good impact factor, why wouldn’t that be from a financial point of view a reason to continue along the same line of being a home for the type of research you’ve been publishing for 30 years? It seems to me, that if I’m the publisher and I have a journal that’s getting such a nice readership, I want to continue with the editorial content that brought that readership in. Why didn’t they see it in that way?

Fava: Well, you see the way you’re reasoning is the way Thomas Karger was reasoning. It’s not the way that is done, unfortunately, these days. It’s more than having a certain direction going to open access and making more money out of scientific journals. The money you make with subscriptions, with the exception of journals that sell thousands of copies, is limited. With other methods it’s really is there a big business.

Whitaker: Two things, what’s going to happen? Is there any way to save Psychotherapy and Psychosomatics? Is the change happening and you got a new editorial direction and you’ll just have to see what happens? Is there anything to save here so to speak?

Fava: Unfortunately, I don’t think so. A thoughtful publisher, if they had the revolt of most of the editorial board, you’d consider that, but they didn’t. Of course, there will be a new editor. Right now the journal is run by a managing editor with no competence in the field, and they come from Frontiers, an open-access company. They have been hired a few months ago just to run the journal. Then they will appoint a new editor.

What they’re looking for is someone who would follow directions. I’m sorry to end this conversation in a little pessimistic way, but I think that the golden years of Psychotherapy and Psychosomatics are gone. Something that has been very impressive to me is that there were hundreds of protests outside of the editorial board for what went on with the journal. The new management of Karger doesn’t seem to be affected by those protests. But if you keep on receiving complaints about what has happened, I don’t know, it may sort out certain effects.

But right now I tend to believe that the experience of Psychotherapy and Psychosomatics is over. I don’t even see any replacement. I think it’s really a major loss in the context of the progressive loss of intellectual freedom. But what you’re doing, Bob, is very, very important, because you keep on talking about issues that are important and are vital, so we never give up.

Whitaker: I have to say, personally, I feel it’s an extraordinary loss. I don’t know another journal that has served as a home for such independent thinking and skeptical thinking. I was counting up the number of times we’ve referenced Psychotherapy and Psychosomatics on Mad in America the other day. It’s over 126 references. We have this financially fueled narrative and guild-fueled narrative, which is always saying how great everything is. Then we had your journal that was rooted in clinical experience which is such a vital part of any sort of understanding of a medical treatment.

It was, as you say, in a larger sense, a place for independent thought, freedom of publication, and now we’re losing this within psychiatry and psychology. I don’t think publishing is changing only in this particular discipline. The problem is broader. But I will tell you, when I first learned about this, I was thinking of writing a blog with the headline, ‘Now We’re All Screwed’ because we’re going to lose this fountain of information.

At Mad in America, we do try to make these clinical experiences known, and your findings known, but one of the things we do is we’re not inventing this stuff. We’re relying on what appears in your journal, for example, and every once in a while, articles in other journals, and yes we always privilege personal stories, because personal stories tell of clinical experience. But I can’t tell you what a loss it is I think to society, especially when you think about how big a place psychiatry now has in society. It’s a loss to public health. It’s a loss to medical integrity and scientific integrity.

What you accomplished over 30 years, I will tell you personally I’m grateful for. It changed my life because it presented information that I could report on, and to lose that is just crushing. That’s all I’m going to say. It is just crushing to lose Psychotherapy and Psychosomatics.

Fava: Yes, but at the same time, let’s close with something more optimistic. It was also an experience that we can do certain things if we have a publisher that is going to support independent thinking. For instance, I’m positive that if we had a subscription-based publisher that was willing to invest in this, things would continue. At the time being, we are stuck.

Let me close with this. I must say, one of the admirers of the journal is Noam Chomsky, who wrote an editorial for us saying how it is important when you find something that you don’t like to write it down. I’ve been concentrating as the editor, but behind me, there was a fantastic group of people who are first-class scientists, who supported all this work. I hope that this group with a new editor may find a new home.

Whitaker: Well, it’s good to close on an optimistic note about what is possible. Let’s think about an optimistic future and possibilities. Dr. Fava, thank you so much for joining us today.

Fava: You’re very much welcome and thank you for giving me this opportunity.

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