Can Psychiatry Turn Itself Around? | Hacker News Reader

Can Psychiatry Turn Itself Around?

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68 pointsokket125 comments

I'm a psychiatrist. It is always amazing to me that despite four years of medical school, six years of residency and fellowships, and four board certifications, the assumption is that I have no idea what I'm talking about and have evil motives.

There are fair criticisms of psychiatry, there are bad psychiatrists, but mostly there are crappy generalizations. Good psychiatrists have an understanding of what medications can and cannot do, and a well-rounded view of the person they are treating as a whole human being.

I work with the mentally ill who are involved in criminal justice, both juveniles and adults. I can assure you, having more psychiatrists would help a lot of people.

Any chance you could answer some questions? I'll get to them after a couple of (relevant) anecdotes.

I was diagnosed with depression by a psychologist. I got a referral to a psychiatrist, and I was told that the psychiatrist would probably want to do his own assessment of where I was at & what kind of therapy would best benefit me.

Nope. It was, "You've got such & such diagnosis; let's try such & such drug. Bye!" Some years later, I was treated by another psychiatrist. Same deal.

Second, I've read a fair amount about various psychoactive drugs. One thing I've noted in the literature is that often drugs are only found to be effective when used in combination with other kinds of therapy: counseling, etc. So if I am taking a psychoactive drug regularly to treat some condition, then I always get regular counseling for that condition as well.

I have mentioned this practice of mine to both psychiatrists, and both indicated their approval. But in both cases, counseling was never mentioned until I brought it up. I'm thinking that, if I were a psychiatrist, then I might insist that my patients get regular counseling in addition to my treatment. To avoid even recommending it strikes me (in my highly inexpert opinion) as an awful practice, possibly rendering psychiatric treatment ineffective. One might even call it a violation of professional ethics.

So, my questions.

1. Would you say my experiences related above are typical?

2. Would you say that these experiences point out problems (with the two psychiatrists at least, and with the profession as a whole, if the answer to #1 is "yes")?

3. If these are problems, then what do we do about them?

1. These experiences are not the norm, but still much too common.

2. Psychiatrists might not recommend talk therapies for a number of reasons (even though they probably should). Many insurance plans don't cover it, and lots of people aren't interested and want a "quick fix" to the problem in the form of a pill. Finally, the education for licensed therapist varies WILDLY, and there are a lot of really bad ones. That can make it hard to recommend in some parts of the country where few/no good therapists are available.

Thanks for the reply.

> Finally, the education for licensed therapist varies WILDLY, and there are a lot of really bad ones.

I hear you there. I had some iffy experiences early on. But a few years ago I found a really good one. He retired, but recommended someone else to me, who also turned out to be really good. I'm seeing him these days.

Maybe what needs to happen is for the norm to be that psychiatrists who see the general public (so not people like you, perhaps) do so in the context of a joint practice that includes various counsellor/therapist types as well. The approach could be that each patient is a client of the practice, with the various specialists contributing their expertise as needed.

(Maybe that already happens a lot. I couldn't say.)

I emphatically agree with your recommendation that more people should seek counseling, even those who lead seemingly happy and/or successful lives. Increased urbanization has unfortunately resulted in less socialization for a lot of people. Especially (at the risk of sounding sexist) for men, who tend to be more introverted. So I see a lot of my male friends struggling with social problems which I think some genuine counseling could really help them with.

We need to remove the stigma attached with seeing a psychiatrist/shrink as something done only by those suffering from mental ailments. And to be honest, I've seen a lot of people turn to self-help "gurus" who just confuse things further by not getting to the root of the problem.

How does one find a good psychiatrist?

Personal referrals.

But the real success in treatments now tends to be self education. Not WebMD I mean reading the actual research papers to evaluate what options would work for you. Know yourself.

Unfortunately, it seems to be a lot of trial and error.

And there's the rub. It's total chance, and there's no guide. You have to understand psychology and psychaitry to have a chance of navigating the system. And when you're struggling, that's the last thing you can do

I'm curious what you make of the claims Robert Whitaker makes in "Anatomy of an Epidemic" and elsewhere? Psychiatry comes off looking quite bad in his analysis and he is far from the only critic of the profession. My attempts to find convincing rebuttals of his claims from Psychiatrists have so far drawn a blank.

In a nutshell for those not familiar with the book, he presents convincing evidence that most psychiatric medicines have no significant short term benefits over active placebos and in fact worsen long term outcomes and that the profession has been complicit in presenting unsupported hypotheses about chemical imbalances in the brain causing conditions such as depression as established fact and in pushing drugs as the primary means of treatment without sufficient evidence of their efficacy and largely ignoring worrying evidence of long term harm.

I'll admit to having a pre existing suspicion of psychiatry stemming from taking a degree in psychology in the UK but after reading this book and digging more deeply I have to say it looks far worse for psychiatry than I previously imagined.

I just heard a convincing criticism of our mental health system from the invisibilia podcast. They went to a European town where mentally ill people were assigned to live with regular people to take care of them. And that they had much better outcomes than in the US.

The full episode is here, there's a lot of interesting observations in it: http://www.npr.org/programs/invisibilia/483855073/the-proble...

It looks like meta-analyses published after that book support the efficacy of anti-depressants, are you familiar with this evidence?

https://en.m.wikipedia.org/wiki/Selective_serotonin_reuptake...

This seems to be a fairly balanced (and pretty long!) review of the evidence from Scott Alexander who is a psychiatrist (I believe) which comes down on the side that the balance of the evidence is that SSRIs do have an effect that can't be explained purely as active placebo: http://slatestarcodex.com/2014/07/07/ssris-much-more-than-yo...

