What's the most important (realistic) change you're hoping to see in psychiatry over the next 20 years?
What makes you optimistic that that change is likely to happen, and conversely what do you think are the biggest barriers or risks that make it less likely to happen?
Wider appreciation of the psychological dynamics around psychopharmacology -- e.g. David Mintz's work on Psychodynamic Psychopharmacology
A conceptual move away from assumptions of categorical disease entities in how we talk about psychopathology
A better scientific understanding of the physiological-psychological-experiential-social causal interactions.
Biggest barriers: professional inertia, reductionistic tendencies, and bureaucratic forces in healthcare focused on hyper-efficiency to the detriment of clinical encounter
Hi... I'm wondering about your thoughts on navigating between The Body Keeps the Score and The Body Does Not Keep the Score? Between van der Kolk and Scheeringa. From someone who was profoundly 'traumatised' by their month in a locked ward, leather restraints, forcible treatment etc, but find it deeply insulting to Trauma survivors (WWI trenches, child soldiers, torture survivors) to use the same word for the experiences... The expansion of trauma into distress renders it meaningless.
What are your thoughts on Bipolar 2, the bipolar spectrum, the dissolving of bipolar 2 and everything is just bipolar, Akiskal's 3,4,5... The loss of the classical illness concept of manic depression? Has it diluted bipolar and made it meaningless (or less meaningful as it's become more heterogeneous).
What about reinstating the Kraepelian distinction between neurosis and psychosis... From a med student perspective very little true/traditional mental illness came through the doors of my tertiary ED, it was mostly "life difficulties" of various ilks... and is medicalising life difficulties really in anyone's best interests? I seem to remember you at one point arguing that if a treatment helped then a diagnosis was useful; I'd problematicise that perception; we treat symptoms like fever with paracetamol quite happily without giving a diagnosis of "fever syndrome" - surely we can treat symptoms/life difficulties without the person needing a psychiatric illness to qualify? (Billing purposes aside)
I think there is compelling evidence that bipolarity is a spectrum. However, outside of a clinical history of mania or hypo mania, I don’t find it clinically very useful to call states on the spectrum as “bipolar disorder” and the further away we are from bipolar I and II, the more difficult and fallible the judgment becomes and harder to differentiate from high anxiety, ADHD, borderline PD, etc. It can also give a misleading impression to patients. So I tend to use “Unspecified Mood Disorder” for such cases.
Many claims in The Body Keeps the Score are poorly supported by evidence or erroneous, so Scheeringa is right in that sense, but adversity, neglect, abuse, trauma are powerful forces nonetheless. They are risk factors for a wide range of psychopathological states and interact with other forms of vulnerabilities.
PS I love reading your posts, and they end up as fodder for conversation eg the head of our local psych ED read the recent article on involuntary hospitalisation and utility in edge cases after I forwarded it to him... If there was a more token subscription amount suitable to a med student single parent with a child with a disability, I'd be on board (recognising their are several medical substacks I find really valuable)
Cass Review showed that evidence for things like puberty blockers and hormonal treatment in adolescents is low quality and we lack scientific data on long-term outcomes. Ok. But that doesn’t by itself mean that clinical use inappropriate, or by and large harmful, or that patients, families and doctors cannot decide to use these interventions while acknowledging uncertainty around them.
Reactions to life difficulties become clinical problems once they generate suffering that is extreme or out of proportion, lead to disability, result in maladaptive behaviors, are not resolved by everyday resources and lead to professional help-seeking. I fail to see why we shouldn’t use whatever tools we have at our disposal to help such individuals, unless it can be shown that the tools are actually hurting them rather than helping them. [At the same time, I don’t advocate characterizing adaptive or socioculturally typical responses as disorders. Even adjustment disorder technically requires that symptoms be out of proportion to the stressor.]
Neurosis vs psychosis was never really abandoned, just retreated into the background. It has its uses. In HiTOP it shows up internalizing spectrum vs thought disorder spectrum.
