Thoughts on anatomy of an epidemic

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neriticzone

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Recently accepted premed who's starting med school in August. I have been reading the book "Anatomy of an Epidemic" by Robert Whittaker. When I first started reading the book, I almost stopped because his attitude seemed so flippant/glib. Eventually though, I found myself questioning my long held assumptions about the efficacy of psychiatric drugs. I've read some critical reviews online, and at times he definetly uses questionable logic to arrive at his conclusions. Nevertheless, he presents a compelling thesis to the non-MD reader (me). For those of you who have read this book, what did you think? Do his conclusions seem in line with what you see in your practice/training or is it off base?

Also- I am not trying be a troll with this post. Psychiatry has long been a specialty I have been interested in, and I have loved lurking on this forum and reading your engaging discussions. I have been trying to reconcile my love of psych with what I have read in this book.

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The drugs work partially for most people. They work amazingly for some people (like jaw droppingly). When you lump those results together the pooled results look less than stellar. We haven't been great at figuring out which subgroups will respond amazingly.
 
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I have not read that book (though I'd be interested to). But re: psychiatric meds, my 2cents: 1) especially as there's more awareness and acceptance of meds, I think far more people are willing to seek out help for mental health issues (although people are so much quicker to accept meds than therapy or both at once, for a variety of reasons, which is too bad) and 2) even if 20% effect is due to placebo effect, for someone in a depressive episode (for example), that can make a huge clinical difference in providing some hope and motivation. And as the post above said, many people respond partially. Partial response can still make a world of difference and is worth a shot, especially if it's the only option someone is willing to consider at the time. As a psychologist though I really appreciate when MDs encourage folks to seek concurrent therapy-- the combo tends to have much better long-term outcomes for most people.

I do think that the broader acceptance of taking meds (and the ease of taking them compared to therapy) and can be obtained often via PCP means people are so much more willing to talk to a health care provider about MH issues. I think that is a major factor in the increase of med prescriptions. Having spent a good bit of my life in really rural communities where there is a lot of stigma about mental health and also a dearth of therapy/related services, people are much more willing to bring up concerns with their physician during usual visits and accept Rx but wouldn't be caught dead scheduling therapy. At least they're willing to do something, whereas in my parent's generation in those same communities, many of those folks would not have rec'd any help at all, cycling through periods of disabling depressive episodes or other symptoms but still never considering applying for disability or seeking help. My 91 year old grandmother is basically the county historian and genealogist and lives in a town of ~600 where she's known everyone and their 3rd cousins for... 9 decades. I have had a lot of convos with her about mental health (and lack of resources in their county) over the past decade and I think it's critical to consider changes in stigma, urbanization, insurance, and awareness but disparity in service access as they relate to these shifting tides.

I'm going to buy this book now- it's been on my list for a while. Thanks for the prompt :)
 
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I did not read the book. However, science is more complicated than it may seem, and it's very easy to, purposefully or otherwise, misrepresent a study to reach conclusions that are either false or not actually supported by the study. Therefore, it's very easy to write a book or an article on a study submitted to the FDA that appears convincing but actually misleads.

Based on the totality of the evidence, I believe psychiatric medications do work. You can find reviews of the book that point out more specifically where it goes wrong.
 
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I don't know much about the works of Robert Whittaker, but I would caution reading any literature from someone who hasn't had specific training on how to read scientific studies, interpret the data, and then apply that evidence clinically. I would also give the same caution to someone who has had that training, but to a lesser extent. The matter of the fact is, anyone can pick and choose studies that confirm their thesis and then ignore the body of literature that doesn't. Even reputable journalists are accused of distorting the literature to fit their thesis (which is the point of writing a book: to provide evidence that confirms your argument and to disregard/dispute the rest), including Michael Polland and Jared Diamond.

It seems like Whittaker is trying to argue that there has been an increase in amount of prescriptions for medications while an increase in psychiatric diagnoses, then ascribes this association to big pharma and capitalization lowering the threshold for "mental illness" so that they can make more money by putting everyone on drugs. As doctors are more able to diagnose psych disorders, and as more patients are able to recognize it and come forward with these illnesses, there will be more diagnoses and treatment for these illnesses. Is there an appreciable decrease in psychiatric illnesses now compared to a few decades ago? No. Are there appreciable decreases in other chronic diseases, such as heart disease, diabetes, chronic kidney disease? No. I don't think this problem is unique to mental illness or psychiatry. I think it's in all of medicine. If you post some of his arguments here (the "compelling thesis") with the evidence he cites, we can help you sort through it.

