1) We did. It turns out there's no genetic smoking guns--no couple-of-genes whose function is disrupted that we can point to as causative--just oodles of genes that each individually have weak associations to clusters of mental conditions.
2) Mental illness risk is inheritable, but genetic mutations don't specifically cause mental illness, so barking up that tree is less likely to yield treatments, which is the whole point.
Anyway, "mental illness is genetic" can be a very strong claim (mental illness is genetic like cystic fibrosis or Tay-Sach's disease is genetic) or a very weak claim (mental illness is genetic because genes are responsible for organizing our brains and it would be shocking if this had no relationship whatsoever to mental illness).
I'm telling you the empirical outcome of the research done in this field. Single-point mutations do not cause mental illness. There are no specific genes that are strongly linked to mental illness. Not because we didn't check. Because they aren't there. There are many weakly linked genes. This doesn't mean "mental illness isn't genetic," although I tried to explain that that statement isn't clear on its own. It means we aren't going to find a gene that's broken, track down its function, and solve the mysteries of mental illnesses like we have for other conditions--like cystic fibrosis, for example. Because the causal pathway doesn't run through a couple of genes, it runs through thousands of them.
If you'd ever done research on genetics and mental health, you'd know how difficult this is.
We've spent over a decade having enormous trouble replicating the results of studies that link Behavior X to Gene 1.
I think people don't appreciate how difficult it is to isolate confounding variables from psychological research. When you're studying insulin absorption or photon behavior, it's pretty straightforward to isolate what you want to study from what you don't want to study.
Psychology is quite a bit messier. And even tools like the fMRI rely on massive inferences and statistical analysis/structuring. So trying to determine why a sample of 5,000 adult men have depression may seem as simple as looking at their genetic sequence...but it's not.
Another factor here is that it’s far easier for a patient to take a pill every morning than it is to revamp their whole lifestyle with diet, exercise, sleep hygiene and sunshine. It’s not just profit-seeking healthcare providers; managing severe depression through “natural” means is extremely challenging to impossible for many people, and depression makes it harder to even get started. I don’t think you’re wrong about capitalism creating perverse incentives, but I think there’s a structural demand-side as well, and that there’s the underconsidered utility in doctors using antidepressants to “kick start” someone’s wraparound depression management instead of aiming for lifelong dependency.
I’ve been on and off most types of antidepressants most of my life (misdiagnosed, turns out I have bipolar), as has most of my family, and if SSRI withdrawal is truly as bad as heroin withdrawal in more than a tiny minority of cases we wouldn’t have an opiate crisis. It’s unpleasant, sure, but speaking as an addict, that’s a ludicrous comparison.
Even the linked article explains that symptoms are both vague and usually mild. Nothing about it rivaling heroin, and even though I’m sure some unlucky people do get hit with that level of severity, I don’t think it’s more than a minuscule fraction of SSRI patients. Dropping that scare sentiment feels along the same lines as “Covid will kill you even if you run marathons” or “vaccines will give you seizures” - like yes, technically it’s true that these things can happen, but they’re outliers and shouldn’t be presented as if they’re commonplace.
I mean, the issue here is more that we don’t have wraparound health services or infrastructure to make good diet, exercise and sleep hygiene easily accessible to everyone (and you basically have to spoonfeed most depressives time get them to do anything uncomfortable or with remote payoff - that’s the nature of depression). Concrete action plans aren’t common, and they should be, and there’s potential in using SSRIs to start them off if there’s follow-through on the rest.
A headache can be anything from mild pressure in the forehead to a debilitating vomit-inducing migraine. Lethargy can be anything from feeling a little sluggish to too exhausted to get out of bed. You're doing a lot of work with equivalencies - "severe symptoms that have a lot in common with heroin cold-turkey withdrawal symptoms" isn't the same as "so severe they're as bad as quitting heroin cold turkey."
FWIW, I have been tried on several different antidepressants, at various points in my life. Stopping them, even cold-turkey, never gave me any difficulty whatsoever, *except* for one. My doctor said it wouldn't be a problem to stop cold-turkey again, then she went on vacation. Unfortunately, this drug gave me withdrawal so psychologically agonizing I previously wouldn't have believed it was possible. I wrote a comment about it on a different Substack. If I can find it, I'll post it.
Found it. Here's a lightly abridged version of it:
A few years back, for a specific reason (improperly managed side-effects of medication withdrawal) and time frame (perhaps a month), I went through an extremely intense depression, like nothing I'd ever experienced. Even having had smaller spells of natural depression in the past, it was a perspective-altering experience that left a lasting impression on me.
One of the strongest features of that depression, in particular, had been a nearly ceaseless awareness of my own existential dread. I could not escape from it or retreat in any way. It was a psychic pain as real as any physical pain I've ever felt, if not moreso. Despite being a solid atheist and raised irreligious, I spent significant portions of those days curled in the fetal position in the bottom of my bathtub, with the shower running, sobbing and pretending that God was real and was holding me. Even in the moment, for me, it was what Kurt Vonnegut might have called "foma" (something untrue, yet comforting nonetheless), but I was willing to take whatever relief I could get.
Thankfully, I knew that there was a very likely endpoint to my suffering (my body adapting itself to the absence of the medication), and I clung to that thought like a life preserver in the empty ocean. It became almost a mantra, repeating to myself that this state was impermanent, and I just had to get to the other side of it. But I remember thinking, more than once, that if this was what some people's lives were like with no endpoint in sight, I could understand suicide. I was firmly convinced that I would not have been able to endure even one year of that level of almost wholly unremitting anguish, if there were no end in sight. Nighttime, right before bed, was most bearable, but waking up was the worst part of my day, each morning a dreaded fresh hell. I'd feel a crushing weight in my chest the instant I was conscious, almost as though I couldn't breathe, though physically, I absolutely could. I would clutch my pillow to myself, waiting for the sensation to relent enough that I could even try to get out of bed. I couldn't -- and can't -- fathom bearing that existence long-term.
Two of the most tangible results of having had this experience are that I changed my position on mental health euthanasia (like they have in the Netherlands) and that I am much more sympathetic to drug addicts' experiences of withdrawal. (Though I had taken my medication exactly as prescribed, my experience was still caused by withdrawal.) I wasn't unsympathetic before, but I simply had no true notion of the possible depths.
The just give me a pill to make it all go away issue. This attitude extends to many medical and health issues and extends to surgery. A friend's father was obese, in his 60s and had to have quadruple bypass. He had the surgery and came out fine but he made no changes whatsoever to his diet and exercise habits (there were none). His stance seemed to be that pills and/or surgery would fix things so why worry about it? I think this is uniquely an American phenomenon, perhaps a confluence of culture and US style capitalism.
Theodore Dalrymple at City Journal has an interesting article entitled "Medicalizing Complexity." It hit on what I think is an important part of healthcare in the West, that our baseline became bliss and deviations are abnormal, rather than the reverse. I've recently become aware of Ivan Ilich who wrote on the medicalization of society. I haven't read Medical Nemesis yet but I worry that we are medicalizing too much as a society, including childbirth.
Multiple comments have mentioned this explosion of SSRI treatments. How is this possible if the pipeline of psychiatrists in the US is so skinny? FDB cited this in another article, but it’s something like 90% of counties in the US don’t have a psychiatrist, and many psychiatrists don’t take Medicaid. Is there evidence that the problem is over-diagnosis systemwide, or over diagnosis among a certain group of extremely wealthy urbanites in coastal regions?
I’ve been prescribed extremely low dose Lexipro by a GP, but I needed to see a psychiatrist for a higher dose and then for other Benzodiazepines. Is that similar in Canada? This isn’t to say that Lexipro is harmless, but it’s definitely less intense than many other anti depressants (and wasn’t effective in my case).
Please beware: Benzos are physically addictive, they tend to require higher doses with time, and the physical withdrawal can be harrowing. They are prescribed too easily for something that is physically addictive -- you won't even know you're addicted until you try to get off. Hell on wheels.
1. Psychiatric nurse practitioners. There are a lot of people prescribing psych meds with a fraction of the training an MD receives. The barrier to entry is lower than ever thanks to online, for-profit universities offering the degree.
My spouse used to supervise several psych NPs, and she has countless horror stories of incompetent care—especially from graduates of for-profit schools. It’s a big and under-discussed problem in mental health care.
2. Like Mariana said, primary care physicians prescribe a lot of psych meds. Sometimes they do okay, and sometimes they don’t know what they’re doing either.
I'm currently seeing a psych NP for my meds, but that's only because finding better care was nearly impossible. (Even being a person with good healthcare, the shortage of experienced psychiatrists is very apparent in my area.) Frankly, I think my psych NP is unreliable and vaguely irresponsible, and I don't trust her to be duly diligent, so I have to research every potential change myself. Nevertheless, that's what I could get, and for me, it's better than having no access at all. That said, in many situations, poor care is much worse than none. Which is all to say, I guess, that I feel very torn on the issue.