Do you think inpatient psychiatric care should include the option of a short stay unit, or maybe more appropriately, what do you think of it? I'm referring here to general hospitals that house psych units and may have capability to provide this. I've been on the one I've linked to, and in the instance I needed it, it seemed to be more of a placeholder until a bed opened in the unit upstairs. But I suppose, in a less severe crisis, it could serve me well. I'm wondering if offering a dedicated short stay unit is starting to trend and if it's something large hospitals want to fund. I don't have access to any data like that. But I do wonder if patients who choose the short stay stabilization option are indeed stabilized, directed to community sources that maintain stabilization, or if the return rate is comparable to typical 7 to 14-day crisis unit stays.
Let me clarify that when I need crisis care, 2 days would generally not suit me as I don't stabilize that quickly and often require med adjustments that take more time. I also need more attentiveness. All of the available groups and therapy sessions at this EmPATH unit are charged separately from the inpatient stay itself, so it sounds more ideal than it is.
I don't know if there's enough there for an entire blog post. Maybe it could also include all emerging alternatives and ways for patients to shorten time spent in the ER.
EmPATH description, if you paste this into new tab:
Also, Psych at the Margins is wonderful, Awais, and I always read new posts, as soon as I'm alerted. Most I can comprehend, with the few exceptions being in depth meds discussions or analysis of studies
Thank you Lisa! So one thing is that sometimes psychiatric emergency rooms have observation beds that they can use to keep a person overnight or for up to 23 hours or so. Such units can be invaluable in a mini-crisis or substance intoxication or if a person presents at midnight and simply needs to be connected to the right outpatient support and nothing can be done at midnight. Such observation beds have been disappearing, and function similarly to short stay units, although regulations around how long a person can stay may be different. I think there is an important role for such short-stay inpatient options and I wish we had a lot more of them.
Apologies you probably don't want a reply from a random on the internet, but our short stay unit is mainly for suicidality crisis containment and to facilitate self regulation, and patients want a hospital stay in that situation. The reality is they're not getting a longer one, as there's no evidence that any length of hospital stay "saves lives" and we don't have the resources to keep people in hospital just because they/family want it... There is no longer inpatient program for that cohort. Yes some bounce back, but that's a reflection on the poor resourcing of suicidality services in the community and poorly resourced services for the "life difficulties" cohort who are usually better off with resources outside of hospital.
There is a framework of mental health/illness that is described by complex systems dynamics at the top level. The complex system's components are, roughly, genes, medical history, environment, some internal states, and the learned priors/predictions of predictive processing. Intense threat and powerlessness predictions (usually maladaptive unless you're actually in an acutely threatening situation) can also activate autonomic threat response states of arousal, panic, freeze, and dissociation.
This framework seems to have convincing mechanistic explanations for a number of phenomena, has a lot of research behind it, and has gained traction in some certain circles of psychotherapy. The focus there is on reconsolidating maladaptive priors, thus shifting the system from a self-reinforcing maladaptive state to a stable adaptive state or states.
Has this framework gained much traction in psychiatry practice? Are there any convincing explanations for why psychiatric drugs work in this framework? Other thoughts on this framework?
Complex dynamical systems approach and computational psychiatry has definitely gained a lot of traction in psychiatric research and many researchers are now studying mental health problems along these lines, for good reasons. These have been some excellent review papers out as well, in JAMA Psychiatry and Lancet Psychiatry, etc. There has been little impact on psychiatric practice so far, as the insights from these frameworks have not translated into new clinical interventions, although slowly clinicians are also learning about these approaches and beginning to think along these lines.
Thanks for the links you provided to JOXVN, especially the one about predictive processing. They are very promising. I have my two-cents of explication regarding predictive processing and mood variation (taking off from an article by Friston) : https://jnicanorozores.substack.com/p/deep-down-mood-is-not-about-feeling?r=lx647
I'm not familiar with this work and I was going to ask a related question about conceptual frameworks, so I'm curious--can you link a source?
(Edit: Thanks for the links! Not that you asked me, but I think PP and related computational /approaches/ are incredibly promising. I'm not sure there's anything resembling a unified framework incorporating all those elements to evaluate yet though.)
