> I'll never understand why there's such a dominance of luddite thinking, bad takes and conspiracy theories on HN, when it comes to the topic of mental health

I imagine there are many professional forums filled with people who know topic X inside out therefore assume they must also be an authority on unrelated topics Y and Z. But I also suspect there’s something about software engineering, perhaps the ability to succeed despite being deeply antisocial, or being very male dominated that means women’s mental health in particular is always going to be a dumpster fire.

It's insane to me that a group of educated and seemingly intelligent people seem to think they understand more about drug safety and prescribing than the FDA, researchers and physicians.

This is reminiscent of the Texas district judge who decided to controversially overrule the FDA on a medication safety decision that recently made the news, not good company one wants to have and I'm hoping is coincidental than suggestive of similar biases.

Its easy to figure out. Religion causes it.

I no longer believe that's the root, or even the primary, cause.

I keep thinking about Michael Crichton. He transmorphed from reality-based to nutter. What happened? Religion wasn't a factor. So what radicalized him?

Historian Joanna Radin's theory, paraphrasing, is that Crichton's full faith and trust in The System was so completely shattered, by the Vietnam War and other outrages, that he completely flipped.

The Speculative Present - How Michael Crichton Colonized the Future of Science and Technology https://www.journals.uchicago.edu/doi/epdf/10.1086/704047

The theme of the second season of Jill Lepore's The Last Archive podcast is about skepticism ("What fed Doubt?") S01E06 "It Came From Outer Space" includes the example of Crichton's radicalization.

https://www.thelastarchive.com/season-2-episodes

Lepore has completely opened up my mind about anti-science, conspiracy, and other social pathogens. Made me a bit more empathetic.

Highest recommendation.

Yeah, you know, when mothers commit suicide and leave behind their young families, the FDA will simply tap the black box warning: "we told you so."

What black box warning are you talking about?

The only one I see for Zurzuvae is: "IMPAIRED ABILITY TO DRIVE OR ENGAGE IN OTHER POTENTIALLY HAZARDOUS ACTIVITIES"[1]

[1]https://documents.sage-biogen.com/us/zurzuvae/pi.pdf

My bad - not a black box in this case. Just a regular box. Sorry for the confusion.

* * *

I haven't yet read the clinical trial results, but suicidal ideation has turned out to be a shockingly common side-effect of many other types of anti-depressants. The comment was unnecessarily inflammatory, but the concern is reasonable.

Hey, you know what causes suicide more than anything else? Depression. Especially untreated depression. And no, cannabis is not a mental health panacea now matter how many times you claim it is. In fact it generally seems to worsen depression. Never have I been more depressed than when smoking daily. It's nothing but a crutch.

Charles Whitman received Valium, and he loved his Dexedrine. He brought along a goodly supply of Dexedrine when he climbed the clock tower at the University of Texas.

The Columbine kids were well-medicated. Remarkably, despite their prescriptions, they were yet to be diagnosed with any mental illness.

When you read about someone who committed crimes, or merely caused a police-involved disturbance, the media will often say that "they had a history of mental/behavioral issues", which means that they were likely taking psychotropic drugs at the time of the incident. Many people choose "suicide by cop" which has been notoriously easy to do.

The FDA still grudgingly labels a few drugs with the "homicidal ideations" spiel, but not as many as they used to.

The sample size is small enough that the correlation vs causation question still goes strong. You're arguing causation, the FDA argues correlation. Is it because they're taking the drugs, or because they're the type of person who would be taking those drugs and therefore have some kind of issue that needed help? It can be hard to know. Did they have these ideas or desires before taking the medication, or only after? If they are young, is it because of the meds, or because they're an angsty and hormonal teenager who has mental issues, or did the drugs exacerbate that?

It's easy to say "look at all these very public cases where this bad thing happened, and they all have this in common!", but that doesn't tip the needle for correlation vs causation at all imo.

>>>"It's insane to me that a group of educated and seemingly intelligent people seem to think they understand more about drug safety and prescribing than the FDA, researchers and physicians."

I'm currently on a psychiatrist prescribed drug which is illegal in Japan, which means I have to discontinue it before an upcoming trip. This is not a new drug, it's a generic.

