- Doctors like names because then they can provide a diagnosis and recommend action based on the diagnosis
- Patients and their loved ones (often) like names because it is easier to think/say "I have schizophrenia" than it is to describe their factor scores on a myriad of benchmarks
- Drug companies like names because they can develop drugs for specific disorders rather than for a combinatorially large number of factors
- Regulators like names because they can approve treatments and standards of care for a finite number of situations
- Insurance companies like names because it allows them to approve or deny claims in a more straightforward way.
While names are often times arbitrary, they make many things more convenient. I am not saying that I personally agree or disagree that there should or should not be names, only that this is a complex issue with many complexities besides the underlying science.
Also, I see nobody has mentioned RDoC yet, which is the taxonomy researchers are starting to use to classify mental disorders: https://www.nimh.nih.gov/research-priorities/rdoc/constructs...
A substantial portion of the things we refer to as "mental illness" are the after-effects of trauma. When you break your leg and you can't walk for 6 months afterwards, people don't say you have a "leg illness". It's not some unspecified thing which caused your leg to stop performing like most people's legs. It's a fracture. If set properly and given time to heal, it will resume normal functioning. If it's never set, or if it gets reinjured, it may lead to a permanent disability.
Minds can be broken as well. Any one who has ever experienced an abusive relationship knows this. Survivors of child abuse know this. A "mental fracture" isn't primarily physical, like a fracture of the leg, but it has a similar effect in terms of impairing the organ to perform its role correctly.
But mental injuries can be "set" and healed, just like physical ones. Perhaps not 100%, perhaps there will always be scar tissue or some version of impaired mobility where the injury occurred. But injuries heal with time, given proper care.
I am aware that this concept is fairly at odds with the western conception of mental health with its myriad disorders, all of which are unexplained and presumably lifelong diseases. I attribute this entire weird world of DSM pseudoscience with its gargantuan and ever-growing list of labels to the massive social pressure against dealing with the actual problem of trauma and abuse.
Correctly diagnosing someone with a "mental injury resulting from trauma/abuse" would lead to some extremely difficult conversations, which most people (even the ones experiencing the abuse) would prefer not to have.
You find the original source, some event or series of events that caused the psyche to fracture. By fracture I mean caused the mind to operate according to some models that were necessary to survive at the time of crisis, but are no longer adaptive in the normal/real/adult world. You then update your mental model to one that is more aligned with reality.
In other words: go to the source of the pain, unlearn whatever lesson you learned at the time to deal with the situation, learn a different/healthier way of looking at it, and then practice a lot until the new mental model is firmly in place.
This is hard. But it gets easier with practice. And it's much easier than trying to set an injury by taking lots of pain-killers.
By that logic, we shouldn't name species either.
I do wonder if we're absolutely fucking up the minds of a generation of people by giving more and more people the made up labels. They come hand in hand with stigma and insecurity. We've been loosening diagnostic criteria continually on the dubious grounds that we "better understand" mental illness in the past. When it gets down to brass tacks we just decided as society labelling more people as "different" and treating them differently was for the best. Beyond the concern I have for individuals more and more people are qualifying for disability assistance every year and its unsustainable financially.
I do wish we had a model of mental health that was more focused on addressing more granular individual strengths/weaknesses and one less prone to just saying a broad swathe of people who are nothing alike are part of the same "spectrum".
The article is sort of strange in that it brings up these issues and then fails to discuss the huge range of research in this area. The p-factor stuff is sort of hot lately but is just one subtopic in a vast area, somewhat controversial, and more of theoretical interest than clinical utility.
Part of the problem is that there are different purposes for classification systems. I think you're right in that categorical diagnoses have all the appeals you mention at least among some subgroups, but those are a little detached from (1) how many clinicians actually think about a lot of problems, and (2) how many researchers think about these things. Putting aside the "syndrome"-favoring clinicians, a lot of clinicians focus more on behavioral patterns, which tend to be very specific, more targetable, and far removed from broad categorical labels. Many researchers are moving away from these categorical labels also, for many reasons, but mostly generally because the patterns you see in behavior don't map onto the categories in the DSM in reality. Think blood pressure or height as analogies for depression or disorganized thinking, rather than Huntington's disease or malaria.
