Friday, December 9, 2022

Comments by Saul.Youssef

Showing 73 of 73 comments.

  • p.s.

    re: “If you have scientific evidence that demonstrates how your simple game can effectively treat these gravely suffering patients and halt or reverse the damage to their brains and cognitive functioning, that would be wonderful. So far, my brief search for such evidence did not produce any such results.”

    The game is new and there is no literature on it yet, although it’s probably in the category of “behavioral activation,” which has been studied. It has been used for about 20 depression patients at the Brigham and Women’s hospital in Boston and has been successfully used by quite a few people on-line. It is a promising area for scientific study, I believe, but this is a little different than DBS. There is clearly no risk to trying this. It is and fast acting and even fun to do. If you are a depressed person, you might as well just try it and see if it works. There is nothing to lose by trying.

  • Hi InfiniteJest,

    I don’t know if you had a chance, but look at this link carefully.

    This is someone who was actually hospitalized for depression with severe symptoms including psychomotor retardation. Someone who “obviously has a real medical problem.” And yet, playing a simple fun game, his problems were gone after only two days. It is hard to imagine a better outcome or a more promising thing to try for a depressed person. If this were in pill form, it would be known to all as a miracle cure.

    You say that depression is a progressive, neurodegenerative disease. Changes in the brains of depressed people have indeed been discovered, but notice that no underlying disease process has been discovered. I think that this is because there actually is no underlying disease process other than a habitual ingrained unconscious reaction to stress. It is controversial whether brain changes in depressives are fully reversible, but people do recover from depression and that’s surely the best thing to do if you are depressed.

    It’s plausible and easy to think that this is a just silly game and can’t have any big effect, but I really think that this is a mistake. You can compare it with meditation. Meditation is also easy to underestimate or mock “sitting and doing nothing is supposed to help??”, but it is now widely accepted that meditation does cause real biological benefits to meditators.

    Regards, – Saul

  • I see the difference, but the fact that different people have different needs does not imply that there is no common problem underlying depression. Any disease with different symptoms in different people is a counter-example.

    I am talking about what I perceive as a very strong claim made here. The claim is that “depression” is just the natural response to life events in a difficult society. There is no common underlying problem among people who have “depression”. Thus, no common treatment makes sense, we should concentrate on fixing society, etc.

    Now, is this really true? If you think it’s true, why do you think it’s true? That’s the discussion I am trying to have. I am not telling you that I know that this is false. I am arguing against accepting things like this as unquestionable dogma.

    – Saul

  • Hi Joanna,

    If depression is a property of human relations and conduct, how do you explain people who get depressed in the winter and who are helped by a light box?

    This part makes me sad.

    “Instead he makes a plea for these feelings to be understood as legitimate responses to difficult circumstances and an increasingly demanding and destructive society.”

    I think that MIA is an important community and has gotten many things right, but I see this view often expressed as if it is supposed to be obvious. I think it is totally wrong. – Saul

  • Incidentally, the game in those notes is a simple fun way to train yourself by making lots of tiny fun decisions as a way of healing depression overall.

    Now, the part of the brain most associated with deciding things (i.e. intention formation, goal-directed action, attention control (among other things)) is the dorsolateral prefrontal cortex.

    And guess what area of the brain they try to stimulate with TMS? The dorsolateral prefrontal cortex. – Saul

  • Hi Norman,

    I am reading your answer

    “3) Given points 1 & 2, the most common outcome of depression screening is people being placed on medication without proper therapy. This is clearly bad treatment.”

    as implying that you think that medication WITH proper therapy could be proper treatment. Isn’t that what you mean?

    Do you actually prescribe antidepressants for your own patients? If so, why? It’s an honest question on my part. I am not an expert and might be misunderstanding something.

    Your answer 3) also suggests something that I see again and again. It is not often spelled out, but there is a strong and constant implication that some combination of medication and therapy is the best treatment for depression. I don’t understand this either. Why isn’t it “some form of exercise and therapy is the best treatment for depression” or any number of other things? I don’t see how either medication or therapy have distinguished themselves as treatment for depression above all other possibilities. There is even an onion about this:

    – Saul

  • Dear Drs. Gold and Hoffman,

    Every once in a while, I see comments at MIA that I find totally baffling. This is one of those times.

    1. As I understand it, Robert Whitaker has shown the depressed people who take antidepressants do worse in the long run compared to unmedicated patients.

    If this is so, why would you ever prescribe antidepressants as a treatment for your patients unless you are in some kind of urgent acute situation? Your answers, Drs. Gold and Hoffman, both imply that you think that patients should normally be prescribed antidepressants, but only with some kind of additional talk therapy.

    2. As I understand it from (for instance recent MIA articles), antidepressants barely (if at all) beat placebo for depression. That means that every single one of the following therapies:

    o Any talk therapy
    o EMDR
    o Brain training
    o Exercise
    o Dietary improvement
    o Tai Chi
    o Yoga
    o Praying to the god Vishnu
    o Eating tic-tacs in the hope of getting a placebo effect

    are better than antidepressants for depression in every way. They are all at least as effective as antidepressants, apparently, and they are far superior in the sense that they are all safe for the patient. If this is so, why would you ever be using antidepressants as an initial treatment?

    Baffled in Boston, – Saul

  • The panel discussion on solutions was interesting. I really agreed with the fellow who was emphasizing ways of guaranteeing informed consent and with the views that nutrition, inflammation, gut problems, etc. are often incorrectly ignored.

    There is one thing that most of the panelists seem to agree upon that I don’t understand AT ALL. Maybe someone can explain it to me. Paraphrasing…:

    “Instead of identifying problem within people, within their brains, characterized in the form of illnesses, we should identify their problems and look to the outside world and the way they responded to the outside world, to come up with human solutions.”

    “The idea that a group of experts can accurately categorize the nature of someone’s experience and decide upon an intervention is a mistake.”

    “Outcomes are determined by the real life problems people have, adversity, discrimination, poverty, abuse…”

    “Clinical psychology still [incorrectly] locates blame within the individual. There is an element of [incorrectly] locating the problem within the mind or the head of the individual.”

    “We adopted a false philosophy of being, for instance that depression is abnormal.”

    “It is nonsense to say that the problems are located within the individual mind.”

    Now, isn’t it obvious that all the above stuff is wrong from, for instance, the example of a person with “combat PTSD?” Such a person goes to a traumatizing environment (War), returns, but has enduring difficulties in their original supportive civilian environment. After returning, they still have problems, but it’s obviously not an environmental problem. There must, therefore, remain a problem within the individual (even if it’s not biological). Furthermore, isn’t it obvious that most or all people with “combat PTSD” basically have the same problem. It is not a separate problem for each person with a separate traumatizing experience.

    I’m also sure about the case of depression (since I had it and having known quite a few depressed people). Depressed people, similarly, do have a real problem that is quite dysfunctional and is not at all just a natural response to environmental situations. Furthermore I believe that most if not all “depressed” people do have the same specific psychological problem.

    I’m not prepared to argue that, for instance, ADHD is a real thing, but I am quite sure that PTSD and depression are real problems located within individuals. This does not, of course imply that I think that these problems are biological or should be treated with drugs.

    What do I know anyway? Am I missing something here?

  • From (seems to be the same as WebMD). I believe this is one of the most used medical sites in the U.S.:

    “Depression is not a sign of weakness or a character flaw. It is a real and treatable medical illness.”

    “While it is not clear what specifically causes depression, a widely accepted theory is a change in brain structure and chemistry. Specifically, substances called neurotransmitters are out of balance in depressed people.”

