Psychiatry under fire from the White House

[jbomba]

Wondering how concerned people are about the language in their Make Children Healthy Again Assessment.

"Assess the prevalence of and threat posed by the prescription of SSRI, antipsychotics, mood stabilizers, stimulants, and weight loss drugs."

Perhaps I'm castrophizing, but I'm growing concerned about their ability to severely limit or outright restrict our ability to use these medications... effectively eliminating our role within the healthcare system. If they steamroll this through, we could be looking at the end of our profession essentially.

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[Stagg737]

Perhaps I'm castrophizing, but I'm growing concerned about their ability to severely limit or outright restrict our ability to use these medications... effectively eliminating our role within the healthcare system. If they steamroll this through, we could be looking at the end of our profession essentially.

At this point I'd say you're catastrophizing. I haven't read the whole thing, but this appears to just be a call for initial data gathering and this section is specifically looking at use of these medications in children. I do think the phrasing of "threat posed" is definitely concerning, but saying this is going to be the end of psychiatry is a pretty big leap.

That said, who knows how biased this will be in terms of what is actually collected and presented. If they look at actual evidence and listen to actual experts, then this will be much ado about nothing other than maybe some new guidelines. If their "experts" consist of cherry-picked, anti-med people like Moncrieff and Horowitz or complete quacks like Mercola and MAHA takes the reigns and the whole country goes into full crunchy mode...there could be problems. Unless you believe we're truly approaching the end of democracy in the U.S. though, I don't think this is something to obsess over. If that is the case though we will have far greater problems to worry about than if our profession continues...

 

[Sushirolls]

Not concerned.

 

[Bartelby]

I agree that worrying psychiatry is over is catastrophizing.

The main concern I would have is misinformation. We have a HHS secretary with a long anti-vax history who has pushed the idea that SSRIs are "addictive" and that they contribute to school shootings. If this all gets formalized in government guidance documents I think it could scare off a not insignificant number of people who could have otherwise benefitted. It might also help open us up to more lawsuits related to a range of patient behaviors. If government guidance clearly spells out that (for example) SSRIs cause violent and homicidal behavior, it gets a lot easier for a Plaintiff's attorney to say we (psychiatrists) are a direct proximate cause of a wide range of violent behaviors.

But who knows? Maybe the system will check RFK's impulses and life will be business as usual.

 

[Crayola227]

I agree that worrying psychiatry is over is catastrophizing.

The main concern I would have is misinformation. We have a HHS secretary with a long anti-vax history who has pushed the idea that SSRIs are "addictive" and that they contribute to school shootings. If this all gets formalized in government guidance documents I think it could scare off a not insignificant number of people who could have otherwise benefitted. It might also help open us up to more lawsuits related to a range of patient behaviors. If government guidance clearly spells out that (for example) SSRIs cause violent and homicidal behavior, it gets a lot easier for a Plaintiff's attorney to say we (psychiatrists) are a direct proximate cause of a wide range of violent behaviors.

But who knows? Maybe the system will check RFK's impulses and life will be business as usual.

It's not just him, though. His leadership and popularity on these issues is a direct result of a broader and more troublesome shift.

He's not the disease, he's the symptom.

As per usual, we just need to wait for the pendulum to swing. No one learns from history no matter what we do so we are doomed to repeat it over and over.

 

[Crayola227]

I should say, those of us who did learn history, are doomed to watch other people repeat it while thinking they're being clever and original. Sigh.

 

[jbomba]

Not concerned.

How come?

 

[Sushirolls]

1) It's catastrophizing.
..................
...................
97) Even if most SSRIs are banned? Stopped? There is still ECT, and it simply works better with greater remission rates...
98) Some meds have non-psychiatric indications and would still be around... TCAs for sleep, or migraines for instance. Neuroleptics with epilepsy.
99) TMS, Ketamine, VNS
100) Therapy / PHP / IOP
101) [bonus point/sarcasm follows -->] Cannabis cures everything, at least numerous patients have told me, so we all just need to open up cannabis farms and dispensaries.

 

[Sushirolls]

Look, the whole MAHA thing is a good thing to spring from.
What is one of the biggest killers in America? Cancers and Cardiovascular disease. [*Not Psychiatry]
And underlying a lot of that is Obesity...
We now also have a whole new hot and exciting specialty called Obesity Medicine. It's like the C/L of of IM or Endo... really... we needed a specialty for this? I digress...
The increasing obesity epidemic is impacting fertility. It impacts military recruitment. Sense of self, wellbeing, myriad of health conditions, all things, y'all know well.

Obesity is a problem. And wellness in America and westernized countries is an issue. Please raise your hand if you work at a Big Box Shop and they have a wellness program with the employer based insurance?

Elements of the structure of the America food system has substantial room to improve. Things that can and should be healthy, potentially aren't. Chicken? It's a cornish cross, a genetic freak chicken that takes 8 weeks to grow to market butcher size. If you let it grow 9, 10, 11 weeks it dies of a heart attack. This rubber is what we are used to eating. Heritage breed chickens take 16 weeks to get to butcher size (and OMG they taste so good, and for those who grew in random corners of the world... those backyard chickens are the ones that have the flavor you know and miss). Most every crop, every animal, every product when you dig it into it... you will like find something to be like WTF. To get quality food, you are practically forced to live on a farm / homestead.

Simply put, the MAHA concept has a core good idea, and lots of low lying fruit to attack. RFK ain't perfect... but he's what we get. Release the Kennedy Kraken.

