> 1. they prescribe both boosters, and inhibitors, to treat the same symptoms. This suggests the aetiology of disease here, is not well defined by a single behaviour because the same symptom (depression, anxiety) is responsive in some people to suppressing of a chemical imbalance, and in others to boosting it.
"Chemical imbalance" isn't actually taught as the root cause of depression. I suspect your psychologist might be overestimating their own knowledge of a different field (psychiatrist formally study these systems and medications, psychologists do not) and underestimating the amount of research being performed in this field.
Regardless, these drugs don't really work as "boosters" like commonly thought. It's better to think of them as modulators. In fact, in conditions like anxiety SSRIs are well-known to actually reduce serotonin transmission in certain areas of the brain. The research has diverged quite a bit from the simple marketing-material models that a lot of people have about these drugs.
The purpose of the drugs is to induce changes that result in positive downstream effects. It's not actually a contradiction that enhancing and inhibiting certain receptors could result in similar downstream effects. For example, a number of receptors in your brain will downregulate in response to both agonists and antagonists, even though they have opposite direct effects. Your psychologist's understanding of this topic is deeply flawed.
> 2. the drugs were tested inadequately across race, age, weight, sex.
SSRIs have been in widespread use since the 80s and tricyclics since the 50s. At this point, the idea that we haven't tested enough or that we haven't collected enough data is just a strawman argument proposed by people with impossibly high standards. I suspect no amount of testing would actually satisfy someone proposing this argument for drugs that have been studied for this long.
> 3. the drugs appear to be best applied for as brief time as possible but are routinely being prescribed for extended periods, and demand de-habituation and great care with withdrawal
It doesn't make sense to make blanket statements about "the drugs" when psychiatric drugs differ widely in this regard. Benzodiazepines should absolutely be prescribed for brief periods and this is reflected in their status as controlled substances and all of the prescribing literature. There are some doctors who ignore this advice and overprescribe, of course, but they are going counter to standard practice.
On the other hand, medications like SSRIs can actually take weeks or months to reach full effect and many patients unnecessarily relapse by quitting them early.
I'd be cautious of taking advice from anyone who makes blanket statements about "the drugs". This is bordering on uninformed anti-psychiatry.
> 4. almost all successful uses of the drugs are accompanied by CBT and like processes
The most successful uses of SSRIs are accompanied by therapy. However, we have plenty of studies where SSRIs are prescribed without any accompanying therapy and a positive result is still seen. If you're suggesting that the therapy is actually doing 100% of the work, that's easily disproven by the studies that test all combination (placebo, therapy alone, SSRI alone, therapy + SSRI).
I'd recommend getting your psychiatry advice from actual psychiatrists. The number of misunderstandings and mistruths in what you've relayed here is quite high.
> It doesn't make sense to make blanket statements about "the drugs" when psychiatric drugs differ widely in this regard.
> I'd be cautious of taking advice from anyone who makes blanket statements about "the drugs". This is bordering on uninformed anti-psychiatry.
Yeah, as someone who has been close to people who need antipsychotics, I sometimes feel the anti-antidepressant crowd extrapolates to all psychiatric drugs and this is very scary. Especially since people with conditions like schizophrenia or bipolar frequently think they don't need medication.
It's interesting that anyone other than the R&D arm of the pharma industry even cares how it works.
From the medical side what's important is what risk/benefit which is independent.
Antidepressant as a term is really only for convenience which the medications themselves being quite broad in action.
Antipsychotics too are having a bit of a revolution, the first generation seemed to all be about D2 blockade, the second generation acting on 5HT-2a much more than D2. Finally, pimavaserin acting only on seratonin (5HT-2a) and not on dopamine at all [0] now there's SEP-363856 [1] which has action not at D2 or 5HT-2A but TAAR1 and 5HT-1A.
The point is that psychiatrists are not particularly married to any mode of action or mechanism. Only the results.
I think you might want to do some research as to why schizophrenics might end up non-compliant. Antipsychotics are serious drugs that, historically, have had severe side effects. Additionally, they’re rarely a complete solution (people can still have delusions and hallucinations while taking medication). Additionally, like other psychiatric medication, not all antipsychotics will work for people, sometimes they’ll stop working, etc.
Antipsychotics are nasty medications. Here are the list of problems I’ve had:
- Sedation (too tired to function)
- Emotional numbness if I need to increase the dose to stop an episode.
