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Noise and Disinformation: Mental Health Treatment and Social Media
168 Plays2 years ago
Today we cover what we see as some of the noise and disinformation around mental health treatment. We explore social media's benefits and pitfalls as a space for learning about potential remedies: from giving patients greater autonomy and information, to unsafe substance usage with potentially harmful outcomes.
We hope you enjoy it and take something away.
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Transcript
Introduction and Podcast Origin
00:00:01
Speaker
Hello, I'm Dr. Farah White. And I'm Dr. Grant Brenner. We're psychiatrists and therapists in private practice in New York. We started this podcast in 2019 to draw attention to a phenomenon called the doorknob comment. Doorknob comments are important things we all say from time to time, just as we're leaving the office, sometimes literally hand on the doorknob. Maybe we're afraid to bring certain things out into the open or are on the fence about wanting to discuss them.
00:00:29
Speaker
Sometimes we know we've got something we're unsure about sharing and are keeping it to ourselves.
Social Media's Impact on Mental Health
00:00:34
Speaker
And sometimes we surprise ourselves by what comes out. Today Farah and I cover what we see as some of the noise and disinformation around mental health treatment. We explore social media's benefits and pitfalls as a space for learning about potential remedies. From giving patients greater autonomy and information, to unsafe substance usage with potentially harmful outcomes. We hope you enjoy it and take something away.
00:01:04
Speaker
Okay, a big deep Zen breath. For anyone feeling some stress, it's been a fun day for me, but a bit of a stressful day.
00:01:15
Speaker
Here's the segue. For people in our profession, we want the best for our patients. And part of that is to have access to good information about mental health, about psychiatry, about therapy. That's one of the things that motivates us. That's one of the missions of our podcast.
00:01:36
Speaker
And so we have seen in the last few years an increase in interest in mental health on social media platforms. And that's great. It shows that stigma is declining, that people are more open about their own problems. But at the same time, we have seen information which can be inaccurate at times misleading.
Challenges of Misinformation in Mental Health
00:01:56
Speaker
And while we want patients to be educated, we want them to be educated with good quality information so that we can offer the best collaborative treatment.
00:02:05
Speaker
With that in mind, Farrah, what have you been noticing?
00:02:10
Speaker
I have seen that a lot of times patients who I'm working with either closely or just getting to know will be exploring various parts of the internet, whether it's going deep into a Reddit thread or just following their favorite influencers journey with mental health or medication or the things that helped them. And sometimes you're right, it can be really great because it sort of
00:02:40
Speaker
destigmatizes and demystifies mental health. But sometimes it really is one person's story. And like in our field, we call that something that's anecdotal, right? So it means that it's just one person's experience.
00:03:01
Speaker
with either a medication or a type of therapy, whether it worked out or it didn't work out, it doesn't really mean that we can apply that to the general population.
00:03:13
Speaker
Right. This is really important because if you think about how advertising and marketing works as an example, not as a direct parallel, these stories, testimonials are very convincing and giving people data is not convincing. And so it creates an information sort of problem. How do you get good information to people in a persuasive way that is aligned with evidence?
00:03:40
Speaker
so that we can make informed decisions. I've seen this a lot with, for example, some of the newer treatments for depression or post-traumatic stress disorder based on psychedelics, like MDMA, psilocybin, ketamine.
The Rise of Psychedelics and Self-diagnosis
00:03:55
Speaker
They can be wonderful treatments for a lot of people. Or we see this with certain forms of therapy, like cognitive behavioral therapy, which are better marketed and packaged for the general public.
00:04:07
Speaker
When you look at the data, they're not necessarily better. And in some cases, it may be that other forms of therapy have a more durable effect. They last longer, create deeper change. And that data is there, but may not be packaged and shared. So for example, we're seeing a rise in TikTok's popularity as reported in Penn Medicine News.
00:04:30
Speaker
In October of 2021, they say TikTok's popularity rapidly increased at the start of the COVID-19 pandemic, growing 180% among 15 to 25-year-old users in 2020. During this time period, the Kaiser Foundation reported a spike in mental health concerns. About four in 10 adults in the U.S. reported symptoms of anxiety or depressive disorder increasing from one in 10 adults in 2019.
00:04:55
Speaker
Now as they say correlation is not equal to causation but it suggests that the increased interest on social media is helping people identify that they may have a problem.
