The article goes to great length to consider possible evolutionary explanations of autism, but never considers another possibility – Lynn Waterhouse's argument [1][2] that ASD does not exist. Waterhouse doesn't deny the symptoms exist – indeed, she spent much of her career trying to help children with those symptoms. She simply argues that the symptoms are caused by numerous unknown diverse causes in the brain, and the concept of a single disorder (ASD), or even a spectrum of related disorders (ASDs, the DSM-IV PDDs, and more recent ASD sub-typing proposals), isn't helpful in understanding those causes. Waterhouse argues that in order to have the best chance of finding effective treatments for people impaired by those symptoms, researchers should abandon the idea that ASD (or even ASDs/ASCs) is a useful concept in understanding what causes them.
If Waterhouse's position is correct, then trying to find a single evolutionary explanation for numerous diverse brain conditions (that people have lumped together under a single label) is probably not a very useful approach.
> She simply argues that the symptoms are caused by numerous unknown diverse causes in the brain, and the concept of a single disorder (ASD), or even a spectrum of related disorders (ASDs, the DSM-IV PDDs, and more recent ASD sub-typing proposals), isn't helpful in understanding those causes.
I think this is a dangerous misunderstanding of the reason for the grouping of autism-spectrum disorders under a common umbrella. The danger lies in the (all-too-common) tendency of people to think that the rejection of autism's categories means "autism doesn't exist" or something similar. The purpose of such categories is not to help understand the causes, but to help cement the reality that autism is a group of very serious disorders with similar traits.
As an analogy, many cancers that are grouped under a single name -- such as breast cancer -- are actually caused by very different genetic alterations. To use these differences as a justification to reject the concept of breast cancer would be ludicrous.
> I think this is a dangerous misunderstanding of the reason for the grouping of autism-spectrum disorders under a common umbrella
Who are you accusing of a "dangerous misunderstanding" here – her, or me? If you haven't read her work, I don't know how you can fairly accuse her of misunderstanding anything; likewise, I think having read at least some of her work is a prerequisite to be able to fairly accuse me of having misunderstood her
If your accusation is that she doesn't understand "the reason for the grouping" may I point out that she played a central role in the drafting of the PDDs section in the DSM-III-R [1]. As a former member of the DSM working group on autism, Waterhouse has a very good knowledge of the reasons and history behind the development of the "ASD" diagnostic label. Waterhouse may or may not be right, but her argument cannot be dismissed anywhere near as easily as you seem to think it can.
> Who are you accusing of a "dangerous misunderstanding" here – her, or me?
I wasn't accusing anyone specifically, merely commenting on the idea you shared. However, since you asked, I would say that the misunderstanding is on both your parts -- yours, for interpreting her arguments to mean "ASD doesn't exist" (as far as I can tell, she makes no such claim); and hers, for arguing that the formal definitions and categorizations of ASD need to be biologically valid (which they can't be, as we don't understand enough about the biology for that to be possible).
It's common for many fields of research to start with "stamp-collecting", where people just identify and group diseases and conditions and birds based on shared characteristics; and later, as the field becomes more mature, to develop more meaningful categories. I think this same concept applies to ASD.
> yours, for interpreting her arguments to mean "ASD doesn't exist" (as far as I can tell, she makes no such claim);
To quote page 431 of her book Rethinking Autism (my emphasis):
> Taken together, these three claims and associated lines of evidence argue against the existence of autism as a single disorder, spectrum, or set of autism subgroups. If autism symptoms are not one disorder, and are not many disorders, what are they? The most parsimonious and least speculative view is that autism symptoms must be symptoms.
Her book is quite explicit in its claim that autism spectrum disorder does not exist. Her conclusion (p. 433) is given under the heading "AUTISM SYMPTOMS WITHOUT A DISORDER". The whole point of her book is to argue that the disorder "Autism Spectrum Disorder" does not exist, but the symptoms do. You might say she rejects the "Spectrum" and the "Disorder" in "ASD", but keeps the "Autism" as a reference to a set of symptoms – however, her "autism" is narrower than the DSM-5's "autism", since it only includes social impairment, and considers repetitive behaviours/restricted interests and sensory issues, to be distinct symptom sets coequal with attention-deficit/hyperactive-impulsive symptoms, intellectual disability, functional language impairment, seizures, see p.434-435
To quote the blurb on the back cover "Rethinking Autism... draws the potentially shocking conclusion that 'Autism' does not exist as a single disorder. The conglomeration of symptoms exists, but like fever, those symptoms aren't a disease in themselves..." (But, the book actually goes further than the blurb says it does, because it not only rejects the idea that autism exists as a single disorder, it also rejects the idea that autism exists as multiple disorders or a spectrum of disorders, as my quote above demonstrates.)