You also have to be careful because some of these drugs haven't been around for that long. Fluoxetine was the first SSRI approved and that was just in 1987. Atypical antipsychotics have been around since only the 1990s. Psychiatric drugs are still in it's infancy save a few outliers. Psychiatric/neuroscience research also has a ton of room to grow and discover new methods of diagnosis and treatment, which is one of the reasons why I wanted to enter psychiatry in the first place.

One of the oldest drugs we use is lithium and it's use in both treatment of acute mania and prophylaxis against relapse/severity of relapse is not a debate. Lithium reduces both suicide attempts and completions by 80% - not a debate. I would consider that extremely efficacious.

I'll leave this here:
 
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I don't know much about the works of Robert Whittaker, but I would caution reading any literature from someone who hasn't had specific training on how to read scientific studies, interpret the data, and then apply that evidence clinically. I would also give the same caution to someone who has had that training, but to a lesser extent.
how do you know he hasn't had such training? FYI he guest lectured one of my classes when was doing my MPH at Harvard and the professor was an epidemiologist and physician and did not find much anything to quibble about with Whitaker's work.
 
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Do pharma companies even make any/appreciable money on long generic medications like fluoxetine? I find it hard to believe $4/month drugs are driving profits but maybe I'm wrong.
 
how do you know he hasn't had such training? FYI he guest lectured one of my classes when was doing my MPH at Harvard and the professor was an epidemiologist and physician and did not find much anything to quibble about with Whitaker's work.

if he did, he did a good job keeping it a secret since he doesn't flaunt it in any of his author bios. i doubt someone who writes about science would hide his scientific training since it would lend him additional credibility.
 
he has better critical appraisal skills than the overwhelming majority of psychiatrists. I know him and while we don't agree upon everything he is very open minded about things and raises some important points that psychiatry as a profession has been too arrogant and resistant to think about. There is nothing new in his writings; he simply draws attention to the long forgotten or suppressed studies that question the conventional wisdom of long term drugs for the majority of patients with mental disorders.
 
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I don't know much about the works of Robert Whittaker, but I would caution reading any literature from someone who hasn't had specific training on how to read scientific studies, interpret the data, and then apply that evidence clinically. I would also give the same caution to someone who has had that training, but to a lesser extent. The matter of the fact is, anyone can pick and choose studies that confirm their thesis and then ignore the body of literature that doesn't. Even reputable journalists are accused of distorting the literature to fit their thesis (which is the point of writing a book: to provide evidence that confirms your argument and to disregard/dispute the rest), including Michael Polland and Jared Diamond.

It seems like Whittaker is trying to argue that there has been an increase in amount of prescriptions for medications while an increase in psychiatric diagnoses, then ascribes this association to big pharma and capitalization lowering the threshold for "mental illness" so that they can make more money by putting everyone on drugs. As doctors are more able to diagnose psych disorders, and as more patients are able to recognize it and come forward with these illnesses, there will be more diagnoses and treatment for these illnesses. Is there an appreciable decrease in psychiatric illnesses now compared to a few decades ago? No. Are there appreciable decreases in other chronic diseases, such as heart disease, diabetes, chronic kidney disease? No. I don't think this problem is unique to mental illness or psychiatry. I think it's in all of medicine. If you post some of his arguments here (the "compelling thesis") with the evidence he cites, we can help you sort through it.

You also have to be careful because some of these drugs haven't been around for that long. Fluoxetine was the first SSRI approved and that was just in 1987. Atypical antipsychotics have been around since only the 1990s. Psychiatric drugs are still in it's infancy save a few outliers. Psychiatric/neuroscience research also has a ton of room to grow and discover new methods of diagnosis and treatment, which is one of the reasons why I wanted to enter psychiatry in the first place.

One of the oldest drugs we use is lithium and it's use in both treatment of acute mania and prophylaxis against relapse/severity of relapse is not a debate. Lithium reduces both suicide attempts and completions by 80% - not a debate. I would consider that extremely efficacious.