 

[jbomba]

Look, the whole MAHA thing is a good thing to spring from.
What is one of the biggest killers in America? Cancers and Cardiovascular disease. [*Not Psychiatry]
And underlying a lot of that is Obesity...
We now also have a whole new hot and exciting specialty called Obesity Medicine. It's like the C/L of of IM or Endo... really... we needed a specialty for this? I digress...
The increasing obesity epidemic is impacting fertility. It impacts military recruitment. Sense of self, wellbeing, myriad of health conditions, all things, y'all know well.

Obesity is a problem. And wellness in America and westernized countries is an issue. Please raise your hand if you work at a Big Box Shop and they have a wellness program with the employer based insurance?

Elements of the structure of the America food system has substantial room to improve. Things that can and should be healthy, potentially aren't. Chicken? It's a cornish cross, a genetic freak chicken that takes 8 weeks to grow to market butcher size. If you let it grow 9, 10, 11 weeks it dies of a heart attack. This rubber is what we are used to eating. Heritage breed chickens take 16 weeks to get to butcher size (and OMG they taste so good, and for those who grew in random corners of the world... those backyard chickens are the ones that have the flavor you know and miss). Most every crop, every animal, every product when you dig it into it... you will like find something to be like WTF. To get quality food, you are practically forced to live on a farm / homestead.

Simply put, the MAHA concept has a core good idea, and lots of low lying fruit to attack. RFK ain't perfect... but he's what we get. Release the Kennedy Kraken.

Improving the quality of our food is good. taking aim at evidence based medicines because you believe in pseudo science is bad. Agree to disagree, but RFK is closer to "dangerous" than he is to "ain't perfect"...even if he has some good ideas.

This is the admin's entire MO though. Take a good idea in theory, like reducing government waste, and run it out in the most awful and divisive way possible. He has so much potential to unify people over some of these things, but he's incapable of that. So here we are.

 

[Mad Jack]

Eh, I do inpatient, so there'll always be a need. Now whether I can actually provide effective treatments or not, that becomes the question

 

[Mad Jack]

Improving the quality of our food is good. taking aim at evidence based medicines because you believe in pseudo science is bad. Agree to disagree, but RFK is closer to "dangerous" than he is to "ain't perfect"...even if he has some good ideas.

This is the admin's entire MO though. Take a good idea in theory, like reducing government waste, and run it out in the most awful and divisive way possible. He has so much potential to unify people over some of these things, but he's incapable of that. So here we are.

Wanting to literally get rid of vaccines and functionally bring back polo, measles, and various other illnesses to the world would have been disqualifying in sane times. Sane times we are not in, however.

 

[Geraltofrivia]

Polio, MMR etc rates were decreasing prior to the vaccines for the same. And if you do a careful read of what he says, he rails not against the vaccines, but the agents that constitute the vaccines. We've had vaccines since the 1700s, but autism rates then were functionally nonexistent. Why? I think its reasonable to investigate this.

I also think many psychiatrists forget that there are entire antidepressants that are not SSRIs. Many of those other antidepressants work substantially better, and with fewer side-effects. I also think it's reasonable to investigate the connection between the pharmaceutical industry and psychiatry. Many big names, who I will not mention but are very very well known, have strong ties. And while we are at it, we should also look into the Foundations Fund for Research into Psychiatry that maybe started this entire thing. This last one is wishful thinking.

 

[lobstar]

I would imagine SSRIs are first up for kids with the black box warning and all. Although RFK may do it poorly, more talks about SI with SSRIs and where we as a community would place the acceptable risk level would be nice--even if just more from an ethical academic talk since the risk might not actually exist. If the running NNT for depression is 7-8, what would we say is an acceptable SI incidence to continue current prescribing?

Same for stimulants. They are certainly helping kids graduate high school, have jobs, etc. But there's also a nonzero rate of other kids using with heavy cannabis, developing schizophrenia, getting a SUD that turns into meth use disorder, and we find these as acceptable loses in the grand scheme of society.

If done right we could have helpful talks from this order, definitely a chance clinical practice is changed on poor data, I agree with others the end of psychiatry is unlikely.

 

[Cath Up]

I would imagine SSRIs are first up for kids with the black box warning and all. Although RFK may do it poorly, more talks about SI with SSRIs and where we as a community would place the acceptable risk level would be nice--even if just more from an ethical academic talk since the risk might not actually exist. If the running NNT for depression is 7-8, what would we say is an acceptable SI incidence to continue current prescribing?

Same for stimulants. They are certainly helping kids graduate high school, have jobs, etc. But there's also a nonzero rate of other kids using with heavy cannabis, developing schizophrenia, getting a SUD that turns into meth use disorder, and we find these as acceptable loses in the grand scheme of society.

If done right we could have helpful talks from this order, definitely a chance clinical practice is changed on poor data, I agree with others the end of psychiatry is unlikely.

Not much of a chance to "do things right" if the executor of the order is a vaccine skeptic lawyer without medical training.

 

[Techmed07]

Best case scenario he limits the prescribing of psychotropics to psychiatrists limiting psychologists and APRNs scope creep.

Worst case scenario psychiatry as a field is decimated and stigmatized.

 

[OldPsychDoc]

I move we all just check out, take a 1 year sabbatical to, I dunno, Spain, Portugal...someplace temperate with good food and wine...
Unlock all the asylums and inpatient units. Close the clinics. Ban all the meds. Stop all the vaccines. (I've got mine...should be good for most of 'em. I mean I'd like another round of influenza shots next fall, especially if this bird thing is circling, but maybe some other country will have them.)
After US society collapses, if anyone is left here to beg us to come back, and if we care to, maybe we'll start things up again.