RDoC is important to mention but it's ending up to be about as controversial as the DSM for various reasons. First, it suffers from the same "names by committee fiat" as the DSM, which is problematic when you are dealing with something like neurobehavioral pathology, which can be examined at many levels and from many directions, which is fuzzy and complex, and about which we know very little. Second, despite its noble intents, was kind of developed by neuroscientists with little connection to actual clinical human behavior. I don't mean any offense to them, but when you get together a bunch of researchers, a substantial number of whom study rodent neurobiology, you're going to start losing touch with what clinicians are actually wrestling with in clinical settings. Look for psychosis or subdimensions of psychosis, for example, and it's missing from RDoC. I like to think of RDoC as "revenge of the neuroscientists," people who got tired of trying to connect their research to human public health, and decided to just redefine problems so it's closer to their own research. A similar initiative is HiTOP, which is more phenotypically focused, and uses statistical/quantitative models for classification rather than committee decisions (I'm not saying HiTOP is better, it just is a similar but different approach from RDoC).
I think the issue is not whether or not mental disorders should have names, it's whether or not there are mental disorders per se, or how to best describe mental-neural-behavioral patterns. You need to be able to quantify to study something scientifically, and quantifying implies labeling; the question is how.
Which then mysteriously only seem to work on a small fraction of people diagnosed with that disorder, no?
He tries to determine what has happened historically but not why.
Why was this guy using drugs starting at age ten? What led up to that? Shouldn't it be classified as a parenting failure, not a "disorder" on his part?
What was the history with the father? Perhaps assaulting his father wasn't simply due to insanity. Some parents are really awful to their kids and it's a huge problem for the kid. That doesn't necessarily stop being true just because the kid became a legal adult.
Labels determine what mental models we use when trying to intercede in a problem. Different labels get very different reactions and treatment modes.
We need to up our game in myriad ways, but labels are a critical tool for this problem space. I hate labels, but they are a useful communication tool.
The biggest advance in the history of psychotherapy was to stop asking why and start asking what and how.
The psychoanalysts broadly believed that mental disorders could be treated by revealing and resolving unconscious conflicts and forgotten childhood memories. That's a very slow process, and eventually randomised controlled trials would demonstrate that it wasn't particularly effective.
Rational emotive and cognitive behavioural therapists essentially argued I don't care why you're nuts, I just want to teach you how to be less nuts. If you have habitually fearful or negative thoughts, you can learn to disregard those thoughts as unhelpful and consciously replace them with more useful thoughts. Knowing who to blame for your cognitive bugs doesn't really help you fix them. Aaron T. Beck had the good sense to subject his psychotherapeutic approach to randomised controlled trials, demonstrating that a relatively short course of cognitive behavioural therapy was at least as effective as several years of psychoanalysis.
Psychiatry, clinical psychology and psychotherapy undoubtedly has a lot of shortcomings and there are a lot of patients we don't yet know how to treat effectively. A far bigger problem however is lack of access - the vast majority of people who could benefit from psychiatric medicine simply don't get treated. In the developed world, it's usually fairly easy to get prescribed medication, but there are often long waits or financial barriers to access psychotherapy. In the developing world, most people can't even access SSRIs despite the cost being around $1 a month. Stigma and a lack of awareness are still a substantial barrier to accessing care.
We need better treatments, but the priority right now must be simply to get more people to try the treatments we do have. Trying a treatment with a 40% success rate is obviously better than doing nothing, but nothing is still the default and it's causing immense amounts of needless suffering.
> Rational emotive and cognitive behavioural therapists essentially argued I don't care why you're nuts, I just want to teach you how to be less nuts.
This is part of why schema therapy is getting so much attention right now: it takes CBT but combines why, what and how into a cohesive whole. The success rates seems to be even better than CBT, a lot better in some cases.
