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  • Lithium Lithium 
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    We should just put lexapro in the water.

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    Haha. Please don’t. 😉

    I’d say 15-20% for current use, not sure about lifetime prevalence. I’m a psychiatrist and tend to think psychotropics are generally overprescribed, though I’d agree that access to care issues result in under prescribing in certain populations. We need more skilled psychotherapists in my opinion, not more drugs.

     

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    I agree with this, as the USA has higher antidepressant Rx rates than anywhere in the world.  I work in a detox unit.  So many of my alcoholic patients are on Lexapro etc, and of course it doesn’t do a damn thing for their mood problems when they are drinking a fifth of whiskey a day.  However, for PCP’s it is much more feasible to write for a cheap Rx than do 10 minutes of motivational interviewing.

    I know many psychiatrists are extremely liberal with prescribing antidepressants even if they think it is just for the placebo effect, justifying it because SSRI’s are so benign.  I don’t count myself among them.  Of course they should be prescribed if the patient needs them.  But we used to be a lot more cavalier about prescribing opioids and benzos and now we have a better understanding of the risks of that.

    Image result for where in the world are antidepressants most prescribed

    FWIW, US suicide rates are about the same or higher than almost all the countries listed (among these, only Korea’s is substantially higher).

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    I mean, in a lot of those countries with low antidepressant use, there is crazy stigma against mental health, they basically don’t even agree that it’s real. And in other countries in the UK they have a lot more structural supports in place so the rates of poverty are lower and access to social goods much higher so less stressors/triggers. In Australia and NZ the first line treatment for depression is 30 minutes of exercise daily and yet they still have pretty high rates of antidepressant use. So I’m not sure what to even do with this data. I don’t think it proves anything as far as the US “overprescribing” and I still say MH is undertreated and stigmatized everywhere in the world. Even doctors still look down on patients with mental health and we should be the most educated about it, yet seems to do nothing for some people. It’s hard enough to open up about depression, imagine doing so and having your provider basically tell you to buck up and go develop a hobby, as though that will fix it.

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    I agree that it’s a simple graph and that the nuances are a lot more complicated.  But to make a long story short, I think doctors are both “overprescribing” and “underprescribing” (giving out the right meds to the wrong patients) and that doctors, especially PCPs, don’t have the time and resources to distinguish depression from “depression.”

    #196419 Reply
    Avatar wideopenspaces 
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    Not sure how that is directly related. I also have no idea what my post says about my person experience with/without ACEs or how that is relevant to my viewpoint.

     

    my point is that it’s not normal for 30 % of the population to be considered to have mental illness that requires drug therapy. I absolutely agree people deal with horrible things that set them up for failure down the line.

    People of all spectrums could benefit from better coping skills so I don’t get the argument ” It’s not about coping skills,” It’s a no lose proposition.

     

    at the end of the day it comes down to everybody deals with stuff in their life. some people have it worse. I don’t think 30% of people face insurmountable challenges in life. especially relative to other non-developed nations where it is luxury to have running water.

     

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    But why do you think 30 percent of the population should not treat their medical condition with medication at some point in their lives? Why is it different than treating pain with pain medication? Or a bacterial infection with an antibiotic? **Why do you think mental illness should be different?**

    When I say it’s not about coping skills, I just mean that teaching coping skills isn’t going to keep people from getting traumatized in the first place, which often underlies mental illness. I think it can still be beneficial, but won’t necessarily prevent illness from developing in the first place.

    And then of course, not everyone who has mental illness has it because of “insurmountable challenges in life” or trauma or whatever. Schizophrenia, bipolar, depression is also genetic. I have plenty of patients who say-life is great, I have no idea why I’m depressed. So there’s a lot of different reasons.

     

    #196420 Reply
    Liked by mapplebum
    CordMcNally CordMcNally 
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    But why do you think 30 percent of the population should not treat their medical condition with medication at some point in their lives? Why is it different than treating pain with pain medication? Or a bacterial infection with an antibiotic? **Why do you think mental illness should be different?**

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    I’m neither agreeing or disagreeing with @panscan but in my experience, those with mental illness will typically be on their medications for basically life whereas (most!) people with pain and infections will only be on those particular medications for a short period so those comparisons are probably not the best.

