This is a beautifully written, brilliantly argued analysis. What stands out is Goulder's open-mindedness, fair-mindedness, and even-handedness in explaining the positions of those holding positions lacking a sound evidentiary (to say nothing of logical) foundation — indeed, in many cases, positions with "supporting" evidence that actually undermines them. This is not to suggest that psychiatry's critics do not have valid critiques. They do. But that psychiatry has harmed some (even many) over the past two centuries does not mean it has helped none. It has certainly helped me and hundreds of thousands of others. Both can be true. Both are true. Sadly, nuance is not a way to build a brand, monetize a movement, or become a talking head. Provocation may sell well; it does not heal.
This is a really useful precis for someone like myself who is under-educated about the background of my practice but feels the consequences of these debates, multiple times per day. One thing that isn't clear to me is how concern over SSRI's morphed into doubts over antidepressants generally, when TCA's were so effective for decades and caused none of these concerns, in fact no one even mentions them. In the above post for example, I don't think I saw "TCA" written even once. It is a strange omission.
I really appreciate this article and the clarity it brings to the public "debate" over antidepressants, but one line feels like it needs a critical response:
"Having worked through a desperate time in mental health, I thought there was all the difference in the world between having a mediocre treatment and no treatment at all."
IMO, it's important to remember that this "all the difference in the world" feeling is for a small minority of patients and, importantly, for the physician. The majority of patients had unsuccessful or frustratingly ambiguous results on the treatment, and if the physician is busy relaxing into the sensation of "at least there's something I can do", they might fail to explain to those patients that their experience is the expected norm and not further evidence that either they are personally unsaveably broken or living under a system that is intentionally gaslighting them that drugs will help when they don't.
And it isn't mysterious what the non-responders need: Most of these teens probably needed, most critically, a resumption of normalcy and an in-person social life, plus guidance once that finally happened to help them catch up on missed developmental milestone and grieve the loss of some of their formative years to COVID lockdown. Those with OCD or other disease-related anxiety probably universally had one or both of attachment disturbance creating an inability to self-soothe or effectively seek and use comfort for the anxieties of the pandemic, or unresolved medical trauma and loss (such as a hospitalization or death in the family, or their own severe illness). There are effective psychotherapy approaches for both these issues, they just take time and often need the external crisis to be resolved first.
The problem with ineffective medication treatment is that the patient is very likely to conclude, given our larger cultural environment, that they are being treated with a chemical because the cause of their disease is chemical, and that if the drug fails, and then 3 more drugs also fail, therapy or life change will surely be even more inadequate to solve the problem. They'll come through the experience of being cycled through med trials for months or years even more depressed as a result, and with the conviction that there really are no treatments at all.
This is a beautifully written, brilliantly argued analysis. What stands out is Goulder's open-mindedness, fair-mindedness, and even-handedness in explaining the positions of those holding positions lacking a sound evidentiary (to say nothing of logical) foundation — indeed, in many cases, positions with "supporting" evidence that actually undermines them. This is not to suggest that psychiatry's critics do not have valid critiques. They do. But that psychiatry has harmed some (even many) over the past two centuries does not mean it has helped none. It has certainly helped me and hundreds of thousands of others. Both can be true. Both are true. Sadly, nuance is not a way to build a brand, monetize a movement, or become a talking head. Provocation may sell well; it does not heal.
This is a really useful precis for someone like myself who is under-educated about the background of my practice but feels the consequences of these debates, multiple times per day. One thing that isn't clear to me is how concern over SSRI's morphed into doubts over antidepressants generally, when TCA's were so effective for decades and caused none of these concerns, in fact no one even mentions them. In the above post for example, I don't think I saw "TCA" written even once. It is a strange omission.
I really appreciate this article and the clarity it brings to the public "debate" over antidepressants, but one line feels like it needs a critical response:
"Having worked through a desperate time in mental health, I thought there was all the difference in the world between having a mediocre treatment and no treatment at all."
IMO, it's important to remember that this "all the difference in the world" feeling is for a small minority of patients and, importantly, for the physician. The majority of patients had unsuccessful or frustratingly ambiguous results on the treatment, and if the physician is busy relaxing into the sensation of "at least there's something I can do", they might fail to explain to those patients that their experience is the expected norm and not further evidence that either they are personally unsaveably broken or living under a system that is intentionally gaslighting them that drugs will help when they don't.
And it isn't mysterious what the non-responders need: Most of these teens probably needed, most critically, a resumption of normalcy and an in-person social life, plus guidance once that finally happened to help them catch up on missed developmental milestone and grieve the loss of some of their formative years to COVID lockdown. Those with OCD or other disease-related anxiety probably universally had one or both of attachment disturbance creating an inability to self-soothe or effectively seek and use comfort for the anxieties of the pandemic, or unresolved medical trauma and loss (such as a hospitalization or death in the family, or their own severe illness). There are effective psychotherapy approaches for both these issues, they just take time and often need the external crisis to be resolved first.
The problem with ineffective medication treatment is that the patient is very likely to conclude, given our larger cultural environment, that they are being treated with a chemical because the cause of their disease is chemical, and that if the drug fails, and then 3 more drugs also fail, therapy or life change will surely be even more inadequate to solve the problem. They'll come through the experience of being cycled through med trials for months or years even more depressed as a result, and with the conviction that there really are no treatments at all.
This article is a helpful and informative article which rings very true in the light of my past clinical experience. Thank you, John.
Dr Peter Kramer wrote about this in his book ‘ Listening to Prozac “Worth reading .