The psychiatric drug crisis
newyorker.com
newyorker.com
Many of the diagnoses given are pulled out of thin air and made to justify a patient's admission, or to appease a patient's desire to feel as if they have a treatable illness. I would ask psychiatrists I trained with to explain why a drug worked or why a disease developed. They would do nothing more than give me the same surface-level information we all know: SSRIs block serotonin reuptake, leading to more serotonin in the synaptic cleft that would then cause increased stimulation, and voila, you're not depressed. This is information anyone can attain with a google search. The majority of their knowledge dealt with pharmacological dynamics.
I sat in on a psychiatry conference one afternoon where the docs discussed the treatment of several patients. Never was a scientific article or concept uttered. It was all "well, let's try him on seroquel and olanzapine, let's also throw Paxil in there." It was evident that their treatment protocol was largely one of extremely unsupported trial-and-error based on very, very unique experiences, anecdotes, and preferences each psychiatrist had.
Now, I don't want to discredit the entire field. I do know friends and family who have benefited from psychiatric medications, although that could entirely be due to placebo effect. What needs to happen first is that we need to attain a much deeper understanding of how the brain works on the low and high levels, mechanically and abstractly. Mechanically so that we may develop effective meds, abstractly so that we may learn how to manipulate cognitive processes, like with what we see with CBT, which has worked wonders for many with depression -- no medication involved.
tl;dr: Psychiatry is a very, very loose and abstract field. You can't run any diagnostic tests on patients. It's mostly a field of educated guessing and confirmation bias. We need better mechanical and abstract understanding of the mind before we douse it in chemicals.
If the drugs had no effect, then why are people (ab)using drugs like Adderall to improve cognition, etc?
A big problem with trying to make a science out of the brain, is that it can be very unique to the person. For example, in people that are blind since birth, the pathways in the brain that are normally used for visual processing can get re-purposed over a lifetime to be used for other things.
I'd almost say that the brain is sort of like an evolutionary algorithm. Given similar parameters, the results largely resemble each other, but alter things enough and the results can be way off.
Placebo effect is certainly an effect. But the claim is not that the drugs don't have an effect (though it's true, some work no more effective than a placebo), but that we have no sound explanation for their effects.
Do you have a citation for this? What drugs on the market today are "no more effective than placebo?"
http://jama.jamanetwork.com/article.aspx?articleid=185157
This study found that SSRIs provided little to no benefit over placebo for patients suffering from mild to moderate depression. SSRIs did provide a benefit to patients suffering from severe depression.
This raises the question, how many of the 30+ million Americans currently prescribed anti-depressants actually suffer from severe depression and benefit from the drugs? How many are taking it unnecessarily, subjecting themselves to unintended side effects and eventual withdrawal symptoms.
Serotonin reuptake inhibitors used for mood management are just a matter of trying them and seeing if you like the way they feel. It's exactly as scientific as drinking liquor or smoking marijuana to see if it makes you more mellow.
But doctors are going around collecting rent on their prescription pads by writing scrips for Paxil and Prozac and the like as if they were technical and carefully calibrated professional tools that required twelve years of college and med school and internships and apprenticeships to master and administer. They're doing all that training and then providing the same service as witch doctors -- but for a lot more money.
Yeah, of course we see the effects, but we still don't really know how exactly it works. For example, no one can tell for sure why Dextroamphetamine and levoamphetamine have different effects (the former is a brain stimulant, while the latter affects mostly the body). Adderall is mostly dextroamphetamine, by the way.
You're making an assumption here -- that people's trust in, and use of, drugs argues that it's not a mere placebo effect. But there are any number of accounts of people persuading themselves that a drug is reliable, for a drug that is in fact a placebo. In fact, that's how the placebo effect is defined.
The only way to sort out these issues is with a double-blind prospective trial. Unfortunately, such trials are nearly nonexistent for this class of drugs, and those trials that have been conducted, are often run badly or published in very selective ways, creating the impression that the drugs are more effective than they really are.
Reference (PDF warning): http://alphachoices.com/repository/assets/pdf/EmperorsNewDru...
There was a lot of disagreement about the paper you referenced. CNS drug are notoriously hard to get positive clinical trial data for. The reasons are: (1) placebo effect is notoriously difficult to control for in psychiatric trials, (2) the clinical trial endpoints are very blunt measures of efficacy.
But you know what? That's the best we have right now. There certainly is a strong requirement for efficacy in psychiatric drugs as evidenced by how many have failed to get approved by the FDA.
The sad thing is that most big drug companies have completely pulled out of doing R&D for new CNS drugs. They are just too hard to get approved. The end result is that patients with psychiatric illnesses will end up with fewer treatments options unless this changes.
You need to read each word and think about it. In a prospective trial, subjects are chosen in advance, they aren't drawn from an existing population of people who have already decided to seek psychological help.
A "double-blind, prospective trial" would have to sign people up from a cross-section of the population who have no interest in, or association with, psychological treatments. Then they would be divided into two groups. One group would receive the drug under test, the other would receive a placebo. And the trial would have to be designed so that the two groups wold not be able to tell to which group they belonged. Unfortunately, about the drugs under test, most of them have side effects, which means the subjects aren't blinded (the placebo group have no problem realizing who they are).
Even will all its defects and shortcomings, what I have just described is unheard of in psychological testing.
> Unless you are referring to very old psychiatric drugs, most of them have gone through such trials.
Absolutely false. The kind of design I am describing is simply unheard of. Most trials are of self-selected psychological treatment clients, and it's not uncommon for the "control group" to be what are euphemistically called "no-treatment controls". Guess what that means -- it means the experimental group is compared to people who are told to go home with no treatment and no sham treatment.
> There was a lot of disagreement about the paper you referenced.
Yes, of course -- and that's the way it should be. But there have been enough similar studies and meta-analyses that the outcome is not in question.
> But you know what? That's the best we have right now.
Different topic.
> There certainly is a strong requirement for efficacy in psychiatric drugs as evidenced by how many have failed to get approved by the FDA.
Most of the drugs that just were proven ineffective were not ever tested for efficacy as psychological drugs, they were prescribed off-label -- they were originally approved for some other purpose.
> The end result is that patients with psychiatric illnesses will end up with fewer treatments options unless this changes.
If the treatments were effective, that would be a shame. But they aren't, so it isn't.
