I have no idea how Delano would feel about your review; that would be fascinating to hear if you ever communicate with her about it. But to me this was the best kind of review one could expect from someone on the other side of the aisle: thoughtful, charitable but also acknowledging your own standpoint and professional observations where that doesn't entirely jibe with hers.
I find antipsychiatry or anti-medication perspectives so much more compelling when it comes through a memoir: you can look at the person's unique experience and testimony, all the rich details, and decide for yourself what to conclude, how much to generalize. *This* person was screwed over in these ways, by *these* psychiatrists (and psychiatry), during *this* era. And has this wisdom to offer us about it. What can we learn, and still leave as open questions? It's almost like the cautionary-tale version of Gordon Paul's famous dictum: what treatment by whom was most harmful for this individual with that specific problem, etc. etc.
This is very helpful, hope it is okay with you if I borrow it: “The diagnoses refer to patterns of distressing and disabling experiences and behaviors that are outside our folk psychological norms, and they do not refer to specific disease processes in the brain. Mental health problems exist at an intersection of temperament, physiology, development, and interpersonal challenges and cannot be understood in isolation. Descriptive diagnoses are fuzzy and fluid, especially early in life. They can change over time, and professionals often disagree. Diagnostic categories do not capture your essence or your identity. What you are experiencing is maladaptive, but it does not lack meaning. Engage with your psychological pain, understand what it is trying to tell you, and seek a meaningful life. Medications are imperfect tools that can assist you in the process. They have the ability to both help and harm, and we will work closely to address any problems you experience with them. If the balance ever shifts such that the medications are hurting more than they are helping, you have other resources at your disposal. The treatment of mental illness does not substitute for family, work, education, and community as sources of meaning and fulfillment.”
I appreciate this review. Will I read the book? Maybe, at some point, probably not. Why? I'm familiar with Laura Delano's stance and the movements and people within those movements that she aligns with. They don't welcome healthy exploration of mental health issues, but will heavily back any kind of denigration around psychiatric care. Another reason I won't is that I've been through my own years of crappy treatment and I don't want to relive that through someone's book. Not only is that painful, but I'd be wondering how much she slants a view, skews the retelling, exaggerates because she's relying on memories that she's only channeling in one direction. When I was left raw and abandoned after lengthy medicating, cascades, no taper discontinuation, all of that, I emerged into a clearing that I mistook for the whole jungle having disappeared. The anti-psychiatry people I'd been buddying around with online kept saying I should write a book. I strongly considered, I was so mad. I wanted to inform the world that psych treatment was only about lies and harm. I wrote blog posts instead. I'm glad because that whole process has lent itself better to my ever-changing views. I went into a psych unit in 2021 and tried to reeducate and liberate my fellow patients. They didn't want to hear it. They just wanted to feel better and to function well enough to go home.
Very much in sympathy with your opinion here. Especially with your caveat about the likely inherent bias of the memories and impressions in such a memoir, one with a clear axe to grind.
Wonderful review of the book. It manages to honor Delanos' perspective while retaining hope that there is way to practice psychiatry that does not lead patients astray, as Delano was led astray. I too would like to borrow (like A. Chak) some excerpts, namely the imagined conversation with a patient (" You can recover, you can be well...) I'll use it as a guide for psychiatry residents. Thanks!
This is such a thoughtful and balanced review, which somehow manages to encompass so many of the complexities and paradoxes of psychiatry care.
While I have my own positive bias towards psychiatry, in part thanks to having received excellent treatment (initially by a psychiatrist at McLean) for depressive psychosis as a teen, I am eager to read Delano’s account of her experiences and how they shaped her own perspective.
This review has firmly placed the question of agency in my thoughts, and when I read Delano’s book I will have this very much in my mind as I read it. From the excerpts provided, it looks like a very well written and intelligent book, that clearly has a message we should consider, even if our experiences and views do not fully align with those of the author.
I very much appreciate Dr. Hickox's comment on how the experiences of patients will differ, with respect to the quality of psychiatric care they have received. The excellent initial treatment Dr. Hickox received at McLean is a case in point. Of course, psychiatry as a profession must never be complacent about the care we provide, and must strive vigorously to improve it at all levels, both inpatient and outpatient. Ms. Delano's book will doubtless be a powerful reminder of that responsibility.
Just throwing it out there but it strikes me that Laura's symptoms were maybe on the generally mild side of the spectrum if she came off medication with only the odd moods and impulses. I am bipolar and if I come off my medication 1) I go up like a rocket 2) I am in a total other dimension. I find a lot of these drugs withdrawal gurus are dysthimic or cyclomythic rather than full throttle mental. Thats why they are able to function in lucrative roles such as activists, academics, artists, podcasters and the like while holding down a bipolar diagnosis.
In addition, we must take into account how much people can change over time (sometimes because of changing life circumstances, sometimes for whatever reason).
