I get weird restless leg things too. My main symptom is that when I get really tired, I *need* to move my legs around. It doesn't hurt to keep them still or anything, it just makes me very, very uncomfortable in a way that is a strange blend of the physical and psychological. I also tend to twitch and kick while falling asleep, and for a while it was violent enough that I took some low-grade muscle relaxants, which helped. They helped my wife more than me, but you know what I mean.
I am as skeptical about psychoactive drugs as the next melancholy narcissist, not least when it comes to the issue of drugging people who haven't been convicted of any offense into an arbitrary "base case" emotional state, but when I mention that to my father, he takes the position that such medications have made it possible for many people to live normally and independently who, as recently as the '70s and '80s, would have languished in lonely misery or simply have died of being misunderstood by friends, family and/or the authorities.
Life sucks. Placebos are the opiate of the bourgeois. See Richard Grieff. I hope the illusion has a long future, because a world where happiness is easy or lethe unavailable is not attractive.
"...pychiatrists are little better than witch doctors. "
"Witch Doctor" is a pejorative name for various kind of traditional healers who use plants based medicines to effect actual cures. There is a good reason Big Pharma sends people all over the world looking for traditional plant based treatments and then analyzes the plants for ingredients that can be turned into patentable medicines. Getting hung up on the chanting and prancing around waving chicken feet is a serious mistake.
I think psychiatry is very much on the level of witch doctors - some complete (and even harmful) bollocks and some genuinely effective cures. Dismissing the whole thing based on the ineffectiveness of some element is very harmful to those who are helped by the effective components of the practice. We ought to be looking at identifying what works and what does not rather than dismissing the whole thing.
And while I'm defending things scientists are supposed to abhor - the placebo effect refers to people actually getting better by taking inert substances. Personally I rather like getting better and don't really give a damn about the means by which it takes place. I strongly suspect that witch doctor's chanting and spooky atmospherics are quite effective for those who genuinely believe, thanks to leveraging the placebo effect.
As you might expect, I am well acquainted with several psychiatrists! They're the BEST!
I'm totally dependent on anti-depressants. If I miss two days in a row, I take to my bed like a Victorian invalid.
It is entirely possible, though, that you can substitute a placebo for my meds and it would work the same way. One theory of why the placebo effect has been increasing for anti-depressants is that the drugs now have a reputation for working. At this point that is very true for me.
(I haven't read the article, but I will if I get some quiet.)
Yeah, I haven't read the article yet either, but the bigger point about drugs not doing better than placebo is that placebos are often pretty good.
SSRIs have well-documented effects in animals.
They're quite possibly widely overprescribed by psychiatrists in the US. I think that, like other MDs doing fee-for-service, when faced with patients asking for improved function who are basically normal, they say yes too often. Are plastic surgeons witch doctors? They serve the burned and the vain alike.
SSRIs definitely help some people who are clearly clinically depressed rather than just unhappy. I'm not an expert, maybe they are also harmful under some circumstances.
The common-sense sounding story that I've heard is that the drugs enhance neural plasticity among other things (definitely true), and so make depressed people even more susceptible to environmental influence (who knows).
Just this morning my psych and I agreed that I will quit taking my SSRI (I'd been tapering down for a while). I am entirely unsure that the few years I was on it did much good; so many things changed in my environment that one could reasonably conclude that all of the effects I was having were the normal reactions to the stresses I was under.
possibly widely overprescribed by psychiatrists in the US
Absolutely over-prescribed and, in my non-rigorous observation, especially so to young women. Almost every woman I know was on them at some point during their twenties.
10: That sounds plausible, even past their 20s. I think every woman I know well enough to know this about them, bar one, is on one or more SSRIs and/or antianxiety medications.
I thought there was a recent study tending to show that the placebo effect was a myth -- that untreated conditions, whatever they are, just get better a certain percentage of the time with or without a placebo, and placebos don't seem to improve things over simple non-treatment. Anyone remember this?
Here's a psychiatry prof in the NYT recently writing in defense of antidepressants.
The question raised in 12 is discussed in the link in 13.
12. The precise definition of "condition" is critical to thinking about this. Good luck on that with disorders like depression or hypertension.
Kramer, linked in 13, is basically dismissed as a stooge in the service of pharma by Salmon in the original post.
I sort of agree that the dsm is compete crap. But I do believe in better living through chem. Drugs do treat symptoms quite usefully. The other mistake its thinking that the rest of medicine is reaaly all that far ahead of the witch-doctoring.
IME, some people react very badly to SSRIs, and the idea that everybody I knew in any definable cohort was on them would terrify me.
And over 95% of the improvement in psych drugs since the early sixties has been making the with fewer side effects. But one mans side effect us another woman's fix
widely overprescribed by psychiatrists in the US
Count me in favor of overprescribing SSRI's. Like statins, they fall into the category of drugs that are so valuable to those who need them, so benign to those who might take them unnecessarily, and so cheap (the off-patent ones, anyway) that there ought to be a bias in favor of overprescribing rather than underprescribing. I'm not quite to the point of wanting to add them to table salt or breakfast cereal, but it's close.
so benign to those who might take them unnecessarily
I'm not sophisticated at all about SSRIs, but I thought side effects could be quite severe.