I'll leave this here:


Like most psychiatric medications, including lithium, the efficacy is grossly overstated. Psychiatry throws diagnosis around like nobody's buisness. Everyone has bipolar and schizoprhenia when the true diagnosis is often more simple ie drug induced or personality driven. Yet we throw antipsychotics and mood stabilizers at them as if it will do something, as if they will have a nurse at home adminstering the crazy medication regimen we perscribe and we wonder why they dont work. For higher functioning people who come in with the bread and butter depression or anxiert, youd be happy if an ssri reduced their symptoms 40%. For lower functioning people with more severe disorders, the goal is to keep them alive and out of the hospital.
 
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Like most psychiatric medications, including lithium, the efficacy is grossly overstated. Psychiatry throws diagnosis around like nobody's buisness. Everyone has bipolar and schizoprhenia when the true diagnosis is often more simple ie drug induced or personality driven. Yet we throw antipsychotics and mood stabilizers at them as if it will do something, as if they will have a nurse at home adminstering the crazy regiments we persdribe. Then we wonder why they dont work. For higher functioning people who come in with the bread and butter depression or anxiert, youd be happy if an ssri reduced their symptoms 40%. For lower functioning people with more severe disorders, the goal is to keep them alive and out of the hospital.

I'm glad you have the power to persdribe regiments. Some of us could only dream of such authority.

how do you know he hasn't had such training? FYI he guest lectured one of my classes when was doing my MPH at Harvard and the professor was an epidemiologist and physician and did not find much anything to quibble about with Whitaker's work.

How often do you see guest speakers openly criticized in high academic settings?

he has better critical appraisal skills than the overwhelming majority of psychiatrists. I know him and while we don't agree upon everything he is very open minded about things and raises some important points that psychiatry as a profession has been too arrogant and resistant to think about. There is nothing new in his writings; he simply draws attention to the long forgotten or suppressed studies that question the conventional wisdom of long term drugs for the majority of patients with mental disorders.

Genuinely curious here - do you have a better idea?
 
I'm glad you have the power to persdribe regiments. Some of us could only dream of such authority.
Nice one , its called typos. You sound like such an understanding person which I am sure comes off well with your patients. Hit a sore spot?
 
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Genuinely curious here - do you have a better idea?
Yes. My practice is not to keep people or recommend indefinite or long term medication for patients with psychosis or manic-depressive illness unless there is clear reason to do so. The most compelling indications in my mind are those with histories of violence (as there is evidence that various medications can reduce violence recidivism in those with serious mental disorders and that has been my experience in clinical and forensic practice). Some people are unable to manage off medications of course. But the evidence does not support long term treatment with antipsychotics or other psychotropic drugs as a rule and it is a shameful state of affairs that this is what has become of American Psychiatry, partly because of the special interests of the pharmaceutical companies, partly due to organized psychiatry, and partly due to misplaced liability fears on the part of psychiatrists. I also try not to start patients on medications unless I really believe they need them, and where patients are asking for them I present a full informed consent of all the potential adverse events that can occur. If they are not deterred having been fully informed of the risks and the minimal, if any, benefits then I will go ahead with it. I regularly receive unsolicited communications from patients (or more commonly family members) with mental illness from across the country, particularly psychotic illness, wanting to come off medications or concerned about the toxic effects of ongoing treatment. It is my opinion that the majority of patients labeled with "schizophrenia" and "bipolar disorder" do not need long-term medications. Many can manage without any medications at all, and are willing to trade off some "symptoms" to be free of medications and their adverse effects on functioning and quality of life. Others can be given medications during acute episodes (I treat bipolar patients with medications during the acute episode and for some months afterwards and then taper off where possible).

I believe we need to put more emphasis on the context in which people become and continue to endure so-called mental illness. As with "physical illness", medical problems are socially determined and the social world plays a huge part in recovery and relapse. We should try to maximize the resources available to people, work with families where possible, help patients understand where there problems are and how to address them, help them find meaning in their experiences of madness and mental distress, help them finding purpose in living, help them develop and maintain meaningful relationships with others, emphasize interpersonal connectedness within our therapeutic work, and consider other things that might help our patients find wellness. In particular, I am very interested in nutrition and the therapeutic value of food, cooking, and eating. I appreciate there is not a great deal of evidence or research into nutritional interventions but think this is a very promising area and would like to see more research into this area. In general, I would like to see NIMH rescue itself from irrelevance and put more effort into looking at a wide range of different treatment interventions for our patients rather than simply focusing on neuroimaging and genetics. We desperately need alternatives to offer our patients who do not want, and do not receive benefit from much of what we offer. At the same time, certain treatments (such as psychotherapies) that do work and can be helpful need to be more widely available.