Psychiatrist here. The problem isn't so much the number of us in the United States, although it probably could stand to be higher, but like many medical specialties it is a distribution problem. The sorts of people who come from backgrounds that tend to make it possible to complete medical school in the first place and especially the kinds of people who are then attracted to an esoteric specialty which is appealing partly because of how hermeneutically interesting the work can be are also the sorts of people who want to live in prosperous urban regions on the coasts.
Psychiatrists in rural areas tend to be foreign medical graduates who need to find a place that will sponsor their visas or people who are very interested in making a ton of money. There is a job in Alaska that gets posted now and again that will pay someone 850,000 if they will commit for a year plus a substantial signing bonus. It does appear to be the case however that you will be responsible for a significant chunk of all mental health care in the state if you sign up and you will not be living in Anchorage. It takes a certain sort to want to do that work.
> So for me, this “vibe shift” about medication is a good thing, because I feel that people who were hurt by these drugs or didn’t find them effective have been ignored by mainstream medicine.
I have quite a few stories where my experiences deviated from the party line and were dismissed, much to my detriment. Try convincing your psychiatrist that the anti-psychotics she prescribed are making your more psychotic while you are in fact psychotic. The medications I take are essential to my well-being but the professionals who dispense them are humans who make mistakes. It can be especially hard to get those mistakes rectified when the premise of your treatment is that there's something a bit wrong with you. Psychiatry I think can be especially revanchist and paternalistic in this way, and defensive on account of its questionable position in society.
(nota bene, I keep hearing about horrible NPs but the one I've been seeing for ~four years now is wonderful and the, uh, crimes of care I've experienced were almost all at the hands of MDs. Anecdotal but while NPs might be a problem, they aren't responsible for all of the malfeasance in psychiatry)
"I have quite a few stories where my experiences deviated from the party line and were dismissed, much to my detriment."
Same here. And the most disturbing experiences involved psychiatry, for the reasons you describe: "Psychiatry I think can be especially revanchist and paternalistic in this way, and defensive on account of its questionable position in society." Plus, psychiatric gatekeepers of all sorts are notoriously overworked, and often just don't have the resources to do more than assign stock treatment and question the patient's cooperation if stock escalation of treatment fails to work.
That doesn't make the psychiatric meds themselves the problem, though. By analogy, Prednisone, an awesomely powerful anti-inflammatory steroid, is not "the problem". It's legitimately a wonder drug. It also comes with some serious costs that can make it a drag even when you need it, and disastrous to prescribe for a problem it cannot help.
"It can be especially hard to get those mistakes rectified when the premise of your treatment is that there's something a bit wrong with you."
To be honest for a long time psychiatrists fell into a bimodal distribution: people who found the field extremely intellectually interesting and were the most literate/humanities-oriented folks in their med school classes, and the people who didn't have the scores to match in anything else. It didn't help that our disorders are defined in an obviously arbitrary way. We thus had an intellectual inferiority complex for a long time.
Additionally, because there were so open residency slots and so many rural or underserved places willing to sponsor visas, psychiatry for a while was the specialty a lot of docs trained overseas were able to practice in the United States even if they were actually, say, surgeons. So there was definitely a generation of psychiatrists, foreign and US-born, who were practicing psychiatry because they didn't have other options and had very little intrinsic interest in mental health or treating the mentally ill. These people were not going to have the intellectual confidence to be able to tolerate people questioning their assertions or not simply accepting whatever they are told.
Psychiatry is getting much more competitive for residency applicants and this is fading, but it's not gone yet.
Also psychiatry is a place where people with their own mental health issues are traditionally thought to practice in, whether because of their own interest but also washing out of other residency possibilities (not just score based).
This is it exactly. There is a huge difference between depression, which many people absolutely have and are basically functional, and psychosis. When I hear Freddie make the argument that we need more psychiatry, I think he is talking about severe mental illness, and I agree. But I think depression and anxiety are overmedicated, especially in kids and young people. I do think that the model is to get you hooked early and stay on for life. I have personal experIence and experience as a teacher. It really is apples and oranges. Freddie often talks about the lack of psychiatrists, esp. those who accept insurance. But most psychiatric drugs are prescribed by regular docs, NPs, and PAs. A LOT of people take psychiatric meds. When people say that “society” or “capitalism” is causing mental illness, I think they are gesturing to the rise in depression and stress in modern society, and they aren’t wrong about that. I think it’s clear that depression and anxiety have genetic factors, but that stress, trauma, even loneliness and isolation can be major contributing factors. That seems really obvious to me. The fact that our society is swimming in easily accessed hard drugs doesn’t help. I know 2 young women whose psychosis was triggered by meth use. They were predisposed to mental illness, but the drugs didn’t help. I think humans have a lot of needs that aren’t met in our culture, and if you are predisposed to mental illness, this is a society that will make you crazy. And some people get very sick on their own. I think the diabetes analogy is good. Some people are type 1, hard to control with treatment, many more are type 2 as a result of a sick culture.
I was prescribed low dose Paxil generic to manage chronic pain, and it worked pretty well, as well as making me feel about 10 years younger. Temporarily, anyway. They stepped me up twice and each time I'd get a lift, then go back to normal after a few weeks.
I was getting (correctly, it turns out) worried about being dependent on me, and when I decided to go off it (this is when I first experimented with smoking pot in my mid40s) they gave me the wrong dose, which was two steps below where I was.
My wife came home one night to find me sobbing hysterically while watching "Person Of Interest". I mean, I love Nolan/Joy, but I was pretty shaky for a while there.
Thanks, very good summary. The misunderstandings are lame and contrary to evidence. After all, if depression has nothing to do with brain chemistry, anti-depressant drugs shouldn't work at all, yet they do.
The scientific illiteracy and ignorance of basic logic among the press and Americans in general is, dare I say it, depressing.
Even severe depression seems to resolve itself within 6 to 18 months. This is a long time! But the timeline to find the proper medication and dose is also 6 to 18 months.
Further, anti-depressants are addictive. One of the biggest side effects of withdrawal is depression.
So it's not impossible (or even unlikely) that the reason some people who have suffered from severe depression recover is because...they just did. However, they're also now addicted to their medication, so when they stop taking it in a year or five or ten, they will immediately feel very depressed.
Sure. Many other chronic problems flare up at some times worse than others, and treating the flare risks dependence on the treatment that would not otherwise develop, courting a potentially-nasty withdrawal. Rheumatoid arthritis and asthma both have this problem. Are things really bad enough yet to bring in the big guns notorious for their big withdrawal symptoms?
Even when temporary palliation doesn't buy total reduction in misery, just shifting the misery around, having the option to shift the misery away from crunch times can be useful. Using misery-shifting power responsibly can be tough, of course. Not all doctors trust patients to do so.
"I don't want to miss the wedding, can I have some Prednisone please?" is not a request all doctors will honor, especially if they don't know you. Other doctors believe giving patients some insurance for participating in major life events, even if they'll pay for it later, is worth it.
I particularly find irksome the "Dont take drugs man, take lots of [vitamin C|D][kelp] etc etc" instead. As if they are not treating those substances like a drug or because its "natural" :( Natural like plutonium ?
Tobacco ? Opium ? Cocaine ? Khat ? are all "natural" addictive substances. Even substances that have no withdrawal symptoms can be deadly in the wrong doses. This sad story popped up just recently.
The point I am making is that just because its "natural" does not make it any better or worse and somehow not make it a "drug"...
WRT addictive or not, if 2 substances had identical results for treating something and the only difference was one had no withdrawal effects (a compounded and processed product ) and the other did not have addictive properties and was "natural" (picked it out of the tree), I would take the one with no withdrawal effects.
When I hear the modifier added, "because its natural" I am pretty sure I am hearing what I am hearing. Otherwise they could just say "because X is not addictive"
That study seems very compelling and very well done. A long study with a very large population.
I think the conclusion is that many, but not all, of mental health diagnoses, are mistreated with these drugs. I think this is a very good thing to have discovered. Everyone owes Tom Cruise a big apology.
you seem to be ignoring the very basic argument I'm laying out here: the fact that one given neurological explanation may not be true in no way suggests that all neurological explanations are true
I think "many, but not all, of mental health diagnoses, are mistreated with these drugs." covers, or at least was my attempt to cover, your point that the study in no way suggest that all neurological explanations are true. My natural father is diagnosed with mild paranoia and mild schizophrenia. He is in his mid 80s and takes care of himself with a bit of outside help. He was on SSRIs for a while and it made him violent and suicidal. And that increased his paranoia that the medical community was trying to kill him. So this is the other part of the study to discuss that the drugs were designed to supplement the missing serotonin, and so even if some or many of the maladies are the result of brain chemistry imbalance (something I don't doubt), I think this is the other important discussion... that these power psychotropic drugs seem to be largely missing their mark.
I highly, highly doubt that the prescribed who issued an SSRI to your dad thought they were actually replacing his missing serotonin. In reality, psychiatry has a dozen or two discrete tools (drugs with different mechanisms of action) to try to make people better (SSRIs, MAOIs, benzodiazepines, atypicals, anti-epileptics, lithium, clozapine, Wellbutrin, stimulants...) and psychiatrists will try them in the indicated order for the condition until the person starts to look a bit well. They absolutely do not see people and think "hmm, this guy I bet is suffering from a lack of norepinephrine, let me up it with some bupropion." They think "the last couple of folks I saw who were kinda like this guy did well on bupropion, let's try that."