Tangent: I have a lot of skepticism about that one being a proper disorder on its own, in the same sense that I wouldn't consider "fever" an illness in and of its own, but a symptom of other illnesses.
I'm not sure that's a fair criticism. They're certainly not doing a perfect job but the number of people who have a higher quality of life than a century ago is a real success.
There are people who are living fulfilling lives who would have been housed in mental institutions or who would have long since killed themselves, given the state of mental health care 50 or 60 years ago.
The Mental Health field collectively doesn't know what the fuck it's doing. More time and money is spent on mental health every year and things are actually getting worse. People are not as skeptical of the mental health field as they should be. Either our current efforts are counterproductive or they're failing to address a bigger picture concern which outweighs any positives of increased mental health treatment.
I think he ever-so-briefly touched on a different angle of that problem: "The psychoanalysts don’t like it because it ignores the “unique milieu of individuality.” The more biologically-oriented clinicians don’t like it because it ignores biology. The DSM lacks “validity,” they say. A diagnosis based on a combination of symptoms is, they might argue, like a constellation of stars — sure, you could reliably identify the Big Dipper, but no one would argue that the Big Dipper is a valid interstellar system. It’s just a name."
The problem is that the label matches no defined model; which is why I think that everyone dislikes it.
>I hate labels, but they are a useful communication tool.
Agreed but without the matching underlying models, they're just added toil; especially, if they're only "valid" in niche use-cases (such as clinical settings).
For example, we have a general idea of what Schizophrenia is but when it comes to the classification, diagnosis, and/or treatment, that's when we lose context. Schizophrenia isn't - implicitly - the same classification, diagnosis, and treatments across the board for every patient. So, effectively, you're coupling a large group of individuals under a very generic label, which has no effective model applied to it.
In many cases, these were Twice Exceptional kids who had started doing really strange things around the time they were toddlers or preschoolers. The strong negative reactions of adults around them then compounded the problem and made it an intractable issue.
I was often able to help parents back off from this dynamic so the family and child could get unstuck. I wrote an anecdote about that sort of process in January. It can be read here: https://raisingfutureadults.blogspot.com/2019/01/the-hand-li...
I'm a former military wife and homeschooling parent. People are quick to be dismissive and tell me I don't know anything about x, y or z, etc.
But my experiences suggest to me that a lot of mental health issues are rooted in relatively prosaic cases of "kids do weird and stupid things because they are kids, some kids do very weird and stupid things for various reasons, and parents often don't have effective tools for handling the situation, thereby compounding the problem." My experiences also suggest that a lot of this is fixable, without drugs or therapy, if you can help the family disengage from long-standing patterns of interaction and help the child in question understand where their dysfunctional behaviors came from in a non-blaming manner and give them some better answers and/or just breathing room to change on their own without interference.
I spent about two weeks writing the above piece and it's based on many years of education and experience. It got more than 60k page views and people are republishing it, some with my permission and giving me credit.
I would like to do more of that kind of writing, but it made me zero money. I am routinely told my writing has zero value and I should go get a real job. I'm not good at the self promotion thing etc.
I think I know some useful things that could help parents avoid becoming mired in the kinds of problems this man in the article has. But I have no audience and people who know what I used to do mostly are in my past or simply unwilling to vouch for me, including some prominent people on HN who knew of my work in that area at the time, to some degree or another.
I've largely made my peace with the fact that I can't afford to write for free and lots of people on the internet expect excellent content for free. They don't want ads and they don't want to pay anything for it either. No, they don't want to be a Patreon supporter.
So I content myself as best I can with leaving comments on the internet and generally being percieved as a blowhard and arm chair politician type who has an opinion on everything and zero credibility.
Que sera, sera.
Helping the family change how they interact with their children is therapy!
Someone would join the list and complain about the intractable, crazy making behavior of their impossible child. I would write a reply and say something like "That's a common issue with gifted kids. It's due to boredom and is easily solved by keeping them adequately occupied." They would go "Oh. My. God. That makes so much sense! Just before the last incident, he did actually say out loud 'I'm bored.'" and a long-standing, intractable pattern of problem behavior that had stubbornly resisted all prior intervention would largely disappear overnight once the parent made sure to keep their kid adequately occupied.
