When is Psychiatry Effective?

[calebprime]

Let's agree for the purpose of this thread that Psychiatry has a mixed record of success and failure, and that in principle, at least, it is improving as knowledge about the brain improves.

Even if we rule out weird quack therapies, there are a lot of tough choices to be made about what treatments we would choose for ourselves or those close to us.

Even if we believe in critical thinking and relying on well-designed studies, there seems to be a lot of contradictory information and philosophies.

While I'm certain that unicorns don't exist and that 9/11 wasn't an "inside job", I'm not so certain about what to believe about psychiatric treatment.

I collect information about the subject, and know a few psychiatrists and a neurologist. I also observe the effects of treatments on the people close to me. It's a very mixed bag. I know some people who seem to be over-medicating for something like plain loneliness. I know some people who can report that SSRI's (such as Prozac or Paxil) have greatly alleviated their Obsessive-Compulsive Disorder.

It's easy to say: "Just try (treatment or drug X). You won't know 'til you do." Yet experimenting with treatments can be a long, excruciating process. I know of one acquaintance who rode that merry-go-round and ended up killing himself. This proves nothing, but it does suggest that finding the right treatment isn't as easy as finding a good restaurant.

There is some question about whether drug company studies about the effectiveness of their own drugs are to be trusted, given that the studies aren't conducted over a long-enough period of time, and there is some evidence that drug companies have selected only those studies that show their drugs to be effective.

I do have a problem with the idea that depression is just like diabetes--the individual is simply suffering from some serotonin imbalance--because there are no tests for such an imbalance, and because improvement in depression isn't an immediate consequence of raising serotonin levels. But SSRI's work for some people.

The relevant writers here are people like Appleton, Breggin, J. Glenmullen, David Karp, Alice Flaherty, Peter Kramer. I'd put Szasz at the extreme end of skepticism about whether mental illness really exists, for present purposes.

I guess the mental status and psychiatric treatment of Challenge applicants is a separate issue, because that really has more to do with JREF's potential liability than whether psychiatry is effective.

How to proceed? If your kid had ADHD, would you consider Ritalin? If you were a little blue, would you consider taking an anti-depressant? What if you were a little shy? What if you (like me) are just insanely sensitive to noise and have an excessive startle reflex?

Sorry if this is both choppy and rambling. Hard to know how to frame it. Happy to be told that my premises are wrong.

 

[Dave1001]

Great questions. I think you know full well that your premises are not all completely wrong. One should be quite skeptical, in particular, about claims that people have chronic mental illnesses due to chemical imbalances in the brain, when those chemical balances can't specifically be measured (the way one can measure insulin levels, etc. in a diabetic). Similarly, when one can't detect the mental illness via brain scan, genetic profile, etc., I think a level of skepticism is warranted. It seems to me the only remaining way for folks to be diagnosed for these type illnesses is by checklist. Hardly authoritative.

 

[Skeptic Ginger]

Let's agree for the purpose of this thread that Psychiatry has a mixed record of success and failure, and that in principle, at least, it is improving as knowledge about the brain improves.

Even if we rule out weird quack therapies, there are a lot of tough choices to be made about what treatments we would choose for ourselves or those close to us.

Even if we believe in critical thinking and relying on well-designed studies, there seems to be a lot of contradictory information and philosophies.

While I'm certain that unicorns don't exist and that 9/11 wasn't an "inside job", I'm not so certain about what to believe about psychiatric treatment.

I collect information about the subject, and know a few psychiatrists and a neurologist. I also observe the effects of treatments on the people close to me. It's a very mixed bag. I know some people who seem to be over-medicating for something like plain loneliness. I know some people who can report that SSRI's (such as Prozac or Paxil) have greatly alleviated their Obsessive-Compulsive Disorder.

It's easy to say: "Just try (treatment or drug X). You won't know 'til you do." Yet experimenting with treatments can be a long, excruciating process. I know of one acquaintance who rode that merry-go-round and ended up killing himself. This proves nothing, but it does suggest that finding the right treatment isn't as easy as finding a good restaurant.

There is some question about whether drug company studies about the effectiveness of their own drugs are to be trusted, given that the studies aren't conducted over a long-enough period of time, and there is some evidence that drug companies have selected only those studies that show their drugs to be effective.