Given that the prognosis of schizophrenia is worse today than it was over 100 years ago, what we are doing is not working. There are small concerted efforts to look at other models of care. The challenge is much of what would benefit our patients will not come from psychiatry. The establishment is not going to bite the hand that feeds them.
 
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Not going to lie, all this negativity about psychiatric treatments on the forums lately kind of is starting to make me less enthusiastic about the field as a future resident. My question is, why practice psychiatry if our treatments don't work? Or am I misinterpreting things here?


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Not going to lie, all this negativity about psychiatric treatments on the forums lately kind of is starting to make me less enthusiastic about the field as a future resident. My question is, why practice psychiatry if our treatments don't work? Or am I misinterpreting things here?


Sent from my iPhone using SDN mobile

Because ppl on SDN are in general depressing and complain a lot. Also SDN membership ironically enough does not mean you're setting up the guidelines for practice in psychiatry.
 
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Yes. My practice is not to keep people or recommend indefinite or long term medication for patients with psychosis or manic-depressive illness unless there is clear reason to do so. The most compelling indications in my mind are those with histories of violence (as there is evidence that various medications can reduce violence recidivism in those with serious mental disorders and that has been my experience in clinical and forensic practice). Some people are unable to manage off medications of course. But the evidence does not support long term treatment with antipsychotics or other psychotropic drugs as a rule and it is a shameful state of affairs that this is what has become of American Psychiatry, partly because of the special interests of the pharmaceutical companies, partly due to organized psychiatry, and partly due to misplaced liability fears on the part of psychiatrists. I also try not to start patients on medications unless I really believe they need them, and where patients are asking for them I present a full informed consent of all the potential adverse events that can occur. If they are not deterred having been fully informed of the risks and the minimal, if any, benefits then I will go ahead with it. I regularly receive unsolicited communications from patients (or more commonly family members) with mental illness from across the country, particularly psychotic illness, wanting to come off medications or concerned about the toxic effects of ongoing treatment. It is my opinion that the majority of patients labeled with "schizophrenia" and "bipolar disorder" do not need long-term medications. Many can manage without any medications at all, and are willing to trade off some "symptoms" to be free of medications and their adverse effects on functioning and quality of life. Others can be given medications during acute episodes (I treat bipolar patients with medications during the acute episode and for some months afterwards and then taper off where possible).

I believe we need to put more emphasis on the context in which people become and continue to endure so-called mental illness. As with "physical illness", medical problems are socially determined and the social world plays a huge part in recovery and relapse. We should try to maximize the resources available to people, work with families where possible, help patients understand where there problems are and how to address them, help them find meaning in their experiences of madness and mental distress, help them finding purpose in living, help them develop and maintain meaningful relationships with others, emphasize interpersonal connectedness within our therapeutic work, and consider other things that might help our patients find wellness. In particular, I am very interested in nutrition and the therapeutic value of food, cooking, and eating. I appreciate there is not a great deal of evidence or research into nutritional interventions but think this is a very promising area and would like to see more research into this area. In general, I would like to see NIMH rescue itself from irrelevance and put more effort into looking at a wide range of different treatment interventions for our patients rather than simply focusing on neuroimaging and genetics. We desperately need alternatives to offer our patients who do not want, and do not receive benefit from much of what we offer. At the same time, certain treatments (such as psychotherapies) that do work and can be helpful need to be more widely available.

Given that the prognosis of schizophrenia is worse today than it was over 100 years ago, what we are doing is not working. There are small concerted efforts to look at other models of care. The challenge is much of what would benefit our patients will not come from psychiatry. The establishment is not going to bite the hand that feeds them.