Oh...almost forgot...F45/47. F the Space Nazi. And F all their enablers. I'm done being nice.

 

[Geraltofrivia]

Best case scenario he limits the prescribing of psychotropics to psychiatrists limiting psychologists and APRNs scope creep.

Worst case scenario psychiatry as a field is decimated and stigmatized.

Psychiatry is already stigmatized as a profession. We don't treat to cure, but I'm not convinced it's because we can't.

Not much of a chance to "do things right" if the executor of the order is a vaccine skeptic lawyer without medical training.

This is an "appeal to authority". If he was a physician with the same skeptical positions, people such as yourself would be up in arms that a "science denier" was getting the job. I for one am very glad, especially compared to the prior HHS Secretary, with RFK Jr. By the way, the prior HHS Secretary was also an attorney without medical training.

 

[J ROD]

Do not treat kiddos but maybe we can start giving out benzos!

 

[jbomba]

I also wonder if this language about threat of thee drugs is strictly related to kids or if it will creep towards in including adults as well.

 

[Cath Up]

Psychiatry is already stigmatized as a profession. We don't treat to cure, but I'm not convinced it's because we can't.



This is an "appeal to authority". If he was a physician with the same skeptical positions, people such as yourself would be up in arms that a "science denier" was getting the job. I for one am very glad, especially compared to the prior HHS Secretary, with RFK Jr. By the way, the prior HHS Secretary was also an attorney without medical training.

Appeal to authority is at times an appropriate response or request, we depend on expertise and authority regularly, and the political movement of rejecting it will continue to cause generational problems. You're right though that some prior HHS secretaries have not been physicians, though they have generally had public health or public office experience previously.

Yes, I would be up in arms if someone who denied widely established scientific realities was put in charge.

 

[TexasPhysician]

At this point, catastrophizing. This could be excellent, terrible, or anywhere in between.

 

[Sushirolls]

I move we all just check out, take a 1 year sabbatical to, I dunno, Spain, Portugal...someplace temperate with good food and wine...
Unlock all the asylums and inpatient units. Close the clinics. Ban all the meds. Stop all the vaccines. (I've got mine...should be good for most of 'em. I mean I'd like another round of influenza shots next fall, especially if this bird thing is circling, but maybe some other country will have them.)
After US society collapses, if anyone is left here to beg us to come back, and if we care to, maybe we'll start things up again.

Oh...almost forgot...F45/47. F the Space Nazi. And F all their enablers. I'm done being nice.

Disappointed OPD. From what I've seen and conceptualized of your historic posts you've usually maintained a decency in your posts that show a tempered nature - even when I've disagreed with them. Hope this is a blip in your usually posting quality.

 

[calvnandhobbs68]

I would imagine SSRIs are first up for kids with the black box warning and all. Although RFK may do it poorly, more talks about SI with SSRIs and where we as a community would place the acceptable risk level would be nice--even if just more from an ethical academic talk since the risk might not actually exist. If the running NNT for depression is 7-8, what would we say is an acceptable SI incidence to continue current prescribing?

Same for stimulants. They are certainly helping kids graduate high school, have jobs, etc. But there's also a nonzero rate of other kids using with heavy cannabis, developing schizophrenia, getting a SUD that turns into meth use disorder, and we find these as acceptable loses in the grand scheme of society.

If done right we could have helpful talks from this order, definitely a chance clinical practice is changed on poor data, I agree with others the end of psychiatry is unlikely.

There are plenty of studies about the black box warning and it all goes back and forth for the last 20 years. I'm assuming as a psychiatrist you have the ability to go look this up yourself. Needless to say, if there is a signal, it's so weak that there are meta-analyses arguing both sides of the issue. Also, if there is any persistent signal, it's for SI and possibly, maybe "suicidal" behaviors which are interesting outcome measures themselves.

I'm not sure where you're getting info that kids being on stimulants at normal dosage ranges for ADHD combined with cannabis use somehow increases risk for developing schizophrenia or developing a substance use disorder that turns into "meth use disorder"? If you have that information, feel free to post it. Actual data as far as I'm aware is that children who are diagnosed and treated properly for ADHD have lower rates of developing a substance use disorder.

Point is, there are "helpful talks" that have been occurring about these subjects because people have been doing research about these topics for some time. Ignoring prior studies to push a particular agenda isn't a "helpful talk".

But yes OP I think you're catastrophizing overall about this, >10% of the US population is on an SSRI. There's gonna be quite a backlash if that rug gets pulled out from under people. If anything, if the classes of medications we primarily deal with are seen as more mysterious and dangerous, everyone ends up coming to see us for them and primary care gets super uncomfortable dealing with them again just like when the black box warning originally came out

 

[Techmed07]

best case scenario: prescribing of psychotropics is limited to psychiatrists.

 

[jbomba]

More thoughts from a neurotic psychiatrist...

If they are intent on doing away with psychiatry, they don't even have to go to battle by eliminating access to these medications. My understanding is all that needs to be done is eliminate parity requirements for mental health. If Medicaid is significantly cut, I don't see how community psychiatric hospitals manage to continue operating. The vast majority of our inpatients are either totally uninsured or on Medicaid.