    The article comes complete with PET scans “proving” that depression is a brain disease.

    Written by: Dr. Roxanne Dryden-Edwards is an adult, child, and adolescent psychiatrist. She is a former Chair of the Committee on Developmental Disabilities for the American Psychiatric Association, Assistant Professor of Psychiatry at Johns Hopkins Hospital in Baltimore, Maryland, and Medical Director of the National Center for Children and Families in Bethesda, Maryland.

  • Oy. Pies is attempting to respond to Robert in the comments of his blog.

    What struck me most about this article is the smug, superior, jocular tone. Oops, we had a “high school crush” and millions of people were harmed. Hahaha. Only naive blogger conspiracy theorists question us. We always knew better.

  • To be fair to Margaret, I have heard a number of people say (on-line) that these psych holds “saved them” or words to that effect.

    I think that one of the hardest things for a medical person to do is to just do nothing for a person in severe distress. I always think of an MD I met on-line. When I asked him why he prescribed antidepressants he basically said “What do you want me to do, turn away patients who come to me crying and desperate, unable or unwilling to go to therapy?” – Saul

  • You’re welcome Stephen;

    Mockery is empowering and is a wonderful weapon against authoritarians, and I think it’s a real part of the tide turning. Some of my favorites:—depression-edition

    Have a great weekend everyone. – Saul

  • Hi cat, Bonnie,

    I really agree. I follow one of those online forums pretty closely and I see major changes just in the past year. Word is getting around in the general public, but when people are vulnerable and in trouble, there is a strong and understandable tendency to put yourself in the hands of the “experts.” I’m sure that the declining opinion of psychopharmacology from M.D.s is going to be a significant step away from harming people on a large scale. That one CNN story on the MIA front page is huge. What vet is going to blindly take their PTSD meds after seeing that story? I keep a collection of depression humor and just the fact that a video like this

    has almost 2M hits means that A LOT of people are getting it 🙂 – Saul

  • Thanks Justin.

    Steve, you are so right. And the fact that Lieberman surely knows that what you say but fails to mention it means that this article is not an honest attempt to inform the public. It is something else.

    Here’s something for my MIA friends, just to cleanse the palate if that horrible NYT piece left a bad taste in your mouth:

    – Saul

  • Hi JohnSmith,

    I wanted to acknowledge your post since this site is supposed to value lived experience. I’m glad that the amitriptyline worked for you. I’ve been following people’s experiences based on their postings at other web sites and I’m confident in saying that your experience is quite unusual.

    I’m also not too surprised that even excellent counseling didn’t help you all that much. I have a suspicion that this is just because most mental problems are self-reinforcing unconscious reactions to stress and, being unconscious, it’s hard to talk your way out of it even if you understand how it started. I suspect that’s why talk therapies in general don’t work that well and something like meditation seems to be good for everything even though it is completely non-specific.

    By the way, I think you might be unintentionally rubbing people the wrong way with your use of the term “anecdote”. Calling someone’s description of their own experience an “anecdote” can be read as “your narrative is unreliable and insignificant” when I think you just mean “your experience is a single case, with meaning, but limited statistical meaning.” I’m sure that you realize and agree that very strong evidence can come from outside the domain of RCTs.

    – Saul

  • Hi JT.

    I’m glad that you spelled this out, because I think it’s important. You say:

    “If one believes as I do, that the brain is the organ that processes our genetics and experience and produces an output we call a soul, the physical and chemical state of our brain is always the proximal “cause” of the state of our souls, and if we are unsatisfied with that state, it can be said to be “unbalanced”. If I can offer a drug that directly relieves that distress, I am likely to emphasize that proximal cause. That does not necessarily deny the role of the experiences that are the fundamental causes of a persons distress.”

    I think that this is an honestly held belief help by at least many psych patients and, I presume, many researchers too. I claim, however, that this is a very serious mistake, even from the hardest, most biological, hard science point of view. The best way that I know of to illustrate the point is to imagine that you have to fix a laptop which has developed “laptop psychosis” because you have downloaded some malware. Taking your point of view, everything happening on the laptop is determined by electrical signals, so the laptop must have an “electrical imbalance.” Your proposed solution is to re-balance the electrical signals as best you can. This can perhaps be done by adjusting the clock speed or adding some wires or removing some capacitors. I think that you will agree that this is totally wrong and likely to harm the laptop and will not solve the underlying problem. Why? Because you have presumed that the laptop has a hardware problem when the laptop actually has a software problem. Brains, I would claim, like laptops, can have “software problems” – problems which are caused by past experiences, trauma, and habitual patterns of thinking and feeling and not by anything being wrong with the underlying hardware. As with a laptop, the solution in this case is to “stop running the bad software” and not to have a hardware intervention.

    – Saul

  • Hi JohnSmith,

    Phil has an excellent blog summarizing why there is an anti-psychiatry movement here

    including the damage caused by telling people that they have a brain disease when they don’t have a brain disease.

    Before discussing the nuances, as you say, I think it is necessary to think long and hard about the vast, enormous tragic damage that these ideas have caused to literally millions of people. Psychiatry is responsible for this damage, and acknowledgement of this fact, and, I think, a very, very large dose of humility is required at this point.

    – Saul

  • Hi bpdtransformation,

    Your post is really interesting to me because I think that others on MIA share your view, and I really do think it’s wrong. I also find your comments insightful and interesting and helpful. I don’t think you’re sounding mean at all.

    I think that we would probably agree that the fact that a particular set of symptoms go together suggests that there is a common underlying problem but by no means demonstrates that there is a common underlying problem. Of course, the idea that no common underlying problem exists for, say, depression, is also an unproven hypothesis.

    To answer: ‘In your comment you gave no evidence for “depressives having a common underlying problem”’

    I can give a specific example. I think that there is a particular unconscious habitual pattern of thinking that is the single common problem underlying depression ( see ). This hypothesis predicts the particular symptoms that depressives should have, it predicts how the problem should progress over time, it predicts what should work to make it better and what shouldn’t work. From this point of view, it’s not at all surprising that there are no simple biomarkers for depression and it suggests that brain research isn’t actually going find either good biomarkers or effective drugs. There is even a reasonable amount of evidence that this actually works with real patients.

    Whether this idea is correct or not, though, it is at least an example of a plausible etiology for depression. I don’t know of anything that excludes this as a possibility. I’m not sure why similar etiologies couldn’t be found for other mental problems as well in spite of the failure to find biomarkers for any of them.

    The issue that you raise about the DSM diagnosis for depression having low reliability is relevant, but I think that the low reliability is just because they don’t have the right set of symptoms. Partly, I am confident that depression “is a real thing” because I had it myself and I think I can reliably detect it in others. I think that depressives generally can recognize other depressives and I’ll be this works better than a DSM checklist (I also expect that experienced therapists can do the same thing easily).

    Best regards, – Saul

  • Hi bpd, Noel, B, rebel, Steve, JohnSmith, everyone,

    I agree with lots, but not all, of what is written in this thread. Noel, I looked at your previous blog entries. I especially liked your first one, with the link to the talk by John Read:

    I believe you about psychotropic drugs and I believe you that trauma and social conditions are major causes or contributing factors to mental problems in many cases. I find John Read’s talk convincing. I find Robert Whitaker’s work convincing.

    Here’s the parts where I disagree:

    1. Paraphrasing: We should use quotes around “mental illnesses” because they don’t really exist. Such problems are merely natural reactions to adverse social conditions and trauma and, quoting Noel “…the evidence suggests that when a person’s basic needs are addressed, such conditions of psychological distress still naturally receded over time.”