00:05:09
Speaker
One of the issues, though, is, for example, when people come to someone so ordinarily, right, if you go to see a health care professional, a physician in our case, you would go to them and say, this is what I'm feeling. These are the problems I'm having. What do you think is happening? And then the doctor therapist, whoever it is, would ask questions, do tests if appropriate. Psychiatry notoriously doesn't have many, if any, tests.
00:05:39
Speaker
And then arrive. We have scales. We have scales. There's certain, you know, you can look for low thyroid problems for depression, but we don't have biological tests like the way for kidney disease. You can check blood, urea, nitrogen and creatinine and electrolyte levels and determine if kidney function is impaired. There's no analogy like that yet.
00:06:01
Speaker
It may be that in the future, say functional brain imaging or some biological markers would serve that function. But right now, I mean, the basic medical paradigm is the same in psychiatry because testing is not the be all end all for diagnosis. Oftentimes it's confirmatory or the gold standard, but you would tell your doctor like what symptoms you're experiencing, what kind of problems you're having. And the doctor would come up with what's called a differential diagnosis, meaning a list of possible diagnoses.
00:06:30
Speaker
In psychiatry, we would look at symptoms and compare them to patterns to come up with a diagnosis. For depression, these criteria are that you have five symptoms out of nine that are present for at least two weeks, not better accounted for by another medical condition like low thyroid function and causing clinically significant distress or dysfunction.
00:06:54
Speaker
But what we're seeing more and more of with social media, and in a lot of ways, I think it's positive, but we're not really there yet with the way information is managed, is people coming in and saying, I think I have X, give me Y medication. And sometimes that's really helpful, self-diagnosis.
00:07:15
Speaker
But sometimes it can throw you off the track of what's really needed. And this is bringing it back to your point about anecdotal evidence. A lot of times that self-diagnosis is based on anecdotal evidence or it may be based on the person reviewing diagnostic criteria online, but not within the context of the bigger picture since many psychiatric problems
Stigma, Misunderstanding, and Trust Issues
00:07:38
Speaker
either masquerade as one another, so it may look like attention deficit disorder, ADHD, hyperactivity disorder, but it may really be an anxiety disorder or bipolar disorder, which can impair attention and vice versa. So the relationship between experts and patients has also shifted.
00:08:00
Speaker
which I don't think is an overall bad thing. I just wish that there were a way to sort of contextualize what people are seeing or reading and understanding that someone else's experience, even if it's someone that, let's say, we admire or we identify with,
00:08:21
Speaker
you know, is not necessarily going to be our experience. You know, I think one of the things that a lot of people don't know about depression is that it can, people can inherit a predisposition for depression or anxiety and low mood or feeling sad for a time. For example, after a breakup or even feeling sad,
00:08:45
Speaker
in the context of something that's more confusing, like something good happens, but then people feel deflated. We should distinguish that from a true clinical depression because the things that help us get better when we're feeling sad, maybe talking to a friend or going to our favorite yoga class, whatever it is, are things that can help shift our mood
00:09:11
Speaker
but are probably not going to lift us out of a true clinical depression. And I do feel that a lot of times when those things get mixed up, the people who are truly really depressed and one of the hallmarks of depression is feeling disconnected and disengaged and not enjoying things anymore. They may feel like, well, I'm doing everything right.
00:09:34
Speaker
how come I'm not feeling better? And I shouldn't take medication because I've seen online that medication doesn't work or it causes these side effects. So they don't even necessarily give themselves a chance to hear without any biases, like what is out there and what's available to them. It sounds like that's been hard for you in some ways. And you mentioned earlier something about, especially with people who you don't know as well, kind of new patients or inquiries,
00:10:03
Speaker
I think there's been a kind of a broken relationship between healthcare professionals, doctors, and patients where there's a level of skepticism. There are people who are like anti-psychiatry, right? As I talk about diagnostics with you, I'm aware that some listeners may not sort of buy into that or believe it or think that they're corporate motives.
00:10:27
Speaker
You know it's true that there are connections with people who you know produce these diagnostic models who might be on the advisory board of pharmaceutical companies but i think for people like you and i who treat patients kind of on the front lines and.
00:10:43
Speaker
find it hard to be caught in the middle of these often difficult to tease apart dynamics. And I can understand patients might have a level of skepticism. I've had plenty of people sort of make a joke like, well, don't you have to prescribe meds or don't you get paid more? And I'm like, no, no. I mean, I don't meet with drug reps.
