> I very well might not be alive if not for my SSRI prescription, but the side effects are brutal and lasting

The history of legal psychoactive medications is littered with dubious and ethically questionable choices. Here's some 1950s era psychiatric medication advertisements targeted at doctors:

https://www.pinterest.ca/epomanic/psychiatric-ads/

The ones with women are jarring. I wonder if future generations will see how we treat children the same way.

>Simone doesn't want to cook breakfast for her husband, a lobotomy and Thorazine fixed her right up.

>Little Timmy doesn't want to do homework for his parents, Adderall and gender reassignment fixed her right up.

I'd say that it is one of progress, but one in which outdated or poor practices overshadow that progress. I can't speak of the prevalence of such practices, but rather I mean the result of mistreatment is apparent and rapid while relative success is subtle and gradual.

It's generally understood that medication should be used as a backup after CBT or other forms of therapy and if you do need medication, it should be concurrent with that therapy. Psychiatric pharmacology is more complex and opaque than others, but there is progress being made on that front as well.

The more apparent progression being made is in understanding the neural mechanisms for these disorders and thus, determining alternative methods of treatment as a result, such as transcranial magnetic stimulation targeting individualized neural correlates (e.g. stimulating areas near the surface of the brain that have functional connectivity with deeper parts of the brain to activate/inhibit areas like DLPFC) and discovering relationships between certain mechanisms and certain disorders to investigate other pharmacological avenues (e.g. ketamine loses antidepressant effects when opioid receptors are blocked with naltrexone).

Another issue is that this progress in research takes awhile before you see results in practice and much longer for it to disseminate through the whole psychiatric community.

>It's generally understood that medication should be used as a backup after CBT or other forms of therapy and if you do need medication, it should be concurrent with that therapy

You say that, but from my experience medication is the first line treatment. Often there isn't even any other type of treatment that comes with it. You just try a whole bunch of different ones and hope for the best.

>The more apparent progression being made is in understanding the neural mechanisms for these disorders and thus, determining alternative methods of treatment as a result, such as transcranial magnetic stimulation targeting individualized neural correlates

Considering what happened the last time psychiatrists fiddled with people's brains I find it fascinating that anyone is willing to try this. Lobotomies were done for years by actual physicians, yet it was pretty much the worst possible horror show imaginable. Did they get it right this time?

I think the greatest problem with it is its adjacency to psychology and patient care. It removes some of the rigor from the treatment that the patient gets, because most of the time the patient is not interacting with doctors or even nurses. It'll be social workers of some form that may or may not have some training in trying to help people with mental health issues.

> You say that, but from my experience medication is the first line treatment. Often there isn't even any other type of treatment that comes with it. You just try a whole bunch of different ones and hope for the best.

I should have expanded on that particular point. It's widely understood in the research side that medicine should be a back up, but the practicing side of psychiatry is often completely detached from the current research, so it takes far too long for the body of knowledge to propagate into the practicing side. The impact of research on application is a far cry from where it should.

> Considering what happened the last time psychiatrists fiddled with people's brains I find it fascinating that anyone is willing to try this. Lobotomies were done for years by actual physicians, yet it was pretty much the worst possible horror show imaginable. Did they get it right this time?

The safety of TMS has been studied for a few decades now and its safety (and efficacy) is also being further understood with scanning someone with fMRI while simultaneously stimulating with TMS, which is pretty difficult since you're blasting a magnetic pulse at the same time that you're imaging using magnetism.

As with most medical interventions, there is a risk. More specifically, there are two primary risks: triggering a seizure from an epileptic patient by using too high of a pulse near the motor cortex or exacerbating a patient's current hypomanic/manic symptoms. It's much less invasive and much safer than things like ECT and DBS. Once again, this is a last resort and used for people things like treatment-resistant depression or PTSD. It's used after trying multiple medications, not because it's riskier, but rather because its effects tend to be acute in lasting anywhere from a few months to a few days after a session.