Here's another 2014 article leaning the other way by Irving Kirsch, one of the more prominent researchers to question the evidence for anti depressant efficacy: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4172306/

In Anatomy of an Epidemic Robert Whitaker details many of the problems around the published studies that raise real concerns how bias free the remaining positive results of these studies might be. In addition, pretty much all of the discussion above is based around short term effects and perhaps the most worrying part of Whitaker's book for me is the suggestive evidence of devastating long term effects of many psychiatric drugs, SSRIs included.

Personally I think the bar should be rather higher for evidence of short term benefit for any drug than the 'optimistic' view of the evidence for SSRIs and especially in light of evidence of the drug making the condition it is supposed to treat significantly worse over the long term. Given that even proponents of SSRIs seem to accept that talk therapy is equally effective I know I'd rather take the drug and side effect free option but Scott Alexander gives a different take on that in his article, pointing out that drugs are much cheaper (and hence more profitable for both psychiatrists and drug companies as Whitaker points out in his book).

Everyone's different, but as a programmer, I'd like more explaination of my psychiatrist's thought process on why they choose particular diagnosis and the medications they use. And preferably a decent bit of pharmacology and statistics of expected outcomes (especially when I ask).

Obviously it's a complicated profession. The medication changes your brain and often only has moderate success. Sometimes the medications can put you into a bad mood (and who do we blame? Probably the doctor). Diagnosis are partially based on subjective information.

I was ruined myself by a psychiatrist that over prescribed benzos and later tried to use her authority to sell 'multilevel marketing' goods and services. It's hard to blindly trust someone based on their degree after that.

Yow. Hopefully you reported her to the licensing board?

I think part of the difficulty is that we don't have a great understanding of consciousness or how the mind actually works. It feels a bit like medicine prior to germ theory.

Even for relatively more understood things like depression it's not like we can test the serotonin levels to validate it before SSRIs and then check them after.

It seems to be a mixture of this seems to work, but given the high variation among people and general complexity of mental states the science is difficult.

It is a difficult field I'd say only out done in complexity by nutritional science. What works for one person fails on a dozen others.

Theodore Dalrymple (a retired prison psychiater from England) wrote a book about how psychiatry undermines morality. It is called 'Admirable Evasions' (1). One of the things he notes: many people call themselves depressed nowadays. Few people call themselves unhappy.

(1) https://www.amazon.com/Admirable-Evasions-Psychology-Undermi...

My money is that that guy will prove to be utterly on the wrong side of history, and in the long term serious crime will turn out to be mostly a medical problem.

And some of the problems that cause bad outcomes are outside of what you control. Laws forbidding families from getting information about their mentally ill adult children, for example.

Also, "the system" (insurance companies, the courts, etc) sometimes make it very, very hard to get someone the help they need.

I had a mentally ill colleague that was very difficult to help. His family was ready and willing, but it was just impossible, given the legal constraints on everyone, to get him the help he needed. He was homeless for 6-9 months before he was committed and then got back on his meds and was able to go home.

There's a reason those laws exist. Mental health is still a taboo topic and as soon as anyone knows there's an issue the reflex is for everything to go into lockdown. This comes up on reddit with some frequency [1][2]. Some of the stories are pretty harrowing. Though a lot of this is to do with the poor state of many mental health institutions.

1) https://www.reddit.com/r/AskReddit/comments/3hlcyu/serious_r...

2) https://www.reddit.com/r/AskReddit/comments/1tdoc1/redditers...

You know the one interesting thing about these "sane person stuck in a mental institution" stories, is they always talk about how nuts the other people were. If it were as common as suggested that normal people end up there for slips of the tongue or other mundane reasons then I'd expect there to be more "normal" people finding each other in these stories.

Probably that otherwise normal people just don't make it into the stories because they're not as memorable. Though often you'll hear of people otherwise healthy who are down on their luck, addiction problems, abuse, or just general anxiety and depression. The other problem is that the definition of sane changes depending on context.

I recall watching a documentary on Japanese school children and their attitudes towards baseball, ritualistically crying when they lost a game. A western therapist could easily justify feeding them all meds, but in reality it wasn't particularly unhealthy. I feel like a lot of ADHD is kids being kids and teachers and parents wanting an easy way to deal with it. Lobotomies used to be common less because anyone believe they cured anyone but because they rendered the patient docile. Mental health ends up being as much about societies easy function as it is about helping the patients.

I feel this comment really hits the spot on the current "epidemic" of ADHD diagnosis and prescriptions. Parents are sooooo worried about their kids not being "normal" (i.e. docile and obedient) that they will do anything to make that happen. I almost feel that it was better before we had modern medicine when parents were resigned to dealing with their kids' unique character instead of chemically forcing them into submission.

Ugh I hate this myth that "ADHD ain't real". It's a real condition that hugely impacts life outcomes. Sure there are worse diseases, and unlike other conditions ADHD people appear normal on the outside. But it makes it hugely difficult to do normal things and succeed in society. Sufferers commonly drop out of school, get worse jobs, are more likely to get involved in crime, and are less happy.

My understanding was that being trapped in an institution with crazy people, being treated like a crazy person, stripped of your dignity, and put in isolation or force-fed medication if you try to upset the status quo or challenge your incarceration in any way is enough to drive people crazy. It certainly would me.

In this personal account, someone who on admission was merely ADHD with possible depression ends up snapping and violently beating someone: https://www.reddit.com/r/AskReddit/comments/1tdoc1/redditers...

How often do you cure your patients?

I'm skeptical of any medical profession which seems to build and depend on lifetime customers.

What a strange question, what does it mean to cure a patient?

Say a patient goes to a doctor and is diagnosed with heart disease - is there anything that can be done to cure this? Or do we simply alleviate the symptoms to make way for a better life? This is the case with so many illnesses: diabetes, cancer, arthritis, the list is so long.