    I don’t think this is right. I think that something like depression or PTSD, for instance, are problems which do reside within the person affected and won’t just disappear if you remove trauma or adverse social conditions. I think that depressives, for instance, do have a real underlying common problem and that’s why they have a particular common set of symptoms.

    2. I think you are underestimating nutrition and, generally, “Functional Medicine.”

    I think that this has historically been really underestimated, but is rapidly changing. You can see this in references to Omega 3 fats and teenage psychosis, and Jill’s article on inflammation even in recent MIA blogs. See, for example,

    for a more general picture. Notice that many socially disadvantaged people who are more at risk for psychosis also have drastically unhealthy diets.

    3. I have to disagree with the main thesis of your paper

    You are arguing against doing brain scan research, genetic research and against doing research into the link between inflammation and mental problems, but I don’t think that you have shown that the claimed negative consequences follow from merely doing this kind of research. I agree very much that there has been tremendous damage done by telling people that they have a brain disease when they don’t, but people weren’t told
    that because of research results. Research results actually showed the opposite for the serotonin and dopamine hypotheses for depression and psychosis. Another way to see that there is something wrong with your argument is to apply it in the past. In the past, it seems to me that you would be arguing that research into, say, the biological affects of lead in the brain shouldn’t be done. I suspect that you are right the the RDoC program isn’t going to work as a diagnostic alternative to DSM-5, but I can’t be sure of that and I wouldn’t argue that the corresponding research shouldn’t be done. Let them do the research and find out that it doesn’t work either.

    I can easily imagine that people want to use this research to justify harming people with psychotropic drugs, but I don’t think it’s tenable to argue that, therefore, the research shouldn’t be done. I don’t think it’s a good strategy in any case. From a funding agency point of view, why do they need you to tell them that some particular research shouldn’t be funded? They already have eminent peer reviewers to tell them that.

    Take this as the view of an outsider, but rather than arguing against research, strategically speaking, I think that you guys should be joining forces with honest researchers in functional medicine, biology, nutrition, public health, yoga, brain research… to construct alternative Clinical Practice Guidelines that integrate everything that works and can provide coherent alternatives to the APA guidelines for PCPs.

    – Saul

  • Hi Noel,

    I did read your article to the end, even though the exact quotes do poop out at some point. I haven’t seen your earlier blogs, but I’ll have a look.

    About the B12 example, OK, but then a more exact version of the BPS statement would be

    “….treatment should be based on a psychosocial framework that honors the individual, *except* when the problem is biologically based.”

    But how do you know if someone’s problem is biologically based or not? Isn’t this then an argument for more brain research?

    – Saul

  • Hi Noel and William,

    Here is some friendly constructive criticism from someone who basically agrees with you and is pro ISEPP:

    1. You keep putting “mental illness” in quotes, suggesting that you don’t think that mental illness exists, but you don’t say what you mean by this exactly.

    2. You quote BPS as follows:

    ‘”mental illnesses” are best conceptualized as problems in living that result from traumatic and societal ills which overwhelm one’s capacity to cope, and that “treatment” should be based in a psychosocial framework that honors individuality”‘

    How do you or BPS know that this thing that you are not quite defining (“mental illness”) is best conceptualized as problems in living resulting from traumatic societal ills, etc.? Isn’t this view contracted by, for example, someone who has mental problems due to a massive vitamin B12 deficiency? What is the framework that the quote refers to? Why is it so great? Is it the best thing to do or just an alternative?

    3. You say

    ‘On the other hand, the mainstream mental health field, and biological psychiatry in particular, in conjunction with various political and corporate powers, is pushing further in a direction of conceiving emotional distress as a brain disease; a direction often referred to as “biological reductionism”‘

    That seems kind of vague and speculative and is not really fair or a good definition of biological reductionism. I don’t think that anyone is saying that just emotional distress in general is a brain disease.

    4. You say

    ‘Further, a brain-based approach to sometimes difficult-to-understand behaviors and experiences of those in extreme distress may be seen as a desperate effort to explain such phenomena without blaming anybody or insisting that someone “just get over it.”‘

    It’s not clear to me what this means.

    5. You say

    “The problem with this approach, however, is that the brain-based initiatives for clinical research rely on a disease model that is based on erroneous logic, a faulty reductionistic view of human nature, and a contradiction of the most robust research findings within the mental health field.”

    What is the erroneous logic you are referring to?

    6. The overall point of the paper seems to be that you are against brain research because you think resources are limited and

    “…focusing our resources on providing psychosocial support for individuals, families, and communities and working towards a social system in which meaningful and rewarding activity, education, and work is accessible to everyone. ”

    You argue against brain research, but don’t say exactly what should be funded instead. Also, why not fund both? If you have a good idea, I don’t see why that means that there should be less brain research. Your paper almost sounds like “We shouldn’t do brain research, we should fix society instead.”

    7. Your argument is much broader than what I would guess from the title. It’s not just about brain scan research.

    Finally, I suspect that you are basically right about brain research, but I keep thinking that one essential point is consistently missed in these arguments. Even if you have the hardest hard science view of this and even if you think that mental problems like depression reside entirely within the person in distress, it may be that a person has a “brain malware” problem – a problem caused by the thoughts that the person is thinking rather than the underlying biology. I think that depression may be like that, for instance. It may be analogous to a laptop that is running malware where no hardware intervention is going to help. Notice that you similarly can’t tell if a laptop has “laptop depression” with a voltmeter (no simple biomarkers). Notice, also, that future research into sophisticated electronic detection of laptop malware isn’t going to really change anything. The answer is always going to be to stop running the malware. It may be the same with brains where problems caused by habitual ingrained thought patterns are never going to be effectively helped by some future super-drug.

    – Saul

  • Hi Kermit,

    I just contributed to the site and I hope others do too. I wonder how we could get MUCH more funding for this site? It seems to me that the resources here are unique and absolutely crucial. Particularly Bob’s videos from the Copenhagen 2014 conference. I don’t know of anyone else who has successfully distilled and evaluated the whole known literature on psych drug risks and benefits and yet can present the results in a way that almost anybody can understand.

    – Saul

  • JohnSmith says: “In medicine we try to protect patients from this by having a learned intermediary – a doctor – act as a gatekeeper between the drug manufacturer and the patient/client.”

    That’s worked out just great for everyone except for the patients.

    “I share your concern about this. $100,000 is clearly enough money to affect anyone’s objectivity.”

    I agree with uprising.

    Name one example of Robert distorting something, hyping something, hiding information or being dishonest in any way in any of his books or talks.

  • I think I found part of where your pessimism comes from Bob. I just found these videos from way back in 2003 with Loren Mosher and Dan Kriegman:

    I didn’t quite realize how long all the main points have been known. I also didn’t quite realize that Loren Mosher was both the Chief of Schizophrenia at NIMH AND the leader of Soteria House. – Saul

  • If I try to make Richard Friedman’s argument for him, it would go like this. Consider the teenagers who are severely depressed and seriously suicidal. Antidepressants are known to help at least severely depressed patients, so perhaps antidepressants will reduce the chance of suicide in this particular subset of the depressed teenage population. In a limiting case, suppose that there are teenagers who are definitely intending to commit suicide. Shouldn’t such teenagers try antidepressants?