00:11:05
Speaker
I don't get any benefit from them. I avoid advertising. I have since I was a resident because I understand how it works. But I think you're expressing a genuine concern for patients who may not have access to treatments that can help because of the noise and disinformation and not knowing where to go and having some mistrust of doctors who they don't know well. And plenty of people have had bad experiences with, you know,
00:11:33
Speaker
with doctors, therapists, et cetera, before they came to see you, stuff. Right, and plenty of people share their negative experiences. I think that there's room for every story, but I do think that, you know, one of the problems with these algorithms is for social media, like if you watch one story, right, about a person who had a lot of trouble titrating off an SSRI, which does happen. Yep, discontinuation syndrome.
Medication and Treatment Standards
00:12:01
Speaker
Right, right, which is not dangerous, but it is pretty unpleasant and... It's not usually dangerous.
00:12:09
Speaker
It's not dangerous the way alcohol withdrawal can be dangerous, which can be lethal and cause serious problems. Sometimes when people abruptly withdraw from psychiatric medications, typically shorter acting antidepressants, which is many of them, they can experience very unpleasant symptoms, occasionally irritability, outbursts of anger, but rarely does it cause any kind of detriment
00:12:34
Speaker
And from a psychiatric point of view, we don't really believe there's long lasting discontinuation syndromes. But certainly if you go on social media discussion groups, people will describe that I try to keep an open mind. And we don't really understand the neurobiology of exactly why that happens yet. Right. Absolutely. And I do think that any time someone is considering a medication,
00:13:00
Speaker
they should have a plan for, you know, well, how long is this going to last and how am I going to come off of it? But the best in my belief, the best prognostic factor, and I think this is like scientific, you know, there's evidence to back this up, is that if you have a doctor that you trust to guide you through it and to prescribe appropriately and taper appropriately. People do better. Yeah. Yeah.
00:13:26
Speaker
Yeah, there's evidence for that. The treatment alliance is one of the predictive factors, one of the relatively few predictive factors for long term outcomes. Yeah. But if there's not a lot of trust there and if people jump around or they're not sure and they don't feel comfortable talking it through, it's not like you and I prescribe things and all of our patients are like, OK, great. Thanks, doc. Like, see you next week. Like, that's that's not what happens.
00:13:55
Speaker
We have to be open to a discussion of why we think something might be helpful. You know, what are the other options? There's always an option not to take medicine.
00:14:05
Speaker
Yeah, I don't think that's how you and I work, but I feel confident that in every profession, there are people who work in different ways. And I've heard plenty of folks come in and say, I saw someone, I saw a psychiatrist, I saw a therapist, they listened to me for five minutes, they made a quick diagnosis, they gave me a fistful of prescriptions. I guess this was back when paper prescriptions were more common.
00:14:30
Speaker
And then I had a bunch of side effects. I didn't really know what it was for. I called and I didn't get a call back. That's one of the reasons why, for me anyway, I started a group that takes insurance and tries to treat people according to best practices. So there's a level of understandable mistrust toward every professional group. You see the same thing in the law, right?
00:14:53
Speaker
where you can do your own legal work basically. If you need to file a corporate thing in your state, you can do it online and avoid higher legal fees and it's probably equivalent. But we've seen the same thing in mental health and it's really debatable whether some of those kind of
00:15:11
Speaker
quick and sort of customer, what's the right word, not customer friendly, but essentially giving people what they think they want, like a quick diagnosis without a proper full evaluation, without good support on an ongoing basis is kind of what people want.
00:15:31
Speaker
Give me my give me my refill. Right. And, you know, I've had I've heard stories like, why can't you just set it up for automatic refill? It's like, well, in medicine, we put patient safety first. It's called, you know, first do no harm. But I think I know the answer for you. I think I know the solution here. Right.
00:15:52
Speaker
Well, if you're kind of caught between being a psychiatrist who is ethical and conscientious and collaborative and patient-centered and influencers who people may identify with,
00:16:08
Speaker
and kind of believe everything that they say because of the glamour and the connection. And there's interesting research on how people relate to influencers as a kind of a substitute for, quote unquote, real relationships. You know what I'm going to say, right? That I need to. You need to be both. Yeah, exactly.
00:16:28
Speaker
And I think in a lot of ways that's what we're seeing. We're seeing people in our profession try to get out there and offer credible, you know, medically sound information. Right. I love that they're doing that.
00:16:44
Speaker
I wanted to bring up the idea of why we can't do the automatic refills and why we can't speak out. And one other thing that sort of distinguishes us from a lot of the other people out there, right? We're held to a certain standard by the medical board and the medical board is this large piece of wood.