- Headache
- Loss of balance.
- Impaired fine motor control.
- My arms and legs don’t move properly. I’ll command my arm to move, and it only moves
halfway. I used to fall a lot before I learned to be very careful walking.
- Inability to orgasm.
These get pretty bad in the first four hours after taking them. During the day, if I get dehydrated or have low blood sugar, I can easily get incapacitated and be unable to drive.
And no, my dosage isn’t too high. This is the lowest effective dose I can be on. The alternative is lithium, which can be worse.
I think it's different for a lot of people. But one common thing is to get grandiose and think that all problems are with other people. Why would such a person need meds? Clearly there is something wrong with the person who might suggest that.
Then potentially add paranoia on top of that...
Edit: and as the sibling comment said, people can feel pretty shitty on them. I know I've heard and been sympathetic to that for many years, so don't want to sound insensitive by only focusing on anosognosia.
There are many, many, many pharmacy drugs that can stop suicidal thoughts fast and don't have the track record of the "modern antidepressants". Long, long, long track records. Small dose lithium and lamotrigine come to mind right away. But how they work--nope, not clear. Okay, we'll agree it's not serotonin, how does that help us? Would it help if American doctors could prescribe 3 weeks for a spa holiday like European doctors? Maybe, for low-level depression, but not for suicidal thoughts, that just won't cut it. There is bipolar I and bipolar II and so big differences. Schizophrenia, big difference. But again, knowing that it isn't serotonin, that's nice, now what?
I'm not a psychiatrist or psychologist. He is, and has professional standing. You're judging him, on my paraphrases of what is said to me. Perhaps what you really should be saying is "don't try to represent the views of professionals in a field you are not an expert in" which btw, I would take as good advice.
None the less, I think the substantive point stands: the field is not in unity about the applicability of these drugs, and their use.
> None the less, I think the substantive point stands: the field is not in unity about the applicability of these drugs, and their use.
Which field? You said he was a psychologist. Your post was about psychiatry and neuroscience topics.
I don't disagree that psychologists have a lot of opinions, but it's not really their domain. I think it's a mistake to think that a psychologist is better educated on psychiatry topics than actual psychiatrists or neuroscientists who actually study these things and understand the research.
I think the gap between GPs, Psychologists and Psychiatrists lies at the heart of this. GPs can (and do) prescribe psychoactive drugs. What they do subsequently is subject to the constraints of the health economics which apply: In the UK (I am told) the delay to be seen by anyone other than your GP can be measured in YEARS because of the backlog in patents presenting. Many of these patients are young people. The GP has the determinant of the path. They can recommend something like CBT and a clinical psychologist, or they can recommend drugs and a psychiatrist. They can do either, for what is the same presentation of problem.
They get seen by a GP, with limited time and tools. They are prescribed SSRIs, and booked in to see "some other health professional" and what emerges is a delay of some significant time, before they get that next stage of engagement.
I was also triaged by my GP, in Australia, and was put into the non-drug path, and I am content. If my health practitioner prefers not to use drugs, and that is a bias, so be it.
I can say that my mother in law was treated in other ways, became addicted to Xanax, and narrowly missed being placed in "deep sleep" therapy which wreaked havoc on many people, although it was "peak treatment" at the time. She was a deeply unhappy woman. I cannot say she would have been better off without drugs, but I do know the process of managing her drug regime was intense.
Deep sleep therapy lasted a long time. It was credible for decades. Psychiatry is as capable as any other science of being led a long way down paths it subsequently walks back on.
ECT, which is much more "confronting" in some ways, remains a useful tool. If you ask most people in the streets, They react with horror.
I place great hopes in ketamine, and in psylocybin. Again, both require a context of use, and are still experimental. What I like about both, is that they appear to being considered as rapid-intervention therapies, not as sustained, long lived treatments. I like that because of the short duration. I guess I don't like the SSRI story precisely because of the long duration, and the consequences on young kids, especially on things like sexual dysfunction. (I'm not a young kid and that isn't an immediate concern for me)
Agree that the system is a bit fucked, in pretty much every country (as far as I can tell).