So is it "insane that a group of educated and seemingly intelligent doctors" in the U.S. are prescribing this drug or "insane that a group of educated and seemingly intelligent doctors" at the Japanese equivilent to the FDA are not authorizing this drug?

I mean, it can't possibly be the case that neither group knows what it's doing, and that our scientific understanding of the brain is primitive, correct? One group has to be the insane one, right?

I think there’s a meaningful difference there. A disagreement between two highly qualified groups of doctors seems valid. A disagreement between a group of highly qualified doctors and someone who did some research on the internet does not.

"A disagreement between two highly qualified groups of doctors seems valid."

Well... if we're talking psychiatrists, they choose the thing they wanted to be highly qualified in. So, any potential "expert" that would disagree with their research methods was selected out so as to not become an expert in the first place.

I guess if I have a point it's that I don't think shouting "trust the science" or "trust the experts" and beating one's chest is contributing much to the conversation.

What's insane is that seemingly intelligent people with zero medical training or research experience somehow think they have the capability to determine drug safety or whether a disease exists and merits treatment with pharmacotherapy.

> So, any potential "expert" that would disagree with them was selected out so as to not become an expert in the first place.

Anyone with some form of training or practical experience in an academic biomedical field (clinical or research) and has knowledge of how to synthesize and analyze evidence in order to make logical arguments may be considered a relevant expert, this is a much larger group than psychiatrists and is how FDA committees are constructed.

Most notably this includes (and is not limited to) other physicians and providers, pharmacologists, pathologists, physiologists and epidemiologists.

> I guess if I have a point it's that I don't think shouting "trust the science" or "trust the experts" and beating one's chest is contributing much to the conversation.

One should absolutely "trust the experts" when it comes to determining safety of a therapeutic or definition of a disease. These are determined by scientific processes and debate based on evidence and not philosophical thoughts and feelings.

Given how complex modern life is one has to defer to experts and regulators on many things beyond medicine. Some other examples: motor vehicles, aviation, building codes, financial institutions and encryption.

> I'd also say that the more I've learned about psychiatry (including as a customer) the lower the opinion I have of it.

The limitations in psychiatric medicine and research are widely acknowledged and not a novel insight that the FDA and medical community are ignorant of as many commenters here seem to believe.

>The limitations in psychiatric medicine and research are widely acknowledged and not a novel insight that the FDA and medical community are ignorant of as many commenters here seem to believe.

One might expect someone who acknowledges the limits of psychiatry wouldn't be chest beating so aggressively about the greatness of the scientific process.

One might also expect a person concerned with mental health issues wouldn't throw around the term "insane" so casually.

>These are determined by scientific processes and debate based on evidence and not philosophical thoughts and feelings.

Who needs philosophy? Just have faith, am I right? That's what science is all about. What do we mean by science? Don't ask that kind of philosophical question. Just have faith.

This is completely and utterly wrong. Psychiatric treatment varies in effectiveness, but there are drugs like lithium which have a fast and marked effect on the diseases they treat (e.g. Bipolar disorder, a crippling illness if left untreated). Depression drugs are less effective overall than other psychiatric illnesses, but even these have proven clinical effects in huge double-blind trials.

You really should read up on the literature, or hang around some people with serious mental health problems before spewing such garbage.

It’s very easy to explain. By going straight to medication you are treating the symptom not the cause. And you don’t even know if it works.

SSRIs don’t work for many people and we only found out 2-3 years ago.

Opioids were prescribed to half of America for back pain.

That gives scope for healthy scepticisms at least. Just because you might have some anecdotal evidence of some chemicals working, doesn’t mean it works for others or that it leads to a good place.

Lastly - there are clearly lifestyle and even moral choices that people make or don’t make that can lead to mental health issues. Just from a common sense perspective it seems much healthier to try and deal with these first, with therapy, than just medicating. And not just therapy. Exercise, diet. We know these affect mental health, yet pills are easy, and they make doctors money.

medicating is much easier than searching, finding and healing the cause. Therapy takes years, if not decades. I can understand why people pick the easier route, but easier is not always better. Also, are you just permanently going to be on pills then? I mean it’s a great subscription business, I can see that.

