Neurologist Pria Anand lauds Khameer Kidia’s new dissection of Western psychiatric imperialism.
Empire of Madness: Reimagining Western Mental Health Care for Everyone by Khameer Kidia. Crown, 2026. 384 pages.
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IN 1951, POW MENG YAP, a Malaysian psychiatrist practicing in colonial Hong Kong, set out to catalog the ways the language of his British medical training seemed entirely inadequate to describe the maladies of his patients. “The psychiatrist in cultures farther removed from the civilization of Western Europe may well have reason to pause and ask if the principles and practice of orthodox psychiatry possess the same degree of truth or usefulness elsewhere than in Western Europe or America,” he wrote, pointing to notions of “psychiatric imperialism” that had recently entered the anthropological discourse.
In his citation-heavy survey titled “Mental Diseases Peculiar to Certain Cultures,” Yap enumerated a list of syndromes anthropologists and other psychiatrists had described in members of Hong Kong’s Malay community that would perplex his British preceptors, ranging from “latah” among middle-aged women—a “hysterical” response to a sudden fright—to “koro” among young men, characterized by the conviction that one’s penis is disappearing into one’s abdomen, which was thought to herald death. In his article, Yap was frank about the messy state of the literature on these conditions, writing of the former syndrome that “in the latah state the patient is completely at the mercy of those who surround her, doing almost anything they command her to do, imitating all their actions, and, it is said, even the swaying of a tree bough or the mewing of a cat—but this is probably not true.”
Still, Yap argued, conflicting descriptions notwithstanding, the existence of latah, koro, and other culturally specific experiences raised questions about the notions of “normal” and “abnormal” that were taken as gospel by the Western psychiatric tradition within which he had trained.
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Decades after Yap’s treatise, latah and koro joined a slew of other “culture-bound syndromes” in a seven-page appendix to the 1994 edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). Other syndromes listed include “pibloktoq” among Indigenous groups in the Arctic, a wintertime psychosis in which women were reported to race naked through the snow after a trauma; “ataque de nervios,” an overwhelming surge of emotion followed by amnesia, which is unique to Caribbean Latin America; and, in a subsequent edition of the DSM, “kufungisisa” in Shona-speaking Zimbabwe, described as “thinking too much” about one’s own problems.
Do these descriptions represent a step toward understanding the diversity of the human experience? Or are they simply the 1990s version of psychiatric imperialism, outdated exoticizations written for an audience of chin-stroking armchair psychiatrists in the Global North? These questions remain hotly debated, and recent formulations argue that this list should include peculiarly American diagnoses like anorexia and bulimia. But mental health researcher Khameer Kidia has a radically different perspective. To him, these “idioms of distress” illustrate not local differences but a shared reality: “[S]uffering, not our response to it,” he writes in his ambitious new book Empire of Madness: Reimagining Western Mental Health Care for Everyone, “is universal.”
It’s difficult to sum up succinctly Kidia’s wide-ranging text, which wanders from inflation in Zimbabwe to the side effects of dopamine-depleting antipsychotic medications. Such side effects include tardive dyskinesia, which is characterized by incessant movements of the lips and tongue, as though savoring some sort of particularly viscous concoction. The condition can persist long after the medications have been stopped, the stigmata of medical treatment often misperceived instead as the stigmata of madness. “If you’ve ever ridden the New York subway on a regular basis, you’ve probably seen someone suffering from tardive dyskinesia and mistaken their condition for an illness that required medical attention, not an illness caused by medical attention,” he writes in one characteristically provocative chapter.
Suffering is at the core of Kidia’s argument: mental anguish, he argues, is a natural response to the humiliations and oppressions of colonization and late-stage capitalism. In recasting this suffering as mental illness, Western psychology obviates the need for any sort of reckoning or reparation. Instead, with medication, it “keeps the oppressed calm and productive instead of outraged and scattered.” A much more painful fix is needed, he suggests, in part because the problem is not personal but structural.
