You all need to have your heads examined
June 22, 2011 2:28 AM Subscribe
The epidemic of mental illness plaguing the Americans and the overmedication of psychiatric patients are in part artifacts of the diagnostic method.
Is the DSM working as designed? Marcia Agnelli, former editor of the New England Journal of Medicine, dissects the current "bible of psychiatry". previously, previously.
Is the DSM working as designed? Marcia Agnelli, former editor of the New England Journal of Medicine, dissects the current "bible of psychiatry". previously, previously.
Ha! I was about to post the post you was about to post, but the helpful posting AI pointed me to the post that shivohum posted previously.
posted by hat_eater at 2:59 AM on June 22, 2011
posted by hat_eater at 2:59 AM on June 22, 2011
This is a double. The second article has already been posted in the open thread from the first article.
posted by OmieWise at 3:36 AM on June 22, 2011
posted by OmieWise at 3:36 AM on June 22, 2011
Why do articles about mental illness always have references to…
Because when they filled them with stories about Uncle Charlie and his proclivities and Cousin Sue and her problems you just stared at me like you had no idea who I was talking about. Which brings us to you.
posted by Civil_Disobedient at 3:47 AM on June 22, 2011 [1 favorite]
Because when they filled them with stories about Uncle Charlie and his proclivities and Cousin Sue and her problems you just stared at me like you had no idea who I was talking about. Which brings us to you.
posted by Civil_Disobedient at 3:47 AM on June 22, 2011 [1 favorite]
Everything's over-medicalised these days. Rather than being a badge of shame as it was in the bad old days some diagnosis of mental problems has become almost a must have fashion accessory. Some kid stares out of the window or loves their train set too much and they've got Asperger's syndrome but if they run about giggling for ten minutes they've got ADHD. So much of this is nonsense. Just because you can't spell 'acknowledgment' without looking it up doesn't mean you've got dyslexia. You don't get post traumatic stress disorder because someone's rude to you at work. A hundred and fifty years ago people in the full bloom of youth and vigour died in their droves from infectious disease but rather than enjoy our good fortune today we'd rather invent a slew of nebulous minor ailments to give us any excuse for not trying so hard. A good friend of mine developed schizophrenia in her late teens and suffered terribly before killing herself in her early twenties, despite all her friends, doctors and family could do. I'm really tired of people afflicted with little more than the normal trials and disappointments of life looking to ride on the coat tails of such very real pain.
posted by joannemullen at 4:07 AM on June 22, 2011 [7 favorites]
posted by joannemullen at 4:07 AM on June 22, 2011 [7 favorites]
Over medication has more than a little to do with the way the provider/insurer combine works.
Most people cannot afford actual mental health services out-of-pocket, so they rely on insurance (if they have it, of course). Insurers, for their part, seek to limit their exposure to a process that can be open-ended. So, most insurers approve a very limited number of visits and limit those visits to the lowest-cost provider possible. So, most people end up seeing a counselor/therapist (not a psychologist or psychiatrist) for a limited number of sessions. The end result is a sort of triage process where they hustle you in, evaluate you, get you on medications, then talk about your problem-of-the-week for the remainder of your allotted sessions.
It's rare you get any actual psychiatric help with your deep-seated problems. You just get meds and talk about what's bothering you this week. Just enough help to get you back to work.
YMMV, of course.
posted by Thorzdad at 4:47 AM on June 22, 2011 [3 favorites]
Most people cannot afford actual mental health services out-of-pocket, so they rely on insurance (if they have it, of course). Insurers, for their part, seek to limit their exposure to a process that can be open-ended. So, most insurers approve a very limited number of visits and limit those visits to the lowest-cost provider possible. So, most people end up seeing a counselor/therapist (not a psychologist or psychiatrist) for a limited number of sessions. The end result is a sort of triage process where they hustle you in, evaluate you, get you on medications, then talk about your problem-of-the-week for the remainder of your allotted sessions.
It's rare you get any actual psychiatric help with your deep-seated problems. You just get meds and talk about what's bothering you this week. Just enough help to get you back to work.
YMMV, of course.
posted by Thorzdad at 4:47 AM on June 22, 2011 [3 favorites]
So the DSM-IV is a cash cow. Who knew?
posted by telstar at 4:48 AM on June 22, 2011 [1 favorite]
posted by telstar at 4:48 AM on June 22, 2011 [1 favorite]
I was talking about this with some people (online - my first mistake) who accused me of being a scientologist
posted by rebent at 4:49 AM on June 22, 2011
posted by rebent at 4:49 AM on June 22, 2011
Hi. Not to get overly defensive, but as someone with ADD I'm in no particular mood to just get over my condition just because some people have actually died. Would you tell people with arthritis to get over themselves because at least they don't have polio and they should live with the pain instead of taking an aspirin?
posted by Deathalicious at 5:09 AM on June 22, 2011 [16 favorites]
posted by Deathalicious at 5:09 AM on June 22, 2011 [16 favorites]
*Are* we overmedicated? I mean, who says? I didn't used to be medicated. I frequently am, now. Guess what else I am now? Functional. Society has always been full of the lazy and the screwups and the people who couldn't seem to accomplish anything with their lives and the people who worried about everything. Look at literature. These are not new problems, any more than it's new to have bad teeth. We just have ways of fixing things now, even things that aren't as bad as cancer or schizophrenia.
My family history is full of people who are described as having the same sorts of problems that current members of my family take psychiatric medication for. The currently-living generations are spectacularly absent of anyone who has spent decades as a shut in among piles of old newspapers, or who spontaneously spent the family savings on a business venture in Mexico without ever having actually been there. Not to mention that the younger generation seems to include no alcoholics *or* smokers, those two things having been time-honored ways for our elders to cope with things we now deal with differently. That's amazing, as far as I'm concerned, and it's the direct impact of treating these things as medical issues with symptoms and a diagnosis instead of just as quirks of personality when they were seriously disruptive.
posted by gracedissolved at 5:18 AM on June 22, 2011 [35 favorites]
My family history is full of people who are described as having the same sorts of problems that current members of my family take psychiatric medication for. The currently-living generations are spectacularly absent of anyone who has spent decades as a shut in among piles of old newspapers, or who spontaneously spent the family savings on a business venture in Mexico without ever having actually been there. Not to mention that the younger generation seems to include no alcoholics *or* smokers, those two things having been time-honored ways for our elders to cope with things we now deal with differently. That's amazing, as far as I'm concerned, and it's the direct impact of treating these things as medical issues with symptoms and a diagnosis instead of just as quirks of personality when they were seriously disruptive.
posted by gracedissolved at 5:18 AM on June 22, 2011 [35 favorites]
A hundred and fifty years ago people in the full bloom of youth and vigour died in their droves from infectious disease but rather than enjoy our good fortune today we'd rather invent a slew of nebulous minor ailments to give us any excuse for not trying so hard.