Or a parent of a particularly hard case would exchange a few emails with me for a week or two and then report back to me months later that all these terrible, intractable issues had magically changed and it had involved almost zero effort on the part of the parent who had spent years sinking enormous time, money and effort into resolving these problems, all to no avail until they spent a little time talking to me.
If it was therapy, it was like an *easy button" version of it, very unlike the roughly 3.5 years of intensive therapy I pursued in my youth to get my personal issues to simmer down to a dull roar before really resolving things around the age of forty when I got divorced and yadda.
"So you say your father broke your arm.... This isn't a bone fracture! It's bad parenting, now go home, no medical attention for you".
You are looking to see if some mental/physiological process is in disorder, so it's not about whether you caused it or your father caused it. The question to ask is does the patient fit in box X, because we have scientific studies saying that a large number of patients in box X when given treatment Y move to box Z, which is classified as being better than X.
I'm not saying the mental health field doesn't take into account external factors. It does especially psychology. I still think psychology overestimates how sick people are and underestimates how sick society is.
So your father broke your arm at age ten. And broke your arm annually every year thereafter because he's an abusive asshat. And doctors decided to label you with some bizarre form of osteoporosis that must be the underlying cause of your frequent and mysterious fractures. And when you finally smack dad in the head with a hammer as an adult in self defense, it goes in your file that you are not only crazy but also dangerous and violent, even though you've never been violent with anyone else ever.
Better solution: You need a restraining order on your father who should not see you without court supervision while he finishes up his jail sentence for assault and battery and child abuse. He goes to therapy. You get put in a safe environment with adults who don't break your arm annually while claiming it's you that's defective.
However, there are stigmas attached to certain diagnoses and not their differentials so some people prefer less negative labels.
In my experience with world class psychiatrists your views are a little outdated, generally the more academic practitioners are much more like Dr Barron.
It matters very, very much whether we label someone as "a victim of a crime suffering PTSD" or "crazy" by some fancier term for crazy. If the diagnostic tools he is using make no effort to make such distinctions, they won't make that distinction for purposes of clinical treatment either.
There's a difference in calling someone "crazy" vs saying they have a mental disorder. The meaning of "crazy" has changed over the years due to the abusive context it's been used in more and more. A lot of words got redefined over the years, so this isn't new, but the idea of dropping labels or trying to eliminate well established scientific and testable classifications is new.
To future generations, I hope you don't create a culture in which you're continuously stressed out about how others will label you publicly. When I was younger, a kid that was bullied in school could escape it by coming home. These days, you have no escape because of social media. I hope you learn to adjust and navigate these new times. Even older folks struggle with how things are currently.
For instance if you say someone your arm is 'broken', they understand something is deeply damaged (not just fissured). They might not know the specifics on how it broke, where exactly, how you are healing it or how it impacts you, but they know the basic criticality of it.
If you say you have "depression", they don't know if you'll take your week off to recover or actually need extensive professional follow up with a long term medication. There is no common sense of how bad it is 'broken'.
From there people all have their anecdotes, visions of how they solved "depression" and come with a very personal idea of what your issue is that most of the time will have nothing to do with your actual diagnosed issue.
In that sense the word doesn't work that much as a conveyor of information, they'll just know you have "something". I see the reasoning behind getting rid of a word in medical context if it doesn't bring any viable information with it.
I think that's primarily because severe and enduring mental illness is still strongly stigmatised.
The public conversation about mental health is dominated by what I call "the narrative". We see a succession of successful and healthy people talking about how they had depression or anxiety, they plucked up the courage to ask for help but now they're OK. Our conversations about mental health are dominated by brief episodes of illness in the past tense.