    “But investing isn’t about beating others at their game. It’s about controlling yourself at your own game.”
    ― Benjamin Graham, The Intelligent Investor

    #196421 Reply
    Liked by Craigy
    Avatar wideopenspaces 
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    Earnest refinancing bonus

    it will fix it though for a lot of people. will a hobby cure schizophrenia or bipolar? of course not. but there’s no way we’d have the same amount of depression and anxiety diagnoses if people had something to do with their time. it’s like a mental hygiene theory. their lives have no stress so they make their own. why do we see celebrities doing hard drugs? because their lives have no stress, so they have to make a challenge to have something to grapple with. I would suggest they make their challenge something productive instead of ingesting substances that rot their bodies out

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    I just don’t understand this. You’re saying my stay at home mom of 6 just doesn’t have enough to do and that is why she is depressed? She just needs a hobby? Certainly I have some patients that need more to do with their time. And we address that. But to say that should fix the problem is just laughable. Why do celebrities do drugs? Why do lots of the forum drink alcohol? Because they like it. They aren’t alcoholics because they are lucky to not have that medical condition. Just like a small percentage of the population will have alcohol or substance abuse issues, so will some celebrities. you just know about it because they are famous. Substance abuse isn’t a moral failing. It isn’t something they are doing to “challenge” themselves. It’s a brain disorder. Is this really news to doctors?

    #196424 Reply
    Avatar Panscan 
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    For starters I don’t think an SSRI is as benign as a week of penicillin and the timelines are quite a bit different. I doubt many people are taking an SSRI for like 2 months and then never again in their life. I feel like a more appropriate comparison in that situation is someone has an acute infection so they get antibiotics for a short duration. I would compare that to someone with increasing difficulties with anxiety, depression, etc and then they go to therapy and figure it out after a couple months and are done. vs an SSRI which for a lot of people is probably going to be years if not lifelong. there aren’t too many times we have people on lifetime abx.

    I’m not trying to put a stigma on mental illness or anything like that. I just think the individuals themselves play a huge part in their own treatment and we overlook that and jump to drugs. Have I been down before in my life? Obviously, everyone has. You gotta get back up and realize that it’s probably not the end of the world and devote yourself to something. Would I tell that to a schizophrenic? Again obviously not, but the stay at home spouse with a rock solid family who apparently has depression? Ya probably and that is the person I have a tough time buying.

     

    #196426 Reply
    Avatar wideopenspaces 
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    But why do you think 30 percent of the population should not treat their medical condition with medication at some point in their lives? Why is it different than treating pain with pain medication? Or a bacterial infection with an antibiotic? **Why do you think mental illness should be different?**

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    I’m neither agreeing or disagreeing with @panscan but in my experience, those with mental illness will typically be on their medications for basically life whereas (most!) people with pain and infections will only be on those particular medications for a short period so those comparisons are probably not the best.

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    You know the research shows that in those with more than one episode of depression, staying on an SSRI for life decreases the chance of relapse by 70%? There’s a reason people stay on them long term. Not just doing it for funsies. I am not aware of similar data for antibiotics.

    #196427 Reply
    Liked by childay
    CordMcNally CordMcNally 
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    But why do you think 30 percent of the population should not treat their medical condition with medication at some point in their lives? Why is it different than treating pain with pain medication? Or a bacterial infection with an antibiotic? **Why do you think mental illness should be different?**

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    I’m neither agreeing or disagreeing with @panscan but in my experience, those with mental illness will typically be on their medications for basically life whereas (most!) people with pain and infections will only be on those particular medications for a short period so those comparisons are probably not the best.

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    You know the research shows that in those with more than one episode of depression, staying on an SSRI for life decreases the chance of relapse by 70%? There’s a reason people stay on them long term. Not just doing it for funsies. I am not aware of similar data for antibiotics.

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    I’m not disputing what you said. I’m just saying that when you asked why it was different than being on pain medications for pain or antibiotics for a bacterial infection…that’s why it’s different.