 

[lobstar]

There are plenty of studies about the black box warning and it all goes back and forth for the last 20 years. I'm assuming as a psychiatrist you have the ability to go look this up yourself. Needless to say, if there is a signal, it's so weak that there are meta-analyses arguing both sides of the issue. Also, if there is any persistent signal, it's for SI and possibly, maybe "suicidal" behaviors which are interesting outcome measures themselves.

I'm not sure where you're getting info that kids being on stimulants at normal dosage ranges for ADHD combined with cannabis use somehow increases risk for developing schizophrenia or developing a substance use disorder that turns into "meth use disorder"? If you have that information, feel free to post it. Actual data as far as I'm aware is that children who are diagnosed and treated properly for ADHD have lower rates of developing a substance use disorder.

Point is, there are "helpful talks" that have been occurring about these subjects because people have been doing research about these topics for some time. Ignoring prior studies to push a particular agenda isn't a "helpful talk".

But yes OP I think you're catastrophizing overall about this, >10% of the US population is on an SSRI. There's gonna be quite a backlash if that rug gets pulled out from under people. If anything, if the classes of medications we primarily deal with are seen as more mysterious and dangerous, everyone ends up coming to see us for them and primary care gets super uncomfortable dealing with them again just like when the black box warning originally came out

Like you said, there's possibly a weak signal for SI. I don’t know why you framed it as if I were taking about suicide or something other than SI. If a kid has SI, a suicide attempt, or self-harm due to the SSRI, you still need to have thought through what number of kids you're okay with this happening to so that a far greater number do better.

I think we're approaching a settled science at this point that cannabis increases the risk of acute and chronic psychosis. Increasingly more kids use it. As for rx stimulants and psychosis there's Mackenzie et al 2016 and Moran et al 2019 and 2024. For SUD we've already gone from Wilens et al 2003 saying rx stimulants are protective for later SUD, to now the Humphreys et al 2013 saying it's neither protective nor harmful--although you can't prove it doesn't happen by failing to reject null anyway. I think it's quite reasonable to worry there is actual risk there. Particularly with so much misuse and diversion of these medications as in McCabe et al 2023.

If you have actual data that combining multiple substances that are both known to cause psychosis, have a risk of dependence, and then combining them without any risk whatsoever for use disorders or chronic psychosis I'd like to see it. There is an NNH for this, and even if small, we need to acknowledge someone will have these side effects and in the medical community they are viewed as an acceptable loss in the grand scale of society to treat ADHD and whatever else.

 

[brosa]

More thoughts from a neurotic psychiatrist...

If they are intent on doing away with psychiatry, they don't even have to go to battle by eliminating access to these medications. My understanding is all that needs to be done is eliminate parity requirements for mental health. If Medicaid is significantly cut, I don't see how community psychiatric hospitals manage to continue operating. The vast majority of our inpatients are either totally uninsured or on Medicaid.

There is also other ways to kill the prescription of SSRIs and others. They can just put under the DEA assistance and they will kill it lol.

"Oh, you want to prescribe an SSRI? Well you need the Y Waiver, 200h of lectures, and a hand-filled 8 pages form every time you prescribe it."

 

[Geraltofrivia]

Midwestern Doc on Substack has written very nice (and extremely lengthy) articles on SSRIs. I would encourage a read. Here's are links:

The Hidden Dangers of Antidepressants and Why They're So Hard To Stop Taking

Unveiling the Depression Industry

www.midwesterndoctor.com

What They Don’t Tell You About Anxiety and The Dangers of Benzodiazepines

The forgotten treatments for anxiety and the immense dangers of inappropriately prescribed benzodiazepines

www.midwesterndoctor.com

The Dark Side of Antidepressants

Why are SSRIs so dangerous?

www.midwesterndoctor.com

The FDA's War Against Sleep

Exploring the Critical Importance of Sleep and the Treatments for Insomnia

www.midwesterndoctor.com

We don't need a psychiatrist skeptic attorney to tell the public that we're a corrupt profession, we've done that for ourselves already:

https://www.psychiatriapolska.pl/pdf-80136-81413?filename=Industry_corrupted.pdf

Edward Shorter has written a beautiful treatise on antidepressants before SSRIs, Shorter, Edward. Before Prozac: The troubled history of mood disorders in psychiatry. Oxford University Press, 2008. I would encourage a read.

How many other chairperson's of the American Psychiatric Association conducted experiments on human beings without their knowledge or consent? I know of just one, for now, Donald Ewen Cameron. Do we not deserve criticism for our failure to acknowledge the injustices we've done, as a profession, on our people? I cannot fault RFK Jr.

 

[Geraltofrivia]

Appeal to authority is at times an appropriate response or request, we depend on expertise and authority regularly, and the political movement of rejecting it will continue to cause generational problems. You're right though that some prior HHS secretaries have not been physicians, though they have generally had public health or public office experience previously.

Yes, I would be up in arms if someone who denied widely established scientific realities was put in charge.

Ipse Dixit is never an appropriate response, unless you are parenting your child. I wish I was a parent... one day, I hope.

 

[splik]

This is actually one of the tamer executive orders to come out of the past few weeks. For those who aren't familiar with politics, typically establishing a commission means they are punting something way down the line that they don't have any intention of acting on. So from that perspective, it is actually reassuring. And most of the plain language of the EO is not particularly objectionable as there are clear risks associated with psychotropics, the use of these drugs in children (especially antipsychotics) is concerning, and we should explore the increase in treatment of "ADHD". Of course, the current administration cannot be trusted to actually look into these things.