It might be nice to think there was some golden age of medical history when nobody considered anything short of smallpox and amputations to be worth worrying about, but that's not really the case.
The history of medicine is full of conditions that many of us would today think of as nebulous minor ailments. Hysteria covered a huge range of symptoms, ranging from physical to psychological, and changed its definition a great deal over the centuries. Melancholia sort of maps to what we'd classify as depression today, but sort of doesn't; plus, a lot of the debates about depression today (is it romanticising a disease to pretend that depressives just see the world more clearly than the rest of us? is the rise in diagnoses just the result of a medical fascination with it? is it actually a disease at all, or just a bunch of well-off people being miserable about nothing?) started in the 17th and 18th centuries. And hypochondria used to be an actual diagnostic term for a real and physical illness, albeit one where physical symptoms were caused by a particular mental state.
These were all conditions that could last for years and years, or even a lifetime. Plus, since the medical understanding of disease before the nineteenth century (and partly during it) was so heavily built around the idea of imbalance or disorder within the body, even patients cured of one of these would probably consider themselves to have lifelong tendencies towards the condition they'd been cured from. These weren't usually crippling conditions, but they were absolutely seen to interfere with everyday life at a relatively minor but persistent level. Not for everyone, to be fair - the poor people crammed into the industrial slums weren't spending months trying different diets to deal with their melancholia - but the rich were the ones who could afford to pay doctors.
I've read a lot of self-reports from eighteenth-century patients (mostly wealthy, and often diagnosed with hypochondria, hysteria or melancholia) and from their doctors. I wouldn't want to retrospectively diagnose any of them, because I'm not a doctor and anyway they're long since dead. But absolutely, there were a lot of people back then being diagnosed with one of these vagueish medical terms based on a smattering of symptoms that don't seem very serious, and arguably not at all medical (things like 'occasional irritability'). You have occasional stomach aches, pale skin, a tendency to catch winter colds easily, and you find yourself intermittently in low spirits? You have a disorder of the nerves which needs to be treated carefully for months, by medicine, spa waters, exercise, long journeys and avoiding emotional excess.
In many respects I'm not sure our understanding of mental health has improved all that drastically over the last three centuries. We have a clearer idea of how the brain works on a neuro-chemical level, and our medication is more effective, and we make a stronger distinction between mental and physical illness. But we're medicalising the same things, just with different names and different treatments, and we're as keen to see these things as chemical imbalances fixable by pills as the eighteenth-century physicians were to see them as disorders of the nerves fixable by environmental change. None of this is all that new.
posted by Catseye at 5:23 AM on June 22, 2011 [18 favorites]
It might be nice to think there was some golden age of medical history when nobody considered anything short of smallpox and amputations to be worth worrying about, but that's not really the case.
The history of medicine is full of conditions that many of us would today think of as nebulous minor ailments. Hysteria covered a huge range of symptoms, ranging from physical to psychological, and changed its definition a great deal over the centuries. Melancholia sort of maps to what we'd classify as depression today, but sort of doesn't; plus, a lot of the debates about depression today (is it romanticising a disease to pretend that depressives just see the world more clearly than the rest of us? is the rise in diagnoses just the result of a medical fascination with it? is it actually a disease at all, or just a bunch of well-off people being miserable about nothing?) started in the 17th and 18th centuries. And hypochondria used to be an actual diagnostic term for a real and physical illness, albeit one where physical symptoms were caused by a particular mental state.
These were all conditions that could last for years and years, or even a lifetime. Plus, since the medical understanding of disease before the nineteenth century (and partly during it) was so heavily built around the idea of imbalance or disorder within the body, even patients cured of one of these would probably consider themselves to have lifelong tendencies towards the condition they'd been cured from. These weren't usually crippling conditions, but they were absolutely seen to interfere with everyday life at a relatively minor but persistent level. Not for everyone, to be fair - the poor people crammed into the industrial slums weren't spending months trying different diets to deal with their melancholia - but the rich were the ones who could afford to pay doctors.
I've read a lot of self-reports from eighteenth-century patients (mostly wealthy, and often diagnosed with hypochondria, hysteria or melancholia) and from their doctors. I wouldn't want to retrospectively diagnose any of them, because I'm not a doctor and anyway they're long since dead. But absolutely, there were a lot of people back then being diagnosed with one of these vagueish medical terms based on a smattering of symptoms that don't seem very serious, and arguably not at all medical (things like 'occasional irritability'). You have occasional stomach aches, pale skin, a tendency to catch winter colds easily, and you find yourself intermittently in low spirits? You have a disorder of the nerves which needs to be treated carefully for months, by medicine, spa waters, exercise, long journeys and avoiding emotional excess.
In many respects I'm not sure our understanding of mental health has improved all that drastically over the last three centuries. We have a clearer idea of how the brain works on a neuro-chemical level, and our medication is more effective, and we make a stronger distinction between mental and physical illness. But we're medicalising the same things, just with different names and different treatments, and we're as keen to see these things as chemical imbalances fixable by pills as the eighteenth-century physicians were to see them as disorders of the nerves fixable by environmental change. None of this is all that new.
posted by Catseye at 5:23 AM on June 22, 2011 [18 favorites]
I spell 'acknowledgment' the British way, with an extra 'e'. That's because I'm OCD.
posted by Obscure Reference at 5:32 AM on June 22, 2011
posted by Obscure Reference at 5:32 AM on June 22, 2011
Also even if this isn't a double it still really is because people have been saying for decades now that people are being overdosed and we've had this conversation over and over on Metafilter. As far as I can figure it, these must be people who either never have experienced a mental disability/illness, or chose not to treat it with medications. And I don't think they can comment on the issue then. And of course the third group is people who are succesfully treating their condition with medication, and they really shouldn't say anything because that'd be asserting "my problem is real enough to be treated but yours isn't" which is literally making judgements about what is going on in other people's heads.