> and hers, for arguing that the formal definitions and categorizations of ASD need to be biologically valid
Biologically valid categories would be a lot more useful than biologically invalid categories, and one of her major points is that the research community's fixation on the later is getting in the way of actually discovering the former ([1], [2]). She argues that, in place of the current widespread practice of doing research with ASD-defined samples (a confirmed ASD diagnosis as a study inclusion criteria), samples should be based on all individuals showing neurodevelopmental symptoms (mixing together ASD, ADHD, epilepsy, intellectual disability, etc, into a single sample) and then trying to study the variation in the sample in order to derive biologically valid categories to replace the existing biologically invalid ones such as ASD. [3] is an example of a study along the lines of what she recommends (indeed, they've obviously read [1] since they reference it)
> The danger lies in the (all-too-common) tendency of people to think that the rejection of autism's categories means "autism doesn't exist" or something similar.
Serious question, do you actually have any evidence for that postulation?
Even with the analogy you have listed doesn't show evidence that people would consider non-existence or reject care from individuals suffering what we today characterize as autism.
To be fair, the article did actually suggest an etiological difference between "high-functioning" and "the most severely disabled" cases.
From TFA:
"Investigating the most severely disabled autistic individuals you almost always discover damaging genetic mutations or early life trauma, such as foetal alcohol syndrome. These are clear cases of biological dysfunction. On the other hand, the less severely disabled individuals (who would once have been called Asperger’s or “high-functioning”) show none of those biological signs of dysfunction, instead showing evidence we expect from functional adaptations: the associated genes are common and complex, brain differences are subtle, the characteristics appear early in life when they are guaranteed to affect reproduction, and the prevalence is high enough that at least one person per Dunbar-sized hunter-gatherer social group of one hundred and fifty would show the same traits – in which case, every one of our ancestors would have known an autistic person. These biological signs are those we expect to see from adaptations, not dysfunction. The question we are led to ask is what autism’s function could have been."
Indeed, this sounds a lot like cancer, which has some similar effects (even on different organs), and can be induced by a variety of methods (genetic, carcinogen, etc), but is fundamentally many different conditions often requiring different treatments.
The desire to categorize and use reductive reasoning is powerful and seductive, but not always effective until you really understand the system. With human biology and brain we're a long way from that.
Waterhouse argues that the boundary between ASD and non-ASD conditions (such as ADHD, intellectual disability, epilepsy, etc) is invalid and needs to be abandoned. I'm not aware that anyone is making a really comparable argument with respect to cancer. Cancers derived from different organ tissues are usually clearly distinguishable from each other, something which is far less true when talking about different psychiatric/psychological/neurodevelopmental diagnoses.
I've not read her book (though it's going on my list), but the second citation in your first comment suggests that it's just on the research side that they should abandon current classifications, but that the DSM definitions are still needed on the clinical side.
Does she propose a better classification system, something like what she'd replace it with in the next DSM if it were up to her? Because if we don't yet know how to split current ASD diagnoses into more specific classifications, isn't it better to have this rough grouping than to say "this person has an unknown disorder"?
> but the second citation in your first comment suggests that it's just on the research side that they should abandon current classifications, but that the DSM definitions are still needed on the clinical side.
Her book is largely focused on research, it has little to say about clinical practice. The paper she coauthored which I cited does argue, yes, that the current DSM diagnosis should be retained in clinical practice for the time being, even while they think it should be largely abandoned in research. However, I think their justifications for its continued clinical use are somewhat undermined by their arguments against its research use. That paper says "The ASD diagnosis remains necessary in the clinic to assign a child to early behavioral intervention and to explain a child’s condition". The paper argues that ASD lacks biological validity and construct validity – how can something which lacks validity actually explain anything? A diagnosis lacking validity must in itself be causally inert; and if the diagnosis is reduced to a symptom set as Waterhouse's book argues, then using it to explain symptoms becomes circular ("the symptoms are explained by the symptoms").
> Does she propose a better classification system, something like what she'd replace it with in the next DSM if it were up to her?
Her book proposes the definition of two phenotypes (not disorders) on p. 434-435. The first is "Neurodevelopmental Social Impairment Only Phenotype", which is basically equivalent to DSM-5 ASD criterion A (social impairment present from childhood), but with an exclusion for atypical sensory behaviours, atypical motor behaviours, rigidity in behaviours or interests, atypical language development (functional language impairment), ADHD symptoms, intellectual disability, developmental delay, or seizures. This phenotype is broadly similar to DSM-5 social (pragmatic) communication disorder (SCD), except it makes no claim to be a disorder, only a phenotype (symptom set), and also that it has broader exclusions – DSM-5 SCD doesn't exclude ADHD symptoms or seizures, for example, her first phenotype does. Her second phenotype is "Neurodevelopmental Social Impairment Multi-symptom Phenotype" which requires neurodevelopment social impairment combined with one or more of the exclusions from her first phenotype.
As well as criticising the DSM-5 for proposing a disorder as opposed to a mere symptom set / phenotype, she also criticises its two-domain model, which requires both social communication symptoms and RRBI/sensory symptoms for a diagnosis. She instead proposes a model with one core domain (social communication) and a set of optional domains, none of which are required, and of which RRBI symptoms and sensory symptoms are just two additional symptom domains out of several. She justifies this on the grounds of clinical experience that social communication impairment can occur without RRBIs or sensory issues – this clinical experience is reflected in the DSM-5 diagnosis of SCD.
