Euphoria At The Burger Joint

The line at the popular local burger joint was much shorter than usual when my fiancée and I arrived arrived with visions of freshly seared beef and milkshakes dancing in our heads. We couldn’t believe our luck: aside from the people currently ordering, there was only a middle-aged woman and a young couple standing in line in front of us. We didn’t notice anything amiss, at first.

Then I saw that the woman was not actually in line, but she was approaching the couple in front of us, apparently looking to strike up a conversation. Her hair was a bit unkempt, her make-up slightly excessive. And she was holding a thick wad of cash in one hand. She was beaming from ear to ear as she asked the couple in front of us, “Are you two on a date?”

“Yeah, it’s our first date,” said one member of the couple.

“How wonderful!” the woman exclaimed. “I can see love, and I can just tell that you two were meant to be together.”

The couple chuckled nervously, and the the woman started talking to them about the importance of Love in the Universe.

I watched what was happening in front of us with growing unease. I’ve seen this kind of irrational exuberance—and lack of boundaries—before during various psychiatric rotations, in patients who were manic or high. It usually didn’t end well. I noticed that my fiancée and I were standing closer together by now, and I glanced at her with a worried look that said, “What do we do?” She shot me a look back that said, “You’re the psychiatrist, you tell me!” We were both quite hungry, so leaving was out of the question. We stayed in line to await the inevitable.

Eventually, the woman held out a $20 bill to the male half of the couple and said, “Here, take this! I want to celebrate your beautiful young love!” As he reached for the money, the woman moved in closer, wrapping her arms around the guy and giving him a big kiss on the cheek. I think it would have been on his lips had he not turned his head at the last second. “Whoa!” he said, as he hastily backed away to free himself of her, with a new $20 bill in his hand.

Thoughts of worst-case scenarios crossed my mind. What if this lady got really agitated if we didn’t want to talk to her, or we didn’t want to take her money (or kiss her, for that matter)? I tried desperately to remember the brief training I got as a psychiatry resident on how to maintain a defensive stance when dealing with potentially aggressive patients. I stood a bit sideways to the woman, so my vulnerable belly was not as exposed. I kept my right foot, which was closer to her, pointed towards her and my weight on my left foot, in case I had to move in either direction. I crossed my arms and then pretended to stroke my chin with my right hand, so my arms would not be sitting uselessly by my side if I needed them.

Sure enough, the woman approached and asked us, “Are you on a date?”

I made sure not to look at her too directly as I mumbled, “Not really, just here for some burgers.”

Still, she held out a $20 and said, “Here, I have a present for you!” Not wanting to escalate the situation by saying no to her, I decided I might as well take it. I stuck my arm out as far as I could towards her, so that it would be more difficult for her to step closer for a smooch. I held my breath as she put the money in my hand and swiftly moved on to the next person in line behind me. “Whew,” I thought. “Guess that training really worked!”

As I looked at the $20 bill in my hand, I asked my fiancée, “What should we do with this?” Again, she would not let me off the hook. “You’re the one who took it, you decide!” I briefly debated paying for our meal with that money, but it just felt a little…crass. I paid with a credit card instead, and put the bill in my wallet. Once we got our food, I turned back towards the entrance to see what the woman was up to, but she had left, presumably to do good deeds elsewhere. I felt guilty, of course. It would certainly have been worse if she had been giving away Benjamins, but who knows what percentage of her personal savings she was wasting like this, one 20-dollar bill at a time?

But would it have made sense to call the police on her for causing a disturbance, or for sexual harassment, given her unwanted kissing? Even if they came, took it seriously, and hauled her to the nearest psychiatric ER, would there have been enough to involuntarily detain her? What if she had just won the lottery and was being very happy and generous?

Still, those burgers and shakes were tasty, and well worth the time spent standing in that particular line.

Readers, what do you think you would have done in this situation?