I do have a problem with the idea that depression is just like diabetes--the individual is simply suffering from some serotonin imbalance--because there are no tests for such an imbalance, and because improvement in depression isn't an immediate consequence of raising serotonin levels. But SSRI's work for some people.

The relevant writers here are people like Appleton, Breggin, J. Glenmullen, David Karp, Alice Flaherty, Peter Kramer. I'd put Szasz at the extreme end of skepticism about whether mental illness really exists, for present purposes.

I guess the mental status and psychiatric treatment of Challenge applicants is a separate issue, because that really has more to do with JREF's potential liability than whether psychiatry is effective.

How to proceed? If your kid had ADHD, would you consider Ritalin? If you were a little blue, would you consider taking an anti-depressant? What if you were a little shy? What if you (like me) are just insanely sensitive to noise and have an excessive startle reflex?

Sorry if this is both choppy and rambling. Hard to know how to frame it. Happy to be told that my premises are wrong.

Google search: Measuring serotonin levels.

Past psychiatric medications did indeed rely heavily on trial and error but the results were objectively measurable. The drugs, however, were not always the best and a large percentage of psychiatry was not evidence based by today's standards. But they also bled people into the early 1900s and removed tonsils despite lack of evidence of benefit only 4 or 5 decades ago as well.

Modern psychiatry may have gotten off to a slower start when it comes to evidence based medicine, but the role of neurotransmitters in the brain has been under careful study for at least the last 40 years. And modern psychiatry is very much evidence based in the USA at least. (I understand they still think Freud was insightful in some European countries.)

There are thousands of studies looking at direct and indirect effects of neurotransmitters and their role in depression. Specific patients are diagnosed with symptoms which correlate with neurotransmitter and receptor deficiencies, but the deficiencies and resulting symptoms have been verified with actual measurements.

I don't have to culture you cold virus to diagnose your infection. I diagnose it based on symptoms that correlate with people who did have the cultures. I can on rare occasions be wrong because I'm not measuring the virus directly. But that doesn't mean the approach of using correlating symptoms is a poor approach. It isn't practical to culture everyone who has symptoms. Instead you develop algorithms.

I do think psychiatry has a recent past akin to woo medicine, but there's a lot more research being done today that might surprise many just how well the brain is becoming understood.

Why would you think the pancreas capable of deficient insulin production but the brain infallible in serotonin production? The brain is an organ. It has a physical structure. It has electro-chemical activity and is made of proteins. How we think, consciousness, and emotions are the result of physical processes the same way digesting food, storing it, using it and disposing of the byproducts are physical processes.

Given my perspective, what I see in your post may not be that the field is lacking as much as the individual providers are. That is true in medicine in a big way. Studies show if you have a complicated disease like HIV-AIDS you do better and survive longer in a big city seeing an expert in the field than seeing a family practice doc in Podunk, Middle America.

I suggest you do your own research, and that you look for the actual studies, not the reports of the studies. While drug company manipulation of data has become more and more prevalent and harder to detect, you can usually still get a good idea about a particular treatment.

A few providers believe ADHD is overdiagnosed in kids but very few evidence based providers believe it doesn't exist at all and that Ritalin isn't a very useful treatment. As far as shyness or noise sensitivity, it really depends on how much it interferes with your life.

Even truly depressed people can benefit from lifestyle changes and learning coping methods. We don't teach people how to get along in school. Instead, we assume they will pick that up from social interactions alone. We don't teach parenting skills. So there are often many things unhappy people can do to improve their lives without drugs.

OTOH, better to take an SSRI than to self medicate with alcohol, a frequent substitute.

Be sure to get a second opinion if it involves a big decision. I go to an outside provider from my HMO and pay out of pocket for the 2nd opinion exam in such cases. (My HMO is a coop and provides decent care, BTW.) It is no different than paying a deductible in a regular insurance plan.

 

[Dave1001]

Given my perspective, what I see in your post may not be that the field is lacking as much as the individual providers are. That is true in medicine in a big way. Studies show if you have a complicated disease like HIV-AIDS you do better and survive longer in a big city seeing an expert in the field than seeing a family practice doc in Podunk, Middle America.

That may be a big part of it. I'm curious what reasonable, skeptical members of the pyschiatric field are estimating to be the instance of misdiagnoses and overdiagnoses in the field. My sense, from the number of people who have told me they've been diagnosed with bipolar disorder alone off of what appears to be nothing more than a checklist, is that overdiagnoses o people as having chronic, lifelong mental illness and overprescription of psychiatric pharmaceuticals for an unending period of time is rampant.