Benign to those who don't need them? What about all the withdrawal symptoms?
I don't think most people are willing to accept that being on a drug high is a useful thing though.
My experience with people on SSRIs is limited and mixed, but I've seen enough kids on various chemicals to have formed an opinion that they are overprescribed.
Benign to those who don't need them? What about all the withdrawal symptoms?
I was overgeneralizing. Some SSRI's (e.g. Paxil) can't really be called benign.
Almost every woman I know was on them at some point during their twenties.
You realize there are other possible explanations for them turning you down.
My impression (which wikipedia agrees with) was that SSRI's often have serious sexual side affects.
What we really need is some way for doctors to be able to prescribe *actual placebos*. Part of the point of "placebos do just as well as SSRIs" is that placebos can be very effective.
But people want a train a drugged self is an authentic self.
so benign to those who might take them unnecessarily
Not so fast, kemosabe. Use in early in pregnancy has been linked to higher autism rates, the sexual side effects of SSRIs are no joke (including permanent libido loss and damaged sperm in men), and I've talked to lots of people who found coming *off* of antidepressants a fairly horrible physical ordeal that required taking periods of leave from work to deal with the symptoms.
Prescribing takes 2 min. Telling a patient to exercise and to address any interpersonal or self-discipline problems that cause unhappiness takes longer, leaves bad feelings.
I would be a lot more open to 19 if the economics of the decision looked different for the prescriber. The prospect of statin-laced bacon also makes me uneasy.
serious sexual side affects.
When I was dating a woman who took SSRIs, I was very disappointed to find out that this meant that she was less interested in sex.
I don't think ssris are over prescribed, but way too many people are RXed them long after it is obvious they should try another class of drug.
Also publication bias is ruining medicine. If you want FDA approval for a drug you should have to publish (and release for free to a preprint server) every study that you do for that drug.
You realize there are other possible explanations for them turning you down.
Maybe. But the ones on anti-psychotic medications never did. So what we need here is a rigorous follow-up study. Who wants to come upstairs and see my subject consent forms?
The state of drug research is way worse than just publication bias
I think my wife has switched from an SSRI that doesn't work but has no effect on the libido to an SSRI that does work and suppresses the libido.
OT: We are not going wingsuiting, because this video makes me queasy.
Neither Felix Salmon nor the author of the original article is a psychiatrist, or an expert in mental illness. Here is a neuroscientist on the topic. There was another blog post that was quite nasty to Salmon for getting in way the hell over his head here, but I can't find it offhand.
Basically, antidepressants may well be overprescribed, but neither the article(s) nor Salmon's post(s) about them are informative.
What we really need is some way for doctors to be able to prescribe *actual placebos*. Part of the point of "placebos do just as well as SSRIs" is that placebos can be very effective.
There was a study recently where patients were given a placebo and told it was a placebo where the positive effects were still significant, so, you know, that shit could happen.
39: A member of Asilon's family is doing something with that. Maybe she will show up and explain it.
One of the first signs I get that I've forgotten to take my medicine is that I become unbelievably, distractingly horny.
Sex can get so confusing and weird, sometimes I think SSRIs relieve depression because they reduce sex drive.
41.2: The Socrates theory of mental health? "Most gladly indeed am I rid of it all, as though I had escaped from a mad and savage master."
The point about Kramer is not that he's a "stooge", it's that he's the poster child for the first wave of SSRI optimism -- Listening to Prozac was a huge splash. Choosing him, of all people, to make the case for the defense was a terrible editorial decision, regardless of the merits of his piece.
Regarding anti depressants, for me if it wasn't for side effects there'd be no effects at all. Lithium, OTOH, seems to have helped me be more functional. Put it in the water supply, I say.
Let's not put anything in the water supply. I'm attached to my current mildly dysthymic state.
45: I believe this has been discussed here previously.
In The British Journal of Psychiatry earlier this year [2009 - JPS], the neuropsychiatrist Takeshi Terao and other researchers showed that communities in Japan's Oita Prefecture with higher levels of naturally occurring lithium in their water supplies had fewer suicides than those with lower levels.
I thought the side effects of drinking water could be quite severe.
That Felix Salmon spends his first paragraph whining about how there are no links in the article, as though Kramer were trying to hide something, leads me to believe he doesn't have much of substance to say.
50: Felix Salmon does that a lot. Part of being a blogger is being befuddled at why magazine cover stories aren't written in hypertext.
FS is pretty consistently interesting. No links is a common theme in his writing about how newspapers don't understand new media.
He hasn't figured this case out, I think, but he's pointing out serious disagreement between prominent people. Actually, this article is I think a good example of competently summarizing a controversy that the writer doesn't personally understand. The articles he's citing talk past each other.
There was a study recently where patients were given a placebo and told it was a placebo where the positive effects were still significant
There was another one about ten years ago that gave anti-inflammatory drugs to one group of patients recovering from knee surgery, and simply put the other group in a room with a middle-aged Spanish operatic tenor.