Consider an SSRI study for depression. I want to know if someone who is depressed and takes it does better thank someone who is depressed and doesn't take it, or takes a different drug. I don't care what it does in a healthy population, since they probably won't be taking it. I mean, the effects of SSRIs in healthy individuals is an interesting topic, but not relevant if I'm investigating depression treatments.
Yes, and with respect to the drugs we're talking about, subsequent meta-analyses show that the original studies were all biased in favor of their sponsors and all the drugs produce the same results, which argues for a massive placebo effect.
For years, studies were published that appeared to support various drug approaches to mental illness, but those studies have been invalidated by more careful analysis that included (as just one well-known example) unpublished studies that came to conclusions not favorable to the drug companies' outlook.
> Consider an SSRI study for depression.
Yes, let's do that. As things stand right now, studies of drugs that increase serotonin levels show the same effects as those drugs that decrease serotonin levels. This causes open-minded scientists to doubt the efficacy of this entire approach.
Reference: http://www.newyorker.com/online/blogs/elements/2013/09/psych...
Quote: "While S.S.R.I.s surely alter serotonin metabolism, those changes do not explain why the drugs work, nor do they explain why they have proven to be no more effective than placebos in clinical trials."
> I mean, the effects of SSRIs in healthy individuals is an interesting topic, but not relevant if I'm investigating depression treatments.
Such studies -- with the diagnosed depressed -- show no clinically significant result that can distinguish the outcome from the placebo effect. Those are the facts.
* Why do some SSRIs work for some people while others don't?
* Why does increasing the dose of a specific SSRI have an increased effect?
Is it not possible that the real reason that SSRIs might be no more effective than placebo in clinical trials is that we don't quite understand the reasons that they work yet? (i.e. a specific SSRI might only have a real effect on 15% of the non-control group)
> * Why do some SSRIs work for some people while others don't?
The placebo effect. Surely you don't think everyone has the same placebo effect? Also, you're not describing the same study with the same participants and different drugs, you're describing different studies, different subjects, and different drugs -- all of which can change the outcome.
> * Why does increasing the dose of a specific SSRI have an increased effect?
The placebo effect. If people believe that a placebo is working, then more placebo produces more illusion.
Also, your use of the term "increased effect" is misleading. The largest doses show an effect, smaller doses show no effect. One theory about that is that the large-dose drug's side effects alert the subjects that they're not in the control group. A proposal has been made to create "active" placebos, placebos that mimic the side effects of the drug under test but not the property under test. This idea hasn't been tried yet.
> Is it not possible that the real reason that SSRIs might be no more effective than placebo in clinical trials is that we don't quite understand the reasons that they work yet?
You're overlooking the fact that placebos produce the same effects as the drugs under test. Our understanding or not understanding isn't an issue, because they've been demonstrated to be indistinguishable from a sugar pill.
And our not having a mechanism is definitely a criticism of this kind of treatment -- it would be like administering a mystery drug that proves essential to health, then deciding to increase the dosage, without understanding that the mystery drug is fatal in large doses (like vitamin A).
The inverse of a prospective trial is a retrospective trial where you have a set of data and you go looking for signals.
Then it's a good thing that I never said or implied that. The subjects must be drawn from a uniform population, not from a population that have already come forward for treatment -- otherwise the result is biased by the experimental population at the outset.
> Prospective simply means you have decided what the endpoints will be before the trial begins.
No, it means the experimental design doesn't recruit from a pre-existing population of subjects with a history or established preferences, instead you choose random subjects from the population at large.
> The inverse of a prospective trial is a retrospective trial where you have a set of data and you go looking for signals.
There's nothing stopping you from actually learning what these terms mean. A prospective study recruits subjects from the population at large, people with no particular interest in, or knowledge of, the topic being studied. A retrospective study relies on self-selected subjects, people who are already engaged with what you want to study.
For example, let's say I want to study the link between daily vitamin use and intelligence -- do people who take a daily vitamin become more intelligent as a result?
I begin to design a study. Shall I enlist people who already take a daily vitamin (retrospective), or do I enlist people with no interest in the issue, divide them into two groups, make one of the two groups take a daily vitamin, and make the other group take a placebo (prospective)?
See the difference? In the retrospective, any conclusion I make may result from a confusion of cause and effect -- for example, if the vitamin-takers turn out to be more intelligent, that might result from a factor like intelligent people taking a vitamin because of their increased awareness of health issues, in other words, it might be an effect, not a cause.
The prospective experimental and control groups, one of which got a vitamin, and the other which got a placebo, is much more likely to produce a meaningful result.
However, you argument stills doesn't hold much water. How can a psychiatric drug be used retrospectively unless it has already been approved for use? If you're complaining about trial data on off-label use, then I won't argue, but the FDA does not accept retrospective trials to support drug approval.
For context, I'm not on any psychiatric drugs, have never been on any, and think they're largely being abused by American society. But the extreme cases suggest to me that they have a use.
Well, the withdrawal effects for quite a few of these drugs includes various acute psychiatric symptoms, include suicide and homicide.
I lost one of my bests friends a number of years ago to this.
Also found: http://ssristories.com/
Because for many, these symptoms are not adequately addressed through more conservative means. There are numerous ways to attack an unusual disposition that do not involve medication -- exercising, weight loss, meditation, psychotherapy, cognitive behavioral therapy, rectifying family issues, finding a job. Many of these options are not adequately pursued. I have never seen a psychiatrist refer a patient to see a psychologist or a cognitive behavioral therapist, and they have no incentive to really.
Plenty do, and there are questions about the efficacy of those techniques as well.
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I have to say, though, as a separate issue: neuroaffective medications of all kinds (whether for chemical imbalances, or hormonal imbalances, or pain-management, etc.) are basically like crutches.
Your problem might not be "just" a chemical imbalance, just like your problem might not be "just" pain. But even if the cause is external, and the "true solution" is external, the symptoms the external problem is causing in you might be too debilitating for you to pursue the external solution on your own, while you're still afflicted. That's when you need a crutch.
If you break your leg, walking on it enough to get it to heal is usually far too painful to do all on your own. So, you get crutches. Now you can get some support to lessen the pain, while still walking on it to help it heal. If you lost your job while you were in the hospital for the leg-break, the crutch can let you go back to work before you otherwise would, which can give you the motivation to keep pushing yourself to heal, rather than just sitting around. Once your leg has healed, you don't need the crutch.
If you're clinically depressed, going out and doing things you'd otherwise enjoy is hard. SSRIs and the like are a crutch that let you feel less pessimistic about your situation, so you can pursue real sources of happiness (getting a better job, finding a relationship, etc.) Once you've done those things, you might not need the crutch.
