Medicalising everyday life doesn't help anyone's mental health
theguardian.com
theguardian.com
I'm sure there are people with mental health conditions that do need treatment, I won't argue that at all. I do think pinning down what is "normal" and should be just waited out and what is abnormal and should be medically treated, although easy at the extreme edges, is very difficult in the middle of the spectrum.
I agree with the article that we are trying to narrow the normal distribution of human traits by medicalising things that are a common occurrence for at least a subset of the population. I'm not sure where this stems from though. Is it the desire for extreme corporate efficiency and competition for resources. Is it a misguided medical system trying to make patients out of more people? Like anything sufficiently complicated its probably a huge confluence of factors.
> […] I don't consider myself to have anxiety.
Everyone has anxiety. Some people have anxiety disorders.
> Isn't it normal to be anxious in stressful situations […]
People with anxiety disorders are anxious in normal, non-stressful situations. They can panic when asking a bus driver which stop they should get off at, when talking to a new coworker, or in other ordinary circumstances. People with depressive disorders are depressed at times even when things are going well. People with severe depression can have a hard time just getting out of bed in the morning, feeding themselves, and going through the motions of ordinary life.
I can somewhat relate from experience: I went to a doctor for terrible trouble sleeping, to the point that it was affecting my physical health, that we assumed was caused by anxiety/depression[1]. I was pretty shocked at the rapidity with which she suggested going on antidepressants, particularly considering the tapering periods and the seriousness of the dependency and side effects that they cause.
I pushed back a little but it turns out that my doctor's cavalier attitude towards antidepressants isn't out of the norm: they're considered a "try it and see what happens" first line of defense, without trying to get a better sense of the patient's specific issues and whether therapy or other interventions, sans medication, would be a better fit (though I should note that the doctor recommended that I go to therapy if possible in conjunction).
Tangentially, this fits with a larger disillusionment I have with the medical system: a combination of screwy incentives, bad lines of communication between generalists and specialists, and a serious institutional/cultural case of a God complex leading to a lack of critical thinking means that I'm at the point where I pretty much keep anything a doctor tells me as just another unreliable information source, weighted more heavily perhaps than my layman's understanding of the research but on categorically the same level.
Ive seen the same disillusionment kick in among my doctor family members: in our conversations over the years, my sister and her husband have gone from a central case of said God complex to as much as telling me not to take doctors' advice without a heavy dose of skepticism.
I should note that I don't actually consider this a criticism of any individual physicians as much as the realities of the system. One of the biggest factors is that the average person showing up at the doctor is simultaneously incredibly dumb and incredibly confident in their understanding of the medical problem. It makes sense for doctors to be a somewhat heavy-handed and reductive, and once you build those habits into your institutions and pedagogy, it's hard to turn it off.
[1] Turns out it was the other way around: consistently not sleeping causes some pretty crappy psychological problems
They didn't disappear at the same time. I was on antidepressants for a year and my time on antidepressants was pretty much independent of the degree to which my sleep problems were fixed. I probably was slightly less anxious while on the antidepressants, but this was far overwhelmed by the fact that I get/got anxious & depressed after the nights my sleep was poor and I don't/didn't whenever I sleep well. I was able to narrow it down to this specific direction of causality (bad sleep -> anxious the next day) through the fact that my sleep was often affected by exogenous physical factors.
I apologize for not going into too much identifying detail on a pseudonymous account, but I solved it by completely ignoring the medical establishment, reading voraciously about the problem, and experimenting on myself until I got myself to an 85% solution that at least allowed me to get back to work. This happened at a far, far slower and more grinding pace than the counterfactual in which I had any competent doctors around me (or rather, if competency wasn't ludicrously uncommon within medicine), since 1) I was sick, 2) I was employed until I quit to focus on the issue, and 3) I don't have an educational background in medicine the way that a doctor (ostensibly) would.
I'm far, far, far more comfortable reading papers in noisy epistemological environments than most people; I can't even imagine how horrible and expensive and drawn-out this process would have been had I not been had the confidence or ability to take this route and had to rely on the medical establishment.