00:17:05
Speaker
It's a different kind of board. It feels like that. It feels like that sometimes. There's a lot that goes into... There's constraints that were held to a higher standard.
00:17:17
Speaker
Right. And that means that we can't say certain things that we might believe, right? We know part of it is rooted in, you know, the history of psychiatry and this Goldwater rule, which meant that psychiatrists couldn't come out and like diagnose people that they hadn't treated. And now we have HIPAA. So there are a lot of things that we can't say, even if we believe.
00:17:43
Speaker
And the stuff about psychedelics, people are able to share their stories, and that's great, but they're not approved for us to give out to patients yet.
00:17:54
Speaker
But I know psychiatrists who will recommend them. And there is data on psychedelics. But if you're if you're constrained by the sort of relationship with your professional bodies, right, that's sort of debatable. But the major psychiatric organizations and the FDA also haven't made a determination that there's an evidence base. And of course, in medicine, a lot of
00:18:20
Speaker
Advances have come from doctors not who do something wrong so to speak but who are willing to be early adopters. And advocate for treatments that can help people.
Evidence-Based Practices and New Treatments
00:18:33
Speaker
I don't doubt that many of these treatments are helpful to people. I've seen them help people. I also think there's, especially early on when something new becomes available and there's a terrible unmet need as there is with the treatment of depression, trauma, other things, that anything that seems to work well and quickly, it's quite natural to want to use that product, right?
00:18:55
Speaker
But the pooled data is still kind of out. So if you're a psychiatrist who waits for the data to come in and get enough of a group of people to make a really reasoned decision and figure out for whom it's going to be helpful and for whom it might hurt and not just kind of jump in feet first because there's almost like a religious fervor sometimes, then there's a lot of people who aren't going to want to take your advice and they'll find people who give them the advice they want. Yeah.
00:19:26
Speaker
which is absolutely fine, but I do think that we should distinguish that from the work that we do, which really is evidence-based and that these constraints and the liability that comes with it is very different from someone who might decide that they're going to be a healer or they're going to help people microdose or they're going to help people
00:19:51
Speaker
at music festivals, that's just a different thing. And the structure around it is different. Well, the psychiatrists who I know and who I respect and who talk about, for example, psychedelic treatments,
00:20:10
Speaker
Will recommend them within the best evidence based framework that there is typically in a certain type of set and setting where there's a significant amount of psychotherapy and intentionality around what the treatment goals are.
00:20:27
Speaker
And I think there's an understanding that those treatments are effective when they're used in a therapeutic way, because they've been around recreationally for a long time and they don't work if they're not used in a therapeutic way. Though I think just to be a little controversial, the evidence for psychiatric medication, conventional medication, is also evidence that we can look at very critically.
00:20:53
Speaker
For sure. And I think there was this backlash against the whole serotonin hypothesis. The difference in my mind is that on one hand, you're using something that has been proven to be relatively safe and things that have been on the market for years and decades. And not generally contaminated or adulterated.
00:21:19
Speaker
Right. Versus, you know, certain things that are of a different market. And I will always say to patients, you know, I'm just, my only concern is the source of this. Because we don't know exactly, you know, if something doesn't come from a pharmacy and we're not sure about the source, that's where the risk is. People may think they're taking one thing and they're taking another.
00:21:43
Speaker
And I'm sure you and I have both seen negative outcomes there. People who have taken something that wasn't what they thought it was and have to deal with recovering from a significant psychotic episode for quite a long time and may even permanently alter them.
00:22:01
Speaker
But in terms of conventional medications, the serotonin hypothesis is interesting. After that news story broke and it just took over the internet, about a week or two later, another paper was published where a group of researchers actually found evidence for serotonin neurotransmission being implicated in patients with depression in one well-designed study. You need to replicate these studies, comparing patients with depression with patients without depression.
00:22:31
Speaker
And they showed evidence for that serotonin was involved. I think we understand that serotonin, neurotransmission, brain activity later on in the brain or downstream as they say,
00:22:44
Speaker
affects the glutamate activity in the brain, which is glutamate is like monosodium glutamate. Same molecule is one of the primary excitatory neurotransmitters in the brain, especially in decision-making areas. But distributed throughout the brain, there's excitatory, like activating factors, and there's inhibitory or damping factors.
00:23:09
Speaker
and the two big neurotransmitters there that everyone's thinking about are glutamate is excitatory and GABA aminobutyric acid is inhibitory. And it's interesting because a lot of the novel therapeutics, the ketamine type drugs, act on the NMDA receptor, which is a glutamate receptor involved in learning.