I think you provide an interesting perspective. I think people have the capacity to change and reinvent themselves and through changing environmental conditions become different. But I'm also under the impression that the whole point of psychiatric medicine is to help allow people to get better and to have the chance to help themselves and that for some people that requires permanent help. Likewise don't you think you're being a tad bit abelist here? I mean I'm a privileged person and able to reinvent and change, but is everyone? Or what if what they love to do in life is what is making them sick? I mean physician depression and suicide happens because people are driven to insanity unable to choose life over their love of medicine.

And again being ignorant, but does bipolar actually ever just decrease or go away or whether you learn to live with it without medication and if so is the quality of life worth being able to say you're medication free?

On the topic of NIMH on neuroimaging and genetics. I think that stuff is cool as crap. All that we are is the incidental physiological expression of an organ doing a bunch of separate functions. Being able to pin point connections between what communication drives what along with what genes predispose people to what and creating therapies in known risk groups is bound to have some potential good.
 
Not going to lie, all this negativity about psychiatric treatments on the forums lately kind of is starting to make me less enthusiastic about the field as a future resident. My question is, why practice psychiatry if our treatments don't work? Or am I misinterpreting things here?


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Psychiatric treatments are about a lot more than medications. In the 80s and 90s psychiatry made a big shift to emphasizing psychopharmacology. Lots of new medications that were quite promising came out and people were optimistic about this. Now we are seeing the efficacy is not quite what we hoped and the rate of better medications being developed has slowed and psychiatry needs to shift to retain its authority. Hearing people like splik and others on sdn talk about these issues and bridge some of the old school stuff like Kraeplin and such with the new school thinking gives me cause for optimism about psychiatry. Or you could just take the free meals and hand out the new trintellix (or was it brintellix) because it cures brain fog. That is seriously what the NP told my patient. Didn't even know brain fog was a thing, but now there's a pill for it.
 
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Given that the prognosis of schizophrenia is worse today than it was over 100 years ago, what we are doing is not working. There are small concerted efforts to look at other models of care. The challenge is much of what would benefit our patients will not come from psychiatry. The establishment is not going to bite the hand that feeds them.

I can think of a 100 things that is different about our society now than 100 years ago that could account for a worse prognosis in schizophrenia and bipolar, and none of it would have to do with medications.

I do agree what we are doing is not working and we need a better model of care. I still think medications will be a very important part of that model, even long term.
 
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And again being ignorant, but does bipolar actually ever just decrease or go away or whether you learn to live with it without medication and if so is the quality of life worth being able to say you're medication free?

I don't believe bipolar just decreases or goes away in the vast majority of cases (maybe in some).
There is a spectrum of severity.
Some people with type 2 learn to manage with lifestyle alone.
Lifestyle is key to managing all types of bipolar, including severe and those who only achieve control on meds.
In type 1, depending on how bad it is, how bad the manic episode(s), perhaps,
but if you've had mania vs hypomania, by definition that is more dangerous.
+/- psychosis, which is always possible no matter how many "psychosis-free" manic episodes you've had, is also dangerous.

To be or not to be on meds,

For bipolar, it depends on a few things.
1) How much time do you spend in euthymia?

2) Most spend up to 80% of their adult lives clinically depressed. Impairment in one or more areas of functioning. Of course, there's coping, and differing levels of distress from that. Doesn't necessitate medication just based on that. How "dangerous" is it when they're in a depressed episode? Is it mixed? Impulsive? Suicidal? Attempts?

3) Besides that, you have to look at mania.

For many, when you see the harm that one severe manic episode can wreak, not to mention the evidence regarding how many episodes of depression or mania one could have in a year.....

One manic or depressive episode could be so dangerous that one decides it cannot be "risked" again over a lifetime.

If I had an illness that could not only cause me to lose touch with reality, but not even know that I had, loss of insight... and during that time, I might be violent towards myself or others, not to mention all the other **** I could do (burn my house down with my cats in it, catch HIV, etc)
I don't know that's a degree of loss of control I could ever be OK with.
If I were on medication that I knew I would never become psychotic, but that off of them that were a possibility....
If it were me, I would likely take medication forever or until it caused me such side effects as to wonder "what now?"

I believe up to 1/4 manic depressives complete suicide. This is a lot higher than for unipolar depressives, which suggests there is something more dangerous suicide-wise about bipolar than just the depressive aspect.

