On the advice of people here on HN, I've started reading Whitaker's "Anatomy of an Epidemic", which is one of the books reviewed here. It's a solid book, but not doing a lot for me. As a counterpoint for pro-drug advertising it's fine, but it feels more like a journalistic expose than science. It's not that it's wrong, rather it feels like the author started out with a conclusion and then did a lot of fine research to find supporting evidence. I feel like I'm being given only half the story: a well-founded and less-told half, but still I worry that the author might have chosen to omit any evidence that weakened his case.
I'm enjoying another book (not reviewed in this article) that I grabbed off the new book shelf much better. "What is Mental Illness" by Richard McNally. He's a Harvard psychology professor who's served on committees for DSM-IV. It touches on a lot of the same issues, seems a little more current rather than historical, and by and large I trust that he's representing the field as he sees it. I also like the prose better: a fun combination of low brow and erudite. It's highly critical of the field, but also balanced in a way that I don't find Whitaker to be. http://mcnallylab.com/
"I feel like I'm being given only half the story: a well-founded and less-told half, but still I worry that the author might have chosen to omit any evidence that weakened his case."
I've been checking since the book came out and I have yet to find any intelligent criticisms of the book. There was one Amazon reviewer who claimed Whitaker was leaving out specific studies that contradicted him, though when I actually read them studies mentioned they either supporter Whitaker or else were orthogonal to the claims. If anyone has found anything intelligent on the subject I'd love to see it though.
It's important to remember also that the best case scenario is that these drugs aren't as outright harmful as the research suggests, the other issue is that most of the research supporting them is of extremely low quality, which is pretty self-evidently true.
Doctors don't diagnose purely on the basis of the DSM or similar statistical tools, and haven't for decades, at least here in the UK which is the system I am most familiar with.
This is too big a subject area to go into here in a HN comment but if you want to know more, a good place to start would be by familiarising yourself with the difference between nomothetic and idiographic knowledge, which is completely key to modern diagnostic practices in psychiatry.
VERY VERY simply, while someone might be considered severely abnormal from a nomothetic viewpoint, from an idiographic viewpoint clinicians might decide that they have always been that way and they have a history of being happy and getting on well in their society and with those around them and being successful, and therefore they cannot call that person crazy, however statistically abnormal their actions may be.
But yeah, it's a lot more complex than that.
EDIT: an important point to remember is that not every doctor is some sort of sucker, prescribing whatever big pharma tells them to. When you see a microsoft press release, do you read it and say "well that sounds convincing!" and start building everything on MS platforms? Thought not.
Obviously this largely depends on the economic relationship between healthcare practitioners and big pharma in your country and your healthcare system, whatever that might be.
If you were unlucky enough to live in a country where MS could just pay you per line of ASP.NET checked in, well I guess there would be a lot of misery and shitty code.
thought: if good, go to grasping. if bad, go to repressing. if neutral, ignore.
grasping: increment mood, repeat until fail. go to fail //always fail
repressing: repeat until fail. go to fail. //always fail
fail: decrement mood, goto thought.
As I understand Theravada, it's about observing what is happening rather than stopping or nullifying; so thought -> observe -> repeat is quite appropriate for it.
Theravada Buddhist Practitioner here. In addition to daily meditation practice, I've attended 8 months worth of meditation retreats in the last 4 years. These retreats consisted of 8-15 hours a day of formal meditation (depending on how hard I was going at it) with an effort to continuity of mindfulness in between formal sessions. At this point, I estimate I have about 3-4k of my 10k hours required for high mastery.
My understanding of the purpose and benefit of practice is to observe experience as it arises (whether physical sensations, sensory input or thoughts) as it arises and see how you react to it.
One key insight you find is we tend to contract toward things that are pleasant and contract away from experience that is unpleasant and space out (or seek distraction) during experience that is neutral or boring. A cognitive understanding of this contraction and spacing out is insufficient to decondition the human brain from doing it. The conditioning is too deep.
It requires using concentration and mindfulness as a microscope on our perception to see and feel the additional pain we create in the contraction. As we repeatedly connect with the pain of contraction we slowly over time stop doing it and begin to experience life in a whole new way. The capacity to face pleasant, unpleasant and neutral experiences without contracting or spacing out is quite literally a life changer.
The Mahayana tradition (in particular Zen) is the one that focuses more on not doing; where-as Theravada very much puts forth the practice as an act of doing. The usual language is to "turn towards" what is happening, not to simply "be one" with it.
Perhaps most notably that the author of this piece is the former editor of the New England Journal of Medicine. In addition to the three books reviewed, Crazy Like Us is definitely also worth a read. It's a more anthropological look at mental illness so it's maybe not quite as good as Anatomy of an Epidemic as the first of these books to read, but it's still incredibly fascinating.