I'm about to begin studying to become a clinical psychologist. What do you think that psychiatry has to learn from clinical psychology and what do you think clinical psychologists should be taking with them from psychiatry?
I think psychiatry can benefit from clinical psychology's emphasis of psychological development, assessment of personality, neuropsychological testing, psychopathology of everyday life, and psychological formulation. PhD clinical psychologists also have more training in research and statistics compared to MDs. I think clinical psychology can learn more from psychiatry about phenomenological psychopathology, nuance of clinical diagnosis, neuroscience, integrative treatment using multiple modalities, challenges of working with individuals with serious mental illness, and psychological dynamics around pharmacology.
I greatly enjoy reading your Substack — thank you for everything you do here!
I’ve been especially appreciative of the attention you’ve paid to Post-SSRI Sexual Dysfunction, and—if I can take advantage of your invitation to suggest topics for future posts—would be very interested to read more about this phenomenon (both its sexual and non-sexual aspects) from your perspective.
1. Thanks for all you do here, love reading this substack and can’t wait for the new book.
2. How would you design an early intervention program for psychosis in the US, if you were starting from the ground up?
3. What advice do you have for a prospective medical student with a strong interest in psychiatry who shares your general stance on the profession?
4. How much hope do you have for meaningful advances in care for and understanding of psychosis in the next few decades? Maybe a little bit in the pharmacological side and a little of anything or everything else.
# Existing FEP programs are generally pretty well-designed IMO. There is variation in programs but I think most offer multiple modalities of treatment, including med management, CBT for psychosis, family psychoeducation, case management, and employment support. I think they can probably benefit from incorporating psychotherapy beyond CBT, better integration with research trials, and incorporation of elements from Open Dialogue, and coordination with programs like Hearing Voices.
# Read widely, develop a good foundation in psychological science and neuroscience, acquire familiarity with philosophy of science, network with people who are doing the kind of work you’d like to do one day.
# I’m uncertain. I think the rate-limiting step is how much we as a society are willing to invest in services and resources for individuals with psychotic disorders. I anticipate our scientific understanding of etiology would greatly improve in 2-3 decades, but I don’t know when we’ll have highly effective interventions.
Whenever I meet other psychiatry-keen, deep-thinking, open-minded medical students, your articles are always the first I recommend.
A quick meta-question on your experiences writing online; what’s the single realisation that made the biggest difference in your writing - the one you wish you’d known when you started?
I don’t know if there was ever a single realization like that, but perhaps something that comes close was the realization that writing to please myself (using a particular sentence, description, metaphor, example, argument that I’m attached to) doesn’t always align with writing that will be most clear or accessible for the reader, so there are always these trade offs. Also, writing on platforms like Twitter or Substack, you have to decide what kind of a relationship you want with the “algorithm,” and someone doing the right kind of writing means you will not go viral in the way you hope.
Are you ever in situations where you first prescribe lifestyle interventions (participation in communal/social activities, exercise, digital detox, diet, sleep, etc) and then turn to prescription medicine once those measures fail? How do you determine how much agency one has over the afflictions they report to you? P.S. — thank you for your work!!
Thank you. Yes. If the depression or anxiety is mild in severity, if there is insomnia that seems linked to poor sleep hygiene, and if the patient is very motivated to utilize lifestyle interventions.
Agency is a tricky concept and there is a lot of philosophical discussion on the topic. Most people who meet commonly accepted clinical criteria for mood disorders have symptoms that are either beyond their control or their control over them is impaired. But this doesn't automatically mean that they lack agency or that they cannot take responsibility for their lives.
We love psychiatry at the margins! So glad you’re on this platform, Awais. Congrats on 15k!
You’ve intimated a little bit about this in various places, but I’m wondering if you could tell us some of your thoughts about the Field’s (this encompassing everything from psychiatry to outpatient psychotherapy) shift away from psychodynamics towards more so-called evidence based practice. Sorry if that’s too broad/speculative.