    I think that’s a defensible view, but I don’t see how any such argument (or anything else) can justify removing a warning of a known true side-effect. It seems to me that patients and MDs are entitled to be informed, ethically speaking, no matter what. I don’t see how anything can justify hiding this information from MDs and patients.

    What I personally find the most disturbing about Friedman’s article is the implicit subliminal messages. Someone reading the article is likely to get a strong impression that the main risks of antidepressants are a minor risk of suicidal thoughts (for, otherwise, he would surely mention other risks) and a strong impression that antidepressants are the most effective treatment for depression (for, otherwise, surely Friedman would be insisting that teenagers should get more therapy, exercise, meditation, etc.).

    – Saul

  • Hello JohnSmith,

    If you want controlled results, the wonderful thing that Robert provides is carefully researched summaries of the literature on long term risks and benefits of psychotropic drugs of various kinds, not just limited to clinical trials. Have a look at:

    I very often point people to the video series from the Copenhagen conference in 2014. In “Part I” of this series, you can find a clear, detailed discussion of the issue you are bringing up: do antipsychotics help in the long run? I often point people to this video series for issues about antidepressants and/or ADHD too. I find the presentations to be very clear, convincing and easily understandable by almost anyone. – Saul

  • “That said–you have no authors who are proponents of the essential need of psychiatric medications for many whose lives have been saved. That is a clinical fact, and one only needs to ask the patients who they have helped. That the side effects are so unpleasant, and people insist on staying on them is suggestive of the importance of these medications in a subset of patients lives.”

    Many people insist on staying on their medications because, once they start, they cannot stop without getting much worse, (presumably due to oppositional tolerance) just as Robert describes in his talks and books. You can find many, many examples here, for instance

    Many people have been told by their “pdocs” that they are “searching for the right cocktail” and/or hoping that some new drug will help. Some wish that they could quit, but many also believe strongly in the path that they are on in spite of suffering side effects. In a way, this is understandable, because their only experience of relief may come from starting a new drug. They have signature lines like the following real one:

    “Diagnosis: Bipolar I, ADHD, C-PTSD, GAD, OCD, Social Phobia, Panic disorder, Substance Use Disorder
    Previous Rx: |Celexa|Sertraline|Lithium|Depakote|Buspar|Wellbut rin| Klonopin|Perphenazine|Cymbalta|Strattera|propranolol|
    current:|Seroquel XR 400mg PM”

    That’s what’s happening to people. Many, many people. The fact that many people choose to stay on these drugs doesn’t mean that they help in the long run.

  • Hi,

    I have no medical credentials whatsoever, but I suppose that your “IED” could possibly be a symptom of an underlying purely medical or nutritional problem that you could check for. I’m really impressed by this video about Functional Medicine and the brain in general:

    Notice 20:00 into the video there is a description of a six year old girl with an uncontrollable violent temper. Her problem turned out to be a massively messed up gut microbiome (see also Jill Littrell’s article ). One this was understood, the problem was easily dealt with and resolved. – Saul

  • Hi Bruce, Robert, Lisa;

    Robert says:

    “So what is a possible solution? It must come from an informed public that will see the need to strip psychiatry of its authority over this domain of our lives, and instead demand that the authority be vested in a multidisciplinary group of professionals, philosophers, and “users” of psychiatric care. Psychiatry could be a part of this multidisciplinary group, but not the ruler of it. But can this really happen? I am rather pessimistic,…”

    I’m not sure if you mean that you’re pessimistic about the overall prospects for keeping patients from being harmed or specifically about the formulation of a multidisciplinary group and removing the authority of psychiatry. I’m very optimistic myself. My impression (partly from watching one of the major mental health web sites steadily for about 10 months) is that things are already changing a lot. Word is getting around. One big sign of progress this is very powerful media stories like this one:

    What veteran, after seeing this story, is going to just defer to their pdocs and take whatever they are given?

    From the interview, I have the impression that you two think psychiatry can’t reform itself, so the only hope is that public pressure will cause someone to “neutralize the economies of interest,” thus causing the currently corrupted institutions and individuals to become uncorrupted and thus stop harming people. Isn’t it a better strategy to simply bypass psychiatry entirely? Isn’t it enough to convince PCPs and the general public? Some people do need drugs (for instance the many, many people who have already been on them for years), but PCPs can take care of that. Psychologists and non-harming Psychiatrists can handle the therapy. Alternative and better treatments can be developed.

    I am sure that many here are decades ahead of me, but wouldn’t it help to have informed consent laws, for, say anti-psychotic drugs where, by law, a patient has to be shown the actual risks and the actual long term prospects of taking particular drugs? I think that this could have a huge effect on both MDs who might prescribe things casually and on patients. For children in foster care, one measure might be making sure that each person in charge of these facilities gets the same informed consent information in a way that can’t be denied after the fact. I’ll bet that a step like that would make a major change.

    The other wonderful thing happening is developing effective alternative ways to treat mental problems. I’m especially thinking of Functional Medicine and new organizations like ISEPP (, advertised on MIA). I think that most people with mental problems first go to their PCPs. If you put effective alternatives with some track record of success in the hands of PCPs, I think many will be happy to use them.

    ———— re: Cognitive Dissonance ————

    Even though I think your book is truly wonderful, I still have a hard time buying into cognitive dissonance theory as an explanation and as a way of finding solutions. For instance, you say

    “So once the chemical imbalance story fell apart publicly, what does Pies do Does he admit, even in his own mind, that psychiatrists told this false story to patients for decades? No, he says well-informed psychiatrists never said it, and places the blame on the pharmaceutical companies for telling that false story.”

    Maybe, as you say, Dr. Pies really is unaware of the truth and he is suffering from “cognitive dissonance,” visible on MRIs (p. 176). However the facts also seem compatible with the old fashioned explanation that Dr. Pies is just lying. Couldn’t the MRI tests in your book be interpreted as lie detector tests? Or is “lying” and “cognitive dissonance” the same thing? [ I was struck by the irony of reducing psychiatrists to helpless victims of their brain function, just as psychiatrists do to their patients! ].

    I also think that CDT as you explain it in your book, just can’t (at least by itself) explain the institutional behavior of the APA. The problem is that even if each person is unaware of their own dishonesty and corruption, as you say in P.U.T.I., they can still clearly see dishonesty and corruption in others (p. 177). Thus, even if all the psychiatrists in APA were afflicted by CD, they would still see corruption all around them.

    Also, at just a basic level, at some point it becomes hard to believe that corruption is really unconscious. Can it really be true that academic psychiatrists put their names on ghost written papers and it never occurs to them that this violates the most basic scientific ethics? Ethics so basic that if they were students turning in a paper, they could expect to be failed and/or expelled from their University? Surely Prof. Biederman *noticed* that Janssen Pharmaceutical paid him $1.6 million (p. 41). Can it really be true that Prof. Biederman never wondered if Janssen was doing that to buy his influence? Maybe I’m mis-interpreting, but Lisa’s “we are all vulnerable” answer above suggests that these people should not be blamed because any one of us could do the same thing. If that is what you mean, Lisa, I disagree. I’m in physics, not in a medical field, but I would never do something like this and I can’t even think of a single case like that in my field.

    I understand and am very sympathetic to the idea that you want to prioritize reform over blaming victims or institutions, but I also have doubts that CDT inspired solutions are going to work. When I think of corrupted institutions, the examples that I think of are a corrupted police department where, say, bribery and stealing is common and the institution of slavery in the U.S. I am sure that what you would describe as cognitive dissonance would be rampant in both cases, but is “neutralizing economies of influence” really a way to reform these institutions, or do they have to be condemned first and then rebuilt or abandoned?