Is medication the answer? I don't know. But I don't think anyone feels very comfortable with all of the above. The stakes are even higher than ruined lives, marriages and careers lost. Death. Psychiatric death is just sad, sadder than some other types of death.

I could write more likening bipolar to epilepsy. Most types of epilepsy, you have 2 seizures, you get meds for life. If you achieve a no seizure state for a certain number of years on meds, than it might be OK to try going off meds. If you have another seizure then, the neurologist will beg you to go back on meds and stay on them for life. This is because for the neurologist, they can't tell when the next seizure will not only cause brain damage, make your seizures harder to control, but which one will be status epilepticus, or SUDEP (sudden death in epilepsy).

Most people tolerate anti-sz meds so well it's not worth the risk of a seizure while driving, swimming, home alone, etc etc etc to try to live a med-free life that you put at risk off meds.

You have to decide if the risk of the even low frequency event (seizure or manic episode/mixed episode/suicide) is worth no meds, or if it's better to be exposed to higher frequency side effects from medications.

Or what if what they love to do in life is what is making them sick? I mean physician depression and suicide happens because people are driven to insanity unable to choose life over their love of medicine.

This is why I say typically purusing medicine as a career meets the most basic definition of addiction: continued pursuit in the face of increasing harms.

I can promise you another thing, if you are a bipolar physician and your condition ever gets bad enough to get any glance from the medical board, they can subpoena your med records, your psychiatrist, and even in "friendly" states they can mandate therapy including medications using their own psychiatrist's recommendations over yours, and mandate regular piss tests to see that you are in compliance with the meds they want you to take to have your license, anywhere from 1 year to your whole career.

There's not a lot of scenarios that I can think of that end in "take these psychotropic meds or lose your livelihood," but there you go. Just interesting is all.
 
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Not going to lie, all this negativity about psychiatric treatments on the forums lately kind of is starting to make me less enthusiastic about the field as a future resident. My question is, why practice psychiatry if our treatments don't work? Or am I misinterpreting things here?


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If I could go back in time and be omnipotent I would choose to have seen a psychiatrist who didn't load me up on benzos, tell me not to look up side effects, and keep me on them indefinitely with no other plan for treatment (and who didn't tell me therapy was a waste of time and that I should "go back in the closet"). Even if I were omnipotent and a time-traveler I couldn't do that if there weren't psychiatrists who know what not to do. You can be a barrier to deleterious treatment. In all fields of medicines there are limitations to what is possible to achieve; being current in you knowledge and practicing judiciously doesn't mean you're not achieving the maximum benefit that is safe. It means you're doing exactly that. If you had a patient with incurable cancer and months to live you wouldn't give them chemotherapy. That's not a hopeful idea, just like certain psychiatric treatments are invariably a bad idea and you're helping the patient by being the person who doesn't prescribe/do them. Because there's someone else who will guaranteed.
 
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Not going to lie, all this negativity about psychiatric treatments on the forums lately kind of is starting to make me less enthusiastic about the field as a future resident. My question is, why practice psychiatry if our treatments don't work? Or am I misinterpreting things here?

Spilk is on the far end of the spectrum. It's true that a lot of longitudinal research in medicine is lacking, this is far from unique to psychiatry due to the way that research is funded. We've all seen the tragedy caused by untreated bipolar and psychotic spectrum illness - literal death is not uncommon. The social components/ACT teams and public perception of SMI is lacking (at best). These diseases also tend to drive away social support, particularly when families are not starting in the upper SES brackets. Does Abilify fix this? Absolutely not. Does it reduce frequency/intensity of manic episodes? Absolutely. Some patients probably don't benefit from being on medications and we don't really do a good job managing those folks, however their are clearly patients who do benefit from the medications. Treating 1st episode psychosis is profoundly rewarding. To see a kid go from frank paranoia on an inpatient unit to getting a 30 on his ACT and landing a full ride scholarship 6 months later is... fantastic to say the least.
 
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The majority of mental illness isn't about untreated schizophrenia, bipolar disorder, etc. It's about the public at large with very poor coping skills, personality disorders and poor insight into their own health. Psychiatry cannot fix this.
 
