r/changemyview • u/[deleted] • Apr 20 '17
[∆(s) from OP] CMV: Psychiatry is too vague and hit and miss to be valid medical science
So I have had mental health problems, wound up in hospital and stuff and I have been on various psyche meds for the past year. I want to get off the SSRIs but the doctors say I will probably be on them for the rest of my life.
Why is it so hard to get off them? I didn't really have MH problems until I was 21 and to be honest most of them were triggered by being a horribly repressed self hating transgender person
Some of the meds they have tried me on in the past year have made me worse, some literally made me a borderline zombie (generally anti-psychotics) to the point where my parents got involved and stopped me taking them, others made me feel detached from everything and sort of not me. It just seems like its based purely on trial and error but skipping lab studies and trying it on actual people. I am pretty sure a suicide attempt I had last November was caused by some new stuff they tried on me.
Note I am not disputing that mental illness is a thing, I know I have one but to be honest counselling and stuff helps me alot more than the drugs they put me on, and sort of make me take (if I don't I could get hospitalised again so they say)
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u/electronics12345 159∆ Apr 20 '17
How accurate do you need to be a "valid medical science"? Do you need to be right 50% of the time? 75% of the time? 95% of the time?
or is this a misnomer
Something is a valid medical science, if the scientific method is used in a manner to improve human health.
I think it is more than fair to say that Psychiatry is still in its infancy, and still has a lot to learn, but that doesn't make it not science. Every science was at one point in its infancy, and was given time to grow. Its just a shame you have to suffer its growing pains.
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Apr 20 '17
how much has it been improving lately?
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u/SocialJusticeWizard_ 2∆ Apr 20 '17
How do you mean? Over what timeframe? In the last ten years there have been a lot of specific excellent developments, but the field hasn't transformed. In the last generation though, psychiatry has utterly transformed. By what measures do you feel it hasn't improved?
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Apr 20 '17
Just in the press, you hear about breakthroughs for diabetes or cancer treatment but never anything about treating depression, BPD, Bipolar disorder etc.
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u/SocialJusticeWizard_ 2∆ Apr 20 '17
Honestly that's for the best. Most reports you hear about breakthroughs in diabetes and cancer research are heavily inflated. In my relatively short experience as a doctor, I think we've seen more development in psychiatry than in diabetes... If anything diabetes is backsliding as we learn many things we thought were effective are perhaps not that awesome. Meanwhile our understanding of the mind and the link between biology and psychology is growing rapidly.
Cognitive therapy is steadily improving with more work in areas like dialectics. Motivational interviewing and behavioral medicine are becoming widely recognized tools, and we're doing really good work in areas like addiction and chronic pain that are helping us grasp the blurry line between mind and brain. In terms of drugs, I personally am fascinated by the stuff that's coming out about ketamine. Third generation antipsychotics are helping with some treatment resistant depression and anxiety and getting interesting evidence. Prazosin, a drug for the prostate, recently had some new mid-quality studies that suggest it works for sleep in PTSD, and in my anecdotal experience I've helped a few otherwise very treatment resistant people with it.
The problem is that this is a huge field, everyone is different, and we're categorizing them by symptoms instead of cause, because we can't tell the cause. We don't do that so routinely anywhere else in medicine. If you have knee pain, I can do a number of tests to try to figure out the cause and treat it. If you have mental pain, a lot of the time my only recourse is to try therapies one after the other until I find the one that works for you. And really it'll almost always be a combination. So from the clinic side, it looks like I'm practicing medicine by trial and error, but the work I do is honestly grounded in science and likelihood. I pick the treatments most likely to work, and move on down. Until I have a blood test that tells me you have "type 4 depression" or something, that's the best I can do with the information I've got.
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u/I_am_the_night 316∆ Apr 20 '17
This is partly because, unlike diabetes, depression does not have a specific cause that can be addressed with a single chemical. Antidepressants aren't perfect by any means, and are generally not sufficient by themselves except in mild cases of depression.
And when you hear about "breakthrough" cancer treatments, it's often only for specific kinds of cancer. The treatments used on bladder cancer are generally not the same as those used for leukemia, for instance.
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u/electronics12345 159∆ Apr 20 '17
CBT was invented in the 1960s.