After getting most of the way there myself, I still have issues sleeping once every week or two, and I decided to visit the relevant specialist to use them as a reference to expedite my path to a 100% solution[1]. It's a criminal indictment of our medical system that the only recourse for patients with complex, multi-factor health problems is to themselves navigate both medical knowledge and the medical system until they've narrowed it down to a fairly well-defined, simple solution. To the extent that the system's abdication of responsibility is driven by individuals' decisions, they should be ashamed of themselves (though again, I will reiterate once again that I think that the problem is systemic; I think most people of average intelligence would behave similarly in the situations that doctors find themselves in and I haven't seen any evidence that leads me to believe that most doctors are particularly extra-bright).
[1] At which point regulatory BS popped up again and I was legally required to have a perfunctory appt (at the cost of several hundred dollars, of course) with a doctor to request a referral to this type of specialist
I know the details are scarce, but why do you say that a competent doctor would have been able to diagnose and treat your condition quickly? Issues related to mental health and sleep are exceptionally difficult. Literally everyone I know, including myself, with mental health or sleep issues has gone through that same slow, grinding pace that you describe. Issues range from anxiety disorders, to bipolar disorder, or idiopathic hypersomnia (where “idiopathic” just means “we don’t know why”).
The etiology of these diseases ranges from completely unknown to “a mix of psychological, environmental, and biological factors”. These diseases are frequently not curable, and the best we can do is manage side effects. Going to a doctor as a legal impediment to getting prescription drugs is damn useful because the drugs carry risks of liver damage to chemical dependency and everything between.
Having been through this process myself, and witnessed close friends and family go through it, I can understand why anyone would be frustrated but it’s not clear what the alternative is. As a society we don’t have the medical knowledge to solve these issues quickly and effectively, and we only have so many brilliant minds to go around. In the meantime, therapy and/or prescription drugs make the difference between functioning member of society and being unable to work or even leave the house, at least for several people I know, including myself.
I wouldn’t be so quick to indict an entire profession, especially given your admitted use of anecdotes.
This point is very well-taken, despite what my earlier comments may have sounded like, as is your point that I may be misunderstanding the scope of the problem as deficiencies in the solution process. Believe it or not, I am sensitive to these possibilities and didn't arrive at my current conclusion hastily or lightly. I didn't lazily interpret the system failing to solve my problem instantly as an indictment of the system, particularly given my small firsthand sample size. As I said, I've also talked to a lot of doctors who I'm acquainted with, and the only facts I'm working off of are fairly uncontroversial among them. I'm talking about specific failures like irrational institutional biases against some types of specialists (that both the doctors and the specialists that I've spoken to in a non-patient context admit exist).
When I say that a competent doctor would have been able to solve my problem _more_ quickly, it's because of the multiple challenges that required retreading the steps that a doctor is ostensibly trained in. The economy is built around paying people to do jobs that you are capable of but haven't spent the time to specialize in: it would be considered a failure of each industry if I needed to become a domain expert to get my cable fixed, or have my shirts tailored, or fly on an airplane. I get that medicine is devilishly more complicated than any of the above, but again, I'm talking about specific problems with either the ability or the will to take the time to apply that medical training through critical thinking. Since those with training abdicated their opportunity to do think critically, I had to bring (a very narrow form of that training) to the only person willing to think critically about the patient: me.
I don't think it's a very controversial statement that the healthcare system has lots of issues: the doctors I've spoken to about the way the system works and has worked for me pretty much all agree with me once they get over their defensiveness and realize that I'm not interested in putting most of the blame on individual doctors and their behavior within a difficult system. Slapdash, cookie-cutter engagement with patients is IMO a lot more reflective of the constraints that doctors operate under wrt time and the average patient[1] than it is a commentary on individual doctor's level of intelligence or something like that.
[1] hell, I don't even judge doctors with the all-too-common undercurrent of almost-contempt for their patients, given the average patient they probably have to deal with
Agreed, and I would say that the answer to this is to have the licensed professionals guide the diagnosis. Don’t just self-diagnose or read a Wikipedia page and think you have an anxiety disorder. (It’s a good starting point and you can take your self-diagnosis to a psych{olog,iatr}ist and explain why you think you have a particular disorder.)