The Paroxetine Study 329 Re-Write

I've not really written about GlaxoSmithKline's infamous paroxetine (Paxil) Study 329, except to briefly allude to it in a previous post. This is probably because I felt others had covered it so extensively already, especially over at the 1boringoldman blog. Another anonymous child psychiatrist has an entire website summarizing the study, and there's even a detailed wikipedia page. So go to those sites if you haven't heard of this study before. However, I wanted to write this post to share my thoughts about the re-analysis of the study's data by an independent, mostly-international team, which was accepted for publication in the BMJ.

First off, I want to be clear that I don't think the new publication's results will be news for anyone in the profession who has been paying attention. In my years of practice (which admittedly are not many), I've never seen a young patient prescribed paroxetine by a child psychiatrist. While studying for a board exam the other day, I saw this (source):

If it's been covered in a textbook published in 2010, you can be sure it's pretty common knowledge by now. In this regard, the profession has been self-correcting. However, it seems that despite acknowledging the risks of paroxetine, the profession has turned a blind eye toward the actions of the psychiatrists who had helped popularize its use in kids in the first place. None of the well-known academics whose names are attached to the study have offered to retract the paper, and as far as I know, none have suffered professionally. In fact, one of them, Karen Dineen Wagner, was just elected president of the American Academy of Child and Adolescent Psychiatry (AACAP).

There have been efforts to address this issue within AACAP, most notably by 2 regional child psychiatry organizations, including the Northern California Regional Organization of Child and Adolescent Psychiatry (NCROCAP). Dr. Mickey Nardo, the brains behind 1boringoldman.com and one of the authors of the Study 329 re-write, informed the AACAP Ethics Committee about the study's faults, and they initially seemed receptive.* However, those efforts went nowhere. At a recent AACAP annual meeting, I was chatting with an older child psychiatrist, who is a "Distinguished Fellow" of the organization and has been involved in AACAP affairs for decades. Somehow, the topic of NCROCAP came up. When I commented that they seemed to be an activist bunch, he replied, "Yes, probably too much so, which is not good for the group process."

Well, now we see the outcomes of this "group process." By prioritizing group harmony over doing the right thing, AACAP has invited outside intervention. This BMJ editorial accompanying the new publication, by Peter Doshi, is one of the most damning things I've ever read about institutional intransigence.* It'll be interesting to see how the organization reacts.

UPDATE: As I was finishing this blog post, I got the following email (New York Times article published around 6:30pm EST, email was sent around 6:34pm*):

Dear Members,

This week, The BMJ published a study, “Restoring Study 329: efficacy and harms of paroxetine and imipramine in treatment of major depression in adolescence,” which reanalyzes data from a clinical trial performed in the late 1990s and published in JAACAP in 2001. The conclusions of this article contradict those of the original study. Please know that the Academy has been fully aware of the pending publication of this article by The BMJ.

Research provides the foundation for child and adolescent psychiatry’s knowledge base. The Academy encourages rigorous scientific design and methodology and supports the highest ethical and professional standards. We also believe it is essential that research be conducted within a strong framework of transparency and disclosure. As an organization, AACAP has been a leader in advocating for the positive changes that have taken place in the last decade in the relationship between the pharmaceutical industry and academic and professional associations.

As the leading national professional medical association dedicated to promoting the healthy development of children, adolescents, and families, through advocacy, education, and research, our response to The BMJ publication is as follows:

• AACAP has the utmost respect for the The BMJ and we thank them for their continued efforts to further scientific knowledge and understanding.
• AACAP supports transparency in clinical trial reporting and welcomes the RIAT initiative, which enables publicly available primary data to be reanalyzed and published as new, potentially revised reports.
• JAACAP is a forum for scientific reporting and scholarly discussion. The scientific process builds on itself over time through a cycle of new research, analysis, and ongoing dialog. This process stimulates debate and moves the field forward toward a better understanding of critical issues.
• As with most medical journals, JAACAP operates with full editorial independence. AACAP does not influence or direct decisions regarding specific publications. Furthermore, the statements and opinions expressed in JAACAP articles are those of the authors, and not necessarily those of AACAP, the editors, or the publisher. Inquiries about the articles and study in question should be addressed to their respective authors.