That's not a terrible narrative and I'm sure it has encouraged a lot of people to seek treatment, but it's a very selective image of mental illness. We don't hear from people in the throes of severe illness. We don't hear from people who have struggled for years or decades and haven't found an effective treatment. We don't hear from people whose lives have been blighted by unmanaged schizophrenia or bipolar disorder. We don't hear from people who know they need treatment, but can't access it for financial reasons.
"There are effective treatments and you don't have to suffer in silence" is an important message, but so is "some people can't access treatment, some people don't benefit from treatment, so we need to work as a society to improve the quality and availability of treatment and help people with unresolved mental illness to live fulfilling lives".
When it comes to mental disorders, it can be very difficult to accurately classify the severity. It reminds me of how doctors prescribe blood pressure medication; it's guess work. e.g, They will prescribe what they think will work and have you come back later to see if it's working properly. In my mom's case, the first prescription made things worse.
Depression can be rooted in chemical imbalances, diet, sudden loss of a job or family member, etc,. It's not like taking a walk will solve everyone's depression. In most cases, it's much more complex than that. That's why there's psychologist and psychiatrist. In some cases cognitive therapy works, some a good diet + workout routine works, and other cases medication is required. There are different levels of depression and they are properly classified by professionals. The word "depression" is like a doctor telling you that you're arm/wrist is broken. e.g, Bipolar Disorder is a type of depression that's treated with medication.
It's a terribly complex thing we're talking about and telling professionals how to define their own vernacular is pretty foolish. It would be like my mom telling me that engineers should drop the phrase "eventually consistent" and just say "consistent". :)
Most DSM disorder categories don't perform well on measures of inter-rater reliability. (https://en.wikipedia.org/wiki/Inter-rater_reliability). One implication of this is that the categories can't be assumed to be well-defined scientific entities. Now, the DSM could be a shadow of some more complete, correct taxonomy of mental disfunction—certainly it's based on observation of genuine distress, so it's not completely arbitrary—but by scientific or medical standards, it's very shaky.
Here's an article about the situation in relation to the DSM:
It's not uncommon for people who haven't looked seriously at the mental health field to assume that the so-called medical model of mental illness meets the same high standards of intellectual rigour as other areas of medicine, or other endeavours such as engineering. I put it to you that you are in exactly that position: the very basic point you are making ("This is as complex as engineering! Leave it to the experts!) indicates that you are unaware of the unique flakiness of psychiatry. This is contested territory, and many professionals are invested in a certain dubious framing of the situation.
The map (the name) should serve as the best possible mental model of the territory (the actual, descriptive physiological condition) - not as the thing-in-itself.
As bad as the state of diagnosis is (some say >50% for certain conditions) there is no way around a diagnosis for treatment as one needs to make decisions and these need to be based in whatever tenuous grasp one has on reality. At this point imho. we can only try to make sure all sources of bias, tendency to defend previous decisions, treatment capacity and financial considerations (diagnosis is key to insurance payments) are as far isolated from decision making as possible. There is lots to be done. SCID is only the symptom.
“Diabetes mellitus” isn’t any kind of a model. It's a symptom description dressed up in Latin. We've since attached a useful model to it, but the name long predates the model and has little to do with it.
So it become six of one and a half dozen of another. For the benefit of the medical community yes we should name them or slot them into broad categories. For the public its best to probably just use broad categories
That said, the point I really want to reach is that it’s my opinion—and there is a body of academic work within and about many clinical fields on this matter— that the longevity of these diagnostic approaches and their bases, the categorization of disorders, how clinical fields themself are taught, how priorities are set in the clinic is owed and hugely influenced by the necessity (and the hegemony) of US insurance coding, especially as it relates to prescription drugs. I’m not insisting that prescriptions, or necessarily any of this is inherently negative in it’s effects, just that insurance coding as it is, health insurance in the US as it is, has (sometimes quite extreme) far reaching influence over essentially every aspect of clinical practice, research practices. At least that’s my opinion/conclusion/interest in this article.
- must have tics that begin before he or she is 18 years of age.
In a medical standpoint that makes it different, but in any practical sense the name conveys all of the information people need, it is perhaps unusual in that it is also a condition that occasionally requires rapid explanation.
