Interesting thread. I did not listen but have read many of the comments.
Having traveled extensively in the East I can attest to the fact that their are highly advanced souls who would be put in mental institutions in the West ( if we had them of course) or at minimum heavily medicated. They function in an entirely different level of consciousness. In the West these states are considered a pathology. In the East they are considered high spiritual states. One in particular in India , Tajuddin Baba was actually thrown in an insane asylum for waliking across a tennis court naked. The British ladies and gentleman were horrified. He spent something like 14 years inside. He was revered by the local populace so much that thousands would be outside the facility in devotion. It created so many problems they finally let him out. His samadhi is still a place of great devotion and pilgrimage almost 100 years after his passing.
In the West we do not even have the vocabulary to describe these states. In the East there are terms such as Majzoob, Rasool, Brahmin Bhoot, Jivanmukta etc, Each has different characteristics and are very different from what one in the West would consider normal consciousness.
Would anyone consider drugging Temple Grandin? She is autistic and has made many contributions to animal husbandry and certainly her particular consciousness is anything but considered normal.
So we are now in the position of placing our faith in the hands of “experts” to decide whether someone should be medicated or institutionalized. Then of course we have the government ( Cia etc) using all kinds of drugs on unsuspecting guinea pigs and “kubarking” those they do not like. And all this ultimately in the name of normalcy.
For several years now, I have occasionally described myself as mildly depressed over the path humanity seems bent on taking. I have even wondered if mild antidepressent medication might be in order.
When Chris made the distinction between depression and demoralization, I had a profound eureka moment.
I’ve never really felt that depression accurately described my state of mind. Now I know why.
Thanks.
Psychiatry and associated disorders is a topic I’ve always felt highly controversial towards. On one hand I’ve seen similar charts as posted above on how medications are typically worse than the alternative and read a book by the psychiatrist Thomas Szasz, who believes that the concept of “mental illness” is mostly a control tool. On the other hand, I have a few close relative experiences that I’ve followed over several years and I’ve listened to psychologist Jordan Peterson’s explanations (who seems to have surprisingly many sound views in general) on how psychiatric medication can truly be a life savior particularly in the short run. Before I mention my anecdotes, let me emphasize that the little I’ve read of the psychiatric literature seems to indicate that there’s no such thing as a “normal” person. We all simply deviate from the average behavior in the societies we live in, those who deviate more than that are considered “eccentrics” and those who deviate even more than that typically fall in the “insane” or even “criminal” category. Where these lines are drawn is highly subjective.
Chris and some others in here who have actually met me face-to-face might recognize me in this, but I’ve been struggling with some forms of mental disorders for about 20 years on top of being labeled both as having ADHD and dyslexia as a child (never medicated for either). The terms mental health professionals have attached to my (claimed) disorder have been mild bipolar, neuroticism, highly functioning depression, melancholy, and simply calling me someone who is “barely socially functional”. I’ve been told to try ADHD medication, anti-anxiety medications and antidepressants, but never dared to take any due to possible side-effects, which is why I gave up on seeing therapists some 15 years ago. The only “treatment” that I’ve found to work is to take on so much actual work, yard work or similar activities that my days are so exhausting that I can’t spend too much time ruminating on things, which stops me from finding my mind in very dark places.
My wife and I have four kids and every time she has given birth she has gotten pretty bad postpartum depression (all her pregnancies and births have been very easy and without complications). This seems to starts about 2-4 weeks after delivery and go on 'til about 9-12 months. Her symptoms have been extreme anxiety. For example, she may refuse to leave the house, she reads every bad online/verbal comment that relates to her far more critically than she should, she may randomly burst into tears from seemingly minor things such as breaking a glass, she may feel so inadequate to become confused how to safely operate household appliances etc. After our first child we went through this and it was horrible. After our second child we knew what to expect and tried supplements such as deep ocean fish oil to balance epa/dha and niacin (a type of vitamin B), which we read had helped others. Her symptoms were better, but the situation was still very bad. After our third child her postpartum worsened until the child was about 3 months old to the point that my wife had to be committed because she frequently left the gas accidentally on in the kitchen etc. During her short stay in psychiatric care she was put on the mildest possible dose on sertraline (typical brand is Zoloft) and stayed on it until the child turned one. She withdrew from it in a month or so, during which she was slightly more irritable than normal, but the situation was overall blissful compared to what I witnessed before. For our fourth child she ended up getting a prescription in advance and took it 2 weeks postpartum when her typical symptoms started to kick in. This halted the symptoms in 3 days and she was fine the entire year. The withdrawal was a bit tricky again due to the irritableness, but far better than what I would have expected to go through without it.
