After the early brouhaha over the serotonin paper last year, several outlets in 2023 have offered in-depth scientific reports & these have reassuringly converged onto the consensus view that depression is complex, 5HT is complex, antidepressant mechanisms are complex, and… (/1) … we should resist simplistic narratives, whether this simplistic narrative reduces etiology to neurotransmitter deficiencies or to social causation. (/2)

awaisaftab.substack.com/p/clarifying-t…

The interesting thing is that almost everyone in the psy-disciplines (even psychiatry, yes) dislikes, disdains, disregards, or begrudgingly tolerates the DSM but they do so for *wildly* different reasons. It is a compromise of sorts that makes no one happy. (/1)

https://twitter.com/chronicallybeee/status/1589000879469838336

The DSM is an imperfect & flawed document but it is also astonishingly misunderstood & its merits often underestimated. Psychopathology is an immature science; there is only so much that any descriptive or explanatory framework can accomplish at present. (/2)

In order to support the claim that mental disorders are brain disorders, several issues need clarification. I’ll raise them here in the form of Qs. These issues pertain to a) relationship b/w mind & brain, & b) relationship b/w mental *dysfunction* & brain *dysfunction* 🧵 1) What is the difference between a “psychological problem that has a neurobiological dimension” and a “brain problem”? This difference is at the heart of the debate. Doesn’t mental disorder = brain disorder conflate this seemingly crucial conceptual distinction?

I’ve been worried about this gap ever since I started training in psychiatry & realized how much disconnect there is. In my short career so far, I’ve been trying to understand the nature of this gap & to remedy it. I’ll share my thoughts here about what I’ve observed… (/1) 🧵

https://twitter.com/justin_garson/status/1575456282206773248

The *average* psychiatrist & clinician — the one you are likely to meet in the clinic/hospital — has little conceptual clarity on the definition & nature of concepts like “disorder”/“dysfunction” or regarding issues of explanatory reductionism/pluralism. (/2)

Working with @nytopinion editors, I created this interactive piece that is designed for readers to explore: why is it that the treatment of depression in the US so often ends in a seemingly endless trials of medications & interventions? (/1)

nytimes.com/interactive/20… It follows a “choose ur own adventure” format that allows various treatment selection decisions & each decision results in probabilistic outcomes pertaining to access, efficacy & tolerability. Each time u play, the outcomes will be different, allowing u to replay & explore. (/2)

@DrGipps examines the difficulties of trying to determine what it means for a computer/calculator to compute/calculate, independent of our relationship with the device & raises some excellent points (as part of our on-going conversation) (/1)

clinicalphilosophy.blogspot.com/2022/07/do-com… I am inclined to think that computers (& calculators, etc) embody or represent relationships between abstract mathematical entities in a physical system. They are designed to do so, by us, so the nature of this representation is fixed. Although we designed them, the design… /2

The October 2022 issue of World Psychiatry - pdf has been circulated by listserv but not online yet - contains a great article by Stein et al on paradigm shift vs incremental integration in psychiatry with an excellent set of commentaries (incl by Kendler, Krueger, & Borsboom) “… the history of psychiatry has been defined by a joint commitment to brain and mind which has led to endless controversies but also a rich tradition of attempted integrations. Abandoning either of these approaches would lead to an impoverishment of our field.” Ken Kendler

It saddens me that vitriol against psychiatry comes so cheap, that legitimate criticisms & grievances are so easily channeled into destructive impulses. How to counter disinformation while remaining receptive to critique is a delicate balance but one that I remain committed to. It is frankly the only choice. The profession has much soul-searching & rectification to do, at the same time it also has fragile truths to defend & to provide care to those who depend on the services in an era of unprecedented need.

Wasn't planning on this thread today but I saw that twitter is buzzing with the new Kirsch paper on antidepressants & this feels like a good opportunity to discuss how impoverished & uncritical the usual discussion of such studies on ADs is. (1/19) 🧵

bmj.com/content/378/bm… It just so happens that I finished reading @PeterDKramer's Ordinarily Well last night, so I am channeling many insights shared by the brilliant Dr Kramer in this thread. Honestly, read the book, it's wonderful, this thread is a poor substitute. (/2)

https://twitter.com/awaisaftab/status/1554432980877287425

@PeterDKramer’s “Ordinarily Well: The Case for Antidepressants” is hands down the best thing I’ve read so far on the controversy surrounding the efficacy of antidepressants. It feels as if I had been stumbling in the dark for answers & someone flipped the light switch on! (/1) What I love about the book is that it is an extended meditation on the dialectic between clinical practice and clinical trials, how both exist as a “spectrum on which sit flawed efforts at objectivity.” EBM becomes sterile, even harmful, when it loses sight of this. (/2)

When it comes to SSRIs/SNRIs, what gives me pause more than anything else are the horror stories of iatrogenic harm — even now, despite everything I know, I see a part of me react with utter bafflement, & then I think of how confusing & terrifying it must be to experience… (/1) … unbearable dread and impending doom that leaves you desperate & incapacitated, with no explanation & no help readily available. Modern medical education, practice, & research struggles with phenomena that resist easy characterization, understanding, & treatment. (/2)

@shayla__love on the controversy and discussion around the new review paper on serotonin hypothesis of depression.