Moving forward, we will continue to monitor any developments and keep the membership informed of relevant information as it becomes available. Please direct any questions to the Communications Department via email at communications@aacap.org.

Thank you for your continued support!

Paramjit T. Joshi, MD
President, AACAP

Like I said, this is gonna be interesting.

* These sentences were added/edited after original publication for completeness.

The Old Man: A Story

Part I

The first time I met the old man was during my residency interviews. He was spry and looked younger than his age, and why not? He was at the top of his game: head of a department, boatloads of research funding, one of the most well-known psychiatrists around. Another psychiatry department chair who had interviewed me previously hinted that the old man was quite a businessman and enjoyed cozy relations with industry.

As he asked me his first question, the old man practically winked: "So, are you single, in a relationship, or married, or what?" That was my first hint that he might not be the most ethically-inclined individual. I had been told by my medical school before interview season that such personal questions were definitely off limits. Yet he made his greeting seem like the most natural and friendly thing in the world.

Part II

The old man was fuming. He was supposed to be giving a talk on depression treatment, but what seemed to preoccupy his mind was a just-published study from Irving Kirsch suggesting that antidepressants were not better than placebo for mild to moderate depression. Our speaker seemed deeply and personally offended. After many words assailing Kirsch's motives, he concluded: "Even if it's no better than placebo, it doesn't mean we shouldn't treat the patient!" Almost sounded like advice from Allen Frances, but twisted.

Part III

By random chance, I saw the old man again recently, when I was going out to dinner in the city where he lives. There he was, walking down the sidewalk with his wife, right past where I had just parked my car. He was wearing a sweatshirt with the name of his university employer on it. I'd never seen him out of a suit before. I thought he seemed older, frumpier, humbled. Or perhaps that was just my wishful thinking?

A lot has happened since the last time I saw him. He was no longer the department chair, replaced by someone known for work related to ethics. I briefly considered going up to him and saying something, but what? "Thank you for being an example of what not to aspire to?" Or, "That's a very plain-looking sweatshirt; did all your industry funding dry up?" Poor sportsmanship and too passive-aggressive. I briefly imagined following him down the sidewalk, yelling: "Shame, shame, shame!"  But he probably would've mistaken me for a Scientologist or something.

The Most Popular Psychiatrists in America (According to Twitter)

All the recent hubbub over Dr. Memhet Oz got me thinking more about fame when it comes to medical doctors: how they gained their popularity, to what end they employ their platforms, and how they keep (or don't keep) their professional integrity. One of the easiest ways to estimate popularity is to look at how many people follow an individual on Twitter. There, Dr. Oz is clearly way ahead of the practicing physician pack with 3.75 million followers. Dr. Drew Pinsky is second at 3.16M, while CNN's Dr. Sanjay Gupta is a distant third with 1.98M. In comparison, well-known blogger Dr. Kevin Pho "only" has 122K followers.

Curious about who the most popular psychiatrists are, I searched Twitter for individuals (not organizations) with profiles matching "psychiatrist" on 4/26/15. I examined the first 100 or so profiles written in English, looking at the follower count and selecting the 4 psychiatrists with the most followers for further scrutiny (and speculation), focusing on the nature of their popularity and just how much B.S. they espouse. Here's what I found:

#4: Judith Orloff (40.0K followers | following 10.3K)