Kidia is a physician—he began writing this book in 2020, the year he finished his internal medicine residency training in Boston—but the book draws on a far deeper well of identity and experience. He interweaves arguments about contemporary global mental health with meditations on the colonial history of Zimbabwe, where he grew up and later returned as a mental health researcher, and his mother’s suffering, the highs and lows of which offer a whiplashing narrative structure for his polemic. When he first witnesses what American physicians would describe as hoarding, during a home visit as a medical student in New York, he thinks of his mother, who stockpiled cans of escargot and water chestnuts during the volatile heights of Zimbabwe’s economic crisis—a rational response to extraordinary circumstances, he argues.
To Kidia’s credit, he grapples with his own identity and privilege alongside those of his patients, even as he indicts social hierarchy as a global driver of anxiety and other forms of suffering. As a Zimbabwean of Indian descent, he grew up in the middle of a colonial hierarchy, “entangled somewhere in the web of power, oppressing some people and being oppressed by others.” He writes about his paternal great-uncle, one of the first non-white citizens to govern as a town mayor in then-colonial Rhodesia, and about his childhood home, a “massive five-bedroom house in the country’s wealthiest white neighborhood” that left his parents “cash poor.”
Kidia also reflects on his own elite credentials. Of the economic devastation of autocrat Robert Mugabe’s Zimbabwe, Kidia writes, “Mugabe and his cronies lived a lavish life. I know because I went to the same school as their children.” He describes his elite private primary and secondary education; his time as an undergraduate at Princeton, where he summarized Zimbabwean inflation to classmates in a macroeconomics course in terms of the mercurial price of Starbucks cappuccinos; and his Rhodes Scholarship to Oxford, where he was first confronted with the legacy of Cecil John Rhodes, namesake of both Rhodesia and the scholarship. “[O]nce I won the scholarship and was in the club, it didn’t make sense to be critical,” he writes. “That’s how colonialism works. If you benefit from it, as many of us do, you have little incentive to change it.”
Now Kidia is unabashedly critical. “I am calling for the end of psychiatry,” he writes, “or at least a kind of end.” To Kidia, who once flirted with the possibility of becoming a psychiatrist, mental illness is a product not of an imbalance in the neurotransmitters and genes of individual patients but rather of something much more immense: a malignant social and economic order that ravages the minds of everyone it touches.
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In an era when health conspiracist Robert F. Kennedy Jr. is the secretary of health and human services and “Make America Healthy Again” partisan and wellness mogul Casey Means is on the verge of being confirmed as surgeon general, calling for an end to psychiatry can feel like dangerous quicksand. Like Kidia, RFK Jr. is a critic of antidepressant medications like selective serotonin reuptake inhibitors, which Kidia cautions can cause sexual side effects, citing a rigorous pharmaceutical literature, and which RFK Jr. has blamed for mass shootings (with no viable citations). And like Kidia, Means has critiqued the capitalist motivations of 21st-century healthcare in treating patients with medications without identifying the root causes of their symptoms. “It’s profitable to keep people sick,” she claimed on comedian Bill Maher’s HBO talk show to resounding applause.
Last year, my father called me from the airport on his way home from visiting our family in India. It’s an over-24-hour journey, but it had gone quickly, he told me. He passed the flight reading a new book, Means’s Good Energy: The Surprising Connection Between Metabolism and Limitless Health (2024), recommended to him by a cousin who viewed it as a bible of sorts for healthy living and metabolic enlightenment. My curiosity was piqued. Before she dropped out of her otolaryngology residency program, Means and I were classmates at Stanford School of Medicine (in her book, Means writes that she graduated at the “top of [her] class,” though a spokesperson from the school clarified that the school uses an entirely pass-fail grading system). I remembered her as being both warm and energetic.