I’m quoted at several places (screenshots in the thread below), check it out:

vice.com/en/article/88q… Relevant comments & references from the VICE story (/2)

Recently crossed 15K followers! 🥳 On twitter that’s both a blessing & a curse 😆 I figure a reintroduction is in order. Hello! I’m a psychiatrist in the US (born & raised 🇵🇰), interested in philosophical & critical perspectives related to psychiatry & mental healthcare… (/1) I see myself as engaged in a two-fold mission:

i) To theorize and promote practice of medicine/psychiatry that is humanistic and pluralistic, and robustly engages with the metaphysical, relational, & phenomenological dimensions of psychiatric distress & disability

and… (/2)

Very interesting, sometimes discordant, responses by various experts to the new paper on serotonin hypothesis:

sciencemediacentre.org/expert-reactio… David Nutt says in the piece above that they have a study under review that found decreased 5HT release capacity in depression & it’s “premature” to dismiss 5HT hypothesis. I guess the scientific debate isn’t over yet! Hard to comment without seeing the study though. /2

I don’t know if we have a good ideological descriptor for the works of psychologists & professionals associated with BPS DCP, PTMF, DropTheDisorder, etc. “Critical” gets frequently employed but they don’t really self-identify with that, at least not in any consistent way. (/1) “Critical Psychiatry” isn’t a good fit, the emphasis is a kinda different, generally coming from within psychiatry (think Bracken, Moncrieff, Double, Steingard etc) & “Critical Psychology” is kinda different too (think Ian Parker et al). (/2)

An analogy can be made with psychotherapy here. Psychotherapy & antidepressants have acute effects of similarly small magnitude (vs placebo) on symptom rating scales, but we know that patients find psychotherapy helpful & meaningful in ways not captured by symptom scores. (/1)

https://twitter.com/awaisaftab/status/1545820877773832193

If we wanted to understand why patients find psychotherapy beneficial, it wouldn’t make sense for us to focus on HAM-D scores & conclude that patients have essentially been bamboozled abt the benefits of psychotherapy because those benefits aren’t obvious on HAM-D vs placebo. /2

The obsession with HAMD scores & DSM categories has obscured the complex effects of psychopharmaceuticals, the relationships ppl have with subtle & not-so-subtle psychoactive effects on minds & temperaments, & the diverse ways in which they find them to beneficial (or harmful) 🧵

https://twitter.com/DrRJChapman/status/1545794137064181760

The increased use of SSRIs & stimulants during the pandemic & in our crumbling, dystopian world is worth analyzing. Many are drawn to these substances as a way of coping with increasingly stressful lives (& the corresponding mental toll), & many do find some form of relief. /2

When it comes to research in biology of mental illness, I think our best bet (à la RDoC) is to identify neurobiological constructs (a specific inflammatory state, abnormalities in neurogenesis, etc), establish the neuropsychological sequela of the phenomena, & determine… /1 … how they overlap at a symptomatic level with various psychiatric syndromes. Working backwards from syndromic categories hasn’t proven productive & a wholesale reduction or reconceptualization of a DSM-style category into a neurobiological category likely isn’t gonna happen…/2

Excellent philosophical account of representations in the brain (representational pragmatism):

“representational status arises from our *practice* of assigning representational contents to entities that play a particular kind of functional role.”

link.springer.com/article/10.100… “it is not helpful to ask: “Is there really a representation here (of X)?” Rather, we can ask only… “Is there a representation here for our purposes?”—where our purposes may be rather expansive, but will always be sensitive to the context in which our… theory will apply.”

The argument that ADHD is ‘pathologising of understandable human responses to a traumatising world’ illustrates the increasing sterile, even reactionary, nature of this sort of ‘critical’ theorizing, because what is erased in the process is the disability of the individual... /1 If your problem is with the term ‘disorder’ because of connotations of ‘defective brain’, your problem is not with the diagnosis or the phenomenon, but with certain connotations of it; you think the term ‘disorder’ is beyond rehabilitation, fine don't call it a ‘disorder’... /2

“so many people with schizophrenia are incarcerated or homeless, or they are dying at age 55… I have to say that I'm not sure I understood that 5 or 10 years ago when I was at NIMH… that this is as much a social justice problem as a scientific problem.”

@thomasinselmd (1/4) “We decided that we’d put a tremendous amount of public funds into building jails & prisons… a prison opened every 10 days through the 1990s. At the same time, we gutted our public mental health system & there were no beds & v few committed community centers.” @thomasinselmd /2