You hit the nail on the head with poor communication between generalists and specialists. This is why it looks like drugs are the first line of defense—because you went to the doctor first. If you had gone to a therapist first, the first line of defense would have been therapy. The doctor understands medication as a lever that they can pull, they can guide you through the process of finding a medication that alleviates your symptoms without bad side effects, and do it all safely. The doctor generally doesn’t understand the process of therapy or its outcomes because it’s not something they administer (except some psychiatrists). I would add that the side effects of modern antidepressants are surprisingly manageable.
This is reasonable to me. Like if you have complaints about your husband and talk to a divorce lawyer, you’ll get a different set of recommendations than if you go to your therapist, your best friend, some strangers online, or a priest.
Sleep problems in particular are troublesome, because so often they are caused by a complex set of factors that we have varying degrees of control over. The doctor’s ability to prescribe you medicine is one of the very limited number of ways that the doctor can help you get sleep. The other ways to help you get sleep might involve moving, modifying your house/apartment, changing your daily habits regarding exercise/eating/alcohol/screen use, therapy, accommodations at work, or a hundred other things.
I could just as easily diagnose myself with “having a crappy boss” and switch jobs, but the doctor (usually) won’t tell you to switch jobs. That treatment option comes with a hell of a lot of side effects, too.
> [1] Turns out it was the other way around: consistently not sleeping causes some pretty crappy psychological problems
That may be the case for you, but psychological problems do cause sleep problems for many people (including myself). There’s often some positive feedback loop / death spiral involved in any ongoing problem.
IMO and IME this is a really bad idea. My experience with specialists is that they're far, far more myopic than generalists: eg if you have symptoms that manifest in the feet, podiatrists or foot orthopedists won't solve your foot problems, they'll provide foot solutions, whether or not these solutions are relevant or helpful. This stems from the same rotten root of the endemic myopia and lack of critical thinking among medical professionals[1].
As I mentioned above, the problem didn't even end up being with anxiety, so going to a therapist would have been worse than useless for me. My complaint is that my conversation with my doctor was very brief, during which I mentioned fairly strong symptoms of anxiety, and the doctor was immediately gung-ho about anti-depressants. I should also note that this was a GP who (at least nominally) was somewhat specialized in mental healthcare issues, so it's not like this was throwing a case at a random doctor and expecting them to be a specialist. On top of that,using a GP as an entry point to the healthcare system is, roughly speaking, their _only_ job, and what's shocking is how widespread a basic lack of competency at this sole task is.
> The doctor understands medication as a lever that they can pull, they can guide you through the process of finding a medication that alleviates your symptoms without bad side effects, and do it all safely. The doctor generally doesn’t understand the process of therapy or its outcomes because it’s not something they administer (except some psychiatrists). I would add that the side effects of modern antidepressants are surprisingly manageable.
I may have failed expressed myself clearly, but this is sort of my point: the bar that I'm setting is one that I think anyone with fundamental critical thinking skills could clear, barring a gross case of apathy towards patient welfare. It's been my unfortunate experience that this minimal combination is pretty lacking when it comes to doctors, either specialist or generalist. The notion that a doctor should jump to prescribing medicine because it's all they know how to do is insane to me, since it completely rules out the possibility of understanding the patient's case further instead of grabbing whatever hammer happens to be lying around.
Now granted, I have a fairly limited sample size personally, but I've seen the same thing play out with family members whose care I've been involved in, and my empirical anecdota are theoretically supported by conversations I've had with doctor friends/family over the years. At the very least, I've _personally_ decided to treat doctors as nothing more than legal impediments to prescription medicine, an incomplete chatbot UI to medical knowledge, and an occasional source of novel medical information. This has worked out _far_ better for me than the alternative of assuming that a typical GP has a baseline of competence (I've made more progress on my sleep issues in the last year than the previous half decade by taking this approach, and dealt with some niggling minor medical issues that every GP I've ever had completely failed to address).
> Like if you have complaints about your husband and talk to a divorce lawyer, you’ll get a different set of recommendations than if you go to your therapist, your best friend, some strangers online, or a priest.