But do you have the same skepticism of a doctor? Of a surgeon? We are not simple machines, us humans. When there are bugs in us they are often not currently fixable. This applies to psychiatry as much as it does to internal medicine.

It means to restore them to a level of health where they are not dependent on the doctor or medicine for continued care.

> Say a patient goes to a doctor and is diagnosed with heart disease - is there anything that can be done to cure this?

And they'd say there possibly is (such as lifestyle changes), and encourage them to pursue those changes while providing temporary medical relief.

> This is the case with so many illnesses: diabetes, cancer, arthritis, the list is so long.

The fact that we don't yet have a permanent cure for some of these illnesses is considered a major problem. Medical professionals are working tirelessly to find cures for conditions like cancer.

Meanwhile, psychiatrists seem to be almost completely uninterested in finding or promoting permanent cures (even when such cures likely exist, including through lifestyle changes). They want to put you on a lifetime drug regime.

I recognize that we're not going to have permanent cures for everything. But psychiatrists don't have permanent cures for anything. If internal medicine insisted that every condition required costly lifetime treatment, I'd be equally skeptical of it. In cases where a cure isn't available, other specialties admit that the best they can do is treat the symptoms—meanwhile, psychiatrists have an attitude that lifetime drug use is the "cure."

Forgive me, but it seems like you have an exceedingly negative view of psychiatrists.

> And they'd say there possibly is (such as lifestyle changes), and encourage them to pursue those changes while providing temporary medical relief.

But Psychiatrists provide prescriptions as well (drugs, therapy etc) which may or may not lead to lifestyle changes.

> But psychiatrists don't have permanent cures for anything

I think this is being too harsh on psychiatrists. The mind is perhaps the most complex and least understood component of the human body. It is an exceedingly complex organ not yet completely understood. The heart, kidney etc are all functional organs, and their mechanisms for working are pretty well understood at the present time. There is much ongoing research to understand how the brain does work though; just probably not by Psychiatrists.

> Forgive me, but it seems like you have an exceedingly negative view of psychiatrists.

You would be correct. :)

> But Psychiatrists provide prescriptions as well (drugs, therapy etc) which may or may not lead to lifestyle changes.

Sure they do. But if I go to a doctor about my heart disease, they're going to ask me to me about my lifestyle and encourage me to make changes which would improve my condition (in addition to providing medication).

Meanwhile, in my experience psychiatrists will jump straight to medication without any discussion of the underlying lifestyle and adjustments which could improve it. At best, they encourage you to see a therapist as well. (To be honest, I'm somewhat skeptical of the hard division between the disciplines. A cardiologist is not a nutritionist, but they can give you a basic idea of the nutritional roots of heart disease and potential remedies, but psychiatrists seem to be entirely uninterested in anything besides drugs.)

> I think this is being too harsh on psychiatrists.

Is it? I don't necessarily think it's necessarily their fault. As someone else in this thread said, mental health seems to be like medicine prior to germ theory: a whole lot of confidence in symptom reducers of questionable efficacy.

> Medical professionals are working tirelessly to find cures for conditions like cancer.

Researchers are, the doctors at your local hospital are very unlikely to be participating in the research of new cures for anything.

> psychiatrists seem to be almost completely uninterested in finding or promoting permanent cures

Psychiatric research has developed hundreds of new, more advanced medicines in the last 10 years alone. More effective anti-depressants, with different interactions so different populations can take them with less risk of drug interaction. More effective anti-anxiety medications that have lower risk factors. Then there's the research of lifestyle changes - I've never met a psychiatrist who didn't believe that exercise was one of the most effective means of getting through depression!

I believe you're against bad psychiatrists, which I understand and agree with. I'm also against bad medical doctors! Bad surgeons, too - though I believe there's a lot of complexity with measuring the performance of that field in particular.

A good doctor recommends lifestyle changes to patients with say diabetes or heart disease - of course they do. But bad ones just give you the prescriptions for drugs that alleviate the worst symptoms without telling you that there's anything you can do to fix it. I just don't see why we'd attack all doctors for the actions of the worst ones.

Some of it might come from creepy movies or sad history of psychiatric institutions, which is unfortunate.

However, recently there was an unexpected result regarding schizophrenia suggesting it might be just a result of a genetic bug of extensive deletion of redundant neurons in the brain, a bio-computational problem when you look at it with the eyes of a hacker. If confirmed, this would invalidate a lot of previous research and force the whole field to take a bit different, algorithmic view on many issues.

Do you have a reference? I didn't hear about this

In Science there exist certain topics that are minefields.

Differences between human groupings. Race. Class. The Brain or Mind. Sexuality. Future/Past analysis. Most of economics.

Most interesting subjects contain taboos and dangers that should you cross them, shall ruin your career or life. That is why if we're really as smart as we think we have to use the Dark Arts. I don't know what would happen to a modern day Darwin but I doubt it'd be pretty.

The most controversial debate on science I ever saw was on Intelligence Squared on the subject of Organic Farming. My intuition is that one side felt strongly enough that they rigged the vote, and that the moderator knew it too when he saw the results.

> I have no idea what I'm talking about

Long term brainwashing can do that to people.

Would you respect someone who has studied Scientology for 10 years, just because it's a long time? I think in that case, the longer the worse.

Psychiatry is no different, pseudo-scientific quackery that exists largely to provide politically comfortable answers to questions society does not want to confront.

Oh, and to rubber stamp who the courts excuse for crime.

A generation of boys on ADHD drugs, thank psychiatry for that.

It is a corrupt and disgraceful occupation.

Meta-comment only: interesting handle, in context of your comments.

The last Psychiatrist I went to prescribed me 4mg of Klonopin a day for anxiety. The one before that prescribed me 40-50mg of Adderall a day for ADHD and about 600mg of Seroquel a night for sleeping problems. Both times I decided to quit going and tapered myself off.