A lot of people who have only met me the way I am now, would probably say the same thing about me - of course I can do without meds, since I'm hardly a serious case to begin with.
But if I could go back in time and take the meds away from my earlier self at certain periods, I would have been soooooo fucked! Would have slid off into the horrible demon world and just been ... scared shitless 24/7 and living in a completely different reality from other people.
The idea that either you qualify for a certain diagnosis or you don't, it's for life or it was never there to begin with, is so damaging for so many reasons.
And as the review suggests, possibly not bipolar disorder at all, but a pattern closer to the “borderline personality” spectrum, where medications may or may not be helpful.
I just finished reading Unshrunk, despite my earlier comment that I probably wouldn't. I also find the strength of the book to be Laura telling her story and not the drug info bits and psych history bits. I kind of skimmed through those. I wonder how many other readers will. I'm a psych patient who started out as a teenager. I've had somewhere around 60 psych unit stays, dealt with anorexia, OCD, self-harm. I'd take breaks from psych treatment then go back. 6 years ago I thought I was done after a psychiatrist stopped mulitple meds at once without taper. I spent time with the hate psychiatry, never go back, meds will sicken you if they don't kill you crowd. I say all that to qualify both my interest and competence in reviewing Unshrunk just a bit here myself. Laura expounds on what if I'd been told this or not had this done in treatment, would I have thrived instead? Speaking for myself, I have those thoughts and my answer is no, maybe I could've done better, but as a teenager, private, feeling weird, lacking clear goals, seeing college and expectations on the horizon, no I couldn't have been reached in that way. And the withdrawal I experienced being yanked off meds was horrid, but after a year I was like, oh, c'mon, it's not withdrawal now. What was it? I left myself open. And I intend to stay open around treatment, which I'm back with now. I had years and years of questionable treatment and adverse effects and crap therapy. Happy to see that we as a society, and with progressive psychiatrists having entered the field, are seeing less of that. And, sorry Laura, but you are anti-psychiatry. At least now. There's also this pattern I see reading the book of her latching on with great excitement to this or that, and that includes her awakening when she read Whitaker's Anatomy of an Epidemic, and I wonder if one day she'll wake up not so charmed by what she sees as the be-all-end-all right now. Toward the end of the book it was like I was reading every anti-psych tweet I had in my angry days and found myself skimming through that old news too. I was left still appreciating Laura telling her story and feeling kinship around parts so similar to my own. But I hope she's not viewing her book as some way to revolutionize like she did as a peer support specialist or as an advert for services to get off meds such as she currently provides.
Just a quick head's up if you wish to comment at NYT. Delano was interviewed for a long piece entitled "The Ex-Patients' Club." Comments there are very revealing of a range of responses that are worth reading and noting. https://www.nytimes.com/2025/03/17/health/laura-delano-psychiatric-meds.html#commentsContainer My comment here is posted at Psychiatry at the Margins, "Memoir for the Iatrogenic Age."
Honestly, there is no way to criticize your analysis or its presentation. Absolutely, so well done. However, I am wondering whether or not, with some of your wording, you are attempting to convey a need or support for keeping in mind what could be iatrogenic outcomes.
Obviously, you have written a review and a certain critique of some of the thinking manifested in Delano's book. I am wondering if you might know if there are any recent articles that attempt to do a comprehensive list of what appear to be iatrogenic outcomes and whether there is an organized effort to gather that information from clinicians. A kind of survey of deemed "likely iatrogenic concerns and reports."
If so, I have two concerns that might be appropriate for such a list, or, for your list if no other list exists. One is related to treatment resistant depression (TRD) (for which there is some good literature). The other is related to suicide attempts and successes in undiagnosed ADHD treated for depression or anxiety with SSRIs during the first several weeks of treatment. It seems to me that would not be a difficult forensic and medical records investigation.
By not properly screening for the ADHD that may be present, the SSRI will make ADHD worse (decreases working memory which increases impatience, impulsiveness, hopelessness, confusion, sleep disorder, suicidal inclinations, more forgetful, less hopeful, etc).
My hypothesis about TRD is that it is often iatrogenically produced by a series of increasing dosages of SSRI which, in the ADHD population adversely affects baseline dopamine presence and functions in the CNS (decreasing working memory significantly), which then produces the findings of worse outcomes.
Not enough research has been done to document how much SSRIs impact working memory (dopamine dependent). I have been talking and writing about this since 2011. I tried to bring more attention to it in 2019 at the APA. Not much luck. There is some good literature looking at both issues: how SSRIs decrease working memory in those who fit the criteria for ADHD, but not in those who are nonADHD. Recent articles have noted undiagnosed ADHD in 35% of adults with TRD. My colleagues don’t seem to get it.