The relationship between SCD and ASD is arguably one of the most poorly thought out aspects of the DSM-5, and in practice many people who strictly speaking should get an SCD diagnosis get given an ASD diagnosis instead, despite not actually fully meeting the ASD criteria – many clinicians are very hesitant to use the SCD diagnosis even when the letter of the DSM-5 would indicate it, due to SCD's lack of public awareness and unclear eligibility for funding. SCD itself is a strange lacuna in Waterhouse's book – despite SCD's obvious relevance to her argument, she hardly ever mentions it by name.
Don't know if you get reply notifications, but I forgot to reply the other day saying thanks for this comment. I'm looking forward to reading more on the subject!
Is the history of psychiatry one of progress? Or is it one of damage and partial repair? I very well might not be alive if not for my SSRI prescription, but the side effects are brutal and lasting, and as a first-line treatment for kids too young to drive it really leaves a ton to be desired.
> I very well might not be alive if not for my SSRI prescription, but the side effects are brutal and lasting
The history of legal psychoactive medications is littered with dubious and ethically questionable choices. Here's some 1950s era psychiatric medication advertisements targeted at doctors:
I'd say that it is one of progress, but one in which outdated or poor practices overshadow that progress. I can't speak of the prevalence of such practices, but rather I mean the result of mistreatment is apparent and rapid while relative success is subtle and gradual.
It's generally understood that medication should be used as a backup after CBT or other forms of therapy and if you do need medication, it should be concurrent with that therapy. Psychiatric pharmacology is more complex and opaque than others, but there is progress being made on that front as well.
The more apparent progression being made is in understanding the neural mechanisms for these disorders and thus, determining alternative methods of treatment as a result, such as transcranial magnetic stimulation targeting individualized neural correlates (e.g. stimulating areas near the surface of the brain that have functional connectivity with deeper parts of the brain to activate/inhibit areas like DLPFC) and discovering relationships between certain mechanisms and certain disorders to investigate other pharmacological avenues (e.g. ketamine loses antidepressant effects when opioid receptors are blocked with naltrexone).
Another issue is that this progress in research takes awhile before you see results in practice and much longer for it to disseminate through the whole psychiatric community.
>It's generally understood that medication should be used as a backup after CBT or other forms of therapy and if you do need medication, it should be concurrent with that therapy
You say that, but from my experience medication is the first line treatment. Often there isn't even any other type of treatment that comes with it. You just try a whole bunch of different ones and hope for the best.
>The more apparent progression being made is in understanding the neural mechanisms for these disorders and thus, determining alternative methods of treatment as a result, such as transcranial magnetic stimulation targeting individualized neural correlates
Considering what happened the last time psychiatrists fiddled with people's brains I find it fascinating that anyone is willing to try this. Lobotomies were done for years by actual physicians, yet it was pretty much the worst possible horror show imaginable. Did they get it right this time?
I think the greatest problem with it is its adjacency to psychology and patient care. It removes some of the rigor from the treatment that the patient gets, because most of the time the patient is not interacting with doctors or even nurses. It'll be social workers of some form that may or may not have some training in trying to help people with mental health issues.
> You say that, but from my experience medication is the first line treatment. Often there isn't even any other type of treatment that comes with it. You just try a whole bunch of different ones and hope for the best.
I should have expanded on that particular point. It's widely understood in the research side that medicine should be a back up, but the practicing side of psychiatry is often completely detached from the current research, so it takes far too long for the body of knowledge to propagate into the practicing side. The impact of research on application is a far cry from where it should.
> Considering what happened the last time psychiatrists fiddled with people's brains I find it fascinating that anyone is willing to try this. Lobotomies were done for years by actual physicians, yet it was pretty much the worst possible horror show imaginable. Did they get it right this time?
The safety of TMS has been studied for a few decades now and its safety (and efficacy) is also being further understood with scanning someone with fMRI while simultaneously stimulating with TMS, which is pretty difficult since you're blasting a magnetic pulse at the same time that you're imaging using magnetism.
As with most medical interventions, there is a risk. More specifically, there are two primary risks: triggering a seizure from an epileptic patient by using too high of a pulse near the motor cortex or exacerbating a patient's current hypomanic/manic symptoms. It's much less invasive and much safer than things like ECT and DBS. Once again, this is a last resort and used for people things like treatment-resistant depression or PTSD. It's used after trying multiple medications, not because it's riskier, but rather because its effects tend to be acute in lasting anywhere from a few months to a few days after a session.
> I think the greatest problem with it is its adjacency to psychology and patient care. It removes some of the rigor from the treatment that the patient gets, because most of the time the patient is not interacting with doctors or even nurses. It'll be social workers of some form that may or may not have some training in trying to help people with mental health issues.
I agree that this where a lot of work needs to be done. In my opinion and in terms of widespread issues like depression and anxiety, psychiatric treatment should sought or referred after clinical psychologists have exhausted most or all of their options and should be taking on the brunt of those problems, not social workers and counselors. Too much rides on the latter's shoulders due to the barriers a lot of people face getting access to effective mental health professionals like clinical psychologists and psychiatrists. It doesn't help that a lot of general physicians will try to play the role of psychiatrist as well.
>Another issue is that this progress in research takes awhile before you see results in practice and much longer for it to disseminate through the whole psychiatric community.