There never really asked how I felt or seemed to care about me in any way shape or form. Just, "Here's your drugs, see you next month."

I have a horrible opinion about the entire profession of Psychiatry and at this point do not trust any of them in the slightest. I have not seen one in years. These days if I have a degenerated mental health in some form (whether that be inability to focus, sleep, or bouts of anxiety), marijuana is my go to solution.

>never really asked how I felt

Psychiatry is distinct from psychology and other forms of talk therapy.

When all you have is a hammer, etc.

The separation is amusingly pronounced. Even for a teenager it is pretty much totally up to the patient whether to see a psychiatrist, psychologist who uses empirically validated methods, psychologist who doesn't, LCSW, GP, etc. and they will all tell you wildly different things.

It doesn't help that most people haven't heard of, or don't know the difference between, many of those things.

I'm married to a psychologist specializing in evidence-based cognitive behavioral therapy for treating anxiety and insomnia. There are ways to deal with these problems without medication. And these methods are backed up by peer reviewed studies to prove they work. If you do end up needing help in the future I'd recommend reading up on CBT.

Isn't it amazing though that CBT wasn't thoroughly examined as an option prior to prescribing multiple prescription medications?

Sad but common. Also, I have had many patients go to therapists and get "CBT" that had nothing in the world to do with CBT as studied and researched.

Yup. I've had multiple negative interactions with psychiatrists and psychologists. There may very well be good ones, but IMO they've become overshadowed by the bad ones.

What does your spouse think of this paper? http://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(...

I will keep that in mind. Thank you.

Psychiatrists are a bit like chiropractors. They want to be seen as "doctors", but none of what they do has any scientific basis. Ever notice how psychiatrists just prescribe you random medications without knowing how, or even if, they work? The most damning fact is that I've never met anyone on psych meds who is doing really great.

1.Psychiatrists go to medical school, just like other "doctors." 2. There is a huge evidence base for the practice of psychiatry, though it would be nice if it were adhered to more rigorously. 3. Incomplete understandings of the mechanisms of action of drugs is rife throughout medicine. For example, why does the hypertension drug HCTZ work at sub-diuretic doses? 4. If they were doing great, they probably wouldn't need to see a psychiatrist. Also, there are very likely people that you have met who are doing great that you have no idea are seeing a psychiatrist.

Show me a guy on psych meds who is doing great and I'll believe you.

o/ heya.

I've been on psychiatrist-prescribed meds for a little over two years now. I've gotten a better job, my salary has increased by 52%, I live with less stress, I have a (mostly) tidy home, I am no longer dependent on alcohol, I care for a wonderful dog, I am cultivating healthy relationships and friendships, and I am more involved in my community.

I've also been seeing a cognitive-behavioral therapist for about three years to work through anxiety, depression, gender identity, and trauma from several childhood sexual assaults.

But maybe I don't count, because I'm not a 'guy' :) but I'm doing absolutely fucking amazing, thank you very much.

and as soon as you go off the meds?

I've learned coping skills to help me deal with what I take the meds for - coping skills that I could not practice / get good at while I was not being treated. I'm not as good as I am when I'm on them, but I'm a whole lot better than I used to be. (How do I know? I take regular doctor-sanctioned drug holidays. Luckily the meds I take do not need to be tapered.)

But you don't really care about that. Or any valid piece of evidence that disputes your already-formed opinion.

I used to be really against psychiatry too. Had docs in high school that didn't ask the right questions. Got misdiagnosed. Spent my 20s a shambling (semi-functional, but shambling) mess.

I'm privileged that I'm able to afford my mental healthcare team (neither of them take insurance). I wish access to quality mental health professionals was more easy to obtain. It's a double edged sword- the practice has a hard time recruiting, and health insurance is often pretty terrible for it. So many people who would benefit from a mental health provider cannot / will not get it.

WTF does this mean?

If you go off your HIV meds you get AIDS and die. If you stay on your HIV meds you have a life expectancy is similar to someone who does not have the virus. (1)

Do you then conclude HIV meds are bad? Or HIV patients need to just suck it up?

(1) http://www.spectator.co.uk/2014/04/why-id-rather-have-hiv-th...

I think he is implying that if he went off the meds, his life wouldnt go to the can: that the effect can be explained by the placebo effect.

Your question only highlights your ignorance. For the vast majority of meds, they should be used in conjunction with therapy to resolve the underlying problem. The meds are not (always) a cure, but rather a treatment of symptoms to make the cure easier to achieve.

"You're nearsighted. You need glasses."

"But as soon as I take off the glasses...?"

There are more invasive procedures that directly fix nearsightedness. Of course, they're riskier than glasses.

What does that have to do with anything? Some conditions are incurable, only treatable.

I'm on psych meds and doing great, been on them for AGES. When I went off them a decade ago I spiraled very far downwards which ended in short term disability. The disability. Back then I thought "oh I'm doing well, I don't need them anymore." Nope, I need them because they keep me well. Because of them I am able to hold down a job and take care of myself.

I don't understand the hostility here.

There are plenty of people who are doing very well on psych meds.

The field is probably a bit too 'medication' heavy, I'll grant you that, but perfect is, as they said, is the enemy of the good.

The important thing about a lot of psychiatric ailments is that people have effectively lost some mental resource that they require to "bootstrap their way" out of the problem. Like, depressed people are usually too depressed to manage to make it to their therapy appointments (which they agree help with their depression, but only if they go...) So just prescribing talk therapy won't do anything; the person can't manage to "take that medicine" correctly.

Psychiatric drugs are great in the same way crutches are great: they let you "take the weight off" the problem, so you can work on the other parts of it. SSRIs let depressed people make it to their CBT therapy appointments. ADHD medications let unmotivated people get a job doing something they're passionate about. Anxiolytics let people make friends to attend social gatherings with. Etc.

