Thread by @Altostrata

@_pem_pem Why this is nonsensical: "Jeffrey Lieberman, a professor of #psychiatry at Columbia University...“The problems that they’ve been criticized for have more to do [with] the way they’re used by doctors & the heterogeneity of the condition that they’re indicated for.” /1

@_pem_pem What Lieberman is saying is that if #antidepressants were prescribed to a population for which they are known to work well, they would have a much better track record. This is true, because it is a tautology. /2

@_pem_pem The reasoning is circular, if #antidepressants were prescribed for those people for whom the drugs worked, they would work. /3

@_pem_pem While true (but nonsensical), there are several wrong assumptions buried in this position. The first is that #psychiatry knows the population for which #antidepressants will work. While data shows they are slightly more effective in "severe depression".... /4

@_pem_pem Prescribers clearly cannot distinguish "severe depression" from any other depression. The clinical prescribing policy is to be safe & "medicate 'em all", just in case there is a suicide hiding in a so-called case of "depression". /5

@_pem_pem Further, the vast majority (~80-85%) of #psychiatric diagnosis & #antidepressant prescription is done by general practitioners, who are even less versed in distinguishing levels of depression & drug adverse effects. Public health policy generates a steady drumbeat.... /6

@_pem_pem ....of mass media campaigns to drive people to their doctors for any sign of depression. A big chunk of any GP's time is now spent on "mental health". It's much easier to reflexively prescribe an #antidepressant & send people on their way than to explain other options. /7

@_pem_pem Many health systems more or less require #antidepressant prescription as first-line response to any sign of "depression", whatever the severity. If the 1st drug doesn't "work", GPs think nothing of switching from drug to drug until the patient stops complaining. That is SOP. /8

@_pem_pem Once you get a #psychiatric diagnosis from any kind of MD, whether deserved or not, it's very hard to remove it. Others doctors will assume it's correct. Even #psychiatrists rarely reverse prior diagnoses, no matter how clueless the earlier doctors. /9

@_pem_pem So once you get a #psychiatric diagnosis OR a prescription for any #psychiatric drug, such as an #antidepressant, any doctor who sees that in your history will assume you are plagued by mental illness, even if original diagnosis & prescription was stupid. /10

@_pem_pem If you don't respond well to an #antidepressant, or have adverse effects, very likely you are in for a prescription cascade, with drug switches, "adjunct" drugs added, the doctor may suggest you are "treatment-resistant" & start hinting about prescribing #ECT. /11

@_pem_pem You'll be struggling in prescription cascade even if whatever was troubling you is long past. For example, your divorce was years ago, you're happily remarried, but you're still taking your #antidepressant because your doctor has heard depression is chronic, like diabetes. /12

@_pem_pem You may believe this, because you heard a rumor that your grandmother was seriously "depressed", & it runs in families. So you might start with being upset about divorce (who wouldn't be), but you end up a life-long #psychiatric patient. /13

@_pem_pem This has been iterated for decades by #psychiatry, that you can't have one bout of "depression" & then it's over. A flaw in your software forever more puts you at risk for escalating severity. Better safe than sorry -- prescribe that #antidepressant & keep people on it. /14

@_pem_pem This is what #psychiatry taught GPs, in concert with pharmaceutical company marketing since late '90s-about 2015. Depression is a chronic illness requiring chronic medication. This has become embedded in our culture. /15

@_pem_pem Embedded in our culture despite that everybody has periods when they're very down. That's why life events are known to be stressful. Have a few life events (any kind of life), react with emotional distress, & you are a candidate for a "depression" diagnosis. /16

@_pem_pem The astonishing expansion of pharmaceutical company profits in the last 30 years was enabled by this medicalization of ordinary experience. #Psychiatry was the first specialty to wholly capitulate. Public health policy dragooned GPs to act as the sorcerer's apprentices. /17

@_pem_pem GPs became overloaded, now there's talk about extending #psychiatric diagnosis & prescribing privileges to nurses, physician assistants, etc. -- because mass media messaging has created such a huge demand for #antidepressants & other brain-holiday drugs. /18

@_pem_pem The essential problem of diagnosis of depression, to which Lieberman alludes, has never been resolved in the specialty of #psychiatry. Nassir Ghaemi, a very prominent research #psychiatrist, mentions discusses "heterogeneity" in this thread /19

https://twitter.com/nassirghaemi/status/1506737457894727690?s=20&t=o0gRmhCu4uzt970UzH62bQ