    – Saul

  • Hi Carina,

    Congratulations on what you are doing in your network. To me, it sounds vastly better than what happens here in the USA. I have a couple of observations about your interview that might seem superficial or even silly at first, but I think that they may actually be very important for you and your clients.

    The first observation is that the clients in all of your photos look quite unhappy to me. Nobody is smiling. They look slumped and passive. You don’t say anything about “depression,” but I would guess that many of your clients would be described as “depressed,” at least in the non-professional sense of the word.

    Here is the second observation:

    At 4:58 into the video, you introduce your idea that you should no longer diagnose your clients and should no longer use psychiatric terms.

    You say that this is one of the best things you’ve done in your professional life.

    THEN… at exactly 5:55 into the video, you say these magical words:

    “It really made a change.”


    I think that at 5:55 into the video, you are accessing something very important within yourself that is not available to many of your clients. I actually think that this is the core problem happening in at least many depressed people. If you are interested, see

    I also think that the idea of not using psychiatric terms is wonderful and, as you say, honest. I hang out at web sites where many people are very deeply identified with their diagnoses and even introduce themselves with a string of DSM categories and corresponding string of drugs. People, who, I am afraid, are in deep trouble.

    – Saul

  • This makes me think of a funny story from Andrew Solomon’s TED talk where he is talking to a Rwandan health care worker.

    Rwandan Guy: We’ve had a lot of trouble with western mental health workers. Especially the ones who came right after the genocide.
    Andrew Solomon: What kind of trouble did you have?
    Rwandan Guy: They would do this bizarre thing. They wouldn’t take people out in the sunshine where you would feel better. They didn’t include drumming or music to get people’s blood going. They didn’t involve the whole community. They didn’t externalize the depression as and invasive spirit. Instead, what they did, was they took people, one at a time, into dingy little rooms and had them talk for an hour about bad things that had happened to them!? We had to ask them to leave the country.

  • Hi Randy,

    Thanks for the article, but I find it hard to share your optimism that publication bias is the main problem and that the reliability of the literature can be fixed by simple technical fixes. From R.W. & L.C.’s latest book and Robert’s earlier work and Peter Gotzsche’s work and David Healy’s writing, my impression of the psychiatric literature is not that it is flawed by unintentional bias. My impression is that it is tainted by gross, widespread institutional corruption. If supposed papers by academics are actually ghostwritten by drug companies on a large scale, that is an abandonment of the most basic scientific standards. I guess I am skeptical that you can get trustworthy results from people who have already shown their willingness to sign ghostwritten papers, or to fudge their data, or bury inconvenient results, no matter what technical measures you put in place. I find it hard to believe that technical measures can replace basic honesty and integrity. – Saul

  • Hi bpdt,

    There is a view that I have seen on MIA where depression is considered as a normal, reasonable response to bad circumstances like isolation, joblessness, homelessness, etc. as you say. There is a lot of depressed people because a lot of people are in these situations. The normal course of depression is that it is self-limiting and will usually resolve itself over time, unless you start to take antidepressants. It is the antidepressant drugs that turn a normal self-limiting natural reaction into the widespread pathological chronic condition that we see today. I have seen similar views expressed also by R.W. and Peter Gotzsche too.

    I suspect that you would agree with the above view, and I agree that antidepressants to more harm than good, but I don’t think that the rest of it is correct. I think I understand what depression is, how it works, why it leads to a particular set of symptoms that depressives have in common and I think I understand how and why it progresses over time. Because of the way depression works, bad things happen to depressed people and depressed people will be fixated on those bad circumstances as the source of their problems. I think that very often people who are depressed “because” of job loss, divorce, money problems,…etc. were actually depressed for a long time before their problems started.

    – Saul

  • Thanks very much Jill,

    You probably know this much better than I do, but your gut microbes, vitamin B, D deficiencies, hypothyroidism, infection, heavy metal toxicity, gluten allergy,… are all common problems that can cause severe mental symptoms. I got convinced that this is important from Mark Hyman, e.g.

    In a better health care system for mental problems, surely checking for all of these issues should be the first step. – Saul

  • Dr. Gotzsche is a hero in my book for uncovering what’s really happening and having the courage to plainly telling us what the data says in the face of initially great opposition. I often point people to his and Robert Whitaker’s talks at the Danish PsykoVision conference last year. It’s interesting to see he and Robert interacting with the audience too:

    Does anyone know what conference he’s referring to in Los Angeles? – Saul

  • Hi Victor,

    “I completely agree with you. I think it’s not totally fair to say I am against the biological model of mental health.”

    OK, that’s what I thought, but I wasn’t 100% sure. You’ve got to admit that it’s hard to tell, if you’re against “the medical model” but in favor of “the biological model” (maybe Corrina has a good point about terminology). It occurred to me that some of your colleagues may also be misinterpreting you in the same way. I know that some people think along these lines….

    Bio-medical thought bubble:

    “The touchy-feely interpersonal stuff may be very nice and truly helpful, but I know that how you feel is determined by brain chemistry. Therefore, if you’re feeling bad for a long time, there must be something bad about your brain chemistry. Maybe it’s not just a simple neurotransmitter imbalance, but science will eventually find it. Yes, there are corruption problems and yes, the drugs don’t work so well, but that’s the best we’ve got now, and the road towards making things better is more research.”

    Now, I don’t agree with this myself, but I think that’s a common view and it may be what some of your colleagues are thinking.

    Partly I’m mentioning this because I think that Functional/Systems/Integrative medicine has lots of potential for helping you and helping people with mental problems, and I’m hoping that that part of medicine isn’t corrupted (I’ll know to be suspicious if I start to hear about Omega 3 fat “Thought Leaders” 🙂 ).

    – Saul

  • Hi Victor,

    I think writing your book for the general public is a really good idea and likely to do a lot of good. I think you’ll find that a big fraction of the public is at least suspicious of psychiatry already.

    Even though I admire what a lot of people are doing here at MIA, I am getting the nagging feeling that some are making a mistake by describing themselves as being against “the medical model” or, as you say, against the “biomedical model”. I looked at the free volume of the journal “Ethical Human Psychology and Psychiatry” that Al Galves pointed us to and the paper by Ken Steiner is even against “biomedical reductionist theories.” I am really surprised by this. It sounds like some are reacting to the failure and corruption of psychopharmacology by rejecting biology or even science entirely and some think that therapy and peer support and humanistic ideas and taking advantage of good biology are somehow mutually exclusive. To me, it’s obvious that the best thing for your patients it to take maximum advantage of good, non-corrupted, health supporting medicine. I expect that you would agree with me and that, for instance, if one of your patients has a vitamin B12 deficiency or hypothyroidism or a gluten allergy, that may be part or all of their problem and they should be treated for that. But then why isn’t this “biomedical reductionism”? I don’t see what’s wrong with good biology is what I’m saying. I suspect that both good biology would play a big role in a system that gave patients the best care possible. I also think that therapy and human beings relating to each other is also completely essential even if you have a completely hard-science reductionist perspective.

    – Saul

  • Hi Victor,

    I admire what you’re doing and I also (with Steve) feel very happy for your patients :).