I have mild clinical depression and have started taking a low dose of Lexapro about half a year ago. The difference in my baseline mood is palpable, and I'm feeling a lot better than previously. Sometimes on my walk home I'll event lightheartedly chant "happy pills, happy pills" to myself a couple of times, because the baseline difference is that noticeable.

"Show me a person with a pacemaker and I'll believe you."

"Show me a guy in an iron lung and I'll believe you."

Sometimes, unfortunately, the best outcome of treatment is simply to keep things tolerably bad.

(y)

I have taken a stable dose of lithium tricarbonate for many, many, many moons (my whole adult life really, 15+ years) now. I have to have quarterly blood panels to know that my actual levels haven't fluctuated, but otherwise it really fixed me up.

> I've never met anyone on psych meds who is doing really great.

Of course you have. You just didn't know it. People don't wear placards around their neck announcing "I'm on psych meds!"

We call this "voluntary response bias".

I have noticed. Multiple times I've gone to a Psychiatrist and they have decided to try something because it's new and supposed to work, when the reality is they've only ever put 2 or 3 clients on it and it has been working for a few weeks, and the medication itself has only been out a year.

In addition, the worst times in my life were the times when I was taking psychiatric medications.

To offer a counter-anecdote, I suffered from severe, recurrent Major Depressive Disorder, Generalized Anxiety Disorder, and ADHD primarily inattentive (it's not at all uncommon for the three of them to present themselves simultaneously in individuals) for over 10 years before I finally started seeing a psychiatrist.

For the last 2 years, I've been taking 3 medications daily, and after the initial hump of spending a few months trying to find an effective combination, we arrived at one that really works for me, and I can't remember ever feeling better.

Furthermore, my psychiatrist has always treated me with respect, empathy, and genuine interest in my well-being. If he doesn't actually care about me as a person, then he's a damn fine actor. From my point of view, the end results are indistinguishable.

You're awesome and your psychiatrist is awesome!

I'm sorry this has been your experience, but please don't throw my entire profession under the bus because of it.

Your profession needs no help from marsrover to find itself under the wheels of a bus.

Every other medical revolution -- such as the rise of antibiotics, the pioneering of complex surgeries, and the advancements in medical imaging -- have resulted in a net reduction of people suffering from the ailments those tools are involved in treating.

Not so with psychiatry. The more drugs that are developed, the more illnesses are discovered to use them on.

You'll have to excuse the skepticism of some us who have seen loved ones suffer through debilitating, sometimes permanent side effects from drugs their psychiatrists prescribed. Your profession will get the benefit of the doubt when fewer of us are caring for those loved ones.

> You'll have to excuse the skepticism of some us who have seen loved ones suffer through debilitating, sometimes permanent side effects from drugs their psychiatrists prescribed.

What debilitating side effects are those? How does their frequency compare to side effects for non-psychiatric drugs and treatments?

You know it's odd: in all those years I spent helping my dad with his knees shot from zoloft induced weight gain or waking my roommate up because she drank too much to counteract the stimulants they prescribed to balance the benzos or sleeping next to a partner with a permanent, random, violent parkinsonian tremor caused by antipsychotics, I never considered doing a frequency analysis against the myriad of unrecommended non-psychiatric drugs and treatments out there.

Unfortunately, neither did any of their doctors, it would seem.

You know, it's odd: I don't recall asking you if you had personally done a study or frequency analysis. I recall asking a rhetorical question as a follow-up to a specific question about your claim in order to head off anecdote poker. Seems like you decided to jump straight into it, though. So, how many people have you had to deal with who had night terrors due to Chantix? Who became addicted to opiod pain medications? Who developed T2DM as a result of corticosteroid use? Who nearly bled out because of blood thinners?

You specifically demonized psychiatric medicine. You know people who have had pretty bad experiences with psychiatric medications but none who have had similar with non-psychiatric medications. My point is not to doubt that these side effects exist, but to illustrate that they exist for a host of non-psychiatric medications as well. Many of those are just as over-prescribed as psychiatric medications, and often by the same general practitioners over-prescribing them.

How does the existence of side effects in other medicines affect the status of psychiatric medicines and their percieved (in)effectiveness or their overprescription status?

You claim I'm 'demonizing' (i.e., being unfair towards) a subset of the medical profession when in fact I'm only relaying my personal experience and skepticism based on that. I don't doubt that there are a whole host of other medicines whose effictiveness is unknown and whose popularity is primarly due to its availability as free samples in doctor's offices and the U.S.'s notoriously effective prescription drug advertisement industry.

But to make that a point in this discussion seems like a misdirection more than an counter-argument. Two things can be bad at the same time independently.

To answer your questions: I dated someone with night terrors from Chantix, have a relative who is addicted to opoids (but who thinks no one knows when he's high at Christmas dinner), but have thankfully never had to deal with the last two.

Even still -- none of those latter series were prescribed to treat disorders discovered after the invention of the drug itself. This is the primary point of skepticism: horrible side effects for well-advertised drugs for disorders we just recently discovered affecting, what was astutely noted by another commentor, the most complex organ of the body.

Many psychiatric medications are an excellent example of 'when you have a hammer, everything looks like a nail.'

> How does the existence of side effects in other medicines affect the status of psychiatric medicines and their percieved (in)effectiveness or their overprescription status?

> You claim I'm 'demonizing' (i.e., being unfair towards) a subset of the medical profession when in fact I'm only relaying my personal experience and skepticism based on that. I don't doubt that there are a whole host of other medicines whose effictiveness is unknown and whose popularity is primarly due to its availability as free samples in doctor's offices and the U.S.'s notoriously effective prescription drug advertisement industry.