The two groups recovered at virtually the same rate, thus verifying scientifically the existence of the Placido Effect.
Felix Salmon does that a lot. Part of being a blogger is being befuddled at why magazine cover stories aren't written in hypertext.
But why don't magazines have standard citations?
Each magazine has its own standard. No problem, I'm happy to help.
FS is pretty consistently interesting.
Agreed, I just added him to my rss feed a month or so ago and I quickly found him one of my favorite bloggers.
I agree! That stuff is bullshit! Except for the specific example that applies to me - that one's totally legit.
I would think people might take issue with the idea of psych med overprescription as benign not so much because of the side effects (though Paxil withdrawal sounds pretty brutal) as because it facilitates a sort of complicit ignorance of other factors. For example: kid can't concentrate, psychiatrist may find it simpler to whip out the pad than have a talk with parent about any number of other factors that might be addressed, parent finds it simplest to give the kid a pill.
For a year I worked in a clinic with a Russian psychiatrist who used to say, after a meeting with a family, "what that kid needs is a parent-ectomy." But then I'm pretty sure she'd make with the prescription anyway because it has become What You Do and anyway a parent-ectomy is not a simple matter.
Hopefully this is not infinitely pwned. Sometimes I'm not good about reading all the way down before commenting.
Restless Leg Syndrome is real! Ever since I was a very small child, I complained of itchiness deep in my legs, especially when I was trying to fall asleep.
I don't have anything cogent to say about the articles yet (beyond having seen anti-depressants work quite well in a number of my family members and yet remaining skeptical of wide-spread use), but holy crap, I could have written this. People still don't believe me, but it used to drive me batty when I was young, especially on long car trips. I haven't medicated myself for it or anything, but still!
Oddly enough, I've had restless leg syndrome twice, and both times I was taking the same over-the-counter medication. When I stopped taking it, it went away. Never had it before or since. Which is further anecdotal evidence for 'is so real'.
I'm attached to my current mildly dysthymic state.
This made me laugh but also reminded me I can never figure out why I'm not more interested in trying anti-depressants*. I'm, you know, unhappy about being unhappy. Ego-dystonic dysthymia. I don't even think it's a fear of my smearcasity diminishing; maybe more an idea that I am gaining something through my unhappiness, that it's like an exercise that will leave me somehow whole and happier. Which sounds like utter bullshit to my rational, conscious self.**
*other than a very anxious year when I tried a few that did fuck all. I acknowledge that others might work better.
**such as it is.
58: because heightening the contradictions its such a fail proof strategy
26
What we really need is some way for doctors to be able to prescribe *actual placebos*. Part of the point of "placebos do just as well as SSRIs" is that placebos can be very effective.
In or related to that article about how the placebo effect is getting stronger, I remember reading some discussion of that. The trick is apparently to just work out phrasing that accurately describes placebos without raising further questions, and without dishonestly telling people that you're giving them some chemically active medication when you're really not. "This thing I'm prescribing you has been shown to help with depression for a significant number of people who take it."
I don't even think it's a fear of my smearcasity diminishing; maybe more an idea that I am gaining something through my unhappiness, that it's like an exercise that will leave me somehow whole and happier.
Mostly, I think that what could be called dysthymia is the result of a series of carefully thought out judgments about the world and my place in it, and if I cheered up I would be less right about everything.
(Really, I've never thought about anti-depressants because I'm not all that unhappy -- I go to work, I sleep fine, I objectively have an extraordinarily pleasant and easy life. I'm just cranky about stuff.)
I'm happy, but I'm also wrong a lot.
I'm less happy now that 65 is stuck in my head.
Count me in favor of overprescribing SSRI's. Like statins, they fall into the category of drugs that are so valuable to those who need them, so benign to those who might take them unnecessarily, and so cheap (the off-patent ones, anyway) that there ought to be a bias in favor of overprescribing rather than underprescribing. I'm not quite to the point of wanting to add them to table salt or breakfast cereal, but it's close.
I agree with KR. In my opinion, many of those anti-drug people are like the rich wondering why those peasants are so upset about going a couple weeks without a paycheck. "It isnt that bad...."
It's hard to say if I hate Joe Walsh or Journey more. Or maybe Steve Miller. Really hard to determine.
It's "does" not "goes", isn't it.
I mean well, but in the end I'm useless.
I mean well, but in the end I'm useless.
See, that's the kind of judgment I'm talking about.
"drugs are overprescribed" also sounds like many other generalization people make about how different people are from how they used to be.
Totall bs with no factual basis.
69: Sorry. The way to do Joe Walsh is forget almost everything after the James Gang.
71: Agree, a vague, Thurberian sense of discontent is the correct attitude towards the world.
72: It's hard not to be a bit alarmed by the prescription rates to kids.
I took an SSRI (Celexa) for awhile last year. It was horrible. The sexual side-effects were the least of it. Not only was I in pretty much constant GI distress of some degree, but every day I would hit this "serotonin wall" around 2 p.m. that would last for a couple of hours, where I would feel about as bleakly suicidal and listless as you could imagine.