In my own practice, where I spent hundreds of hours working with adult clients who were trying to figure out if they fit the criteria for what we call ADHD, I noted: (1) a high percentage of those who clearly fit the criteria for ADHD who had a long history of such characteristics, but no appropriate evaluation, had been treated for their anxiety or depression with SSRIs; and (2) had been exposed to higher and higher doses, and then, often, "augmented" by antipsychotics.
And, so, that end-stage TRD produced by SSRI mistreatment is then generally “treated” with ECT, TMS or ketamine (all dopamine enhancers). The client finally gets the right treatment, the wrong way.
I would recommend adequate screening before using SSRIs. It seems that the guidance has been treating the depression or anxiety first, and then treat the ADHD. My experience and the literature support "treat the ADHD first and if the depression or anxiety disappears, there is no significant need to add in SSRIs or antipsychotics.
I hope that makes sense. Again, thank your excellent writing and analyses. I had a chance to scan a few of your other posts. I noted that you interviewed Dr. Phelps recently. It is interesting that both he and I got into web presentations in 2000. Him, in Corvallis, Oregon, at the time, and I in Seattle at the time. I relied quite a bit on his posted information for a Power Point presentation I did in 2006 on "How Stress Produces Major Depressive Disorder" (it is still in my archives on the web). http://www.dearshrink.com/howstressproducesdepression.pdf
He had a great way of informing folks about the serotonin transporter gene using terms like sunny, pink, and blue people. I tried to contact him and meet up back in the mid-aughts, but, somehow, it never happened. It is so cool to see that he is still standing and working for the good.
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Sternat T, Fotinos K, Fine A, Epstein I, Katzman MA. Low hedonic tone and attention-deficit hyperactivity disorder: risk factors for treatment resistance in depressed adults. Neuropsychiatr Dis Treat. 2018 Sep 17;14:2379-2387. doi: 10.2147/NDT.S170645. PMID: 30271154; PMCID: PMC6149933.
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Chantiluke K, Barrett N, Giampietro V, Brammer M, Simmons A, Murphy DG, Rubia K. Inverse Effect of Fluoxetine on Medial Prefrontal Cortex Activation During Reward Reversal in ADHD and Autism. Cereb Cortex. 2015 Jul;25(7):1757-70. doi: 10.1093/cercor/bht365. Epub 2014 Jan 22. PMID: 24451919; PMCID: PMC4459282.
Dr Sterling, thank you for your kind words and for this fascinating perspective! I have some experience with clinical cases where appropriate treatment of ADHD had a transformative effect on mood and anxiety disorders. I haven’t had much experience with SSRIs worsening ADHD but perhaps I haven’t been paying proper attention to this.
Do you know if any clinical trials have examined the issue of treating ADHD first vs treating depression first in cases of ADHD-depression comorbidity? I suspect not, but a clinical trial like that would be quite useful in providing the necessary guidance.
Unfortunately, I have found none. Two studies are on my wish list, but the momentum against them is huge. One would be exactly as you noted, screening adequately and diagnosing properly, a group of undiagnosed, unevaluated folks who fit the criteria for anxiety or depression disorders who have not been recently prescribed an SSRI. The other is a study related to the incidence of increased suicidal ideation, thinking or behaviors, including successful suicide, in those who were essentially naive to SSRIs, and who in retrospect or otherwise currently fit the criteria for ADHD but were not evaluated, diagnosed or treated for ADHD in their history.
The only studies I am aware of that have helped in understanding the trajectory of close to 40% of TRD patients who had not been diagnosed or treated for ADHD. Are cited in the earlier post. Similarly, the only studies I am aware of that have looked at the downside of SSRIs for dopamine working memory operations, are in that earlier post.
It is not popular, as they say, or allowed to be credible, to discover and make findings that are supportive of the correct medication treatment with dopamine enhancers for anyone. That is a longer article about how scientists let language get in the way and allow for misunderstandings. "Stimulant" is so unscientific it hurts. And, it is great advertising for diversion, since it implies something positive when, in fact, above optimal dopamine enhancement has no significant upside for functionality, but the side effect of “amped-up” is sought.
It is not the goal of dopamine enhancers to get amped up. It is a misused side effect. Continuing to call this class of medications “stimulants” is tantamount to calling ibuprofen “a kidney damage pill.” I say this, because in the last 20 years, the stigma attached to the diagnosis has almost gone away, but the stigma attached to the correct treatment has only gotten much worse as we descend into “anti-medication” dark ages.
However, I had the benefit of being allowed for more than 10 years to be able to spend up to 4 hours with evalutions that required the referral to bring a significant person in their life with them who would participate in the reporting since, as I am sure you know, we all put our best faces forward. With ADHDers it is even more complicated due to distractibility, impatience, poor working memory, and generally quite inaccurate and spotty historical memories.