    It sounds like you are aiming your book at your colleagues and perhaps at those “Powerful and respected people have built careers and lives out of these concepts” that you know personally. Do you think that they would be convinced by your book? I’m just an outsider, but I have the impression that convincing currently powerful psychiatrists to change may be the hardest and least likely way to succeed at what you’re trying to do. I suspect that it’s easier to just kind of declare victory and assume that it is established that psychotropic drugs do more harm than good in the long run (since I think it really is established) and to go ahead and create coherent alternatives that really help people. I always think about an MD I once talked to about this who said, essentially, “Patients come to me crying and desperate. What do you want me to do, turn them away without doing anything?”. I suspect that if this MD had a better clinical plan than the ones provided by the APA (in the US), he would be happy to use that instead. He just wants to be able do to *something*.

    – Saul

  • Hi Norm, Monk, Else, Old, Steve, B, AA, Corrina, Rob,

    It’s an interesting thread for me. I appreciate everyone’s comments. If we stay honest and open-minded, we’re already vastly ahead of the pretend scientists described in R.W. & C.G.’s new book. I’m trying keeping my eyes on the prize, which, for me, is stopping the ongoing horrible mis-treatments and harms that are happening to so many people.

    I am a scientist myself, and one of the unwritten rules is that there is no such thing as a scientific authority. There is no such thing as “you don’t have enough credentials to question us.” To me, the fact that Robert is consistently attacked for being “just a journalist” is not acceptable behavior as a scientist and it makes me suspect even more that Robert and Lisa are correct. If Robert was wrong, they would not complain that he was just a journalist, they would explain where he made a mistake.

    – Saul

  • Hi Oldhead,

    After reading “Psychiatry Under the Influence” I probably share with you a near 0% trust level for academic psychiatry and the APA. In this case, though, I strongly suspect that the issue is going to get investigated by real scientists, not fake scientists. Inflammation as explained above seems to me to be a reasonable, promising hypothesis that you can make without defining “depression” – Does having inflammation in your brain have a bad effect on your mental state? In the hands of honest biologists and neuroscientists, we will find out if it is true or if it is not true.

    I think really, it’s an interesting and promising area and shouldn’t be thrown out with the fake “chemical imbalance”/psychotropic drug story. The fake story also started with reasonable hypotheses: low serotonin causes depression and too much dopamine causes psychosis. These turned out to be false. The unforgivable sin of psychiatry is propagating the false story anyway, as if it were true, while giving drugs that harmed their patients severely in the long run.

    Have a look at that link in my previous post. Notice that the treatments proposed are just good food and supplements aimed at root underlying problems and not toxic drugs treating the end symptoms (which they think include at least some mental problems).

    – Saul

  • Hi Thelonius,

    I’m surprised by your comments. I have learned many things from this site and I think that R.W.’s books have made a huge contribution in exposing an entire field that is thoroughly, shockingly corrupted. I don’t see how he is promoting any sort of mythology.

    Most important of all, for people who are being victimized even now, it is very hard to come to the truth on your own – that many of those people in the white coats, from the best universities, with recommended treatments backed up by long lists of publications in prestigious journals, with the NIMH grants and great bedside manners are, in fact, totally wrong and are harming you severely, not helping you.

    – Saul

  • Hi Thelonius,

    I agree with you here. I think that functional medicine in general is very promising for depression and many other issues. I often point people to this video that I like

    where Mark Hyman discusses this in a way that I find very convincing. He points out that depression may be caused by vitamin B12, Omega 3, vitamin D deficiency, gluten allergy, infection, heavy metal toxicity, hypothyroidism and many other issues, and the right thing to do is to find and fix any such underlying problem rather than saying you have a thing called “depression” and, thus, you get an “antidepressant”. I am really expecting that if someone made Clinical Practice Guidelines that were actually aimed at giving people the best care, this is going to be the first step.

    I personally think that the above issues mainly trigger depression rather than directly cause it and that depression as a mental phenomenon can be understood to be caused by one underlying habitual unconscious thought pattern that is basically the same for at least most people that have depression. That’s why, I believe, things like various therapies and meditation can help, and can sometimes help a huge amount.

    – Saul

  • After reading “Influence”, I know to google Hickie + conflict of interest in these situations

    There always seems to me to be a giant implicit hole in these arguments. Even if the reported results are correct that does not imply that you should use antidepressant drugs. To use those drugs, you must show that they are *superior* to exercise, diet, meditation, therapy, EMDR,…whatever safe treatments exist, *and* that the benefit outweighs the harm.

  • Hi everyone,

    I went to my dentist today and the two receptionists both happened to notice that I was carrying a book with “Psychiatry” in the title (it was Robert & Lisa’s book). They both were eager to talk about it. One of the receptionists, it turns out, has taught college level neuroscience in Boston, Ohio and in Australia. She was very interested and told me that that she was shocked to find that every single one of her 18 undergraduate students in Ohio was taking some serious psychotropic drug and had been doing so for years while none of her students in Boston were on drugs like that. She said that one of the Ohio students was taking valium every day and would get shaky before taking it. Both receptionists already knew that something is very wrong on a very large scale. Both were very interested in the book and wrote down the title and authors. I was pretty encouraged and took it as another sign that people really aren’t buying it anymore and major changes are possible.

    I’m still having a hard time really believing CDT, but that’s not bothering me much, since I agree with the conclusion that APA and Academic Psychiatry is unlikely to reform itself anyway, and that’s probably the main practical point. I’m new, and an outsider, and still a bit shocked at how bad it is, but I’m going to think about this some more and read the “initiatives” part of the site more carefully. One thing that occurs to me is that even though the story told in Robert & Lisa’s book is horrifying, the story also does have heroes, and celebrating individual heroes might be an important positive step to take. I’m not the right person to name who the heroes are, but I’m talking about people who have pointed out the truth for many years and people who have done the very hard work of uncovering and revealing the corruption and fraudulent science. If, for instance, following in Peter Gotzsche’s footsteps becomes a respected and practical career path, that could make a huge difference in itself.

    – Saul

  • Hello Sandra. I guess that there is at least a spectrum between cognitive dissonance and a conspiracy of silence after all. My nominee for the most potentially CD psychiatrist is Dan Carlat

    who is so incredibly clueless that he admits to everything but still expects to be admired for it. He admits to doing essentially nothing but prescribing drugs by matching symptoms with drugs in the DSM, he admits to lying to his patients about how the drugs work, he admits that 1/2 the “scientific” literature is ghostwritten, he admits to essentially being a paid Effexor salesman for a year (paraphrasing: Effexor looked pretty good at the time, according to the information he was given at the Effexor sales meeting). STILL, he thinks he’s a great guy who should be admired for helping his patients and everyone should buy his book.

    I think, B.T.W., that the anger at R.W. comes mainly from the conspiracy of silence crowd. The anger comes exactly from the fact that they know or suspect that Robert is right.

    I am also very much of the “fix the problem, not the blame” philosophy in general. It’s also worth remembering, I think, that what Robert and others have pointed out over the past few years took a lot of digging and is not at all obvious. Robert himself worked in this area for years before realizing that “chemical imbalance” was “just a metaphor”. Also, as Robert points out, clinical experience can easily fool you because clinicians mainly see those who are actively being treated and don’t realize that the untreated population is actually doing better. Oppositional tolerance can also lead you to believe that the drugs are working, if you’re not thinking about things carefully. I am also willing to believe that up till about 2010, the average MD did not appreciate the massive rampant corruption of academic psychiatry.

    – Saul

  • Hello Sandra,

    Well, I have read Robert & Lisa’s new book now. It seems like a valuable contribution to me except for the last two chapters where they propose “Cognitive Dissonance Theory” to explain what’s going on and to guide solutions, just as you are saying. I am a big admirer of R.W., but I think that this theory is not a correct description of what’s going on and is not a reliable guide for how to make things better.