One of my brother-in-laws was diagnosed as a schizophrenic in his late teens. Every time he is on antipsychotics (don’t know exactly which) he’s a functioning person who can maintain a job, pay his taxes, live in a house, take care of himself, i.e. function as a pretty regular adult. If he forgets just two doses he stops taking his pills altogether, because he claims they’re hurting him, and goes off the deep end that includes bizarre delusional fantasies of e.g. Jeff Besos wanting to start a new business with him or Miss America wanting to marry him etc. and while he’s not dangerous in this state, he does erratic things such as empty his bank account and buy a one-way ticket to Washington state just to meet with Besos (who my brother-in-law of course never meets). This situation then ends up with the police finding him and taking him into custody. The unfortunate thing is that every time my brother-in-law stops taking his antipsychotics it takes longer and longer for us to get him back to the normal adult stage and when he stopped taking his drugs the last time (about 10 years ago now) we have not been able to get him back at all (with or without drugs). I’ve been looking to some drug-free group homes where he could live with regular caring adults who have jobs in the hopes of bring him back into normalcy. Unfortunately this sort of arrangement is very expensive, so my borther-in-law is currently roaming around looking to start a family with Miss America or whatever his current delusional fantasy is…
The drugs certainly have their place and help some, but they’re over-used and can make things worse. Looking at the odds of making things worse vs making things better, on average it’s more likely that the risks don’t outway the benefits.
The definition of success shouldn’t be superficially “functioning” on the surface but being well and having a good quality of life. The definition of success of a treatment shouldn’t be maintaining a job and paying taxes -> those only matter because of the way our society is set up.
Can function “normally” (whatever that means) on the surface but be miserable, dead inside, have horrible side effects. Being on medication for the rest of life is suboptimal and I’m sure diminishing cognitive function, makes people feel detached.
So the claims of being “hurt” by the drugs should be taken seriously rather than dismissed and perhaps e alternative solutions sought out so he can live without the drugs should he choose.
I appreciate much discussion on this topic including peoples stories.
One aspect of this I see as an ER doctor is that emotional crises are often “medicalized.” That is, people in emotional crisis are brought to the emergency department for medical “help.”
- A woman is brought in by 4 relatives because she “can’t stop crying” after her husbands death a week earlier. “Can’t you please give her something to calm her down?”
- A shy and petite 12 yo is brought in after cutting her legs with a razor blade and telling her parents “I want to die.” She has no psychiatric history, meds, suicide attempts and is not using alcohol or medications/street drugs. It turns out she is being bullied and ridiculed at school. Her behaviors are a communication of overwhelming stress at a situation she does not know how to deal with and that she needs help from the adults in her life. She does not have psychiatric disease at all.
- A 19 yo man comes into the ED with depression and sadness and “I was thinking about suicide yesterday, but not today.” His friend has started an untrue rumor about him that was very hurtful and he felt betrayed and emotionally wounded. However, saying the magic word “suicide” gets you a medical work up, a consult with the psychiatrist via a telemedicine monitor before being discharged with instructions to call the county mental health office for an outpatient counseling appointment the next week. $1,000 of lab work, 6 hours in the department, $500 ED doctors bill and about the same for the psychiatrist’s 20 minute consult.
- A young adult comes to the ED during the busiest hours late Saturday night complaining that he is “overwhelmed with anxiety.” He is “shaking inside” and “jumping out of his skin.” This is a horrible sensation. Not the time or place to learn the coping skills of cognitive behavioral health or mindfulness based stress reduction. In fact, the doctor needs to spend less than 3 minutes with this patient. We give him ativan, recheck in 60 minutes, then discharge with the phone number for a counseling service.