Claim to fame: According to her Twitter profile, Dr. Orloff is a "psychiatrist, intuitive healer, and author of THE ECSTASY OF SURRENDER about how to let go of stress, trust intuition, and embrace joy." She has also written other books with titles such as [her CAPS]: EMOTIONAL FREEDOM, POSITIVE ENERGY, INTUITIVE HEALING, and SECOND SIGHT. I have never heard of her or any of her books; judging by their descriptions, they are very much targeted toward a non-scientifically-minded audience (which is to say, just about everyone).
B.S. meter: 7 . Dr. Orloff's about page emphasizes the power of intuition to help us "heal—and prevent—illness" and is full of quotations describing her as "a prominent energy-based healer" and a "positive energy guru." I have no doubt that she is a great psychiatrist who helps her patients and readers feel better, and I happen to agree with the message in her latest book about the importance of letting go as opposed to "pushing, forcing, and over controlling people and situations." Yet my intuition tells me that anyone who promotes herself with a sentence like "Dr. Orloff is accomplishing for psychiatry what physicians like Dean Ornish and Mehmet Oz have done for mainstream medicine" needs to be approached with a healthy dose of skepticism.

#3: Daniel Amen (78.7K followers | following 29.3K)

Claim to fame: Frankly, I was surprised that he was not #1. He's the only psychiatrist that I immediately recognized out of the 4 I found doing this search and the only one with a verified Twitter account, which Twitter only bestows upon "key individual and brands." Dr. Amen is the founder of Amen Clinics, which uses SPECT brain scans to purportedly diagnose mental disorders. He has been featured in programs running on PBS, and he even has influence amongst Christian audiences. In 2012, a Washington Post article called him "the most popular psychiatrist in America."
B.S. meter: 8 . There have been numerous well-articulated criticisms of Dr. Amen and his ridiculous claims regarding SPECT scans that I won't rehash here, save for one especially galling fact: his clinic charges $3500 for an initial evaluation and SPECT scan, which is generally not covered by insurance. While the clinic's website does not reveal this cost up front, it does say they've done over 100,000 scans, so you do the math. PBS's own ombudsman has disavowed any association with Dr. Amen's infomercials that were aired by local PBS affiliates without adequate disclaimers. Dr. Jeffrey Lieberman, former president of the American Psychiatric Association, was quoted in the Washington Post article as saying this about Amen: "In my opinion, what he’s doing is the modern equivalent of phrenology." On that point, Dr. Lieberman and I can agree.

#2: Brian Weiss (80.7K followers | following 25)

Claim to fame: Dr. Weiss's website tells us he "was astonished and skeptical when one of his patients began recalling past-life traumas that seemed to hold the key to her recurring nightmares and anxiety attacks. His skepticism was eroded, however, when she began to channel messages from 'the space between lives,' which contained remarkable revelations about Dr. Weiss's family and his dead son. Using past-life therapy, he was able to cure the patient and embark on a new, more meaningful phase of his own career." He is the author of books such as Miracles Happen: The Transformational Healing Power of Past Life Memories, and Many Lives, Many Masters: The True Story of a Prominent Psychiatrist, His Young Patient, and the Past-Life Therapy That Changed Both Their Lives. Not surprisingly, his homepage prominently features a photo of him and Oprah. He runs 5-day workshops costing $1000/person for "anyone interested in exploring these profound psychospiritual techniques."
B.S. meter: 10+ . Someone in a past life once told me, "If you ain't got nothin' nice to say, then it's better to say nothin' at all." I will stick with that for my current life and any of my future lives…

Thus far, the trend seems to be greater popularity correlating with ever escalating levels of B.S. I was losing what little faith I had entering this exercise. So I was shocked by who ranked first:

For a moment, I thought I was looking at Dr. Tobias Fünke from Arrested Development. But no, it's actually this guy:

#1: Norman Rosenthal (101K followers | following 28.3K)