Sometimes, though, we need crutches for life. Once you're old enough to need a cane or a walker, you're never going to not need a cane or a walker. Some people are born with conditions that put them in a wheelchair for their entire lives. If your problem is inherent to your physiology, there's no external problem to solve--so you'll always need the crutch.
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Here's the odd thing about neurotransmitter imbalances, though. I asked a psychiatrist friend of mine about whether, generally, his patients have obvious problems in their lives that could be possible causes of their symptoms, or whether they more often say things like "everything's great so I don't see why I'm so--". He said it was overwhelmingly the latter.
My pure guess to explain this data, is that something happened to our brain chemistry that paralleled the rise of near-/farsightedness as a genetic trait. After the rise of agriculture, sharp near/far vision stopped being something we had natural selection pressuring us to keep--and, unlike traits like height, it's hard to tell how well your partner can see, so it wasn't sexually selected, either. So the likelihood of your vision staying perfectly "in tune" with the reference point became pretty much random chance, with near-/far-sighted people mating with other near-/far-sighted people with no concern for the consequences.
So, just as our eyes have to be tuned to a certain reference point to work optimally, so do our neurotransmitter levels. And just like people don't much care if their partner can see well, people don't much care if their partner has strange moods sometimes (--in fact, some might prefer partners with a certain demeanor.) So we've let genetic drift and random crossovers take the place of selective pressure in determining our brain chemistry. A lot more people are born needing figurative wheelchairs than find themselves needing figurative crutches.
But a wheelchair is a bad metaphor, here, isn't it? A wheelchair is for someone who can't walk at all without it. Whereas, being slightly off your reference point, and using something to bring you back in line? Why, that's a lot more like wearing glasses!
I'm a big "weird crime" geek and pretty much every single one of them, if you dig deep enough (and quick enough--I've seen news articles "cleaned up" after-the-fact to remove references about medications. Doesn't need to be a conspiracy when we have HIPAA), you find that the perpetrator had either been prescribed new meds/upped dosage in the past week or discontinued suddenly. Also, it's a little bit like a miscarriage--if you talk about it even a little, the private stories come out of the woodwork. Some tragedies, some "holy cow, am I glad I figured out what made me want to buy a gun." What kills me is not knowing how many suicides could have been avoided. And that the word isn't out yet, how many more will we see?
I am seriously a little terrified about a mass shortage of these medications (SSRIs and antipsychotics aren't the only medications that can cause akathisia, delusion, homicidal/suicidal ideation...we've got Larium, ADHD meds, I even just read about a weight loss drug with suicidal ideation as a side effect...banned in Europe but A-OK in the US). How irresponsible if pharmaceutical companies just cut these drugs out without giving their patients a method of safely withdrawing from them... Dig around for withdrawal-induced crimes (especially at the local level; more data there), and you'll see that it's actually murderous. The least they can do is research which genotypes are most susceptible to dangerous side effects (for example, is it possible that people with the MTHFR gene mutation or other characteristics are hit with serious withdrawal symptoms?) to share with prescribing doctors.
However, a few decades of real life later I've seen first-hand, successes and turnarounds for people who either found themselves in bad situations or were just plain genetically vulnerable. In fact, I'll go as far as saying that counseling or therapy are nothing compared to the difference that the right medication(s) can make in a life. Finding it is hit-or-miss, and there are still people who ultimately can't be helped but there are countless success stories - they just aren't worth reporting, like every time antibiotics work as expected.
There are many, many more that have been labeled due to loose diagnosing guidelines to have a psychiatric disorder. A psychiatrist might just notice that your affect is slightly off, and label you with schizoaffective disorder, which is pretty well known as the diagnosis you give when you can't really put your finger on what's wrong, and yet they still treat medically.
How many people diagnosed with MDD or hypomania, do you think, genuinely deserve treatment with muddy medications? How many of them do you think may have other rectifiable issues that are leading to their disposition? Psychiatrists tend to overlook identifying those issues, and jump to asking the questions needed to diagnose a disease as per the DSM-IV.
[1] http://www.ncneurocenter.com/eeg/eeg_reference.html
[2] http://en.wikipedia.org/wiki/Quantitative_electroencephalogr...
At least the pills are -- at worst -- mostly harmless, the surgeons who cut at the drop of hat (viz. almost all of them) do far more damage.
Today, many powerful mental illnesses can be brought under control by medication. For example, the brother of a close friend suffers from schizophrenia. His drugs work so well that the biggest risk he faces is deciding that he feels so normal that he's cured, and can stop taking the drugs (which would result in a relapse).
Most mental health disorders are inherently self-limiting and will disappear without any treatment, which makes psychiatry look far more effective than it really is. If you're depressed, you're statistically likely to not be depressed in six months time, regardless of whether you seek treatment or not. In these circumstances, it's easy for a completely ineffective treatment to look like a miracle cure. The key outcome measures for most psychiatric drug trials are episode duration and likelihood of relapse, which speaks volumes.
Source?
If left untreated, a typical major depressive episode may last for about six months, while about 20% of these episodes can last two years or more, with 50% of depressive episodes ending spontaneously.
I can probably find you an article reference if you want. But I have learned this kind of research findings in psychology class.
Which says nothing about the effectiveness of psychiatric treatments. But it does argue for aggressive early treatment, whatever that might mean, in the hope of halting the progression before it could become chronic.
Mental illness is fundamentally hard to study scientifically, and I'm not convinced that any of the treatments we have actually work. But it's humane to make the attempt.
Um, yes they are. Are they reliable data? I'm not convinced they're not.
>If you're depressed, you're statistically likely to not be depressed in six months time, regardless of whether you seek treatment or not. In these circumstances, it's easy for a completely ineffective treatment to look like a miracle cure.
Because never in the history of medicine has a treatment for depression had an immediate effect?
I like this idea. I have one question; in the meantime, while we spend the next five hundred years figuring out the brain (because as we already know, it is wildly complex and we know almost nothing about it), what do we do with the people who really need psychiatric help? Can we hang them out to dry, or would that be too cold?
For the millions of those with 'psychiatric' disorders that are diagnosed using incredibly vague guidelines [0] -- do you ever feel tired? do you ever lose attention? do you ever feel really confident? -- using medications that do not have any observable and immediate symptomatic relief is not worth it. Many of these people have dysfunctions of cognitive processes or issues of their childhood that can be attacked in more conservative ways.