It is more concerning that RFK Jr as HHS Secretary believes that coming off SSRIs are harder to come off than heroin (he's only been on heroin apparently), doesn't know the difference between Medicare and medicaid, has enormous conflicts of interests based on his profiting from lawsuits against pharmaceutical companies, and peddles long debunked theories of an association between vaccines and autism etc.

 

[calvnandhobbs68]

Like you said, there's possibly a weak signal for SI. I don’t know why you framed it as if I were taking about suicide or something other than SI. If a kid has SI, a suicide attempt, or self-harm due to the SSRI, you still need to have thought through what number of kids you're okay with this happening to so that a far greater number do better.

Again, this is acting as if SI is a helpful outcome measure. You even saying "you still need to have thought through what number of kids you're okay with this happening to" is an example of the "harm" mentality. I think it's an issue that we even have it as an outcome measure unless we're trying to link it to some actual functional outcome measure, some kind of short term prediction of actual self harm or completed suicide. Similar to blood pressure or lipid targets....what are we trying to measure with this and what are we actually concerned about?

My other point there was that this is ALREADY being looked at back and forth for some time now and acting like nobody is talking about this is ridiculous. This was already a big debate when the black box warning came out to begin with and led to a big dropoff in SSRI scripts for a while. What exactly is he adding to the research around SSRIs in kids? I mean if they want to increase NIH funding for more research, hey that's awesome. Doesn't seem that's the direction this administration is heading.

I think we're approaching a settled science at this point that cannabis increases the risk of acute and chronic psychosis. Increasingly more kids use it. As for rx stimulants and psychosis there's Mackenzie et al 2016 and Moran et al 2019 and 2024. For SUD we've already gone from Wilens et al 2003 saying rx stimulants are protective for later SUD, to now the Humphreys et al 2013 saying it's neither protective nor harmful--although you can't prove it doesn't happen by failing to reject null anyway. I think it's quite reasonable to worry there is actual risk there. Particularly with so much misuse and diversion of these medications as in McCabe et al 2023.

If you have actual data that combining multiple substances that are both known to cause psychosis, have a risk of dependence, and then combining them without any risk whatsoever for use disorders or chronic psychosis I'd like to see it. There is an NNH for this, and even if small, we need to acknowledge someone will have these side effects and in the medical community they are viewed as an acceptable loss in the grand scale of society to treat ADHD and whatever else.

Yeah dude that's not the way that works, classic burden of proof fallacy there. If you want to prove some positive assertion, you have to actually prove it you can't just go "I have some case control studies here that tall people eat more ice cream vs short people and curly haired people eat more ice cream than straight haired people so tall curly haired people must eat even more ice cream than either of those....you have to prove to me that isn't true".

The studies you're linking are absolutely not prospective controlled or even cohort studies. Hey, again, if RFK is gonna increase funding for controlled studies looking at these questions, awesome! For some reason I doubt that's what's going on here but I'm happy to be proven wrong.

Also forgot to say this but I find the whole premise of your stimulant statement weird. Yeah I agree people shouldn’t be using other substances and stimulants, I tell them that all the time. I agree people generally should not be using stimulants, especially higher dose stimulants, and cannabis together not necessarily because of the psychosis risk but because of the clear negative cognitive impact of regular cannabis use. I believe many child psychiatrists would agree, although I guess I can’t be sure. If you don’t want people to smoke cannabis and take stimulants, drug test them…cannabis is one of the easier things to get reliable drug tests for. What exactly is your argument here?

 

[lobstar]

Again, this is acting as if SI is a helpful outcome measure. You even saying "you still need to have thought through what number of kids you're okay with this happening to" is an example of the "harm" mentality. I think it's an issue that we even have it as an outcome measure unless we're trying to link it to some actual functional outcome measure, some kind of short term prediction of actual self harm or completed suicide. Similar to blood pressure or lipid targets....what are we trying to measure with this and what are we actually concerned about?

My other point there was that this is ALREADY being looked at back and forth for some time now and acting like nobody is talking about this is ridiculous. This was already a big debate when the black box warning came out to begin with and led to a big dropoff in SSRI scripts for a while. What exactly is he adding to the research around SSRIs in kids? I mean if they want to increase NIH funding for more research, hey that's awesome. Doesn't seem that's the direction this administration is heading.



Yeah dude that's not the way that works, classic burden of proof fallacy there. If you want to prove some positive assertion, you have to actually prove it you can't just go "I have some case control studies here that tall people eat more ice cream vs short people and curly haired people eat more ice cream than straight haired people so tall curly haired people must eat even more ice cream than either of those....you have to prove to me that isn't true".

The studies you're linking are absolutely not prospective controlled or even cohort studies. Hey, again, if RFK is gonna increase funding for controlled studies looking at these questions, awesome! For some reason I doubt that's what's going on here but I'm happy to be proven wrong.

Also forgot to say this but I find the whole premise of your stimulant statement weird. Yeah I agree people shouldn’t be using other substances and stimulants, I tell them that all the time. I agree people generally should not be using stimulants, especially higher dose stimulants, and cannabis together not necessarily because of the psychosis risk but because of the clear negative cognitive impact of regular cannabis use. I believe many child psychiatrists would agree, although I guess I can’t be sure. If you don’t want people to smoke cannabis and take stimulants, drug test them…cannabis is one of the easier things to get reliable drug tests for. What exactly is your argument here?

RFK is a vaccine skeptic and I've somehow found a physician who he might be able to help. Remarkable.

You lack an appreciation of risk. We start at the place of precaution and as evidence grows we move to further action. We start at the place of amphetamines are harmful and as evidence grows we use them safely.