Claim to fame: I have never heard of Dr. Rosenthal before, but he is the only psychiatrist I can find with over 100K followers. According to his website, he "has written over 200 scholarly articles, and authored or co-authored eight popular books. These include Winter Blues, the New York Times bestseller Transcendence, and the Los Angeles Times bestseller The Gift of Adversity. Rosenthal has conducted numerous clinical trials of medications and alternative treatments, such as Transcendental Meditation for psychiatric disorders, and the treatment of depression with Botox." Watching him on Youtube, it seemed that his South African accent instantly gave him added authority and gravitas (I call this the Salvador Minuchin effect).
B.S. meter: 1 . I was ready to be skeptical of Dr. Rosenthal, and this promotional page for his newest book is chock full of celebrity endorsements, including one from Dr. Oz himself. But the book actually seems to offer very sensible advice (based on Dr. Rosenthal's own life) on how to cope with adversity, and reading a passage from it on Google books, I even learned some interesting things about how the NIMH worked during the transition to the Steve Hyman/Tom Insel era. Dr. Rosenthal's research publications also left me impressed. He worked at the NIMH for 2 decades, and he did impactful studies on seasonal affective disorder, sleep disturbance in mania, and the use of light therapy for delayed sleep phase syndrome. He still sees patients in his clinical practice, where he seems to emphasize integrating different treatment modalities instead of pretending there's some magic bullet. And this is my own personal bias, but I find it touching that his son Joshua has followed in his footsteps, becoming a child and adolescent psychiatrist.

So what did I learn about psychiatrists and fame, at least when it comes to Twitter? Obviously, it helps to write multiple best-selling books and to regularly appear on television. Presenting oneself as an "alternative" practitioner with special knowledge or healing techniques helps as well. I won't delve into the content of their tweets in this post, but it seems relentlessly positive messages and pithy tips on how to improve one's life are a must in order to reach as broad an audience as possible.

Also, 3 of the 4 psychiatrists employ the method of following tens of thousands of people in hopes of trying to get as many people to follow them back as possible. In contrast, the truly famous doctors tend have much more sane follow counts: Dr. Oz follows 85, Dr. Pinsky follows 422, and Dr. Gupta follows 198. Thus, Dr. Weiss may well have the most impressive follower count amongst psychiatrists, given that he only follows 25 people for a follower:following ratio of 3228!

Before doing this search, I did not follow any of these top 4 psychiatrists on Twitter. Of the accounts that I follow, 8 of them follow Dr. Amen, 4 follow Dr. Orloff, 4 follow Dr. Rosenthal, and only 1 follows Dr. Weiss (really, @AACAP?). While writing this post, I've decided to follow Norman Rosenthal. He's the one out of the 4 who seems to have most preserved his professional integrity without wading deeply into the realm of pseudoscience, pop spirituality, or utter nonsense. I think every psychiatrist (or doctor, for that matter) aspiring to semi-celebrity status can learn something from him ;-)

The Impact of False Diagnostic Labels

Back in April, an extraordinary article was published by Dr. Peter Parry, an Australian child psychiatrist, about his correspondence with an American adolescent who had been diagnosed with pediatric bipolar disorder (PBD) during the PBD craze in the early 2000's. I had linked to the article on Twitter, but I haven't had a chance to write about it until now.

The power of this article comes from the fact that it includes a detailed first-person account from the patient "Adam." He comes across as an extraordinarily thoughtful young man, who had a tragic but far from uncommon encounter with psychiatry. Here's what Adam had to say about being diagnosed with PBD and treated:

I was 12 when first diagnosed. I had suffered depression and anxiety including severe OCD, which has since disappeared. It should also be mentioned I come from a screwed-up family and was physically abused by a sibling. Parents divorced young. My mother had a lot of issues, etc. So it goes without saying there was a lot the psychiatrist should have asked if he was ever so inclined. But unfortunately, he holds a faculty appointment at [edited—A PBD oriented child and adolescent psychiatry clinic].

Within about three months, I was on 8 different medications at one time. Very scientific treatment—all the best—several anticonvulsants, several antipsychotics, a couple of antidepressants and lithium too.