I so rarely see people bemoaning the overprescription of cholesterol or blood pressure medicine, or people despairing over how too many people are given glasses (in my day, we squinted and were glad to do it). It's because unlike "real" illness or disability, mental issues are still not treated seriously. I suppose "hip new fad" is better than "badge of shame" but our attitude lags behind what it should be. There was a time when people who could not see, hear, or walk were kept in asylums and considered incomplete human beings. I'm looking forward to the day when no one avoids taking care of their mental health out of fear that they'll be judged in a way they never would for taking care of their mental health.
And by the way, my parents, one of whom is actually a psychiatrist, tried everything under the sun before using medication. I still am on meds and have been for, wow, 20 years now, and it makes such a difference. If our child (due in September) later develops ADD or depression I won't balk at considering meds.
posted by Deathalicious at 6:14 AM on June 22, 2011 [11 favorites]
I so rarely see people bemoaning the overprescription of cholesterol or blood pressure medicine, or people despairing over how too many people are given glasses (in my day, we squinted and were glad to do it). It's because unlike "real" illness or disability, mental issues are still not treated seriously. I suppose "hip new fad" is better than "badge of shame" but our attitude lags behind what it should be. There was a time when people who could not see, hear, or walk were kept in asylums and considered incomplete human beings. I'm looking forward to the day when no one avoids taking care of their mental health out of fear that they'll be judged in a way they never would for taking care of their mental health.
And by the way, my parents, one of whom is actually a psychiatrist, tried everything under the sun before using medication. I still am on meds and have been for, wow, 20 years now, and it makes such a difference. If our child (due in September) later develops ADD or depression I won't balk at considering meds.
posted by Deathalicious at 6:14 AM on June 22, 2011 [11 favorites]
Obscure Reference: that sounds more like OCPD... or OED.
posted by mr.ersatz at 6:22 AM on June 22, 2011 [2 favorites]
posted by mr.ersatz at 6:22 AM on June 22, 2011 [2 favorites]
As far as I can figure it, these must be people who either never have experienced a mental disability/illness, or chose not to treat it with medications. And I don't think they can comment on the issue then.
How about people who have treated it with medications but have since found non-medical fixes more effective?
posted by enn at 6:23 AM on June 22, 2011
How about people who have treated it with medications but have since found non-medical fixes more effective?
posted by enn at 6:23 AM on June 22, 2011
I don't think you can rationally support adults choosing to use pot, and at the same time scold them for choosing to use psych meds.
posted by miyabo at 6:25 AM on June 22, 2011 [1 favorite]
posted by miyabo at 6:25 AM on June 22, 2011 [1 favorite]
Would you tell people with arthritis to get over themselves because at least they don't have polio and they should live with the pain instead of taking an aspirin?
If you believe that doesn't already happen, you need to rethink that idea.
Without saying that there aren't real medical (chemical) issues in people's brains that medications help with, because it's obvious to me even anecdotally that there are, there seem to be two things going on: first, the medicalization issue, where everything has to have an FDA-approved diagnosis and an insurance code and then a pill to fix it, which is a problem of the way we handle medicine in the US, and second, the way we define "normal", which doesn't seem to allow for a lot of outliers from a very narrow band in all sorts of physical and mental categories.
These observations are brought to you by the above articles and last night's viewing of Orgasm, Inc., a recent documentary on the subject of the search for "female Viagra" and the medicalization of female sexuality, and the friend I was chatting with online about it. One of our observations was that the scientists and doctors interviewed don't seem to know much about the biology of female sexuality and how it differs from male sexuality (particularly the biology of orgasm) but pharmaceutical companies are still rushing to put out pills and creams for the problem without doing the basic research. And this is one where people know from experience that non-medical help like reducing stress on the patient or getting rid of drug side effects from other prescriptions will help with the problem, which is real even if it is all in the (female) patients' heads.
posted by immlass at 6:29 AM on June 22, 2011
If you believe that doesn't already happen, you need to rethink that idea.
Without saying that there aren't real medical (chemical) issues in people's brains that medications help with, because it's obvious to me even anecdotally that there are, there seem to be two things going on: first, the medicalization issue, where everything has to have an FDA-approved diagnosis and an insurance code and then a pill to fix it, which is a problem of the way we handle medicine in the US, and second, the way we define "normal", which doesn't seem to allow for a lot of outliers from a very narrow band in all sorts of physical and mental categories.
These observations are brought to you by the above articles and last night's viewing of Orgasm, Inc., a recent documentary on the subject of the search for "female Viagra" and the medicalization of female sexuality, and the friend I was chatting with online about it. One of our observations was that the scientists and doctors interviewed don't seem to know much about the biology of female sexuality and how it differs from male sexuality (particularly the biology of orgasm) but pharmaceutical companies are still rushing to put out pills and creams for the problem without doing the basic research. And this is one where people know from experience that non-medical help like reducing stress on the patient or getting rid of drug side effects from other prescriptions will help with the problem, which is real even if it is all in the (female) patients' heads.
posted by immlass at 6:29 AM on June 22, 2011
I don't think you can rationally support adults choosing to use pot, and at the same time scold them for choosing to use psych meds.