    “But investing isn’t about beating others at their game. It’s about controlling yourself at your own game.”
    ― Benjamin Graham, The Intelligent Investor

    #196428 Reply
    Avatar wideopenspaces 
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    For starters I don’t think an SSRI is as benign as a week of penicillin and the timelines are quite a bit different. I doubt many people are taking an SSRI for like 2 months and then never again in their life. I feel like a more appropriate comparison in that situation is someone has an acute infection so they get antibiotics for a short duration. I would compare that to someone with increasing difficulties with anxiety, depression, etc and then they go to therapy and figure it out after a couple months and are done. vs an SSRI which for a lot of people is probably going to be years if not lifelong. there aren’t too many times we have people on lifetime abx.

    I’m not trying to put a stigma on mental illness or anything like that. I just think the individuals themselves play a huge part in their own treatment and we overlook that and jump to drugs. Have I been down before in my life? Obviously, everyone has. You gotta get back up and realize that it’s probably not the end of the world and devote yourself to something. Would I tell that to a schizophrenic? Again obviously not, but the stay at home spouse with a rock solid family who apparently has depression? Ya probably and that is the person I have a tough time buying.

     

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    But you DO put a stimga on mental illness when you blame the person for their illness. That’s like, classic. You clearly think that mental illness is self contrived, a moral failing, a fault of the individual. You are literally the doctor having the reaction that makes people afraid to disclose their symptoms.

    #196431 Reply
    Avatar wideopenspaces 
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    But why do you think 30 percent of the population should not treat their medical condition with medication at some point in their lives? Why is it different than treating pain with pain medication? Or a bacterial infection with an antibiotic? **Why do you think mental illness should be different?**

    Click to expand…

    I’m neither agreeing or disagreeing with @panscan but in my experience, those with mental illness will typically be on their medications for basically life whereas (most!) people with pain and infections will only be on those particular medications for a short period so those comparisons are probably not the best.

    Click to expand…

    You know the research shows that in those with more than one episode of depression, staying on an SSRI for life decreases the chance of relapse by 70%? There’s a reason people stay on them long term. Not just doing it for funsies. I am not aware of similar data for antibiotics.

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    I’m not disputing what you said. I’m just saying that when you asked why it was different than being on pain medications for pain or antibiotics for a bacterial infection…that’s why it’s different.

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    You are treating the illness as indicated by research. So how is that fine in one situation but not in another? No one is in an uproar about a diabetic on insulin, a stroke patient on blood thinners, etc. No one is telling those people to go get hobbies instead of treating their problem.

    #196433 Reply
    Liked by FIREshrink
    CordMcNally CordMcNally 
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    You are treating the illness as indicated by research. So how is that fine in one situation but not in another? No one is in an uproar about a diabetic on insulin, a stroke patient on blood thinners, etc. No one is telling those people to go get hobbies instead of treating their problem.

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    You’re missing the point I’m trying to make. I’m not arguing with you. I’m just saying trying to make comparisons that you’re trying to make is useless just like trying to make comparisons between other disease states. But…with your regards to this post, there are many other therapies for some mental illnesses (i.e. CBT) than just medications unlike things like…pneumonia. I know you feel defensive since this is in your wheelhouse but I just think you’re trying to argue against someone that isn’t disagreeing with your main point.

    “But investing isn’t about beating others at their game. It’s about controlling yourself at your own game.”
    ― Benjamin Graham, The Intelligent Investor

    #196436 Reply
    Avatar wideopenspaces 
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    I am going to peace out of this conversation now because it is clearly something I am VERY passionate about. I love my patients and I’m protective of them and it’s painful for me to see their illnesses and struggles belittled by those in the medical establishment. I know I’m not going to change any minds by continuing to argue about this and it just is what it is. I will end by saying that I don’t think that psychotropics are the be-all, end-all treatment to every life ailment, but they certainly have a place in helping people to be functional in their lives. And I would hope that my patients never feel like I’m just a pill pusher as I do my best to try and understand all the facets of their lives and how they are contributing to their current symptoms and what we can do to address those things.