- Some people truly are in great distress and need protective psychiatric hospitalization so that they don’t act out a suicide impulse while they are feeling severely down. And the ED does a real service for these folks.
Killing one’s self is a personal choice that should be respected, just like euthanasia for physical conditions.
dryam2000, sand_puppy, and others involved with the medical industrial complex,
I just watched this 60 minutes segment https://www.cbsnews.com/news/the-problem-with-prescription-drug-prices/ that started with a problem in Rockford, Illinois. Rockford self insures medical expenses for their 1,000 employees and dependents. Because of drug prices (astronomical) increase on one drug in particular (Acthar,) it caused the city to severely downsize other key functions to pay these costs. (That one drug was used on only 2 dependent babies.)
It is presented in typical 60 Minutes fashion, expertly guiding the viewer toward a specific result. This statement pretty much sums it up for me. Of course, I’m on the outside looking in. What does it look like from the inside?
Dr. Peter Bach: The underlying problem we have with prescription drugs in this country is that every single actor has the potential to make money when drug prices go up. Remember that for drugs that doctors give to their patients, they make more money when they give expensive drugs than less expensive drugs. It's true of hospitals, too. It's true of pharmacies as well. And so this ever-expanding pie is serving everyone.Please note that the video is a bit wonky. They get supported by advertising and will interrupt the 14 minute video for "important messages." Ironically, I had a medication for rheumatoid arthritis presented to me before I shut off the video and just read the transcript below the video. Grover
Somewhere it appears this conversation got a little off the tracks. I agree very much that way too many prescription meds are precibed in general, and particularly psychoactive meds. That’s not to say many medications are absolutely essential & play an important role in providing good medical care. Many tomes it just wouldn’t go over well saying “you are suffering from the crap of life, so I’m going to prescribe one full time job, daily exercise & exposure to sin, more socializing, less electronics, less alcohol/smoking, & eating lots of salads, vegetables, nuts, healthy smaller portions of meat, and cut out almost sugars & empty calories”.
Anytime a medication is being taken it means the lesser of two evils is being pursued. There’s the evil of the ailment & the potential evil adverse reactions to the new drug. The two evils have to be weighed a then pick which path has the best risk/benefit ratio for either pathway. Look at any package insert for single medication. Even the simplest med can have severest traction including death. All chrinic medications should be evaluated at least once a year if not more freakishly & there should be a reassessment whether it should be stopped or not. The reality is people’s medication list tend to just keep growing & growing over time because docs are afraid of stepping on the toes of another doc who originally started a medication several years ago, and so the med gets carried over for years & years,
I agree with some of the posters above that “good outcomes” means different things to different people. Everyone & every decision maker has to take in the potential risks & venefits for every treat option. These are very individuals decisions. Unfortunately, the time limitations on doctors works against thoroughly going through all these options in very thoughtful manner by healthcare professionals. This, there’s a quick writing of a medication on a prescription pad, & telling the patient to follow up in a couple of weeks.
Our healthcare system is extremely sick & screwed up, and many of these problems are issues the public is very oblivious to.
I really enjoy my job, but I’m completely disgusted & disillusioned by the industry I work in.
Grover,
I have not personally seen how docs make more by prescribing more expensive meds (I only work within the confines of a hospital & drug reps are not allowed to meet with, give us lunch, etc.)
The problem with docs though is that they are slanted towards writing a prescription for every little ailment that comes their way. Part of this problem results from unreasonable expectations on the part of patients. Here’s what happens. A patient presents with a particular problem(s). A large majority of the time patients have expectations of receiving some type of (immediate…because that’s the world we live in today) help for the problem. The “easy button” for many docs is to whip out their prescription pad & provide some perceived immediate help. The patient feels good because they walk away with something they believe is going to help them, and the doc either feels like he/she truly helped someone or they know all along that they really had no idea how to provide relief and wanted to simply give the perception that they are an all knowing doctor & making the patient walk away somewhat satisfied.
our culture is all about immediate relief, societal expectations are many times unrealistic.