So then I switched to bupropion, which, as you know Bob, works on norepinephrine rather than serotonin. No discernible side effects. Lots more energy and interest in life. Far fewer feelings of shame, inadequacy, hopelessness, etc. than at pretty much any other time in my life. Have also been going to therapy, which has helped a lot too.
Much of my previous distate for psychotropic drugs was based on seeing them massively over-prescribed to my friends in the queer/theater/RPG/nerdy/political set in HS. It kinda seemed like anyone who didn't buy in to the rah-rah pep rally bullshit and whose parents were rich enough was on Prozac. Thankfully, none of them offed themselves, but there were plenty of attempts.
75:
Why?
I dont actually know what they are, but I wouldnt be surprised by an increase in prescriptions. When the option was one medication with many severe side effects and it wasnt approved for children, the doc might not prescribe it. (phenobarbital for example.) But, as medications improve and our knowledge of them improves, a child might be prescribed two medications in combination (phenatoin and vimpat).
A rate doesnt really tell us anything other than we have more options.
74: It's all relative of course, but he expressed it well (from "Preface for a Life") : ...or the suspicion that the piece he has been working for two long days was done faster and probably much better by Robert Benchley back in 1924.
Also, one medication in one dosage doesnt fit all. I hear people say "It was horrible" but they havent gone back to their pharmacist or doc to try to modify them.
73 And listen to Steve Miller when Boz was still in the band. And, really, Journey's first album, when the band really was just a Santana spin-off, isn't the worst thing ever.
79: Eh, sure, but I did adjust the Celexa dosages and nothing worked. And some of my friends in HS were really put through the wringer: 6 months on one thing, didn't work, 6 months on another, didn't work, trip to the kids psych ward, 6 months on something else -- all the while dealing with alcoholic parents, hostile environments at home and school, a wider culture devoted to every form of depravity and oppression, and, in most cases, some actual organic depression that wasn't being helped.
Also, the one girl I knew in HS who was unambiguously happy to be on an SSRI was also the person who seemed to need it least before she got on (although, obvs. I didn't see what her home life or long dark nights of the soul were like).
I sleep well
I hate you just a little bit right now.
It's hard to say if I hate Joe Walsh or Journey more.
That's easy, I think Joe Walsh gets some credit for this song. I get the line, "And anyone who tries to deny it / Wears a tie / And gets paid to lie" stuck in my head from time to time.
It's not certain that there's a problem, but I do not believe that 40% of americans have psychitric conditions that fit any reasonable defintion of disorder.
There are certainly economic incentives favoring prescription drugs instead of tedious life changes. That said, many prescription drugs are big improvements on what came before, developing more of them is cost-effective and efficacious.
But like GM foods or nuclear power, just because it's possible to develop the technology well does not mean that the people at the controls are doing the right things.
77: One problem is that there aren't any studies, and all the prescriptions are off-label. So no one knows what the effects are while you're growing.
From the article in the OP:
Ten percent of ten-year-old boys now take daily stimulants for ADHD--"attention deficit/hyperactivity disorder"--and 500,000 children take antipsychotic drugs.
...
Growing numbers of for-profit firms specialize in helping poor families apply for SSI benefits. But to qualify nearly always requires that applicants, including children, be taking psychoactive drugs. According to a New York Times story, a Rutgers University study found that children from low-income families are four times as likely as privately insured children to receive antipsychotic medicines.
You like to think that you're immune to the stuff, but it's closer to the truth to say you can't get enough.
Oh, allow me to take advantage of the opportunity to speak out vigorously both against and in defense of SSRIs. I took Zoloft for about a year and it definitely helped rebalance things for me. The downside? After tapering off, I found I couldn't bring any complaint to my doctor without getting "You're probably depressed -- let's go back on the Zoloft!"
The CCCtRSM (Charley Carp campaign to rehabilitate Steve Miller) demands it.
91->87. Zoloft might help, however.
A friend of mine who desperately needs two or three years with a shrink has instead started on an SSRI. She is already much calmer and better, but I'm afraid it'll improve things enough that she'll put off the shrink for even longer.
It's a lot easier to get away with being a bad psychiatrist than it is to get away with being a bad, say, surgeon.
I think both "Jet Airliner" and "Jungle Love" are excellent pop songs and I'm fine with their popularity. But then I was just listening to Seals&Crofts "Summer Breeze" on the way to work and really liked it, so maybe I am a teenage girl in 1977.
Joe Walsh seems like he would be fun to hang out with.
I have no opinion about SSRIs, but I have seen severely mentally ill people go "off their meds" with horrific results, which means that the meds must be doing something.
As I understand it the Steve Miller Band were good for a while, and then as soon as they started to suck they became famous. This is also the case for the J. Geils Band and potentially other eponymous Bands.
The Missus and I were once having dinner with this guy, and I earned myself a kick under the table by responding to a comment about someone's depression by saying "They have pills for that now."
If this thread goes off the rails into a discussion of the worst music ever, I will post all fashion and decorating posts until everyone regrets their decision.
I like to make threats I can keep.
He kicked you for that? Maybe he needs to be medicated.
"Jet Airliner"
Paul Pena should get the credit for that one anyhow (plus, his version was better).