All of this is true information about how SSRIs work* and has nothing to do with the process of selecting drugs to treat people with mental illness. The information about serotonin is extraneous to it, it's wholly theoretical. Trying to figure out who does or not does have a "serotonin deficiency" does not play into the treatment process. And if it does it's a necessarily a shorthand for observed behavioral patterns that correspond to observed drugs responses, because no one ever inspects anyone's serotonin levels in the process of treating them, there is no diagnosis of "low serotonin," and there is not even agreement about what the outward presentation of low serotonin would be.
Edit: *this is true information about what SSRIs in fact do in the brain, not necessarily how they treat depression
I think you are missing the point here or I am not understanding your argument.
These drugs were designed to address the suspected/assumed root cause of serotonin deficiency. Yes, wholly theoretical and that theory has been practically debunked by the study.
Nobody inspects serotonin levels. True. But irrelevant to my point.
I have a rare malady and the treatment for that malady has evolved as previous theories of its cause that supported FDA treatment approval have been since debunked. Why get defensive about scientific advance that would help us improve treatment?
Keep in mind we don’t even know how anesthesia works. Very quickly if you start looking into medical research you’ll find the phrase “this occurs through processes not currently understood” everywhere.
Not too long ago in human history, "we don't know why this works" was the default for everything!
Between learning so much about so many things, and getting used to the world's information being in our pockets all the time, we've forgotten that there are everyday things we just don't know.
Even if one accepts your assertions about how compelling and well done the study is, your conclusion would still be a non sequitur of sweepingly epic proportions. But based on the Tom Cruise remark, maybe you were being sarcastic.
A lot of people are very uncomfortable with the idea that the brain could malfunction. In discussions about homelessness some say they are choosing to be homeless. But in many cases the choosing part of the brain is the part that’s malfunctioning. That idea freaks a lot of people out.
Agreed. Nobody likes to feel like their brain can betray them. It’s deeply horrifying to know you can’t trust your judgment or perception. And a lot of people have seen loved ones decline due to mental health, brain injury or dementia-related reasons and know about the devastating, slow, hard-to-treat and often inexplicable agony that can cause - they get a preview of what that may feel like should it happen to them, and often feel it like a genetic sword of Damocles.
I have several friends and family members that suffer or have suffered from depression. It could be argued that environmental factors (e.g., bad marriage, job issues, etc.) contributed to their issues.
However, some experience arguably abnormal lows absent any readily apparent external factor, and some responded to clinical therapy, sometimes supplemented pharmacologically.
I think the tremendous complexity and diversity in the human population makes finding a cure all incredibly difficult. I wish there was some kind of “light switch” solution that worked for everybody because depression can be debilitating, occasionally extremely so. Hopefully those pursuing a remedy continue their pursuit despite the cultural churn creating eddies and currents making their work needlessly more difficult.
Thank you, Mr. deBoer, for your thoughtful treatment of a difficult, often contentious subject, and here is to hoping for a brighter future for those afflicted with depression.
Well, sure — in the ultimate sense, everything is physiological. That doesn’t mean, however, that the solution to many psychological maladies isn’t environmental, in more or less precisely the way that the solution to lead poisoning is to not put lead in the environment.
(As for your point that we all live under capitalism but only some of us are diagnosed with depression — I don’t think that’s inconsistent with an environmental hypothesis. It just means some people are more sensitive to the environmental trigger than others. But that doesn’t mean that, in the absence of the trigger, there’s an underlying “disease” that is caused by a “chemical imbalance” in the brain.)
And I think people would be less skeptical of pharmaceutical interventions if people didn’t keep radically over-claiming for them. “You’re not going to get COVID if you have these vaccinations” is just the dumbest and most extreme example of a long line of the public being told things about all manner of interventions that simply aren’t borne out by the actual science. The efficacy of SSRI’s was massively oversold. Now you’re mad at people for being skeptical? People are gonna be skeptical.
Neurological could mean anything associated with the brain. When people are talking about selective serotonin reuptake inhibition, they're talking very specifically about one neurotransmitter.
No one would doubt that schizophrenia or Alzheimer's are neurological. You can see the way it physically changes the shape of someone's brain. But saying something is neurological is also not the same thing as saying: these neurotransmitters are to blame.
“Practitioners, media, and pharmaceutical companies have played fast and loose with a lie-to-children, using applied ignorance to explain the potential benefits of antidepressants to the public without getting into the minutia of codependent chemical pathways in the brain.”
Then it says that “no one is making” the “serotonin hypothesis” argument.
🤷♂️
If you don’t want the public to think that’s your claim, maybe don’t sell the drugs on the basis of that claim? Otherwise, how can we trust you later when you say, “oh, no, what we REALLY meant was…”
"Sapolsky says it pretty well that from what we know about depression, there seems to be something going on in the interaction of adrenaline, dopamine, and serotonin- each contributing their own ingredient to the special sauce that is depression. This is a much clearer picture of the supposed “chemical imbalance hypothesis.”"
One of the main points of Paul Logan's piece is that "the serotonin hypothesis" is largely a product of pharmaceutical marketing and not a serious position in the field of psychiatry. When you ask "how can we trust you," you appear to be conflating these two. I would hope that you recognize that positions in the field of psychiatry are more important than, and distinct from, marketing oversimplifications. It is only the former that are worthy of serious attention.
As I said elsewhere, I studied this for my degree so I'm fairly aware of the literature and broader discussion.
And the piece you linked comes to the same place that I'm at, which is that depression is not one single thing. Like all aspects of life, but especially with bodily health, everything is quite complicated.
But this is an actual and real debate within the field. Painting skeptics who have spent their careers studying this as dishonest isn't very helpful. Especially when the implication that they're dishonest comes from charlatans using their research for cruel purposes.
Many psychiatric medications are over prescribed and are often prescribed to people who have never seen a psychiatrist. As the research currently exists, there is no evidence of a chemical imbalance causing mental illness. There seems to be something going on there and SSRIs and other medications seem to alleviate symptoms, but they are not meant as a cure. It's also inarguable how massive the influence the pharmaceutical industry has on the field. They fund the conferences, fund the research, they own some of the major periodicals, they publish non-peer reviewed research in those periodicals. And they don't do it purely out of the goodness of their hearts.
So this is a big, messy, complicated question. We need more research and we especially need replication studies (topics, probably, for another time!), but to say that people who find an issue with a theory without an evidentiary foundation are bad actors is just kind of silly.
Like, no one would say that string theory is a nefarious plot to upend what we know about physical reality, but that seems to be the kind of argument deployed with regard to mental health questions.
"there seems to be something going on there and SSRIs and other medications seem to alleviate symptoms, but they are not meant as a cure."
I can justify the defense of these drugs being used to alleviate symptoms as long as they are not exacerbating problems as often the cure is beyond reach.
Today I have an incurable disease that will likely be the thing that takes me out, and I am on modern medication that reduces the symptoms and improves my quality of life. They are expensive drugs and thus I always consider the conflict of interest with the healthcare industry to over-prescribe the drugs, and even steer patients to the drugs rather than new advances that are either less expensive therapy or maybe even breakthroughs for cure. I wish I just trusted the system, but as the COVID era has taught us all, my concerns are well-founded.
A lot of anti-medication people are running with “it’s probably not neurotransmitter imbalance” and turning it into “it’s probably not neurological”, which is akin saying a malfunctioning computer doesn’t have anything wrong with the hardware just because all the cords are intact. There could be other things wrong with the hardware! It could be both hardware and software, or a hardware issue that looks like a software issue, or both! The cords are just one possibility and them being in working order is not a clean bill of health for the machine’s physical parts - it’s inconclusive.
"Some people are more sensitive to the environmental trigger than others' sounds an awful lot like 'something about certain people not explicable in terms of their proximal environment causes these extreme behaviors and thoughts to emerge'. Whether you want to attribute that to individual learning history or culture or capitalism or whatever, that difference has to live somewhere. Unless we embrace the full Cartesian dualist position, that difference in experience trivially has to be reflected somewhere somehow in neurobiology. 'Chemical imbalance' was a dumb theory but the details of brain functioning are still going to matter if you want to understand just how all those abstract concepts actually translate into what an organism does and feels. This is especially true if you are interested in modifying that functioning for any reason, therapeutic or not.
For what it's worth, the diathesis-stress model has been the mainest of mainstream ideas in mental health for decades.
Sure! Of course. Everything is biology! Learning to read is biological at base (it causes changes in the brain), but no one would argue that it’s not caused by the environment. Medieval European peasants were illiterate; now almost everyone in Europe can read. That is due entirely to environment. That some people are great at learning to read and some people struggle with it doesn’t mean that the primary determinant in learning to read isn’t access to education.
Absolutely. But - in an environment in which access to rudimentary education is not the primary obstacle to reading, if you want to make more people literate, you may want to figure out why some people struggle with reading and what can make it easier for them. I certainly don't disagree that environment shapes behavior (I would be stupid to do so) but the problem of "why do two people equal in most respects react radically differently to similar stimuli" can't be explained by environment alone. Even the modern behaviorists have to posit something relatively specific to individuals at that point.