Things got so bad, that I ended up being referred to the neurology department, for different opinions about strange symptoms I began having on this cocktail. Which resulted in their giving me a working diagnosis of some kind of mitochondrial myopathy. "Bipolar plus mitochondrial disease" as it went. Which I have been told only recently could have been precipitated by the huge amounts of divalproex I was taking. The symptoms quickly disappeared when I coincidentally stopped the drug for unrelated reasons. Oh well, but it is a clear illustration of what one of the "best" academic medical centers in the world has to offer a struggling young boy.

And here is Adam's perspective on how the diagnosis and treatment affected him:

But the worst part of this, which I have only been recently able to shake within the last year (2008/9), is the defectiveness I felt. Just kind of in some core way. Like I'm totally different. When I was younger, that feeling was a lot stronger and more prominent. Now I feel like a fool for even having given thought after eight years to the question of whether I might go to sleep one night and wake up manic. I decided with my (new) psychiatrist's support a year ago to stop my medicines. I’m not doing especially well now, but I have at least been able to shake the feelings the diagnosis itself carved into me. The same can’t be said for its physical and social effects though.

It's not just children and teenagers who are vulnerable to being misdiagnosed with bipolar disorder; it can even happen to an NBA millionaire. A couple of weeks ago, I read one of the best articles that I've ever encountered on mental health in professional sports, titled "Why Isn't Delonte West in the NBA?" As a casual basketball fan, I knew that West had been a part of the Cleveland Cavaliers during the LeBron James years. I've heard that he struggled with mental illness and had been diagnosed with bipolar disorder. I recalled that he had been arrested after being found driving around with multiple weapons, and there were even rumors that he had slept with LeBron's mother. But this article provides the inside story of what actually happened, and the facts were deeply unsettling.

Delonte West grew up without a stable home, with a single mother who worked multiple jobs just to keep afloat after his parents divorced.

West has an older brother, a younger sister, and a vast extended family that he refers to as "a village." He stayed with many of those relatives growing up. "I lived off of every exit," he says, rattling off 11 specific ones from memory. "I lived in so many apartments … with cousins, uncles, and aunts, just making it."

In the NBA, he had several outbursts of anger, which led to him seeing a psychiatrist.

West was diagnosed as bipolar by a D.C.-area specialist. He says that when he saw the doctor, he’d been feeling down, having days when he was sad and tired and didn’t want to get out of bed. But he told the specialist that there were also times when he "might just go out and buy a car. Or go to the mall and spend 25 grand." West doesn't think the doctor took into consideration that such behavior might not be unusual for a professional athlete with a big paycheck. He now thinks that he was suffering a temporary bout of depression, not exhibiting symptoms of a chronic disorder.

Another part of the article provided additional context for West's inner struggles:

As a kid, moving from school to school, he often found himself the target of playground taunting. "I was real funny-looking," he says, with big ears, a mole on the back of his head that he had removed once he got to the NBA, and a birthmark below his lip that he's also had partially removed. His light skin and red hair stuck out, too. "I was made fun of a lot growing up, but I just knew the basketball court was the place where you couldn’t make fun of me, you had to respect me." He says he always had "more jokes for me than you had," but that he internalized the cruel things kids said to him. Last year, West told an interviewer that he believed his real problem was not bipolar disorder, but "self-loathing."

This was what actually happened in the weapons incident that contributed to derailing West's NBA career:

It was the offseason, and a few of West's cousins had come over to his house with their children. West's mother was looking after the kids while he slept and the other adults went out. At some point in the evening, West's mother woke him up. She said the kids had gotten into a closet in his small, in-home music studio, where he stored guns that he had bought, legally, in Cleveland. He needed to do something about those weapons, she told him.

With the driveway crowded by his cousins' cars, West got on his motorcycle so he could bring the guns to another residence. Earlier in the evening, he'd taken Seroquel, which is often prescribed for bipolar disorder. Seroquel makes you drowsy, and as he headed out on the highway, he found that he was dozing in and out. After he felt himself drifting off, West was pulled over for making an unsafe lane change, and he told the officer that he was carrying weapons. The day after the arrest, a police spokesman said that West was "very cooperative the entire time."