Look.

It's not some earth shattering revelation that "SSRIs don't work for many people". This has been known since SSRIs first appeared on the scene. This is also true of any other treatment you can think of. The reason they became the first choice as far as antidepressants go is they were a lot safer and better tolerated than the older alternatives. Besides, there's a lot more to psychiatry than just SSRIs. But with people like you it's always about SSRIs. Can't shut up about the SSRIs. If you hadn't noticed, this new drug is not an SSRI!

Psychiatrists recommend therapy, they recommend changes in diet and they recommend exercise. Clinical psychology, though technically a separate discipline from psychiatry, not being under the umbrella of medicine, is very much developed, researched and practiced in tandem and cooperation psychiatry, and vice versa.

You're constructing an elaborate strawman here, where the only reason for using drugs is some evil financial motive. It's just not that simple. There bad apples, and perverse incentives, but not only bad apples. Most doctors do in fact care about helping their patients.

Therapy can't fix everything. Therapy alone is not always sufficient and can be just as hit and miss as medication. Not everything is some deep personal issue that needs to be analysed and resolved. Mental disorder is often genetic, even neurological in nature. All the therapy in the world won't stop a bipolar person from cycling between mood disturbances, or someone with ADHD from being unable to concentrate.

We can't throw the baby out with the bathwater. Medication, therapy, meditation, diet, exercise, sleep hygiene are all part of the psychiatric toolbox.

I agree with you, but what we are arguing about is how much, and when?

Looking at how many people are medicating for mental health issues in the west (or world), I find it extremely unlikely this is because all these people have gone through therapy, exercise and diet and they have to take medication.

No. It’s the easy route to some sort of medicated happiness, and it’s profitable, so everyone does it.

But this many people shouldn’t be doing it. They shouldn’t be taking the easy route, because it’s not dealing with many issues we should be dealing with, as society and as individuals.

It's not the "easy route". It's a route that _works_.

Saying it's "medicated happiness" is ridiculous fearmongering. Antidepressants do not make you happy. They do not change how you think or how you act. They can't. If you think they do, you do not know what you're talking about.

This particular drug is about post partum depression. Sleep deprived women, often functioning as milk machines, while experiencing major hormonal changes and possibly recovering from major abdominal surgery. These are not people “taking the easy route”. Save the bootstraps talk for other patients.

Sorry, but no. I have two children. I as a father probably had mild PPD, and so did my wife after our second child.

You know why my wife had PPD? Because being a mother is hard, and she also had a lot of unresolved anger and issues towards her own mother, and she was reminding herself of her own mother and causing quite a bit of anxiety. We were also at an extremely difficult part of our relationship, we basically hated each other for a year.

What did we do? We both went to therapy, and asked the hard questions about why this was happening, and how to resolve them. My wife spent 6 months in therapy and resolved the issues with her mother, and now she is happy with her own performance as a mother. We went to couples therapy, which was extremely hard, but after over a year, we are basically in love again, and we are STARTING to understand what patterns are causing our issues, and how to deal with them.

We took no medication. But we were on the road to depression, but decided to actually look behind WHY this was happening.

Popping pills of course is much easier. You don't need to face your demons, or your parent's demons.

The trouble is it is at crucial times in life like childbirth when these demons emerge. Yet hardly anyone wants to face them anymore. This is not mentally healthy. And what's even worse, you are very likely to pass on many of these issues to your children if they remain unresolved.

I know this is counter to 70% of what americans believe in, but it's the hard truth, and I think many people deep down know this is the truth, but it's just much easier to take pills and bury the fact that EVERYONE has mental issues that need resolving, without taking medication.

I'm not talking about the extreme cases btw. I know in some instances medication is necessary. But it is WAY overused, to get out of making hard choices.

The resources to send everybody to therapy simply don’t exist. There aren’t enough therapists, nor money to pay them, for what you are suggesting. People aren’t taking the easy way out, they are taking the only path available.

As GP may be aware therapy is recommended first-line either in isolation or combination with pharmacotherapy for every type of depression.