 

[TobiasTheViking]

Hm, this is a hard subject, and i don't personally have all the information needed to answer it. What i do have is a few observations.

The following is my personal opinion.
Psychiatry alone and in and off itself is often not the solution. Psychiatry is a stopgap measure that will eliviate or halt the problem. But not solve it.

Psychiatry should be used to give the individual the time and resources needed to solve the problem at the core. A few times, yes, that isn't possible. But in many cases it is.

For almost all the autistic people who take SSRIs they can be abandoned later. IF the person properly works with the underlying problem. For autism, specificly, stress is a much bigger issue than for NTs(Neurological Typical)*, which results in individuals with autism having depressions longer, harder, and with a higher frequency then NTs.

So what should be done in that case is find the proper SSRI to remove the depression. This gives the person enough space and resources to actually do something during the day instead of just lying in bed all day.(NOTE: not saying that everyone who lies in bed all day have a depression or have autism).

Once the person have resources again one can start talking to a psychologist, and work to have less stress, work to cope with the stress in life, and work to find solutions for that stress, so it doesn't result in a depression. After that is done, the person can stop the SSRI.

I know that this is often the case for autism, and that is what i base my opinion on. I assume that it is the same for many other problems. But not all, for instance epilepsia can, afaik, not be solved with anything but pills.



* I am very lucky in having had only two depressions by the age of 23. Very lucky indeed. And mine only lasted 6 months each. I know people with autism that have had one depression for a few years(2-3) and some that have them every 2-3 months. Whereas i haven't seen any depressions with my NT friends(maybe one, not sure if he had one, but maybe).
Also, many people with other disorders are also predisposed to have more depressions, so what i said may, or may not, be valid in those cases.. in either case, depression in and of itself does not mean one has autism, but if they are recurring there is some underlying problem that should be investigated.

For anything but chronic depression i believe(untill i find contradicting evidence) that psychiatry can solve it while psychiatry keeps it at bay.

ETA: also, i do believe that psychiatry is being used too much as a solution, and too much in general.

Sincerely
Tobias

Hope i'm not spewing crap.

 

[Dave1001]

Hm, this is a hard subject, and i don't personally have all the information needed to answer it. What i do have is a few observations.

Tobias, you are autistic? Fascinating. I don't know much about it, but my girlfriend's nephew is autistic and about 6 years old or so.

Well, you're a very bright guy, so it makes me wonder who in my graduate school/professional sphere may be autistic too.

 

[TobiasTheViking]

I thought it was common knowledge by now that i was autistic. but yes. I have Asperger Autism.

 

[TobiasTheViking]

And now i also have it in my title. No one can ever be surprised by it again.. MUAHAHAHHAHA

 

[orpheus]

Great questions. I can only offer my own (subjective, of course) experience.

In my 41 years, I've had my share of painful experiences, and they have been more or less stressful - some very stressful indeed. But nothing - nothing - like the two episodes of major depression I've had. This wasn't simply a matter of degree; it was qualitatively different. An analogy for those who have been lucky enough to not know firsthand: pain/sadness are to depression as ordinary fatigue is to a really, really nasty virus. (Awkward metaphor, I know, but the best I could do on the spur of the moment.) In his book "The Noonday Demon" (excellent, btw), Andrew Solomon quotes someone who says they know when they're slipping into a depression: you can "feel the chemistry going." Maybe not technically correct, but an accurate description of the experience. So many somatic and mental signals send the message that something is very wrong. And then you can't get up in the morning. For months.

In my case, the diagnoses were certainly the usual checklist ones. But with each episode, there was absolutely no doubt in my mind that something was really, truly, horribly wrong. (There was no doubt in the minds of friends and family, either.) I'm reasonably sure that if we'd progressed to the point where a more objective test was available, it would have registered a big fat positive.

And I did go through the painful process of finding medications that worked. (Harder the second time.) It can - and in my case did - take a while. But ultimately a combination of meds and therapy helped. Enormously.

So, my take on this is that we do know a lot, and we still need to know much more. So it's hard to state categorically when psychiatry is effective (and the word itself, as I understand it, includes talk therapy as well as psychopharmacology). It certainly isn't as exact a science as I wish it was....yet. But I'm so thankful for the degree to which it is already effective.