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Spilk is on the far end of the spectrum. It's true that a lot of longitudinal research in medicine is lacking, this is far from unique to psychiatry due to the way that research is funded. We've all seen the tragedy caused by untreated bipolar and psychotic spectrum illness - literal death is not uncommon. The social components/ACT teams and public perception of SMI is lacking (at best). These diseases also tend to drive away social support, particularly when families are not starting in the upper SES brackets. Does Abilify fix this? Absolutely not. Does it reduce frequency/intensity of manic episodes? Absolutely. Some patients probably don't benefit from being on medications and we don't really do a good job managing those folks, however their are clearly patients who do benefit from the medications. Treating 1st episode psychosis is profoundly rewarding. To see a kid go from frank paranoia on an inpatient unit to getting a 30 on his ACT and landing a full ride scholarship 6 months later is... fantastic to say the least.
I have seen medications have these types of dramatic effects, but that appears to be the exception, not the rule. In so,e ways I think these types of cases are part of the problem. When I have a patient with depression that is difficult to treat and the psychiatrist gives them an SSRI and the patient is completely astmptomatic, I am blown away. Or the little girl who had Bipolar Disorder I treated for a few months with very little progress while awaiting psychiatrist appointment and then boom she was like a normal little girl overnight. If that happened more often, then that would be a good thing, but my experience is that it doesn't and that's when we have a tough time.
The majority of mental illness isn't about untreated schizophrenia, bipolar disorder, etc. It's about the public at large with very poor coping skills, personality disorders and poor insight into their own health. Psychiatry cannot fix this.
True, but psychiatrists can help and the more clear they are on what medications will treat or what medications won't or even possibly make worse, the better off we all will be.
 
Yes. My practice is not to keep people or recommend indefinite or long term medication for patients with psychosis or manic-depressive illness unless there is clear reason to do so. The most compelling indications in my mind are those with histories of violence (as there is evidence that various medications can reduce violence recidivism in those with serious mental disorders and that has been my experience in clinical and forensic practice). Some people are unable to manage off medications of course. But the evidence does not support long term treatment with antipsychotics or other psychotropic drugs as a rule and it is a shameful state of affairs that this is what has become of American Psychiatry, partly because of the special interests of the pharmaceutical companies, partly due to organized psychiatry, and partly due to misplaced liability fears on the part of psychiatrists. I also try not to start patients on medications unless I really believe they need them, and where patients are asking for them I present a full informed consent of all the potential adverse events that can occur. If they are not deterred having been fully informed of the risks and the minimal, if any, benefits then I will go ahead with it. I regularly receive unsolicited communications from patients (or more commonly family members) with mental illness from across the country, particularly psychotic illness, wanting to come off medications or concerned about the toxic effects of ongoing treatment. It is my opinion that the majority of patients labeled with "schizophrenia" and "bipolar disorder" do not need long-term medications. Many can manage without any medications at all, and are willing to trade off some "symptoms" to be free of medications and their adverse effects on functioning and quality of life. Others can be given medications during acute episodes (I treat bipolar patients with medications during the acute episode and for some months afterwards and then taper off where possible).

I believe we need to put more emphasis on the context in which people become and continue to endure so-called mental illness. As with "physical illness", medical problems are socially determined and the social world plays a huge part in recovery and relapse. We should try to maximize the resources available to people, work with families where possible, help patients understand where there problems are and how to address them, help them find meaning in their experiences of madness and mental distress, help them finding purpose in living, help them develop and maintain meaningful relationships with others, emphasize interpersonal connectedness within our therapeutic work, and consider other things that might help our patients find wellness. In particular, I am very interested in nutrition and the therapeutic value of food, cooking, and eating. I appreciate there is not a great deal of evidence or research into nutritional interventions but think this is a very promising area and would like to see more research into this area. In general, I would like to see NIMH rescue itself from irrelevance and put more effort into looking at a wide range of different treatment interventions for our patients rather than simply focusing on neuroimaging and genetics. We desperately need alternatives to offer our patients who do not want, and do not receive benefit from much of what we offer. At the same time, certain treatments (such as psychotherapies) that do work and can be helpful need to be more widely available.

Given that the prognosis of schizophrenia is worse today than it was over 100 years ago, what we are doing is not working. There are small concerted efforts to look at other models of care. The challenge is much of what would benefit our patients will not come from psychiatry. The establishment is not going to bite the hand that feeds them.