    #196437 Reply
    Avatar FIREshrink 
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    Status: Physician
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    When you make the decision to go into psychiatry you make it knowing:

    – you will get the crappiest office in the oldest building on campus, usually without HVAC

    – one of your med school attendings will tell you ‘it is a waste you are going into psychiatry’ and think it is a compliment

    – you will be asked by well-intentioned and concerned colleagues if it’s true that most psychiatrists have their own problems

    – your patients will be stereotyped and stigmatized, even by physicians, even in 2019

    Plus ça change, plus c’est la même chose.

     

    #196512 Reply
    ACPC ACPC 
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    Joined: 12/31/2018

    I am going to peace out of this conversation now because it is clearly something I am VERY passionate about. I love my patients and I’m protective of them and it’s painful for me to see their illnesses and struggles belittled by those in the medical establishment. I know I’m not going to change any minds by continuing to argue about this and it just is what it is. I will end by saying that I don’t think that psychotropics are the be-all, end-all treatment to every life ailment, but they certainly have a place in helping people to be functional in their lives. And I would hope that my patients never feel like I’m just a pill pusher as I do my best to try and understand all the facets of their lives and how they are contributing to their current symptoms and what we can do to address those things.

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    Dear Wideopenspaces – Sorry to pull you back into the conversation, but I’d really like your opinion, along with FIREshrink. Hopefully others will chime in.

    How do you feel about DBS for depression? Or OCD? We’re making some real headway with tech & algorithms, and with emerging pre-implant diagnostic imaging will likely be able to better identify who will benefit. Will you feel comfortable referring your patients for this?

    #196514 Reply
    Avatar Dont_know_mind 
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    Although I do have a lot of sympathy for wideopenspaces view, I do tend to think that mental disorders are still disorders rather than diseases where the pathophysiology is well understood. It is getting there with Schizophrenia perhaps but something like depression is still a fairly heterogenous group. Particularly with the diagnostic inflation that has occurred with subsequent iterations of DSM, there will be societal pushback about labels. We should expect that. There is a cost in handing out labels and the associated sick roles as well as benefit. I find this in medicolegal psychiatry and compensation cases. It ties in with investing, in that we are dealing with human beings where incentives are important motivators of behavior in a significant subgroup (although not all).

     

    #196515 Reply
    Liked by portlandia, Anne
    ACPC ACPC 
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    When you make the decision to go into psychiatry you make it knowing:

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    I’ll preface this post with the caveat that some of the most intelligent people I know and respect the most are psychiatrists.

    At the risk of throwing gasoline onto the fire (pun intended), the most negative stereotype folks from the other two parts of the brain medicine world (neurology/neurosurgery) seem to have about psychiatrists is the following: They function in a cognitive framework that is internally consistent and shrouded in its own lexicon, with some overlapping language (mostly related to either neurotransmitters, or anatomical words that aren’t simply related to the structures they refer to ‘limbic’/’frontal’/etc), but this framework does not have a well-articulated correspondence with the biological substrate (brain) that is the root of the disease. Psychiatrists then prescribe drugs to treat the framework, but these drugs have only limited efficacy and a lot of side effects because their widespread effects on the brain are not well-understood.

    My personal experience is that this stereotype is the one that is most infuriating to psychiatrists, and I suspect that there is some fundamental truth to it. However, given the complexities involved and how poorly we understand the brain network dysfunction that produce most psychiatric diseases, I do not see how it could be any other way. Psychiatry provides an incredibly important service and I feel that this will only grow, since the structure of our daily lives (and society in general) seems to be more and more adept at undermining the mechanisms that our brains evolved to reinforce decisions, actions, and outcomes.

    Is there a concerted attempt within psychiatry to integrate emerging systems neuroscience into the DSM structure (or vice-versa)? Isn’t there some truth to the accusation that psychiatric therapies for serious disease should integrate exercise and radical lifestyle change to alter how endogenous brain mechanisms are influenced by their environment? Isn’t this better than trying to accommodate people as they are with a heavy psychoactive drug regimen (not that it should be one or the other)? Wideopenspaces brought up diabetes and insulin, but as physicians we do encourage radical lifestyle interventions, including surgery, to bring down their weight and reduce their medication load.

    Anyhow, I hope that I have not offended, that is not my intent.

     

    #196516 Reply
    Liked by Craigy

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