Just to reiterate, the complaint is not that your best friend would have something different to say from your priest, but that either of them would respond with a stock answer instead of listening to you and thinking about it. If your pastor says "Say ten hail marys" to any person's request for advice, the problem isn't that he has a narrow view but that he's a shitty priest. If you can replace a doctor, or a priest, or a best friend with a post-it note or a first-page Google search, it seems almost tautological that they're somewhat incompetent.
[1] (though again, I don't think this is because they're dumber than the average person or anything like that; rather, the institutional pushes in the other direction that they get are strong enough that the only doctors I know (sadly, not as a patient) that do think critically about their patients' issues are the very-intelligent ones that would probably excel in most fields).
I wouldn't go that far. Therapy is a broadly-useful non-medical intervention that can increase across-the-board mental health. It bridges the gap between medical intervention, where specialists act as necessary gatekeepers to otherwise-dangerous courses of action, not that they're always successful at reducing the danger, and self-help, which is thoroughly hit-or-miss.
There is an established body of psychological research that the therapist brings you in contact with that the medical community is only tangentially aware of. Sure, you could read up on this stuff yourself. But it's the talk therapist's job to know about it. And even if you don't find purchase on your stated problem, you might find other problems that you didn't realize you'd had.
If you can afford it or get it covered, I highly recommend regular sessions for a few years.
On the other hand, I suppose you may not be able to evaluate that question fully yourself. It's hard to see your own mind clearly.
I wonder though, is this even too broad? Perhaps people need to overcome some of this adversity. Not everything is painless in life nor should it be.
When my anxiety was super bad (before therapy and medication), there were weeks when I was too anxious to go to the grocery store and started skipping dinner because there wasn't any food in the house. I hadn't seen a dentist in 8 years because my phone anxiety was too high to make an appointment - and my social anxiety was terrified that they'd be mean to me about my teeth.
I'm doing much better now, but there are still some times that my anxiety acts as a total blocker to something I have to (or sincerely want to) do.
No, but a lot of things should be. Leaving the house SHOULD be, but for some people it isn't. If it's causing you so much dread you can't bring yourself to do it, that's not just "overcoming adversity" - that's adversity where there shouldn't be any.
But in terms of medicalizing things, who cares if it’s normal. It’s not about being normal, it’s about being better. I get prescribed a lot more medication than I need. I don’t take it often, but I like the options having anti-depressants, sleeping pills, stimulants, and anti-anxiety medication provide. Wirh it I have the ability to easily control my mental and physical state depending on I want to feel and what is required of me.
Do I need to crush code for 48 hours? No problem. Sleeping on a plane, no problem. Etc etc.
Not saying this would work for everyone, and if I took the time, maybe I could use meditation or whatever to achieve the same results. But I’m busy and have things to do, I suppose.
My mind takes the wide application of this to a scary dystopian conclusion, but perhaps it doesn't have to be this way. Or conversely perhaps we are already there.
I didn't care if it was placebo (although why it would be placebo at 8 weeks but deemed not a placebo at 12 weeks I struggle to understand), I felt I needed it more often and eventually found a doctor willing to try it. For me, it works.
What got to me though, is while the doctor wasn't willing to try a vitamin slightly more frequently, he offered anti-depressants at the drop of a hat. He couldn't have been more forwards in offering them and didn't take the hint when I told him I didn't really want them - I had to give him a firm no in the end!
http://sciencenordic.com/high-levels-vitamin-b12-can-increas...
Because the placebo effect fades over time. The doctor has concluded that you'd be safely clear of it at 12 weeks.
It was discovered sometime within the past few years during a routine blood test that I had low hemoglobin from a moderate-to-severe Iron/B12 deficiency (no full blown other condition, though)
I was never recommended injections, however. Doctor told me to take an off-the-shelf supplement and to eat more red meat. (I rarely did)
When I don't follow through with those items I do notice. Following his advice has greatly improved my overall feeling of well-being. I would otherwise feel tired, foggy-headed, weak, faint, anxious, nauseous at times—sometimes a mix of all of the above. Used to think my blood sugar was just low.