Who is scolding? Some of us would just prefer to choose other courses of action without being attacked as anti-science (never mind the science showing that SSRIs are no more effective on average than a placebo). Some of us are skeptical of the constant rhetoric—of which you can find endless examples in AskMe—that no matter how many psych drugs you've tried with no or bad results, you are obligated to keep trying more until either one works or you die, and that if none of them work, it's becauseyour faith isn't strong enough you're not trying hard enough and could not possibly be because medical science is insufficiently advanced to treat your condition.
posted by enn at 6:30 AM on June 22, 2011
Who is scolding? Some of us would just prefer to choose other courses of action without being attacked as anti-science (never mind the science showing that SSRIs are no more effective on average than a placebo). Some of us are skeptical of the constant rhetoric—of which you can find endless examples in AskMe—that no matter how many psych drugs you've tried with no or bad results, you are obligated to keep trying more until either one works or you die, and that if none of them work, it's because
posted by enn at 6:30 AM on June 22, 2011
If you haven't already read the NYRB articles, then you really, really should. Many of the comments in this thread are unresponsive to Dr. Agnelli's points. No one is being scolded for taking psych meds. No one is saying that nobody ever gets better on psych meds.
posted by Sticherbeast at 6:33 AM on June 22, 2011 [1 favorite]
posted by Sticherbeast at 6:33 AM on June 22, 2011 [1 favorite]
The argument isnt that medication doesnt work, it is more that it rarely works better than placebo and has detrimental side-effects.
posted by Saddo at 6:36 AM on June 22, 2011 [1 favorite]
posted by Saddo at 6:36 AM on June 22, 2011 [1 favorite]
Some of us would just prefer to choose other courses of action without being attacked as anti-science (never mind the science showing that SSRIs are no more effective on average than a placebo).
The SSRIs were just barely more effective - more effective, but just barely. From the Epidemic of Mental Illness? article: "The average difference between drug and placebo was only 1.8 points on the HAM-D, a difference that, while statistically significant, was clinically meaningless."
I find this to be even more interesting. It would be one thing if the SSRIs were literally no better than placebos, and it would be another thing if they basically worked, but there's this middle ground of them having a slight chance of working, plus a panoply of side effects. It makes me wonder about a lot of things.
I also enjoyed the parts of the article where she laid out how the presence of side effects actually boosted the effectiveness of the treatment, to a certain extent.
posted by Sticherbeast at 6:41 AM on June 22, 2011
The SSRIs were just barely more effective - more effective, but just barely. From the Epidemic of Mental Illness? article: "The average difference between drug and placebo was only 1.8 points on the HAM-D, a difference that, while statistically significant, was clinically meaningless."
I find this to be even more interesting. It would be one thing if the SSRIs were literally no better than placebos, and it would be another thing if they basically worked, but there's this middle ground of them having a slight chance of working, plus a panoply of side effects. It makes me wonder about a lot of things.
I also enjoyed the parts of the article where she laid out how the presence of side effects actually boosted the effectiveness of the treatment, to a certain extent.
posted by Sticherbeast at 6:41 AM on June 22, 2011
I'm rethinking my views on the basis on these articles. But mental health discussions on the internet start looking a bit too much like breastfeeding wank for my comfort.
posted by KirkJobSluder at 6:51 AM on June 22, 2011
posted by KirkJobSluder at 6:51 AM on June 22, 2011
As far as I can figure it, these must be people who either never have experienced a mental disability/illness, or chose not to treat it with medications. And I don't think they can comment on the issue then.
This is a ridiculous assertion. There's no reason to think that mental illness is a sacrosanct category, and there's no reason to think that only people with direct evidence of a phenomenon can discuss it. These articles aren't about hand-wavy dismissal of personal experience, they're about the limits of psychiatry. Trotting out anecdote, no matter how personally affecting and tragic, to argue that they are wrong demonstrates a paucity of imagination and an unwillingness to examine received assumptions in the face of disconfirming evidence. Replacing one paradigm of explanation with another, or just recognizing that the current paradigm has serious problems and needs to be re-examined, is not disloyal to sufferers, it's how knowledge is advanced. When scientists realized that the phlogiston theory was incorrect candles did not stop burning.
But mental health discussions on the internet start looking a bit too much like breastfeeding wank for my comfort.
I'm not exactly sure what this means, but I think I agree with the sentiment.
posted by OmieWise at 6:54 AM on June 22, 2011 [2 favorites]
This is a ridiculous assertion. There's no reason to think that mental illness is a sacrosanct category, and there's no reason to think that only people with direct evidence of a phenomenon can discuss it. These articles aren't about hand-wavy dismissal of personal experience, they're about the limits of psychiatry. Trotting out anecdote, no matter how personally affecting and tragic, to argue that they are wrong demonstrates a paucity of imagination and an unwillingness to examine received assumptions in the face of disconfirming evidence. Replacing one paradigm of explanation with another, or just recognizing that the current paradigm has serious problems and needs to be re-examined, is not disloyal to sufferers, it's how knowledge is advanced. When scientists realized that the phlogiston theory was incorrect candles did not stop burning.
But mental health discussions on the internet start looking a bit too much like breastfeeding wank for my comfort.
I'm not exactly sure what this means, but I think I agree with the sentiment.
posted by OmieWise at 6:54 AM on June 22, 2011 [2 favorites]
"Everything's over-medicalised these days. Rather than being a badge of shame as it was in the bad old days some diagnosis of mental problems has become almost a must have fashion accessory. Some kid stares out of the window or loves their train set too much and they've got Asperger's syndrome but if they run about giggling for ten minutes they've got ADHD. So much of this is nonsense..."
Ladies and gentlemen, Mr. Andy Rooney!
posted by Eideteker at 7:03 AM on June 22, 2011 [10 favorites]
Ladies and gentlemen, Mr. Andy Rooney!
posted by Eideteker at 7:03 AM on June 22, 2011 [10 favorites]
When scientists realized that the phlogiston theory was incorrect candles did not stop burning.
On that note: it's interesting that SSRIs do appear to work for some people, but medical science still doesn't really understand why they work. Recent research has increasingly contradicted earlier conclusions about SSRIs. There's quite a bit we still don't know about depression or the brain in general.
Here's a clunky metaphor: imagine a medieval village where the village doctor starts washing his hands in blessed water every time he sees a new patient, and at the end of every session he feeds them a blessed poultice of all the nonpoisonous plants within ten feet of his doorstep - this poultice containing, among other things, witch hazel. His patients start faring much better after these improvements. Joyous at his newfound discovery, he starts blessing everything in his workplace and encouraging other doctors to do the same. He also encourages other doctors to make their own poultices out of plants within ten feet of their doorsteps.
Of course, it's not the blessing or the locality of the plants in the poultice that's improving matters. It's the hand-washing and the witch hazel. There still would be some improvement in other doctors' patients, as the hand-washing and maybe even the witch hazel would still carry over, but the mechanism would be, at this point, basically misunderstood, and only further experience would illuminate the real causes and effects.
posted by Sticherbeast at 7:06 AM on June 22, 2011
On that note: it's interesting that SSRIs do appear to work for some people, but medical science still doesn't really understand why they work. Recent research has increasingly contradicted earlier conclusions about SSRIs. There's quite a bit we still don't know about depression or the brain in general.