 

[Dancing David]

That may be a big part of it. I'm curious what reasonable, skeptical members of the pyschiatric field are estimating to be the instance of misdiagnoses and overdiagnoses in the field. My sense, from the number of people who have told me they've been diagnosed with bipolar disorder alone off of what appears to be nothing more than a checklist, is that overdiagnoses o people as having chronic, lifelong mental illness and overprescription of psychiatric pharmaceuticals for an unending period of time is rampant.

The main over prescription is not by psychiatrists but by general practioners.

The mainly over prescribed drugs are the anxyiolitics, most people will not medicate themselves for pleasure with the ADs or APs or mood stabilizers. there are very few soporiphic or sedative effects that people enjoy with those drugs unlike the anxyiolitics.

The second source of over prescription is treatment for situational situations, esp. when it comes to children. If a child or adult victim is living with domestic violence then they will have depression or will manifest depression from the situation, medication will have a palliative effect but not be the best treatment. Children who live in chaotic situations will manifest the symptoms of ADHD although they don't have it.

The third source of overperscription is substance abuse, use of stimulants, especially cocaine and methamphetamine cause people to have a very depressed and anxious mood after a while, so they often seek treatment to counteract their substance abuse. But then there is also a very high co-morbidity for substance abuse and mental illness.

BUT in my fifteen year experience as a social service provider there is a massive under treatment for mental illness.
First off, most people don't seek help until their life has collapsed and it really very painful, and even then the vast majority of people are reluctant to seek help. this is true of heart disease as well, and many other medical conditions.
Second is family and societal pressure, this thread demonstrates the subtle pressure that people are under to not seek treatment. Then in many cultures people are just set against mental health treatment, so there is self stigma as well as societal stigma.
Third is the just plain reluctance to admit that mental illness exists, the nervous system is as much physical and part of the body as the circulatory system, and every body has seen an increase in the treatment for heart disease and diabetes, but people don’t say the same things about them that they say about mental illness, people are just reluctant to even believe that mental illness exists.

 

[Dave1001]

Interesting points in post #10.

I think there is both undertreatment and overtreatment of mental illness in American society.

I think there is overdiagnoses of chronic mental illness and overprescription of endless pharmaceutical treatment in the populations of people who do go to the medical community for psychological treatment. But in the population as a whole, due to continuing stigma of mental health treatment, I suspect there is underdiagnoses and hence undertreatment of all types of mental illness, including chronic mental illnesses.

 

[andyandy]

hey, hey you don't even — you're glib, You don't even know what Ritalin is. If you start talking about chemical imbalance, you have to evaluate and read the research papers on how they came up with these theories, OK. That's what I've done. You don't know the history of psychiatry, I do.






*The world according to Tom cruise

 

[calebprime]

great answers so far. exactly at the right level of theory vs. personal experience I was looking for. I'm just making a "Quick Reply" right now so I can think more about what people have said, esp. Skeptigirl (sp?).

and, o wise Father andyandy, I WAS jumping up and down on the couch when I wrote the OP. How could you tell?

the link Skeptigirl provided was to a Google search. I read some of the first entry, which was quite interesting. I take your point that "Specific patients are diagnosed with symptoms which correlate with neurotransmitter and receptor deficiencies, but the deficiencies and resulting symptoms have been verified with actual measurements." and "I don't have to culture you(r) cold virus to diagnose your infection". Really good point.

further, I *was* thinking of my experience with a GP (general practitioner or family doctor) plus some other conversations with a GP I know.

great stuff so far. keep it coming. I'm learning.

 

[calebprime]

...

I suggest you do your own research, and that you look for the actual studies, not the reports of the studies. While drug company manipulation of data has become more and more prevalent and harder to detect, you can usually still get a good idea about a particular treatment.

...

(my bold)

While everything you say is spot on, I'm not sure I'm any more capable of interpreting the raw data than is Mr. Cruise. I'm partial to those little abstracts at the beginning of the studies. Sometimes it's better to listen to the experts. I understand very little of statistics. They don't teach statistics in Conservatory. They teach outmoded fixed-do Solfege from the 1800's.

I have to go get clawed by a certain kitten, but I'll return.