As someone who has taken a variety of treatments for depression (never SSRIs -- only Bupropion, St. John's Wort, and most recently S-Adenosyl methionine, or "SAM-e") I can say from my own personal experience that they most definitely do _something_, and for me it's almost always positive. In fact, the only reason I've begun to suspect the role of "chemical imbalances" (which are likely caused by the environment and my own response to it) is because of SAM-e's effectiveness.
I have absolutely no financial interest in saying so, but because of its positive effects I'd like to make a plug: SAM-e has been completely wonderful for me -- it's worth checking out the extensive literature on it, which show results that are arguably more impressive than those of the SSRI and tricyclic crowd, especially because SAM-e has virtually no negative side-effects.
The problem is that virtually every form of sensory or neurochemical novelty elevates mood: acupuncture, aromatherapy, sex, exercise, socializing, sensory deprivation, electrical stimulation, god helmet, music, binaural beats, self-mutilation, menthol, etc.
Similarly, every conceivable way you can possibly monkey around with your brain also raises your mood: raising dopamine, lowering dopamine, raising serotonin, lowering serotonin, raising norepinephrine, lowering norepinephrine, etc. You'd literally be hard pressed to find any form of novel sensory stimulation that didn't improve mood, at least in the short term. So why the focus on serotonin depletion? There's no real evidence for it, it was just an arbitrary decision made by drug companies based on the very early research in the field.
I don't think anyone would argue that messing around with a person's serotonin levels can't elevate their mood, at least for a while. The issue is that there isn't any real evidence that the depression springs from a chemical imbalance, and there is definitive proof that longterm messing with your neurotransmitter levels causes semi-permanent changes to the structure of the brain which we don't really understand.
Also, for what it's worth, St. John's Wort is believed to be an SSRI, at least according to Wikipedia.
The issue is that there isn't any real evidence that the depression springs from a chemical imbalance
Well, if its not a chemical imbalance, what is it? Neurotransmitters do the work of transporting signals through the brain - they tell neurons when to fire and what intensity to fire with. If its not a neurotransmitter issue, then what is it?
If the brain only had a couple of neurons, then it might make sense to pump up the transmitters between them to get a more intense response because you don't need very refined control. However there are 100 billion neurons in the brain, and are connected in very complicated ways.
Since there's evidence that cranking up the seratonin for _every_ neuron or suppressing the dopamine for _every_ neuron isn't healthy, it stands to reason that treating "mental illness" is more complicated than turning a water faucet on or off. Who knows exactly what causes it? It could be related to patterns of connection, i.e. neuron A is better off connected to neuron B at site C, but is connected strongly to neuron D at site E. And then comes the question of whether the neuron is sending weird patterns of action potentials. Or it could be the timing, speed or synchronization compared to other neurons is off. Or it could be poor overall health of each individual neuron. Or subtle brain damage. And the problem might be localized to just some neurons in one part of the brain, and not another, making treatment of the whole brain with drugs a messy approach. You see, there are no obvious answers right now, but there are plenty of alternate explanations besides global chemical imbalance. :)
EDIT: Also, you could think of mental illness as being psychological, and something that the brain can heal on its own, given the right environment.
I think a good analogy is when you leave a paused DVD on a plasma TV for too long so it starts ghosting. Your brain, being a neural net, works suspiciously like a neural net. If you 'practice' being depressed for long enough then it's going to get easier and easier to be depressed, and being not depressed gets harder and harder.
That's not to say what actually causes mental illness or what the solution is, but if you want a metaphor that operates on the hardware layer of abstraction that you can frame other theories and/or best practices in terms of then I think that's probably as good as any.
I had virtually the opposite experience to you, including it for the sake of discussion. I'd tried most of the same list as you and had very little positive outcome (all over the counter items or meds that were easy enough to get by saying the right things in order to a local GP)
Through the period I'd experienced some significant lows that all met different criteria - extended depression, severe self harm and mutilation, social difficulties, drugs, alcohols, other unsavoury behaviour (not quite hookers and blow but close enough). Most of the chemical strategies weren't effective, or it was easy enough to discontinue them them shop around for something else a few weeks later.
In the end, I think I reached a point where I was genuine about change and engaged with a psychologist, and within a couple of months the outcomes were very apparent, and positive. Not saying its a good measure of anything either way, just a demonstration of another scenario I suppose.
I'd agree with you on the psychotherapy thing. I'm currently in some pretty intense therapy and it's been really good. I would recommend it strongly to anyone who can afford someone they're willing to trust.
I can't tell from your response, though, if you had tried out SAM-e ? I called it a drug earlier, but it's currently sold as a (n admittedly pretty expensive) supplement. It's hard to find a research study that doesn't show a pronounced effect of the supplement over placebo -- in fact, it was my psychiatrist who recommended it to me (I had stopped taking the bupropion and things were getting pretty bad again).