Here's a clunky metaphor: imagine a medieval village where the village doctor starts washing his hands in blessed water every time he sees a new patient, and at the end of every session he feeds them a blessed poultice of all the nonpoisonous plants within ten feet of his doorstep - this poultice containing, among other things, witch hazel. His patients start faring much better after these improvements. Joyous at his newfound discovery, he starts blessing everything in his workplace and encouraging other doctors to do the same. He also encourages other doctors to make their own poultices out of plants within ten feet of their doorsteps.
Of course, it's not the blessing or the locality of the plants in the poultice that's improving matters. It's the hand-washing and the witch hazel. There still would be some improvement in other doctors' patients, as the hand-washing and maybe even the witch hazel would still carry over, but the mechanism would be, at this point, basically misunderstood, and only further experience would illuminate the real causes and effects.
posted by Sticherbeast at 7:06 AM on June 22, 2011
I'm not exactly sure what this means, but I think I agree with the sentiment.
Meaning that the discussion becomes loaded with people wanting to grind a particular moralistic socio-political axe with little connection to the complexities that people face in making these decisions.
posted by KirkJobSluder at 7:09 AM on June 22, 2011
Meaning that the discussion becomes loaded with people wanting to grind a particular moralistic socio-political axe with little connection to the complexities that people face in making these decisions.
posted by KirkJobSluder at 7:09 AM on June 22, 2011
Meaning that the discussion becomes loaded with people wanting to grind a particular moralistic socio-political axe with little connection to the complexities that people face in making these decisions.
Exactly!
posted by OmieWise at 7:18 AM on June 22, 2011
Exactly!
posted by OmieWise at 7:18 AM on June 22, 2011
The main problem is that for many psychiatric drugs (I'm looking at you Zoloft) there isn't a lot of rigorous scientific evidence that they are effective for alleviating the problems they're meant to address. This is true for other major pharmaceuticals as well. The medical profession and the regulatory agencies aren't all that interested in the ultimate relevant clinical endpoints and I guarantee the industry doesn't want to take the time and expense to evaluate them thoroughly either. The faster the drug gets to the market, the sooner the cash starts to roll in. So you're left with underpowered studies that address some poor surrogate endpoint and too short-term to address long-term outcomes.
It's not clear how much of what has been observed in psychiatry (whether in reference to drug therapy or to talking therapy) is the placebo effect. Metaanalyses attempting to discover the answers have not been able to show unequivocal benefit for things like depression. We, as a society, are willing to spend enormous amounts of money on administering therapies that we are unwilling to spend a fraction of that amount on proving. It's nuts, I tell ya.
posted by Mental Wimp at 7:46 AM on June 22, 2011 [2 favorites]
It's not clear how much of what has been observed in psychiatry (whether in reference to drug therapy or to talking therapy) is the placebo effect. Metaanalyses attempting to discover the answers have not been able to show unequivocal benefit for things like depression. We, as a society, are willing to spend enormous amounts of money on administering therapies that we are unwilling to spend a fraction of that amount on proving. It's nuts, I tell ya.
posted by Mental Wimp at 7:46 AM on June 22, 2011 [2 favorites]
"...and are too short-term..."
posted by Mental Wimp at 7:47 AM on June 22, 2011
posted by Mental Wimp at 7:47 AM on June 22, 2011
Metaanalyses attempting to discover the answers have not been able to show unequivocal benefit for things like depression.
This isn't true. Meta-analyses of psychotherapy (multiple meta-analyses) show an effect size of 0.80 for people, including those with depression, receiving psychotherapy.
posted by OmieWise at 7:57 AM on June 22, 2011
This isn't true. Meta-analyses of psychotherapy (multiple meta-analyses) show an effect size of 0.80 for people, including those with depression, receiving psychotherapy.
posted by OmieWise at 7:57 AM on June 22, 2011
If you haven't already read the NYRB articles, then you really, really should. Many of the comments in this thread are unresponsive to Dr. Agnelli's points. No one is being scolded for taking psych meds. No one is saying that nobody ever gets better on psych meds.
I was actually really responding to a comment in this thread that seemed to suggest that to suggest my diagnosis of ADD is "nonsense" and that all the struggles I endured were from me not trying hard enough. I recognize that there are some real issue with how some medications work and that we live in a society where people often over-medicate. What I object to is the undercurrent of prejudice against mental illness as a serious issue. I frequently hear people stating that medicine should be considered as a "last resort" for mental issues, but I rarely hear that raised for people who are physically sick or disabled.
I think a better way to think of them is as steroids- you can pump in extra chemical help all you want, but if you don't lift the weights you won't feel the advantages. In the case of depression and anxiety, crazy meds are one of the tools used to facilitate brain regrowth, while some variant of talk therapy is the rehabilitative means by which you're supposed to do this. Which is why crazy meds unsupervised are only mildly useful, while crazy meds with a shrink have a much more positive effect.
This. Without medication, there was no way for me to be a conscious observer of my own behavior, and so I couldn't learn to change it. I can now survive a day without meds much better than I could have when I was younger, because the medication was a tool that put my brain into a state where I could learn how to be a whole, focused human being.
Uh, and that being said, I'd better get back to work.
posted by Deathalicious at 8:21 AM on June 22, 2011 [4 favorites]
I was actually really responding to a comment in this thread that seemed to suggest that to suggest my diagnosis of ADD is "nonsense" and that all the struggles I endured were from me not trying hard enough. I recognize that there are some real issue with how some medications work and that we live in a society where people often over-medicate. What I object to is the undercurrent of prejudice against mental illness as a serious issue. I frequently hear people stating that medicine should be considered as a "last resort" for mental issues, but I rarely hear that raised for people who are physically sick or disabled.
I think a better way to think of them is as steroids- you can pump in extra chemical help all you want, but if you don't lift the weights you won't feel the advantages. In the case of depression and anxiety, crazy meds are one of the tools used to facilitate brain regrowth, while some variant of talk therapy is the rehabilitative means by which you're supposed to do this. Which is why crazy meds unsupervised are only mildly useful, while crazy meds with a shrink have a much more positive effect.
