Thank you for this, as a practicing Child and Adolescent psychiatrist it is a hugely underdiscussed and misunderstood territory and your article is informative and balanced. Three things come to mind, one is the paucity of data on SSRI related sexual side effect in adolescent populations (if we look at the range of sexual side effects in adults including loss of libido, anorgasmia etc it ranges from 58-73%), there is little to no meaningful data on the incidence of these sorts of side effects (which would have enormous implications for normal adolescent psychosexual development) in younger populations. Is this because we are afraid or uncomfortable to ask? I often wonder about this with my patients. Secondly, the discussion of SSRIs and suicidality- it is my understanding that only two drugs have real data to support any influence on incidence of suicide, lithium and clozapine. SSRIs do not and have not shown efficacy around reducing suicidality for either adults or adolescents, though by reducing anxiety load they may downstream reduce discomfort and therefore secondarily suicidality. Thirdly, with all medications there is a tension between the individual and the data. Meaning that while data may indicate a medication has limited efficacy on a study level, that same intervention may be profoundly influential on an individual level. This is what makes evidence based medicine ideology so complex in psychiatry. Personally, I tend to think of SSRIs in adolescents as possibly being able to soften symptom burden, which would allow the teen to engage in more meaningful lifestyle changes, tolerate therapeutic interventions more deeply, and overall be able to engage in non-medication interventions that would actually be making the bulk of the difference.
I’m grateful for your persistence with this issue, because it makes me very tired. These debates keep going around of circles because of the underlying assumption that there is one universal best treatment for depression (SSRIs, therapy, social reform, exercise, resilience) despite the fact that depression is an incredible heterogeneous condition and frequently co-occurs with a highly diverse range a other condition (treating some over with concurrent MDD and GAD is very different to treating MMD+PTSD, and very different again if there is substance use involved, or they are neurodiverse) Even though there is more acceptance and research into personalized medicine, we still get caught up in wanting generalized, universal solutions. Further complicating this (and this is the issue I don’t see discussed as much) is too often treatment decisions aren’t based on ‘best evidence based practice’, but on ‘best available treatment’. These debates keep wanting to frame that question as ‘what is the best treatment for depression’, when the reality for clinicians is ‘what is the best treatment for this person with these difficulties in this context, that is also acceptable AND available to the patient.’ Trying to find treatments that tick all of those boxes feels like an impossible task some days (especially if you want to write a snappy headline’, so I get the appeal of wanting blaming everything on something like screentime!
I think you do a fantastic job of highlighting the complexity and diversity in assessment and treatment - it’s the main reason I subscribe to your Substack.
Thanks so much for this Awais. My personal problems with anxiety were not medicalised until my early 20s when I was only offered benzodiazepines or inpatient group therapy. I declined both and am pleased I did although depression arrived afterwards. My brother however, with severe childhood onset OCD might have beneftited from SSRIs but they were not available then. In clinical work with young adults I always aimed to get a person to CBT first. The Talking Therapies results are disappointing but, from working in those services, reflect real life outcomes not trials. We have so much more to do, but society has a massive role to play in this.
This seems about right. Blind Freddy can see that some people respond poorly to SSRIs. How many? who knows? But it certainly happens.
It's an odd sort of bias to me, the idea that people "need" an antidepressant and if they don't get one they might commit suicide. I get it on some relativistic level, but it's a cock-eyed logic that implies something like an antidepressant diffency. It's not case-wise thinking. If I was going to think in generalisable terms, I would suggest that, generally, all things being equal you should be slow to prescribe unless you can achieve a clear cut clinical improvement. The scale needs to tip quite a bit for age. Teenagers have a lot more to lose and and a far greater capacity for spontaneous recovery. Also if suicide is an actual possibility, then I wouldn't be looking to SSRIs as a solution.
I really like psychopharmacology but I cannot fathom why some people can't see what a drug is doing. Years ago I started lurking around recreational drug chat rooms, not because I'm into it but because I was so starved of consensus opinions on drug effects. The scientific state of psychopharmacology was gaslighting me so hard it was causing existential dread, so went to read experiences just to soothe the cognitive dissonance. What I found was that recreational drug users have no difficulty coming to a group consensus on the general effects of a drug. This is not to say that there is no individual variation or that some subtle effects don't escape their notice. Rather, it simply means that the drugs had noticeable effects that could be recognised without great difficulty. You don't need a telescope to see the end of your nose.
I feel actually think it’s a pretty odd comparison. Recreational and therapeutic drugs are used in really different ways. Of course a group of people taking shrooms or weed are going to have some shared experiences since they’re all doing it in a similar setting and kind of reinforcing what each other feels. That can turn into its own kind of gaslighting too
You quote Strawn repeatedly, including his 2015 meta-analysis. Yet in that paper "Dr. Strawn has received research support from Eli Lilly, Shire, Forest, Lundbeck " Of course he will find in favor of the pills, he needs to satisfy his paymasters at these multi-billion dollar companies. Why do you not factor in these major fCOI when you write about psychiatry? Ploderl is not paid by drug companies, yet Strawn is. Who is more credible to discuss these pills and their efficacy and harm?
My own view is that fCOIs alert us to potential bias but they are poor justifications on their own to dismiss/disbelieve research results or other arguments. If there is something wrong with the data or the argument, we should be able to say what it is, but merely bringing up fCOI is inadequate. fCOIs are very common in the medical research world; anybody who’s a somebody is likely to work with industry in some form. So fCOI can even be seen as an index of a certain sort of expertise. And just because someone lacks fCOI doesn’t mean that they are not subject to stronger ideological biases. As my discussion should make clear, I don’t blindly accept anything anyone is saying.