Unless you are involuntarily committed, you won't be put on the drug path if you don't want to. Psychiatric medications like SSRIs are generally awful. What I mean when I say "awful" is that the experience of taking them is awful. You may end up with symptoms that are under control, but you may still experience symptoms, or the symptoms can sometimes get worse, and the side effects are often just kind of shitty to deal with. These are generally not habit-forming drugs. These are nasty pills that you'll look at in the morning and dread taking.
Non-compliance rates are already high, when you have patients who want to take the medication. There is no way you're going to prescribe antidepressants to somebody who says they don't want to take them. It's just a waste of time.
Xanax is different. It's a benzodiazepine. The entire category of benzodiazepines is known to have a high rate of misuse, and Xanax in particular has a high rate of misuse. It's prescribed because it's an extremely effective and fast-acting. Very different from SSRIs.
I would add the caveat that low doses of SSRI do seem to be quite effective for issues like compulsiveness and anxiety without much in the way of negative side-effects.
I'm not sure what the scientific support for this is, but at least anecdotally I know 5+ people who take an low-dose SSRIs and claim it works.
This is for the most part a thread about SSRIs. Xanax is a benzodiazapine. There are no controversies on this thread, or really any ordinary place, about the dangers of benzodiazapines; they're scary drugs.
To stick to SSRI's I know one person who reacted badly to a change of meds, predicated on her personal dislike of the effects of the prior, but finding the replacement had extremely strong negative effect. I think had she been absent any support, this could have ended tragically, the effect was so strong and so sudden.
This, coupled with the emerging reports of longterm sexual dysfunction in young women, I think represent pretty severe concerns. Obviously anecdata is not science, but this is what informs my own sense of place here. I am not anti drug in the wider sense. I think drugs of all kinds have been and are and will be beneficial. I am concerned with how SSRIs are being used in practice, with what longterm consequences, and short-term risks.
There's a strong vibe of "butt out, stick to your knowledge" in responses to my posting here. I will take that advice. I'm off-piste, this isn't my area of work.
"Chemical imbalance" isn't actually taught as the root cause of depression. I suspect your psychologist might be overestimating their own knowledge of a different field (psychiatrist formally study these systems and medications, psychologists do not) and underestimating the amount of research being performed in this field.
Regardless, these drugs don't really work as "boosters" like commonly thought. It's better to think of them as modulators. In fact, in conditions like anxiety SSRIs are well-known to actually reduce serotonin transmission in certain areas of the brain. The research has diverged quite a bit from the simple marketing-material models that a lot of people have about these drugs.
The purpose of the drugs is to induce changes that result in positive downstream effects. It's not actually a contradiction that enhancing and inhibiting certain receptors could result in similar downstream effects. For example, a number of receptors in your brain will downregulate in response to both agonists and antagonists, even though they have opposite direct effects. Your psychologist's understanding of this topic is deeply flawed.
> 2. the drugs were tested inadequately across race, age, weight, sex.
SSRIs have been in widespread use since the 80s and tricyclics since the 50s. At this point, the idea that we haven't tested enough or that we haven't collected enough data is just a strawman argument proposed by people with impossibly high standards. I suspect no amount of testing would actually satisfy someone proposing this argument for drugs that have been studied for this long.
> 3. the drugs appear to be best applied for as brief time as possible but are routinely being prescribed for extended periods, and demand de-habituation and great care with withdrawal
It doesn't make sense to make blanket statements about "the drugs" when psychiatric drugs differ widely in this regard. Benzodiazepines should absolutely be prescribed for brief periods and this is reflected in their status as controlled substances and all of the prescribing literature. There are some doctors who ignore this advice and overprescribe, of course, but they are going counter to standard practice.
On the other hand, medications like SSRIs can actually take weeks or months to reach full effect and many patients unnecessarily relapse by quitting them early.
I'd be cautious of taking advice from anyone who makes blanket statements about "the drugs". This is bordering on uninformed anti-psychiatry.
> 4. almost all successful uses of the drugs are accompanied by CBT and like processes
The most successful uses of SSRIs are accompanied by therapy. However, we have plenty of studies where SSRIs are prescribed without any accompanying therapy and a positive result is still seen. If you're suggesting that the therapy is actually doing 100% of the work, that's easily disproven by the studies that test all combination (placebo, therapy alone, SSRI alone, therapy + SSRI).
I'd recommend getting your psychiatry advice from actual psychiatrists. The number of misunderstandings and mistruths in what you've relayed here is quite high.