0:00

that I think points to this

0:02

kind of binary tendency that either

0:04

a problem is a problem of

0:07

biology or we want to say

0:09

that if the problem is not

0:11

a clear biological problem or a

0:14

problem biological abnormality, then you know,

0:16

nothing much is to be gained

0:18

by understanding the biological dimension of

0:21

it. Mental health problems, mental disorder,

0:23

exists precisely in this middle ground

0:25

where they are not primarily problems

0:28

of biology gone wrong. Mental health

0:30

problems are problems of

0:33

behavior gone wrong and,

0:35

you know, psychological experiences

0:38

gone wrong, but they

0:40

nonetheless have a biological

0:42

dimension. and then they're,

0:45

you know, because they

0:47

have a biological dimension,

0:50

we can study

0:53

that, we can

0:55

intervene on that,

0:58

you know, often

1:01

in, you

1:03

know, remarkably

1:05

effective ways

1:08

at times. And it's

1:10

not actually me conducting today's conversation,

1:12

but my co-host, Dr. Anya Borisova.

1:15

For those of you newer to the podcast,

1:17

she's a clinical and academic registrar

1:19

at the South London and Multis

1:21

Trust, and today she's in conversation with

1:23

Dr. Ayr's Aftab. Dr. Aftab is a

1:26

psychiatrist working in Ohio in the

1:28

US and is also the clinical

1:30

assistant professor of psychiatry at the

1:32

Case Western Reserve University. Dr. Aftab

1:34

is interested in philosophy and history

1:36

of psychiatry and writes about these

1:38

topics. on his sub-stack, psychiatry at

1:41

the margins. He's also the author

1:43

of the recently published Conversations

1:45

and Critical Psychiatry. Today's Conversation

1:47

focuses on the philosophy of

1:49

psychiatry, what assumptions and frameworks

1:51

shape the field and how

1:54

this impacts things like diagnosis

1:56

or decisions about treatment or

1:58

understanding mental disorders. They discuss

2:00

what defines a mental disorder,

2:02

how biological, psychological and social

2:04

factors interact with mental health,

2:06

the evolution of psychiatric diagnoses,

2:08

and how these have shifted

2:10

over time, the benefits and

2:12

limitations of psychiatric medications, their

2:14

potential harms, and some of

2:16

the public relations challenges that

2:18

psychiatry has faced and continues

2:21

to face in the modern

2:23

day. As ever, it's really

2:25

helpful if you can give

2:27

us a rating or a

2:29

comment or a review. We

2:31

really enjoy hearing from you.

2:33

and you can also give

2:35

us feedback directly at our

2:37

email at Thinking Mind podcast@gmail.com.

2:39

This is The Thinking Mind,

2:41

a podcast all about psychiatry,

2:43

psychology, self-development and related topics.

2:45

We hope you enjoy and

2:47

as always thank you for

2:49

listening. for this week's episode

2:51

of the Thinking Mind podcast.

2:53

Dr. Aftup, welcome and thank

2:55

you for joining us. Thank

2:57

you for having me. You

2:59

are a psychiatrist and you

3:01

write blogs. You do a

3:04

lot of thinking about what

3:06

the practice of psychiatry should

3:08

be like and how it

3:10

can be improved. What got

3:12

you thinking about this? What

3:14

made this important for you?

3:16

I had been interested in

3:18

in philosophy for a long

3:20

time even before I started

3:22

med school. I was interested

3:24

in philosophy and and in

3:26

fact I was I was

3:28

considering the possibility of going

3:30

into philosophy as an academic

3:32

profession, but I was in

3:34

Pakistan at the time and

3:36

you know philosophy as a

3:38

kind of profession was just

3:40

not really a viable option.

3:42

So I ended up in

3:44

medical school and in medical

3:46

school I realized pretty quickly

3:49

that the psychiatry was a

3:51

subject that interested me, it

3:53

felt a great fit for

3:55

my temperament and also for

3:57

my interests. And so I

3:59

started pursuing psychiatry. To my

4:01

delight I discovered that there's

4:03

this huge overlap between philosophy

4:05

as a discipline and the

4:07

subject better of psychiatry and

4:09

there's this burgeoning field of

4:11

philosophy of psychiatry which is

4:13

inhabited by both by medical

4:15

professionals, by psychologists, by philosophers.

4:17

So I started reading up

4:19

on that and started getting

4:21

familiar with the literature and

4:23

I really got interested and

4:25

curious about fundamental issues in

4:27

psychiatry, various kinds of concepts

4:29

that drive our clinical work

4:31

and our scientific work. and

4:34

I started realizing how fundamental

4:36

they are to do clinical

4:38

practice and scientific practice. So

4:40

my profession as a psychiatrist,

4:42

my career as a psychiatrist,

4:44

I have used the opportunity

4:46

to explore these basic questions

4:48

with the help of the

4:50

philosophical literature. What as a

4:52

quite a novice to philosophy

4:54

literature? and I imagine a

4:56

lot of our listeners are

4:58

as well, could you give

5:00

us more of an idea

5:02

of what kind of questions

5:04

those are, even what philosophy

5:06

means, particularly when applied to

5:08

psychiatry? Yes, so in, you

5:10

know, the range of questions

5:12

that are subject to philosophical

5:14

analysis or philosophical inquiry is

5:17

pretty broad. But a helpful

5:19

way to think about is

5:21

what are some of the

5:23

assumptions and ideas that are

5:25

guiding clinical work and what

5:27

are some of the basic

5:29

concepts that we rely on

5:31

in the field. So a

5:33

basic concept that that is

5:35

ubiquitous is the idea of

5:37

mental disorder or mental illness.

5:39

So we can ask about

5:41

when we characterize a behavioral

5:43

state as being disordered or

5:45

when we characterize a behavioral

5:47

state as being an illness

5:49

or a medical problem in

5:51

a certain sense. What kind

5:53

of judgments are we making?

5:55

Due to what extent are

5:57

these judgments grounded in facts

5:59

about biology? Are facts about

6:02

physiology? And to what extent

6:04

are these judgments grounded in

6:06

various values that guide human

6:08

decision making? To what extent

6:10

are these values social cultural

6:12

in nature? To what extent

6:14

are these driven by perceptions

6:16

of distress and judgments of

6:18

harm? And what is the

6:20

end? and it'll end product

6:22

of this confluence of judgments.

6:24

When we classify conditions within

6:26

the realm of mental disorders

6:28

and within the realm of

6:30

mental health problems, when we

6:32

let's say draw a line

6:34

between depression as a syndrome

6:36

and anxiety as a syndrome,

6:38

what is the nature of

6:40

that classification? What exactly are

6:42

we carving? Are we the

6:45

kind of categories that we

6:47

have separated? What is their

6:49

metaphysical status? Do these categories

6:51

present an essence, a unique

6:53

singular category that is particular

6:55

to or specific to that

6:57

group? Or are these just,

6:59

for example, practical groupings that

7:01

we're using for our practical

7:03

purposes and they don't necessarily

7:05

capture the underlying structure of

7:07

the problems or mechanisms of

7:09

the problem? So these are

7:11

metaphysical debates around what we

7:13

call essentialism and pragmatism. And

7:15

then when we look at

7:17

the nature of psychiatric explanation

7:19

and nature of psychiatric knowledge,

7:21

we can use a philosophy

7:23

of science perspective and we

7:25

can think about how science

7:27

progresses, how is it that

7:30

scientific knowledge is generated, what

7:32

kind of limitations biases it

7:34

is subject to, what is

7:36

the relationship between our... to

7:38

practical understanding of a phenomena

7:40

and the phenomena as did

7:42

exist independent of human concerns

7:44

or perception. So we can

7:46

apply a lot of those

7:48

philosophy of science questions about

7:50

realism, anti-realism, and epistemology and

7:52

the basis of scientific knowledge

7:54

to psychiatry as well and

7:56

think about how is it

7:58

that psychiatric knowledge is generated,

8:00

what is it that we

8:02

are trying to study, what

8:04

kind of inferences we can

8:06

make, and we can also

8:08

look at the methods of

8:10

knowledge production. what kind of

8:12

perspectives are being excluded, for

8:15

example, from the way we

8:17

currently generate psychiatric knowledge and

8:19

what are the consequences of

8:21

those things. And because psychiatry

8:23

deals with behavioral phenomena, but

8:25

also deals with brain mechanisms

8:27

and processes, we inevitably come

8:29

up with these philosophical issues

8:31

around the mind-body relationship. So

8:33

what is the relationship between

8:35

mental health symptoms, behavioral disservice

8:37

experiences, what is happening in

8:39

the brain, to what extent

8:41

we can reasonably think of

8:43

mental disorders as being brain

8:45

disorders? And what are the

8:47

advantages and disadvantages of thinking

8:49

of them in that kind

8:51

of manner? can conceivably be

8:53

the limits of biology in

8:55

explaining these problems. So that's

8:58

just, you know, I'm going

9:00

through a list of some

9:02

of the questions that, you

9:04

know, if psychiatry is interested

9:06

in philosophy and others working

9:08

in this area, you have

9:10

tackle, but it's just a

9:12

subset of things that are

9:14

being discussed. I guess to

9:16

go back to one of

9:18

the specific examples, so you

9:20

talk about, for instance, using

9:22

a philosophical viewpoint to inquire

9:24

around. diagnosis like depression anxiety

9:26

and to what extent these

9:28

might be separate entities to

9:30

what extent they're categories that

9:32

are sort of pragmatic to

9:34

use. What I mean what

9:36

what do you think about

9:38

that question? Yeah so the

9:40

The people involved in these

9:43

specific debates, you'll hear them

9:45

talk about natural kinds, social

9:47

kinds, and practical kinds. Natural

9:49

kinds are... categorizations that reflect

9:51

the structure of the of

9:53

the natural world as it

9:55

exists independent of human interests.