Like Empire of Madness, Good Energy blends argument and memoir. But that’s where the similarities end. Good Energy tempers any actual science with conspiratorial diatribes and woo-woo lifestyle advice, and unlike Empire, its arguments rely largely on nebulous implication—in one chapter, suggestively titled “Everything Is Connected,” Means leaps from the medications her mother was prescribed to treat high blood pressure, high cholesterol, and prediabetes to her sudden diagnosis of pancreatic cancer, implying a causal relationship without ever showing her work. In an appearance on The Tucker Carlson Show last year, she blamed Americans’ poor health at least in part on the use of contraception: “The things that give life in this world, which are women and soil, we have tried to dominate and shut down the cycles.”
By contrast, Kidia meticulously shows his work. In one chapter, titled “Hell on Earth,” he excavates the carceral nature of mental health, describing the cage-like “bed enclosures” used to restrain elderly patients suffering from delirium, and naming the company, Posey, that holds a virtual monopoly on the manufacture of medical restraints—the handcuffs, shackles, and cages used to bind overly active hospitalized patients to their beds. In another chapter, “Death by Debt,” Kidia traces an epidemic of suicides among Indian farmers to the Monsanto-manufactured genetically modified seeds that flooded the market in the 1970s, forcing farmers to take out high-interest loans that they could not pay off and ultimately leaving them landless and destitute.
Their prescriptions are equally divergent; although Means’s critiques are systematic—hospitals and vaccine schedules are making us less healthy, she claims—her solutions are personal: better sleep, more natural light, and the expensive continuous glucose monitoring, labs, and supplements hawked by her company, Levels (Means has promised to resign her position and sell her stock in the company if she is confirmed as surgeon general). The routines she recommends seem impossible for anyone with a job, let alone the multiple shifts and hourly wages that many of the patients I care for are hostages to. I recently spoke with a friend from medical school who, like me, is a parent of toddlers. She jokingly pondered whether Dr. Means’s prescribed hour-long morning wake-up routine is likely to change now that she has become a parent.
In short, Means’s prescription for the “limitless health” advertised in the subtitle to her book is an unapologetically capitalist individualism: eat less, exercise more, and be better. Kidia’s solution is harder and more expensive, but exponentially more honest: “[T]reat mental illness at its source by building a world that is fairer and more humane.”
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Kidia’s critiques don’t end with the healthcare system; he goes further, taking aim at the very idea of mental illness. “Diagnoses themselves,” he writes, “are not natural entities but invented categories that help doctors analyze symptoms in their heads—narrowing the complex histories we hear from patients into manageable buckets.” A case in point: the mid-19th-century condition called drapetomania, a bogus diagnosis applied to enslaved people who tried to escape their captivity. Mental health diagnoses, Kidia argues, are as much a function of culture and context as they are of biology. Under the pseudo-objective guise of “science,” they can serve as a weapon as much as a salve, pathologizing the entirely sane ways in which marginalized communities respond to dehumanizing circumstances. In the 1960s, psychiatrists labeled Black men with a diagnosis of “protest psychosis” characterized by “delusional anti-whiteness”—a 20th-century take on drapetomania—and even more recently, the diagnosis “excited delirium” has been used by medical examiners and law enforcement to explain away the deaths of Black men killed in police custody.
Even those diagnoses that reflect actual biological variation—for instance, schizophrenia—are shaped by culture. Kidia points to the work of Tanya Luhrmann, an anthropologist who studies the experience of hearing voices across cultural contexts. In one study, Luhrmann’s team surveyed 60 patients who heard voices and met diagnostic criteria for schizophrenia across three countries: the United States, Ghana, and India. The researchers found that the American patients heard violent, disturbing, anonymous voices that they attributed to their disease; these voices were assaultive, intruding into the intimate depths of their minds. In India, more than half of the participants heard the voices of family members, of parents and spouses and in-laws; some heard the voice of Hanuman, the loyal and righteous monkey god of the Hindu epic Rāmāyaṇa, others the voices of divine spirits who felt as familiar to them as siblings. In Ghana, where the idea of disembodied spirits speaking to the living is not restricted to the wards of a psychiatric hospital but is part of the culture at large, the majority of participants didn’t identify the voices they heard as pathological or diseased at all; 80 percent described hearing the voice of God helping to guide their decisions. “They just tell me to do the right thing,” one man reported. “If I hadn’t had these voices I would have been dead long ago.” In some cultures, then, hearing voices is a frightening illness, while in others it is a part of normal human experience.