Thanks Sorbie! Briefly speaking, I think the shift towards some sort of DSM-III style operationalized descriptive criteria for diagnosis was needed in 1970s to conduct necessary scientific work, clinical trials, and epidemiological research, but the shift became too hegemonic and all-encompassing, and it implicitly sneaked in neo-Kraepelinian assumptions about disease entities that were unhelpful and false. With regards to evidence-based medicine and practice, there was always this tension between those who wanted to augment and enrich clinical decision-making with the best available empirical data VS those who were fundamentally suspicious of clinical experience and patient reports, and were of the view that unless something was studied with rigorous RCTs, we didn't have good reasons to accept it as legitimate. This latter strand of EBM has been very harmful. Peter Kramer has commented on this as well, about how clinical experience and RCTs bring their own limitations and strengths and are fallible in their own ways. He said something to this effect in my Q&A with him:
"Researchers’ implicit faith in a narrow version of evidence-based medicine has set the academy against practitioners and raised suspicions that what doctors arrive at through daily practice is often misguided. I mostly begin with the opposite assumption, that despite all the research on sources of bias, clinicians are good observers, and that we do well to listen to their extrapolations about cause and effect. But... I sometimes lean the other way."
With evidence of efficacy of rTMS mounting and innovation like the SAINT protocol taking place are psychiatry and health authorities moving too slow on deployment? The magnitude of economic loss from depression and associated issues of pain and anxiety surely mean that it is cost effective. Do I have that right?
Also, do you think the predictive processing model of how the mind works is still very much under-appreciated in clinical psychiatry and psychology?
The standard rTMS is fairly accessible and efficacy is rather limited but I do wish rTMS was more accessible as a first-line treatment in lieu of medications. SAINT protocol and deep TMS etc are very inaccessible right now and that’s kinda unfortunate.
Love reading our articles - i don't have the intelligence for some but many are hugely illuminating and of course the bridge between practitioners, philosophers and those of us with lived experience ! So much can happen with dialogue - here is one of the questions i recently asked during my recent speech at the British Academy - i would love your take on it :
'We need to know how sectioning happens and its trends and the communities most affected by it but maybe it would also be good to know why so many of us, when everyone knows we need help, withdraw entirely from services. Why do we do it? Yes, to illness, yes, to fear of services but we also avoid the services we trust completely. Why is it when we suffer, so many of us avoid our friends and our relatives? Why do we do the opposite of what people think we should do?'
I suppose my answer is going to be somewhat prosaic: denial, fatigue, exhaustion, weariness, embarrassment, guilt, fear of being judged, and a desire to disappear.
I've heard from a few people that they tapered off SSRIs which originally worked well for them, had a negative experience with psychedelics, and then were unable to go back on SSRIs, facing terrible symptoms including brain zaps. I'd love to know if there are theories as to why that happens.
That's interesting. I'm not familiar with such cases. I need to look into this. There is no reason as such why psychedelics should alter a person's tolerability for SSRIs in the future, but there are also a lot of unknowns.
Congratulations on the book deal! It sounds like an important book for our times.
Thank you!
What's the most important (realistic) change you're hoping to see in psychiatry over the next 20 years?
What makes you optimistic that that change is likely to happen, and conversely what do you think are the biggest barriers or risks that make it less likely to happen?
A few things:
Mainstream adoption of dimensional approaches to diagnosis and diagnostic pluralism-- https://www.awaisaftab.com/uploads/9/8/4/3/9843443/aftab_jnmd_2024_psychiatric_diagnosis.pdf
Wider appreciation of the psychological dynamics around psychopharmacology -- e.g. David Mintz's work on Psychodynamic Psychopharmacology
A conceptual move away from assumptions of categorical disease entities in how we talk about psychopathology
A better scientific understanding of the physiological-psychological-experiential-social causal interactions.
Biggest barriers: professional inertia, reductionistic tendencies, and bureaucratic forces in healthcare focused on hyper-efficiency to the detriment of clinical encounter
Hi... I'm wondering about your thoughts on navigating between The Body Keeps the Score and The Body Does Not Keep the Score? Between van der Kolk and Scheeringa. From someone who was profoundly 'traumatised' by their month in a locked ward, leather restraints, forcible treatment etc, but find it deeply insulting to Trauma survivors (WWI trenches, child soldiers, torture survivors) to use the same word for the experiences... The expansion of trauma into distress renders it meaningless.