I developed my own questionnaires, protocols and dove deep into the literature. So, I have a data set, both recorded and experienced that comes from over 300 such evaluations in a 10 year period as I developed a more accurate picture from these investigations and trials. It is overwhelmingly clear the ADHDer population has been radically deprived of adequate evaluations and follow-up. Screening has descended into primary caregivers asking one question "How did you do in high school?" Or they use superficial questionnaires. Or... the list of poor assessments goes on and on.
This, as you may know, is the result of downgraded and absent medical school and training (internships, residencies) about ADHD. The traditional biases are so programmed that docs learn to find ways around even trying to evaluate, much less treat properly with, again, a pejorative, inaccurate "stimulant." The language needs to change before docs will ever get scientific about ADHD and its treatment, rather than engage in emotional responses based on, essentially, propaganda.
Several studies are available noting the huge ignorance factor in primary care docs and psychiatrists to the extent of only 30% or so providing passable Dx/Rx care based on international guidelines.
Sorry for the mini-diatribe. But, no, I wish I had come into my academic phase earlier in my life, so possibly I could have done some of this work in academia. All the momentum of training, insurance payment processing, formulary protocols, war against drugs, misinformation from leading media, like NYT, and the bias of a bootstrap cultural programming goes against what is correct for the diagnosis and treatment.
So, my data clearly shows that those who I discovered to have had a history of TRD and treatment that went as far as ECT (I retired in 2021, so not much exposure to TMS or ketamine for TRD) clearly fit the criteria for ADHD, but had never been evaluated, or even apprised of the possibility.
One of the other things about evaluations is there has to be some attempt at assessing working memory as part of understanding baseline and treatment effects. I developed a protocol for that based on a uniform, consistent, audible prompts with recorded responses using reverse digit span testing. The literature fully supports that it is the most cost-effective accurate way of establishing working memory markers for initial baseline and ongoing assessment of results. My experience and long-term studies of the best ways to assess and treat adult ADHD clearly showed TRD and other "sickening" effects of mis-diagnosis and mistreatment of ADHD with SSRIs happens all of the time.
The other study on my wishlist, which should be easy enough to do, is figuring out what the prevalence is of suicidal ideation, behaviors, and successes in the first two months of treatment of depression or anxiety with SSRIs. I cannot say enough about this mistaken understanding that eventually showed up on black box warnings that is so general as to be hurtful. In my practice, the data was clear and got more accurate as to the cause of such downsides to SSRIs was not universal, but was overwhelmingly found in my patients to be related to undiagnosed ADHD treated with SSRIs. You can even find a number of newspaper articles documenting, at least for me, sudden suicides mostly in men, and "out of the blue" where they had been treated with SSRIs for their symptoms, which also happened to be accompanied by clear ADHD characteristics as reported in the news coverage. How obvious can it be? No one wants to know, apparently, since it is not a medication problem, but a doctor problem.
It is a perfect storm set up for an undiagnosed ADHDer showing up in an emergency room or other emergent care, being diagnosed and given SSRIs. The documentation of how SSRIs have this adverse effect on ADHDers, by reducing dopamine functionality and presence which then reduces working memory, is ignored. You reduce an already impaired working memory and what do you get? More risk tolerant, less fearful, less thoughtful, fuzzed up, more forgetful, more impulsive, impatient, overwhelmed easily, and feel worse, not better, and thus, lose hope. A perfect storm for suicide. So, what do we do for suicide prevention? You know that answer. Give advice, do good followup checks, and SSRIs. It is so disappointing.
Next? Oh. There are a couple of great studies showing how the prevalence of undiagnosed and untreated ADHD among diagnosed anxiety disorders (including panic disorders and PTSD in a couple of studies) is around 38% (interestingly, close to the same percentage of undiagnosed ADHD found in the TRD study).
There is more. I developed a new system for accurate, relevant categorizations of ADHD diagnoses for clinical use. Sensory sensitivities need to be evaluated. Too long to address here. I can send you copies of my protocols, summaries of my finding on sensory sensitivity and poor working memory combinations, and medication strategies and tracking sheets I developed.
I really would recommend that you download my free pdf of my 2013 book to get most of the full story. It is still ahead of its time. And, I would love to continue this discussion and, truthfully, one of my most important bucket-list items is to find a younger professional to continue looking at what I have discovered, because, I have not found one yet, and I am hampered by coming to this academic endeavor at the age of 65 to 79 so far. First book I ever published was 2011 at age 65. It is next to impossible to have credibility at that age. I was forced to self publish since the APA and Columbia press, and a UK publisher associated with London Metro Univ, who all found some excuse not to publish (usually, "we already have something in the pipeline"). I showed up at the 2019 APA with a carry-on full of copies of my paperback that I gave out. So, there you go.
One last thought for now. I also have an incredibly reliable and almost miraculous new use for clonidine and quanfacine in the realm of sensory sensitivities after a huge deep dive into what I now call "sensory amplification syndrome." In the lit, often called sensory over-responsivity (SOR). There are some good reports on SOR assessments in ADHD evaluations and suggestions about including SOR data in the diagnosis as a potential relevant clinical data point.
