
The psychiatric drug crisis - npalli
http://www.newyorker.com/online/blogs/elements/2013/09/psychiatry-prozac-ssri-mental-health-theory-discredited.html
======
kyro
Good riddance. Psychiatry by and large is a sham field. Physicians who
practice it love seeing themselves as artists who are experts in identifying
the subtleties of human behavior. That's their way of saying there's very
little underlying science guiding their practice.

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.

~~~
OldSchool
As a young engineer-type with no exposure to the psych field, I had about the
same opinion when I was in my early 20's.

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.

~~~
neurotech1
As a programmer and former EEG tech, all I can do is nod quietly. They could
be way more scientific about their medication selection if they wanted to be
[1][2] but most psychiatrists are overconfident in their own judgement.

[1]
[http://www.ncneurocenter.com/eeg/eeg_reference.html](http://www.ncneurocenter.com/eeg/eeg_reference.html)

[2]
[http://en.wikipedia.org/wiki/Quantitative_electroencephalogr...](http://en.wikipedia.org/wiki/Quantitative_electroencephalography)

~~~
vacri
There's a difference between "how about we approach it more appropriately" and
kyro's "we shouldn't use this at all until we have a near-complete
understanding".

~~~
kyro
I never advocated discontinuing the use of medications. In fact, I
acknowledged their efficacy. I'm all for treating the people that cannot
function otherwise -- they may have no other choice. I think for millions of
others, there are other choices that are not being adequately pursued or
encouraged.

------
md224
Fun Fact: Selective Serotonin Reuptake Inhibitors, the class of drugs used to
treat depression and anxiety disorders by increasing the availability of
serotonin, have a mirror opposite: Tianeptine
([http://en.wikipedia.org/wiki/Tianeptine](http://en.wikipedia.org/wiki/Tianeptine)),
which acts as a Selective Serotonin Reuptake Enhancer.

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.

~~~
xxpor
Both are effective on the same people? Otherwise, it kind of makes sense. If
depression is just an imbalance, it may be that there is either too much
serotonin or too little.

~~~
jes5199
unfortunately, we don't have good data on which drugs are effective on the
same people versus on different people. The clinical trials just aren't set up
that way, and there hasn't been a concerted effort to gather that information
from the general population.

------
dancric
The book, "Anatomy of an Epidemic", provides a really comprehensive look at
how we ended up in this situation. Some of the keys here:

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...](http://alumni.stanford.edu/get/page/magazine/article/?article_id=64350)

~~~
scythe
>A desire to bring a level of "science" to a part of our physiology we don't
understand.

 _Confer:_

[http://thelastpsychiatrist.com/2006/11/massacre_of_the_unico...](http://thelastpsychiatrist.com/2006/11/massacre_of_the_unicorns.html)

[http://thelastpsychiatrist.com/2010/01/the_massacre_of_the_u...](http://thelastpsychiatrist.com/2010/01/the_massacre_of_the_unicorns_i.html)

------
FrankenPC
Maybe humans are just...unhappy? By that I mean as a race, we are inherently
unstable (see: entire human history) and for a long time we kept it together
by forming very tight family and community bonds. We had central, realistic,
and tangible goals. We had an invisible friend (religion). As science has
systematically stripped all that away (for the better mind you...), nothing
has filled those needs. We don't need more facebook and texting, we need human
contact.

HAHAHA! Just kidding! Did you see the latest iPhone! It's got moar processors!

~~~
guard-of-terra
[http://blog.wilshipley.com/2005/05/on-being-
crazy.html](http://blog.wilshipley.com/2005/05/on-being-crazy.html) is a very
insightful read on that subject, from a successful but unstable person.

 _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._

~~~
kirubakaran
Disproof : Richard Feynman

~~~
gohrt
How many offspring did Feynman have?

~~~
kirubakaran
"Feynman would marry twice more and have two children with his third wife."
[http://www-history.mcs.st-and.ac.uk/Biographies/Feynman.html](http://www-
history.mcs.st-and.ac.uk/Biographies/Feynman.html)

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.

------
jorleif
The article has an interesting argument structure. First it undermines the
science behind psychiatric drugs by referring to their discovery as
serendipitous. Then it proceeds to point out that there is no good theoretical
understanding for how the drugs work, even if there is understanding in what
neurotransmitter levels are effective. Then the author proceeds to drop the
"not better than placebo" results.

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.

------
jotm
The discoveries of antidepressants and anxiolytics weren't accidental: testing
something and seeing what it does, then finding a purpose for it is not
accidental, it's basic science. It's how most chemicals were discovered.

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.

------
whalemaker
Obscure psychiatric drugs are also ridiculously expensive sometimes. A friend
of mine switched from a brand name anti-psychotic to a generic version. He
went from paying over $1200 a month to $22 for 30 pills, for something as
important as preventing his psychotic episodes.