The problem is that when I was a teenager I could walk into any psychiatrists office and leave with whatever drug I had decided I wanted to get high off for that weekend. I memorized a list of symptoms, said I had them to a GP, got a referral to a specialist and repeated them there again. If I started on Monday I could get a prescription by Thursday. Having talked to "problem" kids of friends it that's still the case today.
I never took the field seriously, and until I became an adult didn't realize anyone else did either. I just thought of them as legal drug dealers with good quality product, but not as fun as the unregulated product you could get on the street.
Imagine my surprise when I found out people actually took prescriptions for decades at a time, something that is as horrifying to me as drinking yourself to sleep every night because someone told you to.
So your problem with the field of psychiatry is that psychiatrists can be lied to and they don't put more effort into second-guessing their patients' experiences?
...
...
I think you might just be blaming other people for your unethical behaviour as a teenager.
> If there is no way to detect false positives, then everyone is a false positive.
That does not logically follow.
Proof by contradiction:
I have invented a dumb test for COVID-19: I look at a linkedin profile of someone, then I lick a block of salt. If my tongue tastes salty, then I conclude they have COVID-19. Trivially, my test has no way to check for false positives. So, if ran this test on someone, your statement implies that they would be a false positive and therefore they would definitely be free of COVID-19.
Unless you think my salty tongue has magical COVID-curing powers, then even a broken clock is still right twice a day.
I've never seen anyone use false negatives to argue that we should accept false positives as reasonable. I guess there's a first time for everything.
But to answer your question, yes, it would be statistically prudent to assume that everyone who passed your test is free of covid because the proportion of the general population who have it is less than 1% currently and your test produces a 100% positive rate.
And how about people without real psychological problems who ruin their lives?
Psychiatry has a rolling history where everything that was done 30 years ago is so barbarous that the treatments are criminalize, and it has been that way for a century. At what point are we going to realize that there is no baby in the bathwater?
I totally forgot to elaborate on that sentence. I meant to say that it's widely understood within the research community and recently graduated psychiatrists. There's still a lot of bad practice, outdated methodology, and general laissez-faire that the field is still shaking off. It's lingering way too long and dissemination of the up-to-date knowledge is much less effective within psychiatry than other areas. This may be due to it not being readily apparent that you're harming the patient compared to say cardiology, but I can't say for sure.
The field of mental health is definitely in a sorry state today, at least in the US. A lot of progress is being made in terms of research and knowledge, but it's not as impactful on the practicing community as it should be.
I believe more research is required for r-ketamine (arketamine) I wonder if it has effects on the opiod system also
They also thought that the mtor pathway was necessary but trials with human subjects and rapamycin showed that it potentiated the AD effects in humans . Which is sad to hear because it was the basis to the creation of NV-5138 that's heading towards phase 2 soon . It could very well work because the mtor pathway Is complicit In mood disorders .
Also advances towards TMS is very interesting check out stanford's SAINT TMS trial
Currently what I'm interested in is vistagen's pipeline of drugs . It works unlike any thing else and also the various FAAH inhibitors
I'm really angry at Pfizer and co for ditching MAOIs for SSRIs. All research shows that they are much more effective, have no emotional blunting effect and have less impact on libido, at the cost of not being allowed to eat cheese and some insomnia.
SlateStarCodex wrote about it in his prescription perversity post. [1]
I remember being told to watch out for side effects when switching from an SSRI (Trintellix) to a RIMA (Manerix), which is essentially a de-fanged MAOI. Younger psychiatrist kept pushing for the brand-new SSRI, I kept pushing back. Never mentioned anything else despite my attempts to open the discussion, and my own research (and in fact, experience thanks to darknet markets) over years.
Eventually "agreed to disagree" (I hate this expression), I moved on from that place where I was stagnating in pain, and found a sensible knowledgeable psychiatrist who happens to be much older, and we made the switch.
It's hard to understate how much of a change that was in my life. I try not to be bitter about any fresh new psychiatry grad on the block, but I really hope they get their shit together as a collective and observe what their own patients (and their older peers) seem to know better than them.
No matter how much tyramine I ingest (which is supposed to be a no-no on MAOI/RIMA) the worst side effects I suffer can't even get anywhere near what the SSRI would TYPICALLY do to me.
On Trintellix: morning headaches, being unable to have any caffeine, becoming lactose intolerant, frequent cramps and diarrhea. Depression very very mildly alleviated. Transition period when stopping the meds: 2 weeks. Cost of monthly refill: $110 CAD.
On Manerix: some cramps if I ingest gigantic amounts of tyramine (I'm french, I'm talking cured meats+cheese plates and red wine bottles in the same meal). Could be back to coffee and milk with no headaches nor cramps within a couple weeks. Depression mostly alleviated. Transition period when stopping the meds: 2-4 days. Cost of monthly refill: $30 CAD.
Oh and the kicker? Manerix is actually one of the few antidepressants that actually has a chance to "increase libido" as a side effect!
I'm glad someone wrote a good article on what I've been hoping to articulate in different places over time, thanks for the share.
This seems like an arbitrary and unhelpful distinction to make. Better medicine can be made later, all that new medicine has to be in the present is better than what was previously available.