[0] http://www.mayoclinic.com/health/depression/DS00175/DSECTION...
I've been in first-hand contact with a fair number of doctors, psychiatrists, psychologists and their patients in Scandinavia, and I haven't seen the rampant prescription of drugs to treat vague diagnoses that you describe. If you're in psychotic and in a mental hospital, they'll prescribe drugs, ditto if you have a mood disorder that is severely affecting your functioning. If you have something that reminds of ME or a similar poorly-understood conditions, the meds usually remain off the table and other forms of therapy attempted. Regardless of the situation, if meds are attempted, it's an ongoing experiment to figure out if something works.
Psychiatry would benefit tremendously from a better understanding of brain chemistry. But you're suggeating that we shut down our interim attempts at improving the lives of patients who are suffering greatly today. Psychiatry uses our best guesses yet, and is the best option we have. Its similarities to quack medicine are superficial and incidental.
One data point? You're talking about the 'how are we going to treat our current patients' conferences? I've been in a couple of those myself, and you're expecting something weird from them. It'd be like spending the afternoon with engineers and saying "I didn't hear any of them mention any of the laws of thermodynamics!".
I've worked with engineers building hardware, both medical and agricultural, and much of their day-to-day work is based on their innate understanding of the tasks at hand. At critical points in the design process, they will break out their formulas, but when they're discussing the generalities of what to do with their colleagues, they're not citing canonical resources. What you're desiring is a fantasy world.
You can't run any diagnostic tests on patients.
As someone who spent several years as a neuro tech, this isn't true. Some things have some tests. It is a very difficult field of study - possibly the most difficult in all of human experience - and it's true that there isn't a great amount of test coverage over the whole field. But you're mischaracterising it to say there are no tests.
We need better mechanical and abstract understanding of the mind before we douse it in chemicals.
That's a nice throwaway line. You make it sound like the mind is an easy thing to understand, and that it won't take long. And apparently, until we have this complete understanding, we should just say 'fuck you' to the people who are currently in need of help?
Overuse of pharmaceuticals is a problem, but the answer isn't to run screaming into the absolutist opposite direction.
2. Yes, the best and most practical test we have is an EEG that, at best, tells you that something wonky is going on in this vague region of the brain. Good for seizure disorders, little else. The other tests we can run are to detect physiological causes of psychiatric symptoms external to the brain, like thyroid disorder, uremia, overdose, etc. Nobody sends a patient down for a routine fMRI. What tests are you referring to?
3. I'm not advocating to wait until we've achieved a complete understanding of the brain, but rather we explore more conservative managements while we get a better understanding of the mechanical workings on the brain. CBT, DBT, psychotherapy, etc, should be actively encouraged by psychiatrists as first-line options for many of these conditions. They simply aren't.
Unlike psychiatrists, I do not believe the DSM criteria can substitute for actual clinical diagnostic skills.
The reason for that is the complexity and uniqueness of projects (Does that study at IBM really apply to my small company? If this is a good way for NASA to make hardware, is it a good way to design android aps?). But also because engineers are focused on doing a job using a body of knowledge they draw from school, experience, and a bit of reading. They are not academic engineers. This is probably a good thing.
Similarly, I think doctors are not academic researchers. They apply treatment algorithms, bending them to the patients specific situation is so far as won't get them sued.
If the algorithm doesn't say EEG, then why would they believe they know better than the professors that signed off on it?
If the insurer requires a diagnosis, they will look in the DSM and find something they could justify at an inquest. Then they will treat the diagnosis, according to the algorithm, fitted to the patient.
I think doctoring has more defined procedures than engineering. These are not academics, and I think expecting them to be is based on an assumption that 'dr means phd'. It doesn't for medical people.
That's what research is for and is doing, but in the meantime what you're suggesting is that we sit on the sidelines and watch those that need help suffer because what we know isn't up to your standard? So we're going to take your anecdotal experiences in the psychiatric community about how psychiatry is anecdotal and is thus largely discredited?
Would you really be willing to let millions of people suffer because of that hypocrisy? Very frightening.
Criticism of its lack of rigor may be fair in many cases, but for you to call it a "sham field" is reactionary and completely inflammatory. Don't backpedal with "I don't want to discredit the entire field" when you're going to lead your comment with, "Good riddance."
It isn't just you. EVERYONE knows people that have benefited from medication. I've seen people go from horrible, twisted states of mind turn into happy, functional people within months by taking medication. The idea that this is just a placebo effect is completely counter-intuitive, for too many reasons to list.
Don't believe for a second the idea that studies or science have anything to do with the author's opinion. People have been saying the same things ever since these medications were first released, without any facts or reasoning to back up their claims.
It isn't a surprise that after 30 years they've been able to come up with a couple of studies to back up what they're saying. What is surprising is that they'd be willing to ignore the tens of thousands of doctors all over the country that have seen these medications work, and the millions of people that have benefited from them. Studies have shown that about 75% of patients treated with antidepressants make a recovery. This is a miracle of modern medicine.
The idea that treating depression is a "loose and abstract field" is absurd. Millions of patients suffer from a range of similar systems. They get treatment, those symptoms are gone. There is nothing abstract about it. Yes, patients react differently to different medications, which is true for thousands of non-psychiatric conditions as well. In these cases, doctors also use trial and error.
Public figures against antidepressants are no better than Christian scientists who encourage patients not to seek treatment for cancer. They're also much more influential: they've persuaded hundred of thousands of people suffering from depression not to seek treatment.
It's an extremely young field, and like Artificial Intelligence, is rapidly growing and seeking to understand the brain (a very, very difficult thing to understand after all).
As evidence of that growth, NIMH just recently abandoned their vast use of an older method to diagnose patients. Until now that was the best thing they had. Fortunately, new technology opens new doors, and they are willing to walk through them. [1]
Psychiatry is a very young field, but it is very necessary.
Positive psychology is also a relatively new field which focuses on making patients happy, rather than diagnosing their problems, which seems to be major nitpick you have with psychiatry. Of course in some cases medicine is required simply due to physical malfunction.
[1] http://www.huffingtonpost.com/dr-harold-koplewicz/dsm-mental...
They know the research articles cold, suggest approaches based on actual research, can explain the best scientific understanding of why something should work, and when it doesn't, why that theory may be wrong, etc.
Now, as for " What needs to happen first is that we need to attain a much deeper understanding of how the brain works on the low and high levels, mechanically and abstractly."