After his arrest, West played for the Cavaliers for another season, but the article makes the plausible argument that because West had been labelled with a mental illness, people were willing to believe whatever crazy things they heard about him, including the false rumor that he had slept with his teammate's mother. Undoubtedly, taking Seroquel contributed to his arrest. Without the "bipolar disorder" label, if instead the narrative had been that West had emotional issues due to childhood stresses, he may well still be in the NBA.

Earlier this week, Dr. David M. Allen had a blog post on misdiagnosis: "Is Your Psychiatrist Committing Malpractice Even if Doing What a Lot of Other Psychiatrists Are Doing?" (The short answer is "yes.") However, according to Dr. Parry's article, when Adam looked into his legal options, he was told "his treatment would be deemed 'standard practice' where he lived," which is a big deterrent for the lawyers when it comes to medical malpractice lawsuits. What a sad irony: the crappier the standard diagnosis and treatment becomes, the more the practitioner is protected by the herd.

When I was in medical school at a very biological psychiatry-oriented institution, the psychiatry professors made sure to educate us on the past evils of blaming refrigerator mothers for schizophrenia. And yet, as Dr. Parry pointed out, we have gone from the "brainless psychiatry" of the psychoanalysts to today's symptom-focused "mindless psychiatry" that tends to ignore the patient's inner life and the developmental biopsychosocial context. Here is my favorite section of Dr. Parry's article:

In addition to being a method of inquiry, science is a social process and there is a vast research literature concerning the sociology of science. Scientific disciplines do not build on knowledge in a purely linear fashion, but at times undergo dramatic upheavals according to paradigm shifts. The dominant paradigm governs what is acceptable to study, research, publish and practice. Softer sciences like psychiatry can be more susceptible to extreme paradigm shifts. The history of psychiatry reflects this. 

One of my biggest frustrations while reading Dr. Parry's words is that his wisdom is relegated to an opinion article published in a little known open-access journal, while the leading child psychiatry journal, which claims to be "advancing the science of pediatric mental health and promoting the care of youth and their families" [emphasis mine] would never permit such a sharp critique within its pages.

Conflicts of Interest

The following story was recounted to me by someone who was there:

He was indignant. Outraged, even. He was a department chair. A prominent psychiatrist and author of textbooks. A Key Opinion Leader in the field. How dare the New York Times question him?

The psychiatry residents sat in silence as he went on his rant. Every other medical specialty does the same thing! How come they didn't go after the orthopedic surgeons or the cardiologists, who made much more money from industry relationships than psychiatrists? They went after psychiatry and psychiatrists because of the stigma surrounding mental health. And what is this whole conflict of interest business, anyway? The New York Times even had an article on Michelle Obama's clothing retailer having a conflict of interest. It's ridiculous! And the senator who started all this, Senator Grassley? What about all of his campaign contributions? Does he have conflicts of interest?

He had more choice words for the Times and for Senator Grassley, but you get the idea. His mindset seemed to be that because what he was doing would ultimately help patients, he was beyond reproach as long as he was not committing any crimes. Since funding was limited, what was wrong with working with industry? When all the other specialities make more than psychiatrists, why shouldn't psychiatrists take part in entrepreneurial activities?

Not surprisingly, he is no longer the department chair. However, five years later, this mindset about conflicts of interest still remains with some (many?) of psychiatry's leaders. How else to explain the recent revelations about David Kupfer, chair of the DSM-5 task force? He failed to disclose that he was part of a company making a dimensional assessment for depression, both during the DSM-5 process and on an article that he co-authored with his business partner, statistician Dr. Robert Gibbons, who seems to be creating a commercial product with public money.