Why it's not absorbed varies, I was tested for pernicious anaemia which is a relatively common cause but I don't have that. That seems to be the end of the line for investigations on the UK NHS, they pretty much just said you can't get it from your diet, it doesn't matter why, so we'll inject it.
That my mother and siblings, and we all live apart, also have it and they don't seem short of dietary B12 either seems to add to the picture.
Maintaining a "stiff upper lip" means learning to ignore unpleasant symptoms, which can both reduce their frequency and severity. There is usefulness in "manning up", to use an increasingly unpopular turn of phrase. I disagree with the increasingly common idea that suppressing one's negative emotions is generally harmful.
You cannot recommend it without an actual trial, it is not safe.
That last statement is rather asinine and seems at odds with the rest of the article. I think it's fair to say negative emotions aren't the same as mental illness, but ignoring those negative emotions and keeping a "stiff upper lip" can lead to much bigger emotional problems down the road. There's a middle ground that involves accepting & experiencing the lows along with the highs as a part of life.
To me, keeping a "stiff upper lip" isn't so much about ignoring negative emotions, but more about behaving in the right way even when emotions pull you the wrong way. In my experience, exercising that skill doesn't create emotional problems, but solves them.
Be like a rocky promontory against which the restless surf continuously pounds; it stands fast while the churning sea is lulled to sleep at its feet. I hear you say, "How unlucky that this should happen to me!" Not at all! Say instead, "How lucky I am that I am not broken by what has happened and am not afraid of what is about to happen. The same blow might have struck any one, but not many would have absorbed it without capitulation and complaint."
This stance is immoral in many ethical systems. Not to mention everyone has a breaking point.
The real thing that's happening with mental health in the US and probably the UK is that people aren't so much deciding that their personal problems are diagnosable psychiatric conditions as they are deciding that they would like to become mentally healthier and are seeking help. And the medical profession, being ill-equipped to actually provide a means to change, is turning to psychiatric medicines to control what are essentially patterns of thinking and being. At the gym it would be like people seeking to become better and instead of receiving personal training they would be given steroids.
I was one of those people who wanted to change how I thought about things and how I acted. And so I sought therapy not necessarily because I had a clinical disorder, but because there were a lot of probably sub-clinical issues I was having with my thinking, and having someone rational and well-trained helped me change my thinking and my behavior so it was no longer causing problems for me. Frankly I was nearing a meltdown of some sort.
It's not the same as needing psychiatric care for a personality disorder or for Schizophrenia or for any number of treatable, identifiable psychiatric disorders. But he's standing up this straw man that people like me are just wimps and they just need to suck it up and have a cup of tea or something. It's pretty patronizing.
I also think there's a social point: we often feel bad because we fear that other people will think less of us for various reasons (money, status, lifestyle). A lot of the time, it's important to resist that natural social impulse and to live on your own terms.
The part I'm not so sure I agree with is the "system is too jammed up so don't come," sentiment.
I think if someone is having a hard time & they want to reach out to a medical professional that's probably for the best.
Unfortunately that does shift the burden onto the system to train professionals to determine the difference between prescribing antidepressants or talk and time therapy. It's a lot easier to write someone that prescription than hear them out.
In a related article [1], it was mentioned that 70% of children with mental issues do not receive treatment because lack of resources - high rates of mental illness mean there's simply not enough healthcare to go around. Even those that do receive treatment end up facing "unacceptably long waits." The current ambitious goal in restructuring the system would still leave some 65% of those with diagnosed medical conditions, without treatment. Wiki also has a number of decent citations for further information. [2]
When things are provided through public funding there is an obligation of society to ensure that they are utilized in a sustainable way. If that obligation is not met, the systems become, quite tautologically, unsustainable.
[1] - https://www.independent.co.uk/news/health/mental-health-cris...
[2] - https://en.wikipedia.org/wiki/National_Health_Service#Fundin...
So why are people bothered by their anxiety or reoccurring blue moods being "medicalized?" As far as I can tell, it's just the stubborn lingering stigma associated with mental illness. The fact that a person's cold is a physical illness feels harmless to them, but the idea that they might be suffering from a "mental" illness, even a mild and common one, feels way more momentous and scary than it should.