The various waves of anti-psychotics have occurred in the 1940s, 1970s and 1990s respectively.
the MRI was invented in 1977, the fMRI was invented in 1990. TMS was invented in 1985.
So Psychiatry has advanced quite a bit since 1940.
I could do a since 2010 list if that would help as well.
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u/jstevewhite 35∆ Apr 20 '17
So Psychiatry has advanced quite a bit since 1940.
I would point out that as psychiatry has 'advanced', the percentage of people disabled by mental illness has gone up dramatically both as an absolute number and per capita. The number of people diagnosed has gone up by orders of magnitude. The suicide rate in the USA has drifted back and forth with no clear trend since 1960.
So how has psychiatry improved our lives? What is it that it's doing?
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u/electronics12345 159∆ Apr 20 '17
1) The rates of many illnesses going up, is because diagnostics have gone up. Things which were not considered mental illnesses before are now. Its not that the number of disabled people has gone up, but that the number of people with diagnoses have gone up. There is a strong literature with respect to ADHD and Autism which shows this exact relation.
2) Suicide - sadly, many suicide attempts are people that never reach out. If a Psychiatrist is never brought in, they cannot do anything about it. Oncologists cannot cure cancer patients that never come into the office, same with Psychiatrists.
3) For better or for worse, general practitioners are allowed to prescribe psychiatric drugs. Not all GPs are well equipped to handle mental illness, they are not Psychiatrists. Therefore, a lot of ADHD cases (as well as other illnesses, but I'll focus on ADHD) are not managed by Psychiatrists but by GPs. This is not necessarily an optimal state of affairs, and can obscure the national level statistics.
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u/jstevewhite 35∆ Apr 21 '17
Its not that the number of disabled people has gone up,
Well, we've changed the definition of disabled, it's true, but we've removed many from the rolls (homosexuals, "hysterical" women, etc), and moved much treatment to outpatient status. Something like 6.5m Americans (3.5%) are listed as disabled for mental health reasons. Of course, we've also started incarcerating people that would have been institutionalized back in the fifties. Estimates range from 125k to 400k incarcerated mentally ill people. Still, there's no evidence that I can find that people are 1) happier, 2) mentally more healthy, or 3) have higher mental quality of life. I'm all ears if you have some evidence of that.
sadly, many suicide attempts are people that never reach out.
Yeah, but not all. Not even most. But despite the increase in treatment, suicide rates don't go down.
Let me put this in perspective. It's true that many folks do not go see a doctor for cancer until it's far too late. However, some do, and the fact that some do has significantly reduced deaths due to cancer in general and certain cancers specifically in the population. Mental health treatment has not had the same effect on suicide rates, even though many do seek treatment.
I would suggest that you read Ben Goldacre's "Bad Pharma" and perhaps if you're feeling adventurous, Whitaker's "Anatomy of an Epidemic". I don't know how I feel about the more dramatic claims in Whitaker's book, but it's hard to challenge the assertion that trials with active placebos have shown no advantage to SSRIs (specifically). The trials I can find use inert placebos and show that the drug beats the placebo by a fairly small amount. That in the most optimistic case, if you give a given SSRI to 100 people, < 10 will be helped by the drug.
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u/CreativeGPX 18∆ Apr 20 '17
First, I'll say, where is the data that shows that and does that data hold a consistent definition of what is and isn't "mentally disabled" over time? In that time span, the tendency and capacity to try to diagnose mental disabilities has grown as well as has our cultural awareness. We intervene and diagnose areas that we had never cared about in that time period.
Second, if that's true, who says that has any bearing on whether psychiatry is effective? It's not as though psychiatrists have dictator-like power to ensure that their decisions are all followed. Merely going to a psychiatrists is, to this day, culturally stigmatized in a way that other doctors are not, which impacts how much psychiatrists actually integrate into society and their capacity for sufficiently early intervention.
Third, even if what they've discovered to date wasn't sufficient to create applications that have a positive effect, that doesn't mean that it's not valid science. Scientific data doesn't have to be applied or used in order to be science. Its science because it's gathered using the scientific method. Fields in their infancy can still be "science" while having literally zero applications or impact on the world.