Let's not get ahead of ourselves here -- antidepressants don't really have an effect. If a person was feeling suicidal before, they would certainly not stop feeling this way after taking SSRIs. Symptoms of depression is our psyche showing us that something going on in our lives is not going well, and using drugs to suppress these feelings is the worst thing I can think of that modern medicine came up with.
As someone who has taken SSRIs they usually do have effects. You can take them as a healthy person and they also have usually effects.
There is more diversity to people and their thoughts than your simple philosophy suggests; people may suffer from mental illnesses for no apparent reason, like how people may suffer from poor health in the same environment as a healthy person. And with antidepressants on a person with a condition stemming from a poor lifestyle, the effects can be what makes the difference that helps them transition to a more sustainable lifestyle.
Ignorant, grandiose claims like these really don't help people suffering from mental illnesses.
My understanding of the research is that, compared to a placebo, antidepressants help as much as 20% more of the population (20% -> 40%), and the broader scope of drugs can help around 30% to 40%[1] of people. People routinely feel suicidal, take SSRIs, and later stop feeling suicidal.
The main stumbling block of evolutionary psychiatry (psychology?) is that one is always in danger of coming up with ever more clever just-so stories that can never be proven or rejected by experiment but rely on who has the most compelling argument.
The author also makes a grave but subtle misstep when he says “the eye evolved to see” - the eye most decidedly DID NOT evolve to see. The eye evolved and does see but importantly evolution has no intent, it has no goal and it has no purpose. I might sound pedantic but there is an important distinction between “the eye sees” and “the eye was meant to see”.
What remained the same: healthy people still can't relate very well to people with a mental disorder. That's probably why cancer research gets a multiple in funding of what research into mental disorders gets.
People with mental disorders cannot relate very well to people with very different mental disorders as well. Someone with a mood disorder may still be bigoted towards someone with a developmental condition like ADHD.
It is not just issue of feeling related. Some mental health issues have massive impact on those around and on their mental health.
For example, mood disorder may mean you get yelled at and insulted or put down a lot, unpredictably and for no own fault. It may be result of sickness, but verbal abuse consequence is same.
> What remained the same: healthy people still can't relate very well to people with a mental disorder.
I'm not sure if there exists a such crisp boundary. Lifetime prevalence of mental illness in the US is about 50%. In any given year 25% of the adult US population will have a mental illness. [1]
> That's probably why cancer research gets a multiple in funding of what research into mental disorders gets.
Cancers amounts for 15% of disability claims while mental illness does 10%, that might be one driving factor. (Not saying it is justified). The other one is, unlike cancer, most mental illnesses are explained with a bio-psycho-social model, which is incredibly hard to design comprehensive interventions for, or to get enduring results with one-shot interventions.
We know quite a good deal about how adverse childhood experiences, economic hardships, familial structures etc affect mental health. The problem is there is only so much space for intervention there that doesn't hinge on societal restructuring. Which is why the agency we exercise in response is limited to pharmacotherapy and talk therapy, at least those insurance would pay for.
Everything I know about psychiatry and therapy has me believe we are in the alchemy phase of mental health practice.
We have a huge number of theories and arguments that all sound reasonable but are contradictory and fail horribly when applied to everybody with the same disfunction label.
We are not without success examples but I don't know if overall we are at net possitive.
What I dislike mostly about the situation is pacients and families rarely being made aware of the gamble that is treatment. If the situation is bad enough you have basically nothing to lose, so sure, try anything at your disposal. But medicating young boys for being unruly for example...
There are certainly treatments that are based on evidence and capable of helping individuals in a variety of circumstances. From what I've read, Cognitivr Behavioral Therapy and some of its spin offs really do help people recover from trauma. The problem, as far as I can tell, is that not all practicing psychiatrist choose to use them.
The trouble with evolutionary explanations of human psychology is that they are "just so stories". Actual tests of these hypotheses are extremely difficult. Sometimes you can get somewhere with experiments on other mammals, but for the most part its high piles of speculation. The little story about the possibly autistic reindeer herdsman is a case in point. Nice anecdote, but the plural of anecdote is not evidence.
Then you mix in speculation about primitive tribes with considerations of supernormal stimulii and possible actual disease or genetic damage, and you wind up with exactly the same morass that the article complains about in current psychiatry.
And even when you have a tested theory it provides very little guidance about how to help afflicted individuals live in modern society.
This article is fascinating. It proposes an evolutionary theory of mental illness (e.g., "Psychopathy...as a cheating strategy which is game theoretically optimal for some portion of a group."). What might be the evolutionary reasons for Depression and Anxiety?
I take 225mg of venlafaxine every day and I am entirely serious that this medication saved my life. I've tried tapering off and the debilitating malaise came back.
I'll probably take these pills as long as I live, and I'm okay with that because they give me the energy to function, to improve and thrive. Without medication I would not have been able to work on my mental health in non-psychiatric ways, which has also been tremendously useful.
There is plenty of empirical evidence that antidepressants and other psychiatric medications have a significant effect of reducing or relieving symptoms, which help manage living with the respective disorder and/or help the patient work towards "healing", such as giving a patient enough relief to be motivated to actually go to recurring therapy or CBT sessions.