I couldn't more strongly disagree. What you say could be applied to every area of medicine. We have been very wrong in very many fields about very many causes of very many diseases.
We only gain understand through trying and failing, and trying and succeeding. Sitting around waiting for scientific knowledge to magically increase through some unspecified process will do nothing.
If you want to argue psychiatrists are overconfident and usually wrong, that's one thing. If you want to argue that the diagnosis criteria are essentially vague bullshit that reads like the stuff they used to use to convict people of being witches, i'm right there with you. But you seem to be arguing we should stop trying with medications until we understand things better.
If we did that, we should stop roughly all modern medication, because in large part, we only know it works, not why or how, at any real level. We irradiate cells to try to solve cancer. This is basically at the level of using leeches.
We have theories. People are trying these theories out on real live people through making test medications, performing trials and treatments. Sometimes they pan out, sometimes they don't.
Sitting around doing MRI imaging studies (and any other kind of study you can think of) of the brains of various mentally ill people has been done, and the results analyzed. It has not helped.
So let's start simple: What exact process would you use to increase knowledge to the point you suggest?
Past that, if your real argument is that more conservative approaches should be favored over medication first, well, the problem there is simple at it's core:
Nobody is willing to pay for it.
Insurance companies are happy to cover a pill at 10 bucks a month for months.
Most people can't get outpatient CBT/DBT except at significant out of pocket cost.
So the fact that you have plenty of psychiatrists willing to sit around and prescribe med after med is partially an artifact of "that is what they can do for their patients".
First, you're very lucky! From what I understand, those psychiatrists are not only expensive (usually they are not on insurance plans), but also hard even to schedule (as they are rare, and in high demand)
Slightly OT, but were you diagnosed as a child or as an adult? If the former, did your treatments change as you grew older? If the latter, what was your impetus in getting diagnosed/treated?
I was diagnosed as a child about 27 years ago (IE well before the current "popularity").
My treatments did change. I learned to cope with some aspects, the medications I used changed (I am on a non-stimulant now, Straterra, that works as well as my stimulants did).
Besides being able to be more introspective and self-aware as I got older, I also chose a path that would set me up for success.
I have a job that has multiple roles, and essentially requires me to pay short amounts of attention to a large number of things at once, which is somewhat ideal for my ADHD. The things that require longer amounts of focus tend to be lower priority.
That's interesting - thanks for sharing. IIRC Strattera is relatively new; I wonder if the drugs themselves are getting more effective, or if the most effective drug for a person changes over time based on physiological changes or external factors.
I don't have any personal experience to compare it with, but of my friends who have been treated for ADHD for more than 15 years, it seems all have had to switch medications multiple times.
I don't see your email address on your profile, but mine is my username at gmail - mind dropping me a line?
Yes, Straterra is relatively new. I became immune to ritalin (well, roughly) after taking it for so many years, and Adderall, even in the XR version, started becoming less and less effective for me. This is apparently normal, and medication switching is common over long term treatment.
My doctor said she could up the dosage, but that she'd rather try Stratterra first, given the advantages of that vs high-dose stimulants
Note that 20 years ago, the common viewpoint was that adult adhd did not exist, that it simply "wore off" as you got older.
Straterra has worked fine for years so far, and i have not seen any of the gradual reduction effect that was completely obvious in all the stimulants over time.
I'll drop you a line.
I think this article puts psychiatry's dilemma into some good perspective: http://www.sciencebasedmedicine.org/dsm-5-and-the-fight-for-...
I do think that it's interesting how people conceive of psychiatry. We cannot really objectively measure or test pain. There's no blood test or scan that confirms it. But as everyone has experienced it, nobody doubts it exists. There's migraine headaches, which are, like psychiatric illness, diagnosed based on history and symptoms. It's pretty uncontroversial. Yet, as everyone believes themselves to be an expert in behavior, if they have not experienced or known someone with mental illness, it's suddenly all invented.
http://en.wikipedia.org/wiki/Dolorimeter
Perhaps you meant in the brain.
Reading that wiki entry, it looks like any objective measurements that arose from dolorimeters are not in active use, because they weren't helpful.
What's happening in the research world takes time to translate into practice, especially if it's not been validated in a large multi-center trial.
>Now, I don't want to discredit the entire field.
Looks like that's exactly what you want to do. Luckily, you're not doing a good job of it.
>What needs to happen first is that we need to attain a much deeper understanding of how the brain works
Yes, and until then what? Do nothing and let the suffers suffer? Per your own admission many people are helped. Perhaps that should be your clue to lay off the righteous indignation at lack of precision. Yes, we all want something that works in all cases, but in the mean time we should use something that works occasionally.
Incredibly, this drug has also been effective at treating depression. That's right: two classes of drugs with polar opposite first-order effects are used to treat the same disorder, and both of them apparently work.
I think one possible understanding of depression is that it is a feedback loop - it's a sort of standing wave or Nash equilibrium of patterns of thought causing patterns of behavior causing patterns of sensation causing patterns of emotion that cause patterns of thought, etc. And, perhaps, that just by changing any random variable(s) in that loop (mucking with reuptake, or cognitive behavioral therapy, or any of a whole bunch of other possible changes) has a probability of disrupting the equilibrium and suspending the depression.
It's not clear to me how to test this hypothesis, though.
Depression is a heterogeneous condition. The "truth" is that it's probably not one, but several conditions with similar symptoms; we just don't have the means to distinguish between them yet. So, we (ie, psychiatrists) try different medications that are known to work on some subset of depression patients, and hope that we find one that fits.
I think this is part of why psychiatry gets a bad reputation - even when practiced well, it's an attempt to develop a model for one of the most complicated systems in existence: the human mind & body. When you think about it like that, it's almost a miracle that we're able to do anything given our limited understanding of the way the mind works.
(With many medications, we know what chemical effect the medicine has, and we know what subjective effect the medicine has, but we actually don't have a solid understanding of the link between those two).
But that's not an indictment of the field as a whole, just an observation of how much more we have yet to learn.
[0] http://www.npr.org/blogs/health/2012/01/23/145525853/when-it...
I would have said they both appear to work. Recent findings cast doubt on that appearance (PDF warning): http://alphachoices.com/repository/assets/pdf/EmperorsNewDru...
They have similar etymologies, but their current meanings are diverging. An apparent difference may not be visual -- at least, not to the degree that an examination of the word's history would lead one to believe. An appearance of difference still is primarily visual.
And yes -- this is to some degree splitting hairs.
