Khameer Kidia straddles two worlds and two roles. He is a physician and an anthropologist, works at Harvard Medical School and the University of Zimbabwe, and spends his life between Washington, DC, and Harare. Kidia has many accolades to his name: he is a Rhodes Scholar and a 2023 New America Fellow. His papers have appeared in elite medical journals, including The Lancet Psychiatry, and his stories and essays have appeared in outlets including The Yale Review and the Los Angeles Review of Books. His recent book, Empire of Madness: Reimagining Western Mental Health Care for Everyone, was covered by The Washington Post. His experience navigating two cultures and his expertise across disciplines allow him to see that psychiatry, as it currently stands, needs to end.
In this interview, we discuss how the tentacles of an exploitative global order reach into people’s lives and minds. Disclosing his own difficult history with stimulant medications, Kidia exposes how current psychiatric practices can superficially anesthetize pain in order to return us to the hamster wheel of productivity. Sharing his mother’s struggles with “nervous breakdowns,” Kidia shows us the importance of patient autonomy and liberty, and the grace in letting go when people choose a path that does not align with our priorities.
The transcript below has been edited for length and clarity. Listen to the audio of the interview here.
Khameer Kidia: For most people, what psychiatry is doing is helping them cope with symptoms. That is a worthy cause. Without psychiatry, there would be a lot of suffering, too. So I am calling for the end of psychiatry, or at least a kind of end.
Psychiatry helps to anesthetize pain and allows people to get back to work. I went to Princeton, and I had never been to the US before I arrived here. I realized that I was struggling to cope with what was going on in school. My grades weren’t very good. There was a lot of reading, and we had a lot to keep up with.
I looked around and realized that many of my friends and colleagues were on stimulants. They were taking drugs like Ritalin and Adderall to help them study harder and pay attention. I ended up getting a referral to a psychiatrist. Within a few minutes, she said, “You have ADHD.”
I didn’t have to lie on the questionnaire I filled out. The questions were about whether I was completing my assignments on time, whether I was organized or disorganized, and whether I felt overwhelmed with my work—very natural feelings for a stressed-out college student.
She gave me a prescription for Adderall, which ended up helping me feel really good, in the moment, about the work I was doing. Stimulants were incredibly motivating for me and really helpful. They allowed me to get back to work, to stay up, and to study. But I ended up having a much more complex relationship with stimulants by the end of my college experience. I was using them in ways that were actually making things worse for me.
You could say I was addicted to stimulants, because they were starting to cause harm in my life. At one point, I fell asleep during a final exam because I had stayed up for multiple days in a row.
I was a motivated college student who wanted to go to medical school. Falling asleep in an exam was probably one of the most awful things I felt I could do.
What these stimulants were allowing me to do was get back to work. ADHD is a diagnosis that essentially pathologizes under-productivity. Back in Zimbabwe, I was one of the top high school students in the country. When I came to a competitive American liberal arts institution, I was underproductive, and I was pathologized. That was my first wake-up call to what psychiatry was, how it worked, and how it operated.
Kidia: There were a couple of turning points for me, and both of them were related to being queer as a person and caring about queer communities.
I was trying to decide, in my fourth year of medical school, whether to become an internist or a psychiatrist. I was doing an advanced rotation in LGBTQ psychiatry, where I was helping conduct psychiatric assessments for patients who wanted gender-affirming surgeries. I saw a lot of trans people who would come to us to get the checkbox ticked.
A patient named Vanessa came into my clinic and sat down. She presented herself in such an orderly way. It was my job to do her mental status exam, to make sure her behavior was appropriate, that her eye contact was good, and that she was dressed appropriately. These are all subjective things that we document as clinicians and pretend are objective.
Kidia: Yes, that to me is ridiculous, because it gives the veneer that the mental status exam is entirely objective, when it is actually entirely subjective. Here I am, looking to see whether Vanessa has any tattoos, whether she’s presenting herself in a well-behaved and orderly way, and whether her thinking processes are linear and coherent. She had all of those things. She also had all the checkboxes for gender dysphoria.
It was clear to me that she had rehearsed. She had practiced in order to be able to have this diagnosis, because that is what trans people in the United States have to do in order to access the care they need. They need to make sure they can convince a physician that what they have is this thing that physicians are calling gender dysphoria, even though not all trans people or queer people experience dysphoria. Some people experience gender euphoria.