9:57

So a good example of

9:59

that is the periodic table

10:01

of elements in chemistry and

10:03

physics. It's it captures something

10:05

genuine about the way elements

10:07

exist and they're distributed. It

10:09

corresponds to the structure of

10:11

the atomic nuclei. It has

10:13

tremendous explanatory and predictive power.

10:15

on the position of the

10:17

element in the periodic table,

10:19

we can predict a lot

10:21

of things about them. And

10:23

it is the, it is

10:25

the correct, objectively correct way

10:28

of categorizing and classifying elements

10:30

as well. If we imagine

10:32

different chemists, you know, starting

10:34

from different theoretical ideas about

10:36

what elements are. if they

10:38

do empirical work good enough

10:40

if they're doing scientific work

10:42

correctly over time they would

10:44

all converge onto the same

10:46

model so it's it's it's

10:48

exist independently captures it's the

10:50

you know it has powerful

10:52

explanatory value and independent of

10:54

human interest versus in think

10:56

of So those are natural

10:58

kinds. The complete opposite are

11:00

social kinds, and these are

11:02

categorizations and distinctions that are

11:04

almost completely dependent on human

11:06

interests. So a good example

11:08

of this would be something

11:11

like the political borders. They're

11:13

entirely dependent on human perceptions

11:15

and human negotiations. They exist

11:17

in our minds, so to

11:19

speak. There's nothing in the

11:21

natural, you know, geographical landscape

11:23

that corresponds to the border

11:25

itself. And if humans were

11:27

to suddenly despair, you know,

11:29

the political borders would no

11:31

longer exist. And as human...

11:33

conflicts occur, we change these,

11:35

you know, border space based

11:37

on our negotiations. So that's

11:39

an example of something that

11:41

depends on human interests, you

11:43

know, almost completely with no

11:45

correspondence to the natural world.

11:47

And in between natural and

11:49

social kinds, there is this

11:51

messy gray area of what

11:53

we call practical kinds. And

11:56

these are these are phenomena

11:58

that that are enmeshed with

12:00

human interests and that we

12:02

have multiple ways of looking

12:04

at this phenomena from different

12:06

perspectives, different angles, depending on

12:08

what it is that we

12:10

want to achieve. And depending

12:12

on what we want to

12:14

achieve, we can make categorizations

12:16

that are useful to us,

12:18

but they are not the

12:20

one objectively correct way of

12:22

looking at it in the

12:24

same way as the periodic

12:26

table of elements is. So

12:28

a lot of medications in

12:30

medicine and a lot of

12:32

them in psychiatry tend to

12:34

fall into this area of

12:36

practical kinds. Now there are

12:39

exceptions to it. So for

12:41

example infectious diseases are a

12:43

clear example of you know,

12:45

natural kinds in medicine, you

12:47

know, whether some, whether a

12:49

syndrome is, is caused by

12:51

a spirokeyed infection, you know,

12:53

we can identify, we can,

12:55

you know, we can discover

12:57

that it's a, it's a

12:59

well-defined entity and things like

13:01

autosomal genetic disorders, you know,

13:03

can come pretty close to

13:05

something like that too. But

13:07

for other conditions like depression,

13:09

anxiety, psychosis that are highly

13:11

heterogenous and where we're kind

13:13

of, you know, the boundaries

13:15

are fuzzy and the actual

13:17

distribution of symptoms is very

13:19

dimensional as well. Any boundaries

13:21

and thresholds that we draw

13:24

and any distinctions that we

13:26

make, they are not going

13:28

to be the one objective.

13:30

correct way of looking at

13:32

it, but rather it's going

13:34

to question of what it

13:36

is that we that we

13:38

want to achieve. If we

13:40

want to achieve, for example,

13:42

a schema that corresponds to

13:44

response to treatment, that is

13:46

going to look very different

13:48

from some classification that optimizes,

13:50

let's say, genetic associations. And

13:52

if you want to optimize

13:54

something like neuroimaging findings, a

13:56

schema based on neuroimaging finding

13:58

is going to look very

14:00

different from you know, from

14:02

clinical description, for example. And

14:04

that's what we see. So,

14:06

in a, in a, in

14:09

a, in to tell, to

14:11

speak of this in other

14:13

terms, people talk of validators

14:15

and convergence of validators. When,

14:17

when we are dealing with

14:19

natural kinds, the converge, the

14:21

validators tend to converge. They

14:23

all tend to point in

14:25

the same direction. Versus when

14:27

we are dealing with practical

14:29

kinds, there's a misalignment between

14:31

different validators and different validators.

14:33

point or somewhat different things

14:35

and and you know how

14:37

to optimize that depends on

14:39

what it is that we

14:41

want to accomplish so so

14:43

there there is it's not

14:45

so we cannot make things

14:47

up it's not it's not

14:49

arbitrary you know it but

14:52

the optimal solutions will depend

14:54

on goals that we have

14:56

set for ourselves okay so

14:58

how you think about depression

15:00

as a psychiatrist or how

15:02

you think about finding the

15:04

boundary between depression anxiety will

15:06

depend on whether you're for

15:08

example thinking about what kind

15:10

of treatment to prescribe versus

15:12

how to explain that to

15:14

the patient or how the

15:16

patient might understand it themselves?

15:18

Yes, so the first thing

15:20

to note is that even

15:22

in terms of, you know,

15:24

symptoms themselves, depression and anxiety

15:26

share symptoms. So the boundaries

15:28

between them are fuzzy for

15:30

you know, based on that

15:32

reason alone. So, so many,

15:34

many. things like you know,

15:37

sleep disturbances, distractibility, irritability, you

15:39

know, other changes can be

15:41

seen in both. And then

15:43

depression and anxiety, as syndromes

15:45

are highly comorbid as well.

15:47

People oftentimes, you know, have

15:49

both of them. And in

15:51

fact, when you look at

15:53

the way these symptoms cluster

15:55

together, due to the hydrogenate

15:57

and in high comorbidity, depression

15:59

and anxiety do not show

16:01

up as distinct syndromes in

16:03

the statistical sense, in the

16:05

psychometric sense, but rather they

16:07

show up in kind of

16:09

in mesh together in this

16:11

larger subfactor known as the

16:13

distress subfactor, which is one

16:15

of the, you know, one

16:17

of the kind of dimensions

16:19

in a classification known as

16:22

hierarchical taxonomy of psychopathology. you

16:24

know, which is based on

16:26

statistical association. So even statistically

16:28

speaking, they do not separate

16:30

out as distinct syndromes. And

16:32

another way to think about

16:34

is you can think of

16:36

it of what happened in

16:38

the United States in terms

16:40

of diagnostic practices. So if

16:42

you look at 1960, 1960s,

16:44

very commonly, we're the most

16:46

common kind of, you know,

16:48

psychiatric diagnosis and, you know,

16:50

utilized and given to patients

16:52

and, and common treatments at

16:54

that time were benzodazepine medications.

16:56

So, so people were getting

16:58

diagnosed with anxiety and they

17:00

were, a lot of them

17:02

were being prescribed benzodazepines. And

17:05

at that time, psychiatrists are

17:07

also working with this general

17:09

idea of neurosis, which kind

17:11

of heavily in which anxiety

17:13

symptoms featured pretty prominently. When

17:15

DSM-3 was published in 9-4,

17:17

1980, the people behind the

17:19

DSM-3 had a somewhat kind

17:21

of anti-psychodynamic bias. And as

17:23

a result of that, they

17:25

took the category of neurosis

17:27

and they divided that up

17:29

into several distinct anxiety disorders.

17:31

So general anxiety disorder became

17:33

its own thing, panic disorder

17:35

began its own thing, obsessive

17:37

compulsive disorder began its one

17:39

thing. And they set the

17:41

criteria relatively conservatively. So for

17:43

general anxiety disorder, you have

17:45

to meet a threshold of

17:47

six months in order in

17:50

order to feed. diagnosed. Now

17:52

prior to DSM 3, depression

17:54

did not exist as a

17:56

unified entity or a unified

17:58

category in the DSM. In

18:00

DSM 1 and 2, you

18:02

see manic depressive, a kind

18:04

of, manic depressive, insanity, depressive

18:06

episodes. You had psychotic depression

18:08

separately. You had psychotic depression

18:10

separately. And you even had

18:12

a depressive personality kind of

18:14

separate, you know, and separate.

18:16

And then... convolutional melancholia which

18:18

was kind of depression in

18:20

the old age that that

18:22

that was a separate category

18:24

and people sometimes spoke of

18:26

this primarily as being a

18:28

distinction between melancholic endogenous styles

18:30

of depression and and neurotic

18:33

styles of depression so but

18:35

depression was a was fragmented

18:37

across the manual in DSM

18:39

1 and 2 in DSM

18:41

3 it is all brought

18:43

together in the in a

18:45

unified category of major major

18:47

major depression and and and

18:49

compared to anxiety disorders, the

18:51

threshold is set relatively low.

18:53

You just need two weeks

18:55

of, you know, peer, you

18:57

know, symptom period in order

18:59

to meet depression criteria. And

19:01

we, and in 1980s, it

19:03

also when we, when we

19:05

start seeing the development of

19:07

antidepressant medications. Prior to 1980,

19:09

depression as a diagnosis was

19:11

rare, because it was only

19:13

being given to people who

19:15

had severe melancholic symptoms, and

19:18

anyone who had milder forms

19:20

because they tend to have

19:22

comorbid anxiety too, they were

19:24

diagnosed with an anxiety disorder.

19:26

Post 1980, we see this

19:28

large shift that, you know,

19:30

depression starts becoming a more

19:32

common diagnosis. People who would

19:34

have been diagnosed with anxiety

19:36

in 1960, 1970s, 70s, are

19:38

now being diagnosed depression and

19:40

the treatment of selection also

19:42

changes and becomes, you know,

19:44

as the surreiser being developed

19:46

and others, so anti-depression start

19:48

getting utilized more. symptoms have

19:50

not changed. You know, people

19:52

were still experiencing the same

19:54

mix of depression and anxiety

19:56

as they were all always

19:58

experiencing. But our understanding and

20:00

conceptualization of that changed dramatically.