00:23:32
Speaker
and the brain's ability to change, which is called neuroplasticity. And even some of the newer oral antidepressants, there's one that broke in the news, which is a combination of well-butrin, which most people have heard of if they've heard of psych meds, and dextromethorphan, which is better known as a cough suppressant. Turns out dextromethorphan actually interacts with NMDA receptors and may have some ability to help patients with a rapid antidepressant effect,
00:24:00
Speaker
And one of the interesting pharmacology factoids about that is it's not necessarily well butrin's antidepressant actions that make that useful in combination with dextromethorphan.
00:24:12
Speaker
but it's that it inhibits the metabolism of dextromethorphan. And so it increases levels in the brain so it can be more therapeutic and maybe minimize some of the side effects. So there's some understanding what's the take-home point here is, well, one of the things is hopefully a prescribing psychiatrist will have that expertise that they understand things like drug interactions.
00:24:36
Speaker
or something people may not know is that, doesn't grapefruit juice do something? This is a Socratic question because I know the answer to it. But what does grapefruit juice do to a lot of drugs?
00:24:48
Speaker
increases their metabolism. It inhibits some liver enzyme, right? 2D4 or 4A6. I don't remember. I'm teasing about cytochrome P450s. But these are some of the things we're saying where influencers are great, like there's a lot of benefit that they do by raising awareness, but the detail of knowledge that people may not know
00:25:11
Speaker
is that there is medicine behind these things, things like food and when you need to take the drugs and how they can interact with other medications, that there's safety issues, right? Yeah, safety issues and liability issues.
00:25:31
Speaker
which, you know, maybe that's where that's the difference between taking something from your psychiatrist and taking something from someone at a party. Well, the liability is probably higher if you take something from someone at a party in the sense that that would be criminal.
00:25:49
Speaker
No, no, no. Our right. No, but I mean, there's no, they don't, they're not necessarily going to be held accountable. There's no treatment agreement. There's no duty. You know, we have a duty to do right by our patients. And I think that's,
00:26:05
Speaker
if I'm sort of translating, why is that important to you and to me too, is it constrains us, as you said earlier, from maybe suggesting things that we might think could help because our first duty is to do no harm. So what do you do, you know, when someone comes in and they say, like, I want to try micro dosing. And, you know, it's like, okay, it's
00:26:31
Speaker
If you're taking, you know, if you can get access to unadulterated psilocybin, which is questionable, and I have no way of checking that. Like, I don't know that there's a lab where I could do that. Right. We can't do quality control. It's not within our scope of practice at this point. It may be FDA cleared. That would change things. And they say, well, I know it can interact with antidepressants because, hey, they both act on the serotonin system in different ways.
00:26:57
Speaker
Is it safe and you kinda go i don't know but i don't recommend that combination for x y and z reasons. That's a tough spot for you to be in because you know that for some people that could help and then.
00:27:11
Speaker
if they go ahead and do it anyway, then you're there for them, right? Unless you think that it's something really dangerous and then you kind of say, I can't in good conscience, you know, participate. That might be the case if they're consuming a significant amount of alcohol with medications that are known to interact with alcohol and significantly increase the risk of liver damage. Then you might have to say, I can't keep working with you. So you have to make a judgment.
00:27:37
Speaker
All of these complexities are things that we think about every time we write a prescription. Yeah, that's right. And you don't get that from an Instagram reel. Right. That person doesn't know what other medicines you might be on. They don't know your family history. They don't know necessarily what previous episodes of depression were like in intensity.
00:28:03
Speaker
or duration. Right. Or reactions you had with other drugs. Right. Right. So I just that's what I want people to know that when we make those decisions or we have those conversations, the intent behind it, it doesn't mean that everything we prescribe is better than, you know, psychedelic therapy. It doesn't mean that at all. And I've seen patients, my own patients who really
00:28:31
Speaker
had great experiences with it. And I'm so happy for them. And that's something that they sought out. And it was a conversation that we had, because they weren't getting the results from the treatment with me. Right. And we wish that there had been more research earlier, right? There's not great reasons why that hasn't happened yet with a lot of different
00:28:52
Speaker
potentially useful molecules. Including cannabis is also controversial. There's real evidence that high potency THC heavy cannabis increases the risk of serious mental illness for some people. There's more evidence that CBD might have therapeutic benefits. There's a couple of formulations that have been tested for certain conditions. But I think what you may be experiencing is there's not a tremendous amount of sympathy for
00:29:23
Speaker
professionals nowadays. In fact, there's probably more skepticism on average, or at least it's more publicized, right? People are not going to get up on a social media platform to like champion sort of good old fashioned, careful psychiatric medical care. They're going to get up and
00:29:41
Speaker
make strong claims that depression isn't a real thing. And if you essentially blaming people for being depressed, if you ate better, it's like blaming people for having cancer. If you're eating too much sugar, it's causing inflammation.