Thank you for this, as a practicing Child and Adolescent psychiatrist it is a hugely underdiscussed and misunderstood territory and your article is informative and balanced. Three things come to mind, one is the paucity of data on SSRI related sexual side effect in adolescent populations (if we look at the range of sexual side effects in adults including loss of libido, anorgasmia etc it ranges from 58-73%), there is little to no meaningful data on the incidence of these sorts of side effects (which would have enormous implications for normal adolescent psychosexual development) in younger populations. Is this because we are afraid or uncomfortable to ask? I often wonder about this with my patients. Secondly, the discussion of SSRIs and suicidality- it is my understanding that only two drugs have real data to support any influence on incidence of suicide, lithium and clozapine. SSRIs do not and have not shown efficacy around reducing suicidality for either adults or adolescents, though by reducing anxiety load they may downstream reduce discomfort and therefore secondarily suicidality. Thirdly, with all medications there is a tension between the individual and the data. Meaning that while data may indicate a medication has limited efficacy on a study level, that same intervention may be profoundly influential on an individual level. This is what makes evidence based medicine ideology so complex in psychiatry. Personally, I tend to think of SSRIs in adolescents as possibly being able to soften symptom burden, which would allow the teen to engage in more meaningful lifestyle changes, tolerate therapeutic interventions more deeply, and overall be able to engage in non-medication interventions that would actually be making the bulk of the difference.
I’m grateful for your persistence with this issue, because it makes me very tired. These debates keep going around of circles because of the underlying assumption that there is one universal best treatment for depression (SSRIs, therapy, social reform, exercise, resilience) despite the fact that depression is an incredible heterogeneous condition and frequently co-occurs with a highly diverse range a other condition (treating some over with concurrent MDD and GAD is very different to treating MMD+PTSD, and very different again if there is substance use involved, or they are neurodiverse) Even though there is more acceptance and research into personalized medicine, we still get caught up in wanting generalized, universal solutions. Further complicating this (and this is the issue I don’t see discussed as much) is too often treatment decisions aren’t based on ‘best evidence based practice’, but on ‘best available treatment’. These debates keep wanting to frame that question as ‘what is the best treatment for depression’, when the reality for clinicians is ‘what is the best treatment for this person with these difficulties in this context, that is also acceptable AND available to the patient.’ Trying to find treatments that tick all of those boxes feels like an impossible task some days (especially if you want to write a snappy headline’, so I get the appeal of wanting blaming everything on something like screentime!
You are quite right of course. This would be good for me to highlight in future discussions.
I think you do a fantastic job of highlighting the complexity and diversity in assessment and treatment - it’s the main reason I subscribe to your Substack.
Thanks so much for this Awais. My personal problems with anxiety were not medicalised until my early 20s when I was only offered benzodiazepines or inpatient group therapy. I declined both and am pleased I did although depression arrived afterwards. My brother however, with severe childhood onset OCD might have beneftited from SSRIs but they were not available then. In clinical work with young adults I always aimed to get a person to CBT first. The Talking Therapies results are disappointing but, from working in those services, reflect real life outcomes not trials. We have so much more to do, but society has a massive role to play in this.
This seems about right. Blind Freddy can see that some people respond poorly to SSRIs. How many? who knows? But it certainly happens.
It's an odd sort of bias to me, the idea that people "need" an antidepressant and if they don't get one they might commit suicide. I get it on some relativistic level, but it's a cock-eyed logic that implies something like an antidepressant diffency. It's not case-wise thinking. If I was going to think in generalisable terms, I would suggest that, generally, all things being equal you should be slow to prescribe unless you can achieve a clear cut clinical improvement. The scale needs to tip quite a bit for age. Teenagers have a lot more to lose and and a far greater capacity for spontaneous recovery. Also if suicide is an actual possibility, then I wouldn't be looking to SSRIs as a solution.
I really like psychopharmacology but I cannot fathom why some people can't see what a drug is doing. Years ago I started lurking around recreational drug chat rooms, not because I'm into it but because I was so starved of consensus opinions on drug effects. The scientific state of psychopharmacology was gaslighting me so hard it was causing existential dread, so went to read experiences just to soothe the cognitive dissonance. What I found was that recreational drug users have no difficulty coming to a group consensus on the general effects of a drug. This is not to say that there is no individual variation or that some subtle effects don't escape their notice. Rather, it simply means that the drugs had noticeable effects that could be recognised without great difficulty. You don't need a telescope to see the end of your nose.
I feel actually think it’s a pretty odd comparison. Recreational and therapeutic drugs are used in really different ways. Of course a group of people taking shrooms or weed are going to have some shared experiences since they’re all doing it in a similar setting and kind of reinforcing what each other feels. That can turn into its own kind of gaslighting too
You quote Strawn repeatedly, including his 2015 meta-analysis. Yet in that paper "Dr. Strawn has received research support from Eli Lilly, Shire, Forest, Lundbeck " Of course he will find in favor of the pills, he needs to satisfy his paymasters at these multi-billion dollar companies. Why do you not factor in these major fCOI when you write about psychiatry? Ploderl is not paid by drug companies, yet Strawn is. Who is more credible to discuss these pills and their efficacy and harm?
My own view is that fCOIs alert us to potential bias but they are poor justifications on their own to dismiss/disbelieve research results or other arguments. If there is something wrong with the data or the argument, we should be able to say what it is, but merely bringing up fCOI is inadequate. fCOIs are very common in the medical research world; anybody who’s a somebody is likely to work with industry in some form. So fCOI can even be seen as an index of a certain sort of expertise. And just because someone lacks fCOI doesn’t mean that they are not subject to stronger ideological biases. As my discussion should make clear, I don’t blindly accept anything anyone is saying.