20:03

You know, the same person,

20:05

you know, who would be

20:07

classified as, you know, anxiety

20:09

disorder in one decade is

20:11

classified as as depressive disorder

20:13

in another decade, but the

20:15

same exact mix of symptoms.

20:17

And what has changed is

20:19

what... symptoms we are emphasizing,

20:21

what thresholds we are using,

20:23

and in kind of how

20:25

we are approaching the treatment.

20:27

So that's a good example

20:29

of how we're not dealing

20:31

with some kind of objective

20:33

essence of something that we

20:35

are identifying through our diagnostic

20:37

schemas, but rather different diagnostic

20:39

approaches emphasize different cardinal symptoms,

20:41

they emphasize different thresholds, between

20:43

these conditions in a different

20:46

way. So you could, you

20:48

know, divide up, you know,

20:50

syndromes into smaller, you know,

20:52

categories, like, as we did

20:54

with anxiety disorders, or you

20:56

could combine smaller things, previously

20:58

smaller things, into one big

21:00

larger category, and suddenly a

21:02

lot more people would fit

21:04

into that. What do you

21:06

think about the present in

21:08

terms of how depression is

21:10

diagnosed, how anxiety is not...

21:12

is often not thought about

21:14

in people who have depression.

21:16

What do you, what are

21:18

your thoughts on that? Yeah,

21:20

I think so. I think

21:22

that the first thing we

21:24

have to recognize are the,

21:26

is the fluid fuzzy nature

21:28

of these diagnostic constructs. You

21:31

know, we are working with

21:33

these symptom level descriptions and

21:35

we have to recognize that

21:37

these are highly heterogeneous conditions,

21:39

different people are presenting with

21:41

very different combinations of symptoms.

21:43

And so, and that is

21:45

what we see in depression

21:47

is that people... you know,

21:49

present, you know, with depressive

21:51

states and I'm right right

21:53

here away. Some people have

21:55

very severe psychomotor retardation, agitation,

21:57

they have very severe cognitive

21:59

problems, they have severe anedonia,

22:01

sometimes kind of, you know,

22:03

severe, severe existential flavor to

22:05

suicidality, versus we see, there

22:07

are other people whose depression

22:09

is very enmeshed with their

22:11

life circumstances. They're experiencing a

22:13

very stressful time, they're going

22:16

through a divorce, they're having...

22:18

you know, job problems or

22:20

they have other, they have

22:22

financial, you know, stressors or

22:24

unstable housing and because of

22:26

that excessive stress, you know,

22:28

that they're experiencing a lot

22:30

of low mood and dysphoria.

22:32

And then there are other

22:34

situations where someone by their

22:36

temperament is predisposed to high

22:38

neuroticism and that high neuroticism

22:40

makes them vulnerable to experiencing

22:42

low mood and idonia at

22:44

kind of various points in

22:46

their life and perhaps... they

22:48

live with a certain amount

22:50

of low mood and an

22:52

anedonia that that you know

22:54

fluctuates with life stressors but

22:56

you know remains elevated at

22:59

all times. So these are

23:01

these are very different styles

23:03

of depression you know everyone

23:05

manifesting but in current diagnostic

23:07

schemas they're not gonna sort

23:09

it out very very well

23:11

and we know everyone is

23:13

being treated in a somewhat

23:15

similar kind of manner. So

23:17

I think we have to

23:19

recognize that our I can't.

23:21

schemas don't do justice to

23:23

this heterogeneity and also the

23:25

boundaries that we have made

23:27

between kind of disard different

23:29

conditions disorders at the symptom

23:31

level these boundaries are not

23:33

respected at the mechanistic level

23:35

the the mishmash of mechanism

23:37

that processes that exists between

23:39

you know it does not

23:41

respect DSM or ICD boundaries

23:44

you know we see this

23:46

with genetics too the you

23:48

know the genetic associations don't

23:50

respect whether this is schizophrenia

23:52

or better is bipolar or

23:54

schidzab effect, there were some

23:56

other kind of thing. So

23:58

we have to start thinking

24:00

that our boundaries, whether they

24:02

might be useful in terms

24:04

of description in a certain

24:06

clinical context, but they're not

24:08

going to be that particularly

24:10

helpful when we're looking at

24:12

things from a mechanistic standpoint,

24:14

or when we are looking

24:16

at things from a psychological

24:18

process standpoint, that is why

24:20

when we look at things

24:22

from, for example, from a

24:24

psychoanalytic or psychodynamic perspective, the

24:27

usual. descriptive categories are less

24:29

important and what matters more

24:31

is the is the pattern

24:33

of psychological experiences. So so

24:35

being mindful of that you

24:37

know we're dealing with a

24:39

multifaceted phenomena and and the

24:41

boundaries we use from one

24:43

perspective are not going to

24:45

hold, you know, looking at

24:47

things on another perspective. And

24:49

then secondly, we have to

24:51

be scientifically smarter about even

24:53

at the descriptive level about

24:55

examining these things. If the

24:57

traditional GSM ICD syndromes and

24:59

boundaries are kind of semi-arbitrary

25:01

in the sense that they

25:03

are built on clinical impressions

25:05

that people have had over

25:07

years and there's a kind

25:09

of semi-consensus around them, we

25:12

have to look at other

25:14

approaches about how we can

25:16

approach them in a sophisticated

25:18

matter. And that has been

25:20

happening in the psychology world

25:22

with the classification system known

25:24

as hierarchical text on me

25:26

of psychopathology, where people are

25:28

taking statistical data. seriously and

25:30

they're asking you know what

25:32

happens if we look at

25:34

the at the co variation

25:36

and co-occurrence between symptoms if

25:38

you know how do we

25:40

what kind of latent factors

25:42

emerge you know in this

25:44

classification and the answer first

25:46

is that you know these

25:48

kind of the The dimensions,

25:50

we see dimensions emerge rather

25:52

than categories. So the phenomena

25:54

are distributed in a population

25:57

in a latently continuous manner

25:59

rather than there being discontinuities.

26:01

One, and second, we see

26:03

a hierarchy of dimensions where

26:05

we have symptoms and traits

26:07

as being narrow dimensions, you

26:09

know, at the bottom that

26:11

that cluster together to form

26:13

larger dimensions such as distress

26:15

of factor, fears of factor,

26:17

that then cluster together to

26:19

form things like. internalizing disorders

26:21

and externalizing disorders and thought

26:23

disorders. And then there's this

26:25

very intriguing thing at the

26:27

top called the general factor

26:29

of psychopathology or the P

26:31

factor that it seems to

26:33

statistically speaking explain a shared

26:35

variance among all mental health

26:37

disorders and also kind of

26:40

is a reflection of the

26:42

fact that all mental disorders

26:44

are comorbid with each other

26:46

at a certain level. So

26:48

just as all aspects of

26:50

intelligence are. are in a

26:52

sense linked to each other

26:54

such that we can talk

26:56

about a G factor, a

26:58

general factor of intelligence. All

27:00

aspects of psychopathology are related

27:02

to each other through mechanisms

27:04

we don't understand very well

27:06

and we see a single

27:08

statistical factor emerged called the

27:10

P factor. And there's a

27:12

very interesting debate in the

27:14

scientific literature around how to

27:16

understand that, whether the P

27:18

factor is just some statistical

27:20

way of talking about things

27:22

or whether it represents some

27:25

kind of, you know, set

27:27

of processes that that confer

27:29

some kind of general vulnerability

27:31

to mental health. problems. So

27:33

the thing I want to

27:35

emphasize is that we have

27:37

to take the kind of

27:39

the pragmatic practical nature of

27:41

our classification seriously, which means

27:43

being humble about their limitations

27:45

and looking at these things

27:47

from a variety of different

27:49

perspectives and optimizing our classifications

27:51

for a variety of things.

27:53

Let me give you another

27:55

example. So take take blood

27:57

pressure. blood pressure is a

27:59

continuum. Everyone has a systolic

28:01

blood pressure, you know, and

28:03

there's nothing magical about our

28:05

current threshold for essential hypertension

28:07

as a diagnosis. So saying

28:10

that, oh, a 140 millimeter

28:12

mercury of the systolic blood

28:14

pressure, you know, we're using

28:16

it at a diagnostic threshold.

28:18

It's got some arbitrary. You

28:20

know, you could have said

28:22

139 or 141 and it

28:24

wouldn't be much different. So,

28:26

but there's no natural discontinuity

28:28

continuity at 1. It's just

28:30

a smooth line. So why

28:32

is it that we go

28:34

with 140 millimeter of mercury

28:36

thresholds? It's because we have

28:38

looked at the data and

28:40

we are interested in reducing

28:42

the risk of future cardiovascular

28:44

negative events. So we are

28:46

interested in reducing the risk

28:48

of heart attacks and we're

28:50

interested in reducing the risk

28:53

of heart attacks and we're

28:55

interested in reducing mortality. And

28:57

if we look at, so

28:59

we identify a goal, we

29:01

look at the data and

29:03

we say what can threshold

29:05

would make the most sense

29:07

to try to optimize mortality

29:09

reduction and that gives us

29:11

the answer that if you

29:13

want to achieve this then

29:15

you know try to keep

29:17

the blood pressure lower than

29:19

140 and that also gives

29:21

us the wiggle room to

29:23

revise it so for diabetics

29:25

we know that even with

29:27

140 the mortality risk can

29:29

be higher so for diabetics

29:31

we set the blood pressure

29:33

threshold lower right so our

29:35

thresholds are going to be

29:38

sensitive to what it is

29:40

that we want to accomplish.