 

[andyandy]

and, o wise Father andyandy, I WAS jumping up and down on the couch when I wrote the OP. How could you tell?

there really needs to be a better way to express sarcasm on message boards....i've no idea if you've misinterpreted my cruise post as a criticism of your OP and you've taken offense, or if you're playing along......

ho hum....i think you're playing along.....

 

[calebprime]

yeah. playing along, ineptly.

don't worry about me taking offense.

I notice a certain paranoia around here about people's true intentions. Which is justified in some cases: You know, the CT's who say: "I'm just asking questions."

Must practice my banter. Must. Practice. Banter.

 

[ponderingturtle]

Great questions. I think you know full well that your premises are not all completely wrong. One should be quite skeptical, in particular, about claims that people have chronic mental illnesses due to chemical imbalances in the brain, when those chemical balances can't specifically be measured (the way one can measure insulin levels, etc. in a diabetic). Similarly, when one can't detect the mental illness via brain scan, genetic profile, etc., I think a level of skepticism is warranted. It seems to me the only remaining way for folks to be diagnosed for these type illnesses is by checklist. Hardly authoritative.

How often can mental illness(say psychosis) be detected in such absolute manors, instead of saying "you know the guy running around ranting about the turkeys is probably not all that sane"?

Still there is a lot of woo in this, but discounting everything not measureable is also hard. Are there such tests for full autism and such instead of descriptive tests?

 

[drkitten]

How often can mental illness(say psychosis) be detected in such absolute manors

Very rarely. "Mental illness" is usually diagnosed on behavioural criteria, not biological ones. So althouth we know that there's a strong correlation between serotonin levels and schizophrenia, we also know that unusual levels of serotonin can be related to many other behavioural disorders. We also know that there are a number of people with unusual serotonin levels that behave normally, and there are some people with schizophrenia that have normal levels.

But Dave1001's complaint about diagnosis-by-checklist is hardly valid. What else would you use to diagnose mental states? For all the accuracy with which we can measure serotonin levels.... the ultimate test of whether someone has depression is whether they feel depressed. To argue otherwise is fatuous.

 

[Dave1001]

Very rarely. "Mental illness" is usually diagnosed on behavioural criteria, not biological ones. So althouth we know that there's a strong correlation between serotonin levels and schizophrenia, we also know that unusual levels of serotonin can be related to many other behavioural disorders. We also know that there are a number of people with unusual serotonin levels that behave normally, and there are some people with schizophrenia that have normal levels.

But Dave1001's complaint about diagnosis-by-checklist is hardly valid. What else would you use to diagnose mental states? For all the accuracy with which we can measure serotonin levels.... the ultimate test of whether someone has depression is whether they feel depressed. To argue otherwise is fatuous.

If you (or any third party observer) takes a look at my posts, they'll see nothing I wrote contradicts anything you wrote. My primary concern is with diagnoses of chronic mental illness which entail a lifetime of pharmaceutical treatment, off of what can be as little as a 1 hour interview using a checklist. I think that's signficantly different than treating a temporary depression for a few months using a combination of talk therapy and pharmaceutical treatment. Checklists may be our best form of mental illness diagnoses currently, but I think they'll be supplanted in the coming decades as our brain imaging, genetic evaluation, and other technologies improve.

 

[Soapy Sam]

After taking NSAIDs for osteoarthritis , I wound up in a Finnish hospital with a bleeding esophagus, then in a Scottish one with gut & urinary tract problems caused by internal bleeding. I stopped taking the anti inflammatories and went to see my GP.
After hearing my litany of complaints, he asked (apparently sincerely) if I felt I might be depressed...

This struck me as amusing.
I was just about to turn fifty and apparently falling to bits. Was I supposed to be excited about it? Of course I was depressed. Fix the damn knees and I'll cheer up!

I was after an alternative to the NSAIDs that wouldn't put holes in my gut. I was not seeking cheer-up pills. I'm Scottish. I'm meant to be dour.

My neuropeptide levels may, or may not be odd, but I see living with that as my responsibility- indeed as being "me". Fixing knees, I had supposed, was the doctor's job.
If I take a flat tyre to a garage for repair, I do not require counselling about the age of my car. I require a puncture repair.

I wonder if, as neural disorders which long proved wholly untreatable by psychoanalysis are seen to be amenable to drug therapy - possibly GPs are starting to think they know rather more about the mind than they actually do?