    For those who haven’t read the book, “Cognitive Dissonance Theory” goes like this: According to Cognitive Dissonance Theory, it would be a “fundamental attribution error” to blame any individual psychiatrist, because psychiatrists are not even consciously aware of their own conflicts of interests or corruption and they are not aware that they are harming their patients. Whitaker and Cosgrove propose that with only rare exceptions, individual psychiatrists in the APA believe that they behave ethically and think that they act in the best interests of their patients. Also, an organization like the APA cannot be blamed either because it has “institutional blindness” and is only unconsciously responding to “economies of influence.” Thus, no person is to blame and no institution is to blame. We must, instead, understand how “institutional blindness” develops and we must, as a society, modify the “economies of influence” to minimize corruption and the resulting harms to patients.

    I have multiple objections to this theory, but, first of all, I don’t think it makes any sense. According to CDT, even if an individual is unable to see their own unethical behavior, they can easily see the unethical behavior of others (p. 177). Thus, if CDT is correct, an individual member of the APA would believe that they behave ethically themselves, but would still find themselves in an organization surrounded by widespread corruption. Even in this case, many psychiatrists would be obliged to act, speak out or at least resign. I am afraid that the fact that only a few have done so suggests that CDT is not correct and suggests that a better model for what’s going on is the well known conscious phenomenon called a “Conspiracy of Silence” (

    – Saul

  • Hi Ted,

    I just happened to listen to your impressive interview the other day

    I want to let you know that I agree with your post here even though I haven’t been harmed by psychiatry myself (I’m not a health care professional).

    Hello Sandra:

    I am not blaming you personally for anything, but I’m afraid that I read this

    “Concepts such as cognitive dissonance are not concepts that are applied by experts and used to undermine the credibility of one class of humans, but is a comment on the vulnerability of human thought in general. I am as vulnerable as anyone else. ”

    exactly as an attempt to evade even a label of “cognitive dissonance” for psychiatry much less actual responsibility for the harms done. I haven’t read Cosgrove & Whitaker’s new book yet, but, to me, the barest starting point of taking responsibility would be and acknowledgement and honest accounting of the harms that have been done, an acknowledgement and exposure of gross corruption, and taking immediate steps to prevent more people from being harmed in the future.

    – Saul

  • “I think you are right that there are real limits to just challenging depressive thoughts, though I think there can be some benefit to it, especially when one doesn’t see it as an attempt to “replace the negative thoughts with positive ones” but rather to come up with balanced thoughts that admit what is true in the negative thoughts while also noticing what is also true that allows for possibility and hope.”

    This is why I think that CBT is slightly off target for a depressed person. When people are depressed they end up compulsively ruminating over various things and end up with out of control emotions – usually fear or anger or both. When you’re in it, these thoughts and feelings are incredibly captivating. It really helps to see that this is the one giant misdirection trick of depression. It automatically keeps you from seeing what the real problem is. It doesn’t actually matter if the thoughts are positive or negative or whether they are true or not and it doesn’t matter what kind of emotions come along with them. The essential problem is not the particular thoughts and emotions. The essential problem is the WAY thoughts and emotions are entering your mind in general. I believe that’s why the technique in the notes works so well (sometimes with really startling rapid transformations). It’s getting right to the root of the problem instead of fighting the particular symptomatic thoughts and emotions that you end up with. That’s why meditation often works for depression even if no one has to say a single word to the meditator the entire time.

    Thanks for that pointer to the Scientific American article. I think that there is quite a bit of truth to that. Obsessively ruminating does often yield real insights and real results.

    – Saul

  • Hi Ron,

    I don’t know about psychosis, but if anyone is using CBT for depression, you might be interested in this

    It’s spreading on-line and has been used in the Behavioral Activation group at Brigham and Women’s hospital in Boston. It’s new, and I could be wrong, but I do think that this is really right. I think that depression really is caused by one single specific unconscious habitual thought process. It explains what symptoms should appear, how a depression should evolve over time, why there won’t be a simple biological marker for depression and which therapies should work and which shouldn’t.

    I have tried CBT in the past for my own depression. I found it to be helpful and interesting, but not transformative. In retrospect, I think the basic problem is that the thoughts and beliefs that it is aimed at are really symptoms of a depression and they are not quite the root of the problem. I would say that a problem with Beck’s approach specifically is that many of the most painful negative thoughts of depressed people actually are perceptive and correct and if you examine the “evidence for” and “evidence against” dysfunctional thoughts it’s not going to help.

    – Saul

  • Hi Duane,

    I know where you’re coming from. The Onion always helps

    It’s relatively easy for me to be nice as I haven’t been harmed myself, but I have seen some amazing stories on the psychcentral web site like (paraphrasing)…

    I’m 18 years old and just broke up with my girlfriend. My doctor gave me Zoloft. Should I take it?

    Someone who suddenly can’t get their prescriptions refilled and is in trouble. Why? Because her M.D. just lost his medical license. It turned out that her MD was both a physician and a pharmacist and was taking money from drug companies and too many of his patients were dying.

    Many people with prescriptions for multiple psych drugs who literally decide what drug to take when on an hourly basis depending on how they are feeling.

    Many, many people are proud of their diagnosis and proudly display their DSM categories and their meds and doses in their signature line, even as they suffer through severe side effects. Many people very strongly want to believe the chemical imbalance story and will automatically discount anything that contradicts that or points out long term harms.

    – Saul

  • Dear Norm,

    Your honesty and willingness to consider alternatives is a breath of fresh air. I think that posting it here shows courage and shows that you care about your patients. I once asked an MD a similar question on another web site and he said the following:

    “Try treating someone who comes in with severe depression. They can’t or won’t commit to exercise (depression has sapped their motivation, their living area isn’t conducive to exercise, injury, climate whatever) they’ve had a bad experience with therapy and refuse to go. Supplements to treat holistically will run over 50 dollars a month compared to a 5 or 10 dollar copay for medication. And this isn’t an extreme case I describe. In certain areas, this is a typical patient profile”

    I don’t actually agree with this, but I think it’s an honestly held belief that was perhaps reasonable to hold a few years ago (basically before MIA) when anyone could be forgiven for believing research literature and treatment guidelines which are now just widely known to be grossly corrupted.

    My impression is that the vast majority of M.D.s (even psychiatrists) sincerely do want to help their patients, but many are now in a crisis as it has become clear how bad things really are. There has been lots of discussion at MIA and elsewhere about the DSM and how that should be changed and what the roles of the various existing professions should have. I think it might be more helpful to first try to construct new treatment guidelines and protocols for people having various problems and then try to see how the existing professions fit in afterwards. I say “new” because current guidelines like this one

    seem to me to be very bad and more likely to be leading to harms than ridiculous DSM categories that M.D.s probably don’t pay much attention to anyway.

    Take depression, for instance. I’m not a medical professional, but it’s clear to me that the basic existing plan is very simple and it goes like this:

    1. Have patient’s PCP check for purely medical conditions that might be causing a problem (Sometimes skipped).

    2. Start the patient on some antidepressant, optionally recommend therapy, mention that exercise might help.

    3. When new symptoms appear, add new corresponding meds. When depression reappears, change to a new antidepressant, searching for the “right cocktail.”