29:42

The problem with DSM-ICD is

29:44

that they haven't had. had

29:46

clarity on what it is

29:48

that they're trying to optimize.

29:50

Let's say we have the

29:52

threshold for depression in DSM

29:54

of five out of nine

29:56

symptoms for a two-week period.

29:58

what is that threshold trying

30:00

to optimize? I mean it

30:02

doesn't optimize treatment response because

30:04

you know people people still

30:06

respond to treatment even if

30:08

they don't meet that criteria.

30:10

It doesn't it doesn't optimize

30:12

you know near imaging finding

30:14

that we know it. It

30:16

doesn't optimize you know a

30:18

long course of illness. So

30:21

you know we have a

30:23

variety of things in mind

30:25

and we're you know we're

30:27

going about them in a

30:29

somewhat muddled manner versus if

30:31

we had clarity on what

30:33

what was the practical aim,

30:35

what was the clinical aim,

30:37

a scientific aim, we can

30:39

come up with different classification

30:41

schemes that optimize those goals

30:43

and, you know, make more

30:45

progress, you know, with that

30:47

kind of clarity. Is this

30:49

something that you apply in

30:51

your clinical practice at the

30:53

moment? This kind of thing,

30:55

or does this kind of

30:57

thinking modify how you practice?

30:59

In a certain amount of

31:01

way, in a certain sense,

31:03

I think one is that

31:06

my conceptualization of what a

31:08

person is going through, what

31:10

they're experiencing, is informed by

31:12

that. So I'm not just

31:14

thinking in terms of, hey,

31:16

you know, I'm going to...

31:18

you know, this person meets

31:20

X, Y, Z, you know,

31:22

DSM ICD, criteria, and, you

31:24

know, and then I'm just

31:26

going to blindly follow the

31:28

treatment algorithm, but rather, I'm

31:30

thinking, you know, in this,

31:32

all right, you know, what

31:34

are the different ways in

31:36

which I can conceptualize this

31:38

person's problem? And what way

31:40

of thinking makes the most

31:42

sense, you know, for this

31:44

particular patient in this particular

31:46

sense? And sometimes the diagnostic

31:48

category, the diagnostic category, is

31:51

a very useful way of

31:53

talking about, you know, you

31:55

know, you know, ADHD or

31:57

autism, sometimes it really, you

31:59

know, really can be a

32:01

life-changing explanation for them to

32:03

think of their problem in

32:05

that sense. In other cases,

32:07

it's, you know, whether I

32:09

call this major depression with

32:11

anxious distress or I call

32:13

this, you know, GAD, you

32:15

know, it... that doesn't matter

32:17

that much because the person's

32:19

problem is very linked to

32:21

a certain life circumstances and

32:23

it's very linked to their

32:25

personality and temperament and it's

32:27

it's much more fruitful for

32:29

me to think about this

32:31

person as having hey this

32:34

is a person who is

32:36

high in neuroticism who is

32:38

experiencing this acute life stressor

32:40

and this interaction is generating

32:42

a current you know syndrome

32:44

of distress for them. So

32:46

it you know it so

32:48

it allows me to adopt

32:50

a kind of flexible conceptualized

32:52

And then second thing is

32:54

that I try to communicate

32:56

that to patients as well

32:58

that do not attribute more

33:00

reality to these diagnostic labels

33:02

than they actually possess. They

33:04

are symptom level descriptions of

33:06

you know, of these problems

33:08

and they have fuzzy boundaries

33:10

and they can change over

33:12

time and they don't they

33:14

don't capture some kind of

33:16

essence that exists in your

33:19

brain. And even that, you

33:21

know, superficial level explanation can

33:23

be very helpful for patients

33:25

because the average lay person,

33:27

their understanding of these diagnostic

33:29

categories is very, very reductive

33:31

and biomedical, you know, it's

33:33

informed by decades of this

33:35

language of chemical imbalance in

33:37

brain diseases. So date and

33:39

to think that these categories

33:41

actually reflect the structure of,

33:43

you know, how brain functions

33:45

or how brain goes wrong

33:47

or, you know, or what

33:49

happens never scientifically. So being

33:51

clear about the nature of

33:53

these diagnostic, thresholds and diagnostic,

33:55

you know, mapings can be

33:57

very helpful for patients to

33:59

understand their own problems in

34:01

a better way. It's a

34:04

tricky point that you bring

34:06

because it's... speaks to sort

34:08

of a side of the

34:10

debate around diagnosis that can

34:12

become quite binary. And I

34:14

can hear that in the

34:16

explanations that you give to

34:18

your patients, it's in trying

34:20

to convey to them that

34:22

a diagnostic category is not

34:24

like a periodic table element

34:26

that is a hard natural

34:28

fact. But I think that

34:30

can sometimes go into an

34:32

area of the debate that

34:34

says Well, then these conditions

34:36

just don't exist and actually

34:38

they're not worth diagnosing at

34:40

all and they aren't biological

34:42

things in any sense of

34:44

the word and they are

34:47

just social constructs. How do

34:49

you tread that line? How

34:51

do you think about those

34:53

kind of questions? Yeah, and

34:55

I think we have been

34:57

seeing this kind of dynamic

34:59

play out in both. popular

35:01

and as well as academic

35:03

discussions around the nature of

35:05

mental illness. And my whole,

35:07

the direction of my academic

35:09

and clinical work has been

35:11

in challenging these binaries and

35:13

in showing that this dichotomous

35:15

way of thinking about mental

35:17

health problems, in fact, it

35:19

doesn't even apply very well

35:21

to medicine, you know, let

35:23

alone to psychiatry. And things

35:25

are much more complicated than

35:27

that, you know, than that.

35:29

and we have to be,

35:32

we have to, you know,

35:34

use better conceptual tools than

35:36

thinking of this in this

35:38

biomial fashion. And again, I

35:40

think the problem comes down

35:42

to the kind of biomedical

35:44

reductive idea that people have

35:46

about medicine generally. They tend

35:48

to think of all medical

35:50

diagnostic categories as being like

35:52

infectious diseases or being like

35:54

autosomal genetic disorders, when in

35:56

fact, most chronic conditions. in

35:58

medicine are highly multifectorial. and

36:00

you know, and can be,

36:02

you know, described and classified,

36:04

you know, with, you know,

36:06

some degree of kind of

36:08

debate and wiggle room, you

36:10

know, things like that. So,

36:12

the, and what happens is

36:15

that if that is the

36:17

conceptualization we work with, that,

36:19

that medical diagnosis have essences

36:21

that that are neurobiological dysfunctions,

36:23

then it, you know, we,

36:25

we, we, we, we either.

36:27

We either fit a mental

36:29

health problem into that kind

36:31

of category or we just

36:33

reject that understanding and we

36:35

say that, oh, there's, you

36:37

know, the biology has nothing

36:39

to do with this. This

36:41

is, you know, kind of

36:43

completely some kind of psychosocial

36:45

kind of issue that medical

36:47

diagnostic terminology is completely unsuitable

36:49

for this. So it sets

36:51

people up for this kind

36:53

of flip-flopping between two extreme

36:55

views. Versus, you know, If

36:57

we understand that many problems

37:00

exist in medicine that do

37:02

not have an essence in

37:04

the traditional sense, and we

37:06

can identify problematic behaviors based

37:08

on the negative impact it

37:10

has on a person's life,

37:12

if a person is persistently

37:14

and severely depressed to a

37:16

point where they're unable to

37:18

function, they're unable to function.

37:20

Let's say they're, you know,

37:22

they are so, their psychomotor

37:24

functioning as slow down to

37:26

a point, they can barely

37:28

get out of bed, they

37:30

can barely brush or, you

37:32

know, change clothes and their

37:34

appetite has gone down and

37:36

they're losing weight. That represents

37:38

a significant state of impairment

37:40

and there are many different.

37:42

biological, physiological ways in which

37:45

that state can be produced

37:47

or realized, which accounts for

37:49

the mechanistic hydrogenity of it.

37:51

So there is. there's not

37:53

going to be, you know,

37:55

there's no single, singular cause

37:57

or a final common pathway

37:59

or a fine, you know,

38:01

or a common biological deficit

38:03

in all of that. But

38:05

that state is clearly a

38:07

state of impairment of harm

38:09

of suffering. And if we

38:11

have, you know, medical tools

38:13

to alleviate that suffering, at

38:15

least for some people, you

38:17

know, in the form of

38:19

medications and neurostim therapies, then

38:21

withholding those tools. simply because,

38:23

you know, that condition does

38:25

not satisfy some kind of

38:28

abstract idea of what a

38:30

medical disorder is, is just,

38:32

you know, is just the

38:34

wrong thing to do, in

38:36

my view. So we have

38:38

to expand our understanding of

38:40

what it is that we

38:42

mean when we call something

38:44

to be a medical condition.

38:46

When we encounter states of

38:48

suffering that are kind of

38:50

clearly outside of the norms,

38:52

of our expected social cultural

38:54

norms and other norms of

38:56

functioning. And they are amenable

38:58

to be described in medical

39:00

clinical terms. And we have

39:02

clinical ways of helping at

39:04

least some people with that.

39:06

Then in my view, that

39:08

becomes a bona fide medical

39:10

medical conditions, which again, you

39:13

know, emphasizes the kind of

39:15

pragmatic approach that I have

39:17

been advocating, that these things

39:19

are pragmatic constructs. When we

39:21

say it. that depression is

39:23

a medical condition or anxiety

39:25

is a medical condition. We're

39:27

not making a claim that,

39:29

oh, there is some hidden

39:31

medical cause behind these syndromes

39:33

that is causing it, and

39:35

that's what we're trying to

39:37

fix. But we're rather simply

39:39

making a very practical claim

39:41

that these are states of

39:43

immense suffering that are out

39:45

of the ordinary by some

39:47

standard, and we have things

39:49

we can do, you know,

39:51

in our medical toolkit that

39:53

can help. person in that

39:55

kind of state of suffering.