Okay, enough... Yah, I don't get out much.
Thank you again for your excellent work and best wishes. Hope we can continue to discuss. Take care, Ron
I have no idea how Delano would feel about your review; that would be fascinating to hear if you ever communicate with her about it. But to me this was the best kind of review one could expect from someone on the other side of the aisle: thoughtful, charitable but also acknowledging your own standpoint and professional observations where that doesn't entirely jibe with hers.
I find antipsychiatry or anti-medication perspectives so much more compelling when it comes through a memoir: you can look at the person's unique experience and testimony, all the rich details, and decide for yourself what to conclude, how much to generalize. *This* person was screwed over in these ways, by *these* psychiatrists (and psychiatry), during *this* era. And has this wisdom to offer us about it. What can we learn, and still leave as open questions? It's almost like the cautionary-tale version of Gordon Paul's famous dictum: what treatment by whom was most harmful for this individual with that specific problem, etc. etc.
I really appreciate the way you communicate the complexities and heterogeneities of mental health care while maintaining compassion and hope.
Thank you Emily!
This is very helpful, hope it is okay with you if I borrow it: “The diagnoses refer to patterns of distressing and disabling experiences and behaviors that are outside our folk psychological norms, and they do not refer to specific disease processes in the brain. Mental health problems exist at an intersection of temperament, physiology, development, and interpersonal challenges and cannot be understood in isolation. Descriptive diagnoses are fuzzy and fluid, especially early in life. They can change over time, and professionals often disagree. Diagnostic categories do not capture your essence or your identity. What you are experiencing is maladaptive, but it does not lack meaning. Engage with your psychological pain, understand what it is trying to tell you, and seek a meaningful life. Medications are imperfect tools that can assist you in the process. They have the ability to both help and harm, and we will work closely to address any problems you experience with them. If the balance ever shifts such that the medications are hurting more than they are helping, you have other resources at your disposal. The treatment of mental illness does not substitute for family, work, education, and community as sources of meaning and fulfillment.”
By all means 😊
I appreciate this review. Will I read the book? Maybe, at some point, probably not. Why? I'm familiar with Laura Delano's stance and the movements and people within those movements that she aligns with. They don't welcome healthy exploration of mental health issues, but will heavily back any kind of denigration around psychiatric care. Another reason I won't is that I've been through my own years of crappy treatment and I don't want to relive that through someone's book. Not only is that painful, but I'd be wondering how much she slants a view, skews the retelling, exaggerates because she's relying on memories that she's only channeling in one direction. When I was left raw and abandoned after lengthy medicating, cascades, no taper discontinuation, all of that, I emerged into a clearing that I mistook for the whole jungle having disappeared. The anti-psychiatry people I'd been buddying around with online kept saying I should write a book. I strongly considered, I was so mad. I wanted to inform the world that psych treatment was only about lies and harm. I wrote blog posts instead. I'm glad because that whole process has lent itself better to my ever-changing views. I went into a psych unit in 2021 and tried to reeducate and liberate my fellow patients. They didn't want to hear it. They just wanted to feel better and to function well enough to go home.
Very much in sympathy with your opinion here. Especially with your caveat about the likely inherent bias of the memories and impressions in such a memoir, one with a clear axe to grind.
Wonderful review of the book. It manages to honor Delanos' perspective while retaining hope that there is way to practice psychiatry that does not lead patients astray, as Delano was led astray. I too would like to borrow (like A. Chak) some excerpts, namely the imagined conversation with a patient (" You can recover, you can be well...) I'll use it as a guide for psychiatry residents. Thanks!
This is such a thoughtful and balanced review, which somehow manages to encompass so many of the complexities and paradoxes of psychiatry care.
While I have my own positive bias towards psychiatry, in part thanks to having received excellent treatment (initially by a psychiatrist at McLean) for depressive psychosis as a teen, I am eager to read Delano’s account of her experiences and how they shaped her own perspective.
This review has firmly placed the question of agency in my thoughts, and when I read Delano’s book I will have this very much in my mind as I read it. From the excerpts provided, it looks like a very well written and intelligent book, that clearly has a message we should consider, even if our experiences and views do not fully align with those of the author.
I very much appreciate Dr. Hickox's comment on how the experiences of patients will differ, with respect to the quality of psychiatric care they have received. The excellent initial treatment Dr. Hickox received at McLean is a case in point. Of course, psychiatry as a profession must never be complacent about the care we provide, and must strive vigorously to improve it at all levels, both inpatient and outpatient. Ms. Delano's book will doubtless be a powerful reminder of that responsibility.