Huh, I'd forgotten about that. I liked "Genghis Blues."
98: Nobody mention the Whip My Hair Back and Forth song! She's serious!
I think my uncle auditioned for the J. Geils Band at one time or another.
I like Shaker furniture. My father narrowly missed a chance to buy an old Shaker meetinghouse that had been converted into a very nice, sunny residence.
Winners don't use drugs, he typed, and ordered more Japanese giant hornet vomit powdered sports drink.
It's called hitting to all fields, hippies.
I hear people say "It was horrible" but they havent gone back to their pharmacist or doc to try to modify them.
Well, but then how long are you supposed to switch around before deciding maybe you're not someone it works for? I was on a very low dose of Paxil for a week, a week I spent lying on a couch, shaking (akathisia, like restless leg x 100), largely unable to sleep; then I switched to Zoloft which had no noticeable effect on my anxiety even as I ramped up; then I took one nobody seems to take called Serzone for several months, and the only perceptible thing that happened during that time, though I don't know how much it had to do with the Serzone, was that I stopped being able to get to sleep before 6 a.m. without taking Ambien. And then I did something I have, in a professional capacity, repeatedly told people not to do: I got exasperated and took myself off the stuff.
This is turning into anecdotomania but it certainly colored how I think of these things. In the year after dropping SSRIs, I moved out of the dark apartment I shared with another depressed person into my own place, got a cat, dropped out of a PhD program I wasn't suited to, continued to do some behavioral stuff for anxiety, and became human again, a dark cloud still but a functional one.
I'm not saying depressed people just need to snap out of it. I've known plenty of people with depression more serious than what I went through, and they needed their meds (though I note that some of them aren't helped that much by them.) I do question whether there's such a bright line between clinical depression and situational unhappiness, and this does make me critical or anyway gut-level wary of antidepressants as automatic first response.
(Oh look a teal deer.)
98: Any suggestions on how we could get this young thread to better focus?
Any suggestions on how we could get this young thread to better focus?
Alcohol's bad for depression. How about if we take it to a nice beach, maybe Costa Rica or Sardinia, and treat it kindly for a few weeks.
Well, but then how long are you supposed to switch around before deciding maybe you're not someone it works for?
You know who might be able to tell you that? A good psychiatrist.
109: We've tried nothing, and we're all out of ideas!
Neither Felix Salmon nor the author of the original article is a psychiatrist, or an expert in mental illness. Here is a neuroscientist on the topic.
That link from the neuroscientist (in 38, didn't copy) supports what Angell/Salmon were saying -- basically that psychiatry doesn't have a clue, and in general neuroscience is not advanced enough to figure out how to reliably regulate complex moods. Making credentialism seem particularly misplaced here. (Not to mention that the link is to a review by an MD of books by a psychiatrist and a psychologist).
I trust mood regulating drugs that have well defined effects that clear my system quickly and I can figure out how to handle through moderate experimentation without permanent effects. Like beer.
I do question whether there's such a bright line between clinical depression and situational unhappiness
There is no way at all to distinguish clinical depression from situational unhappiness or ordinary unhappiness without introducing a shitload of normative premises which you would not get widespread agreement on, as well as a shitload of premises describe the society the patient lives in, which very often describe things that can and should be changed.
Angell is sharp. I like her.
I like 114 and posts about fashion and decorating
112: "Most of those books haven't been discredited yet!"
113: This was my reaction to the link in 38. I wonder if Sifu can elaborate further on his intent.
Are we anecdoting? I was a very depressed teen (probably spurred in part by anorexia, which was my own choice) and went through a whole lot of medication options in hopes I'd find something that would let me function. I did, but then went to college and had the whole sexual assault thing that led to me dropping out and spending as much of the next year as I could lying on my bed trying to think of nothing. I think it's the drugs they tried next that left me with no almost memory of that year and a much worse memory than I'd had before.
Luckily for me, the Tardive dyskinesia didn't last, nor did any of the Parkinsonian shakes. My eyes are still dilated at all times, though, fifteen years later, and (as I said, I realize) my memory is fine but not remarkable. On the plus side, though, I'm alive, and while I don't think I can attribute that directly to the drugs they were certainly part of what was going on then.
There are two things I recommend from experience. One was inpatient hospitalization on a teen psych unit. I've never forgotten the feeling of peace when the door locked behind me and I felt like all the pressure in the world had lifted off me. The other is that it's useful to think of antidepressants as a useful tool if you're unable to get through the day. They can build a wall between you and the underlying agony, if you'll forgive the dualism involved, and then you can just focus on living your daily life, though of course this only works if you're strengthening yourself to be able to handle what's beyond the wall once it lifts and full reality intrudes again. That's probably not true for everyone, but I found it's resonated with others dealing with sexual assault/abuse.
The first real cry off anti-depressants is the sweetest thing, the purity and clarity of the emotion and the excitement of being able to feel it. I am probably not someone who should talk about this because I fall into such adolescent modes of speech.