39:58

it's useful or necessary to

40:00

identify the brain basis for

40:02

those states of suffering? I

40:04

think it's useful and in

40:06

some ways even necessary to

40:08

try to have a scientific

40:10

line of inquiry that seeks

40:12

to understand what the brain

40:14

mechanism and processes involved are.

40:16

you know, acting on those

40:18

mechanisms is one of the

40:20

ways in which we can,

40:22

you know, better improve the,

40:24

you know, the lives for

40:26

those individuals. And because we

40:28

are, you know, our minds

40:30

are embodied, you know, we

40:32

don't have free floating mental

40:34

substance, you know, that exists

40:36

independent, all of our behaviors

40:38

are mediated by the brain.

40:41

So even extreme... impairing disabling

40:43

behavioral states, they are somehow,

40:45

you know, the brain processes

40:47

through their, you know, in

40:49

their complex direction are somehow

40:51

producing them, and those states

40:53

are somehow emerging in the

40:55

ways that brains interact with,

40:57

you know, with the environment,

40:59

and then the way that

41:01

brains interact with other brains,

41:03

you know, in our interaction

41:05

with other people. So there's

41:07

a brain basis to that,

41:09

you know, to be discovered

41:11

and to be talked about.

41:13

Now, it's not going to

41:15

eliminate the need. for us

41:17

to you know rely on

41:19

psychological behavior language to describe

41:21

stuff that is going on

41:23

because when we when we

41:26

use psychological cognitive language we

41:28

are talking we are describing

41:30

we're approaching these phenomena at

41:32

a higher level we are

41:34

talking about how kind of

41:36

you know the you know

41:38

like we're not just talking

41:40

about a brain in isolation

41:42

but we are we're talking

41:44

about a brain in interaction

41:46

with the environment we are

41:48

talking about multiple brains so

41:50

the the language of neurology

41:52

for example cannot capture those

41:54

interactions because the language of

41:56

neurology is focused on what

41:58

is happening inside one brain

42:00

versus the language of psychology

42:02

and psychodynamics is captures those

42:04

higher level dynamics, higher level

42:06

interactions quite well. And many

42:09

times behavioral health problems are

42:11

linked with those higher order

42:13

things. We are dealing with

42:15

how we are perceived by

42:17

other people and things that

42:19

other people say to us

42:21

and our status within, you

42:23

know, asserting things. And we're

42:25

talking about things in the

42:27

estates that we have acquired

42:29

through learning. and behaviors, you

42:31

know, so that all of

42:33

that remains essential. But for

42:35

certain, you know, for many

42:37

of these conditions, learning more

42:39

about how is it that,

42:41

you know, the brain mediates

42:43

these behaviors. Why is it

42:45

that some people get stuck

42:47

in certain depressive states? You

42:49

know, even when they desperately

42:51

want to change their own

42:54

behaviors, they're not able to?

42:56

And what role, for example,

42:58

does neuroplasticity play in that?

43:00

Why is it that in

43:02

certain cases there's a very

43:04

strong family history of mental

43:06

health problems? And why is

43:08

it in some people genetics

43:10

seems to confer a huge

43:12

degree of vulnerability? And the

43:14

thing with genetics is that

43:16

genetics factors cannot directly manifest

43:18

in psychological terms. Any expression

43:20

of genes has to go

43:22

through cellular pathways and expression

43:24

in brain network, etc. So

43:26

any link between behaviors and

43:28

gene is gonna be mediated

43:30

through intervening neurobiological pathways, which

43:32

means that there are things

43:34

we can say. How is

43:36

it that, you know, genes,

43:39

for example, confer high vulnerability

43:41

to schizophrenia or bipolar disorder?

43:43

And understanding what those mechanisms

43:45

are, you know, has the

43:47

potential for us to develop

43:49

new... interventions. Now it does

43:51

not mean that that the

43:53

reason a person, let's say,

43:55

you know, dwell is bipolar

43:57

disorder or depression or schizophrenia

43:59

is because they have abnormal

44:01

genes. You know, that's a

44:03

very different thing. That would

44:05

be a false way of

44:07

understanding this. You know, it

44:09

would be a mistake to

44:11

say that, oh, that, you

44:13

know, bipolar disorder is a

44:15

disorder of abnormal genetics in

44:17

the same way as Huntington's

44:19

disease that is a disorder

44:22

of normal genetics. You know,

44:24

that's a different kind of...

44:26

But it nonetheless remains the

44:28

case that there is a

44:30

genetic component to a bipolar

44:32

disorder, to schizophrenia, to a

44:34

smaller extent even in depression.

44:36

And that there are coherent

44:38

ways in which that genetic

44:40

contribution is being expressed. And

44:42

in trying to understand that

44:44

means that we better understand

44:46

at the brain level what

44:48

is happening to a depressed

44:50

person. And then, you know,

44:52

hopefully, the hope is that

44:54

that gives us more tools

44:56

to understand. more tools to

44:58

intervene on that and help

45:00

a person. So again, that

45:02

I think points to this

45:04

kind of, you know, this

45:07

binary tendency that we want

45:09

to say that either a

45:11

problem is a problem of

45:13

biology. you know, and that's

45:15

why we would take biologically

45:17

seriously, or we want to

45:19

say that if the problem

45:21

is not a clear biological

45:23

problem or a problem by

45:25

logical abnormality, then, you know,

45:27

nothing much is to be

45:29

gained by understanding the biological

45:31

dimension of it. And so,

45:33

and, you know, versus mental

45:35

health problems, mental health problems

45:37

are not primarily problems of...

45:39

you know biology gone wrong.

45:41

Mental health problems are problems

45:43

of behavior gone wrong and

45:45

you know psychological experiences gone

45:47

wrong but they nonetheless have

45:49

a biological dimension and then

45:52

they you know because they

45:54

have a biological logical dimension,

45:56

we can study that, we

45:58

can intervene on that, you

46:00

know, often in, you know,

46:02

remarkably effective ways at times.

46:04

A couple thoughts jump up,

46:06

one of which is moving

46:08

away from the conversation and

46:10

depression, but I think you

46:12

drew to some of the

46:14

nuances that we can also

46:16

use to think about diagnoses

46:18

like bipolar, schizophrenia, because I

46:20

think sometimes we focus a

46:22

lot of the conversation about

46:24

the psychosocial contributors to... to

46:26

conditions like anxiety and depression.

46:28

I mean, I feel like

46:30

the more that I work,

46:32

the more patients that I

46:35

see, it feels unagnorable that

46:37

patients who have conditions like

46:39

schizophrenia have so many different

46:41

stresses and factors in their

46:43

lives that either contribute to

46:45

relapses over their lifetime, but

46:47

also when you see the

46:49

story of the initial illness,

46:51

it feels like you... you

46:53

can't ignore the psychosocial aspect.

46:55

What, I guess, do you

46:57

see that coming through more

46:59

in psychiatry nowadays? Did it

47:01

used to be thought about

47:03

more before and then biology

47:05

took over for a time?

47:07

What's your view? Yeah, I

47:09

mean, I completely agree with

47:11

you. You know, psychosocial factors,

47:13

you know, both, you know,

47:15

in terms of, you know,

47:17

individual psychological factors in terms

47:20

of their... personality structure in

47:22

terms of a temperament, in

47:24

terms of their psychological developmental

47:26

history, in terms of their,

47:28

you know, the traumatic experience

47:30

that they have had and

47:32

their perceptions of those inoid

47:34

verse experiences, as well as

47:36

the larger societal organization around

47:38

them, you know, their state

47:40

of poverty. kind of financial

47:42

stress, you know, housing instability,

47:44

you know, access to food,

47:46

those kind of things, all

47:48

of them are extremely important.

47:50

The contributions vary from, you

47:52

know, from person to person

47:54

and in case, you know,

47:56

kind of condition to condition,

47:58

but they are absolutely vital

48:00

and essential. And in many

48:03

cases, the mental health problems

48:05

and psychopathological problems, they are

48:07

enmeshed with these psychological and

48:09

social kind of stressors and

48:11

issues. So any psychiatry that

48:13

ignores them or minimizes them

48:15

or neglects them, it's going

48:17

to be a highly impoverished

48:19

psychiatry and is not going

48:21

to serve patients very well.

48:23

What happened in the... in

48:25

the 90s was that there

48:27

was this tremendous exuberance around

48:29

the potential for neuroscience and

48:31

genetics and there was this

48:33

tendency to just conceptualize these

48:35

problems as these are brain

48:37

diseases, these are genetic disorders,

48:39

and there was this strong

48:41

optimism that just any day

48:43

now we're going to find

48:45

the genes, any day now

48:48

we're going to find the

48:50

brain circuits, and then we'll

48:52

be able to fix these

48:54

problems in a particular kind

48:56

of way. Now that in

48:58

the in you know that

49:00

that hope did not kind

49:02

of was not successful, you

49:04

know, by early 2000s, it

49:06

became pretty clear that the,

49:08

you know, biology is much

49:10

more complicated than that, but

49:12

it also became clear that

49:14

that some of the kind

49:16

of, you know, most important

49:18

drivers and contributors of these

49:20

problems are in fact things

49:22

that are happening outside the

49:24

brain. It is these childhood

49:26

adverse experiences, it is these,

49:28

you know, terf like, you

49:30

know, tribal life circumstances, stressful

49:33

life events. happening. And it's,

49:35

you know, in order to

49:37

improve clinical outcomes, both at

49:39

the individual level and at

49:41

the population level, we have

49:43

to tackle those, those kind

49:45

of, you know, larger psychosocial

49:47

psychosocial dynamics. And medicine, I

49:49

think, has struggled to do

49:51

that in psychiatry as well,

49:53

but also, you know, medicine

49:55

generally. And this is, I

49:57

think, in order to take

49:59

effect. psychosocial action, we need

50:01

a certain kind of political

50:03

movement, we need a certain

50:05

kind of political action, and

50:07

we need by and from,

50:09

from, you know, social forces

50:11

and social stakeholders. And the

50:13

political climate has not been

50:16

conducive to the, to, you

50:18

know, producing the kind of

50:20

effective public health changes that

50:22

people really, really need. And

50:24

so the emphasis has been

50:26

more and more on individual-centric

50:28

interventions. What can we do

50:30

to improve the functioning of

50:32

this particular individual while, you

50:34

know, leaving their, you know,

50:36

their, you know, environment? surroundings,

50:38

you know, as much, you

50:40

know, intact as much as

50:42

possible. And this kind of

50:44

basic dynamic, you know, shows

50:46

up in you know, in

50:48

all areas of medicine, you

50:50

know, not just in psychiatry.