You are making the same error as the docs prescribing opioids due to lack of evidence that they're harmful. You are making the same error as people not wearing masks, saying there's no evidence masks work yet so let's not wear them.

 

[calvnandhobbs68]

RFK is a vaccine skeptic and I've somehow found a physician who he might be able to help. Remarkable.

You lack an appreciation of risk. We start at the place of precaution and as evidence grows we move to further action. We start at the place of amphetamines are harmful and as evidence grows we use them safely.

You are making the same error as the docs prescribing opioids due to lack of evidence that they're harmful. You are making the same error as people not wearing masks, saying there's no evidence masks work yet so let's not wear them.

🙄 okay dude. Don't even know what you're trying to say with that first line and that last part is hilarious.

I guess I’m also talking to someone who doesn’t know the difference between different types of studies, correlation vs causation and logical fallacies. So I guess we’re talking past each other here.

The "starting at a place of precaution" is why there are clinical trial phases...or did you forget that there are preceding clinical trials for EVERY approved version of ADHD medication on market right now? We certainly don't start at the place of amphetamines or methylphenidate based stimulants at their approved dosages are harmful when they are being used for their FDA indication. You can question long terms risks vs benefits, possible downsides of chronic use, quality of ADHD diagnoses over time, adults getting prescribed high doses of amphetamine based stimulants, etc. but that's absolutely not the same thing.

Again what is your actual argument? Adolescents shouldn’t smoke weed, especially if they take stimulants? What does that have to do with prescribing stimulants to treat ADHD in children in general? I agree (though not exactly for the reasons you’re stating) because of actual prospective data such as MTA trial followup:

Psychotic Symptoms in Attention-Deficit/Hyperactivity Disorder: An Analysis of the MTA Database - PMC

To assess the prevalence of psychotic symptoms among youths (age 14-25 years) with a childhood diagnosis of attention-deficit/hyperactivity disorder (ADHD) combined type. The participants in the Multimodal Treatment Study of Children with ADHD (MTA) ...

pmc.ncbi.nlm.nih.gov

"Of the 26 MTA participants who screened positive, 8 had originally been randomized to combined treatment, 7 to medication management only, 4 to behavior therapy, and 7 to community comparison. The difference in the rate of positive screening by the original treatment group was not statistically significant."
"There was no evidence that ADHD increased the risk for psychotic symptoms. In both the ADHD and normative comparison groups, more frequent cannabis use was associated with greater likelihood of experiencing psychotic symptoms, thus supporting the recommendation that youth should not use cannabis."

 

[Psychresy]

More thoughts from a neurotic psychiatrist...

If they are intent on doing away with psychiatry, they don't even have to go to battle by eliminating access to these medications. My understanding is all that needs to be done is eliminate parity requirements for mental health. If Medicaid is significantly cut, I don't see how community psychiatric hospitals manage to continue operating. The vast majority of our inpatients are either totally uninsured or on Medicaid.

In all seriousness, do we think this is a likelihood? I'm an early career shrink but I have a younger brother who also wants to go psych. He's current ms3. Are we at the point where we would tell people to avoid the field?

 

[Sushirolls]

I've been telling family to avoid all of medicine.

 

[Psychresy]

I've been telling family to avoid all of medicine.

I mean I make 500k a year and work 32 hrs a week currently. Not many similar non medicine jobs like this.

 

[B52slinger]

In all seriousness, do we think this is a likelihood? I'm an early career shrink but I have a younger brother who also wants to go psych. He's current ms3. Are we at the point where we would tell people to avoid the field?

We need to keep in mind that even worst case scenario (RFK Jr under Trump goes full scientologist and messes psych up in some meaningful way which I highly doubt considering how much pushback they will be getting from the medical/pharmaceutical establishment), they will be here until 2029 at the latest then a reactionary Bernie Sanders type could very well be voted in who undoes everything twice over

the new administration is already catching a lot of heat and I doubt that 4 years from today, public opinion will be favorable for MAGA assuming they are able to actually achieve any semblance of project 2025

 

[2025DandW]

1) It's catastrophizing.
..................
...................
97) Even if most SSRIs are banned? Stopped? There is still ECT, and it simply works better with greater remission rates...
98) Some meds have non-psychiatric indications and would still be around... TCAs for sleep, or migraines for instance. Neuroleptics with epilepsy.
99) TMS, Ketamine, VNS
100) Therapy / PHP / IOP
101) [bonus point/sarcasm follows -->] Cannabis cures everything, at least numerous patients have told me, so we all just need to open up cannabis farms and dispensaries.

Where are you located that ECT is so easy to get? That is not my experience in multiple large, urban areas. TMS for the average person, not a chance. Who has that kind of time?

We need to keep in mind that even worst case scenario (RFK Jr under Trump goes full scientologist and messes psych up in some meaningful way which I highly doubt considering how much pushback they will be getting from the medical/pharmaceutical establishment), they will be here until 2029 at the latest then a reactionary Bernie Sanders type could very well be voted in who undoes everything twice over

the new administration is already catching a lot of heat and I doubt that 4 years from today, public opinion will be favorable for MAGA assuming they are able to actually achieve any semblance of project 2025

This is what I am thinking will happen. The bottom 50% are looking for a savior, and it doesn’t appear they will get it from the current administration, so an AOC or one of the other super progressives, Saunders may be too old, could be the antidote people reach for to save the day.

 

[Crayola227]

Improving the quality of our food is good. taking aim at evidence based medicines because you believe in pseudo science is bad. Agree to disagree, but RFK is closer to "dangerous" than he is to "ain't perfect"...even if he has some good ideas.