Are you sure about that? Tics don't always manifest in obvious ways. You may well have had them in a very mild form but never noticed.
Could it be a cultural thing? While I grow older I find it more natural to think of things as continuous or to assign uncertainty to "facts", but perhaps our educational system does not give much attention to this. Perhaps it's too much about facts and names and boundaries.
In this articles' case though, of course mental disorders are a continuum but the drugs and methods for treatment we have are not. So perhaps in this case a label is nice. One should always keep the continuous nature in the back of one's mind though.
The broader point I'm getting at is, first you need to learn about the artificial distinctions so you can "from" the subject. Then, once you know all the rules by heart, you can feel free to break them.
Maybe a better analogy would be to the informally defined neighbourhoods which exist in many cities. Everyone knows there's a Little Italy and a China Town, and could point out the main street of each. But whether or not an apartment three blocks away is or isn't in that neighbourhood gets pretty fuzzy, and depends a lot on what the realtor thinks you are looking for.
If A is a male, B is a female, C is a male, your operator definition is even troublesome within a species.
What kind of mathematical object comes closer to this abstraction of a species? Maybe it's not about names and boundaries, but about getting to understand things for which you need abstractions.
I always appreciate when people do not fuss about definitions and easily change them but reason consistently after indicating their interpretation of those concepts.
Yay! You've overcome splitting! Now if the profession could achieve what they want from patients...
Back in highschool we had a massively depressed friend. They tried it all with her: cognitive behavioral therapy, drugs (ALL OF THEM), weed, religion. Tough love. Exercise. Diet. Nothing cured her and her depression killed her via suicide. What's the psych tell me after? Sometimes there's nothing we can do? That sucks. Human genome, done. Prevent HIV from killing someone. Can't do shit about depression sometimes.
And if you get depression - do you take the ssris? Fuck knows? http://www.healthtalk.org/peoples-experiences/mental-health/... and the "next page." Sometimes they make you numb to the world or feel like you're being controlled. Sometimes they make you have suicidal thoughts. Sometimes they take a weight off your shoulders. Sometimes they make you feel like you actually have a chance. None of my psychs were able to describe any of this. I had to research it on my own.
And Lord forbid you've got multiple. Is it ADHD still? Newest psych has the idea that it's all ADD now - so, my memories of wildcat behavior that I'd be ashamed of in seconds as a kid, what was that? When shit bubbles up out of my mouth without me thinking, is that not the H anymore but just something else? And why did nobody tell me in 2 decades that a common symptom of ADD is shit memory? I had to find out on Reddit. Is it actually? Who knows!
Does Adderall help? Well, I suppose! Hard to say. Technically, I could work without it. I am more productive with. But, also more robotic. And, it's nearly impossible to track the subtle personality changes that come with medicating via Adderall, no matter how hard I journal. Ask the psychs and they shrug and say "keep a journal." Ask what dosage and they say "higher until the side effects are unbearable, then one dosage down," instead of "lower until the medicine is ineffective, then one dose up." And as for those personality changes - perhaps that's a "better" me anyway? It's certainly a smarter one.
Don't get me started on what fresh hell you find yourself in if the State discovers someone is suicidal and locks them in a psych ward. Came damn close to ruining my life by performing a full on jail break to get my friend out of that psuedo science nightmare.
I welcome all thoughts on my rambles and I apologize if no helpful meaning was able to be extracted, on this subject I can think of no other way to get my thoughts on paper.
The main takeaway from the Human Genome Project was that we understand less about DNA now than we thought we did in 1999.
I'd argue that chemistry really began with Lavoisier in the late 1700s. Physics? Late 1600s with Galileo and Newton. What about psychiatry? I'd argue that it really got going in the latter half of the 20th century. Freud and lobotomies? They were the equivalent of alchemy. Other fields have been around in a recognizably modern fashion for hundreds of years. The same cannot be said of psychiatry and psychology.