I honestly have no idea why someone would make such a comment whilst being so blatantly ignorant of the subject.
Linking to an arbitrary article that is somewhat related to the topic is not helpful. Please try to at least give some context for why you believe the article contains a relevant response to your parent comment, out of common courtesy if nothing else.
For a lot of depressed people, medication can significantly improve their life. This has been proven time and time again through double-blind clinical trials, just like any other medication that gets sold.
While for some people the medication becomes a permanent part of their lives, there are others it just helps get over an episode. Are they suffering from the same disease, just with a chronic vs episodic form? Are they in fact separate diseases? Are the drugs curing some people but only 'sustaining' others? I don't think we have the answers to these questions yet, but that doesn't mean that we don't have a wealth of evidence that these drugs can do more good than harm.
Medication alone does not cure those things (who’s saying that?) but it does help you endure them and make you available to other kinds of treatment. You can’t do psychotherapy if you cannot talk or leave the house at all, for example.
Some conditions require life long management with or without medication.
Some people will eventually be able to stop taking the meds. Others won’t.
For anyone reading this and considering seeking help: There is a strong anti-psychiatry movement online following in the footsteps of the anti-vax movement.
Please ignore it. If you have concerns about your mental health, please don’t hesitate to contact a medical professional. Note that medications are not the only approach to treatment, although we have decades of evidence showing that they do show benefit in helping many people as part of their journey toward better mental health. However, plenty of people have great success with therapy-only if that’s your preference. The most important thing is to try to make progress, try different treatment modalities, and see what works for you.
It's not like there are two discrete camps who are either for or against everything modern psychiatry has to offer. Equating it to the anti-vax movememt is disingenuous.
Yes, if you need help, seek it. Also don't be afraid to see several psychiatrists just like you might see several doctors. Feel free to question their decisions like you might question a normal doctor. There are rarely perfect cures for mental illnesses. Be wary of anecdotal evidence online. Be wary of the side effects of both prescription medicines and herbal/nutritional supplements. Suicide is never the best option. Be honest with your medical providers about how the medications are working for you and don't be content with poor outcomes. It may take a while but you will probably find some combination that works for you. Like any medical treatment, the best cure may not be perfect and you may have to accept some undesirable side effects though. Just keep trying and have as much patience as you can muster.
> It's not like there are two discrete camps who are either for or against everything modern psychiatry has to offer. Equating it to the anti-vax movememt is disingenuous.
I was responding to the parent comment, which claimed (falsely) that scientific consensus showed that psychiatry does not work at all. Claims like that are indeed equivalent to anti-vax movements.
I’m not suggesting that psychiatry is without nuance or debated topics, but the parent comment was spreading false and potentially damaging information.
As always, please consult with a medical professional, not random internet comments dismissing entire fields of medicine as a hoax.
OP said "It's clear scientifically that no medication heals depression or addiction and yet these pills are happily prescribed in psychiatries."
That is a far fetched claim regarding psychiatric medications(not psychiatry in general) but it is not without merit. I chose to forgo most medications because of the side effects. I have a friend with a similar set of problems and he's on something like 7 different meds and they're still changing after years of working with his doctor. They have kept him alive and yet he is worse off every time I see him.
There are also many, many people who are helped by psychiatric medications. OP is wrong that there is no evidence for effectiveness of any medications but there is still some debate over the effectiveness of some classes of drugs(SSRIs for instance, last time I looked).
We will have to agree to disagree on the appropriateness of likening criticism of psychiatric medications to the anti-vax movement.
> OP is wrong that there is no evidence for effectiveness of any medications but there is still some debate over the effectiveness of some classes of drugs(SSRIs for instance, last time I looked).
Strongly the agree that the OP is wrong. I’m not sure why it’s so contentious.
As for SSRIs: The famous paper questioning their effectiveness has been widely panned for coming to misleading conclusions. If you read the paper, even their conclusions show SSRIs outperforming placebo. The authors used a cherry-picked analysis technique (“effect size”) to argue that the effect size was not as large as they’d like, despite showing that the effective size of SSRIs was in the direction of showing superiority to placebo.
It’s also difficult to evaluate these topics without fully understanding the science. SSRIs aren’t evaluates in isolation, they’re evaluated in relation to placebo. The problem is that placebo shows remarkable efficacy in some patients. This doesn’t mean that SSRIs are placebo (they still separate from placebo) but it does require careful analysis of the data. For example, SSRIs are significantly more effective than placebo in patients with severe depression, but they separate less in patients with mild depression. None of this means they are ineffective, but the data is often misconstrued as such by those with an anti-medicine agenda.
I’m glad you’ve found a solution that works for you, but please refrain from projecting your own medication choices on to other vulnerable people online based on a cursory understanding of the research.
> There are also many, many people who are helped by psychiatric medications.
Strongly agree.
Everyone should defer to medical professionals rather than HN comments for treatment decisions. It’s very unfortunate to see so many people choosing to avoid treatment for years out of unfounded fears of medications they’ve read online, just as it’s sad to see people avoiding vaccinations due to something they read on Facebook.