Do you have references for the bolded parts, especially the second one? I know the first one does not have a solid basis in reality. This is Psychiatric Times, but the review is excellent, regardless: http://www.psychiatrictimes.com/cou...eatment-effective-and-often-necessary-caveats

I'm with the other poster in believing that neuroimaging research will likely help the field far more than things like nutrition. You can't throw money at random treatment ideas hoping something would work. In no field of medicine are successful treatment found until the causes have been clarified.
 
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The majority of mental illness isn't about untreated schizophrenia, bipolar disorder, etc. It's about the public at large with very poor coping skills, personality disorders and poor insight into their own health. Psychiatry cannot fix this.
I think that the field of psychiatry greatly underestimates how attracted people are to the idea of being damaged. Lots of people want to have a label that marks them as disadvantaged, as especially challenged, as broken. It's romanticized in American culture. Deep down inside almost all of us burns that fire of "if you only knew what I've been through". When we give people the "depression" or "anxiety" label for what really is "poor coping skills" and "poor insight", they often feel grateful because we have validated this fire. If we tell them, "it sounds like you have a lot of work to do in your marriage" or "life is really difficult and you need better coping skills", what they hear is "your life may be challenging, but not in a special, interesting way". They want the label. And I get that there are things like trying to get disability that contributes to this as well. But don't underestimate the desire to wear the badge of honor that reads: "even a medical professional has determined that my pain represents profound suffering".

I agree. Psychiatry cannot fix this, but it does seem we are making it worse by embracing the disease model too firmly and, in turn, encouraging patients to adopt an external locus of control.
 
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I think that the field of psychiatry greatly underestimates how attracted people are to the idea of being damaged. Lots of people want to have a label that marks them as disadvantaged, as especially challenged, as broken. It's romanticized in American culture. Deep down inside almost all of us burns that fire of "if you only knew what I've been through". When we give people the "depression" or "anxiety" label for what really is "poor coping skills" and "poor insight", they often feel grateful because we have validated this fire. If we tell them, "it sounds like you have a lot of work to do in your marriage" or "life is really difficult and you need better coping skills", what they hear is "your life may be challenging, but not in a special, interesting way". They want the label. And I get that there are things like trying to get disability that contributes to this as well. But don't underestimate the desire to wear the badge of honor that reads: "even a medical professional has determined that my pain represents profound suffering".

I agree. Psychiatry cannot fix this, but it does seem we are making it worse by embracing the disease model too firmly and, in turn, encouraging patients to adopt an external locus of control.


Again, isn't this a bit ableist? No one is saying that people are broken. But some people are legitimately unable to achieve the same experiences due to inherent things about them. Like sure, if someone is a person with an adjustment issue causing depression that's one thing. But if someone is legitimately suffered from depression or anxiety all their life, that's who they are and that affects them just in the same way that losing the function of an appendage or vision.
 
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Again, isn't this a bit ableist? No one is saying that people are broken. But some people are legitimately unable to achieve the same experiences due to inherent things about them. Like sure, if someone is a person with an adjustment issue causing depression that's one thing. But if someone is legitimately suffered from depression or anxiety all their life, that's who they are and that affects them just in the same way that losing the function of an appendage or vision.
I see it similar to diabetes. There are different etiologies (and fundamentally different diseases) that result in a pathway that leads to one identifying factor -- elevated blood glucose. This can happen for a myriad of reasons. It's not always a lifestyle problem but the reality is that 90% of diabetics are type 2.

There's no denying that depression and anxiety can severely impair many people and otherwise make them appear "broken" in the absence of major underlying personality pathology or characterological failings. The problem is that for each one of these individuals that there are, there are ten others with dysfunctional life syndrome looking for validation and subtle reinforcements to the external locus of control -- and these people present to our clinics, too, arguably at a much higher rate than the first group. There's also a lot of inbetween and it's not really black and white, but you get the idea.
 
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Not going to lie, all this negativity about psychiatric treatments on the forums lately kind of is starting to make me less enthusiastic about the field as a future resident. My question is, why practice psychiatry if our treatments don't work? Or am I misinterpreting things here?
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I am not a psychiatrist but I would not be where I am today without psychiatry/psychotropic medications...biggest gripe is side-effects of the meds (weight-gain, decreased libido)...if it's all placebo then I wonder why my freakin glucosamine chondroitin do not work as well...
 
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