@_pem_pem Clinically, #psychiatry has not successfully differentiated between types of depression & cannot even find that particularly severe kind for its studies because there's so much noise in diagnoses. (FYI, suicidal people are excluded from #antidepressant studies by design.) /20

@_pem_pem Delegating the bulk of #psychiatric diagnosis to ever-less informed prescribers has made it a joke. Anybody can get an #antidepressant if you show the least bit of interest in it. Depression can be diagnosed in a ham sandwich. /21

@_pem_pem Though, IMO, GPs providing the majority of #psychiatric diagnosis & prescription is a public health disaster, leading to massive overprescription worldwide, #psychiatry has done little to straighten this out. Individual clinical #psychiatrists are as confused as anyone else. /22

@_pem_pem Even apologists like Lieberman will only hint that diagnosis & consequent #antidepressant prescription is a mess (as he did in this article). #Psychiatrists mutter about GPs but don't want to point fingers. However, their diagnostic acumen isn't much better. /23

@_pem_pem Fact is, #psychiatry can't find a population that would consistently benefit from #antidepressants because diagnostic paradigm is based on a motley collection of "symptoms" that are subjective & change frequently, which it tries to measure as though they were blood pressure. /24

@_pem_pem Back in the Stone Age before mass #antidepressants, there was a RARE condition of severe, unrelenting depression (Ghaemi was trying to tease this out) that, theoretically, might be the target population for these drugs. /25

@_pem_pem But since then, in its enthusiasm for #antidepressatns for all (cf Kramer), #psychiatry itself has deliberately blurred the boundaries of "depression". It has only itself to blame for "heterogenous" diagnosis. /26

@_pem_pem Lieberman is a joker, it's not like he'd argue prescribing #antidepressants to fewer people -- that's a 3rd rail in #psychiatry. The practices of most clinical #psychiatrists are filled with working people with good jobs & insurance, not incapacitated by severe depression. /27

@_pem_pem "It's those damn GPs," #psychiatrists mutter. But they can't accurately diagnose "depression", either. The reliability tests for DSM-5 depression diagnosis by presumably top #psychiatrists were dismal, & a dive in reliability from earlier DSM versions. /28

@_pem_pem Lieberman trots out to give this defense of #antidepressants in many articles. But claiming they'd work if they were given to the right people -- well, yeah, let's see #psychiatry do that, & teach it to the other prescribers. /29

@_pem_pem This is not to say that any individual might have a good experience with #antidepressants. They are psychotropics. Every psychotropic has been found to be "antidepressant" by a very slim margin of efficacy. It's probably a random effect. /30

@_pem_pem But putting millions of a near-random population on chronic psychotropics with no clear benefit has enormous fallout. The more people that take a drug, the more that experience the adverse effects. With social media, the complaints become obvious. /31

@_pem_pem 50% or more of those taking #antidepressants will experience drug-induced sexual dysfunction. (#Psychiatrists claim this can be countered with addition of a 2nd #antidepressant, often buproprion. Why not prescribe that first, instead?) /32

@_pem_pem #Antidepressant-induced sexual dysfunction is often accompanied by emotional blunting, but emotional blunting occurs on its own ~50% of the time as well. You can have both, or either, while taking the drug. Substituting another drug tends to have the same adverse effects. /33

@_pem_pem Then there is the problem of coming off after your body has adapted to a chronic psychotropic, a universal law of psychotropics. Lerner, A., & Klein, M. (2019). Dependence, withdrawal & rebound of CNS drugs. doi.org/10.1093/brainc… /34

@_pem_pem Each person taking an #antidepressant thinks they are are the only one experiencing any of these EXTREMELY common adverse effects (until they start Googling) because doctors don't tell patient about them -- & doctors often don't know about them. /35

@_pem_pem That's how terrible medical education about #antidepressants is. Your prescriber, even if a #psychiatrist, may deny that your drug-induced emotional blunting is an adverse drug effect, or claim it's vanishingly rare. /36

@_pem_pem Instead, your prescriber will tell you the drug-induced symptom is in fact a worsening or elaboration of your #psychiatric disorder, & prescribe more drugs for it. Welcome to being a life-long #psychiatric patient. /37

@_pem_pem Jeffrey Lieberman should just hang it up. But he's pretty reliable for spouting the party line, even if it makes no sense. #Psychiatrists are consoled by the idea that the drugs they prescribe so prolifically are just the thing for someone, somewhere, somehow. Sciencey! /end