Ronald W. Pies, MD
Just throwing it out there but it strikes me that Laura's symptoms were maybe on the generally mild side of the spectrum if she came off medication with only the odd moods and impulses. I am bipolar and if I come off my medication 1) I go up like a rocket 2) I am in a total other dimension. I find a lot of these drugs withdrawal gurus are dysthimic or cyclomythic rather than full throttle mental. Thats why they are able to function in lucrative roles such as activists, academics, artists, podcasters and the like while holding down a bipolar diagnosis.
In addition, we must take into account how much people can change over time (sometimes because of changing life circumstances, sometimes for whatever reason).
A lot of people who have only met me the way I am now, would probably say the same thing about me - of course I can do without meds, since I'm hardly a serious case to begin with.
But if I could go back in time and take the meds away from my earlier self at certain periods, I would have been soooooo fucked! Would have slid off into the horrible demon world and just been ... scared shitless 24/7 and living in a completely different reality from other people.
The idea that either you qualify for a certain diagnosis or you don't, it's for life or it was never there to begin with, is so damaging for so many reasons.
Well said Sofia! I agree
And as the review suggests, possibly not bipolar disorder at all, but a pattern closer to the “borderline personality” spectrum, where medications may or may not be helpful.
I just finished reading Unshrunk, despite my earlier comment that I probably wouldn't. I also find the strength of the book to be Laura telling her story and not the drug info bits and psych history bits. I kind of skimmed through those. I wonder how many other readers will. I'm a psych patient who started out as a teenager. I've had somewhere around 60 psych unit stays, dealt with anorexia, OCD, self-harm. I'd take breaks from psych treatment then go back. 6 years ago I thought I was done after a psychiatrist stopped mulitple meds at once without taper. I spent time with the hate psychiatry, never go back, meds will sicken you if they don't kill you crowd. I say all that to qualify both my interest and competence in reviewing Unshrunk just a bit here myself. Laura expounds on what if I'd been told this or not had this done in treatment, would I have thrived instead? Speaking for myself, I have those thoughts and my answer is no, maybe I could've done better, but as a teenager, private, feeling weird, lacking clear goals, seeing college and expectations on the horizon, no I couldn't have been reached in that way. And the withdrawal I experienced being yanked off meds was horrid, but after a year I was like, oh, c'mon, it's not withdrawal now. What was it? I left myself open. And I intend to stay open around treatment, which I'm back with now. I had years and years of questionable treatment and adverse effects and crap therapy. Happy to see that we as a society, and with progressive psychiatrists having entered the field, are seeing less of that. And, sorry Laura, but you are anti-psychiatry. At least now. There's also this pattern I see reading the book of her latching on with great excitement to this or that, and that includes her awakening when she read Whitaker's Anatomy of an Epidemic, and I wonder if one day she'll wake up not so charmed by what she sees as the be-all-end-all right now. Toward the end of the book it was like I was reading every anti-psych tweet I had in my angry days and found myself skimming through that old news too. I was left still appreciating Laura telling her story and feeling kinship around parts so similar to my own. But I hope she's not viewing her book as some way to revolutionize like she did as a peer support specialist or as an advert for services to get off meds such as she currently provides.
Wise words, Lisa
Just a quick head's up if you wish to comment at NYT. Delano was interviewed for a long piece entitled "The Ex-Patients' Club." Comments there are very revealing of a range of responses that are worth reading and noting. https://www.nytimes.com/2025/03/17/health/laura-delano-psychiatric-meds.html#commentsContainer My comment here is posted at Psychiatry at the Margins, "Memoir for the Iatrogenic Age."
Dear Dr. Aftab:
Honestly, there is no way to criticize your analysis or its presentation. Absolutely, so well done. However, I am wondering whether or not, with some of your wording, you are attempting to convey a need or support for keeping in mind what could be iatrogenic outcomes.
Obviously, you have written a review and a certain critique of some of the thinking manifested in Delano's book. I am wondering if you might know if there are any recent articles that attempt to do a comprehensive list of what appear to be iatrogenic outcomes and whether there is an organized effort to gather that information from clinicians. A kind of survey of deemed "likely iatrogenic concerns and reports."
If so, I have two concerns that might be appropriate for such a list, or, for your list if no other list exists. One is related to treatment resistant depression (TRD) (for which there is some good literature). The other is related to suicide attempts and successes in undiagnosed ADHD treated for depression or anxiety with SSRIs during the first several weeks of treatment. It seems to me that would not be a difficult forensic and medical records investigation.
By not properly screening for the ADHD that may be present, the SSRI will make ADHD worse (decreases working memory which increases impatience, impulsiveness, hopelessness, confusion, sleep disorder, suicidal inclinations, more forgetful, less hopeful, etc).
My hypothesis about TRD is that it is often iatrogenically produced by a series of increasing dosages of SSRI which, in the ADHD population adversely affects baseline dopamine presence and functions in the CNS (decreasing working memory significantly), which then produces the findings of worse outcomes.