Because you singled out and attacked psychiatrists and psychiatry as if there were something inherent to that field of medicine and that class of medications that is not present in other fields and types. You specifically said:

>> Every other medical revolution -- such as the rise of antibiotics, the pioneering of complex surgeries, and the advancements in medical imaging -- have resulted in a net reduction of people suffering from the ailments those tools are involved in treating.

>> Not so with psychiatry. The more drugs that are developed, the more illnesses are discovered to use them on.

That is not merely relating your experience. That is throwing a particular medical specialty under the bus for what are in fact widespread issues with medical practice.

> Even still -- none of those latter series were prescribed to treat disorders discovered after the invention of the drug itself. This is the primary point of skepticism: horrible side effects for well-advertised drugs for disorders we just recently discovered affecting, what was astutely noted by another commentor, the most complex organ of the body.

Are you claiming that there were no mental disorders until the advent of psychiatric drugs? That a subset of disorders are just marketing ploys by a psychiatrist-industrial complex?

It's here you might benefit from the book:

Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness

To explain further the unique situation that mental health drugs present. You might benefit especially from the notes section, to which his citations refer.

Am I saying there is a conspiracy between psychiatrists and pharmacuetical companies? Were it only so simple! There are a myriad of complex reasons why we're in the situation we're in -- but claiming that the situation is not unique, that my discussion of my personal experience and the research behind it is somehow a 'demonization' of an otherwise unremarkable industry belies both the thesis of the article and experiences of millions of patients.

> To explain further the unique situation that mental health drugs present.

...

> claiming that the situation is not unique, that my discussion of my personal experience and the research behind it is somehow a 'demonization' of an otherwise unremarkable industry belies both the thesis of the article and experiences of millions of patients

You are saying it is unique, I am saying it is not. How am I misrepresenting the thesis?

Don't do that. You can look up the debilitating side effects yourself. Asking someone to re-live watching their loved one lose their self from benzos or anti-psychotics that were prescribed as a first measure rather than a last resort - which Does happen, and far too often - is crueler than you know.

Nonsense. Asking for evidence and examples is not "cruel", especially when a broad claim is being made based on a personal experience.

I have many dark, hurtful experiences in my life. And when I share them, the only thing I expect in return is respect. Asking a question about my experience or asking me to provide evidence in support of my broader claims is not disrespectful. It's something I would expect might happen. If I couldn't handle it, I wouldn't bring it up. Or I would end the conversation.

In all honesty, I would be more offended at the implication that I cannot speak for myself.

There was no implication whatsoever that intopieces couldn't speak on their own behalf. It's disrespectful to suggest there was.

I suggest you read intopieces' reply to vonmoltke, and have a think about this exchange from a fresh perspective. Remember that when people talk about losing their loved ones, a little tact goes a long way.

Asking so bluntly for research you could look for yourself (that pharma companies would never actually publish) comes across as tactless in this situation, which is why you're being greyed.

> There was no implication whatsoever that intopieces couldn't speak on their own behalf. It's disrespectful to suggest there was.

Except for that fact that you chose to interject on behalf of the emotions you presumed he would have?

> I suggest you read intopieces' reply to vonmoltke, and have a think about this exchange from a fresh perspective.

I did read it. What you read into it was some kind of assault that isn't necessarily there in the first place. I read it as a challenge to back up his claims (especially now due to subsequent posts), but one could also read it as simply being curious. Perhaps you should try the fresh perspective?

Being challenged on a broad claim that is supported only with anecdote is pretty par for the course on HN. This isn't a support group, it's adult discussion. Should we stop challenging broad claims whenever people bring personal anecdotes to the table? After all, even seemingly innocuous anecdotes could be deeply painful for the people involved.

> Remember that when people talk about losing their loved ones, a little tact goes a long way. Asking so bluntly for research you could look for yourself (that pharma companies would never actually publish) comes across as tactless in this situation...

You've moved the goalposts. You didn't say you had a problem with how he said it (i.e. tact), you said you had a problem with what he said (i.e. "don't do that...") Even so, being "blunt" (your interpretation) isn't being disrespectful. Not everyone wants sugarcoating on their cereal. I'd say your perspective here has quite a lot to do with how you would like to be treated, but that doesn't mean others feel the same way.

> ...which is why you're being greyed.

I've been upvoted, actually. Does that mean I'm right and you're wrong? You seem to think this means something...

> Asking so bluntly for research you could look for yourself (that pharma companies would never actually publish) comes across as tactless in this situation, which is why you're being greyed.

First, pharmaceutical companies are required to publish study data as part of the approval process. Whether the requirements are sufficient is a tangent all its own.

Second, I can obviously look up research. I have. It indicates debilitating side effects for a host of non-psychiatric medications as well, which intopieces seems to be ignoring because of bad personal experiences.

Third, if you don't want to re-live bad experiences, don't use references to them to score points in a debate.

http://www.nimh.nih.gov/health/topics/mental-health-medicati.... That's from the National Institute for Mental Health

Tics, liver damage, abnormal thinking are all listed as side effects. So is violent behaviour.

You can find those side effects for a number of non-psychiatric medications as well.

Aye. However,

"Antidepressants and ADHD Drugs Top List of Most Violence-Inducing Drugs"

http://articles.mercola.com/sites/articles/archive/2013/10/0...

Psychiatry is, by far, the most difficult medical specialty. The human mind is so complex that the diagnostic 'bible', the DSM, has two sections - one for mental illnesses, and one for all other medical conditions.

> Your profession needs no help from marsrover to find itself under the wheels of a bus.

HN comment of the day :)

I don't doubt that there are great Psychiatrist out there (you're probably one of them, and I'm sorry to have offended you). However, due to my past experiences I'm reluctant to find out where or who they are or recommend this form of treatment to others.

That sucks, and I hope you will find what works for you.