They have to convince us that they are experiencing dysphoria in order to receive the diagnosis that will help them get what they need. Just as we were finishing, she asked me, “Do you think I’m going to get the surgery?” I said, “I think you are.” It was in that moment, when I realized that I was gatekeeping something she needed to survive and thrive, that I realized psychiatry did not have the same kind of power back in Zimbabwe.
Zimbabwe is an extremely homophobic place, with colonial-era anti-sodomy laws. Yet a diagnosis of gender dysphoria in Zimbabwe is definitely not helpful to a queer person. It may actually cause more violence and expose them to prejudice within the medical system.
I realized that these diagnoses sometimes have social and political power. Gender dysphoria and PTSD diagnoses can help people access benefits and care. In Zimbabwe, psychiatry did not have that kind of power. In fact, diagnosis in general would not be that helpful, because most people in Zimbabwe do not express their mental distress in those terms.
They do not say “depression.” They do not say “anxiety.” They say things like, “Ndiri kufungisisa,” meaning, “I’m thinking too much.” Or, “Moyo unorwadza,” meaning, “My heart feels burdened.” These are cultural idioms of distress that are more local and more pertinent to how people express distress.
Think about the causes of mental distress in Zimbabwe, which include poverty and violence. Diagnosing people with depression and anxiety when they are living in poverty, and then giving them medications, is a type of gaslighting. It is a type of nonrecognition of their true structural problems.
I spent the next 10 years working on mental health interventions in Zimbabwe. Queer people were really, really struggling. Trans people were dying by suicide. They approached me as a member of the queer communities and asked if I could help. I started writing this multimillion-dollar NIH grant examining queer people’s mental health in Zimbabwe.
My mentors at Harvard kept pushing me to make this grant focused on an HIV intervention because they felt it was more likely to be funded. The more I spoke to queer people in Zimbabwe, the more I realized this was the opposite of what they wanted. They told me they did not want anything related to HIV or their sexual health. All they wanted were safe spaces. They wanted to be able to hang out and feel comfortable. They wanted to go to bars, parties, and nightclubs and just be themselves.
I realized that this project I was doing to study queer people’s mental health was completely off base. I ended up deciding not to submit the grant because it felt unethical to me. From queer people in Zimbabwe, I learned about the idea of mutual aid: helping each other out while also trying to change the world that is oppressing you. That is very different from charity.
Kidia: It was through this collective called Harare Queers. During the pandemic, queer people were struggling in Zimbabwe because they were forced to move back in with their conservative families, often in rural areas.
Harare Queers asked queer people, “What is it that you need?” Queer people said, “We need money. We need transportation to get out of the home every day. We need to be able to pay our rent so we don’t have to live in places where we’re threatened and harassed.”
They started a GoFundMe that collected cash and gave people a $50 unconditional cash transfer. They drove to people’s homes, delivered the money, and made sure they were safe. Cash transfers, in particular, have incredible evidence.
Kidia: The type of colonialism that the British practiced in Zimbabwe was settler colonialism. Settler colonialism is where British people, or any colonizing power, decide that they want to actually live on the very land that Indigenous people have.
That process is inherently physically violent. It requires forced migration, ethnic cleansing, and genocide. White settlers moved Indigenous people onto arid settlements, where it was difficult to grow food and difficult to raise livestock. They had a scorched-earth policy that killed the crops of Indigenous people and made it very difficult for them to raise animals.
That forced so many people into starvation. People died not just from the direct violence of encountering the military but from the kind of slow death that came with that type of settler colonialism. It’s not as if all the land in Zimbabwe looked like that. Zimbabwe is an incredibly arable place, with wonderful agricultural reserves. The British took that land and its natural resources for themselves, and they built a thriving export economy on it. They also created an apartheid state, where they restricted movement and segregated neighborhoods and schools.
My parents still grew up in that apartheid state, where they weren’t allowed to go to white schools, restaurants, or bars.
My mother had a white stepfather who was extremely, extremely violent within the home. In mental health research, we measure childhood adversity using the ACE score, for adverse childhood experiences. If you have four or more ACEs, you essentially have a greater risk of developing mental illness, a substance use disorder, and also physical illnesses like heart disease and diabetes. My mother had eight out of the 10 ACEs because she had such a tumultuous and violent childhood.