50:52

If you look at kind

50:54

of epidemiological data around metabolic

50:56

disorders and cardiometabolic disorders, you

50:58

see this tremendous, you know,

51:01

association with social determinants of

51:03

health, with poverty, with access

51:05

to food, with access to

51:07

exercise, you know, and so

51:09

there's a there's a case

51:11

to be made that, you

51:13

know, a public health. approach

51:15

is necessary for all health,

51:17

not just mental health and

51:19

physical health, but it is

51:21

certainly much more important in

51:23

psychiatry than even it is

51:25

in general medicine. So there's

51:27

a difference of degree, but

51:29

not a difference of quality

51:31

when it comes to these

51:33

issues in psychiatry versus medicine.

51:35

I think the trick again

51:37

is in holding both, accepting

51:39

both truth at the same

51:41

time. We can acknowledge that

51:43

yes, there are factors within

51:46

an individual and there are

51:48

factors outside an individual and

51:50

we have to tackle both.

51:52

And worse than instead. we

51:54

see this weird polarity in

51:56

like IT where one group

51:58

just tries to insist that,

52:00

oh, you know, let's just

52:02

focus on the individual and

52:04

forget everything that's outside, and

52:06

the other group said, let's

52:08

just focus on the society

52:10

and, you know, forget what's

52:12

happening in the person. And

52:14

the reason to point out

52:16

is that Again, you know,

52:18

because these things are highly

52:20

biologically heterogenous, you know, we

52:22

have not been very successful

52:24

in mapping traditional DSM ICD

52:26

categories to specific biological processes.

52:29

But if you look at,

52:31

you know, what are some

52:33

of the biggest predictors for

52:35

the development of these conditions

52:37

and for the course, these

52:39

are actually the kind of

52:41

broader temperamental factors and personality

52:43

factors like neuroticism. that can

52:45

heavily predict whether a person,

52:47

for example, is going to

52:49

have depressive disorder, anxiety disorder,

52:51

other things now. And oftentimes

52:53

the contribution of personality factors

52:55

like neuroticism tends to be

52:57

greater than the contribution we

52:59

see from adverse childhood experiences

53:01

in general. So at the

53:03

very least, even if you

53:05

put aside questions of biological

53:07

mechanisms, we are seeing a

53:09

very strong interaction between individual

53:11

factors in the form of

53:14

their personality structure and life

53:16

events in the form of

53:18

both childhood adversity as well

53:20

as acute stressors later in

53:22

life. So any kind of

53:24

binary that tries to split

53:26

the two, that tries to

53:28

say either we focus on

53:30

the individual, either we focus

53:32

on the society, is actually

53:34

going to miss the interaction

53:36

that drives psychopathology to begin

53:38

with. And I think that

53:40

interaction feels very intuitive. probably

53:42

to most people, you know,

53:44

whether you practice in this

53:46

field or if you know

53:48

people who have experienced difficulties

53:50

with their mental health. What

53:52

do you think is at

53:54

the root of the fact

53:57

that nonetheless I guess we

53:59

struggle with? either biological

54:01

empirical evidence for

54:03

this or that we struggle

54:05

to turn it into interventions

54:08

that work for the majority of

54:10

people rather than just, you know,

54:12

40-50% of people. Yeah, I think

54:14

that the causes are, you

54:17

know, complex and have a

54:19

rich history. I think part

54:21

of it is because the

54:23

mental health fields is professionally

54:25

very fragmented. So it's not,

54:28

it's not a pure, you

54:30

know, pure medical system. So

54:32

for example, cardiologists, you know,

54:34

when they're, you know, they're

54:37

dealing with hard problems, they

54:39

are the main specialty devoted

54:41

to that. we have, you

54:43

know, people with psychiatric background, so

54:46

we have sex psychiatrists, you know,

54:48

who are into this. We also

54:50

have general practitioners and family doctors

54:52

in all this. We have people

54:55

from psychology background, so kind of,

54:57

you know, people who have a

54:59

psychology degrees, who might even have

55:01

PhDs in psychology, you know, involved

55:04

in this. And then we have,

55:06

you know, social people with social

55:08

work background, and especially in the

55:10

US, most people providing some form

55:12

of... or psychotherapy actually have a

55:15

social work background rather than a

55:17

psychology background. So we have multiple

55:19

kind of you know different disciplinary

55:22

backgrounds all you know engaged in

55:24

and trying to help people and

55:26

working with people and and they

55:29

all bring different assumptions and different

55:31

background ideas and different preferences and

55:33

different methodologies and they're in a

55:36

sense they're all competing for for

55:38

resources that the system has to

55:40

offer and they're competing. for prestige

55:43

that the system has to offer.

55:45

And if there are asymmetries

55:47

in how those resources and

55:49

how that prestige and how

55:51

the language that the public

55:53

gets to hear, how those

55:55

are distributed, then we set

55:57

up the scene for conflict

55:59

between. different disciplines and we set

56:02

up the scene for kind of

56:04

competition between disciplines for that which

56:06

ultimately ends up you know hurting

56:08

patients because they don't they don't get

56:10

the integrated care we need so especially

56:12

I think in the in the UK

56:15

with you know with the heavy reliance

56:17

on and the chess funding, you know,

56:19

there's a kind of zero-sum mindset where,

56:21

you know, you have a fixed pot

56:23

of money and it can either go

56:26

here, it can either go here. So

56:28

people in that effort to try to

56:30

obtain access to resources, that they have

56:32

to kind of bolster the narrative that

56:34

they're offering, they have to kind of

56:37

oversell, you know, what these problems

56:39

are and they have to exaggerate

56:41

their side of their perspective, you

56:43

know, so that they can secure.

56:45

for the kind of funding and

56:47

access to care that people need.

56:49

So I think, so that sets

56:51

up the scene where I think

56:53

different stakeholders are incentivized to promote

56:55

one side of the story rather

56:57

than, you know, try to produce

56:59

an integrated picture that recognizes everything.

57:02

And I think that the second

57:04

thing is that, you know, at

57:06

the philosophical level, again, you know,

57:08

because we're dealing with the

57:10

mind-body relationship and it is

57:12

so easy. for people to fall

57:14

into this mind body split

57:16

tendencies and you know what

57:18

locally you can call the dualism.

57:21

And it is so difficult

57:23

to talk about mind body

57:25

in an integrated sense because you

57:27

know the Western world doesn't

57:29

really have the language to

57:31

talk about that. We have to

57:34

tackle these centuries of bias

57:36

towards dualism as well as

57:38

reductionism, that is very hard

57:40

to overcome, especially for a

57:42

layperson. So there are these

57:44

kind of, you know, broader

57:46

philosophical challenges than we face.

57:48

And then finally, the reliance

57:50

on these symptom, heterogenous symptom

57:52

categories, I think, has obscured

57:54

the underlying complexity. It is

57:56

so easy to just say,

57:58

oh, you have... generalized anxiety

58:00

and here, you know, we have

58:03

medication or CD for that, that,

58:05

you know, relying on just that,

58:07

you know, actually ignores all the

58:10

messiness and none of that really

58:12

gets conveyed to the public and

58:14

sometimes not even, not even to

58:17

the clinicians. And that has held

58:19

back, you know, kind of appreciating

58:21

the nuanced nature of these problems

58:24

too. because I guess in

58:26

conducting, even just thinking to

58:29

the very basics of conducting

58:31

research, if you're recruiting

58:33

people with, you know,

58:35

recruitment will be people with

58:38

a diagnosis of major

58:40

depressive disorder as made by,

58:42

you know, the clinical

58:44

psychologist or the psychiatrist

58:47

who's running the study, but

58:49

to the often to the

58:51

exclusion of other diagnoses,

58:53

even... though that is not necessarily

58:55

the reality of that patient's existence

58:58

in the world, you know, they

59:00

will likely be experiencing

59:02

obsessive thoughts that perhaps don't

59:04

meet criteria for a diagnosis

59:07

of compulsive disorder, but they

59:09

might still be quite bothered

59:11

by thoughts when they're feeling

59:14

particularly distressed, particularly on edge,

59:16

that they've left something turned

59:18

on or that something terrible

59:20

is going to happen or

59:22

that... you know if they don't take a

59:24

certain action they'll be responsible

59:26

for all sorts of ills. But yeah

59:29

so if when research is so limited

59:31

to to doing the categories and

59:33

like you say actually in the large

59:35

part that's because of funding you know

59:37

you get funding to research a

59:39

disorder it's hard to move forward

59:42

I guess. Yes, yeah, and that's why

59:44

I think, you know, the scientific

59:46

community has been realizing that too,

59:48

and that's why there has been

59:51

this big push towards trans-diagnostic dimensional

59:53

research, because people have realized that

59:55

just having this methodology where you

59:57

take one DSM-ICT category and that

1:00:00

to healthy controls. That's actually not

1:00:02

the ideal kind of, you know,

1:00:04

study design because, you know, heterogeneity

1:00:06

and non-specific of the mechanisms, you

1:00:09

know, both at psychological and biological

1:00:11

level, and that it makes much

1:00:13

more sense to study these conditions

1:00:15

at different levels of specificity. You

1:00:17

know, looking at larger clusters of

1:00:20

these problems like intern, like what

1:00:22

it is that internalizing disorders all

1:00:24

share with each other, and in

1:00:26

some cases drilling down on specific

1:00:28

symptoms, example, an anedonia, what mechanisms

1:00:31

might be involved in anedonia

1:00:33

versus like a motor retardation,

1:00:35

versus just talking about a

1:00:37

depression-level syndrome. So looking at

1:00:39

these things that, you know,

1:00:41

in the trans-diagnostic manner and

1:00:43

also at a kind of

1:00:45

multi-dimensional manner, is very important

1:00:47

if you want to make

1:00:49

progress. And right now, it

1:00:51

is the case that our

1:00:53

treatments have generally limited efficacy.