Environmental and Social Influences on Mental Health
00:29:57
Speaker
You're not gonna get a lot of sympathy as a psychiatrist.
00:30:00
Speaker
Unless you become a very, very influential, you know, influencer. Right. But I don't think we should have to be influential to tell people that listen, your cancer or your depression is nothing that you did or didn't do. Most likely. Well, there's environmental factors and we want to kind of understand that. Okay, but most. Right. Most likely. I learned a new word recently for that. You know, what's that?
00:30:31
Speaker
I'm going to look it up. I think it's the exposome though. Exposome? Yeah, it's exposome. And it's defined by the CDC. The exposome, E-X-P-O-S-O-M-E, like genome, can be defined as the measure of all the exposures of an individual in a lifetime and how those exposures relate to health. An individual's exposure begins before birth and includes insults from the environmental and occupational sources.
00:30:59
Speaker
Understanding how exposures from our environment, diet, lifestyle, etc. interact with our own unique characteristics such as genetics, physiology, and epigenetics impact our health is how the exposome will be articulated. It comes up with what are called the social determinants of health.
00:31:15
Speaker
things like low educational socioeconomic status. It fits in with what we call the biopsychosocial model, which is the holistic psychiatric model. And it includes things like structural racism or systemic racism's effect on health. And what they found is that adverse ADIs, which is like adverse
00:31:35
Speaker
I'm forgetting what the acronym means, but it's basically the zip code you're from is a strong correlate of negative health outcomes. And if they move you to a better zip code, your health gets better. And there's even studies that things like chronic effects of racism affect how the genome is translated so that there's more stress reactions, you know, the epigenetics. So there's environmental factors that people can control. But by and large, if someone has a serious mental health issue, we don't think
00:32:01
Speaker
that environmental modification alone will get them out of that, depending on the severity and the cause. And obviously, and obviously, we don't think that it's anything that they did or didn't do. And we distinguish actually between psychosis that's like organic. And, you know, we don't we can't pinpoint the reason versus psychosis that comes from, let's say, taking
00:32:31
Speaker
either a medical reason for that, which is known sort of as delirium or potentially something that they may have taken.
00:32:41
Speaker
Well, delirium is characterized by a fluctuating course, usually differentiated from dementia, and psychosis can have many causes. And we also, I think in general, don't think that medications are the right treatment for everyone who comes in with X, Y, or Z a problem. Right. But my point is that when someone is unstable or psychotic,
00:33:07
Speaker
And let's say in the absence of infection or intoxication, it's probably not something that they did. In terms of causing the problem. Yeah. Correct. Because I think that there's.
00:33:21
Speaker
sometimes people look like, oh, why did this happen to me? Well, I think that goes to the stance, like, how do you hold yourself accountable in a healthy way? And maybe that's a different podcast episode. But you know, on one hand, like extreme self criticism, or professionals essentially blaming people for their problems versus
00:33:41
Speaker
let's look together at all the different factors and see what's gonna get you where you wanna be. And some of those things might be environmental changes and some of those things are under our control in theory and some of them aren't. Right, but for the most part, I would say that like we don't know as much as we would like to know about why people suffer from one thing or another.
00:34:05
Speaker
Yeah, there's more we don't know than we do know. And I think the future holds a lot of promise, because I think the better we understand how the brain works, the better, you know, interventions are going to be. But you're using neuroscience right now by talking and listening and thinking. Most people aren't aware of that. But yeah, I'm just saying that, yeah, I find all of this stuff really interesting. And
00:34:31
Speaker
I try to make use of it in the ways that it's useful, but I also maintain a degree of skepticism. Well, there's a lot of uncertainty and ambiguity in medicine and other areas of life. And in psychiatry, it's quite high for the reason that you're describing. And I do think that the scientific approach so-called, you know, holds promise. In the meantime, it's understandable that in the absence of clear direction and
00:34:56
Speaker
for sure, you know, outcomes. People who are suffering will try different things because conventional treatments don't always work. And we acknowledge they don't work as well as we want. I think every psychiatrist that I know would like something that would work right away and be safe and effective, right? That would be amazing. Do you have anything in the works?