Oh, for sure. I agree. I just think that it can be hard to tease out environmental factors, and the fact that some people are affected more by a particular environmental cause than others are doesn’t mean that the effect wouldn’t be greatly altered if the environment were changed. (E.g., in this case, I think it’s possible that some of our mental health problems are caused by environmental factors.)
"And I think people would be less skeptical of pharmaceutical interventions if people didn’t keep radically over-claiming for them. 'You’re not going to get COVID if you have these vaccinations' is just the dumbest and most extreme example of a long line of the public being told things about all manner of interventions that simply aren’t borne out by the actual science."
It's not just pharmaceutical interventions, though. Behavioral interventions, or what we might call the patient's moral improvement, also gets oversold.
Take, for example, asthma. After an unfortunate detour of medical history where asthma was supposed to be psychosomatic, asthma was properly recognized as an immune and pulmonary disorder. That has not, however, absolved asthmatics of the expectation that, if they fail to meet certain moral standards, they should blame themselves for their poorly-controlled asthma.
The moral code asthmatics are expected to follow simply in order to breathe involves self-denial, scrupulous hygiene and indeed neat-freakery, unusual regularity of habits... Many asthmatics achieve excellent asthma control while falling short of such lofty standards, but if you fall short of these standards and you haven't yet achieved...
Asthma guilt is real. And, as a natural experiment discovered during COVID shutdowns, perhaps misplaced. The steps asthmatics can take to control their own lives and home environments just don't seem to matter as much as asthmatics were previously taught.
*Any* individualistic intervention tends to get oversold. Precisely because so much of the cosmos is outside our control, what little control we do have is precious, cherished and idealized as our individual identity and dignity. Especially in a Prosperity-Gospel country like the US, we *desperately* want this individual dignity to manifest as material improvement.
Swallowing a pill isn't a dignified act as such, but it's an individualized intervention within many people's reach -- no wonder we oversell it! We also oversell individualized *moral* interventions -- like yoga, CBT, and figuring out how to keep one's house scrupulously cleaned all by one's lonesome without exposing oneself to the steps of housecleaning known to trigger asthma. (Take my HEPA vac -- please. I'm supposed to use it so scrupulously it'll need frequent emptying yet never be the one to empty it myself.)
I clicked on the link to see the meta-analysis. Quoting from the summary: "The results showed that both TCAs and SSRIs *were* effective for depression." (Emphasis mine.) How are people concluding from this that SSRIs don't work? (Or that serotonin isn't somehow implicated in depression?)
I couldn't find it in the meta-analysis to see whether it had any rates of efficacy for SSRIs but googling around the web I get results between 40%-60%. I think the reason people think SSRIs don't work is because they're using a different heuristic of "effective" than the medical literature.
From the perspective of psychiatrists, being able to help ~50% of patients with SSRIs seems like a good outcome. But from the individual perspective, something having a ~50% chance of working doesn't seem like a good outcome.
"Why are so many people who do not suffer from mental illnesses or work with them professionally, both left and right-wing, so deeply eager to deny the physiological basis of mental illness and the efficacy of psychiatric medication?"
You cannot ask that question without acknowledging that there are evil people with a financial incentive to oversell the phsyiological basis of mental illness and the efficacy of psychiatric medication. The reason the serotonin theory of depression took such deep hold in the popular consciousness despite dubious scientific grounding is because of an enormous marketing campaign to convince people that medication was the best and perhaps only answer to depression. You are absolutely right that the issue calls for nuance and compassion to people who are suffering, but I think you are wrong to cast outrage and backlash over the success of profiteering in health care as some kind of mean-spirited "eagerness" to invalidate people's pain.
Just a hypothesis, but without denying the physiological basis of medication, how do you describe the soul? What part of you goes to Heaven if “you” can be so malleable in the face of mental diseases and solutions? This might not be correct, but I think there is a deeply human desire to believe in an utter essence of a person that cannot be changed. To many, perhaps choosing not to believe is merely a way to cope with problems that have plagued humans for all time.
Of course we should be compassionate and not dismissive of those for whom the drugs work. But, that is not to say that we should not demand more from our doctors. As stated, "we know depressingly little about the brain," therefore, if doctors are to maintain their oath and "do no harm", they should not be prescribing drugs willy-nilly, and much less also conclusively parroting unproven theories, such as the serotonin re-uptake one they all authoritatively mouthed when this Prozac Nation period began, some 20+ years ago.
I, for one, am absolutely livid at the doctors who prescribed this to me, and many loved ones, throughout the last few decades, while authoritatively parroting the re-uptake b.s.
In this, and other areas of medicine (trans care for minors?) perhaps doctors should be more humble and just say, "This may work, but we don't know what the consequences may be, nor whether or how it works."
The issue many have with doctors, medical/health institutions or both is the certainty with which they make statements. Do we need any more evidence of their corruption and incompetence that COVID and the pandemic? Science is a process, not a conclusion.
I don't understand this sentiment at all. Using your example of COVID, I can promise you that all over the world, scientists and researchers and doctors were all scrambling desperately to reach firm conclusions about the SARS-COV2 virus and the disease it causes.
It's fine for it to be "all about the journey, man" when you're smoking peyote in the desert with your friends, but no one involved in the physical sciences would have that attitude. It's just unthinkable.
Yes and they were often wrong about those conclusions, like the vaccine stopping the spread of COVID. Or ignoring the women who said their periods changed. They had their conclusions and evidence (even anecdotal at the time) be damned. The issue is the absolute certainty they have that their conclusion is right and works as they expected.
Scientific medical opinion coalesces around a conclusion and challenges are dismissed. Ignaz Semmelweis for example.
I don't think there was ever an actual scientific consensus that vaccines would stop the spread of COVID. This was instead a hopeful fantasy popularized by the media and various popular figures.
And sure, there are examples of unhealthily entrenched consensus in the history of science. Of course, those examples (as with Semmelweis) also show that the new paradigm eventually succeeded, and the consensus evolved to accept it. Yet that doesn't imply that all scientific consensus is therefore wrong by default.
There are certainly limitations to any research, and therefore conclusions may necessarily be provisional. But again, that doesn't mean that the provisional consensus should be summarily dismissed. What are you going to replace it with, conspiracy theories on the internet?
When I was studying neuroscience at university it was shocking to me when we discussed the chemical.imabalance theory. Shocking because there had *never* been any evidence behind it. Even so, much of the field treated this as a settled fact.
Obviously there's something neurological going on causing mental illness. People who say otherwise are simply lying or don't know enough to even lie about it.
But this study is very important. The pharmaceutical industry has massive sway in the field, funds tons of research, funds many of the major international conferences, and has even bought some of the major periodicals (where, incidentally, they publish non-peer reviewed research).
That's not to say pharmaceuticals play no part in treating illness, mental or otherwise. But many people within the field and especially outside of it treat the pharmaceuticals that alleviate symptoms as the cure. Also, many people prescribed these medications never meet with a psychiatrist in a meaningful way. It's not infrequent that an educator recommend that a parent get medication for their child, for example.
So, yes, of course there are bad actors, but this is pretty important. It's the kind of research that has been sometimes difficult to fund and difficult to get published because of the immense influence of the pharmaceutical industry on the field.
Also worth pointing out: Dr. Joanna Moncrieff, who led the metastudy, is a known critic of psychopharmaceutical interventions, it's kinda her life's work. Sometimes, when you look for something, you find you what you are looking for.
I think most people in the mental health field want broader adoption of a bio-psycho-social approach to treatment, but it's been wild to watch New Age bypassers celebrate this study like SSRI/SNRIs do not massively benefit people
Thanks for pointing that out -- I agree that researchers often find what they're looking for. I also think that applies to pharma-sponsored research that finds that their drugs work well. It makes it all very hard for consumers to know WTF to believe.
"Chemical imbalance" was always an overconfident phrase masking the level of ignorance that you rightly note. People overgeneralizing from headlines is typical behavior, especially online. So is indiscriminate destruction of a perceived shibboleth.
It's fine, your meaning was clear!
1) We did. It turns out there's no genetic smoking guns--no couple-of-genes whose function is disrupted that we can point to as causative--just oodles of genes that each individually have weak associations to clusters of mental conditions.
2) Mental illness risk is inheritable, but genetic mutations don't specifically cause mental illness, so barking up that tree is less likely to yield treatments, which is the whole point.
Anyway, "mental illness is genetic" can be a very strong claim (mental illness is genetic like cystic fibrosis or Tay-Sach's disease is genetic) or a very weak claim (mental illness is genetic because genes are responsible for organizing our brains and it would be shocking if this had no relationship whatsoever to mental illness).
I'm telling you the empirical outcome of the research done in this field. Single-point mutations do not cause mental illness. There are no specific genes that are strongly linked to mental illness. Not because we didn't check. Because they aren't there. There are many weakly linked genes. This doesn't mean "mental illness isn't genetic," although I tried to explain that that statement isn't clear on its own. It means we aren't going to find a gene that's broken, track down its function, and solve the mysteries of mental illnesses like we have for other conditions--like cystic fibrosis, for example. Because the causal pathway doesn't run through a couple of genes, it runs through thousands of them.