Many docs find saying things “I don’t know” to be the hardest thing & rarely say it. Many physician-patient interactions should probably end by the doc saying “I’m not really sure how to help you, and going through the process of writing a prescription and subjecting you to all sorts of side effects makes no sense”. When this occurs patients walk away disgruntled because they spent time, energy, & money to here a doc say “I’ve got nothing”. Patients typically don’t like spending money to be told their chronic shortness of breath, fatigue, and depression stems mostly from obesity & they need to pursue some type of activity/exercise program & eat a lot of salads, vegetables, nuts, some fruit, and cut out most cakes, cookies, sweets, candies, processed food, etc. Some of these conversations go ok, but many not so much.
What I do see from the medical indrustrial complex is that docs are being forced to progressively cut down on patient interaction times by fresh out school business types who follow very closely how long the average interaction takes. They want to shave these times down from 8.3 minutes to say 6.4 minutes because that helps the clinic make a lot more many. The losers in this is the patients. Docs only time to do a superficial assessment write a prescription that’s simply a bandaid for the real problem that unaddressed because lack of time. And what happens to the docs who don’t get their patient interaction times down? They led out the door by the pencil pushers because to them it’s all about the bottom line & nothing else. People things every growing medical systems are a good thing. Nothing could be further from the truth. The larger the medical system the more that their only focus is on the bottom line. Their advertising about they deeply care about each & every patient is a total crock. They deeply care how much they are going to make off every patient.
dryam2000,
Thanks for your thoughtful response. I can only guess how busy you are and I appreciate the time you took to write down your thoughts. I have no doubts that you haven’t benefited directly from the pharmaceutical industry. I’m not so sure about the bean counters who just want to speed up the operations (pun intended.) Is there a list - formal or informal - of “preferred” medications that might be more expensive than cheaper alternatives?
When I was working as an engineer, I knew engineers who would go out of their way to design the work so that certain specialty contractors would be needed during the design and/or construction. At first, I thought the engineer’s bag of tricks was pretty limited. Over time, I suspected that kickbacks were involved.
I was evaluating a landslide near one of our projects that was being constructed. One of these specialty contractors was doing some work and I wanted to get my feel for their work. It just so happened that the company owner was on the project at the same time as I was. He came over to see why I was poking my nose where it didn’t really belong. When I explained that I didn’t quite understand the intricacies of their process, he explained it. (The problem they were correcting could have been corrected much more inexpensively with a different solution.) When I mentioned the alternate solution, he told me why his solution was superior. (It was basically a sales job with some underlying truth.)
After I had seen enough, I thanked him for his time. He asked me if I would ever consider using his company. I responded by saying that I would when the situation warrants his expertise. Then, he hinted that it could be lucrative for me. At the time, his comment didn’t seem out of place. On the drive back to the office, in my mind I replayed the odd way that conversation ended. I realized that he just opened the door for me to get a kickback if I were so inclined.
Kickbacks cause an asymmetrical benefit/cost condition. Both the groups involved in the kickback (giver and receiver) get the benefit while those not involved get added costs. It doesn’t matter if it is medicine, engineering, or politics (or any other profession where kickbacks are involved.) If the product can compete without resorting to bribes or kickbacks, there’s no need to resort to bribing (other than to counter some other company’s bribes.)
Statistical analysis is a wonderful way to identify anomalies. It doesn’t mean that those anomalies aren’t justified, just that they are repeatedly used. It takes experts in the field to determine if something fishy may be happening. For instance, repeatedly telling patients to take 2 aspirin and call in the morning doesn’t mean you’re getting a kickback from the aspirin manufacturers consortium. On the other hand, a doctor who prescribes a $10,000 treatment when a $100 treatment would satisfy most of the same conditions would be suspect. That’s where experts come into play.
Someone familiar with statistics and computer databases could develop a lucrative business identifying these anomalies and at what level in the hierarchy those anomalies persist. All I’m missing are the skills and the motivation to learn the skills.