> I think the greatest problem with it is its adjacency to psychology and patient care. It removes some of the rigor from the treatment that the patient gets, because most of the time the patient is not interacting with doctors or even nurses. It'll be social workers of some form that may or may not have some training in trying to help people with mental health issues.

I agree that this where a lot of work needs to be done. In my opinion and in terms of widespread issues like depression and anxiety, psychiatric treatment should sought or referred after clinical psychologists have exhausted most or all of their options and should be taking on the brunt of those problems, not social workers and counselors. Too much rides on the latter's shoulders due to the barriers a lot of people face getting access to effective mental health professionals like clinical psychologists and psychiatrists. It doesn't help that a lot of general physicians will try to play the role of psychiatrist as well.

>Another issue is that this progress in research takes awhile before you see results in practice and much longer for it to disseminate through the whole psychiatric community.

The problem is that when I was a teenager I could walk into any psychiatrists office and leave with whatever drug I had decided I wanted to get high off for that weekend. I memorized a list of symptoms, said I had them to a GP, got a referral to a specialist and repeated them there again. If I started on Monday I could get a prescription by Thursday. Having talked to "problem" kids of friends it that's still the case today.

I never took the field seriously, and until I became an adult didn't realize anyone else did either. I just thought of them as legal drug dealers with good quality product, but not as fun as the unregulated product you could get on the street.

Imagine my surprise when I found out people actually took prescriptions for decades at a time, something that is as horrifying to me as drinking yourself to sleep every night because someone told you to.

So your problem with the field of psychiatry is that psychiatrists can be lied to and they don't put more effort into second-guessing their patients' experiences?

...

...

I think you might just be blaming other people for your unethical behaviour as a teenager.

https://slatestarcodex.com/2018/10/24/nominating-oneself-for...

If a 14 year old can consistently outsmart multiple professionals then it's not the 14 year old that's the problem.

If there no way to detect false positives then everyone is a false positive.

> If there is no way to detect false positives, then everyone is a false positive.

That does not logically follow.

Proof by contradiction:

I have invented a dumb test for COVID-19: I look at a linkedin profile of someone, then I lick a block of salt. If my tongue tastes salty, then I conclude they have COVID-19. Trivially, my test has no way to check for false positives. So, if ran this test on someone, your statement implies that they would be a false positive and therefore they would definitely be free of COVID-19.

Unless you think my salty tongue has magical COVID-curing powers, then even a broken clock is still right twice a day.

I've never seen anyone use false negatives to argue that we should accept false positives as reasonable. I guess there's a first time for everything.

But to answer your question, yes, it would be statistically prudent to assume that everyone who passed your test is free of covid because the proportion of the general population who have it is less than 1% currently and your test produces a 100% positive rate.

This is a specific case of https://en.wikipedia.org/wiki/Prosecutor%27s_fallacy

We live in a world of trade-offs.

I would rather live in a world where people with real psychological problems can get help and you can get high than the reverse.

And how about people without real psychological problems who ruin their lives?

Psychiatry has a rolling history where everything that was done 30 years ago is so barbarous that the treatments are criminalize, and it has been that way for a century. At what point are we going to realize that there is no baby in the bathwater?

I totally forgot to elaborate on that sentence. I meant to say that it's widely understood within the research community and recently graduated psychiatrists. There's still a lot of bad practice, outdated methodology, and general laissez-faire that the field is still shaking off. It's lingering way too long and dissemination of the up-to-date knowledge is much less effective within psychiatry than other areas. This may be due to it not being readily apparent that you're harming the patient compared to say cardiology, but I can't say for sure.

The field of mental health is definitely in a sorry state today, at least in the US. A lot of progress is being made in terms of research and knowledge, but it's not as impactful on the practicing community as it should be.

>ketamine loses antidepressant effects when opioid receptors are blocked with naltrexone).

. That was a small trial and another trial showed opposite results such as this one

https://pubmed.ncbi.nlm.nih.gov/30624551/

More details here

https://www.tandfonline.com/doi/full/10.1080/17460441.2020.1...