Have we met? I'm a person who takes medication daily for the last 7 years for bipolar and it has improved my quality of life immeasurably. I have a great job, a great relationship, own a house, have a cute dog and my professional and personal relationships have never been better. I haven't seen the inside of a hospital in 7 years.

They run to the meds first for the nice freebies the drug reps give out for their best dea..../prescribers.

if a publicly traded, large market cap, privately owned pharmaceutical company owned a patent for marijuana it would be legal and pushed heavily by psychiatrists.

however, it is a plant, and cannot be patented, so instead we made it illegal.

We're all aware that most of the drugs that are common in the profession have serious side effects.

I'm glad the author called for his colleagues to focus more on the whole body, since realistically lifestyle and nutritional changes can have as profound effects as drugs, with no side effects.

I tend to think subclinical deficiencies in various nutrients can play a big role. Most people are already aware of the imporant brain benefits of Vitamin D and Omega 3, but there's others.

Tryptophan:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3405680/#RSTB201...

Lithium:

http://www.nytimes.com/2014/09/14/opinion/sunday/should-we-a...

Uridine:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3080753/

Magnesium:

https://www.psychologytoday.com/blog/evolutionary-psychiatry...

NAC:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3044191/

Lithium, uridine... no side effects? You must be joking.

Even at subclinical dosages there are sometimes side effects from those.

Dietary changes have a ton of shoe effects as well. Even the dieteticians cannot really find precise enough consensus on these.

As the article mentions, the dosages of lithium that are naturally in water tend to be well below the levels that we're familiar with in prescription lithium. (Less than 1/1000th the amount)

But if lithium is more like a micronutrient, then long term administration of low dose lithium would be much better than temporary use of prescription dosages, and have very few side effects.

Zinc and Copper belong on that list too. Zinc: http://europepmc.org/articles/PMC3868572 Copper: http://www.naturalnews.com/047834_copper_toxicity_depression...

I consider Natural News to be as reliable a source as Rachel from Cardholder Services.

There might or might not be a medical use for copper, but that's not a place you should get information from.

https://en.wikipedia.org/wiki/Natural_News

Had a doctor prescribe two meds once, then a few weeks later asked me how one of them was working. I was honestly confused by the question, since I have no idea how one drug is working when I've only ever taken it in tandem with something else. The very question indicates at best an unacceptable level of indifference, at worst outright incompetence.

Wouldn't that imply that the second drug might just be there to ease side effects of the first? Regulate hormonal levels or blood pressure, or any other functions that might not be directly related to how effective the other one is but simply keeps everything in order? I get what you're saying, but incompetence is a bit of an extreme conclusion to draw from you not knowing what your prescription is meant to do.

did you continue working with that doctor afterwards? did you continue your prescription?

There seems to be a huge gap between what psychiatrists believe and how psychiatric knowledge is presented to the general public.

For example, I'm not aware of any scientific evidence that depression is qualitatively different from being unhappy, or that depression can't be caused by events that would make a typical person unhappy, or cured by the opposite. And I'm fairly certain that very little such evidence exists, because this is not the concern of psychiatrists, they just want to treat the person, not define categories per se. But I believe that psychiatrists allow the public to form this flawed understanding because they think it will lead people to treat people with depression with more sympathy and treat depression like a real problem. To me the more honest approach would be to simply say that unhappiness is a real problem and any approach or treatment that works should be considered.

If you'd look you'd find plenty of evidence of the sort that you think doesn't exist. Try a popular book like Against Depression as a starter. I think that the existence of such evidence also invalidates the rest of your prejudices that you express.

I don't have time to read every book out there, so when I look for answers to questions like this I look for sources that are authoritative, that is, sources that summarize the majority opinion in a field. The book you recommend doesn't seem to be that, and so I'm not convinced that it's worth reading. Are there particular studies in the book that specifically address whether depression is qualitatively different from unhappiness? Does the book cite mainstream opinions by psychiatrists and if so, what opinions does it cite?

This is not secret information, some key google terms may be "biology of depression" or something like that.

Just one piece of the literature that you might find convincing (not sure if its from that book or another) that you might find convincing is that there are structural differences in the pre-frontal cortex that can be seen under a microscope. The biological basis of depression is something that's so well established that strident doubt of it means that you can't be troubled to look for anything. It's like being convinced that evolution can't possibly be true because biologists can't be trusted.

I think that a "biological basis" means something different to you than to me. How exactly do these studies show that depression is different from being unhappy? Did they study the brains of merely unhappy people and find no such biological differences? Again, in my understanding psychiatrists and researchers make no attempt to differentiate between depression and unhappiness because they have no reason to make this distinction.

I'm going to assume that your argument is that if depression is caused by biological factors then it must be treated differently from unhappiness that is caused by life events. But in that case you will have to explain how this is consistent with the fact that "...depressive episodes are strongly correlated with adverse events..."[0]. This fact seems more consistent with either reverse causation (depression causes biological changes) or that depression can have multiple causes, and can occur in the absence of a biological cause.

[0] https://en.wikipedia.org/wiki/Major_depressive_disorder#Psyc...

Most drugs on the market today have side effects that are serious to most people. Also the fact is that now a days it seems that almost all kid have "ADHD" or "ADD" and are getting put on stimulants for it. I don't get it at all. I was put on antidepressants when I was young and it really could have fucked me up if my parents kept listening to my doctor.

ADHD is overdiagnosed and under diagnosed. (It's just badly diagnosed, really.)

On the one hand, parents get their kids prescribed stimulants (which necessarily entails a—usually fake—ADD diagnosis) for the same reason university students go pick up illicit stimulants: they think it'll "make" them study. That is not the problem that ADHD causes, nor is that the benefit stimulants provide, but it's what parents think.