> I was responding to the parent comment, which claimed (falsely) that scientific consensus showed that psychiatry does not work at all. Claims like that are indeed equivalent to anti-vax movements.
You didn't respond specifically to the claim. It was just used to dismiss all caution in dealing with psychiatric medication as though it has the degree of certainty and understanding as vaccines.
But how would a depressed individual (I'm talking extreme depression) be able to consult multiple doctors and try different medications which also only become effective after several weeks?
This sounds like a task a healthy individual could carry out, but a depressed person is suffering every minute, they need immediate relief.
I saw that esketamine got approved both in the US and EU, but it's only prescribed after 2 classical medications failed.
How is a person suffering daily expected to wait so long?
I'm bipolar with a touch of OCD so I know the struggle. I've managed to get by with illicit substances and nicotine at times but I know that's not a real option for most people. When I finally decided to seek help, the first psychiatrist I saw was nuttier than I was though.
If someone is extremely depressed, they probably aren't even going to seek out help. It's up to the people around them, if there are any, to try to get them the best care. What I was getting at with my comment isn't so much for the emergency situation as it is for the long term. You have to start somewhere, but then continue to push for better. Honestly, even healthy folks have issues with fighting for the best care though.
The real solution, if there is one, for mental health is to have healthy, intact families, communities, police, social workers, medical systems and governments all coordinating, but now that looks like a pipe dream so we do what we can.
Many people live with spouses, friends, or relatives that can help with that.
And some actually can take their medication as prescribed. I (bipolar disorder) certainly could and can. It’s a very low effort treatment. Just take the pills.
On that "try different treatment modalities" note, for talk therapy (which is very often not handled by a psychiatrist, but by a psychologist), don't be afraid to find someone else if you feel your therapist isn't helping. Having been in and out of therapy for half my life, I've had therapists I really related to, and ones who actively made me feel worse. That being said, it can take a few sessions to figure out whether you're going to get along with your therapist. I recognize that many people might simply not have other options, and it can take months to find a replacement, but trust me when I say that sunk cost fallacy thinking of "oh, it took me 2 months to get my first appointment, and now I need to find someone else who I'll also have to wait 2 more months to see" is a trap.
Absolutely. Also note that any primary care doctor or psychiatrist will have a list of psychologists or therapists to refer.
Making medical appointments, especially therapy appointments, has never been easier now that Coronavirus has pushed everyone to adopt virtual health appointments. You can find a provider and book appointments from an app on your phone in most cases. The appointments are handled virtually as well. No need to pick up a phone to schedule something. No need to get in the car to drive somewhere.
> For anyone reading this and considering seeking help: There is a strong anti-psychiatry movement online following in the footsteps of the anti-vax movement.
There has been a strong anti-pschiatry movement in academia/science. It's not just "online", it's in the real world.
> The most important thing is to try to make progress, try different treatment modalities, and see what works for you.
We also have a over medication issue which leads to a lot of deaths just on mistakes alone.
"Well over 125,000 people die from drug reactions and mistakes each year, landmark medical studies of the 1990s suggest."
More people die from drug mistakes in the US each year than has died from covid so far.
There is a lot of "anti-X" online, but there are also a lot of "pro-X" online from fanatics, pharma advertisers, etc. And for all the psychiatry and drugs, we keep getting more mental issues rather than less. Perhaps it's society.
But I've noticed a very vocal and well placed "pro-[fill in the blank]" online. Haven't a clue who is funding the "anti-X", but I have a good idea who is funding the "pro-X". But yes, people who really truly absolutely need help should seek it. There has to be a balance between no medication and overmedication because both are harmful to individuals and society at large.
> For anyone reading this and considering seeking help: There is a strong anti-psychiatry movement online following in the footsteps of the anti-vax movement.
I don't think it is fair to compare criticism of psychiatry to criticism of vaccination. The science behind vaccines is actually far more advanced than that behind psychiatry. With vaccines, we have identifiable infectious agents which we know exist and are distinct, and we are trying to develop safe and effective ways of teaching the body's immune system to fight those identifiable infectious agents. In psychiatry, the targets of treatment haven't even been clearly identified – documents like the DSM-5 contain long lists of "disorders", but few believe the DSM-5 is an accurate reflection of what's really going on in the brain [1]. People talk about entities like "ADHD","ASD","OCD" as if they are distinct entities in nature, when we have evidence that the distinction between them is mostly invented by humans [2]
The effect of psychotropic drugs on the brain, and other body systems, is very complex and not completely known. The side effects of vaccination are significantly less, and vaccines tend to act much more narrowly on just the immune system. As a generalisation, vaccines are more safe and more effective than psychotropic drugs. I don't argue that nobody should take psychotropic drugs–some people are really helped by them–but it is unfair to compare people who are concerned about their harmful side effects (e.g. antipsychotic-induced brain atrophy [3], [4]) to anti-vaxxers
Meta studies on vaccines find them to be generally effective [1] but the government has managed to screw up major drives and damage peoples view of vaccines because of those [2].
Psychiatry on the other hand has evidence that disappears every time someone tries to replicate original drug trials:
>The replication crisis addresses a fundamental problem in psychological research. Reported associations are systematically inflated and many published results do not replicate, suggesting that the scientific psychological literature is replete with false-positive findings (Pashler and Harris, 2012; Yong, 2012; Aarts et al., 2015) [...] outline some specific issues underscoring that inconsistent and systematically biased research findings persistently compromise the yield of clinical research.