If you'd ever done research on genetics and mental health, you'd know how difficult this is.
We've spent over a decade having enormous trouble replicating the results of studies that link Behavior X to Gene 1.
I think people don't appreciate how difficult it is to isolate confounding variables from psychological research. When you're studying insulin absorption or photon behavior, it's pretty straightforward to isolate what you want to study from what you don't want to study.
Psychology is quite a bit messier. And even tools like the fMRI rely on massive inferences and statistical analysis/structuring. So trying to determine why a sample of 5,000 adult men have depression may seem as simple as looking at their genetic sequence...but it's not.
Another factor here is that it’s far easier for a patient to take a pill every morning than it is to revamp their whole lifestyle with diet, exercise, sleep hygiene and sunshine. It’s not just profit-seeking healthcare providers; managing severe depression through “natural” means is extremely challenging to impossible for many people, and depression makes it harder to even get started. I don’t think you’re wrong about capitalism creating perverse incentives, but I think there’s a structural demand-side as well, and that there’s the underconsidered utility in doctors using antidepressants to “kick start” someone’s wraparound depression management instead of aiming for lifelong dependency.
I’ve been on and off most types of antidepressants most of my life (misdiagnosed, turns out I have bipolar), as has most of my family, and if SSRI withdrawal is truly as bad as heroin withdrawal in more than a tiny minority of cases we wouldn’t have an opiate crisis. It’s unpleasant, sure, but speaking as an addict, that’s a ludicrous comparison.
Even the linked article explains that symptoms are both vague and usually mild. Nothing about it rivaling heroin, and even though I’m sure some unlucky people do get hit with that level of severity, I don’t think it’s more than a minuscule fraction of SSRI patients. Dropping that scare sentiment feels along the same lines as “Covid will kill you even if you run marathons” or “vaccines will give you seizures” - like yes, technically it’s true that these things can happen, but they’re outliers and shouldn’t be presented as if they’re commonplace.
I mean, the issue here is more that we don’t have wraparound health services or infrastructure to make good diet, exercise and sleep hygiene easily accessible to everyone (and you basically have to spoonfeed most depressives time get them to do anything uncomfortable or with remote payoff - that’s the nature of depression). Concrete action plans aren’t common, and they should be, and there’s potential in using SSRIs to start them off if there’s follow-through on the rest.
A headache can be anything from mild pressure in the forehead to a debilitating vomit-inducing migraine. Lethargy can be anything from feeling a little sluggish to too exhausted to get out of bed. You're doing a lot of work with equivalencies - "severe symptoms that have a lot in common with heroin cold-turkey withdrawal symptoms" isn't the same as "so severe they're as bad as quitting heroin cold turkey."
FWIW, I have been tried on several different antidepressants, at various points in my life. Stopping them, even cold-turkey, never gave me any difficulty whatsoever, *except* for one. My doctor said it wouldn't be a problem to stop cold-turkey again, then she went on vacation. Unfortunately, this drug gave me withdrawal so psychologically agonizing I previously wouldn't have believed it was possible. I wrote a comment about it on a different Substack. If I can find it, I'll post it.
Found it. Here's a lightly abridged version of it:
A few years back, for a specific reason (improperly managed side-effects of medication withdrawal) and time frame (perhaps a month), I went through an extremely intense depression, like nothing I'd ever experienced. Even having had smaller spells of natural depression in the past, it was a perspective-altering experience that left a lasting impression on me.
One of the strongest features of that depression, in particular, had been a nearly ceaseless awareness of my own existential dread. I could not escape from it or retreat in any way. It was a psychic pain as real as any physical pain I've ever felt, if not moreso. Despite being a solid atheist and raised irreligious, I spent significant portions of those days curled in the fetal position in the bottom of my bathtub, with the shower running, sobbing and pretending that God was real and was holding me. Even in the moment, for me, it was what Kurt Vonnegut might have called "foma" (something untrue, yet comforting nonetheless), but I was willing to take whatever relief I could get.
Thankfully, I knew that there was a very likely endpoint to my suffering (my body adapting itself to the absence of the medication), and I clung to that thought like a life preserver in the empty ocean. It became almost a mantra, repeating to myself that this state was impermanent, and I just had to get to the other side of it. But I remember thinking, more than once, that if this was what some people's lives were like with no endpoint in sight, I could understand suicide. I was firmly convinced that I would not have been able to endure even one year of that level of almost wholly unremitting anguish, if there were no end in sight. Nighttime, right before bed, was most bearable, but waking up was the worst part of my day, each morning a dreaded fresh hell. I'd feel a crushing weight in my chest the instant I was conscious, almost as though I couldn't breathe, though physically, I absolutely could. I would clutch my pillow to myself, waiting for the sensation to relent enough that I could even try to get out of bed. I couldn't -- and can't -- fathom bearing that existence long-term.
Two of the most tangible results of having had this experience are that I changed my position on mental health euthanasia (like they have in the Netherlands) and that I am much more sympathetic to drug addicts' experiences of withdrawal. (Though I had taken my medication exactly as prescribed, my experience was still caused by withdrawal.) I wasn't unsympathetic before, but I simply had no true notion of the possible depths.
The just give me a pill to make it all go away issue. This attitude extends to many medical and health issues and extends to surgery. A friend's father was obese, in his 60s and had to have quadruple bypass. He had the surgery and came out fine but he made no changes whatsoever to his diet and exercise habits (there were none). His stance seemed to be that pills and/or surgery would fix things so why worry about it? I think this is uniquely an American phenomenon, perhaps a confluence of culture and US style capitalism.
I actually know plenty of Canadians who are even worse about it.
Theodore Dalrymple at City Journal has an interesting article entitled "Medicalizing Complexity." It hit on what I think is an important part of healthcare in the West, that our baseline became bliss and deviations are abnormal, rather than the reverse. I've recently become aware of Ivan Ilich who wrote on the medicalization of society. I haven't read Medical Nemesis yet but I worry that we are medicalizing too much as a society, including childbirth.
https://www.city-journal.org/the-complexities-of-depression
Multiple comments have mentioned this explosion of SSRI treatments. How is this possible if the pipeline of psychiatrists in the US is so skinny? FDB cited this in another article, but it’s something like 90% of counties in the US don’t have a psychiatrist, and many psychiatrists don’t take Medicaid. Is there evidence that the problem is over-diagnosis systemwide, or over diagnosis among a certain group of extremely wealthy urbanites in coastal regions?
I’ve been prescribed extremely low dose Lexipro by a GP, but I needed to see a psychiatrist for a higher dose and then for other Benzodiazepines. Is that similar in Canada? This isn’t to say that Lexipro is harmless, but it’s definitely less intense than many other anti depressants (and wasn’t effective in my case).
Please beware: Benzos are physically addictive, they tend to require higher doses with time, and the physical withdrawal can be harrowing. They are prescribed too easily for something that is physically addictive -- you won't even know you're addicted until you try to get off. Hell on wheels.
60%
I was prescribed SSRIs by my primary care provider. Lots of PCPs prescribe them. (I find SSRIs very helpful, by the way.)
1. Psychiatric nurse practitioners. There are a lot of people prescribing psych meds with a fraction of the training an MD receives. The barrier to entry is lower than ever thanks to online, for-profit universities offering the degree.
My spouse used to supervise several psych NPs, and she has countless horror stories of incompetent care—especially from graduates of for-profit schools. It’s a big and under-discussed problem in mental health care.
2. Like Mariana said, primary care physicians prescribe a lot of psych meds. Sometimes they do okay, and sometimes they don’t know what they’re doing either.
I'm currently seeing a psych NP for my meds, but that's only because finding better care was nearly impossible. (Even being a person with good healthcare, the shortage of experienced psychiatrists is very apparent in my area.) Frankly, I think my psych NP is unreliable and vaguely irresponsible, and I don't trust her to be duly diligent, so I have to research every potential change myself. Nevertheless, that's what I could get, and for me, it's better than having no access at all. That said, in many situations, poor care is much worse than none. Which is all to say, I guess, that I feel very torn on the issue.
PCPs prescribe a majority of psychotropic medications in the US, even now with so many NPs setting up shop.
Psychiatrist here. The problem isn't so much the number of us in the United States, although it probably could stand to be higher, but like many medical specialties it is a distribution problem. The sorts of people who come from backgrounds that tend to make it possible to complete medical school in the first place and especially the kinds of people who are then attracted to an esoteric specialty which is appealing partly because of how hermeneutically interesting the work can be are also the sorts of people who want to live in prosperous urban regions on the coasts.
Psychiatrists in rural areas tend to be foreign medical graduates who need to find a place that will sponsor their visas or people who are very interested in making a ton of money. There is a job in Alaska that gets posted now and again that will pay someone 850,000 if they will commit for a year plus a substantial signing bonus. It does appear to be the case however that you will be responsible for a significant chunk of all mental health care in the state if you sign up and you will not be living in Anchorage. It takes a certain sort to want to do that work.