1:00:55

This stands for both medical

1:00:57

treatments and psychological. treatments. The,

1:00:59

you know, our psychotherapies and our

1:01:01

medications are not as effective as we

1:01:03

would like them to be. It would

1:01:05

be great if we had more effective

1:01:08

treatments, but, you know, but we're not

1:01:10

there yet. And it's important to be

1:01:12

transparent with patients about that, that the

1:01:14

tools we have right now are limited

1:01:16

and somewhat imperfect, and they come with,

1:01:18

you know, fair degree of risks and

1:01:20

problems, too. And that they're not going

1:01:22

to be a magic fix. They're going

1:01:24

to, you know, you know, for a

1:01:26

lot of people, you know, they can

1:01:28

make the symptoms more tolerable and bearable

1:01:31

enough that you know there's

1:01:33

an improvement in functioning and

1:01:35

a smaller subset of people

1:01:37

experience more dramatic improvements

1:01:39

but for a lot of people

1:01:41

the symptoms are not going to go

1:01:43

away. They might get reduced to

1:01:45

more kind of bearable functional levels and

1:01:48

that You know, we should not over

1:01:50

promise or we should not present a

1:01:52

hyped up version of what what our

1:01:55

current tools can can accomplish and I

1:01:57

think the problem has been that we

1:01:59

We have not been sufficiently

1:02:02

humble as a profession.

1:02:04

The narrative that we

1:02:06

have told the public

1:02:08

is quite disconnected from

1:02:11

the scientific and medical

1:02:13

reality of what we

1:02:15

can actually accomplish. Yeah, and

1:02:17

I think it's refreshing and

1:02:20

I think luckily perhaps

1:02:22

starting to become

1:02:24

increasingly common to discuss

1:02:26

this level of nuance. in

1:02:28

terms of the limitations of

1:02:31

our treatments. And I think it's

1:02:33

again an area where binaries

1:02:35

often arise in saying that

1:02:37

if the treatments aren't helpful

1:02:39

then they aren't helpful at all

1:02:42

or how dare you say that

1:02:44

the treatments aren't helpful, they're

1:02:46

extremely helpful, there

1:02:48

aren't any problems with them. I

1:02:51

mean can we can we think

1:02:53

about some of the issues that

1:02:55

there are with treatments? both if

1:02:57

we think in the group of depression

1:02:59

anxiety type conditions but

1:03:01

also conditions where people

1:03:04

might experience disorders of thoughts,

1:03:06

psychosis, what are some of the problems

1:03:08

that you find and how do you

1:03:10

manage them when working with patients?

1:03:12

Yeah, I think so it varies quite

1:03:14

a, you know, quite a bit,

1:03:17

especially with regards to the problems

1:03:19

that people tend to experience in

1:03:21

the short term or in the

1:03:23

cute term, you know, when perhaps

1:03:25

medication is new when it is

1:03:27

being started, versus when they have

1:03:29

been on medications for for some

1:03:31

time and you know and you

1:03:33

know they're in a more maintained

1:03:35

stage of treatment and so the

1:03:37

nature of problems kind of often

1:03:39

differs based on that in the

1:03:41

short term we tend to see

1:03:43

a variety of what you can

1:03:45

call paradoxical reactions where let's say

1:03:48

you know you have someone with

1:03:50

depression and anxiety and you start

1:03:52

them on an antidepressant and they'll

1:03:54

suddenly have a flare up there

1:03:56

their anxiety will get worse you

1:03:59

know on soon after starting an

1:04:01

intebress and they might experience states

1:04:03

of agitation, they might experience states

1:04:05

of irritability, they'll have this intense

1:04:08

dysphoria that can sometimes even, you

1:04:10

know, turn into suicidality at times.

1:04:12

So we have to be mindful

1:04:15

of those that, you know, sometimes,

1:04:17

you know, we start a medication

1:04:19

and instead of things immediately starting

1:04:21

getting better, we get a paradoxical

1:04:24

response where things suddenly get worse.

1:04:26

And so we have... to be

1:04:28

any kind of, you know, when

1:04:30

we're starting a new medication or

1:04:33

we're increasing the dose, you have

1:04:35

to be mindful for those possibilities.

1:04:37

Then we have to discuss them

1:04:39

with patients that, you know, something

1:04:42

like this happened beyond the, you

1:04:44

know, beyond the lookout for that.

1:04:46

And then there are various kinds

1:04:48

of physical side effects, you know,

1:04:51

that post-dolerability challenges, you know, where

1:04:53

that's a surreise, for example, you

1:04:55

get a lot of gastrointestinal side

1:04:58

effects, people can have sexual dysfunction

1:05:00

issues, you know, with kind of,

1:05:02

you know, ongoing use, that can

1:05:04

become distressing, people can have things

1:05:07

like headaches, other things, and so

1:05:09

there are various kinds of tolerability

1:05:11

issues that that that... we need

1:05:13

to be mindful of. When we

1:05:16

start entering into the kind of

1:05:18

long-term maintenance therapy, then the metabolic

1:05:20

effects start becoming problems. So weight

1:05:22

gain over time, increased risk of

1:05:25

diabetes, increased risk of hyperlipidemia. And

1:05:27

that often poses, you know, a

1:05:29

challenge that if a person has

1:05:32

responded very well to a particular

1:05:34

medication, but now six months later

1:05:36

they, you know, they have gained

1:05:38

a lot of weight and their

1:05:41

kind of HPA1C is creeping up,

1:05:43

you know, we can't. just leave

1:05:45

it like that and you know

1:05:47

and you know increase their risk

1:05:50

of cardiometabolic problems. So the considerations

1:05:52

change so we have to do

1:05:54

that with with antesagotic medications as

1:05:56

you're well aware the risk of

1:05:59

more you know motor movement. disorders,

1:06:01

becomes prominent, you know, kind of

1:06:03

like, you know, as we increase

1:06:06

duration of treatment. And then something

1:06:08

that has been generally neglected historically

1:06:10

has been the risk of antidepressant

1:06:12

withdrawal, you know, and discontinuation issues

1:06:15

and not just with antidepressants, but

1:06:17

with other forms of psychotropics as

1:06:19

well, because people stay on these

1:06:21

medications for years, you know, when

1:06:24

they do decide to come off

1:06:26

them, historically they were, they were,

1:06:28

they were being. taken off very

1:06:30

fast and then they would have

1:06:33

severe withdrawal related effects. And because

1:06:35

we didn't have enough research investigating

1:06:37

that, there was a general skepticism

1:06:39

in the medical community about whether

1:06:42

these things even caused that, you

1:06:44

know, that's where a protected kind

1:06:46

of withdrawal. So it took a

1:06:49

lot of effort by kind of

1:06:51

service users and other other kind

1:06:53

of patient communities who had been

1:06:55

through really negative experiences. and they

1:06:58

raised enough of a human cry

1:07:00

that the medical community began to

1:07:02

pay attention and began to recognize

1:07:04

this as a serious problem. So

1:07:07

I think with all psychotropic use

1:07:09

long term, withdrawal issues become pretty

1:07:11

significant and we have to be

1:07:13

mindful of them. Why do you

1:07:16

think there was such a reluctance

1:07:18

for professionals to hear? the concerns

1:07:20

of patients when it came to

1:07:23

the issue of medication withdrawal symptoms?

1:07:25

It was a, I think it

1:07:27

was a combination of different factors.

1:07:29

One was that we did not

1:07:32

have good research data on this

1:07:34

phenomena. We, you know, there wasn't

1:07:36

any major funding agency that was

1:07:38

interested in exploring you know what

1:07:41

happens with long-term medication use what

1:07:43

kind of problems emerges so there

1:07:45

was a big gap for example

1:07:47

in the in the US Institute

1:07:50

of Mental Health is the biggest

1:07:52

public funder of research and in

1:07:54

the last three decades they have

1:07:57

been much more interested in doing

1:07:59

basic science research or doing in

1:08:01

or developing innovative medical treatments and

1:08:03

they have left clinical trials largely

1:08:06

to pharmaceutical companies. pharmaceutical companies obviously

1:08:08

are more interested in developing a

1:08:10

medication and studying its acute efficacy.

1:08:12

They're not interested in studying long-term

1:08:15

side effects. So there was a,

1:08:17

we had this problem with incentive

1:08:19

that no major research funder was

1:08:21

really that interested in the question.

1:08:24

You know, ideally, a national history

1:08:26

of mental health should have been.