Oh, and the other person who shouldn't talk about it is the fucking therapist who told me I'd probably feel better about myself if I went to the mall and got Glamo(u?)r Shots taken. And that since I was ex-anorexic, maybe they could get me on a sleep aid that would have weight loss as a side effect, since that should make me feel better. I was way too depressed to report him and then I met Lee and started building a better life for myself and switched therapists.
Thorn's story made wonder if there's a positive case for credentialing therapists. Maybe successful therapy is like successful witch-doctoring, but failed therapy can be incredibly disastrous.
Aren't therapists conventionally credentialed? I mean, I didn't think a case for credentialing them was necessary.
They can build a wall between you and the underlying agony
My biggest fear, before I started taking antidepressants, is that this would happen. I was greatly relieved at first when I felt more like walls had been torn down. Then I spent several more years taking the pills and not getting real help, and apparently in the interim the wall came up.
90: Doctors are annoying this way. I've never been diagnosed with depression, and don't think I've ever been clinically depressed, but I do have some physical medical issues that somehow make doctors think I'm depressed.
it's useful to think of antidepressants as a useful tool if you're unable to get through the day
...but I disagree with this part. I spent way too long thinking I wasn't really depressed because I was always able to get through the day, because I couldn't imagine being unable to get through the day. And, to turn it around, if you can't get through the day, you need more than just meds.
There is no way at all to distinguish clinical
depression from situational unhappiness
I'm happy to go with "I know it when I see it." I've been situationally unhappy lots of times, including now. I've been clinically depressed twice (once w/ and once w/o medicating). Perhaps that's really a distinction between major depression and mild dysthymia. But, at some point on the spectrum, depression becomes pretty unmistakable.
As for side effects being benign... Statins? Can cause pretty serious liver damage, for one, while the risk posed by elevated cholesterol to someone who otherwise has low-risk of heart disease or stroke is generally overstated. I'm all for better living through modern chemistry, but modern chemistry always comes with a lengthy disclosure of all its various downsides.
121: PGD is 113 was questioning credentialism for psychiatrists, given their abysmal track record. And really, if there's no evidence for their effectiveness, then why should they be credentialed? We don't credential fortune tellers.
I'm happy to go with "I know it when I see it."
Because you automatically use the extra stuff I said you needed to define clinical depression: you automatically use the moral criteria that make sense to you and automatically don't blame yourself for aspects of society you think should change.
The problem isn't for personal judgments. Its for Science.
I do have some physical medical issues that somehow make doctors think I'm depressed
I'm pretty sure I've linked my friend's similar story here previously, but probably a long time ago.
They asked me if I had repetitive thoughts or performed rituals. The only repetitive thought I could think of was, "You're not listening to me." I was pressed for a different answer. "Uh, like, would flossing between two teeth and repeating this act over and over until I run out of spaces, and sometimes doing it twice in a row--would that be one?" They decided that because I kept telling them "I don't think I'm depressed," I was obsessive-compulsive.
126: Of course we don't, we leave that to the free market.
It's about time for anecdotes about depression. Here's mine.
Yeah, that big ol' gray area is the problem. I'm in it. I was on anti-depressants for a while, and now I'm not. It was always a mild case of depression, and when my last prescription renewal ran out... I was getting by well enough that I weaned myself off the last refill. So what helped? I don't know. The pills? The therapy sessions? (The ones during college or the ones for a couple years following it or both or what?) Would sugar pills have worked just as well? If the pills helped, did they help so much that they were worth the $120 I paid out of pocket per month for over two years thanks to my crappy insurance coverage?
On the other hand, a distant cousin of mine was in the gray area too. He killed himself... He was 37 and had been battling depression since he was 12, I was told, which sounds like a long time. He was a lawyer, which I knew, an EMT according to the NYT death notice, which I didn't know, and he was apparently being maintained very well until he wasn't.
In hindsight, it's obvious that I'm fine (at least these days, etc.) and whatever was being done for him wasn't enough. And if the right person looked at our respective medical files, maybe they would say it should have been obvious even in advance; maybe there were warning signs that were ignored and stuff. But given the fact that there is such a broad gray area of mental health, I can't blame people for overprescribing slightly, at least on this particular issue.
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I do question whether there's such a bright line between clinical depression and situational unhappiness
There's also a chicken-and-egg thing going on there. In some cases there's a bright line, but in other cases I think clinical depression makes people less likely to do anything about unhappy situations and vice versa.
IMHO it's interesting that the NYT rebuttal to the NYRB articles ignores the most critical assertions in the latter: that ddrugs are commonly prescribed outside their approved uses; that precious little study has been done of their actual effects; that most prescriptions have little follow-up and most practitioners act almost solely on anecdotal evidence, etc. Medicine- not an art nor a science!
Thorn's story made wonder if there's a positive case for credentialing therapists.
Oh dear oh dear oh dear.
I'm not and now will never be a therapist in part because of how therapists are credentialed. I wanted to be one, once. I don't know if I would have been the best therapist ever, but I daresay my weeding out was not how things should have gone.
You know who might be able to tell you that? A good psychiatrist.
You know who might often have no idea? A good psychiatrist.