> So for me, this “vibe shift” about medication is a good thing, because I feel that people who were hurt by these drugs or didn’t find them effective have been ignored by mainstream medicine.
I have quite a few stories where my experiences deviated from the party line and were dismissed, much to my detriment. Try convincing your psychiatrist that the anti-psychotics she prescribed are making your more psychotic while you are in fact psychotic. The medications I take are essential to my well-being but the professionals who dispense them are humans who make mistakes. It can be especially hard to get those mistakes rectified when the premise of your treatment is that there's something a bit wrong with you. Psychiatry I think can be especially revanchist and paternalistic in this way, and defensive on account of its questionable position in society.
(nota bene, I keep hearing about horrible NPs but the one I've been seeing for ~four years now is wonderful and the, uh, crimes of care I've experienced were almost all at the hands of MDs. Anecdotal but while NPs might be a problem, they aren't responsible for all of the malfeasance in psychiatry)
"I have quite a few stories where my experiences deviated from the party line and were dismissed, much to my detriment."
Same here. And the most disturbing experiences involved psychiatry, for the reasons you describe: "Psychiatry I think can be especially revanchist and paternalistic in this way, and defensive on account of its questionable position in society." Plus, psychiatric gatekeepers of all sorts are notoriously overworked, and often just don't have the resources to do more than assign stock treatment and question the patient's cooperation if stock escalation of treatment fails to work.
That doesn't make the psychiatric meds themselves the problem, though. By analogy, Prednisone, an awesomely powerful anti-inflammatory steroid, is not "the problem". It's legitimately a wonder drug. It also comes with some serious costs that can make it a drag even when you need it, and disastrous to prescribe for a problem it cannot help.
"It can be especially hard to get those mistakes rectified when the premise of your treatment is that there's something a bit wrong with you."
Yep.
To be honest for a long time psychiatrists fell into a bimodal distribution: people who found the field extremely intellectually interesting and were the most literate/humanities-oriented folks in their med school classes, and the people who didn't have the scores to match in anything else. It didn't help that our disorders are defined in an obviously arbitrary way. We thus had an intellectual inferiority complex for a long time.
Additionally, because there were so open residency slots and so many rural or underserved places willing to sponsor visas, psychiatry for a while was the specialty a lot of docs trained overseas were able to practice in the United States even if they were actually, say, surgeons. So there was definitely a generation of psychiatrists, foreign and US-born, who were practicing psychiatry because they didn't have other options and had very little intrinsic interest in mental health or treating the mentally ill. These people were not going to have the intellectual confidence to be able to tolerate people questioning their assertions or not simply accepting whatever they are told.
Psychiatry is getting much more competitive for residency applicants and this is fading, but it's not gone yet.
Also psychiatry is a place where people with their own mental health issues are traditionally thought to practice in, whether because of their own interest but also washing out of other residency possibilities (not just score based).
This is it exactly. There is a huge difference between depression, which many people absolutely have and are basically functional, and psychosis. When I hear Freddie make the argument that we need more psychiatry, I think he is talking about severe mental illness, and I agree. But I think depression and anxiety are overmedicated, especially in kids and young people. I do think that the model is to get you hooked early and stay on for life. I have personal experIence and experience as a teacher. It really is apples and oranges. Freddie often talks about the lack of psychiatrists, esp. those who accept insurance. But most psychiatric drugs are prescribed by regular docs, NPs, and PAs. A LOT of people take psychiatric meds. When people say that “society” or “capitalism” is causing mental illness, I think they are gesturing to the rise in depression and stress in modern society, and they aren’t wrong about that. I think it’s clear that depression and anxiety have genetic factors, but that stress, trauma, even loneliness and isolation can be major contributing factors. That seems really obvious to me. The fact that our society is swimming in easily accessed hard drugs doesn’t help. I know 2 young women whose psychosis was triggered by meth use. They were predisposed to mental illness, but the drugs didn’t help. I think humans have a lot of needs that aren’t met in our culture, and if you are predisposed to mental illness, this is a society that will make you crazy. And some people get very sick on their own. I think the diabetes analogy is good. Some people are type 1, hard to control with treatment, many more are type 2 as a result of a sick culture.
I was prescribed low dose Paxil generic to manage chronic pain, and it worked pretty well, as well as making me feel about 10 years younger. Temporarily, anyway. They stepped me up twice and each time I'd get a lift, then go back to normal after a few weeks.
I was getting (correctly, it turns out) worried about being dependent on me, and when I decided to go off it (this is when I first experimented with smoking pot in my mid40s) they gave me the wrong dose, which was two steps below where I was.
My wife came home one night to find me sobbing hysterically while watching "Person Of Interest". I mean, I love Nolan/Joy, but I was pretty shaky for a while there.
Thanks, very good summary. The misunderstandings are lame and contrary to evidence. After all, if depression has nothing to do with brain chemistry, anti-depressant drugs shouldn't work at all, yet they do.
The scientific illiteracy and ignorance of basic logic among the press and Americans in general is, dare I say it, depressing.
Even severe depression seems to resolve itself within 6 to 18 months. This is a long time! But the timeline to find the proper medication and dose is also 6 to 18 months.
Further, anti-depressants are addictive. One of the biggest side effects of withdrawal is depression.
So it's not impossible (or even unlikely) that the reason some people who have suffered from severe depression recover is because...they just did. However, they're also now addicted to their medication, so when they stop taking it in a year or five or ten, they will immediately feel very depressed.
Sure. Many other chronic problems flare up at some times worse than others, and treating the flare risks dependence on the treatment that would not otherwise develop, courting a potentially-nasty withdrawal. Rheumatoid arthritis and asthma both have this problem. Are things really bad enough yet to bring in the big guns notorious for their big withdrawal symptoms?
Even when temporary palliation doesn't buy total reduction in misery, just shifting the misery around, having the option to shift the misery away from crunch times can be useful. Using misery-shifting power responsibly can be tough, of course. Not all doctors trust patients to do so.
"I don't want to miss the wedding, can I have some Prednisone please?" is not a request all doctors will honor, especially if they don't know you. Other doctors believe giving patients some insurance for participating in major life events, even if they'll pay for it later, is worth it.
I particularly find irksome the "Dont take drugs man, take lots of [vitamin C|D][kelp] etc etc" instead. As if they are not treating those substances like a drug or because its "natural" :( Natural like plutonium ?
Tobacco ? Opium ? Cocaine ? Khat ? are all "natural" addictive substances. Even substances that have no withdrawal symptoms can be deadly in the wrong doses. This sad story popped up just recently.
https://www.cnn.com/2022/07/05/health/vitamin-d-toxicity-wellness/index.html
The point I am making is that just because its "natural" does not make it any better or worse and somehow not make it a "drug"...
WRT addictive or not, if 2 substances had identical results for treating something and the only difference was one had no withdrawal effects (a compounded and processed product ) and the other did not have addictive properties and was "natural" (picked it out of the tree), I would take the one with no withdrawal effects.
When I hear the modifier added, "because its natural" I am pretty sure I am hearing what I am hearing. Otherwise they could just say "because X is not addictive"
That study seems very compelling and very well done. A long study with a very large population.
I think the conclusion is that many, but not all, of mental health diagnoses, are mistreated with these drugs. I think this is a very good thing to have discovered. Everyone owes Tom Cruise a big apology.
you seem to be ignoring the very basic argument I'm laying out here: the fact that one given neurological explanation may not be true in no way suggests that all neurological explanations are true
please engage with the text
I might be crazy, but I thought his post was sarcasm. Now I just hope it was…
"please engage with the text"
a more perfect exhortation to internet culture doesn't exist.
I think "many, but not all, of mental health diagnoses, are mistreated with these drugs." covers, or at least was my attempt to cover, your point that the study in no way suggest that all neurological explanations are true. My natural father is diagnosed with mild paranoia and mild schizophrenia. He is in his mid 80s and takes care of himself with a bit of outside help. He was on SSRIs for a while and it made him violent and suicidal. And that increased his paranoia that the medical community was trying to kill him. So this is the other part of the study to discuss that the drugs were designed to supplement the missing serotonin, and so even if some or many of the maladies are the result of brain chemistry imbalance (something I don't doubt), I think this is the other important discussion... that these power psychotropic drugs seem to be largely missing their mark.
I highly, highly doubt that the prescribed who issued an SSRI to your dad thought they were actually replacing his missing serotonin. In reality, psychiatry has a dozen or two discrete tools (drugs with different mechanisms of action) to try to make people better (SSRIs, MAOIs, benzodiazepines, atypicals, anti-epileptics, lithium, clozapine, Wellbutrin, stimulants...) and psychiatrists will try them in the indicated order for the condition until the person starts to look a bit well. They absolutely do not see people and think "hmm, this guy I bet is suffering from a lack of norepinephrine, let me up it with some bupropion." They think "the last couple of folks I saw who were kinda like this guy did well on bupropion, let's try that."
https://www.mayoclinic.org/diseases-conditions/depression/in-depth/ssris/art-20044825
All of this is true information about how SSRIs work* and has nothing to do with the process of selecting drugs to treat people with mental illness. The information about serotonin is extraneous to it, it's wholly theoretical. Trying to figure out who does or not does have a "serotonin deficiency" does not play into the treatment process. And if it does it's a necessarily a shorthand for observed behavioral patterns that correspond to observed drugs responses, because no one ever inspects anyone's serotonin levels in the process of treating them, there is no diagnosis of "low serotonin," and there is not even agreement about what the outward presentation of low serotonin would be.