What are your thoughts on Bipolar 2, the bipolar spectrum, the dissolving of bipolar 2 and everything is just bipolar, Akiskal's 3,4,5... The loss of the classical illness concept of manic depression? Has it diluted bipolar and made it meaningless (or less meaningful as it's become more heterogeneous).
What about reinstating the Kraepelian distinction between neurosis and psychosis... From a med student perspective very little true/traditional mental illness came through the doors of my tertiary ED, it was mostly "life difficulties" of various ilks... and is medicalising life difficulties really in anyone's best interests? I seem to remember you at one point arguing that if a treatment helped then a diagnosis was useful; I'd problematicise that perception; we treat symptoms like fever with paracetamol quite happily without giving a diagnosis of "fever syndrome" - surely we can treat symptoms/life difficulties without the person needing a psychiatric illness to qualify? (Billing purposes aside)
Finally... The Cass Review!
I think there is compelling evidence that bipolarity is a spectrum. However, outside of a clinical history of mania or hypo mania, I don’t find it clinically very useful to call states on the spectrum as “bipolar disorder” and the further away we are from bipolar I and II, the more difficult and fallible the judgment becomes and harder to differentiate from high anxiety, ADHD, borderline PD, etc. It can also give a misleading impression to patients. So I tend to use “Unspecified Mood Disorder” for such cases.
Many claims in The Body Keeps the Score are poorly supported by evidence or erroneous, so Scheeringa is right in that sense, but adversity, neglect, abuse, trauma are powerful forces nonetheless. They are risk factors for a wide range of psychopathological states and interact with other forms of vulnerabilities.
My comment on another post today is also relevant here: https://paintingwithlightning.substack.com/p/schrodingers-trauma-if-everything/comment/139235925
PS I love reading your posts, and they end up as fodder for conversation eg the head of our local psych ED read the recent article on involuntary hospitalisation and utility in edge cases after I forwarded it to him... If there was a more token subscription amount suitable to a med student single parent with a child with a disability, I'd be on board (recognising their are several medical substacks I find really valuable)
Cass Review showed that evidence for things like puberty blockers and hormonal treatment in adolescents is low quality and we lack scientific data on long-term outcomes. Ok. But that doesn’t by itself mean that clinical use inappropriate, or by and large harmful, or that patients, families and doctors cannot decide to use these interventions while acknowledging uncertainty around them.
Reactions to life difficulties become clinical problems once they generate suffering that is extreme or out of proportion, lead to disability, result in maladaptive behaviors, are not resolved by everyday resources and lead to professional help-seeking. I fail to see why we shouldn’t use whatever tools we have at our disposal to help such individuals, unless it can be shown that the tools are actually hurting them rather than helping them. [At the same time, I don’t advocate characterizing adaptive or socioculturally typical responses as disorders. Even adjustment disorder technically requires that symptoms be out of proportion to the stressor.]
Neurosis vs psychosis was never really abandoned, just retreated into the background. It has its uses. In HiTOP it shows up internalizing spectrum vs thought disorder spectrum.
Do you think inpatient psychiatric care should include the option of a short stay unit, or maybe more appropriately, what do you think of it? I'm referring here to general hospitals that house psych units and may have capability to provide this. I've been on the one I've linked to, and in the instance I needed it, it seemed to be more of a placeholder until a bed opened in the unit upstairs. But I suppose, in a less severe crisis, it could serve me well. I'm wondering if offering a dedicated short stay unit is starting to trend and if it's something large hospitals want to fund. I don't have access to any data like that. But I do wonder if patients who choose the short stay stabilization option are indeed stabilized, directed to community sources that maintain stabilization, or if the return rate is comparable to typical 7 to 14-day crisis unit stays.
Let me clarify that when I need crisis care, 2 days would generally not suit me as I don't stabilize that quickly and often require med adjustments that take more time. I also need more attentiveness. All of the available groups and therapy sessions at this EmPATH unit are charged separately from the inpatient stay itself, so it sounds more ideal than it is.