My father was forced to fight for the white Rhodesian army against Black nationalists. In the army, he ended up using alcohol to cope, and alcohol became a crutch for him for the rest of his life. My mother ended up having these nervous breakdowns, where she would have periods of paralytic mental distress. She could go for weeks to months where she would be a shadow of herself. She could barely interact. She stayed in bed. These were the very direct effects of colonialism on their psychology.
But there are so many more subtle and nuanced ways that colonialism continues to have a psychological toll today. There are colonial-era anti-sodomy laws that discriminate against homosexuals. Then there are all the neocolonial ways the Global North continues to maintain a stronghold over the Global South through mechanisms like global debt and a global political economy set up to take resources and labor from the Global South and divert them to the Global North. The Global North ends up living off of the Global South and creating poverty and structural violence in the Global South. These are some of the ways that colonialism, both then and now, has a psychological toll.
Kidia: I first started to think about debt when I was in medical school. I had this patient, one of my first patients ever. Her name was Sheila.
Unusually, she had chest pain in the hospital, which is not what we expect from someone who is waiting for a colonoscopy. We did an EKG on her. The EKG looked OK at first. We said we’d order another one. Then she went missing. We had to look for her all over the hospital.
Eventually, we found her in the hospital lobby trying to escape. We said, “Where are you going?” She said, “I don’t want another EKG. The last time I got an EKG, it ruined my life.”
She explained to us that, a few years earlier, she had been to an emergency department. She had gotten an EKG, and the whole visit ended up costing thousands of dollars that went into collections. She now was on the hook for something like $50,000. She was working three jobs. She had two children. She was a single mother living on the edges of poverty.
Kidia: Absolutely. Certain kinds of debt affect marginalized people more. Think about payday loans. They are associated with inflammation, anxiety, depression, and all sorts of mental distress.
There are other kinds of debt that rich people get to take out that end up making them wealthier.
Medical debt is a problem in the United States that has gotten completely out of hand. There are so many people struggling to pay back their medical debts after small procedures or trips to the emergency department.
Some state governments have been trying to buy off people’s medical debt and get rid of it. And what happens when you do that? Nothing bad happens when you get rid of the debt. We need to think of debt cancellation as a type of mental health care. We need to change the way we think about mental health care and expand it.
In medicine, we are given such a small toolbox — therapy and medications — that we end up obscuring these structural determinants, thereby closing off opportunities for interventions that could be really helpful in improving people’s lives.
The global mental health movement is so focused on reaching millions of people all over the world. People are interested in putting Friendship Benches in their cities. But that is not the point. That works well in that context and that culture for those people. The point is not to put a million Friendship Benches all over the world. The point is to work at a higher sociopolitical structure than just the individual level. Medicine continues to disguise the fact that this is what we need to be doing when we think about scaling mental health care.
Kidia: First, these disciplines are individualizing. They see mental distress on an individual level rather than on a social and structural level. There is biological reductionism. They see mental distress as something that is purely biological, in the brains of people. Second, there is historical blindness. The psy disciplines are blind to the fact that what has happened historically to a person and to a society bears on our current emotions, behaviors, and feelings.
Mental illness is biological. It is biological in that while you are experiencing distress, there are neurotransmitters and neurochemicals firing off in your brain, just as they are in the conversation that we are having right now.
Seeing what a depressed brain looks like on a scan is not showing you the cause. We have to remember that whatever you see on an fMRI scan is just a reflection of that person’s state of mind.
Kidia: In primary care, we are typically given 10 minutes to see a patient. Using the PHQ-2, we ask patients two questions about their symptoms of mental distress. From that, we can flag whether they are screening positive for depression. And if they are screening positive, we are like, “Oh, gosh, now what do we do with this? Time is already ticking. I’ve spent eight minutes dealing with all of the other things, and I have two minutes left. What do I do now? I can refer this patient to a psychiatrist or a therapist. But both of those have very long waiting lists, and the patient is clearly extremely distressed right now, so we can have a conversation about medication.”
We end up putting people on an SSRI to help them cope with what is going on because, in the confines of that very, very brief encounter, seeing a patient in distress who is there asking you to help, it is all you are able to offer. This is what I want people to realize about overmedicalization.