This. Without medication, there was no way for me to be a conscious observer of my own behavior, and so I couldn't learn to change it. I can now survive a day without meds much better than I could have when I was younger, because the medication was a tool that put my brain into a state where I could learn how to be a whole, focused human being.
Uh, and that being said, I'd better get back to work.
posted by Deathalicious at 8:21 AM on June 22, 2011 [4 favorites]
To grind my axe a bit, people dealing with mental health issues deal with a morass of discrimination, cultural taboos, unavailable or unaffordable services, treatment options and paradigms, and moral judgements about how to live on top of how these issues affect the person involved. Most people end up suffering in silence without any kind of support. And that makes me profoundly skeptical of both arguments about diagnosis and treatment/support. The argument tend to be weighted toward evaluating this or that method of treatment/support and push empowerment of the people in question into the background.
posted by KirkJobSluder at 9:14 AM on June 22, 2011 [2 favorites]
posted by KirkJobSluder at 9:14 AM on June 22, 2011 [2 favorites]
Everybody wants to be given medical treatment that is proven. You hear a lot today about "evidence based medicine." it's become a real buzzword.
Evidence based medicine sounds like it should be a good thing, but I am not so sure about it's implementation in mental health. As an example, after an inpatient stay in a psychiatric hospital, I was referred to a partial hospital program. The therapy model was what they called "a crash course in DBT." They kept telling us how much clinical evidence there is that DBT works. As far as I can tell from my research, DBT is incredibly effective at preventing future hospitalizations if the program was done in a very particular way with patients who were women with Borderline Personality Disorder.. The people in my program were not women with BPD and we certainly weren't doing anything resembling the studied use of DBT. I learned some helpful skills and left the program in a much better state, but I have to wonder if this a case of the insurer approving a program because it is "evidence based" even though the evidence doesn't seem to apply to this actual program.
You'll have to excuse me if I've expressed this poorly. Most of it was thought out during a hypomanic period wherein I was convinced I had discovered some kind of important scam. Now from the safety of the mellow provided by my new med regimen I still think it's an interesting example of the use of "evidence based" in the world of mental health care.
posted by Biblio at 10:20 AM on June 22, 2011 [1 favorite]
Evidence based medicine sounds like it should be a good thing, but I am not so sure about it's implementation in mental health. As an example, after an inpatient stay in a psychiatric hospital, I was referred to a partial hospital program. The therapy model was what they called "a crash course in DBT." They kept telling us how much clinical evidence there is that DBT works. As far as I can tell from my research, DBT is incredibly effective at preventing future hospitalizations if the program was done in a very particular way with patients who were women with Borderline Personality Disorder.. The people in my program were not women with BPD and we certainly weren't doing anything resembling the studied use of DBT. I learned some helpful skills and left the program in a much better state, but I have to wonder if this a case of the insurer approving a program because it is "evidence based" even though the evidence doesn't seem to apply to this actual program.
You'll have to excuse me if I've expressed this poorly. Most of it was thought out during a hypomanic period wherein I was convinced I had discovered some kind of important scam. Now from the safety of the mellow provided by my new med regimen I still think it's an interesting example of the use of "evidence based" in the world of mental health care.
posted by Biblio at 10:20 AM on June 22, 2011 [1 favorite]
It's tough working in psych. For an awful lot of medicine, the tinctures and rituals we provide have no proven benefit beyond placebo when applied to an undifferentiated population, yet millions of people avail themselves of these unproven remedies in the absence of widespread, concerted movements to deny the "reality" of these "medical" conditions. When I work in the ED and get people coming in with acute coronary syndromes, there are very few of them willing to deny the existence of heart disease (but there are, indeed, a few!). Yet I often meet people willing to deny the existence of psychiatric illnesses or some of the demonstrated linkages between, say, some cardiac disease morbidity and mood states. Are these separate illnesses stemming from a common root cause, or are they different symptom clusters of a single underlying etiology? In the absence of individualised, comprehensive genomic data, personalised analyses of their cerebral and neurohumoral maps, complete characterisation of their adaptive immune system (and an understanding of the adaptive hypermutation coding), and a complete theory of mind, it's impossible to say definitively. How many of the health issues presented at family and urgent care clinics could be recharacterised as exotic forms of conversion syndromes is an interesting question.
When I consider the health risks and then prescribe a random SSRI for a person, I know there's only a minority probability that it will produce an objective, lasting change in their mood state that exceeds anything that could be produced by placebo or alternative therapies. But I also know that because of inherited SERT and polymorphisms, certain clades of genetically related patients will demonstrate much more predictable, grouped responses to specific SSRIs (or SNRIs, or NDRIs). That's why the history is so important - to find out how other family members have expressed related behavioural phenotypes and what they have tried that "worked", and the existence of EBM protocols to encourage switching between medications of similar class but different sites or mechanisms of action upon SERT (or similar), and to encourage switching to a different class entirely. Unless and until the large studies of antidepressant medications can be performed alongside individualised patient profiling and better characterisation of the quality of their "depression", and with proper intention-to-treat analyses, then a lot of the analyses are flawed, with input data too noisy to get anything other than placebo/noise on the output.
I also like ECT, One Flew be damned. For the right patients, with either intractable illnesses or health conditions that preclude the administration of potentially harmful drugs, I've seen ECT produce huge and incredibly quick improvements in people's basic functioning without any of the Hollywood-style "zombification". We're talking about people so catatonic that they are just sitting in their own poop, slowly starving to death, and nothing else has worked. A condition doesn't have to be that dramatic for ECT to work, but when it does, it's amazing.
posted by meehawl at 10:24 AM on June 22, 2011 [3 favorites]
When I consider the health risks and then prescribe a random SSRI for a person, I know there's only a minority probability that it will produce an objective, lasting change in their mood state that exceeds anything that could be produced by placebo or alternative therapies. But I also know that because of inherited SERT and polymorphisms, certain clades of genetically related patients will demonstrate much more predictable, grouped responses to specific SSRIs (or SNRIs, or NDRIs). That's why the history is so important - to find out how other family members have expressed related behavioural phenotypes and what they have tried that "worked", and the existence of EBM protocols to encourage switching between medications of similar class but different sites or mechanisms of action upon SERT (or similar), and to encourage switching to a different class entirely. Unless and until the large studies of antidepressant medications can be performed alongside individualised patient profiling and better characterisation of the quality of their "depression", and with proper intention-to-treat analyses, then a lot of the analyses are flawed, with input data too noisy to get anything other than placebo/noise on the output.