I don't know if there's enough there for an entire blog post. Maybe it could also include all emerging alternatives and ways for patients to shorten time spent in the ER.
EmPATH description, if you paste this into new tab:
https://www.inovanewsroom.org/expert-commentary/2024/11/inova-opens-innovative-empath-unit-to-handle-psychiatric-emergencies/
Also, Psych at the Margins is wonderful, Awais, and I always read new posts, as soon as I'm alerted. Most I can comprehend, with the few exceptions being in depth meds discussions or analysis of studies
-Lisa Wallace
Thank you Lisa! So one thing is that sometimes psychiatric emergency rooms have observation beds that they can use to keep a person overnight or for up to 23 hours or so. Such units can be invaluable in a mini-crisis or substance intoxication or if a person presents at midnight and simply needs to be connected to the right outpatient support and nothing can be done at midnight. Such observation beds have been disappearing, and function similarly to short stay units, although regulations around how long a person can stay may be different. I think there is an important role for such short-stay inpatient options and I wish we had a lot more of them.
Yes, so do I.
Apologies you probably don't want a reply from a random on the internet, but our short stay unit is mainly for suicidality crisis containment and to facilitate self regulation, and patients want a hospital stay in that situation. The reality is they're not getting a longer one, as there's no evidence that any length of hospital stay "saves lives" and we don't have the resources to keep people in hospital just because they/family want it... There is no longer inpatient program for that cohort. Yes some bounce back, but that's a reflection on the poor resourcing of suicidality services in the community and poorly resourced services for the "life difficulties" cohort who are usually better off with resources outside of hospital.
There is a framework of mental health/illness that is described by complex systems dynamics at the top level. The complex system's components are, roughly, genes, medical history, environment, some internal states, and the learned priors/predictions of predictive processing. Intense threat and powerlessness predictions (usually maladaptive unless you're actually in an acutely threatening situation) can also activate autonomic threat response states of arousal, panic, freeze, and dissociation.
This framework seems to have convincing mechanistic explanations for a number of phenomena, has a lot of research behind it, and has gained traction in some certain circles of psychotherapy. The focus there is on reconsolidating maladaptive priors, thus shifting the system from a self-reinforcing maladaptive state to a stable adaptive state or states.
Has this framework gained much traction in psychiatry practice? Are there any convincing explanations for why psychiatric drugs work in this framework? Other thoughts on this framework?
Complex dynamical systems approach and computational psychiatry has definitely gained a lot of traction in psychiatric research and many researchers are now studying mental health problems along these lines, for good reasons. These have been some excellent review papers out as well, in JAMA Psychiatry and Lancet Psychiatry, etc. There has been little impact on psychiatric practice so far, as the insights from these frameworks have not translated into new clinical interventions, although slowly clinicians are also learning about these approaches and beginning to think along these lines.
Thanks for the links you provided to JOXVN, especially the one about predictive processing. They are very promising. I have my two-cents of explication regarding predictive processing and mood variation (taking off from an article by Friston) : https://jnicanorozores.substack.com/p/deep-down-mood-is-not-about-feeling?r=lx647
Thanks, I'll take a look. I read Scott Alexander's coverage of that same paper a few times and recall just ending up confused. Apparently a lot of people are confused by Friston's papers though :P. https://slatestarcodex.com/2018/03/08/ssc-journal-club-friston-on-computational-mood/
I'm not familiar with this work and I was going to ask a related question about conceptual frameworks, so I'm curious--can you link a source?
(Edit: Thanks for the links! Not that you asked me, but I think PP and related computational /approaches/ are incredibly promising. I'm not sure there's anything resembling a unified framework incorporating all those elements to evaluate yet though.)
Complex systems in psychotherapy: https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-020-01662-2
Predictive Processing and memory reconsolidation: https://www.lesswrong.com/posts/i9xyZBS3qzA8nFXNQ/book-summary-unlocking-the-emotional-brain
Defense Cascade: https://journals.lww.com/hrpjournal/fulltext/2015/07000/fear_and_the_defense_cascade__clinical.3.aspx
I'm about to begin studying to become a clinical psychologist. What do you think that psychiatry has to learn from clinical psychology and what do you think clinical psychologists should be taking with them from psychiatry?