Grover
Check out the dollars for docs section.They have a data base on how much money doctors receive from medical device companies as well as big pharma.One doctor alone has received 50 million.They have also proven that doctors prescribe more expensive meds when receiving money from the companies with another database.The investigation was exhaustive and done for free.I was referred to a specialist a few years ago and after I found out he was paid 350 grand from one company alone I asked for another doctor…
One physician in our community has given thousands of pharmaceutical talks over the years & we looked him up on that website. Turns out he ranks very high on the pharmaceutical pay list. We admit his patients to the hospital & it’s not uncommon for those patients to be on 20+ meds. Crazy.
However, a large majority of docs have no direct connection to the pharmaceutical industry. Most docs are looking for the cheapest possible medications as a majority of our patients can’t afford the most basic of meds.
One problem is that the pharmaceutical industry is always trying to throw propaganda towards doctors as to why the new expensive meds are so superior to older cheaper meds. Many medical conferences are cooped by the drug companies. I stopped going to my annual national conference several years ago because it had morphed into one grand infomercial for the pharmaceuticals & federal propaganda from Medicare & the folks who make all the real rules in healthcare.
Dryam2000,
I really appreciate you staying engaged in this conversation and providing your perspective from your position as an med. If you could, what are the one or two things you would change in the system in order to improve mental health outcomes? It’s easy for me to rail about people feeling disempowered about their healthcare, so I am curious about you think would actually make a difference.
Thanks,
Suzie
This is a complex & vast topic. The answer to your question greatly depends on which mental health issues one is talking about; severe or potentially severe illness such as schizophrenia & the bipolar spectrum…and I’m not talking about the thousands & thousands of people in this country who game the disability system by faking & living their “bipolar disorder” so can they can live a free life and have a built in excuse for their family & friends for why they have failed at pretty much everything in life, “ADHD”…wildly over diagnosed and treated with meds inappropriately IMHO, run of the mill depression from mild to extremely debilitating & sometimes fatal, personality disorders such as anti-social personality disorder (there’s no pill for that even though many sedative type meds are given for this), anxiety from mild to extremely debilitating, substance abuse, inappropriate prescribing of medications by MDs, the changing culture in the U.S. from markedly decreased resiliency to the increasingly unrealistic expectation for a quick fix for everything to declining quality of nutrition to ever decreasing levels of physical activity to decreasing amounts of “real” social engagement (as opposed to unhealthy engagement on social media, decreasing amounts of governmental funding for mental healthcare not just from the “medical” side but also the social program side, our so-called justice system that now makes it ok for the police to shoot people who “aren’t following their commands” (many mentally I’ll people are in their own little psychotic world) and our prisons being full of inmates who have severe organic mental illness & instead of treating that they are put behind bars to rot their lives away, and the need for compromising on people’s “rights “ & allowing more scrutiny of children (and adults) who display overt concerning behavior (easier said than done…remember that theater shooting by that joker looking guy in Colorado? His psychiatrist knew he was a ticking timebomb but the legal obstacles & medical obstacles blocked her from being able to definitely intervene before that massacre)…I could go on & on.
In America many mental health problems are treated much more from a medical perspective than a social perspective. It’s simple & clean that way. Plus, the pharmaceuticals and their top level D.C. lobbyists get rich, politicians get more money to get re-elected (and get richer), doctors get to feel like they are doing good or at least feeling good because patients will be more likely to be repeat “customers” or like them because they get prescribed feel-good bandaids that just mask their real psychological issue, and patients are given hope that their deep seeded issue can be treated easily, effortlessly, & quickly with a simple pill(s).
As a politician how popular do you think it would be to propose big funding increases for mental health hospitals, mental health social services, & revamping the criminal justice system for those with true mental illness? Local politicians have enough on their hands trying to stave off protesting, striking teachers demanding 2% pay increases.