00:35:16
Speaker
What are you going to do, though, for a job after we can do that? Oh, my gosh. I have so many things I want to do once everyone is better. Yeah. Well, yeah, I know. There's plenty of jokes that come to mind for me. One of them is like everyone in mental health profession should go on strike until the world decides to act supportive, collaborative, and kind with one another in sort of idealistic wishes.
00:35:43
Speaker
What about nutraceuticals? Is there a word to say here on that in terms of like, you know, essentially a lot of there's very so first of all, there's very little data. There's only a couple of nutritional interventions that have been shown to have any clinical effectiveness for people with clinical conditions.
00:36:01
Speaker
meditation has probably a stronger and better proven effect size, and I'm much more comfortable recommending and reviewing the evidence on meditation. There's a few supplements that seem to help with mild depression and anxiety. Many of them have unacknowledged risk factors, like lavender, I think, can cause certain types of problems. I think hepatic damage, but I may be confusing that with cava.
00:36:24
Speaker
It's also teratogenic. It can cause birth defects. So there's not a lot of information and there's a lot of advertising. It's very anecdotally based. It's very testimonial based. The placebo effect is huge for everything, for conventional psychiatric.
00:36:41
Speaker
placebo effect is when people take something that's not really better than like a placebo, which is a sugar pill. But they because they believe that they're taking it, it has an effect on right? Yeah, the brain's ability to kind of quote unquote heal itself. And that goes for the therapeutic alliance. There's
00:37:00
Speaker
a large body of less recognized evidence that the relationship with the psychiatrist or the prescribing clinician, it could be a nurse practitioner or a PA in some cases, some cases psychologists, that the relationship, the therapeutic alliance is a bigger predictor of the benefit of medication than the medication itself, which is sort of startling.
00:37:24
Speaker
But with nutraceuticals, you see like a lot of claims and then the fine print, these statements have not been evaluated. I don't quite understand why that is allowed.
00:37:34
Speaker
Well, it's allowed because it's something that's really, really hard to legislate. People can put anything that they want in a bottle and sell it. They don't need FDA approval.
Risk Management and Patient Safety
00:37:47
Speaker
That's the difference between that and something that comes from a pharmacy and something that we've written. So I guess what I'm saying is there's endless, there's really endless opportunity for something
00:37:59
Speaker
That's amazing to come out of that, you know, like potential new cures for depression. But on the flip side, because of the lack of regulation, it could be really dangerous.
00:38:13
Speaker
And some nutraceuticals will have lab testing that you can obtain, at least to verify that you're taking what's being sold. And people could make the same criticism of psych meds. They talk about the therapeutic benefit, and then someone speaks really fast at the end of the commercial, the fine print.
00:38:32
Speaker
but you're hopefully getting a conversation about the risks and benefits. That's a big difference, yeah, for sure. But you can think through it with someone informed. It's not just like, exactly. It's not like, just take this, it's gonna change your life. And by the way, there's no risk, right? I look at things and I think there's always risk. And there are certain things that are like more good than bad, but even this ideal vegan diet, eight hours of sleep, all of this, it's not right for everyone.
00:39:01
Speaker
I think one of the things is people, and I know we're coming to the end of our time, and this is a whole other topic that's really interesting to me, goes back to this idea of uncertainty, but also how do people think through things nowadays when it's so fast, the information is coming all the time, social media, and
00:39:22
Speaker
I see this because people oftentimes don't want to read stuff. They don't want to think through things or it's maybe not that they don't want to. It's just not our habit as much anymore. And so I see this when I teach, you know, I see it in blog posts, they're getting shorter and shorter. And so our, you know, the attention span, social media and the pandemic, you know,
00:39:45
Speaker
makes it such that this kind of conscientious risk management, well-trained and educated service that someone such as yourself offers
00:39:59
Speaker
is not necessarily what people are looking for, even if it is sort of arguably likely to be safer and more effective. And then there may be other people who don't have as much of a concern about risk. And so they're more comfortable offering things that aren't tried and true. And yeah, of course, some of the times that's going to really help people a lot.