Edit: *this is true information about what SSRIs in fact do in the brain, not necessarily how they treat depression
I think you are missing the point here or I am not understanding your argument.
These drugs were designed to address the suspected/assumed root cause of serotonin deficiency. Yes, wholly theoretical and that theory has been practically debunked by the study.
Nobody inspects serotonin levels. True. But irrelevant to my point.
I have a rare malady and the treatment for that malady has evolved as previous theories of its cause that supported FDA treatment approval have been since debunked. Why get defensive about scientific advance that would help us improve treatment?
Keep in mind we don’t even know how anesthesia works. Very quickly if you start looking into medical research you’ll find the phrase “this occurs through processes not currently understood” everywhere.
Not too long ago in human history, "we don't know why this works" was the default for everything!
Between learning so much about so many things, and getting used to the world's information being in our pockets all the time, we've forgotten that there are everyday things we just don't know.
Even if one accepts your assertions about how compelling and well done the study is, your conclusion would still be a non sequitur of sweepingly epic proportions. But based on the Tom Cruise remark, maybe you were being sarcastic.
A lot of people are very uncomfortable with the idea that the brain could malfunction. In discussions about homelessness some say they are choosing to be homeless. But in many cases the choosing part of the brain is the part that’s malfunctioning. That idea freaks a lot of people out.
Agreed. Nobody likes to feel like their brain can betray them. It’s deeply horrifying to know you can’t trust your judgment or perception. And a lot of people have seen loved ones decline due to mental health, brain injury or dementia-related reasons and know about the devastating, slow, hard-to-treat and often inexplicable agony that can cause - they get a preview of what that may feel like should it happen to them, and often feel it like a genetic sword of Damocles.
I'm not saying it's different; I'm saying that the horror of it feels different to people.
I have several friends and family members that suffer or have suffered from depression. It could be argued that environmental factors (e.g., bad marriage, job issues, etc.) contributed to their issues.
However, some experience arguably abnormal lows absent any readily apparent external factor, and some responded to clinical therapy, sometimes supplemented pharmacologically.
I think the tremendous complexity and diversity in the human population makes finding a cure all incredibly difficult. I wish there was some kind of “light switch” solution that worked for everybody because depression can be debilitating, occasionally extremely so. Hopefully those pursuing a remedy continue their pursuit despite the cultural churn creating eddies and currents making their work needlessly more difficult.
Thank you, Mr. deBoer, for your thoughtful treatment of a difficult, often contentious subject, and here is to hoping for a brighter future for those afflicted with depression.
Well, sure — in the ultimate sense, everything is physiological. That doesn’t mean, however, that the solution to many psychological maladies isn’t environmental, in more or less precisely the way that the solution to lead poisoning is to not put lead in the environment.
(As for your point that we all live under capitalism but only some of us are diagnosed with depression — I don’t think that’s inconsistent with an environmental hypothesis. It just means some people are more sensitive to the environmental trigger than others. But that doesn’t mean that, in the absence of the trigger, there’s an underlying “disease” that is caused by a “chemical imbalance” in the brain.)
And I think people would be less skeptical of pharmaceutical interventions if people didn’t keep radically over-claiming for them. “You’re not going to get COVID if you have these vaccinations” is just the dumbest and most extreme example of a long line of the public being told things about all manner of interventions that simply aren’t borne out by the actual science. The efficacy of SSRI’s was massively oversold. Now you’re mad at people for being skeptical? People are gonna be skeptical.
ALso, an important distinction not being made in the piece:
Saying something is not caused by an imbalance in neurotransmission is not the same as saying it is non-neurological.
Really? That seems like virtually the whole point of the post
Neurological could mean anything associated with the brain. When people are talking about selective serotonin reuptake inhibition, they're talking very specifically about one neurotransmitter.
No one would doubt that schizophrenia or Alzheimer's are neurological. You can see the way it physically changes the shape of someone's brain. But saying something is neurological is also not the same thing as saying: these neurotransmitters are to blame.
Here's a good explanation of a more complicated and nuanced explanation: https://laulpogan.substack.com/p/begging-the-serotonin-hypothesis
That piece says this:
“Practitioners, media, and pharmaceutical companies have played fast and loose with a lie-to-children, using applied ignorance to explain the potential benefits of antidepressants to the public without getting into the minutia of codependent chemical pathways in the brain.”
Then it says that “no one is making” the “serotonin hypothesis” argument.
🤷♂️
If you don’t want the public to think that’s your claim, maybe don’t sell the drugs on the basis of that claim? Otherwise, how can we trust you later when you say, “oh, no, what we REALLY meant was…”
But also
"Sapolsky says it pretty well that from what we know about depression, there seems to be something going on in the interaction of adrenaline, dopamine, and serotonin- each contributing their own ingredient to the special sauce that is depression. This is a much clearer picture of the supposed “chemical imbalance hypothesis.”"
One of the main points of Paul Logan's piece is that "the serotonin hypothesis" is largely a product of pharmaceutical marketing and not a serious position in the field of psychiatry. When you ask "how can we trust you," you appear to be conflating these two. I would hope that you recognize that positions in the field of psychiatry are more important than, and distinct from, marketing oversimplifications. It is only the former that are worthy of serious attention.
As I said elsewhere, I studied this for my degree so I'm fairly aware of the literature and broader discussion.
And the piece you linked comes to the same place that I'm at, which is that depression is not one single thing. Like all aspects of life, but especially with bodily health, everything is quite complicated.
But this is an actual and real debate within the field. Painting skeptics who have spent their careers studying this as dishonest isn't very helpful. Especially when the implication that they're dishonest comes from charlatans using their research for cruel purposes.
Many psychiatric medications are over prescribed and are often prescribed to people who have never seen a psychiatrist. As the research currently exists, there is no evidence of a chemical imbalance causing mental illness. There seems to be something going on there and SSRIs and other medications seem to alleviate symptoms, but they are not meant as a cure. It's also inarguable how massive the influence the pharmaceutical industry has on the field. They fund the conferences, fund the research, they own some of the major periodicals, they publish non-peer reviewed research in those periodicals. And they don't do it purely out of the goodness of their hearts.
So this is a big, messy, complicated question. We need more research and we especially need replication studies (topics, probably, for another time!), but to say that people who find an issue with a theory without an evidentiary foundation are bad actors is just kind of silly.
Like, no one would say that string theory is a nefarious plot to upend what we know about physical reality, but that seems to be the kind of argument deployed with regard to mental health questions.
"Painting skeptics who have spent their careers studying this as dishonest"
You'll have to let me know when I do that. It'll be the first time.
Good post.
"there seems to be something going on there and SSRIs and other medications seem to alleviate symptoms, but they are not meant as a cure."
I can justify the defense of these drugs being used to alleviate symptoms as long as they are not exacerbating problems as often the cure is beyond reach.
Today I have an incurable disease that will likely be the thing that takes me out, and I am on modern medication that reduces the symptoms and improves my quality of life. They are expensive drugs and thus I always consider the conflict of interest with the healthcare industry to over-prescribe the drugs, and even steer patients to the drugs rather than new advances that are either less expensive therapy or maybe even breakthroughs for cure. I wish I just trusted the system, but as the COVID era has taught us all, my concerns are well-founded.
A lot of anti-medication people are running with “it’s probably not neurotransmitter imbalance” and turning it into “it’s probably not neurological”, which is akin saying a malfunctioning computer doesn’t have anything wrong with the hardware just because all the cords are intact. There could be other things wrong with the hardware! It could be both hardware and software, or a hardware issue that looks like a software issue, or both! The cords are just one possibility and them being in working order is not a clean bill of health for the machine’s physical parts - it’s inconclusive.
"Some people are more sensitive to the environmental trigger than others' sounds an awful lot like 'something about certain people not explicable in terms of their proximal environment causes these extreme behaviors and thoughts to emerge'. Whether you want to attribute that to individual learning history or culture or capitalism or whatever, that difference has to live somewhere. Unless we embrace the full Cartesian dualist position, that difference in experience trivially has to be reflected somewhere somehow in neurobiology. 'Chemical imbalance' was a dumb theory but the details of brain functioning are still going to matter if you want to understand just how all those abstract concepts actually translate into what an organism does and feels. This is especially true if you are interested in modifying that functioning for any reason, therapeutic or not.
For what it's worth, the diathesis-stress model has been the mainest of mainstream ideas in mental health for decades.
Sure! Of course. Everything is biology! Learning to read is biological at base (it causes changes in the brain), but no one would argue that it’s not caused by the environment. Medieval European peasants were illiterate; now almost everyone in Europe can read. That is due entirely to environment. That some people are great at learning to read and some people struggle with it doesn’t mean that the primary determinant in learning to read isn’t access to education.