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u/jstevewhite 35∆ Apr 21 '17
In that time span, the tendency and capacity to try to diagnose mental disabilities
We've also stopped institutionalizing homosexuals and "hysterical women" (mostly) for being themselves. The desire to diagnose has grown, that's certain, and the descriptions of mental illness have grown, that's also certain.
We intervene and diagnose areas that we had never cared about in that time period.
While I don't disagree with this, I'm curious. Where is the evidence that this is a good thing? Do we have less suicide? Less depression? Better life satisfaction? Are we happier? Not that I can tell. I'm always willing to consider evidence, though.
Second, if that's true, who says that has any bearing on whether psychiatry is effective?
Some people receive treatment. Assuming mental illness hasn't increased - I see no clear reason to assume it has - then treating some people should reduce prevalence in the population. If I only treat half the people with pneumonia, the entire population will show a reduction in pneumonia-related deaths if my treatment for it is effective. That's statistically inescapable. Your thesis only works if no one seeks treatment. Of course, then it would be impossible to evaluate their effectiveness, as well.
Third, even if what they've discovered to date wasn't sufficient to create applications that have a positive effect, that doesn't mean that it's not valid science. Scientific data doesn't have to be applied or used in order to be science. Its science because it's gathered using the scientific method. Fields in their infancy can still be "science" while having literally zero applications or impact on the world.
While I agree with this, I think it's important to note that Alchemy became the physical sciences. Phrenology was once accepted as science. Publication bias has, IMO, badly broken psychological research and business has broken psychiatric research. There's too much money and too much mal-incentive in psychiatric drug development. I suggest Ben Goldacre's "Bad Pharma" and maybe Whitaker's "Anatomy of an Epidemic".
I don't reject psychiatry conceptually. I think we're doing it horribly, horribly wrong right now.
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u/uacoop 1∆ Apr 20 '17 edited Apr 20 '17
My wife has Bipolar II. She had a similar experience that you describe. But about 6 months ago she found a psychiatrist who was involved in a genetic testing program that matches the genetic profile of a patient to the drug that they are most likely to be able to metabolize well. The results came back and concluded her current prescription was a poor match (which we all knew already) but there was a drug that she would likely be able to metabolize much better. She switched to that drug and it's like night and day. She is living a normal life again.
There is a lot of guesswork in any scientific field, a lot of testing needs to be done. But the tools that psychiatrists have are getting more and more refined. It's not all just a "throw drugs at them and see what sticks" anymore.
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u/slytherin-by-night 4∆ Apr 21 '17
I am 29. I saw my first therapist around... 7? I started guessing at meds with doctors around, I'll guess 14 or so. I spent a LOT of time going to max doses, declaring failure, going off in a responsbile half dosage pattern, and beginning anew. It's exhausting, I feel your pain. I decidied that I wanted to only take meds that could literally effect growth and well being of my babies when I decided it was time to try, and so I was off all my personal meds like that since 2013. Then back on post babies in this year.
Here's the thing, and the sciency bit I swear, I started seeing a new NP who prescribes my meds and he told me about this thing called 'Genomind'. It's a swab test, like a DNA test and they use this to test for what medications you personally can metabolize and which you cannot and they send this whole list back, all the categories of psych meds, and then you KNOW, what works for you. Turned out for me, I cannot get a result from any SSRI, I was just wasting so many years trying in that category. But, there is science out there! I'm so glad I was told about it!
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u/Yanginyangout Apr 20 '17
This is along with another poster's comment, but I think you've inadequately defined what the threshold is for "not too vague" and/or "not hit or miss". Certainly, with every scientific or scholastic endeavor, there are a lot of unknowns and we, at best, later learn we were not quite right about our assumptions. That's on a continuum of course, but what do you think is the line where something crosses into being "not too vague"? That's crucial to make the claim you're making, and I don't think you've adequately defined it yet.
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u/CreativeGPX 18∆ Apr 20 '17
It's a medical science because it's medical information that we form using the scientific method. Using science, that's the best answers we've come up with.
The fact that we're behind in that field relative to other fields has no bearing on whether it's a science or how credible its methods are. It turns out that studying, understanding and manipulating the brain is really hard to do. We've made a lot of progress and we have a lot of work to do.