I believe more research is required for r-ketamine (arketamine) I wonder if it has effects on the opiod system also

They also thought that the mtor pathway was necessary but trials with human subjects and rapamycin showed that it potentiated the AD effects in humans . Which is sad to hear because it was the basis to the creation of NV-5138 that's heading towards phase 2 soon . It could very well work because the mtor pathway Is complicit In mood disorders .

Also advances towards TMS is very interesting check out stanford's SAINT TMS trial

Currently what I'm interested in is vistagen's pipeline of drugs . It works unlike any thing else and also the various FAAH inhibitors

I'm really angry at Pfizer and co for ditching MAOIs for SSRIs. All research shows that they are much more effective, have no emotional blunting effect and have less impact on libido, at the cost of not being allowed to eat cheese and some insomnia. SlateStarCodex wrote about it in his prescription perversity post. [1]

[1] https://slatestarcodex.com/2015/04/30/prescriptions-paradoxe...

I remember being told to watch out for side effects when switching from an SSRI (Trintellix) to a RIMA (Manerix), which is essentially a de-fanged MAOI. Younger psychiatrist kept pushing for the brand-new SSRI, I kept pushing back. Never mentioned anything else despite my attempts to open the discussion, and my own research (and in fact, experience thanks to darknet markets) over years.

Eventually "agreed to disagree" (I hate this expression), I moved on from that place where I was stagnating in pain, and found a sensible knowledgeable psychiatrist who happens to be much older, and we made the switch.

It's hard to understate how much of a change that was in my life. I try not to be bitter about any fresh new psychiatry grad on the block, but I really hope they get their shit together as a collective and observe what their own patients (and their older peers) seem to know better than them.

No matter how much tyramine I ingest (which is supposed to be a no-no on MAOI/RIMA) the worst side effects I suffer can't even get anywhere near what the SSRI would TYPICALLY do to me.

On Trintellix: morning headaches, being unable to have any caffeine, becoming lactose intolerant, frequent cramps and diarrhea. Depression very very mildly alleviated. Transition period when stopping the meds: 2 weeks. Cost of monthly refill: $110 CAD.

On Manerix: some cramps if I ingest gigantic amounts of tyramine (I'm french, I'm talking cured meats+cheese plates and red wine bottles in the same meal). Could be back to coffee and milk with no headaches nor cramps within a couple weeks. Depression mostly alleviated. Transition period when stopping the meds: 2-4 days. Cost of monthly refill: $30 CAD.

Oh and the kicker? Manerix is actually one of the few antidepressants that actually has a chance to "increase libido" as a side effect!

I'm glad someone wrote a good article on what I've been hoping to articulate in different places over time, thanks for the share.

This seems like an arbitrary and unhelpful distinction to make. Better medicine can be made later, all that new medicine has to be in the present is better than what was previously available.

Let's not get ahead of ourselves here -- antidepressants don't really have an effect. If a person was feeling suicidal before, they would certainly not stop feeling this way after taking SSRIs. Symptoms of depression is our psyche showing us that something going on in our lives is not going well, and using drugs to suppress these feelings is the worst thing I can think of that modern medicine came up with.

As someone who has taken SSRIs they usually do have effects. You can take them as a healthy person and they also have usually effects.

There is more diversity to people and their thoughts than your simple philosophy suggests; people may suffer from mental illnesses for no apparent reason, like how people may suffer from poor health in the same environment as a healthy person. And with antidepressants on a person with a condition stemming from a poor lifestyle, the effects can be what makes the difference that helps them transition to a more sustainable lifestyle.

Ignorant, grandiose claims like these really don't help people suffering from mental illnesses.

My understanding of the research is that, compared to a placebo, antidepressants help as much as 20% more of the population (20% -> 40%), and the broader scope of drugs can help around 30% to 40%[1] of people. People routinely feel suicidal, take SSRIs, and later stop feeling suicidal.

[1] https://youtu.be/NOAgplgTxfc?t=2294