One-sixth of Americans are on SSRIs at the moment, and some people who are experiencing extreme symptoms can really benefit from these drugs. But many people have been put on these drugs for normal reactions to life circumstances, like being a stressed-out teenager or being heartbroken. Many people are trying to get off of these medications. We have to think about patient autonomy, too.
I was in a unique residency program at the Brigham, where I was allowed to tailor my training. My preceptors and directors allowed me hourlong primary care appointments for my patients who had complex chronic illness and mental distress, which was an absolute gift.
I had this patient named Alice who was having these mysterious fainting spells. She would just collapse in the middle of the street, in church, at work, and we couldn’t figure out why. I sent her for cardiac tests. I sent her to a neurologist. The neurologist said, “I think you have functional illness,” which is medical speak for “we think it’s in your head.”
But I had seen Alice collapse in front of my eyes, and she wasn’t making it up. I knew she was truly distressed, and I couldn’t figure out what to do. My preceptor said, “Why don’t you just bring her back?”
Eventually, I started seeing her weekly or every other week, and we’d have these hourlong appointments. I dealt with all of her medical things — Pap smears, vaccines, diabetes medicine, blood pressure pills — and we ended up getting time to learn about each other.
I learned that she was living on the edges of poverty and homelessness. She was taking care of her mother, who was elderly and frail, and she was housing insecure. Sometimes I was able to give her very practical advice, like, “Why don’t you change your schedule around and do that first, and then go see your mom afterward?” It was just listening to the troubles in her daily life. That is a kind of empathy and care that a primary care doctor often does not have time to provide.
Kidia: Exactly. Primary care doctors see how chronic illness is the embodiment of so many of the social and political problems in people’s lives. They see the ways that mental distress is intertwined with chronic illness. People who are chronically ill are more likely to be depressed, and people who are depressed are more likely to be chronically ill. Primary care doctors are the people who deal with this, which is why 80 percent of SSRI prescriptions are written in the primary care setting.
Sometimes I was even able to help Alice structurally. I was able to fill out some forms that helped get her government housing in the same housing block where her mother was living. That is also a role that we have in medicine as gatekeepers.
A lot of primary care doctors, a lot of doctors in general, say things like, “That’s not my job.” But it is our job. This went on for a couple of years. Then one day Alice walked into my office and she had this huge smile on her face. She said, “Doc, you won’t believe this. I’ve stopped fainting.”
I’ll never know exactly why. I can’t say that it was the housing, the medical care, the social care or the empathy. But what I do know is that the problems she had were enmeshed with her social life, and to be able to contextualize that distress, I needed the time to sit with her.
Having that time is a way we can subvert the capitalist way that health care systems in America are structured.
Kidia: Cognitive liberty is an idea that I learned from Mad in America, and it is really about the right to mental self-determination. It is the idea that we should be able to alter our consciousness however we like, whether that is through drugs or yoga or therapy. But we should also not be coerced by others to alter our consciousness, whether that is through drugs or yoga or therapy. It is something we have to determine on our own.
At one point, I was caring for my mother, and she was in a period of particularly severe mental distress, shortly after the pandemic had started. Her business went bust, and she was extremely anxious about the financial precarity she was in and the strain and burden she would put on me as her son while taking care of her. She wasn’t sleeping enough. She wasn’t interacting with her friends and family. She was cutting herself off from social connections. I was with her in Zimbabwe, but I had to get back to Boston. The time was ticking, and I needed to leave.
Together with her psychiatrist, I ended up forcing her to start the drug quetiapine, which is an atypical antipsychotic drug that has many side effects, which I’ll talk about in a second. I watched her take the pills every day. I did what we call directly observed therapy, where I gave her the pills and watched her take them with a glass of water. I begged her to please carry on taking these meds while I was gone.
I noticed that the quetiapine really helped with her anxiety. She started to sleep more. She was sleeping a lot, sometimes 10 to 12 hours a night. She was less impulsive when she woke up. She was much less likely to start a fight. She wasn’t having these snappy outbursts. But she told me that the meds were making her feel groggy and zonked out, and she was begging me not to make her take them. I said, “Please, Mom, if you do one thing for me, take these meds.”
