
Can Psychiatry Turn Itself Around? - okket
http://blogs.scientificamerican.com/mind-guest-blog/can-psychiatry-turn-itself-around/
======
phren0logy
I'm a psychiatrist. It is always amazing to me that despite four years of
medical school, six years of residency and fellowships, and four board
certifications, the assumption is that I have no idea what I'm talking about
and have evil motives.

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

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

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

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

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

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

[https://en.m.wikipedia.org/wiki/Selective_serotonin_reuptake...](https://en.m.wikipedia.org/wiki/Selective_serotonin_reuptake_inhibitor)

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

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

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

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

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

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

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

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

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

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

~~~
phren0logy
I'm sorry this has been your experience, but please don't throw my entire
profession under the bus because of it.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

~~~
intopieces
It's here you might benefit from the book:

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

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

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

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

...

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

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

------
nwah1
We're all aware that most of the drugs that are common in the profession have
serious side effects.

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

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

Tryptophan:

[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3405680/#RSTB201...](http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3405680/#RSTB20120109C25)

Lithium:

[http://www.nytimes.com/2014/09/14/opinion/sunday/should-
we-a...](http://www.nytimes.com/2014/09/14/opinion/sunday/should-we-all-take-
a-bit-of-lithium.html)

Uridine:

[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3080753/](http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3080753/)

Magnesium:

[https://www.psychologytoday.com/blog/evolutionary-
psychiatry...](https://www.psychologytoday.com/blog/evolutionary-
psychiatry/201106/magnesium-and-the-brain-the-original-chill-pill)

NAC:

[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3044191/](http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3044191/)

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

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

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

~~~
nwah1
As the article mentions, the dosages of lithium that are naturally in water
tend to be well below the levels that we're familiar with in prescription
lithium. (Less than 1/1000th the amount)

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

------
1_2__3
Had a doctor prescribe two meds once, then a few weeks later asked me how one
of them was working. I was honestly confused by the question, since I have no
idea how one drug is working when I've only ever taken it in tandem with
something else. The very question indicates at best an unacceptable level of
indifference, at worst outright incompetence.

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

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

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

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

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

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

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

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

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

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

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

~~~
derefr
ADHD is overdiagnosed _and_ under diagnosed. (It's just _badly_ diagnosed,
really.)

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

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

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

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

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

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

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

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

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

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

------
pc2g4d
Psychiatry's trouble is that it tries to treat emotional problems using drugs.

That's also the entire point of psychiatry.

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

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

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

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

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

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

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

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

[https://theintercept.com/2016/03/25/in-las-vegas-
embattled-f...](https://theintercept.com/2016/03/25/in-las-vegas-embattled-
forensics-experts-respond-to-scandals-and-flawed-convictions/)

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

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

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

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

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

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

~~~
serge2k
I honestly have no idea what you are talking about here.

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

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

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

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