And that's not surprising. The brain and mind are incredibly difficult to study directly. Until the advent of EEC, fMRI, and other modern tools, the only real way to do it was by studying behavior. Similarly, the brain is very complex. We didn't have, what could be considered, a modern picture of the atom until the early 1900s and that was after several major discoveries spread over a few decades. It's not surprising that we're still struggling with the brain.
>Back in highschool we had a massively depressed friend. They tried it all with her: cognitive behavioral therapy, drugs (ALL OF THEM), weed, religion. Tough love. Exercise. Diet. Nothing cured her and her depression killed her via suicide. What's the psych tell me after? Sometimes there's nothing we can do? That sucks. Human genome, done. Prevent HIV from killing someone. Can't do shit about depression sometimes.
That's still the case for a lot of things. You have ALS? On average, you'll be dead in two to four years. 90% of people die within 10 years. Treatment is mainly supportive. Likewise, it's the 1800s and you contract a bacterial disease? Can't do anything about that, antibiotics won't be invented for decades. Drain the pus and hope that you survive.
On ADHD, it turns out that Concerta and Adderall are indistinguishable to me. I take a low dosage and the side effects are basically non-existent and it also gets rid of my anxiety and depression. But it also happens that exercise reduces the intensity of all my symptoms. I only found this out when I stopped going to the gym for two weeks and noticed that my medication doesn't seem to be as effective.
It's quite possible that, if I hadn't been in the habit of exercising regularly, I would've required a higher dosage that would give me severe side effects. It's also possible that I would be fine. How is my psychiatrist supposed to know that? Maybe exercise doesn't work for some people, maybe diet is critical, maybe it's getting enough sunlight. The entire web of interactions is extremely complex and we don't currently have the ability to examine it at a fine level.
Speaking of complex interactions, ADHD is predominantly genetic and there are a number of genes that can contribute to it. For example, a variant of the gene that codes the protein Latrophilin 3 is estimated to be responsible for roughly 10% of ADHD cases. People with this variant are also very responsive to stimulant medication. Given the way that I respond to medication, it wouldn't be surprising if that's responsible for my ADHD.
But other people might have multiple gene variants, each contributing to a portion of the severity of their ADHD. Adequately treating them might require a very specific combination of drugs. The current process is trial and error, but it's possible that you'll never hit that magic combination. Likewise, maybe there is no magic combination in existing drugs or maybe the ideal dose is 6mg, but it only comes in 5mg and 10mg doses.
The medication situation is getting better. There are services that will run a genetic analysis to determine which medications might be most effective. But it's still in its infancy and that's only a portion of the picture.
The brain is complex and our current tools for examining and treating it are still blunt. Don't get me wrong, there are definitely systemic issues in those fields that need to be corrected. But a lot of criticisms seem to boil down to the equivalent of "It's 1819, why haven't chemists invented acrylic to replace the glass in my glasses?"
"I need help. My life is falling apart. I'm struggling with work and school. I might have a learning disability."
"You sound depressed. Here's a prescription for some obscure variant of an SSRI not covered by your insurance."
"These meds you put me on make me feel sick."
"Let's increase your dose."
"I want to hurt other people. I want to die."
"It takes 4-6 weeks for it to take full effect."
"This just isn't working."
"Let's add another variable to the equation. Here's a second prescription. Take both and see what happens."
The experiment must continue. It always ends the same way.
I know psychiatry helps some people (especially where sedatives are involved), but for the rest of us who slip through the cracks it's just the new Nazi science.
This also cannot be answered with isolated consideration such as the effectiveness of drug 'x' since there are externalities involved. What happens to these individuals in the longrun? The treatment of ADHD with amphetamines is a great one for this question. For those who showed no response to the treatment, are their outcomes better or worse than if they had never pursued treatment? What is the false positive rate and what is the affect of medication on these individuals?
The answer to this question should be obvious, but I'm not so sure it is anymore.