Again, I think this may be splitting hairs -- I might be making too much of this.
"Apparent" in a thesaurus: http://thesaurus.com/browse/apparent
"appear" in a thesaurus: http://thesaurus.com/browse/appear
Quite a difference.
However, you might want to take the description of "reuptake enhancer" with a grain of salt. The mechanism of action (MOA) for drugs is notoriously difficult to determine.
The best example of this is Lyrica (Pfizer). The drug was designed to be a GABAase enzyme inhibitor (prevents GABA from being metabolized, increasing it's action). This MOA was pushed during the entire development of Lyrica. It wasn't until the drug hit the market that a researcher finally figured out that it works by modulating the glutamate neurotransmitter. It's effectiveness has nothing at all to do with GABA.
Or
Some people with heat stroke will improve if given water. Others will get worse.
All these paradoxical effects prove is that the human perception of symptoms does not have a direct connection to the root causes of those symptoms. It doesn't mean that stimulants or water (or SSRIs) therefore have questionable efficacies.
You can put out a campfire with water, but adding
water to a grease fire does the opposite. So obviously
the use of water to put out fires is nothing but hokum!1) A desire to bring a level of "science" to a part of our physiology we don't understand. The thinking here is that while we do not understand the etiology of depression, we can at minimum begin to use blunt tools to solve problems. The issue as anyone who has studied complex systems understands, is that the feedback loops are so dense, there is no method to understand what is happening.
2) Financialization of treatment – drugs make more money than therapy and other methods. Or to use an HN phrase, drugs are more easily scaled to the population than other methods. The incentives throughout the entire system push people this direction, regardless of the underlying research.
3) Treatment doesn't happen instantly in any case. The issue with much of the research today is that we take a very limited time window to evaluate the efficacy of different treatments. If, instead, we looked at treatment over the life course, the results are often radically different.
This is where startups like Seven Cups of Tea will hopefully play the world. This mental health crisis offers a huge opportunity for disruption and creativity. As a quote in the Stanford alumni magazine said this month: "One hundred years from now, people will look back at the age of giving SSRIs and they will have a reputation that's akin to bloodletting."[1]
[1] http://alumni.stanford.edu/get/page/magazine/article/?articl...
Here's to hoping so! And sooner than that.
Confer:
http://thelastpsychiatrist.com/2006/11/massacre_of_the_unico...
http://thelastpsychiatrist.com/2010/01/the_massacre_of_the_u...
HAHAHA! Just kidding! Did you see the latest iPhone! It's got moar processors!
Is mankind only so smart because if we get any smarter, we cease to function correctly? Maybe it's just not evolutionarily advantageous to be smarter than we are; it makes us mopey, and we end up cutting our ears off when we're trying to woo girls, which rarely results in offspring.
Anyway, my point is, being smarter is not an excuse for "cutting one's ears off when trying to woo girls" (re:my parent comment) or for otherwise being socially dysfunctional.
Without knowing any psychiatric science, this narrative nevertheless seems suspicious. First of all, it is entirely irrelevant whether a discovery was made serendipitously or as a result of incremental science, as long as the effect is clear enough to be repeatedly found. This is not true in well understood fields, such as physics, where the theories are mostly not changed every now and then, but in complex fields, such as medicine and social sciences, the fact that something matches pre-existing theory is no evidence per se. The problem is "bumpy" enough that any theory is likely to flatten every bump that is not directly observed, even if that bump would be very useful in practice. This leads to most discoveries of any value being serendipitous. It also leads to incremental research failing to advance rapidly most of the time.
So the lack of theory and serendipitous discovery are not problems in themselves. The finding that psychiatric drugs would not be better than placebos is indeed a problem. It does raise the question, of how the serendipitous discovery was ever made. Did it arise out of spurious correlations, so that when the drug was first discovered there happened to be a big incidental recovery in most treated patients? Then in later retrials people managed to trigger a sufficient placebo effect to get the whole thing going. It does seem a little unlikely, but one would have to examine how the first trials were performed.
And there's no doubt these medications work in a lot of people (but not all), even though we don't understand how they actually work. Our ancestors did not know what fire was or how it worked, but they did use it because it was useful, the same applies here.
Further development is going to be difficult without a good understanding of how the brain works, though - pharma companies need to focus on finding better ways to probe deeper and more accurately into the brain (and create good simulators for that later on) before developing new drugs.
I understand that it takes R&D to develop new drugs, but the amount of profit sought by drug companies is stomach churning.
I sell digital, single-player video games. My manufacturing cost is zero and markup is infinite.
1. Producers and consumers are both equally informed 2. There are so many producers and so many consumers that no single producer or no single consumer is able to appreciably change the market price
Neither of those assumptions hold with the the drug market. Drug makers are massively more informed about the benefits and side effects of their drugs than I am. And there aren't that many drug manufacturers - and ongoing mergers keep shrinking the pool. In reality, the drug market is a barely regulated oligopoly, where a few large players manipulate the price signal to coordinate behavior so that they can move in relative unison to screw over the consumer. It's just like oil companies or airlines.
Your manufacturing cost is not zero at all. You have significant fixed costs; your marginal cost is zero, or so close to it as to be negligible. Your average fixed costs fall with each copy sold, but unless you consider your time and labor entirely worthless you have to sell quite a few copies before you break even.
Also, since your game is a discretionary expense, there's no significant opportunity cost to the non-purchaser, whereas the opportunity cost to someone who eschews or can't afford to purchase medication might be the person's life.
What's the right amount of profit a company should seek? For reference, following are the latest reported profit margins of several companies:
Eli Lilly: 20.34% AstraZeneca: 13.33% Novartis: 17.33%
Apple: 19.53% Google: 18.11% Microsoft: 24.95%
It's not at all clear to me that drug companies are somehow seeking more profits than other companies (or that they would generally be able to attain them in any case).
Could it be high-level tax evasion ?
It's not only profits: lifestyle drugs, like statins and medication for ED are obviously a source of easy profit, meanwhile research into antibiotics is falling by the wayside.
The fact that the existing antibiotics are becoming useless and there is nothing to replace them is going to be a disaster. There is this current discussion about vaccination skepticism (to use a polite word); one reason that parents omit to vaccinate their children is that no one living has experienced what a genuine measles or polio epidemic is like.
The availability of antibacterials since the 1930s has been a similar miracle. You do not have to die of a severe infection, you can take medication against it. Unless there is investment in research, serious infectious diseases will be back.