>Concerning replicability in psychotherapy research, the main question to pose is: How much can we rely on the published evidence? To start with it needs to be acknowledged that the average efficacy of psychotherapy based on the scientific literature is systematically overestimated due to publication bias (Cuijpers et al., 2010a; Driessen et al., 2015; Cristea et al., 2017a).
> There is a strong anti-psychiatry movement online following in the footsteps of the anti-vax movement.
Yeah, I don't think it's fair to compare the two. I won't pretend to be an expert, but vaccines have a much better history when compared to antidepressants.
I agree that people suffering should seek help, and antidepressants may be key to that. But I also think we should be honest, for some they cause more problems than they solve.
It annoys me that any criticism of medicine puts you into the anti-vax camp. It's dismissive. Have we forgotten what happened with opioids?
Could you explain what is meant by "same amount of evidence"? Do you literally mean the number of articles published finding beneficial uses of psychiatric medications? The number of positive testimonials? Newspaper articles? YouTube videos?
They have the same kind of evidence. There are double-blinded studies demonstrating their efficacy or they wouldn't be on the market. When used properly most vaccines are highly effective and protect the large majority of people who get them. Maybe more importantly we understand in some detail how they work. Psychiatric conditions and their treatments are much less well understood. The medications generally don't have as powerful an effect as a vaccine. That isn't a reason not to use them.
Literally every psychiatric drug on the market has a clincal trial or study. In order to be FDA approved any drug has to have large scale double blind studies to prove it's safety and efficacy and those studies are public. That's the law. Here's how to find info on them. That isn't to say every drug is good, or that occasionally there are side effects which cause a drug to be withdrawn from the market, after approval, but that's very rare.
Why would anyone want to continue to engage with your bad faith argument? Science doesn't work on the basis of "linking to one study" and to try to make a point by demanding one shows that you're not interested in an actual discussion. But, sure, here's a single, arbitrary metanalysis on several studies on the efficacy of a single antidepressant: https://journals.sagepub.com/doi/pdf/10.1177/204512531662907...
You're incredibly hostile in your remark to someone asking for a study. I haven't made any argument, and you continued with logical fallacies (strawman argument), I never said anything about one study proving anything.
I've actually researched this area for years, I was curious what your study would show and how it would evaluate the efficacy of antidepressants.
What your arrogant and antagonistic communication hasn't mentioned is that there is no link here to show anything a link to the brain, only to the symptoms (which you did mention), but failed to take the actual argument -- which is about chemical imbalances which Psychiatry as an industry (as an individuals) have been claiming they're close to since the 70s and have failed to prove that claim -- ever.
Blocking symptoms also needs to be shared with the accompanying side effects which were neglected both in your study reference and in any mention of the drug -- and you will find them _with all_ anti-depressants.
The particular one you mentioned, also in the Wellbutrin family, has had studies in eight different countries which detail their side effects, including suicide, mania, and psychosis.
You've linked an article that cites one study which found weak evidence for the effectiveness in depression of one particular medication that is not widely approved for use in depression.
What is the point of this link supposed to be? That we shouldn't be prescribing bupropion to patients? Perhaps - most likely SSRIs and other drugs are more reliable, but it doesn't hurt to have a wider variety of classes of drugs to try.
Thank you. This is a much more intellectually honest response.
> That isn't a reason not to use them.
To give one example of where this is unclear, consider antipsychotics. Brain shrinkage is a known issue in schizophrenic patients that hasn't been ruled out as not coming from medication due to ethical issues in conducting the associated studies. Some schizophrenic patients also recover without them.
Comparing a valid concern like that to anti-vaxxers seems disingenuous to say the least.
Psychiatry as a profession is very dark. Even today if someone is wronged by it. They will receive little to no remedy unless very financially well off, or public outcry, and or the psychiatrist admitted wrong to his or her actions.
I frequent a website where most people are seeking to end their life from an assortment of mental illnesses. Majority of them have tried multiple psychiatrists as well as therapists and with little to no success in curing their suffering. I find it egregious that people may think psychiatrists actually seek the benefit of the patient's wishes because I know personally the request for MAiD falls on deaf ears. Instead these patients continue to experience involuntary treatment if they live in less civil countries or advised to try different medication.
I've known someone labeled schizophrenic where it costed their insurance well over 60k and in less than a year from involuntary hospitalization while being drugged & observed. I know other psychological illnesses like Gender Dysphoria where a person went through the wrong puberty never get that funded for their quality of life to improve (fixing voice & appearance). Anyway I think the whole field is very questionable if psychiatrists have a sincere interest in the person their treating that's basically their customer that keeps coming back.
If Waterhouse's position is correct, then trying to find a single evolutionary explanation for numerous diverse brain conditions (that people have lumped together under a single label) is probably not a very useful approach.
[1] https://books.google.com/books?id=IaFY8r0rpn8C&printsec=fron...
[2] https://link.springer.com/article/10.1007/s40489-016-0085-x