This is the admin's entire MO though. Take a good idea in theory, like reducing government waste, and run it out in the most awful and divisive way possible. He has so much potential to unify people over some of these things, but he's incapable of that. So here we are.

Well and then the issue becomes, you could put any one of us in that position and we could easily be on that same page of things that are good, like improving food quality. That isn't original. So then, what is RFK adding that others would not? Then the only thing he's really adding is quackery and antivax. He's nothing but a net negative when you figure something like food quality would be a common denominator.

Trump literally could have picked up a phone book and pointed to anyone with MD or DO after their name and had a more qualified & better candidate. Most of us are not in any industry pocket, either. We didn't need someone like RFK so we wouldn't, or psychiatry wouldn't, have been sold down the river.

He doesn't de-corrupt the system, he only corrupts it in a different way.

Specifically, against any fundamental scientific backing of any kind.

 

[2025DandW]

In terms of food, Michelle Obama was attacked by Republicans when she tried to improve the quality of food being served to school children. As a parent of school age children, I remember the complaints that the kids will never eat that healthy crap. In terms of fraud and waste, his dior’s getting rid of all the probationary federal employees rid the system of fraud and abuse? How does getting rid of the inspector generals, who look for fraud and abuse, rid the government of fraud and abuse? Where are the auditors and law enforcement that are trained to look for these things? My understanding is DOGE is to deregulate and cut spending. I’m confused what positive initiatives people are expecting in health care when departments are being slashed without a thought as to what they do. I don’t understand why anyone with half a brain would take a pay cut to work for
the government when there is no job security and you are dealing with people who don’t believe in any of the research that his been conducted in the last 50 years. If you’re deregulating, anything goes. Would safe guards will we have to make sure are food and medicines are safe? I’m seriously missing why physicians are applauding this destruction of the US government, so it can be replaced by private corporations. That is the whole plan of Project 2025. Why do people think this is a good idea? Also, RFK was not part of the plan, so I don’t see him as a long term member of this administration.

 

[Mad Jack]

More thoughts from a neurotic psychiatrist...

If they are intent on doing away with psychiatry, they don't even have to go to battle by eliminating access to these medications. My understanding is all that needs to be done is eliminate parity requirements for mental health. If Medicaid is significantly cut, I don't see how community psychiatric hospitals manage to continue operating. The vast majority of our inpatients are either totally uninsured or on Medicaid.

I doubt most of the public would stand for not having acute psychiatric care, particularly when those on the left and the right have their own issues that they credit to mental illness. The public, at the very least, seems to understand some people are very sick and need care and it would likely cause quite an outcry. I think everyone really needs to chill in general, as one nutty meat mech driven by a worm can't undo all of the progress we've made in getting mental health to be taken as a serious matter in this country

 

[Mad Jack]

RFK is a vaccine skeptic and I've somehow found a physician who he might be able to help. Remarkable.

You lack an appreciation of risk. We start at the place of precaution and as evidence grows we move to further action. We start at the place of amphetamines are harmful and as evidence grows we use them safely.

You are making the same error as the docs prescribing opioids due to lack of evidence that they're harmful. You are making the same error as people not wearing masks, saying there's no evidence masks work yet so let's not wear them.

We have studied the hell out of the topic and quantified the risks about fifty different ways. There is ample proof of the benefits, with stimulants being among the most effective medications in all of medicine (NNTs as damn close to 1 as you can imagine) and ample proof that they result in decreased psychosocial, academic, criminal, and other outcomes, while simultaneously decreasing the risk of substance use by a third in a population that is very prone to substance use disorders. Just undoing the benefits with regard to substance use disorders alone would likely result in death and disability on a scale that far outstrips the known risks of ADHD medication that has been prescribed for *longer than anyone on this forum has likely been alive.* If there are remarkable, disturbing, widespread negative effects of stimulants we would have noted them in the last 65 years.

The argument that the absence of evidence for safety leads to something being by default unsafe is an impossible standard to meet. It's why we have the drug approval process we do, by which ever larger populations are studied and postmarketing surveillance is performed, as there may always be some new, rare event that comes up. But no medication, and no substance, is safe for everyone. There will always be a small number of people that react negatively to a medication, and providing informed consent about the risks and benefits, as well as the magnitude of each, exists for this very reason. If you say no medicine with any degree of risk should be provided to a child, you're basically saying no medicine can be provided to a child, as everything has risks. This is the fallacy that leads to people avoiding vaccines, fearing a one in a million event when an actual illness can disable their child a thousand times more often. It is throwing the baby out with the bath water, as it were.

 

[michaelrack]

I was at a conference last week, and one of the speakers advised caution in the use of valproic acid in MEN under 55, due to the approximately 1.5 risk of neurodevelopment abnormalities (neurodevelopmental abnormalities included autism and adhd and several others); vpa appears to damage sperm Understanding the impact of valproate on male fertility: insights from preclinical and clinical meta-analysis - PubMed . I don't think it's necessarily wrong to have a commission look further into the use of psych drugs in children, although I can understand the concern that the commission might go overboard.

RFK, Jr was certainly an interesting cabinet pick.... with concerns on both the left and right (and the center).

As far as vaccines, as long as he doesn't mess with any vaccine that came out before 9/11/2001, I will be happy.

 

[jbomba]

Does anyone remember what psychiatry was like prior to 2008 when ACA required coverage?