~~~
eksith
That's just obscene! All that markup over just the label.

I understand that it takes R&D to develop new drugs, but the amount of profit
sought by drug companies is stomach churning.

~~~
jaredhansen
>amount of profit sought by drug companies is stomach churning

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).

~~~
HarryHirsch
It's the fact that pharmaceutical companies are involved in the sphere of
public health that makes people uneasy about excessive profits, whatever
"excessive" means.

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.

~~~
ninguem2
Statins are a lifestyle drug? Come on.

~~~
HarryHirsch
First-line treatment for high cholesterol is still dietary changes and
exercise.

------
dhubris
Medication is only one tool, and often needs to be used in combination with
other tools, but people are always looking for the quick fix. Dealing with
some of this shit can take hard work over time. Here is a small look at my
experiences dealing with depression, PTSD and medication:

[http://dhubris.livejournal.com/14447.html](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?

------
TheLegace
My ADHD medication Strattera costs $170 a month and since the generic version
only saves me $20 causes serious nausea and vomiting I don't have any choice.

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.

~~~
aweisberg
For the last 18 years or so I have been taking some form of low cost Ritalin
with a co-pay between 15-25 dollars.

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?

~~~
rsl7
the cayman islands.

------
danmaz74
This article has its own very naive bias: Thinking that every phenomenon must
have a "root cause" \- ie, a simple cause-effect explanation - and that if you
don't find the root cause, you can't control the phenomenon.

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.

~~~
tsotha
From a drug designer's perspective, though, this is a problem. If you don't
know why the current drugs work you're going to have a lot of trouble
improving them.

~~~
danmaz74
Yes, but to know "why" (I'd much rather say "how") current drugs work you
don't need to know "why" people get certain illnesses - that's my issue with
the article.

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.

~~~
tsotha
>Yes, but to know "why" (I'd much rather say "how") current drugs work you
don't need to know "why" people get certain illnesses - that's my issue with
the article.

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.

------
bdclimber14
I think it's relevant to point out the potent anti-depressant effects many
people experience with natural supplements such as sam-e and 5htp. It's
unfortunate that these drugs are rarely prescribed (in the U.S.). Few clinical
studies have been done on these and there is little economic motivation for
drug companies since these are un-patentable substances.

------
brownbat
Eh, maybe understanding of the brain is ripe for some kind of "scientific
revolution." If so, I really hope Ed Boyden and the Synthetic Neurobiology
Group are a part of it:

[http://www.ted.com/talks/ed_boyden.html](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.

------
tokenadult
"Gary Greenberg is a practicing psychotherapist"

What evidence does Gary Greenberg provide in his writings that would convince
a skeptical onlooker that what he does for his patients is helpful?

~~~
lutusp
> 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...](http://news.sciencemag.org/people-events/2012/11/final-report-
stapel-affair-points-bigger-problems-social-psychology)

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."

~~~
tokenadult
I think you are saying that we can't be sure that the author of the article
kindly submitted here really knows what he is talking about.

Diederik Stapel is a disgrace,

[http://retractionwatch.wordpress.com/2013/08/02/measure-
by-m...](http://retractionwatch.wordpress.com/2013/08/02/measure-by-measure-
diederik-stapel-count-rises-again-to-54/)

but he also hasn't had any influence on the clinical practice of psychiatry in
the United States, the main topic of the article.

~~~
lutusp
> I think you are saying that we can't be sure that the author of the article
> kindly submitted here really knows what he is talking about.

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...](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](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._

------
paul9290
I haven't read this entire article, but my experiences with a handful of anti-
depressants is that they all are a placebo. Though not for profits. Sell
people hope and promise of becoming "normal," and they buy it in the million.

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!

~~~
nwh
I'm sure your anecdotal experience with a handful of drugs is representative
of everybody else's experience.

(It's not)

------
unono
Hackers can make huge money in psychology/psychiatry (both prescientific
fields). Life logging and it's analysis - quantified self. Positive psychology
would be the better angle to play it, unregulated, big money in the self-help
culture. Mobile apps are the right medium for it. There was recent doc on it
'Monitor Me' by bbc horizon.

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'

~~~
sillysaurus2
I'm trying to understand what you're saying, but honestly I have no idea what
you just said. Would you clarify your meaning?

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.)

~~~
unono
OK. I try to see articles and find a positive spin where I can say "hackers
could ...". To some people it would be obvious, but to young or non-tech
people it might not be, so it could be helpful to them.

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.

~~~
totierne
I would pay folding money for this software+usage data - and I am just an
affected individual (bipolar for 20 years). I went through a phase of asking
for survey information (after they had published their paper article etc.)- no
one would give it up.