As far as physicians are concerned, monitoring prescribing habits very closely not unlike what is being done for narcotics and other controlled substances via statewide databases would be a good start. Without knowing the precise numbers I can tell you doctors are absolutely getting the memo about greatly decreasing narcotic prescribing. Btw, before anyone wants to give MD’s all the blame for that problem it wasn’t long ago that the federal government & medical licensing boards were dinging doctors for not fully controlling patients pain. It will take time because it takes a while to wean down people who have become addicted or dependent on high dose narcotics that they’ve been taking for years. Also, mental healthcare should be viewed from a complete system perspective that is multifaceted: doctors have their role, but also social workers, case workers, fighting homelessness, psychologists, law enforcement, schools, the community, etc, etc. With this I believe there would be more appropriate medication prescribing and “outcomes” would improve.
Education all the way around is the simplest and best strategy for improving mental healthcare…education for medical professionals, the public, the government, etc. Mental illness is still a very taboo subject. Many aspects of it are unpleasant for people to address. Many people would rather pretend it’s not much of a problem, or pretend it’s not their problem to deal with or contribute to. Mental illness is all of societies problem as it affects everyone either directly or indirectly, and it should be viewed from a socialist type perspective (& I’m very much against socialism in general).
There were a few things with this podcast I took exception with. First, it appeared to me this was a slanted conversation mixing up all sorts of psychiatric issues (from people “not being happy” (there’s no pill for that) to ADHD to severe disease such as schizophrenia) without the contextual knowledge to look at the “data”. The Hippocratic Oath can be interpreted various ways. I’ve always felt that the best doctors are the ones who are the best at recognizing their limitations, and not ones who sell themselves as knowing the most. Thus, in my mind knowing one’s limitations is very much part of the Hippocratic oath. My interpretation of this podcast was that their was little to no addressing of the limits of the speaker’s knowledge. He did give a bit of a sarcastic laughing answer to Chris when asked if he could define bipolar disorder when he said something like “absolutely not!”. I didn’t perceive that as a humble acknowledgement of the lack of understanding, instead my interpretation was that he was saying the definition for bipolar was so nebulous it couldn’t be defined and all sorts of people are given the diagnosis for no good reason. The fact is that bipolar is a spectrum disease which is likely derived from multiple genes which may or may not be expressed as actual disease depending on a wide variety of environmental factors, and consists of fluctuating swings from depression (very mild to very severe) to various levels of mild hypomania, severe mania, to full blown psychosis. Some people have more of a tendency towards depression, some more equal, and some slanted much more towards the manic side. Add to that, there are thousands and thousands who fake their symptoms to game the system as I stated above who do not actually have bipolar disorder. There is no definitive test to diagnose it so if someone wants to game the system bad enough it’s pretty easy to do. I see it all the time. Second, the “data” on benzodiazepines was a bit of cherry picking. It’s already well understood benzodiazepine are widely overprescribed and are in general bad medications (although they do have a small role in various situations). The war on narcotics has been carrying over to benzodiazepines such as Xanax. Xanax is associated with falls (hip fractures) in the elderly, withdrawal seizures, overall increase in mortality, earlier onset of dementia, etc, etc. There seemed to be an implication that evidence based medicine isn’t widely practiced in the medical community. The problem is there are good doctors & bad doctors. It’s always been difficult to sort out the bad ones & get them the remedial training they need, or ultimately taking away their medical licenses. This is a whole other topic. However, given the fact healthcare records have mostly been switched over to computerized records going forward there will likely be plenty of data on doctors and patient “outcomes” depending on how “outcomes” are defined. This data will hopefully at minimum allow licensing boards to hone in on which docs to closer scrutinize.
That brings me back to your question about “outcomes” in particular. Defining what a desirable outcome is for a mental health patients can be very nebulous & depends on the cultural setting. Is it overall mortality? Are they able keep a job? Number of times the police are called to the residence for a domestic situation? Number of hospitalizations? Number of “productive” days in a year…however one wants to define productive? Adverse side effects from medications? Etc, etc.
Anyway, these are just some random opinions on my part. I’m not a psychiatrist or psychologist. The value of my comments are just $.02…actually less.
Excellent example, Uncletommy - Cheerios (which most people give their kids and feel virtuous about it), had the highest measured levels of RoundUp. And then RoundUp impacts our gut microbiota, impacting our mental state…whoops!