In the external world, these differences—the identity of those illusory speakers, whether they are loved ones or threatening strangers, and even the content of their speech, whether they are critical or supportive, intrusive or merely irritating—are consequential, playing a part in whether a person who hears voices suffers from that experience or welcomes it. By way of prescription, Kidia points to the Hearing Voices Network, a movement that suggests a path forward is to name one’s inner voices and interact with them, even negotiate with them, in the service of forging relationships with these invisible speakers rather than suffering alone.
While reading Empire, I thought of my own grandmother, whose mother was a devotee of a Hindu guru whom she believed could divine the future. Unlike her mother, my grandmother believed more in science than in faith. She began a master’s degree in mathematics while still a teenager and was devastated when her father took her out of school at 19 to marry my grandfather. As an adolescent living in a village along the floodplains of the Ravi River during the tumultuous decades preceding the Partition of India and Pakistan, my grandmother was used by her mother as a medium through which my great-grandmother called the spirits of Hindu saints, god-men who would guide the family’s choices. My grandmother heard their voices in her brain, spoke their words, until her father began to fear that she had become too porous. Some malevolent spirit might slip into her skull alongside the sanctified ones, he thought, taking hold and never leaving. He stopped the séances, and my grandmother never again spoke of the voices she had heard, neither to her children nor to her husband.
I learned the story after my grandmother died, filtered through generations of other relatives—her siblings, their descendants—who had witnessed the séances or heard about them in stories, handed down like folklore. I have since wondered about whether the voices my grandmother heard felt forced or desired, frightening or welcome, within her control or beyond it. I wondered whether the experience was lonely—hearing a voice that no one else could hear—or whether the voices felt like company.
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Often, the psychiatric medicine described in Empire feels as violent and brutal as the ravages of any colonial regime. Early in the book, Kidia describes the sea changes that shaped 20th-century psychiatry as practitioners yo-yoed between biological and psychoanalytic approaches to their work. He describes the frontal lobotomy of Rosemary Kennedy, sister of JFK and aunt of RFK Jr., performed to treat her mood swings: “To control her behavior, surgeons drilled into her skull and cut out part of the frontal lobe of her brain until she was tranquilized into complacency.”
The description is a rare misstep in a text that is otherwise careful about the nuances of language. In fact, a lobotomy does not remove any of the tissue of the frontal lobe. Surgeons would make an incision in an awake patient’s skull, no wider than an inch, and then swing a blunt instrument one biographer described as “looking like a butter knife” back and forth to tear the bonds between the frontal lobe and the rest of the brain. The surgery was awarded the Nobel Prize in Medicine in 1949.
I can understand how Kidia might make this mistake; I once cared for a man who had undergone a lobotomy decades earlier. On an MRI, his frontal lobe seemed to have vanished, a dark shadow where I expected to see gray folds of brain tissue. At the most basic level, our brains are simply a web of relationships, dendrites and axons thirstily searching for one another the way roots search for water. As it turns out, there’s no need actually to remove any tissue from the frontal lobe during a lobotomy; when its connections with the rest of the brain are severed, it eventually withers away, isolated and purposeless.
That might actually be a better metaphor for Kidia’s thesis. Psychiatric diagnoses, he argues, render suffering intimately personal, making us believe that we are each at fault for our own distress. The true pathology is not plural but singular: we are all embedded in a web much larger than ourselves from which no one person’s suffering can be extricated.
For all the work it does autopsying the diseased corpse of Western psychiatry, Empire stops just short of offering a prescription—unlike Means, Kidia does not traffic in easy answers. The knotty problems Kidia catalogs have complex histories, and their solutions are just as complex. In a moment when snake oil seems to be the currency du jour, his candor is refreshing.
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