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Letter to the Editor

Art Does Not Answer to Psychiatry: A Response to "Game of Thrones: A Cliché About Madness? (spoiler alert)"

Sérgio M. Martinho, MD

Published: September 3, 2020

See reply by Mallet and Guessoum and letter by Mallet

Art Does Not Answer to Psychiatry: A Response to "Game of Thrones: A Cliché About Madness? (spoiler alert)"

To the Editor: I have read with great interest the letter to the editor "Game of Thrones: A Cliché About Madness? (spoiler alert)"1 by my fellow psychiatrist Dr Mallet published in a recent issue of the Primary Care Companion for CNS Disorders. Although I support the spirit and motivations of the letter, I cannot share its reasoning or its conclusions. Dr Mallet argues that, through their fictional plots, the Game of Thrones’ author and screenwriters are liable for disseminating several stigmatizing ideas regarding mental illness through the concept of madness. I cannot find evidence supporting this claim.

First of all, in reality, madness is not a psychiatric disorder. Furthermore, madness and its potential atavism have long been established as a literary topic within Western literature, from Sophocles’ Oedipus Rex2 to Ibsen’s Ghosts.3 Despite this, the issue raises the wider question: Should the Game of Thrones’ author and screenwriters have been, by principle, concerned with stigma associated with mental illness? From my point of view, the answer is no. Artists do not have any obligation or intrinsic duty to adapt to psychiatry needs or struggles; they might, but they should not be expected to do so. Moreover, art is a space of freedom, and artistic expression has, above all, an aesthetic purpose. Artistic content does not have to adapt to ethical, moral, or scientific standards. Otherwise, why stop at psychiatry? Why not gynecology, pneumology, or otorhinolaryngology? Should Kafka4 have explained exactly how Samsa turned into an insect? Should biologists be upset that he did not? Such specialistic concerns would render artistic expression impossible. Moreover, is it plausible that the author and screenwriters had the intention of promoting mental illness stigma?

Dr Mallet has every right to consider the plot predictable and tedious and is entitled to feel defrauded as a spectator. In this regard, I confess I share her frustrations. Nonetheless, I struggle to see how a psychiatrist, as such, could be defrauded by a work of art. Artistic expression could be of extreme value to psychiatry, as well as to any other area, as a discussion starting point. However, artists have no inherent duty to use art as a means to an end. Aesthetic appreciation stands outside the realm of psychiatry.

The stigma surrounding mental illness remains a critical problem within the general population.5 To fight this stigma, psychiatrists should focus on promoting positive pedagogical actions to increase mental health literacy. I am not sure that denouncing fiction and attempting to shackle artistic expression is the most beneficial strategy.


1.Mallet J. Game of Thrones: a cliché about madness? (spoiler alert). Prim Care Companion CNS Disord. 2020;22(2):19l02529. PubMed CrossRef

2.Sophocles. The Three Theban Plays. London, England: Penguin Books; 1984.

3.Ibsen H. Ghosts and Other Plays. London, England: Penguin Books; 1964.

4.Kafka F. Metamorphosis and Other Stories. London, England: Penguin Books; 2018.

5.Robinson P, Turk D, Jilka S, et al. Measuring attitudes towards mental health using social media: investigating stigma and trivialisation. Soc Psychiatry Psychiatr Epidemiol. 2019;54(1):51-58. PubMed CrossRef

Sérgio M. Martinho, MDa

aPsychiatry and Mental Health Department, Leiria Hospital Center, Leiria, Portugal

Published online: September 3, 2020.

Potential conflicts of interest: None.

Funding/support: None.

Prim Care Companion CNS Disord 2020;22(5):20l02718

To cite: Martinho SM. Art does not answer to psychiatry: a response to "Game of Thrones: a cliché about madness? (spoiler alert)." Prim Care Companion CNS Disord. 2020;22(5):20l02718.

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