I should add that the reason I stopped taking the bupropion was that I felt it "worked" by turning down the gain on the more critical parts of my mind, rather than allowing me to reinterpret my own critical thoughts. In other words, I felt like it improved my mood but made me a bit more dimwitted.
I managed to resolve my depression/anxiety with magnesium, 5-HTP and Rhodiola Rosea. I've also had huge realisations about how simple most mental health problems are, when approached from the perspective of removing the cause as opposed to treating the symptoms.
The pharma industry is likely lobbying against these simple treatments because they are not patentable. No single company stands to profit from them. Capitalism provides a rather ugly way of dealing with this issue (and yet people still insist that it's the best system we have). I really do think that the lack of real solutions in the mainstream are a result of economical and political idiocy.
I was/am scared of the long term effects of psychoactive medication, and so wanted the least potent thing available. Plus SSRIs have side-effects that made me less-than enthusiastic.
I've known two people who've been on this stuff. It's pure evil - nearly killed both of them through side effects and made the problem significantly worse:
This all makes sense to me. My mom has been one one psychoactive drug or another since 1989. Her cognitive ability is in the toilet and she's on a cocktail of different things now. I had a breakdown 5 years ago. Was on some drugs for a few weeks until I stabilized and I've been ok ever since. I think the standard course of action would have been to stay on them indefinitely. Thank goodness for lack of healthcare I guess. I wish there was a way society could actually help the mentally ill instead of causing harm as usual.
That's terrible, and I'm sorry for you. I'm very thankful for my medication though, because whilst not dependant on them, they do patch a few annoying bugs.
When we look at poor societies, or even much of Western Europe >100 years ago, we see vast swaths of the population with stunted physical growth suffering from preventable and treatable nutrient deficiencies. E.g., currently around 50-70% of people in Africa are anemic, in large part due too deficiencies in dietary iron [1].
In the same way, I'm wondering if at some point in the not-too-distant future we'll look back to today and see the mental health of whole populations as "malnourished", the psychological equivalent of mean population height being 5 feet tall.
Alternatively, perhaps it's currently being over-diagnosed.
There seems to be a trend toward medicalizing behavior, emotion, and personality traits, including those that fall within the normal range of human variation, or that may actually be healthy responses to external stimuli.
Is it really reasonable to describe 'ADHD' and mild forms of depression as mental illness?
I am not a chemist nor a psychiatrist, so I know next-to-nothing about any of this. However, I have on occasion read various reports on trace pharmaceutical presence in drinking water supplies (e.g., http://www.cbsnews.com/stories/2008/03/10/health/main3920454...) -- clearly the amounts are too small to have acute effects, but, taken over the course of an individual's life? Especially in the earliest stages of childhood? Is it a possible contributor towards this "epidemic"?
I know there are a few HN folks better versed in this kind of stuff. I'd love to hear why those reports are bunk, or why it doesn't work that way. Just curious.
Humans aren't meant to stare at a computer all day, and they're not meant to stay inside an isolated domicile the rest of the time. I think our lifestyle is mostly to blame.
The doctors' job is to diagnose people's illnesses. They get money for medicating people. However, there are definite procedures and thresholds that separate physical health and illness.
Not so for mental health. Without any incentive to diagnose perfect health and without any way to mechanically prove health, doctors are bound to have a bias for false positives.
I am not saying that the doctors are at fault. But doctors are rewarded for finding illnesses, not curing them. Sad.
As someone who suffers some psychological issues... I sometimes wonder whether it's the result of our consumer-whoring-omg-think-of-the-children-be-vewey-afraid society than drugs/exercise. I mean, are you really going to be all you can when people are condescending towards you because you don't have an iPhone? Shit, what are they going to be like if they ever heard what I've been through scaredhidesruns away
If people are condescending towards you because you don't have an iPhone, I think you should try to find other people to be around. Running away is the correct response. :) It's easier said than done, of course.
Here's another reason - people are rich. If you have no slack, you just work every day to put food on the table.
Having decent resources, but expectations that you will put those resources to work, and being fed conflicting values as to what success actually means (as well has how to achieve it) can send you; well; crazy.
I'm enjoying another book (not reviewed in this article) that I grabbed off the new book shelf much better. "What is Mental Illness" by Richard McNally. He's a Harvard psychology professor who's served on committees for DSM-IV. It touches on a lot of the same issues, seems a little more current rather than historical, and by and large I trust that he's representing the field as he sees it. I also like the prose better: a fun combination of low brow and erudite. It's highly critical of the field, but also balanced in a way that I don't find Whitaker to be. http://mcnallylab.com/