113, 118: arguing that some specific method by which anti-depressants are supposed to work may not obtain is not an effective counter-argument to the effectiveness of anti-depressants, because anti-depressants are not evaluated on the basis of the plausibility of a given model for their effectiveness. The argument that they are only mildly better than placebo is an effective argument that they are only mildly effective in many cases, but there is reasonably good evidence that they are strongly effective in many cases of severe depression, albeit by a possibly unknown method. Now, all of this obviously has lots of fuzziness to it, as the blog post acknowledges, but if you think that blog is trying to discredit the entire basis of psychiatric medicine because a given model is simplistic or a given treatment's clinical effectiveness is positive but uncertain, you're massively misreading it.
Another interesting post on antidepressants from the same dude.
134: I suppose a good psychiatrist would benefit from being able to admit that she has no idea, that psychoactive meds have different effects on different people that we don't understand, etc, etc. But I mean, when I think of what a good psychiatrist is, it'd have to be someone who knows what to try, on who to try it, how long to try it before trying something else.
A good psychiatrist can be hard to find.
And honestly I think he's probably fairly sympathetic to Angell, my previous responses to the contrary.
All the hand-waving about witch doctors and the jokiness of psychiatric credentials still bugs me, but whatever. Argument averted; back to work.
From 136: Prozac and the other SSRIs changed the game completely. They're much less toxic, the side effects are milder, and you can eat as much cheese as you want.
That's an off-label use of Prozac I didn't know about. Forget the statins! And the lactase!
124: Sorry, unsigned, I definitely didn't mean that this is the only case in which medication is warranted, just that one thing drugs that work do well is help you get up in the morning and one thing they can't at all do is fix your fucked-up family or whatever. I think you and I are basically saying the same thing different ways, but I certainly don't want to imply what you thought I did.
Oh, and I was only seeing the bad therapist because the psychiatrist in his practice would only give me anti-anxiety medications if I was seeing a therapist in the practice. I loved those meds, but getting a good therapist (who was, in fact, Christian to the point that she and her staff fasted and prayed together daily but was also great about the whole gay atheist thing I have going on) helped me more.
gay atheist
I suppose a "gaytheist" would be someone who believes Cobain's proposition that God is gay.
[T]he whole gay atheist thing I have going on....
You wear it well.
I've been on a bunch of different anti-depressants, including three SSRI's and one stimulant. I'm also in the category of patient that they're supposed to be the most effective for (severe long term depression) Not sure if they work, though I like to think that my current one does, but god knows they have wildly different side effects which don't make any sense - the intensity that is, not the symptoms themselves. Zoloft is the drug from hell for me: it definitely doesn't work for anything except permanent severely upset stomach, fuzzy head and drymouth. Lexapro seems to work in high enough doses with much milder side effects. Same for Celexa except that the side effects are almost non existent. Given that Celexa is the same thing as Lexapro except with only half of the drug working for SSRI purposes but all of it for the unpleasant side effects, my shrink is baffled. He reluctantly switched me to the equivalent Celexa prescription when I balked at spending $250/mo on megadoses of Lexapro.
Reviewing this thread, I am struck by how many commenters have been prescribed, or are close to people who have been prescribed, what I think are very serious medications for very serious conditions. Not a random sample, of course, but I think I understand my father's position, in comment 2, better than I had.
It occurs to me that information technology has grown wide over and deep into the world of educated, informed people over a period not entirely out of synch with the growth in the development and use of psychopharmaceuticals, but anyone one asked would say that information technology is more important to contemporary life. I wonder how long that will continue to be the case.
We are not going wingsuiting, because this video makes me queasy.
Perhaps you should try blob jumping instead.
What I'd say here has largely been said by Natilo in 81, Smearcase in 106, and Helpy-chalk in 114, so I'll take this comment to urge you all to reread those three, in sequence.
I give this round to Kramer. The crucial part of his argument is that the unpublished studies just aren't very good at measuring effects of medication on mild depression - so a finding that these medications had a statistically significant, but clinically insignificant, effect on mild depression is actually not that significant.
Instead, we can look to other evidence, with better controlled populations, to ascertain effect. When we do, it appears antidepressants can have highly significant effects.
That argument, which if true devastates the NYRB article, goes unanswered.
Salmon's response hints at corruption on Kramer's part (even, somewhat bizarrely, the part of the NY Times for not linking to the other articles - as though readers could not possibly use Google themselves) and fails to respond substantively to any arguments.
My tongue in cheek theory is that a disproportionate number of the NYRB's readership still prefer psychoanalysis, and that the paper is pandering to its subscribers.
Salmon's response hints at corruption on Kramer's part (even, somewhat bizarrely, the part of the NY Times for not linking to the other articles - as though readers could not possibly use Google themselves) and fails to respond substantively to any arguments.
I don't think he's hinting at NYT corruption. Not linking to source material, or external sites, is a bugbear of Salmon's. He brings it up almost every other post.