Absolutely. But - in an environment in which access to rudimentary education is not the primary obstacle to reading, if you want to make more people literate, you may want to figure out why some people struggle with reading and what can make it easier for them. I certainly don't disagree that environment shapes behavior (I would be stupid to do so) but the problem of "why do two people equal in most respects react radically differently to similar stimuli" can't be explained by environment alone. Even the modern behaviorists have to posit something relatively specific to individuals at that point.
Oh, for sure. I agree. I just think that it can be hard to tease out environmental factors, and the fact that some people are affected more by a particular environmental cause than others are doesn’t mean that the effect wouldn’t be greatly altered if the environment were changed. (E.g., in this case, I think it’s possible that some of our mental health problems are caused by environmental factors.)
"And I think people would be less skeptical of pharmaceutical interventions if people didn’t keep radically over-claiming for them. 'You’re not going to get COVID if you have these vaccinations' is just the dumbest and most extreme example of a long line of the public being told things about all manner of interventions that simply aren’t borne out by the actual science."
It's not just pharmaceutical interventions, though. Behavioral interventions, or what we might call the patient's moral improvement, also gets oversold.
Take, for example, asthma. After an unfortunate detour of medical history where asthma was supposed to be psychosomatic, asthma was properly recognized as an immune and pulmonary disorder. That has not, however, absolved asthmatics of the expectation that, if they fail to meet certain moral standards, they should blame themselves for their poorly-controlled asthma.
The moral code asthmatics are expected to follow simply in order to breathe involves self-denial, scrupulous hygiene and indeed neat-freakery, unusual regularity of habits... Many asthmatics achieve excellent asthma control while falling short of such lofty standards, but if you fall short of these standards and you haven't yet achieved...
Asthma guilt is real. And, as a natural experiment discovered during COVID shutdowns, perhaps misplaced. The steps asthmatics can take to control their own lives and home environments just don't seem to matter as much as asthmatics were previously taught.
https://www.theatlantic.com/health/archive/2021/07/the-pandemic-drove-asthma-attacks-down-why/619396/
*Any* individualistic intervention tends to get oversold. Precisely because so much of the cosmos is outside our control, what little control we do have is precious, cherished and idealized as our individual identity and dignity. Especially in a Prosperity-Gospel country like the US, we *desperately* want this individual dignity to manifest as material improvement.
Swallowing a pill isn't a dignified act as such, but it's an individualized intervention within many people's reach -- no wonder we oversell it! We also oversell individualized *moral* interventions -- like yoga, CBT, and figuring out how to keep one's house scrupulously cleaned all by one's lonesome without exposing oneself to the steps of housecleaning known to trigger asthma. (Take my HEPA vac -- please. I'm supposed to use it so scrupulously it'll need frequent emptying yet never be the one to empty it myself.)
Absolutely.
I clicked on the link to see the meta-analysis. Quoting from the summary: "The results showed that both TCAs and SSRIs *were* effective for depression." (Emphasis mine.) How are people concluding from this that SSRIs don't work? (Or that serotonin isn't somehow implicated in depression?)
Nobody reads anything but the headlines
I think the link might be wrong? It should go to the recentl Molecular Psych paper here: https://www.nature.com/articles/s41380-022-01661-0#Sec13
And not the Cochrane SLR which is just comparing TCs and SSRIs in people with depression and their reported outcomes.
I couldn't find it in the meta-analysis to see whether it had any rates of efficacy for SSRIs but googling around the web I get results between 40%-60%. I think the reason people think SSRIs don't work is because they're using a different heuristic of "effective" than the medical literature.
From the perspective of psychiatrists, being able to help ~50% of patients with SSRIs seems like a good outcome. But from the individual perspective, something having a ~50% chance of working doesn't seem like a good outcome.
"Why are so many people who do not suffer from mental illnesses or work with them professionally, both left and right-wing, so deeply eager to deny the physiological basis of mental illness and the efficacy of psychiatric medication?"
You cannot ask that question without acknowledging that there are evil people with a financial incentive to oversell the phsyiological basis of mental illness and the efficacy of psychiatric medication. The reason the serotonin theory of depression took such deep hold in the popular consciousness despite dubious scientific grounding is because of an enormous marketing campaign to convince people that medication was the best and perhaps only answer to depression. You are absolutely right that the issue calls for nuance and compassion to people who are suffering, but I think you are wrong to cast outrage and backlash over the success of profiteering in health care as some kind of mean-spirited "eagerness" to invalidate people's pain.
Just a hypothesis, but without denying the physiological basis of medication, how do you describe the soul? What part of you goes to Heaven if “you” can be so malleable in the face of mental diseases and solutions? This might not be correct, but I think there is a deeply human desire to believe in an utter essence of a person that cannot be changed. To many, perhaps choosing not to believe is merely a way to cope with problems that have plagued humans for all time.
Of course we should be compassionate and not dismissive of those for whom the drugs work. But, that is not to say that we should not demand more from our doctors. As stated, "we know depressingly little about the brain," therefore, if doctors are to maintain their oath and "do no harm", they should not be prescribing drugs willy-nilly, and much less also conclusively parroting unproven theories, such as the serotonin re-uptake one they all authoritatively mouthed when this Prozac Nation period began, some 20+ years ago.
I, for one, am absolutely livid at the doctors who prescribed this to me, and many loved ones, throughout the last few decades, while authoritatively parroting the re-uptake b.s.
In this, and other areas of medicine (trans care for minors?) perhaps doctors should be more humble and just say, "This may work, but we don't know what the consequences may be, nor whether or how it works."
The issue many have with doctors, medical/health institutions or both is the certainty with which they make statements. Do we need any more evidence of their corruption and incompetence that COVID and the pandemic? Science is a process, not a conclusion.
> Science is a process, not a conclusion.
I don't understand this sentiment at all. Using your example of COVID, I can promise you that all over the world, scientists and researchers and doctors were all scrambling desperately to reach firm conclusions about the SARS-COV2 virus and the disease it causes.
It's fine for it to be "all about the journey, man" when you're smoking peyote in the desert with your friends, but no one involved in the physical sciences would have that attitude. It's just unthinkable.
Yes and they were often wrong about those conclusions, like the vaccine stopping the spread of COVID. Or ignoring the women who said their periods changed. They had their conclusions and evidence (even anecdotal at the time) be damned. The issue is the absolute certainty they have that their conclusion is right and works as they expected.
Scientific medical opinion coalesces around a conclusion and challenges are dismissed. Ignaz Semmelweis for example.
I don't think there was ever an actual scientific consensus that vaccines would stop the spread of COVID. This was instead a hopeful fantasy popularized by the media and various popular figures.
And sure, there are examples of unhealthily entrenched consensus in the history of science. Of course, those examples (as with Semmelweis) also show that the new paradigm eventually succeeded, and the consensus evolved to accept it. Yet that doesn't imply that all scientific consensus is therefore wrong by default.
There are certainly limitations to any research, and therefore conclusions may necessarily be provisional. But again, that doesn't mean that the provisional consensus should be summarily dismissed. What are you going to replace it with, conspiracy theories on the internet?
The scientific consensus was that the vaccines would keep people from getting the worst symptoms of Covid.
Which was and is correct.
Yes, I agree with that.
When I was studying neuroscience at university it was shocking to me when we discussed the chemical.imabalance theory. Shocking because there had *never* been any evidence behind it. Even so, much of the field treated this as a settled fact.
Obviously there's something neurological going on causing mental illness. People who say otherwise are simply lying or don't know enough to even lie about it.
But this study is very important. The pharmaceutical industry has massive sway in the field, funds tons of research, funds many of the major international conferences, and has even bought some of the major periodicals (where, incidentally, they publish non-peer reviewed research).
That's not to say pharmaceuticals play no part in treating illness, mental or otherwise. But many people within the field and especially outside of it treat the pharmaceuticals that alleviate symptoms as the cure. Also, many people prescribed these medications never meet with a psychiatrist in a meaningful way. It's not infrequent that an educator recommend that a parent get medication for their child, for example.
So, yes, of course there are bad actors, but this is pretty important. It's the kind of research that has been sometimes difficult to fund and difficult to get published because of the immense influence of the pharmaceutical industry on the field.
Also worth pointing out: Dr. Joanna Moncrieff, who led the metastudy, is a known critic of psychopharmaceutical interventions, it's kinda her life's work. Sometimes, when you look for something, you find you what you are looking for.
I think most people in the mental health field want broader adoption of a bio-psycho-social approach to treatment, but it's been wild to watch New Age bypassers celebrate this study like SSRI/SNRIs do not massively benefit people
Thanks for pointing that out -- I agree that researchers often find what they're looking for. I also think that applies to pharma-sponsored research that finds that their drugs work well. It makes it all very hard for consumers to know WTF to believe.
"Chemical imbalance" was always an overconfident phrase masking the level of ignorance that you rightly note. People overgeneralizing from headlines is typical behavior, especially online. So is indiscriminate destruction of a perceived shibboleth.