I also like ECT, One Flew be damned. For the right patients, with either intractable illnesses or health conditions that preclude the administration of potentially harmful drugs, I've seen ECT produce huge and incredibly quick improvements in people's basic functioning without any of the Hollywood-style "zombification". We're talking about people so catatonic that they are just sitting in their own poop, slowly starving to death, and nothing else has worked. A condition doesn't have to be that dramatic for ECT to work, but when it does, it's amazing.
posted by meehawl at 10:24 AM on June 22, 2011 [3 favorites]
The author of the article write: That makes it possible to expand diagnostic boundaries or even create new diagnoses, in ways that would be impossible, say, in a field like cardiology.
I think she's wrong about the uniqueness of psychiatry in that regard. The definitions of obesity have been re-written in recent years, for instance, in part in response to the desire on the part of drug companies and providers of bariatric treatments to create a larger pool of treatable people (I'm remembering this from either Fat Politics or The Obesity Myth--something like 100,000 American became obese overnight when the definitions were changed, and this is part of what drives our perception that there is an epidemic). Just recently diabetes was redefined--this graph at Sociological Images shows the effect of that redefinition. I've read an argument that osteoporosis is defined by certain bone densities without underlying data about what bone densities are normal, and what bone densities are really correlated with greater risk of injury. A friend who is a doctor talked to me once about being frustrated by the widespread prescription of cholesterol drugs despite limited evidence that they are effective, or that, when they do lower cholesterol, that this actually lowers health risks.
I find these arguments about psychiatry very interesting, given my own mental health history and that of various loved ones. But I don't think psychiatry's subjectivity is as unique among medical specialties as she claims it is.
posted by not that girl at 10:37 AM on June 22, 2011
I think she's wrong about the uniqueness of psychiatry in that regard. The definitions of obesity have been re-written in recent years, for instance, in part in response to the desire on the part of drug companies and providers of bariatric treatments to create a larger pool of treatable people (I'm remembering this from either Fat Politics or The Obesity Myth--something like 100,000 American became obese overnight when the definitions were changed, and this is part of what drives our perception that there is an epidemic). Just recently diabetes was redefined--this graph at Sociological Images shows the effect of that redefinition. I've read an argument that osteoporosis is defined by certain bone densities without underlying data about what bone densities are normal, and what bone densities are really correlated with greater risk of injury. A friend who is a doctor talked to me once about being frustrated by the widespread prescription of cholesterol drugs despite limited evidence that they are effective, or that, when they do lower cholesterol, that this actually lowers health risks.
I find these arguments about psychiatry very interesting, given my own mental health history and that of various loved ones. But I don't think psychiatry's subjectivity is as unique among medical specialties as she claims it is.
posted by not that girl at 10:37 AM on June 22, 2011
Meta-analyses of psychotherapy (multiple meta-analyses) show an effect size of 0.80 for people, including those with depression, receiving psychotherapy.
Yes, if you pay attention only to certain ones and ignore the fact that the bulk of the underlying studies were poorly controlled and suffer from uncorrectable selection biases.
posted by Mental Wimp at 10:59 AM on June 22, 2011
Yes, if you pay attention only to certain ones and ignore the fact that the bulk of the underlying studies were poorly controlled and suffer from uncorrectable selection biases.
posted by Mental Wimp at 10:59 AM on June 22, 2011
And then I think, "You know, I kind of like my life so I think I'm gonna stick with the meds."
Well, as an experiment you and I could always take the advice of the fine people on the internet, and switch to eating right, our exercise, meditation, and all that. And if it goes wrong and we die, they'll see that as evidence for...nothing. They'll chalk out down to the fault of the medical establishment, and go on saying that depression shouldn't be treated with meds.
The bottom line is that the critics of medication aren't our friends- they don't give a shit if we live or die, as long as they can criticize the medical establishment. If they had been so vocal when I was first doing trial-and-error with meds, I would have given up, and almost certainly be dead now. So as far as I'm concerned these "well-meaning" people speaking out against over-medication are enemies who want me and everyone else who can be helped with meds dead...unless they can give experimental proof to the contrary.
posted by happyroach at 12:25 PM on June 22, 2011 [1 favorite]
Well, as an experiment you and I could always take the advice of the fine people on the internet, and switch to eating right, our exercise, meditation, and all that. And if it goes wrong and we die, they'll see that as evidence for...nothing. They'll chalk out down to the fault of the medical establishment, and go on saying that depression shouldn't be treated with meds.
The bottom line is that the critics of medication aren't our friends- they don't give a shit if we live or die, as long as they can criticize the medical establishment. If they had been so vocal when I was first doing trial-and-error with meds, I would have given up, and almost certainly be dead now. So as far as I'm concerned these "well-meaning" people speaking out against over-medication are enemies who want me and everyone else who can be helped with meds dead...unless they can give experimental proof to the contrary.
posted by happyroach at 12:25 PM on June 22, 2011 [1 favorite]
Yes, if you pay attention only to certain ones and ignore the fact that the bulk of the underlying studies were poorly controlled and suffer from uncorrectable selection biases.
No, even accounting for confounding studies.
posted by OmieWise at 1:30 PM on June 22, 2011
No, even accounting for confounding studies.
posted by OmieWise at 1:30 PM on June 22, 2011
And then I think, "You know, I kind of like my life so I think I'm gonna stick with the meds."
AND
Well, as an experiment you and I could always take the advice of the fine people on the internet, and switch to eating right, our exercise, meditation, and all that. And if it goes wrong and we die, they'll see that as evidence for...nothing. They'll chalk out down to the fault of the medical establishment, and go on saying that depression shouldn't be treated with meds.
This may be something that comes up "on the internet," and there may be strains of it in any conversation about mental health even here at Metafilter, but that certainly isn't the tone of this conversation, and it has nothing to do with the subject of this series of articles.