"The trigger of the opioid crisis was a misrepresentation of a 1980 letter published in the New England Journal of Medicine, reporting on 11,000 hospitalized patients receiving opioids. It concluded that “despite widespread use of narcotic drugs in hospitals… addiction is rare in medical patients with no history of addiction.” This became a landmark study, cited more than 600 times, particularly after Purdue Pharma introduced OxyContin (extended-release oxycodone) in 1995.
Large opioids manufacturers began funding nonprofit groups such as the American Pain Society; and pain experts advocated for pain to become an important “fifth vital sign” to be queried in every doctor’s visit when checking blood pressure, heart rate, respiration and temperature.
Caught in the trend, the Federation of American Medical Boards encouraged punishing physicians for under-treating pain. This policy was drafted by individuals with ties to opioids manufacturers. Some were members of industry speakers’ bureaus, and later became company executives.
Purdue funded more than 20,000 educational programs between 1996 and 2002 to influence physician prescription habits nationwide, and developed a misleading advertising campaign that claimed that the risk of addiction from prescription opioids was “much less than 1%.” OxyContin sales grew from $48 million in 1996, to over $1.5 billion in 2002. With increased sales came increased abuse and addiction. By 2004, OxyContin was the leading drug of abuse in the United States.
In 2007, Purdue (and three executives) pleaded guilty to misrepresenting the risks of OxyContin addiction and paid $634 million in penalties, a fraction of the $35 billion in sales in two decades."
It's pretty sick stuff, but extremely clear evidence that these comes have come to see profit as the sole point of their existence. And these companies have extensive reach. And opioids are obviously not the only example here. This is a typical pattern, even if a rather extreme case. For instance the nonprofit industry tool used to push medicating and diagnosing of ADD is CHADD - Children and Adults with ADD.
 - https://www.houstonchronicle.com/opinion/outlook/article/Opi...
I think the branch itself is too immature to have as much clout as it does, but we'd make a lot of progress if they'd start listening to their patients more than they listen to their drug reps.
I don't know what they're teaching at psych school but it should include a single class on "researching all the shit your ADHD and depression patients, who will be your most common patients, have to look up on their own."
So, knowledge of all the treatments to depression, from ssris (and what they do to you) through diet and exercise, meditation, mindfulness, etc. Basically Try Harder.
Maybe I was just unlucky?
Once you're in the "this isn't working" phase of your story, shit is pretty dire. Hard to blame the caregiver for trying something else.
Bad treatments often exacerbate or inflict the symptoms they're supposed to correct.
And of course, I'm not literally saying this SCID is the attributes to the DSM "PCA," or any other subspace method.
I don't work with subspace methods often, so if anyone wants to fill me in on what is done in the medical world (or other high stakes domains) in practice, much appreciated.
In cases of segmenting customers and then targeting each one differently, I have found that subspace methods work well for raising typical startup metrics. But the interpretability was not cut and dry in my experience, something that obviously is needed when you work with individuals like Doctors, not populations like many companies.
My guess is that the DSM segments patients to different treatments though. If this is the case then it does't really matter what the name of the constellation is as long as after they send the patient there, everything is hunky dory.
What's interesting is that the people who developed the SCID (and the DSM and its predecessor, the RDC) actually developed a very similar tool in the 60s, but instead of it producing binary diagnoses, it produced scale scores more like test scores. It actually had better statistical properties and provided fairly detailed information. It's always been a mystery why they moved away from that, except that the DSM as a whole moved away from that.
You casually drank a psychoactive drug. Is "normal" just another word for common?
If your culture demanded that you keep your dead refrigerated, and everyone around you did exactly that, would that behavior be promoted to normality?
It seems that people are just running out of shit to write about at this point.
And from Scientific American! I trusted you as a kid!
The author ends by musing about mental diseases being described by coordinates in several dimensions. Sure, perhaps connected regions of that space can be given their own names, but in general, the author believes that our vocabulary lacks the granularity to identify the fingerprint of individual diseases.
I know a lot of hands have already been wrung over the ineffectiveness of natural language in describing the phenomena of the inner world, but in a clinical setting this takes on a new meaning, and the essay is, in my opinion, poignant.