Tuesday, December 6, 2022

Comments by Hunter Yost MD

Showing 8 of 8 comments.

  • The gene-drug interaction tests can tell if there is an incompatibility with a medication, (it doesn’t work for work for lithium) but the test does not tell the doctor or provider if they have the correct diagnosis to begin with. A favorable interaction for an antideprrssant does not matter unless the person has a pure unipolar depression. If a person has mixed states or features, which comprises 60% of all “depressive” presentations, they should not receive antidepressants even if the test is favorable.


  • It is possible that the 15% of responders may have recurrent severe depressive episodes consistent with the classic disease entity of Manic-Depressive Illness of which Bipolar is a smaller subset. MDI was always defined as recurrent depressive episodes with or without mania. MDI was confirmed in over 40 years of family studies but was not acknowledged by DSM-5. The 85% of non-responders may have chronic low grade depression, previously called “neurotic depresion” or mixed depressive symptoms with subsyndromal mania (i.e. mild mania) or mood temperaments of hyperthymia or cyclothymia for which antidepressants do not help. There is a historical opposition by the makers of DSM against research for biological markers.

  • I would guess this landmark study will not be welcome with the mainstream psychiatric establishment in the U.S. I would also suspect that there will be opposition papers published to discredit it in the near future. This study in unlikely, unfortunately, to change the praticice habits of providers anytime soon. Psychiatrists are not trained to find the 15% who are most likely to benefit by using the most important diagnostic validators, course (i.e. onset of symptoms and peridocity over time) and detailed family history including blood relatives who may not have been treated). These validators are not used in the DSM but are in other specialities. The absence of blood tests in the field is a long and sad story. There is no other medical speciality that has not come up with at least one new blood test in the past 40-50 years and often newer ones replace older ones.

  • There are a couple ways out of this conundrum. One is on page 132 of the DSM-5 which says, “A diagnosis of personality disorder should not be made during an untreated mood episode”, (i.e. manic, mixed or depressed). Because if the mood disorder is treated first and fully, what was thought to be a personality issue most often goes away so it would not be co-morbid. Unfortunately this happens all the time.
    Another is the “psychological falacy” explained by the researchers of split-brain experiments after corpus callosotomy years ago showing that when the laft and right brain are unable to communicate people will confabulate an answer just to give an answer. To them is seems like common sence but we all do it. “I think I got depressed or manic because of a,b & c”. Those researchers concluded that our brains are “rationialzing machines”, that we come up with “common sence” reasons for our experiences which usually are not causative.
    Personality disorders are last on the list of a Diagnostic Hierarchy (see Ghaemi’s Clinical Psychopharmacology-2019) with Mood disorders i.e. manic, depresssed or mixed #1, psychotic disorders of schizophrenia and schizoaffective #2, anxiety disorders of OCD, PTSD #3 and ADD, personality disorders #4. This hierarchy is used in other medical specialities and recommended for psychiatry over 40 years ago but never adopted.

    I review come of these concepts at https://medicalmodelredux.com/

  • I agree many factors are at play, and IMO, a central issue in the over prescription of antidepressants is the expansively defined diagnostic criteria of “depression” and the restrictively defined criteria of “mania” in the 1980 DSM-III which we still live with today. According to modern research as well as that of a century ago, 60% of all mood presentations are “mixed” and only 20% are either depressed or manic. I cover these issues at: https://medicalmodelredux.com/

  • In addition to the history given above, it is important to know the DSM-III committee in 1980 split Manic-Depressive Illness-MDI (for which bipolar is a smaller category) into two categories of MDD and Bipolar based on six years of family studies. Subsequent research over the past 40 yrs. has disproven that decision but the current DSM committee decided they did not want to put Humpty-Dumpty back together, an unscientific decision. The full MDI disease syndrome is severe recurrent depression with or without mania whether a person is sad or not.

    I cover these issues in depth at https://medicalmodelredux.com/

  • As a psychiatrist who has taken many CME training programs through Nassir Ghaemi, I would have to agree with the “failed paradigm of care” argument. Almost 2 generations of psychiatrists since DSM-III-1980 have been incorrectly trained to think of “depression” in overly broad terms and mania in highly restrictive terms with little understanding of “mixed states”, the most common presentation. I review many of these issues in blogs at: