Any chance you could answer some questions? I'll get to them after a couple of (relevant) anecdotes.

I was diagnosed with depression by a psychologist. I got a referral to a psychiatrist, and I was told that the psychiatrist would probably want to do his own assessment of where I was at & what kind of therapy would best benefit me.

Nope. It was, "You've got such & such diagnosis; let's try such & such drug. Bye!" Some years later, I was treated by another psychiatrist. Same deal.

Second, I've read a fair amount about various psychoactive drugs. One thing I've noted in the literature is that often drugs are only found to be effective when used in combination with other kinds of therapy: counseling, etc. So if I am taking a psychoactive drug regularly to treat some condition, then I always get regular counseling for that condition as well.

I have mentioned this practice of mine to both psychiatrists, and both indicated their approval. But in both cases, counseling was never mentioned until I brought it up. I'm thinking that, if I were a psychiatrist, then I might insist that my patients get regular counseling in addition to my treatment. To avoid even recommending it strikes me (in my highly inexpert opinion) as an awful practice, possibly rendering psychiatric treatment ineffective. One might even call it a violation of professional ethics.

So, my questions.

1. Would you say my experiences related above are typical?

2. Would you say that these experiences point out problems (with the two psychiatrists at least, and with the profession as a whole, if the answer to #1 is "yes")?

3. If these are problems, then what do we do about them?

1. These experiences are not the norm, but still much too common.

2. Psychiatrists might not recommend talk therapies for a number of reasons (even though they probably should). Many insurance plans don't cover it, and lots of people aren't interested and want a "quick fix" to the problem in the form of a pill. Finally, the education for licensed therapist varies WILDLY, and there are a lot of really bad ones. That can make it hard to recommend in some parts of the country where few/no good therapists are available.

Thanks for the reply.

> Finally, the education for licensed therapist varies WILDLY, and there are a lot of really bad ones.

I hear you there. I had some iffy experiences early on. But a few years ago I found a really good one. He retired, but recommended someone else to me, who also turned out to be really good. I'm seeing him these days.

Maybe what needs to happen is for the norm to be that psychiatrists who see the general public (so not people like you, perhaps) do so in the context of a joint practice that includes various counsellor/therapist types as well. The approach could be that each patient is a client of the practice, with the various specialists contributing their expertise as needed.

(Maybe that already happens a lot. I couldn't say.)

I emphatically agree with your recommendation that more people should seek counseling, even those who lead seemingly happy and/or successful lives. Increased urbanization has unfortunately resulted in less socialization for a lot of people. Especially (at the risk of sounding sexist) for men, who tend to be more introverted. So I see a lot of my male friends struggling with social problems which I think some genuine counseling could really help them with.

We need to remove the stigma attached with seeing a psychiatrist/shrink as something done only by those suffering from mental ailments. And to be honest, I've seen a lot of people turn to self-help "gurus" who just confuse things further by not getting to the root of the problem.

How does one find a good psychiatrist?

Personal referrals.

But the real success in treatments now tends to be self education. Not WebMD I mean reading the actual research papers to evaluate what options would work for you. Know yourself.

Unfortunately, it seems to be a lot of trial and error.

And there's the rub. It's total chance, and there's no guide. You have to understand psychology and psychaitry to have a chance of navigating the system. And when you're struggling, that's the last thing you can do

I'm curious what you make of the claims Robert Whitaker makes in "Anatomy of an Epidemic" and elsewhere? Psychiatry comes off looking quite bad in his analysis and he is far from the only critic of the profession. My attempts to find convincing rebuttals of his claims from Psychiatrists have so far drawn a blank.

In a nutshell for those not familiar with the book, he presents convincing evidence that most psychiatric medicines have no significant short term benefits over active placebos and in fact worsen long term outcomes and that the profession has been complicit in presenting unsupported hypotheses about chemical imbalances in the brain causing conditions such as depression as established fact and in pushing drugs as the primary means of treatment without sufficient evidence of their efficacy and largely ignoring worrying evidence of long term harm.

I'll admit to having a pre existing suspicion of psychiatry stemming from taking a degree in psychology in the UK but after reading this book and digging more deeply I have to say it looks far worse for psychiatry than I previously imagined.

I just heard a convincing criticism of our mental health system from the invisibilia podcast. They went to a European town where mentally ill people were assigned to live with regular people to take care of them. And that they had much better outcomes than in the US.

The full episode is here, there's a lot of interesting observations in it: http://www.npr.org/programs/invisibilia/483855073/the-proble...

It looks like meta-analyses published after that book support the efficacy of anti-depressants, are you familiar with this evidence?

https://en.m.wikipedia.org/wiki/Selective_serotonin_reuptake...

This seems to be a fairly balanced (and pretty long!) review of the evidence from Scott Alexander who is a psychiatrist (I believe) which comes down on the side that the balance of the evidence is that SSRIs do have an effect that can't be explained purely as active placebo: http://slatestarcodex.com/2014/07/07/ssris-much-more-than-yo...

Here's another 2014 article leaning the other way by Irving Kirsch, one of the more prominent researchers to question the evidence for anti depressant efficacy: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4172306/

In Anatomy of an Epidemic Robert Whitaker details many of the problems around the published studies that raise real concerns how bias free the remaining positive results of these studies might be. In addition, pretty much all of the discussion above is based around short term effects and perhaps the most worrying part of Whitaker's book for me is the suggestive evidence of devastating long term effects of many psychiatric drugs, SSRIs included.

Personally I think the bar should be rather higher for evidence of short term benefit for any drug than the 'optimistic' view of the evidence for SSRIs and especially in light of evidence of the drug making the condition it is supposed to treat significantly worse over the long term. Given that even proponents of SSRIs seem to accept that talk therapy is equally effective I know I'd rather take the drug and side effect free option but Scott Alexander gives a different take on that in his article, pointing out that drugs are much cheaper (and hence more profitable for both psychiatrists and drug companies as Whitaker points out in his book).

Everyone's different, but as a programmer, I'd like more explaination of my psychiatrist's thought process on why they choose particular diagnosis and the medications they use. And preferably a decent bit of pharmacology and statistics of expected outcomes (especially when I ask).

Obviously it's a complicated profession. The medication changes your brain and often only has moderate success. Sometimes the medications can put you into a bad mood (and who do we blame? Probably the doctor). Diagnosis are partially based on subjective information.

I was ruined myself by a psychiatrist that over prescribed benzos and later tried to use her authority to sell 'multilevel marketing' goods and services. It's hard to blindly trust someone based on their degree after that.

Yow. Hopefully you reported her to the licensing board?

I think part of the difficulty is that we don't have a great understanding of consciousness or how the mind actually works. It feels a bit like medicine prior to germ theory.

Even for relatively more understood things like depression it's not like we can test the serotonin levels to validate it before SSRIs and then check them after.

It seems to be a mixture of this seems to work, but given the high variation among people and general complexity of mental states the science is difficult.

It is a difficult field I'd say only out done in complexity by nutritional science. What works for one person fails on a dozen others.

Theodore Dalrymple (a retired prison psychiater from England) wrote a book about how psychiatry undermines morality. It is called 'Admirable Evasions' (1). One of the things he notes: many people call themselves depressed nowadays. Few people call themselves unhappy.

(1) https://www.amazon.com/Admirable-Evasions-Psychology-Undermi...

My money is that that guy will prove to be utterly on the wrong side of history, and in the long term serious crime will turn out to be mostly a medical problem.

And some of the problems that cause bad outcomes are outside of what you control. Laws forbidding families from getting information about their mentally ill adult children, for example.

Also, "the system" (insurance companies, the courts, etc) sometimes make it very, very hard to get someone the help they need.

I had a mentally ill colleague that was very difficult to help. His family was ready and willing, but it was just impossible, given the legal constraints on everyone, to get him the help he needed. He was homeless for 6-9 months before he was committed and then got back on his meds and was able to go home.

There's a reason those laws exist. Mental health is still a taboo topic and as soon as anyone knows there's an issue the reflex is for everything to go into lockdown. This comes up on reddit with some frequency [1][2]. Some of the stories are pretty harrowing. Though a lot of this is to do with the poor state of many mental health institutions.

1) https://www.reddit.com/r/AskReddit/comments/3hlcyu/serious_r...

2) https://www.reddit.com/r/AskReddit/comments/1tdoc1/redditers...

You know the one interesting thing about these "sane person stuck in a mental institution" stories, is they always talk about how nuts the other people were. If it were as common as suggested that normal people end up there for slips of the tongue or other mundane reasons then I'd expect there to be more "normal" people finding each other in these stories.

Probably that otherwise normal people just don't make it into the stories because they're not as memorable. Though often you'll hear of people otherwise healthy who are down on their luck, addiction problems, abuse, or just general anxiety and depression. The other problem is that the definition of sane changes depending on context.

I recall watching a documentary on Japanese school children and their attitudes towards baseball, ritualistically crying when they lost a game. A western therapist could easily justify feeding them all meds, but in reality it wasn't particularly unhealthy. I feel like a lot of ADHD is kids being kids and teachers and parents wanting an easy way to deal with it. Lobotomies used to be common less because anyone believe they cured anyone but because they rendered the patient docile. Mental health ends up being as much about societies easy function as it is about helping the patients.

I feel this comment really hits the spot on the current "epidemic" of ADHD diagnosis and prescriptions. Parents are sooooo worried about their kids not being "normal" (i.e. docile and obedient) that they will do anything to make that happen. I almost feel that it was better before we had modern medicine when parents were resigned to dealing with their kids' unique character instead of chemically forcing them into submission.

Ugh I hate this myth that "ADHD ain't real". It's a real condition that hugely impacts life outcomes. Sure there are worse diseases, and unlike other conditions ADHD people appear normal on the outside. But it makes it hugely difficult to do normal things and succeed in society. Sufferers commonly drop out of school, get worse jobs, are more likely to get involved in crime, and are less happy.

My understanding was that being trapped in an institution with crazy people, being treated like a crazy person, stripped of your dignity, and put in isolation or force-fed medication if you try to upset the status quo or challenge your incarceration in any way is enough to drive people crazy. It certainly would me.

In this personal account, someone who on admission was merely ADHD with possible depression ends up snapping and violently beating someone: https://www.reddit.com/r/AskReddit/comments/1tdoc1/redditers...

How often do you cure your patients?

I'm skeptical of any medical profession which seems to build and depend on lifetime customers.

What a strange question, what does it mean to cure a patient?

Say a patient goes to a doctor and is diagnosed with heart disease - is there anything that can be done to cure this? Or do we simply alleviate the symptoms to make way for a better life? This is the case with so many illnesses: diabetes, cancer, arthritis, the list is so long.

But do you have the same skepticism of a doctor? Of a surgeon? We are not simple machines, us humans. When there are bugs in us they are often not currently fixable. This applies to psychiatry as much as it does to internal medicine.

It means to restore them to a level of health where they are not dependent on the doctor or medicine for continued care.

> Say a patient goes to a doctor and is diagnosed with heart disease - is there anything that can be done to cure this?

And they'd say there possibly is (such as lifestyle changes), and encourage them to pursue those changes while providing temporary medical relief.

> This is the case with so many illnesses: diabetes, cancer, arthritis, the list is so long.

The fact that we don't yet have a permanent cure for some of these illnesses is considered a major problem. Medical professionals are working tirelessly to find cures for conditions like cancer.

Meanwhile, psychiatrists seem to be almost completely uninterested in finding or promoting permanent cures (even when such cures likely exist, including through lifestyle changes). They want to put you on a lifetime drug regime.

I recognize that we're not going to have permanent cures for everything. But psychiatrists don't have permanent cures for anything. If internal medicine insisted that every condition required costly lifetime treatment, I'd be equally skeptical of it. In cases where a cure isn't available, other specialties admit that the best they can do is treat the symptoms—meanwhile, psychiatrists have an attitude that lifetime drug use is the "cure."

Forgive me, but it seems like you have an exceedingly negative view of psychiatrists.

> And they'd say there possibly is (such as lifestyle changes), and encourage them to pursue those changes while providing temporary medical relief.

But Psychiatrists provide prescriptions as well (drugs, therapy etc) which may or may not lead to lifestyle changes.

> But psychiatrists don't have permanent cures for anything

I think this is being too harsh on psychiatrists. The mind is perhaps the most complex and least understood component of the human body. It is an exceedingly complex organ not yet completely understood. The heart, kidney etc are all functional organs, and their mechanisms for working are pretty well understood at the present time. There is much ongoing research to understand how the brain does work though; just probably not by Psychiatrists.

> Forgive me, but it seems like you have an exceedingly negative view of psychiatrists.

You would be correct. :)

> But Psychiatrists provide prescriptions as well (drugs, therapy etc) which may or may not lead to lifestyle changes.

Sure they do. But if I go to a doctor about my heart disease, they're going to ask me to me about my lifestyle and encourage me to make changes which would improve my condition (in addition to providing medication).

Meanwhile, in my experience psychiatrists will jump straight to medication without any discussion of the underlying lifestyle and adjustments which could improve it. At best, they encourage you to see a therapist as well. (To be honest, I'm somewhat skeptical of the hard division between the disciplines. A cardiologist is not a nutritionist, but they can give you a basic idea of the nutritional roots of heart disease and potential remedies, but psychiatrists seem to be entirely uninterested in anything besides drugs.)

> I think this is being too harsh on psychiatrists.

Is it? I don't necessarily think it's necessarily their fault. As someone else in this thread said, mental health seems to be like medicine prior to germ theory: a whole lot of confidence in symptom reducers of questionable efficacy.

> Medical professionals are working tirelessly to find cures for conditions like cancer.

Researchers are, the doctors at your local hospital are very unlikely to be participating in the research of new cures for anything.

> psychiatrists seem to be almost completely uninterested in finding or promoting permanent cures

Psychiatric research has developed hundreds of new, more advanced medicines in the last 10 years alone. More effective anti-depressants, with different interactions so different populations can take them with less risk of drug interaction. More effective anti-anxiety medications that have lower risk factors. Then there's the research of lifestyle changes - I've never met a psychiatrist who didn't believe that exercise was one of the most effective means of getting through depression!

I believe you're against bad psychiatrists, which I understand and agree with. I'm also against bad medical doctors! Bad surgeons, too - though I believe there's a lot of complexity with measuring the performance of that field in particular.

A good doctor recommends lifestyle changes to patients with say diabetes or heart disease - of course they do. But bad ones just give you the prescriptions for drugs that alleviate the worst symptoms without telling you that there's anything you can do to fix it. I just don't see why we'd attack all doctors for the actions of the worst ones.

Some of it might come from creepy movies or sad history of psychiatric institutions, which is unfortunate.

However, recently there was an unexpected result regarding schizophrenia suggesting it might be just a result of a genetic bug of extensive deletion of redundant neurons in the brain, a bio-computational problem when you look at it with the eyes of a hacker. If confirmed, this would invalidate a lot of previous research and force the whole field to take a bit different, algorithmic view on many issues.

Do you have a reference? I didn't hear about this

In Science there exist certain topics that are minefields.

Differences between human groupings. Race. Class. The Brain or Mind. Sexuality. Future/Past analysis. Most of economics.

Most interesting subjects contain taboos and dangers that should you cross them, shall ruin your career or life. That is why if we're really as smart as we think we have to use the Dark Arts. I don't know what would happen to a modern day Darwin but I doubt it'd be pretty.

The most controversial debate on science I ever saw was on Intelligence Squared on the subject of Organic Farming. My intuition is that one side felt strongly enough that they rigged the vote, and that the moderator knew it too when he saw the results.

> I have no idea what I'm talking about

Long term brainwashing can do that to people.

Would you respect someone who has studied Scientology for 10 years, just because it's a long time? I think in that case, the longer the worse.

Psychiatry is no different, pseudo-scientific quackery that exists largely to provide politically comfortable answers to questions society does not want to confront.

Oh, and to rubber stamp who the courts excuse for crime.

A generation of boys on ADHD drugs, thank psychiatry for that.

It is a corrupt and disgraceful occupation.

Meta-comment only: interesting handle, in context of your comments.