The continued equation of any question about psychiatric nosologies and medication efficacy with some nefarious plot to keep people miserable is counter-productive and disingenuous. The entire point of these exercises, made in good faith, is to help more people feel better in more effective ways. Yes, there is a world of anti-psychiatry, that ranges through Thomas Szaz to the Scientololgists, but that isn't this. Neither is this akin to global warming deniers or Creationists. This, by which I mean the intellectual area represented by these articles and books, and for the most part, by this discussion, is an attempt to identify and detail the limitations in our current system in order to make it better. This is, broadly, science. It is ironically those who equate any questioning of the current nosologies and modalities with heresy (and death wishes for the mentally ill) who are being anti-science. The folks who espouse it should at least be required to let us know why they think we've come to the end of the history of psychiatry and psychology, and neither needs refinement or self-reflection.
posted by OmieWise at 1:41 PM on June 22, 2011 [2 favorites]
AND
Well, as an experiment you and I could always take the advice of the fine people on the internet, and switch to eating right, our exercise, meditation, and all that. And if it goes wrong and we die, they'll see that as evidence for...nothing. They'll chalk out down to the fault of the medical establishment, and go on saying that depression shouldn't be treated with meds.
This may be something that comes up "on the internet," and there may be strains of it in any conversation about mental health even here at Metafilter, but that certainly isn't the tone of this conversation, and it has nothing to do with the subject of this series of articles.
The continued equation of any question about psychiatric nosologies and medication efficacy with some nefarious plot to keep people miserable is counter-productive and disingenuous. The entire point of these exercises, made in good faith, is to help more people feel better in more effective ways. Yes, there is a world of anti-psychiatry, that ranges through Thomas Szaz to the Scientololgists, but that isn't this. Neither is this akin to global warming deniers or Creationists. This, by which I mean the intellectual area represented by these articles and books, and for the most part, by this discussion, is an attempt to identify and detail the limitations in our current system in order to make it better. This is, broadly, science. It is ironically those who equate any questioning of the current nosologies and modalities with heresy (and death wishes for the mentally ill) who are being anti-science. The folks who espouse it should at least be required to let us know why they think we've come to the end of the history of psychiatry and psychology, and neither needs refinement or self-reflection.
posted by OmieWise at 1:41 PM on June 22, 2011 [2 favorites]
No, even accounting for confounding studies.
Are you thinking of a particular metaanlysis, Omiewise?
posted by Mental Wimp at 7:12 AM on June 23, 2011
Are you thinking of a particular metaanlysis, Omiewise?
posted by Mental Wimp at 7:12 AM on June 23, 2011
I don't have it in front of me, so I can't list chapter or page numbers, but Bruce Wampold, in The Great Psychotherapy Debate discusses the strengths and weaknesses of the various meta-analyses in quite a lot of detail. He then explains why his meta-analysis accounts for those issues. I don't agree that the whole lot of them must be thrown out, nor that they don't show robust evidence for change from psychotherapy.
posted by OmieWise at 7:40 AM on June 23, 2011
posted by OmieWise at 7:40 AM on June 23, 2011
He then explains why his meta-analysis accounts for those issues.
Is Dr. Wampold's metaanalysis published in the peer-reviewed literature? I can't seem to find one that matches your generalized description in the indexes. He has published a lot of metaanalyses, along with some ax-grindy methodological publications arguing that the whole set-up of evidence-based medicine is wrong. In any event, I urge you to review the individual studies so you can see what a hopeless mess the literature is. GIGO.
As an aside, I see Dr. Wampold is of the opinion that randomized, controlled trials aren't relevant to discovering what works clinically. I'm not sure how one can trust metaanalyses from someone who doesn't believe in rigorous study designs.
posted by Mental Wimp at 10:57 AM on June 23, 2011
Is Dr. Wampold's metaanalysis published in the peer-reviewed literature? I can't seem to find one that matches your generalized description in the indexes. He has published a lot of metaanalyses, along with some ax-grindy methodological publications arguing that the whole set-up of evidence-based medicine is wrong. In any event, I urge you to review the individual studies so you can see what a hopeless mess the literature is. GIGO.
As an aside, I see Dr. Wampold is of the opinion that randomized, controlled trials aren't relevant to discovering what works clinically. I'm not sure how one can trust metaanalyses from someone who doesn't believe in rigorous study designs.
posted by Mental Wimp at 10:57 AM on June 23, 2011
Your comment seems disingenuous to me. It makes me think you're seeking to dismiss Wampold's work, which you don't seem to have read, with ad hominems and implications of excessive (and therefore ludicrous) zeal. You misrepresented the article you linked to, which constructively points out some unintended pitfalls of uncritical research design (focused on clinical psychology, not all of evidence-based medicine). You slur Wampold by suggesting that "Dr. Wampold is of the opinion that randomized, controlled trials aren't relevant to discovering what works clinically," when I think that's a completely incorrect reading of his work. Even your tone, with the exaggerated formality of calling him "Dr. Wampold" seems to try to turn the title into an insult. This is a guy who has written scores of peer reviewed papers, many book chapters, and quite a few books, all within his area of expertise (in other words, he isn't a nuclear physicist writing about how climate change or evolution are not true). That includes research design as well as therapeutic effectiveness. Your simple version of his position is belied by just a quick glance at his CV. Surely you can disagree with my opinion (and by extension his work), without being such a false interlocutor.
Yes, his meta-analytic papers have been published in peer reviewed journals. I'm not sure exactly where to direct you, but I think you can either figure it out (if you want to), or, as seems more likely at this point, dismiss it without another thought.
posted by OmieWise at 2:18 PM on June 23, 2011
Yes, his meta-analytic papers have been published in peer reviewed journals. I'm not sure exactly where to direct you, but I think you can either figure it out (if you want to), or, as seems more likely at this point, dismiss it without another thought.
posted by OmieWise at 2:18 PM on June 23, 2011
There's no reason to accept my word for any of this, as you rightly point out, Omiewise. I do urge you to read the original literature and see for yourself whether it meets rigorous standards, rather than taking a conflicted party's word for it. If it works for you, I have nothing more to say on the matter.
posted by Mental Wimp at 2:48 PM on June 23, 2011
posted by Mental Wimp at 2:48 PM on June 23, 2011
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