On the other hand, many people only discover as adults that they've had ADHD their entire lives, and have suffered unnecessarily through 3+ decades of being unable to motivate themselves to do homework/projects before they're overdue, or practice anything, or focus on reading rather than (badly) multitasking five different things, or put themselves to bed before 4AM, or even remember half the things they need to bring with them when they leave the house.

As for the stimulants: A lot of people do great on stimulants. And yes, the stimulants have side effects that some people experience. Many don't. Or the side effects are quite manageable compared to not taking it.

I have personally seen it help 2 persons I know well, don't know anyone who has hurt by stimulants that have been legally prescribed and used. (but I know one who quit because the cost/benefit wasn't there).

As for why people did well without stimulants in earlier times the answer might also contain: they didn't necessarily. Not finishing even basic schooling was more common.

Also there were more less rules and more options that didn't require sitting >5 hours a day.

"It is no measure of health to be well adjusted to a profoundly sick society." - Jiddu Krishnamurti

If Psychiatry wants to "turn itself around", it needs to do some house cleaning.

In a recent "skeptic" magazine [1], Harriet Hall, M.D. had this to say about the situation:

"Psychotropic drugs are far from ideal. They don’t work well for everyone, and they can sometimes cause devastating side effects. But they do save lives, and they do allow some patients to lead a more-or-less normal life. They are the best we have at the moment. " (emphasis added)

[1] http://www.skeptic.com/magazine/archives/21.1/

This is an apology for the status quo, and distracts from the main issue. My girlfriend is one of the ones for whom "psychotropic drugs" don't work at all - in fact, I believe that the psychotropic drugs that she's been prescribed have a lot to do with her present predicament. Haldol - sold as an anti-psychotic - is well known to cause the condition it supposedly treats. Dr. Hall states that these drugs "save lives", but I wonder what the ratio of "lives ruined" to "lives saved" is.

There are non-psychotropic drugs that have been very helpful for my girlfriend, but her psychiatrists don't know to use them. I've spent a few hours today revising my latest petition to the courts asking them protect my girlfriend from the palliative treatments that she has been ordered to endure. The main thrust of my argument is that the medications aren't working because they do not address the causes of her condition. The causes are perfectly obvious to me, but the doctors have all been "shooting in the dark", hoping that the next pill will work better than the last one.

I suspect that "exhaustion" is related to most psychiatric problems. New research linking psychosis to an inability to produce cortisol is a good clue: https://www.jcu.edu.au/news/releases/2016/june/stress-hormon...

Psychiatry's trouble is that it tries to treat emotional problems using drugs.

That's also the entire point of psychiatry.

It's in a crisis because "stabilizing" people by numbing their brains does nothing to help them face their problems. A profession of cleaners whose main technique was to sweep everything under the rug would also face crisis at some point.

Thats not the problem, its a tool to solve a situation. If someone is emotionally suffering so much as to not perform a job, not get out of bed, talking with them will not save their lifes. Treating the symptoms is one very legitimate way of dealing with a disease.

> Psychiatry programs attract medical students with lower board scores and fewer academic honors on average compared to other specialties.

It sounds like a self-reinforcing problem. Psychiatry's bad reputation leads to it having less qualified practitioners, thereby justifying the poor reputation.

I personally do not place much value in the field. It seems to monopolize on creating problems where none existed, and thereby increasing profits. In particular, the fact that most treatments seem to be lifetime is suspicious.

Working as a psychiatrist is hard. Reimbursement is low, and many serious patients do not have private insurance.

Interesting that the author does not cite anything describing the resounding success of psychiatry...

Still it was more honest than the forensic odontologists' assessment of their profession.

https://theintercept.com/2016/03/25/in-las-vegas-embattled-f...

The resounding success being "still depressed but at least not suicidal?" I guess it's all relative.

The future is really about making advance in understanding the human brain and neurosciences. If AI could be really good at anything, it's really about making solid steps in psychology and have opportunities to stomp down myths.

Doesn't scientology have some kind of weird self-declared feud with psychiatry? I wonder if they've perhaps been sowing FUD whenever and wherever possible.

Last week I posted a section [1] from Robert Whitaker's book Anatomy of an Epidemic about how Scientology was probably used to deflect attention from the ineffectiveness of commonly used drugs.

[1] https://news.ycombinator.com/item?id=12222898

The basic lie that psychiatry is based upon, is that there is a sickness where there is suffering. Not neural phenotype, that yes can suffer, but have been useful for various enterprises and endeavor of humans kind. Manic-Depressive where our "suicidal" explorers, alcoholics stopped us from being nomadic, gays pressured into churches formed the first institutions and created contract security. The list continues near endless. If psychiatry would be a honest science, it would look upon cause and effect, asking what did this or that creatures side effect accomplish do to pay the ferry-woman. And can we optimize that- can we create creature constellations which produce new ideas like a machine. But it does not want to know, it wants to heal, which it can not heal as long as it cant resequence DNA in a living human. It doesn't even want to know the possible consequences if it could cure.

Do not interpret this statement as a general dismissive of proper treatment. Treatment of some neuronal constitutions allows some humans to live in this society. But i want to know what society trades personal meh-ness for.

I honestly have no idea what you are talking about here.

He's riffing on pop psych theories about the "warrior gene" and suchlike. I'm pretty sure there were institutions predating Holy Mother Church.

Disliking complexity, are we? And having a warrior gene, is actually something worthy of treatment in current society. Warriors, are useless today and will be for the foreseeable time. If there is such a gene, that shapes its owners brain in such a way.

But the main point is, that hunting for local optima of personal happiness, is sacrificing the upholding or even gain regarding personal happiness in the future. And psychiatry is neither cartographic why and for what society became composed of what it is and is neither offering constellations society could become.

BRB Got to go to Turings Barbershop. Best haircut in the city. Though sometimes conversation gets stuck on who shaves the barber.

Me too.

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