Not enough research has been done to document how much SSRIs impact working memory (dopamine dependent). I have been talking and writing about this since 2011. I tried to bring more attention to it in 2019 at the APA. Not much luck. There is some good literature looking at both issues: how SSRIs decrease working memory in those who fit the criteria for ADHD, but not in those who are nonADHD. Recent articles have noted undiagnosed ADHD in 35% of adults with TRD. My colleagues don’t seem to get it.
In my own practice, where I spent hundreds of hours working with adult clients who were trying to figure out if they fit the criteria for what we call ADHD, I noted: (1) a high percentage of those who clearly fit the criteria for ADHD who had a long history of such characteristics, but no appropriate evaluation, had been treated for their anxiety or depression with SSRIs; and (2) had been exposed to higher and higher doses, and then, often, "augmented" by antipsychotics.
And, so, that end-stage TRD produced by SSRI mistreatment is then generally “treated” with ECT, TMS or ketamine (all dopamine enhancers). The client finally gets the right treatment, the wrong way.
I would recommend adequate screening before using SSRIs. It seems that the guidance has been treating the depression or anxiety first, and then treat the ADHD. My experience and the literature support "treat the ADHD first and if the depression or anxiety disappears, there is no significant need to add in SSRIs or antipsychotics.
I hope that makes sense. Again, thank your excellent writing and analyses. I had a chance to scan a few of your other posts. I noted that you interviewed Dr. Phelps recently. It is interesting that both he and I got into web presentations in 2000. Him, in Corvallis, Oregon, at the time, and I in Seattle at the time. I relied quite a bit on his posted information for a Power Point presentation I did in 2006 on "How Stress Produces Major Depressive Disorder" (it is still in my archives on the web). http://www.dearshrink.com/howstressproducesdepression.pdf
He had a great way of informing folks about the serotonin transporter gene using terms like sunny, pink, and blue people. I tried to contact him and meet up back in the mid-aughts, but, somehow, it never happened. It is so cool to see that he is still standing and working for the good.
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Dr Sterling, thank you for your kind words and for this fascinating perspective! I have some experience with clinical cases where appropriate treatment of ADHD had a transformative effect on mood and anxiety disorders. I haven’t had much experience with SSRIs worsening ADHD but perhaps I haven’t been paying proper attention to this.
Do you know if any clinical trials have examined the issue of treating ADHD first vs treating depression first in cases of ADHD-depression comorbidity? I suspect not, but a clinical trial like that would be quite useful in providing the necessary guidance.
Unfortunately, I have found none. Two studies are on my wish list, but the momentum against them is huge. One would be exactly as you noted, screening adequately and diagnosing properly, a group of undiagnosed, unevaluated folks who fit the criteria for anxiety or depression disorders who have not been recently prescribed an SSRI. The other is a study related to the incidence of increased suicidal ideation, thinking or behaviors, including successful suicide, in those who were essentially naive to SSRIs, and who in retrospect or otherwise currently fit the criteria for ADHD but were not evaluated, diagnosed or treated for ADHD in their history.
The only studies I am aware of that have helped in understanding the trajectory of close to 40% of TRD patients who had not been diagnosed or treated for ADHD. Are cited in the earlier post. Similarly, the only studies I am aware of that have looked at the downside of SSRIs for dopamine working memory operations, are in that earlier post.
It is not popular, as they say, or allowed to be credible, to discover and make findings that are supportive of the correct medication treatment with dopamine enhancers for anyone. That is a longer article about how scientists let language get in the way and allow for misunderstandings. "Stimulant" is so unscientific it hurts. And, it is great advertising for diversion, since it implies something positive when, in fact, above optimal dopamine enhancement has no significant upside for functionality, but the side effect of “amped-up” is sought.
It is not the goal of dopamine enhancers to get amped up. It is a misused side effect. Continuing to call this class of medications “stimulants” is tantamount to calling ibuprofen “a kidney damage pill.” I say this, because in the last 20 years, the stigma attached to the diagnosis has almost gone away, but the stigma attached to the correct treatment has only gotten much worse as we descend into “anti-medication” dark ages.
However, I had the benefit of being allowed for more than 10 years to be able to spend up to 4 hours with evalutions that required the referral to bring a significant person in their life with them who would participate in the reporting since, as I am sure you know, we all put our best faces forward. With ADHDers it is even more complicated due to distractibility, impatience, poor working memory, and generally quite inaccurate and spotty historical memories.
I developed my own questionnaires, protocols and dove deep into the literature. So, I have a data set, both recorded and experienced that comes from over 300 such evaluations in a 10 year period as I developed a more accurate picture from these investigations and trials. It is overwhelmingly clear the ADHDer population has been radically deprived of adequate evaluations and follow-up. Screening has descended into primary caregivers asking one question "How did you do in high school?" Or they use superficial questionnaires. Or... the list of poor assessments goes on and on.