Clearly I am not alone in my sense that we have already hit the boundaries of how far we can sensibly apply the paradigm of mental health as a means of understanding and addressing human misfortunes.
This is ridiculous. We certainly haven't gone far enough when people identify "mental health" with an inability to function without professional support. How ridiculous would it be if people denied having a physical injury when they had a scraped knee, because they felt denial was the only way to avoid seeing a doctor? How ridiculous would it be if people didn't brush their teeth because they didn't want to give up their precious self-reliance to "dental health" professionals? We reduce our reliance on professionals by applying knowledge from those professions, not by denying their relevance.
The whole stiff upper lip nonsense is the problem. Neglecting and suppressing emotions for long periods of time cause mental health issues.
The problem is that we don't have a clue about mental health in general, the blind are leading the blind.
Antidepressants don't cure depression. In fact, they can make it harder to process emotions. They reduce the symptoms and make it easier to ignore the environmental issues that are causing it.
Actually treating depression requires understanding and addressing the true cause. And the true cause is not a chemical imbalance or people not being tough enough.
Self-pity or using issues as a crutch does not help, but it is also not the cause.
"I want to argue that it is necessary to reframe the growing problem of stress (and distress) in capitalist societies. Instead of treating it as incumbent on individuals to resolve their own psychological distress, instead, that is, of accepting the vast privatization of tress that has taken place over the last thirty years, we need to ask: how has it become acceptable that so many people, and especially so many young people, are ill? The 'mental health plague' in capitalist societies would suggest that, instead of being the only social system that works, capitalism is inherently dysfunctional, and that the cost of it appearing to work is very high".
Anyway, since I've just violated de mortuis nil nisi bonum, let me finish by saying that Fisher had good taste in music.
Whole swathes of jobs are not truly productive, e.g. marketing and advertising, psychologists, priests, yoga-teachers.
- ADHD = boredom
- Learning disabilities = stupid
Again, no connection with capitalism.
Just food for thought.
Couple of years ago I started to go outside for long periods of time, at the start of the season, all season. Biking and laying about at the waterside with my nose in the grass. First year, first months, I had symptoms. But after like 2 months of exposure I started to become free of symptoms.
Up to my 'real' school we played outside extensively and I never had symptoms.
When I was about 15 years I was prescribed pills and whatnot.
If I go outside 'enough', I consider myself 'cured'.
Not mental, but I felt it was related.
However, I am at a loss as to how to approach her to help her. Trying to convey this to her would sound more like an accusation of hypochondria.
We can be much harder on ourselves than we would ever be on a friend, and if you can get her to think about her own set of problems as if they were yours, what sort of advice would she offer you?
We get wrapped up in a set of outcomes and every setback feels like a harbinger of doom. I saw a retweet recently from someone with chronic fatigue who wished they could go back in time and use their dwindling energy to set themselves up for the future instead of spending everything on trying to 'get back to normal so they could start their life again'.
Look at where you are. What could you do this week or month to get to something you could live with or even enjoy? Don't let the perfect be the enemy of the good.
He says, realizing he needs to follow the same advice...
I wish I could tell you how to help your friend. What my spouse needed was therapy from a professional, who could maintain appropriate boundaries -- I wasn't, and couldn't.
The awful thing I learned about 'hypochondria' is that psychosomatic effects, and stress, can have real physical consequences. I never did learn how to navigate that conversation without causing distress
I think it is becoming accepted to make excuses everywhere. For individuals and groups, it is now seen as as okay to not to aim higher.
There are so many hard working people who were never handed anything, have actual physical disabilities, and they still work extreme hours to take care of their families and not be a burden.
I always think of how we construct Kobayashi Marus to tell ourselves and others that there are no-win scenarios, in some odd attempt to justify limiting ourselves to only grim options and schadenfreude for those who fail to echo acceptance.
What if this belief in a gritty realpolitik is an excuse for not wanting to think harder to achieve what is right? That individuals and groups willingly believe in a local maxima, because the hill climbing required to get the right outcome is accepted as fantasy?