More anecdata! I've been on Prozac for about a year, and it has given me (as others have better expressed in this thread) a wall, a bit of time/space to manouevre around my depression/anxiety - it's still there, but now I have some distance from it and can use non-medical self-care (exercise, meditation, etc.) to push it further away. I feel undamaged and strong and capable for the first time in my life - not convinced there will be no more storms, but sure that I can weather them. I expect to taper off the Prozac in a few months, but I will remain totally grateful to it, even if its effects are entirely psychosomatic and it might as well be a sugar pill. (Also - I was not happy about the possibility of impaired libido, and did feel less, er, vigorous for the first couple of months - but once I was feeling generally good, and kind of forgot to fret about side effects, that problem went away. So maybe I am just more prone to suggestion than most, but perhaps well-publicized side effects have psychosomatic capacities themselves!)
If Kramer is a shill, he's an unusually thoughtful one, and a psychiatrist who was somewhat reluctant to prescribe Prozac to me recommended that I read "Listening to Prozac" instead, many years ago, when I was a teenager. I can't really speak to how it would read now, but at the time it seemed... not disingenuous.
The part of the Angell articles that stood out for me was the question of long-term iatrogenic cognitive changes -- that is, the idea that if you've been on the drugs for a while, you can't ever reach any kind of status quo ante, and your ability to function normally without them may even be compromised. (This is mostly discussed in the section on Whitaker's book.) Now, being unable to reach a status quo ante may just be the human condition (please no "opinionated Heraclitus," or I will weep), and you can't really speculate about changes to your own cognitive development if the antidepressant-using period was, like, all of college. Anecdotally, it seemed to me that I had much more severe anxiety, and was much more prone to anger, after withdrawing from medications than I had been prior to taking them, and I will wonder fruitlessly for the rest of my life about the causality.
The overprescription of SSRIs does not scare me anywhere near as much as the overprescription of antipsychotics -- I was blithely given one as a teenager when it had been on the market for 2 months, had never been approved for anyone under 18, and was clearly not being used against psychosis in this case (it's possible that my shrink simply didn't know what psychosis was, but I didn't have it). Later, the evidence that it fucks up your weight and can give you full-blown diabetes emerged. My weight is (and has generally been) pretty controllable; jury's still out on blood sugar. I can add to my list of parenting nightmares the scenario where some pediatrician recommends to my extremely distressed child a round of the stuff: I want to believe that I would ALWAYS SAY NO, but I fucking hope it never happens. I just cringe in horror when I read the stories about prescriptions for 2-year-olds.
46: Areas with higher levels of naturally occurring lithium (not anything like what someone would take as medicine) nevertheless have drastically lower rates of suicide. I think a tiny bit probably should be put in the water.
Damn, pwned by the next comment.
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I was less impressed with Kramer. Kramer concedes that bias against publishing negative studies and drug company money are problems.
Kramer's discussion of the placebo response seems muddled. He seems to claim that it is due to people being included in studies who aren't actually depressed. But this is wrong many depressed people will recover on their own. Furthermore studies show (according to the NYRB article) that people receiving a placebo do better than people receiving no treatment. Kramer appears reluctant to believe there is a placebo effect at all which makes it easy for him to dismiss the claim that the main mechanism of action of anti-depressants is the placebo effect. Incidentally the existence of a placebo response seems important and worthy of more study than it has received.
Kramer didn't just omit links to the NYRB articles he repeatedly quotes results without precise cites making it very difficult to verify that he is representing them fairly.
And the stuff about anti-depressants for stroke victims seems like a diversionary tactic as it has nothing to do with the main issues.
James, Kramer's argument about the unpublished studies, though, was not simply that depressed people sometimes recover on their own. The argument is that in a broad study, with poor screening, those who we would agree are really not depressed are accepted into the study. This renders the results questionable, since we no longer know what we're measuring, or what our sample sizes actually are.
Remember, it's not as though the FDA didn't know about these studies. It's that they didn't find them significant in evaluating the proposed drug.
Narrow studies, by contrast, offer great control, and greater confidence that the population of the study really does have condition X. So we should place more confidence in the results of narrow studies. And narrow studies show significant effects from anti-depressants.
Moreover, maintenance studies, also better than very broad studies, show significant effects from anti-depressants as well.
Also... I get the sense that Angell is credulous about claims of side-effects while skeptical about claims of efficacy. She cites research that antipsychotic medication may reduce gray matter volume in certain areas, but doesn't mention how complicated the issue is: that the illnesses which prompt antipsychotic treatment may themselves cause gray matter volume in certain areas, for example. She implies that withdrawal from SSRIs can be "exceedingly difficult" when in fact that hasn't shown to be the case.
O HAI. There's a whole 'nother thread on this that I didn't read.
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... And narrow studies show significant effects from anti-depressants.
This what Kramer claimed but as I said he gave no specific cites so this is hard to verify. A specific example comparing the results of broad and narrow studies for a drug like Prozac would have been helpful if his argument is that narrow studies are more trustworthy.
And there is an additional issue. Even if you grant that these drugs are helpful for some specific conditions they are being prescribed and used much more broadly. This should be expected if it has proven hard to limit their use to appropriate cases in clinical trials. While the drug companies may support (for obvious reasons) providing expensive and poorly understood drugs to many people if a few will benefit I am not convinced that this is good policy.