To further illustrate the accessibility point when I lived in Canada therapy was not covered by the public health system and is entirely out of pocket.

In the US it obviously depends on the highly variable coinsurance/copay and assumes you can either take time off work or find a provider that works outside of business hours.

A 30-day supply of Lexapro is $4.50 and also has evidence that it works.

Different people have different experiences. Some people don't experience PPD or PPA at all. For many people PPD and/or PPA are significantly harder than what you experienced, and for a tragically high number it can be fatal for them and sometimes for others, including children and other family members.

You and your spouse have had your experiences which are completely valid and true. Your truth does not invalidate others' truth. This medicine is for them, not you.

You did the right thing no doubt.

However your experience seems to prevent you from seeing the bigger picture.

"Popping pills" is probably chosen not because people don't want to solve problems and change their lives. It is probably because it is only available solution at that time to actually function as a person and member of the society.

It is great that you had money and event time to go to therapy for 6 months as new parents. A lot of parents of newborns will simply not be able to afford it both financially and because of time constrains. Did you bring your new born to the therapy? How much did it cost? Would every single mother be able to afford 6 months of therapy? Some middle-lower class family? Some family in very rural area? Please try to see a bigger picture here and befriend more people from different paths of life.

People take pain medication for back pain not because they don't want to fix their backs. If anybody could fix their back today instead of taking pills they would do it.

> By going straight to medication

Initial treatment recommendations:

For mild to moderate postpartum unipolar major depression, we suggest psychotherapy as initial treatment. This approach is consistent with multiple practice guidelines, and is especially useful for lactating patients who do not want to expose their infants to antidepressants.

However, antidepressants (eg, selective serotonin reuptake inhibitors [SSRIs], serotonin-norepinephrine reuptake inhibitors, bupropion, and mirtazapine) are a reasonable alternative if psychotherapy is not available, not successful, or is declined, or if the patient has previously responded to antidepressants.

In addition, combination treatment with pharmacotherapy plus psychotherapy is useful for some patients.

Source: UpToDate.

> And you don’t even know if it works.

While evidence for SSRIs is weak in meta-analyses this is not one of them. I will also agree that a single trial (i.e. the original post and what led to approval) is not definitive but does in fact suggest it works and will continue to be assessed in post-market studies.

While I agree there are often additional deeper causes, picking up a prescription will begin faster than waiting for capitalism to be done away with.

Shit, I needed SSRIs before I was in any way capable of processing and dealing with my internal issues. I wasted a decade before giving in and trying the SSRI route and I regret not doing it sooner. It would've saved me and my loved ones a lot of suffering.

Capitalism isnt depressing anyone. Jealousy? Thatll do it

> SSRIs don’t work for many people and we only found out 2-3 years ago.

If you only found out 2-3 years ago that SSRIs don't work for many people that's decidedly a you-problem. Psychiatry has known this for ages, which is one of the reasons that depression treatment is still tricky. You have to try what works for each person individually. And usually it's a combination of things.

The compartmentilzation of intelligence

>What's the alternative? Prayer circles? Ayahuasca tourist traps? Cannabis? Homeopathy? Give me a break.

PPD aside, if we're talking about the issues that psychiatry seeks to alleviate, every one of those 'solutions' has had thousands of advocates/adherents/patients that claim to have gained positive effect.

and before I get considered a proponent of any of those; i'm not -- but I recognize the cohort of people who claim to have gained benefit just as I recognize the group who claim to have benefited from psychiatry.

mental health needs not be a monopoly; many people go through issues that they fix through specific personal events or patterns that are specific only to them.

You can complain about the style of thinking that you encounter on HN without disparaging the things that have helped people outside of clinical settings.

Mental health and well-being is one of the most mysterious things that we study, if a suicide or otherwise bad decision is staved off by chanting in makeup and visiting exotic locations then so be it, that's what worked for them.

And another aside : psychiatry will never incorporate extreme things that may help certain individuals, nor should they -- but that means that the breadth of things that are helpful is greater than the breadth of things that will ever fall within the umbrella of clinical mental health; so you should probably hold off on judging things based on whether or not the industry has adopted them.