    This is a life-destroyingly horrible plan and leads many people into deep trouble. If anyone wants a visceral view of this, I suggest that you visit the “psychiatric medications” section of the psychcentral web site. This plan is so incredibly bad that I spend some of my time advising that people not do this and, instead, to follow the obviously much better:

    1. Deal with any physical/nutritional issues first.

    This should be MUCH more extensively done than what usually happens since many common conditions (Vitamin B, D deficiencies, Omega 3 deficiency, hypothyroidism, heavy metal toxicity, pre-diabetes, infection, gluten allergy,…) can contribute to mental problems. [I just learned yesterday at MIA, that a urinary tract infection, for example, can apparently cause psychosis!]. As a layman, I’m impressed by the “Functional Medicine” view of this.

    2. Try all of the safe healthy ways to overcome depression next.

    There are many good things to try and many, like exercise, diet, meditation, breathing exercises, talk therapy,… (listed in the link below). Many have zero cost and/or are great for your health anyway.

    3. If 1 and 2 really fail and you are still feeling really bad, discuss the next steps with your M.D.

    (details listed here ).

    I think it would be good for well-meaning professionals to get together and try to construct better guidelines and protocols for people with depression symptoms, people hearing voices, people with panic attacks, people with sleep problems, people who are angry all the time, people who are afraid all the time, people who have “brain fog” or memory problems, people who are addicted to drugs, people who have suffered sexual abuse, people who are already on psych meds and are having problems, people with mental problems who are in prison, etc. I think that if well meaning professionals can agree on a protocol, just thinking of a patient’s benefit, that’s a good starting point for forming new organizations, organizing how the various existing professions fit in, finding areas where more resources are needed, and getting to better outcomes.

    – Saul

  • Dear Dr. Hoffman,

    If I understand things correctly, Peter Gotzsche and his collaborators have shown that antidepressant drugs barely beat placebo at best for treating depression. That means that every single one of the following treatments: exercise, meditation, dietary improvement, yoga, acupuncture, light therapy, various talk therapies, behavioral activation, EMDR, hypnosis, acupuncture,… are at least as good as antidepressants, just because antidepressants apparently do almost nothing good. Antidepressants are tied for last place in effectiveness, but they are also clearly in last place in terms of safety to the patient. From this, I would conclude that antidepressants should only be used in rare situations at most when everything else has failed. However, you seem to use them frequently:

    “To be up front, I prescribe psychiatric medication frequently, though usually as an adjunct to psychotherapy.”

    Why do you do that? Am I missing something here? – Saul

  • Hi James,

    > I know many who have received a diagnosis, and have seen it as an empowering, freeing idea (again, > for better or worse), in that they no longer feel solely responsible for their deficiencies or struggles.

    I think it’s pointing out how bad the “worse” alternative above is. I sometimes hang out at a web site where you can find many, many people who proudly have signature lines listing, for instance:

    Bi-Polar I / GAD / Panic Attack Disorder / ADHD
    – Welbutrin XL 150mg
    – Latuda 20mg
    – Adderall 20mg 2x day
    – Nuvigil 150mg
    Xanax as needed

    And who discuss among each other what is the best “cocktail” for their particular diagnoses.

    Part of the dishonesty of diagnoses like that is a fake specificity that gives a false impression that it’s a scientific answer. I don’t really object to someone saying “you are depressed”, but if someone tells you that you have

    “Bi-Polar I / GAD / Panic Attack Disorder / ADHD”

    they are just lying to you and pretending to know things that they do not know.


    – Saul

  • Hi Ted,

    If you picket them, they will call you Scientologists.

    Julia, the question and answer was interesting, but Dr. Lieberman is a past president and still a recognized and respected leader in the APA, apparently. By belonging to that organization, you are accepting his leadership and the leadership of others like him. How can well meaning professionals stand to belong to an organization like that? Why don’t you start an alternative? – Saul

  • That was the most shocking part of a shocking interview for me. Notice that 57:00 in,

    Lieberman mentions that his own son was diagnosed with ADHD and given a prescription for Ritalin by a pediatric psychiatrist. It’s fine for everyone else, apparently, but when it was his own son, Lieberman actually refused the drugs.

    I don’t have anything to do with psychiatry myself, but I find it really disturbing that someone like this is considered a leader of the field. Is there an alternative to the APA as a professional organization? I am sure that here are many well-meaning psychiatrists out there, but I’m having trouble reconciling this. – Saul

  • Hi James,

    I also have mixed feelings about the concern for labeling and stigma expressed here at MIA. Is labeling really the problem? People used to be labeled “type A personalities,” for example. This might have been a little silly, but it didn’t really harm anyone because no one developed type A personality drugs and convinced people that they had “type A disorder” and had to take type A drugs for the rest of their lives. I don’t think that banning all labels and saying that nothing is dysfunctional is a tenable position. Any real understanding of mental problems has to come with labels, it seems to me. “Procrastination”, for example, is the name of a common dysfunctional behavior that is recognizable in many people in many different circumstances. Even though I think it is very unwise to treat procrastination as a medical problem, I still think that “procrastination” is a useful term and a real thing in the sense that everyone who is procrastinating is basically doing the same thing, independent of social forces and their particular life circumstances.

    Another aspect of the concern for labels is strongly focusing criticism on the DSM. To me, this is very justified criticism, but, still, don’t the greater harms come from the actual treatment guidelines like this one?

    Could it be that these guidelines are why PCPs prescribe psych drugs so freely and not because they are influenced by TV commercials or drug company perks? To me, the greatest sins are of psychiatry are harming patients very severely, gross institutional and scientific corruption and pretending to understand things which are not understood, in that order.

    I’m also concerned about the anti-stigma concern! Just a few days ago, I saw a giant (more than six feet tall) advertisement at a bus stop here in Boston:

    The web site shows a spontaneous gathering of color coordinated citizens with a giant sign “IMAGINE IF YOU GOT BLAMED FOR HAVING CANCER”

    Is this concern for the harms of stigma or is this an effort to perpetuate the medical model via the unspoken assumption of the site (mental problems are medical problems, like cancer) and to encourage people to admit that they are biologically damaged and need to get the usual treatment?

    – Saul

  • Greetings Dr. Hickey,

    I’d like to suggest an answer to Scott Alexander’s argument that when Psychiatrists say “chemical imbalance” they really mean

    “(A): Depression is complicated, but it seems to involve disruptions to the levels of brain chemicals in some important way”

    At one level, this seems completely reasonable. If brain chemistry determines how I’m feeling and I’m feeling bad, there must be something wrong with my brain chemistry, right? What could be wrong with that?

    To see what’s wrong, imagine that your laptop has a virus and has developed “laptop depression.” Your laptop is sluggish, unenthusiastic and sleeps too much. Suppose you take it to the Apple store and they say that since everything happening in your laptop is determined by electrical signals, your laptop has an “electrical imbalance.” We are therefore going to try increasing your clock speed, add some more wires and pull out a few capacitors. Notice that even though it is correct that your laptop’s behavior is determined by electrical signals, the Apple store is about to make a very serious mistake that will likely harm your laptop and will likely not solve the problem. The point is that the Apple store has mistaken a software problem for a hardware problem. I think that depression (at least) is essentially a brain software problem and not a brain hardware problem. I think that depression is essentially caused by an ingrained, habitual, unconscious thinking pattern and not by neurotransmitter imbalances. If that’s so, it’s not surprising that no biochemical test for depression has been found. It’s the same for laptops. You can’t get out a voltmeter and test if your laptop has a virus. Notice that technology improvements won’t change what you should do here. Even if extensive research into laptop depression shows that you can sometimes electrically determine if a laptop has a virus, the right treatment is still going to be to remove the bad software and not to have a hardware intervention.


    Saul Youssef