00:40:23
Speaker
But you're much less likely to hear about someone talking about a negative experience than a positive experience in a testimonial because it's not balanced in any way. And you can criticize the scientific method, but still there's an effort to be balanced. I don't know, it's hard to make, moral relativism gets in the way. It's hard to say who's better than anyone else. And that's part of the problem because the argument is going to be, well, how can you make a claim that your expertise is any better?
00:40:52
Speaker
And then the argument, the discussion goes nowhere. Right. And I am not saying necessarily that it is better. I think that's okay. I think you think it's a preferred approach. Well, it's the approach that I chose, right? Because I am someone who's risk averse, right? And I wouldn't want to take a medication without sort of understanding exactly
00:41:17
Speaker
what it's supposed to be doing in my body and understanding what the risks are. That's, you know, just the type of person I am. And so, yeah, my professional identity is consistent with that. But I know that it's not right for everyone. It seems wise, right? That's so old school. You know, just make impulsive decisions. I mean, about some things I do, right? Like what am I going to have for lunch, but not like what am I going to put in my body?
00:41:44
Speaker
for the next four to six weeks. Like, no, I want to know what that's going to do. I mean, that seems to make sense, but it's just, it's so curious to me that not everyone sort of thinks that way. And of course you need people who take risks. You know, I'm thinking on an evolutionary perspective, if you have a group of 10 people trying to kind of build an effective community, you need a few people who are really risk averse.
00:42:08
Speaker
because they're going to go like, hold on. And then you need a bunch of people who are going to be like, no, like cowabunga, like, let's let's let's give it a shot. And then the risk averse people can be like, OK, let me know how it goes.
Evolutionary Perspectives on Risk and Conclusion
00:42:21
Speaker
If it works, like, I'll try it, right? It's like a food taster. There's always going to be if you're starving, someone's got to be the person who's kind of inclined by evolution or environment to take the risk for the group.
00:42:35
Speaker
We also see that's why certain age groups are more willing to go to war and probably who die from homicide and suicide more are kind of young, stereotypically male risk takers. It's good for the group to have people who are more risky and so people like you can hang back and reap the benefits of our sacrifice.
00:42:59
Speaker
and carry the wisdom forward for future generations. It makes sense evolutionarily. That's a good point. If you believe in evolution. You're right. Oh, God. I think our listeners believe in evolution. Okay. Well, thank you for talking about this today. Yeah. I appreciate your patience today. I know it's a tough day for you. We had some tech problems and
00:43:29
Speaker
We overcame though. I really didn't respond. There's a strong evidence base for resilience. I guess that's it for today. Anything else you wanted to throw into the hopper? No, thanks for listening.
00:43:47
Speaker
I had one thing. This is sort of a paper I read and it's going to leave things open more than not. But it was a review of all the data on lifestyle-based interventions for depression. And so they looked at like thousands of papers and they went through them. They rated them based on the quality of the evidence.
00:44:08
Speaker
The best quality evidence is either a large review of data or trials that compare treatment to a placebo, to a control group. And they had like exercise, sleep, smoking cessation, workplace interventions, mindfulness.
00:44:28
Speaker
green space interventions and maybe one diet and maybe one other. And they had three or four, they had four categories of evidence from like strong, limited, low and absent. And none of the lifestyle based interventions for depression had a strong evidence base. The strongest evidence base was limited. And so the way they translated that into action and they did have, you know, recommendations. And I posted it as a blog on one of the blogs I write for.
00:44:58
Speaker
strong evidence would be should, limited evidence is could, low evidence is may or might help. And so I just found it really interesting that at least based on the evidence for a spot like lots and lots of people, individual, you need to make your own plan, right? That works. The best evidence for lifestyle interventions wasn't any better than could help.
00:45:23
Speaker
doesn't totally surprise me. There's kind of a book on that called Natural Causes, sort of along this line. Right, but that doesn't necessarily say anything about lifestyle interventions. It says more about how well researched it is and for whom, right? Oh, and social factors. So on that note, I apologize if people have gotten tired of me talking more. I feel like, you know, I'm not sure if you wanted to talk more, if you're just kind of like laconic today, but thanks for listening.
00:45:53
Speaker
Thank you for listening to the doorknob comments podcast. We appreciate your time and hope you've gained something from joining us today. Please let us know what you think. You can email us at hello at doorknobcomments.com. Find us on Instagram at doorknobcomments on iTunes and on our website doorknobcomments.com.
00:46:11
Speaker
Let us know if there are any particular topics you'd like us to address. We'd love to hear from you. Remember, the Doorknob Comments podcast is not medical advice. If you may be in need of professional assistance, please seek consultation without delay.