1:08:28

but they set their priorities kind

1:08:30

of differently. And in similar kind

1:08:33

of ways, I'm sure that, you

1:08:35

know, among European funding agencies, no

1:08:37

one had really made this a

1:08:40

priority. So because there was no

1:08:42

research money going in that direction,

1:08:44

it was never studied. So there

1:08:46

was no general knowledge base to

1:08:49

link to. And because these problems,

1:08:51

you know, the severe versions of

1:08:53

them were sufficiently that the average

1:08:55

clinician was not seeing them. So

1:08:58

a person could treat hundreds of

1:09:00

cases of depression and not come

1:09:02

across a very severe case of

1:09:04

withdrawal. And the milder cases, when

1:09:07

they would come across milder cases

1:09:09

of withdrawal, they might just attribute

1:09:11

that to, oh, this is the

1:09:14

person's depression returning or this person's

1:09:16

anxiety returning or it has just

1:09:18

kind of had a change in

1:09:20

quality. So there was a kind

1:09:23

of an inherent bias towards interpreting

1:09:25

these symptoms. withdrawal related symptoms as

1:09:27

you know in relapse terms rather

1:09:29

than rather than withdrawal terms. So

1:09:32

when when people did kind of

1:09:34

start you know raising this concern

1:09:36

more fiercely you know the physicians

1:09:38

would look to their own experience

1:09:41

and they would say you know

1:09:43

I've been treating these patients I

1:09:45

myself I'm not seeing this and

1:09:48

then they would look to the

1:09:50

literature and like they were saying

1:09:52

you know there's no there are

1:09:54

no studies on this so they

1:09:57

would they would start from a

1:09:59

place of skepticism given given given

1:10:01

given that and and they would

1:10:03

they would the tendency would be

1:10:06

to you know there's something unusual

1:10:08

going on here that you know

1:10:10

but it's it's probably not the

1:10:12

mess versus the situation would have

1:10:15

been quite different if you know

1:10:17

if we had paid attention to

1:10:19

to long-term you know effects from

1:10:22

the very beginning then then people

1:10:24

would have started from an informed

1:10:26

place. Should there be a responsibility

1:10:28

for pharmaceutical companies to study more

1:10:31

than the acute effects of their

1:10:33

drugs? I think so. I would

1:10:35

personally say so, but you know,

1:10:37

but... forcing them to do it,

1:10:40

you know, it's going to, it's

1:10:42

in places like the US and

1:10:44

also Europe too, would require legislative

1:10:46

action. And pharmaceutical companies have far,

1:10:49

you know, stronger lobbying than most

1:10:51

positions. And so the general tendency

1:10:53

is that pharmaceutical companies tend to

1:10:55

only do what they're strictly obligated

1:10:58

to do. But you know, so

1:11:00

for example, FDA requires, you know,

1:11:02

you need to do large placebo

1:11:05

control trials. So, you know, they

1:11:07

can compel to do it. If

1:11:09

the, for example, if it was

1:11:11

mandated that, you know, you have

1:11:14

to do long-term safety study to,

1:11:16

you know, you know, things, and

1:11:18

there are certain, there are certain

1:11:20

minimal post-marketing requirements even now in

1:11:23

the US, but they were not.

1:11:25

strong enough to pick up these

1:11:27

kinds of issues. So there's certainly

1:11:29

I think a responsibility on the

1:11:32

pharmaceutical company side and we should

1:11:34

look into getting them to do

1:11:36

it. But I think at this

1:11:39

point, what I think we really

1:11:41

need is public. funding agencies to

1:11:43

make hydrogenic harm a priority. They

1:11:45

need to recognize that this is

1:11:48

getting to a point where this

1:11:50

is a crisis in many different

1:11:52

ways. It's a crisis of clinical

1:11:54

care, but it is also kind

1:11:57

of a crisis. of you know,

1:11:59

you know, public relations too around,

1:12:01

you know, around psychiatry medicine, etc.

1:12:03

And there's genuine suffering. So many

1:12:06

people, you know, are dealing with

1:12:08

this problem and feel abandoned by

1:12:10

the medical community. So this needs

1:12:13

to be a funding priority in

1:12:15

my view and by, you know,

1:12:17

made a priority by by medical

1:12:19

research organizations. With the public relations

1:12:22

crisis in mind. And again, we're

1:12:24

not focusing on other types of

1:12:26

treatments, but we aren't going to

1:12:28

be focusing on today, but things

1:12:31

like the debunking of the serotonin

1:12:33

hypothesis of depression and other issues

1:12:35

like that. My question is, how

1:12:37

do you how do you bear

1:12:40

these iatogenic calms in mind in

1:12:42

your clinical practice? How do you

1:12:44

use these medications? And again, we're

1:12:46

not focusing on other types of

1:12:49

treatments, but specifically what is your

1:12:51

approach and in your practice, but

1:12:53

perhaps also more broadly to this

1:12:56

public relations crisis. Yeah, my approach

1:12:58

has generally been to, you know,

1:13:00

talk about patients kind of in

1:13:02

an open and transparent manner about,

1:13:05

you know, about you know, the

1:13:07

nature of these problems as well

1:13:09

as the nature of these treatments.

1:13:11

So I try to convey to

1:13:14

them that the reason, for example,

1:13:16

they are depressed or anxious is

1:13:18

because of a confluence of different

1:13:20

factors coming together. You know, again,

1:13:23

the contribution raised from person to

1:13:25

person. So my form relation of

1:13:27

what is going on in any

1:13:30

particular case is going to be

1:13:32

different. a depressed state or an

1:13:34

anxious state and how this does

1:13:36

not just involve biology but there

1:13:39

are these you know psychological factors

1:13:41

involved there are these life factor

1:13:43

involves there are these developmental factors

1:13:45

involved and and I myself don't

1:13:48

do not use the language of

1:13:50

chemical imbalances or brain disorders because

1:13:52

I because I find that to

1:13:54

be very misleading and deceptive. So,

1:13:57

and once in a while, a

1:13:59

patient might themselves bring up the

1:14:01

language of chemical imbalance. And in

1:14:04

that case, I kind of correct

1:14:06

them. You know, this is actually,

1:14:08

you know, it's not literally true.

1:14:10

Sometimes people, you know, use it

1:14:13

as a metaphor, but it doesn't

1:14:15

represent the nature of the problem

1:14:17

very well. And so we talk

1:14:19

about that. And then with regards

1:14:22

to medication, you know, like in

1:14:24

way that they are not fixing

1:14:26

an abnormality in. in your brain,

1:14:28

rather, you know, we're using them

1:14:31

to control symptoms and make these

1:14:33

conditions more, you know, bearable for

1:14:35

you and to improve your functioning

1:14:37

or shift your emotional processing in

1:14:40

a prominent, you know, in a

1:14:42

positive direction or we're using it

1:14:44

to control your body state of

1:14:47

arousal, etc. You know, whatever the

1:14:49

specifics of, you know, in the

1:14:51

medication condition might be. but they're

1:14:53

not they're not going to be

1:14:56

the magic fix you know they

1:14:58

you know to the extent that

1:15:00

the your mental health problems are

1:15:02

enmeshed with your life circumstances with

1:15:05

your you know psychological patterns the

1:15:07

medication would not change that and

1:15:09

then those things required to be

1:15:11

addressed through other means of help

1:15:14

and I think if we if

1:15:16

we take the time to have

1:15:18

these honest transparent conversations with the

1:15:21

patients, then they would not leave

1:15:23

with these mistaken ideas about chemical

1:15:25

imbalance or medications fixing a chemical

1:15:27

imbalance or them having some kind

1:15:30

of a biological disease in the

1:15:32

same sense as diabetes or biological

1:15:34

dysfunction. So that's what I have

1:15:36

been doing and you know emphasizing

1:15:39

the you know, a more sophisticated

1:15:41

conceptualization of problems as well as

1:15:43

treatment. And again, I emphasize medications

1:15:45

are in for effect tools. They

1:15:48

help, but they also have the

1:15:50

capacity to harm. the balance is

1:15:52

dynamic. You know, if the medication

1:15:55

is helping you right now and

1:15:57

you're not having a lot of

1:15:59

problems with that, that's wonderful, but

1:16:01

it does not mean that three

1:16:04

years later, the balance will not

1:16:06

shift. And if the balance ever

1:16:08

starts shifting, that the medication is

1:16:10

causing more problems than it is

1:16:13

helping with, then we need to

1:16:15

take action and, you know, either,

1:16:17

you know, change treatments or, you

1:16:19

know, figure out other non-medication strategies.

1:16:22

And so I think patients being

1:16:24

aware of the fact that benefit

1:16:26

risks is a dynamic thing over

1:16:28

time is very important too. Dr.

1:16:31

Raftab, thank you so much for

1:16:33

that. toward a force around these

1:16:35

varied and complex topics. I'm really

1:16:38

sad that we are running out

1:16:40

of time, as I think I

1:16:42

could probably carry on quizzing you

1:16:44

for hours. I'm just wondering if

1:16:47

there is anything that you would

1:16:49

want to point people to in

1:16:51

terms of your work, any other

1:16:53

sort of important facets you'd like

1:16:56

to highlight that I haven't brought

1:16:58

out as yet today. Yeah,

1:17:00

I think the, you know, over

1:17:03

the past two and a half

1:17:05

years or so, I've been working

1:17:07

on a sub-stack newsletter called Psychiatry

1:17:09

at the Margins. So that's kind

1:17:11

of a useful public-facing resource that

1:17:13

I've been working on that goes

1:17:15

into some detail around these conceptual

1:17:17

and scientific debates in the field.

1:17:19

So I'll refer people to that.

1:17:21

There's also a recent book from

1:17:23

Oxford University Press called Conversations and

1:17:26

Critical Psychiatry that is an editing.

1:17:28

collection of interviews that examines these

1:17:30

issues in more detail too and

1:17:32

I think those would be useful

1:17:34

resources for people that are interested

1:17:36

in exploring these questions. Amazing. We'll

1:17:38

definitely make sure to link to

1:17:40

those in the show notes as

1:17:42

I've really enjoyed reading your work

1:17:44

there as well myself. Thank you

1:17:47

so much for your time. It's

1:17:49

been a pleasure seeing you today

1:17:51

and speaking to you. And thank

1:17:53

you for having me. I enjoyed

1:17:55

this. Thank you. You