Were almost all outstanding visits cash? Were inpatient units running at significant losses? How was the overall job and economic prospects of the field?

 

[Mad Jack]

Does anyone remember what psychiatry was like prior to 2008 when ACA required coverage?

Were almost all outstanding visits cash? Were inpatient units running at significant losses? How was the overall job and economic prospects of the field?

Tons of jobs, much lower pay was my understanding. This led to much less interest in the field and it being a specialty of last resort for many, as the pay was quite low. Parity, however, is enshrined in law and won't be undone unless the ACA is, which would be quite the undertaking, and even then I would imagine strong advocacy for continued parity

 

[tr]

Does anyone remember what psychiatry was like prior to 2008 when ACA required coverage?

Were almost all outstanding visits cash? Were inpatient units running at significant losses? How was the overall job and economic prospects of the field?

Yes this law came down when I was an intern. It significantly changed clinical practice. Prior to the ACA, many insurance companies required a "parity" diagnosis for coverage, meaning only certain diagnoses were eligible. This pushed physicians to give more severe diagnoses that would be more likely to make the cut for coverage. At the same time, many of these same diagnoses were used by insurance companies to exclude people from buying coverage in the first place. So it was a double-edged sword, where you could either come down on the side of helping the patient get coverage for their currently active issue, or reduce the likelihood that they would be denied coverage in the future. Either way, diagnoses given were strongly influenced by insurance factors, rather than by the actual facts of the case presentation.

And yes, psychiatry was really a bottom-of-the-barrel specialty when I applied. I think it was about even with family medicine for least competitive specialty. A lot of FMGs used to end up in psych because they couldn't match in anything else.

Inpatient units did run a loss.. don't a lot of them still though? Not sure as I haven't worked inpatient in a long time.

 

[calvnandhobbs68]

Tons of jobs, much lower pay was my understanding. This led to much less interest in the field and it being a specialty of last resort for many, as the pay was quite low. Parity, however, is enshrined in law and won't be undone unless the ACA is, which would be quite the undertaking, and even then I would imagine strong advocacy for continued parity

Yeah I mean they can't repeal the law through reconciliation and what it seems like they want to do at this point is basically cut ACA marketplace subsidies and pull back Medicaid expansion/matching while leaving in place all the popular stuff (required coverage for pre-existing conditions, lack of lifetime limit caps, coverage until 26yo, mental health parity).

There's a bill up for repeal but there's also a bill up to put Trumps head on Mount Rushmore so ya know....

 

[jbomba]

Yes this law came down when I was an intern. It significantly changed clinical practice. Prior to the ACA, many insurance companies required a "parity" diagnosis for coverage, meaning only certain diagnoses were eligible. This pushed physicians to give more severe diagnoses that would be more likely to make the cut for coverage. At the same time, many of these same diagnoses were used by insurance companies to exclude people from buying coverage in the first place. So it was a double-edged sword, where you could either come down on the side of helping the patient get coverage for their currently active issue, or reduce the likelihood that they would be denied coverage in the future. Either way, diagnoses given were strongly influenced by insurance factors, rather than by the actual facts of the case presentation.

And yes, psychiatry was really a bottom-of-the-barrel specialty when I applied. I think it was about even with family medicine for least competitive specialty. A lot of FMGs used to end up in psych because they couldn't match in anything else.

Inpatient units did run a loss.. don't a lot of them still though? Not sure as I haven't worked inpatient in a long time.

I was digging through data, inflation adjusted salaries from 2005 to today are essentially the same. In 2025 dollars 3-325k a year.

How was it that pay essentially stayed the same?

 

[lobstar]

We have studied the hell out of the topic and quantified the risks about fifty different ways. There is ample proof of the benefits, with stimulants being among the most effective medications in all of medicine (NNTs as damn close to 1 as you can imagine) and ample proof that they result in decreased psychosocial, academic, criminal, and other outcomes, while simultaneously decreasing the risk of substance use by a third in a population that is very prone to substance use disorders. Just undoing the benefits with regard to substance use disorders alone would likely result in death and disability on a scale that far outstrips the known risks of ADHD medication that has been prescribed for *longer than anyone on this forum has likely been alive.* If there are remarkable, disturbing, widespread negative effects of stimulants we would have noted them in the last 65 years.

The argument that the absence of evidence for safety leads to something being by default unsafe is an impossible standard to meet. It's why we have the drug approval process we do, by which ever larger populations are studied and postmarketing surveillance is performed, as there may always be some new, rare event that comes up. But no medication, and no substance, is safe for everyone. There will always be a small number of people that react negatively to a medication, and providing informed consent about the risks and benefits, as well as the magnitude of each, exists for this very reason. If you say no medicine with any degree of risk should be provided to a child, you're basically saying no medicine can be provided to a child, as everything has risks. This is the fallacy that leads to people avoiding vaccines, fearing a one in a million event when an actual illness can disable their child a thousand times more often. It is throwing the baby out with the bath water, as it were.

I've already said stimulants in ADHD have loads of benefits. I'm saying this perception you're pushing that the risks are minimal to negligible is inaccurate and likely underestimates the risks. I think more research into it is worthwhile and if it happens to be RFK who accomplishes that then so be it.

Not a week goes by on here where someone asks how to get out of prescribing stimulants or how to avoid seeing patients who might have a diagnosis that needs a stimulant. This is quite counter to this story that stimulants are all sunshine and rainbows. These are trained psychiatrists asking this question--this collective clinical experience would at least suggest that the risks are currently underestimated and there's a need for more research.