Remove advertising and reduce prices accordingly.
http://dhubris.livejournal.com/14447.html
As I said, it works for me, but may not work for you. The study of the brain and how it works physically, electrically, chemically, consciously and emotionally, and all the complex interactions within that is in its infancy in a lot of ways. So yes, if you think there is a lot of stumbling around trying to figure out what works and what doesn't, you're right. Isn't that how most science starts?
And its one of the only medications you can't develop a tolerance for.
Luckily I'm Canadian, working part time at a Canadian university where health insurance covers the costs.
This ancient medication that is a generic costs 130 dollars a month and that is the negotiated rate!
The money isn't going to research and it isn't going to manufacturing so where does it go?
I don't know about Ritalin, but with Adderall, the reason for inflated prices is that the DEA artificially restricts the supply (hence the 2011 disaster[0][1]).
It's simple economics: if it were possible for new companies to enter the market (or for existing companies to produce more), supply would increase, prices would fall, and markets would clear at a (lower) equilibrium price. However, because the US is waging a war on drugs (including psychiatric medicine!), ADHD patients have to suffer the burden of increased prices (that is, when they're lucky enough to even find any in stock).
[0] https://encrypted.google.com/search?hl=en&q=adderall%20short...
[1] http://www.google.com/trends/explore?q=adderall#q=adderall%2...
Take for example serotonin reuptake inhibitors. It's not important to know if a deficiency in serotonin is the "cause" of depression. All we need to know is if increasing the levels of serotonin correlates with an improvement of the condition of the patient better than placebo.
Their logic is: low serotonin levels aren't the cause of depression - so raising serotonin levels will not eliminate the cause of depression - so doing that isn't useful. That's a naive (and wrong) logic. Your heart going into fibrillation is not the cause of your heart problems, but treating the fibrillation can save your life - whatever the "cause" of that fibrillation.
Well, that's true. But I think he makes a reasonably compelling argument that we don't in fact know why the current generation of drugs works.
http://www.ted.com/talks/ed_boyden.html
The video is a little more optimistic, maybe even risks TED-utopianism... but it still has some really cool ideas, and shows that we have at least figured out a couple of things about brains.
What evidence does Gary Greenberg provide in his writings that would convince a skeptical onlooker that what he does for his patients is helpful?
The same question could be asked of any psychologist, psychotherapist or psychiatrist, regardless of their publication record. There are no objective, scientific, rigorous evaluation criteria anywhere in the field, which explain why the mental health field has the reputation it does.
No one asked it of Diederik Stapel, and, in spite of his enviable publication record and fame, he turned out the be a total fraud:
Link: http://news.sciencemag.org/people-events/2012/11/final-repor...
Quote: " In their exhaustive final report about the fraud affair that rocked social psychology last year, three investigative panels today collectively find fault with the field itself. They paint an image of a "sloppy" research culture in which some scientists don't understand the essentials of statistics, journal-selected article reviewers encourage researchers to leave unwelcome data out of their papers, and even the most prestigious journals print results that are obviously too good to be true."
If a medical drug were proven ineffective as anti-depression drugs have, doctors would have to stop prescribing it or be sued for malpractice. You can't sue psychologists for malpractice, because there's no such thing as good psychological practice for comparison.
If psychologists were forced to adopt evidence-based practice, they would be subject to lawsuits for the first time, which is why they have resisted such proposals:
Link: http://www.apa.org/monitor/feb05/pc.aspx
Quote: "Some APA members have asked me why I have chosen to sponsor an APA Presidential Initiative on Evidence-Based Practice (EBP) in Psychology, expressing fears that the results might be used against psychologists by managed-care companies and malpractice lawyers."
The critics were right -- evidence-based practice would have been a disaster for psychology -- and the proposal (2005) was shouted down.
Anti-depressive (and other psychiatric) drugs are a subset of "medical drugs".
> You can't sue psychologists for malpractice, because there's no such thing as good psychological practice for comparison.
You can, in fact, sue a psyschologist for malpractice [1], but a psychologist isn't going to be prescribing anti-depressants in the first place (and, if they try to, they've got bigger legal problems than potential malpractice, starting with practicing medicine without a license.)
[1] e.g., http://www.insurancejournal.com/news/west/2007/11/19/85123.h...
No, they are not. Medical drugs are prescribed by doctors to treat medical conditions, not psychological ones. There are some medical drugs that are prescribed off-label to treat mental conditions, but that's a shady practice (albeit a common one).
> You can, in fact, sue a psyschologist for malpractice ...
Yes, but you can't compare what he does to effective practices, because there aren't any. This is why such cases are so rare, and why malpractice insurance is nearly unheard of among psychiatrists and psychologists. Many psychologists and psychiatrists have ruined the lives of their clients but proved immune to prosecution -- for example, the psychiatrist who prescribed the drugs that killed Rebecca Riley was eventually allowed to continue practicing psychiatry, and was neither prosecuted or sued (Rebecca's father was convicted of first-degree murder, her mother of second-degree murder).
http://www.boston.com/news/local/breaking_news/2010/03/hold_...
Quote: "Shortly after Rebecca died, Kifuji had entered into a voluntary agreement with the board to halt her practice. But two years later, after a grand jury declined to indict her and the board conducted its own inquiry, the board last fall allowed her to return to practice. She is currently seeing patients at Tufts Medical Center."
> ... but a psychologist isn't going to be prescribing anti-depressants
True, unless by the term "psychologist" we mean anyone practicing clinical psychology, in the same way that a physicist practices physics -- a way of speaking that groups particle physicists and cosmologists together, two fields much less alike than psychiatry and clinical psychology.
There is no such thing as a "medical condition". There are physical conditions (of which psychiatric conditions are a subset) and medical (as opposed to, e.g., surgical) treatments for physical conditions.
For psychiatric conditions not to be physical would involve mystical mind-body dualism, which is an anti-scientific proposition.
> Yes, but you can't compare what he does to effective practices, because there aren't any.
Psychological malpractice is generally a subset of medical malpractice, whose standard isn't about "effective practices" but, like all professional malpractice, is about accepted standards within the profession.
> This is why such cases are so rare
Psychological malpractice cases aren't that rare. It's probably somewhat harder to establish causality in psychological malpractice cases than, say, some of the more obvious kinds of surgical malpractice cases, but that's not a matter of standards but of the difficulty in tracing particular harms to particular failures to meet the professional standard of care.
> why malpractice insurance is nearly unheard of among psychiatrists and psychologists.