I think psychiatry can benefit from clinical psychology's emphasis of psychological development, assessment of personality, neuropsychological testing, psychopathology of everyday life, and psychological formulation. PhD clinical psychologists also have more training in research and statistics compared to MDs. I think clinical psychology can learn more from psychiatry about phenomenological psychopathology, nuance of clinical diagnosis, neuroscience, integrative treatment using multiple modalities, challenges of working with individuals with serious mental illness, and psychological dynamics around pharmacology.
I greatly enjoy reading your Substack — thank you for everything you do here!
I’ve been especially appreciative of the attention you’ve paid to Post-SSRI Sexual Dysfunction, and—if I can take advantage of your invitation to suggest topics for future posts—would be very interested to read more about this phenomenon (both its sexual and non-sexual aspects) from your perspective.
1. Thanks for all you do here, love reading this substack and can’t wait for the new book.
2. How would you design an early intervention program for psychosis in the US, if you were starting from the ground up?
3. What advice do you have for a prospective medical student with a strong interest in psychiatry who shares your general stance on the profession?
4. How much hope do you have for meaningful advances in care for and understanding of psychosis in the next few decades? Maybe a little bit in the pharmacological side and a little of anything or everything else.
# Existing FEP programs are generally pretty well-designed IMO. There is variation in programs but I think most offer multiple modalities of treatment, including med management, CBT for psychosis, family psychoeducation, case management, and employment support. I think they can probably benefit from incorporating psychotherapy beyond CBT, better integration with research trials, and incorporation of elements from Open Dialogue, and coordination with programs like Hearing Voices.
# Read widely, develop a good foundation in psychological science and neuroscience, acquire familiarity with philosophy of science, network with people who are doing the kind of work you’d like to do one day.
# I’m uncertain. I think the rate-limiting step is how much we as a society are willing to invest in services and resources for individuals with psychotic disorders. I anticipate our scientific understanding of etiology would greatly improve in 2-3 decades, but I don’t know when we’ll have highly effective interventions.
Thank you!
Congratulations on the milestone!
Whenever I meet other psychiatry-keen, deep-thinking, open-minded medical students, your articles are always the first I recommend.
A quick meta-question on your experiences writing online; what’s the single realisation that made the biggest difference in your writing - the one you wish you’d known when you started?
I don’t know if there was ever a single realization like that, but perhaps something that comes close was the realization that writing to please myself (using a particular sentence, description, metaphor, example, argument that I’m attached to) doesn’t always align with writing that will be most clear or accessible for the reader, so there are always these trade offs. Also, writing on platforms like Twitter or Substack, you have to decide what kind of a relationship you want with the “algorithm,” and someone doing the right kind of writing means you will not go viral in the way you hope.
Thank you kindly for the thoughts; those darn pretty sentences are still too alluring to me…
Here’s to the next 15,000 subscribers!
Are you ever in situations where you first prescribe lifestyle interventions (participation in communal/social activities, exercise, digital detox, diet, sleep, etc) and then turn to prescription medicine once those measures fail? How do you determine how much agency one has over the afflictions they report to you? P.S. — thank you for your work!!
Thank you. Yes. If the depression or anxiety is mild in severity, if there is insomnia that seems linked to poor sleep hygiene, and if the patient is very motivated to utilize lifestyle interventions.
Agency is a tricky concept and there is a lot of philosophical discussion on the topic. Most people who meet commonly accepted clinical criteria for mood disorders have symptoms that are either beyond their control or their control over them is impaired. But this doesn't automatically mean that they lack agency or that they cannot take responsibility for their lives.
Congrats! Great updates.
We love psychiatry at the margins! So glad you’re on this platform, Awais. Congrats on 15k!