I went back to the United States. A few months later, I got a call from her. She was in the emergency department, and she had been hospitalized because her blood sugars were through the roof. She was on IV insulin, and she had developed severe diabetes from being on this drug. Atypical antipsychotics like quetiapine and olanzapine can cause metabolic syndrome, which can cause heart disease, diabetes, and weight gain.
They are used very heavily in patients with schizophrenia, and patients with schizophrenia die most frequently from what? Not suicide. Suicide is No. 2. They die most frequently from cardiovascular disease, and that is due to smoking but also due to these medications that they are on. We need to reckon with that when we talk to patients about these medicines: they have extremely consequential adverse effects.
So we stopped the quetiapine, and my mom got better. Her diabetes got better. She got off insulin. She is now just on metformin. But after that, I stopped interfering as much in her life and her relationship with her psychiatrist. I stopped overmanaging her because, as a doctor trained in America, I just had this instinct to intervene. And that instinct may, on the surface, seem like a good thing. But sometimes you have to do nothing to help someone, or help them in ways that let them see things for themselves.
I think one of the main ways we can bring cognitive liberty into clinical practice is by being very honest with our patients. Awais Aftab has an idea called conceptual competence, which is about teaching clinicians the limitations of their own field. We need to be teaching medical students, residents, and fully trained doctors what mental illness is, what we mean when we say someone has anxiety or depression. Because he shows us that these categories are just that: categories. They are buckets we use to organize how we think about people.
These diagnoses are not mapped onto anything biological occurring in people’s brains. They are not causative. Someone does not have anxiety because they have generalized anxiety disorder. Rather, generalized anxiety is this bucket that we put them in because we have seen that pattern of behavior.
Then we need to have honesty about what treatments are and what they do. I need my patients to understand that when I am giving them an antidepressant or an antipsychotic, I am not giving them a silver bullet that is working on the depression lesion in their brain or the psychosis lesion in their brain. I am giving them a neurochemical that has all kinds of effects on their brain and all over their body. They are not curing an illness. I think we have done a great disservice with the chemical imbalance theory of the way these drugs work.
But patients do not know that there is, in fact, no chemical imbalance in the brain of people who are depressed, or people who even have schizophrenia. We have not shown any kind of chemical imbalance, and I think most people are shocked to learn that.
Kidia: There is a discourse going on in the critical literature about care, and there is also this discourse about lack of access to what most people think of as medical care. Care inherently involves a hierarchical relationship between people. There is vulnerability and power, and that power dynamic can easily lend itself to situations of abuse and violence.
Under colonialism, colonizers frequently used the idea of care as a way of disguising violence against the natives, putting them into asylums because they did not fit the social norms of that colonial society. Mental health care itself is something that can be extremely powerful in a way that causes violence and oppression and harms people who are out there trying to get help.
The reason medical care is more valuable than social care is because of professionalization, because of the way economic power has filtered into the medical guilds. Now doctors, clinical psychologists, even social workers are trying to protect their guilds’ economic and social power in society, because they want to continue earning the same amount. What they do is gatekeep who can provide care and who cannot. They call certain types of care “official care” and other types of care “peer support” or “lay health worker care,” and that care is considered not as legitimate.
But as that example shows, a peer counselor can save five lives in the amount of time that a neurosurgeon is taking out a benign tumor. Social care comes not from money but from interconnectedness and reciprocity, a type of care that comes from your community, from your social world and your social life. That is because no mental illness is created in a vacuum.
Here is where I think a lot about the African philosophical concept of ubuntu, which, directly translated, means, “I am because we are.” The idea is that our minds are interconnected. I exist because the people around me exist, and without that connection, I am nothing.
Mental health care is not provided only by psychiatrists and psychologists. It is what primary care doctors do, what nurses do. But it is also what physical therapists do, what teachers do for their students, what mothers do for their children, what babysitters do for the kids they are looking after, what sex workers do for their clients, and what bartenders do for the man who has just gotten divorced.
The motivation for us to do it comes purely from our social interest in each other, and that social interest is good for our mental health. I am going to leave this conversation feeling a whole lot better about myself than when we started, and that is because we have had such a lovely chat about things that are important to us and values we share. That is something the capitalist health care system can never understand, but it is also something it can never take away from us.
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This post was originally published on Mad In America.