Malpractice insurance is a practical necessity for psychiatrists -- who are, after all, medical doctors -- and is not at all uncommon for psychologists in clinical practice.
> Many psychologists and psychiatrists have ruined the lives of their clients but proved immune to prosecution
And many medical doctors in specialties other than psychiatry have killed patients and yet not been successfully prosecuted. That doesn't mean that medical doctors are, as a class, immune to malpractice claims, it just means that not every thing that they do that ends up causing harm ends up resulting in legal liability. Psychiatrists are no different.
> unless by the term "psychologist" we mean anyone practicing clinical psychology
Psychiatry isn't clinical psychology, it is medicine, and its practiced by medical doctors with a particular specialty, not psychologists. Making up your own non-standard definitions of terms to justify your completely inaccurate rants isn't helpful.
> There is no such thing as a "medical condition".
Are you sure you want to go down that road? Cancer is a medical condition. ADHD is not. Psychologists are not doctors and cannot treat medial conditions -- they are neither trained or licensed to do that.
Psychiatrists are psychologists with an M.D. degree. When you call a psychiatrist "doctor" , you are acknowledging his medical training, not his psychological training. There is no mental doctor, and there is no mental specialty in medicine.
The reason? Modern medicine is evidence based, and psychological treatments are not evidence-based.
> Psychological malpractice cases aren't that rare.
They are very rare. Public records show that, when something goes wrong in psychological treatment of children, the parents are more likely to face charges than the psychologist or psychiatrist, and I already gave one well-known example of a psychiatrist still practicing after being involved in a case that led to murder charges against the parents, who administered the drugs the psychiatrist prescribed.
> Psychiatrists are no different.
The public record shows that this is false. There are cases, but they represent a small fraction of those in medical fields, and the behaviors tend to be more egregious -- sexual abuse, damage to the patient through outright incompetence or prescribing the wrong drug. There are fewer cases such as one sees in medical specialties that have established procedures based on long clinical experience -- and scientific evidence to support clinical practice.
> Psychiatry isn't clinical psychology, it is medicine
A psychiatrist is a psychologist with an M.D. degree. The M.D. degree is acquired before the person begins psychiatric training, for a number of reasons including the fact that psychiatry is not a medical field in the modern sense of the word -- fields based on science, and on evidence.
The only reason psychiatry exists is to confer an unearned status on psychologists and psychology. And recent changes will make this obvious even to those who have been avoiding reality. One of those changes is the NIMH's recent decision to abandon the DSM, psychiatry's "Bible" and primary diagnostic guide. The reason? It's not reliable enough to be useful in research. About this decision, NIMH director Thomas Insel said "While DSM has been described as a “Bible” for the field, it is, at best, a dictionary, creating a set of labels and defining each. The strength of each of the editions of DSM has been “reliability” – each edition has ensured that clinicians use the same terms in the same ways. The weakness is its lack of validity."
Source: http://www.nimh.nih.gov/about/director/2013/transforming-dia...
Now - imagine someone in authority deciding to throw out an influential oncology textbook on the ground that it's not valid. Imagine the uproar. But in this case, it caused some comment but no great surprise -- most people in the field saw this coming. The reason for that muted reaction is that psychiatry isn't evidence-based and it is not medicine, all public claims to the contrary.
> Making up your own non-standard definitions of terms to justify your completely inaccurate rants isn't helpful.
Shall I give you Insel's email address so you can complain to the source of my views about how inaccurate he is?
Diederik Stapel is a disgrace,
http://retractionwatch.wordpress.com/2013/08/02/measure-by-m...
but he also hasn't had any influence on the clinical practice of psychiatry in the United States, the main topic of the article.
That's true in all intellectual pursuits, and particularly true in science -- there are no truths, only evidence.
> ... but he also hasn't had any influence on the clinical practice of psychiatry in the United States, the main topic of the article.
He published in the same journals as U.S. researchers and therapists, working to the same standards (or lack thereof) and with the same contempt for science that is a hallmark of the field. It certainly does indict the entire field, or do you think Europe is located on a different planet?
Since you seem to think Holland is located on an alien moon, here's a similar recent scandal involving a Harvard professor:
http://chronicle.com/article/Marc-Hauser-Resigns-From/128296...
Quote: "Marc D. Hauser, the Harvard psychologist found responsible for eight counts of scientific misconduct by the university, has resigned ..."
In scientific fields, such misbehavior isn't tolerated, and exposures of this kind end careers (example Jan Hendrik Schön, http://en.wikipedia.org/wiki/Sch%C3%B6n_scandal). Hauser, on the other hand, is, in his own words, moving on, exploring "some exciting opportunities in the private sector" and that he had been involved in some "extremely interesting and rewarding work focusing on the educational needs of at-risk teenagers."
So this public fraud, this person who holds science and professional responsibility in contempt, is going to be allowed to treat at-risk teenagers? Only in psychology.
Again this is my own personal experience in taking various anti-depressants for a few years. Overall what helped me was talking to other people and realizing were all nuts (deal with same issues) and yet very normal.
So if your dealing with depression and anxiety and are hiding it, from my experiences please do not. Please talk about it with as many people as possible; realize we are all the same and deal with the same similar issues!
(It's not)
edit: to replyers, it didn't want to post links for everything, so
google 'monitor me bbc horizon youtube', 'quantified self', 'self help industry', 'positive psychology'
edit to reply to your edit: no, you'll have to do much better than that if you want to actually communicate with people and not be ignored or dismissed as crazy. Would you please spend at least 10 minutes typing an explanation of (a) what are you talking about, and (b) why is it valuable?
Maybe I should point out that your edit seems to assume that most people understood part of your original comment. Actually, I think nobody understood any of it. So you'll have to rewrite what you originally said. (One strategy would be to make your comment longer and more thorough, and don't assume that anyone understands what you're saying unless you've explained it thoroughly, even if it seems obvious to you.)
As other commenters have said, psychiatry/psychology is an ineffective field and also expensive.
The self-help industry is kind of related to psychology/psyciatry, is unregulated, and a $11 billion a year field.
I gave a mention of a documentary that came out recently about people building apps in this category of self help/health/life monitoring kind of stuff. Some terms to google to find out more are what I typed in the OC.
He's suggesting the development of software to help people track their mental health, in much the same way people currently track other aspects of their day to day life, such as with a fitbit or mapmyrun. If people could track their mood, medications their taking, when and how frequently they take them, etc, that information would be valuable at both an individual and aggregate level.