You’ve intimated a little bit about this in various places, but I’m wondering if you could tell us some of your thoughts about the Field’s (this encompassing everything from psychiatry to outpatient psychotherapy) shift away from psychodynamics towards more so-called evidence based practice. Sorry if that’s too broad/speculative.
Thanks Sorbie! Briefly speaking, I think the shift towards some sort of DSM-III style operationalized descriptive criteria for diagnosis was needed in 1970s to conduct necessary scientific work, clinical trials, and epidemiological research, but the shift became too hegemonic and all-encompassing, and it implicitly sneaked in neo-Kraepelinian assumptions about disease entities that were unhelpful and false. With regards to evidence-based medicine and practice, there was always this tension between those who wanted to augment and enrich clinical decision-making with the best available empirical data VS those who were fundamentally suspicious of clinical experience and patient reports, and were of the view that unless something was studied with rigorous RCTs, we didn't have good reasons to accept it as legitimate. This latter strand of EBM has been very harmful. Peter Kramer has commented on this as well, about how clinical experience and RCTs bring their own limitations and strengths and are fallible in their own ways. He said something to this effect in my Q&A with him:
"Researchers’ implicit faith in a narrow version of evidence-based medicine has set the academy against practitioners and raised suspicions that what doctors arrive at through daily practice is often misguided. I mostly begin with the opposite assumption, that despite all the research on sources of bias, clinicians are good observers, and that we do well to listen to their extrapolations about cause and effect. But... I sometimes lean the other way."
https://www.psychiatrymargins.com/p/30-years-of-listening-to-prozac-a
Hope this is what you sorta had in mind :)
Super, thank you! I’ll check out the Kramer interview.
With evidence of efficacy of rTMS mounting and innovation like the SAINT protocol taking place are psychiatry and health authorities moving too slow on deployment? The magnitude of economic loss from depression and associated issues of pain and anxiety surely mean that it is cost effective. Do I have that right?
Also, do you think the predictive processing model of how the mind works is still very much under-appreciated in clinical psychiatry and psychology?
Predictive processing model… yes, familiarity with that still remains limited among practitioners.
The standard rTMS is fairly accessible and efficacy is rather limited but I do wish rTMS was more accessible as a first-line treatment in lieu of medications. SAINT protocol and deep TMS etc are very inaccessible right now and that’s kinda unfortunate.
is deep TMS markedly more efficacious?
There is some preliminary evidence to suggest so
Love reading our articles - i don't have the intelligence for some but many are hugely illuminating and of course the bridge between practitioners, philosophers and those of us with lived experience ! So much can happen with dialogue - here is one of the questions i recently asked during my recent speech at the British Academy - i would love your take on it :
'We need to know how sectioning happens and its trends and the communities most affected by it but maybe it would also be good to know why so many of us, when everyone knows we need help, withdraw entirely from services. Why do we do it? Yes, to illness, yes, to fear of services but we also avoid the services we trust completely. Why is it when we suffer, so many of us avoid our friends and our relatives? Why do we do the opposite of what people think we should do?'
I suppose my answer is going to be somewhat prosaic: denial, fatigue, exhaustion, weariness, embarrassment, guilt, fear of being judged, and a desire to disappear.
Yes i expect you are right! Thank you
I've heard from a few people that they tapered off SSRIs which originally worked well for them, had a negative experience with psychedelics, and then were unable to go back on SSRIs, facing terrible symptoms including brain zaps. I'd love to know if there are theories as to why that happens.
That's interesting. I'm not familiar with such cases. I need to look into this. There is no reason as such why psychedelics should alter a person's tolerability for SSRIs in the future, but there are also a lot of unknowns.
Hi Awais, the origins of DSM are not well known.
Dr James Davies interviewed the man who led the committee that wrote DSM-3.
Could you review Dr James Davies’ video on the Origins of the DSM?
https://youtu.be/6JPgpasgueQ?si=ekJCYcSsprRzJL54
Thanks Barbara. I saw the video many years ago. It presents a rather selective picture IMO.
This post may be of interest to you: https://www.psychiatrymargins.com/p/are-critiques-of-dsmicd-as-devastating
Thanks Awais. I will check out your article.