This, as you may know, is the result of downgraded and absent medical school and training (internships, residencies) about ADHD. The traditional biases are so programmed that docs learn to find ways around even trying to evaluate, much less treat properly with, again, a pejorative, inaccurate "stimulant." The language needs to change before docs will ever get scientific about ADHD and its treatment, rather than engage in emotional responses based on, essentially, propaganda.
Several studies are available noting the huge ignorance factor in primary care docs and psychiatrists to the extent of only 30% or so providing passable Dx/Rx care based on international guidelines.
Sorry for the mini-diatribe. But, no, I wish I had come into my academic phase earlier in my life, so possibly I could have done some of this work in academia. All the momentum of training, insurance payment processing, formulary protocols, war against drugs, misinformation from leading media, like NYT, and the bias of a bootstrap cultural programming goes against what is correct for the diagnosis and treatment.
So, my data clearly shows that those who I discovered to have had a history of TRD and treatment that went as far as ECT (I retired in 2021, so not much exposure to TMS or ketamine for TRD) clearly fit the criteria for ADHD, but had never been evaluated, or even apprised of the possibility.
One of the other things about evaluations is there has to be some attempt at assessing working memory as part of understanding baseline and treatment effects. I developed a protocol for that based on a uniform, consistent, audible prompts with recorded responses using reverse digit span testing. The literature fully supports that it is the most cost-effective accurate way of establishing working memory markers for initial baseline and ongoing assessment of results. My experience and long-term studies of the best ways to assess and treat adult ADHD clearly showed TRD and other "sickening" effects of mis-diagnosis and mistreatment of ADHD with SSRIs happens all of the time.
The other study on my wishlist, which should be easy enough to do, is figuring out what the prevalence is of suicidal ideation, behaviors, and successes in the first two months of treatment of depression or anxiety with SSRIs. I cannot say enough about this mistaken understanding that eventually showed up on black box warnings that is so general as to be hurtful. In my practice, the data was clear and got more accurate as to the cause of such downsides to SSRIs was not universal, but was overwhelmingly found in my patients to be related to undiagnosed ADHD treated with SSRIs. You can even find a number of newspaper articles documenting, at least for me, sudden suicides mostly in men, and "out of the blue" where they had been treated with SSRIs for their symptoms, which also happened to be accompanied by clear ADHD characteristics as reported in the news coverage. How obvious can it be? No one wants to know, apparently, since it is not a medication problem, but a doctor problem.
It is a perfect storm set up for an undiagnosed ADHDer showing up in an emergency room or other emergent care, being diagnosed and given SSRIs. The documentation of how SSRIs have this adverse effect on ADHDers, by reducing dopamine functionality and presence which then reduces working memory, is ignored. You reduce an already impaired working memory and what do you get? More risk tolerant, less fearful, less thoughtful, fuzzed up, more forgetful, more impulsive, impatient, overwhelmed easily, and feel worse, not better, and thus, lose hope. A perfect storm for suicide. So, what do we do for suicide prevention? You know that answer. Give advice, do good followup checks, and SSRIs. It is so disappointing.
Next? Oh. There are a couple of great studies showing how the prevalence of undiagnosed and untreated ADHD among diagnosed anxiety disorders (including panic disorders and PTSD in a couple of studies) is around 38% (interestingly, close to the same percentage of undiagnosed ADHD found in the TRD study).
There is more. I developed a new system for accurate, relevant categorizations of ADHD diagnoses for clinical use. Sensory sensitivities need to be evaluated. Too long to address here. I can send you copies of my protocols, summaries of my finding on sensory sensitivity and poor working memory combinations, and medication strategies and tracking sheets I developed.
I really would recommend that you download my free pdf of my 2013 book to get most of the full story. It is still ahead of its time. And, I would love to continue this discussion and, truthfully, one of my most important bucket-list items is to find a younger professional to continue looking at what I have discovered, because, I have not found one yet, and I am hampered by coming to this academic endeavor at the age of 65 to 79 so far. First book I ever published was 2011 at age 65. It is next to impossible to have credibility at that age. I was forced to self publish since the APA and Columbia press, and a UK publisher associated with London Metro Univ, who all found some excuse not to publish (usually, "we already have something in the pipeline"). I showed up at the 2019 APA with a carry-on full of copies of my paperback that I gave out. So, there you go.
One last thought for now. I also have an incredibly reliable and almost miraculous new use for clonidine and quanfacine in the realm of sensory sensitivities after a huge deep dive into what I now call "sensory amplification syndrome." In the lit, often called sensory over-responsivity (SOR). There are some good reports on SOR assessments in ADHD evaluations and suggestions about including SOR data in the diagnosis as a potential relevant clinical data point.
Okay, enough... Yah, I don't get out much.
Thank you again for your excellent work and best wishes. Hope we can continue to discuss. Take care, Ron