The ends do not justify the means. Just because someone else is doing it doesn't make it right. These may be rote lessons from childhood, but it seems that some people have conveniently forgotten them. In my opinion, this most likely happens not because of greed, but when people truly believe that they are doing good; therefore they must be good, and their critics must be bad. Narcissism is a powerful and dangerous thing.

The Risks to Adolescents of Legalizing Marijuana

2014 is a banner year for proponents of marijuana legalization, with cannabis becoming legal in Colorado and Washington state. The upcoming Super Bowl will go down in history as the Marijuana Bowl. Even President Obama has weighed in, saying in a New Yorker profile that he believes marijuana is less dangerous than alcohol "in terms of its impact on the individual consumer."

I acknowledge that there are probably going to be societal benefits to decriminalizing cannabis. Fewer people would be locked up on minor drug charges, police departments can devote their resources elsewhere, and there would be higher revenues for states. I also believe that most adults can smoke weed responsibly without abusing the privilege.

However, what I don't see mentioned much in the popular press is the deleterious effect of marijuana on adolescent brains, and how the drug could fundamentally alter a young person's life. As a psychiatric resident working in a university hospital ER, I saw a slew of college students who became extremely paranoid and had disturbing hallucinations after taking just a few hits of marijuana. At first, I and some of the other doctors thought that their weed had to have been laced with amphetamines, but all of their urine tests came back positive only for THC's. Since I've completed my training, I have seen numerous people in their late teens and early 20's with no family history of schizophrenia, who became very psychotic after months or years of regular cannabis use. Sadly, the psychosis does not always go away even after they stop smoking.

For the past decade, there has been convincing evidence that cannabis use is correlated with higher rates of psychosis. What was not clear was whether this correlation meant causation, as it was also plausible that people who go on to develop psychosis like to use cannabis to self-medicate. However, study after study has now shown that people who use cannabis earlier in adolescence (or use more of it) also develop psychosis earlier, with the same effect not being true for alcohol or tobacco, strongly implying that cannabis causes psychosis.

One of the latest studies, published in December 2013, had the following results:

The prevalence of psychosis and schizotypal personality disorder increased significantly with greater cannabis use in a dose-dependent manner. The associations between cannabis use and psychosis were 1.27 (95% CI 1.03-1.57) for lifetime cannabis use, 1.79 (95% CI 1.35-2.38) for lifetime cannabis abuse, and 3.69 (95% CI 2.49-5.47) for lifetime cannabis dependence. There was a similar dose-response relationship between the extent of cannabis use and schizotypal personality disorder (OR=2.02 for lifetime cannabis use, 95% CI 1.69-2.42; OR=2.83 for lifetime cannabis abuse, 95% CI 2.33-2.43; OR=7.32 for lifetime cannabis dependence, 95% CI 5.51-9.72). Likelihood of individual schizotypal features increased significantly with increased extent of cannabis use in a dose-dependent manner.

Even if the worst-case scenario of psychosis does not occur, there's the potential for other harmful outcomes. I have had patients who became physically dependent on cannabis to the extent that they felt nauseated and could not keep food down unless they have smoked. Not surprisingly, cannabis use also appears to be correlated with lower educational attainment, especially for those who started using before age 15.

Already, even before it had been legalized anywhere, there were some unsettling trends among teenagers when it comes to marijuana. The good news is that teenage use of alcohol, tobacco, and most illicit substances is trending down. However, use of marijuana has steadily increased in recent years, such that it is now the second-most abused substance after alcohol. Teens are also increasingly perceiving marijuana as being not so risky, with the percentage of 12th graders who see regular marijuana use as posing "great risk" decreasing from about 56% to 42% between 2006 ad 2012. And now, with the legalization of cannabis in some states and comments like those from our President, the perceived risk will only continue to decrease.

What are the societal and ethical implications of this? Perhaps marijuana is safer for most people than alcohol or tobacco. But for those who are susceptible to the psychosis-inducing effects of marijuana, its effects can be horrendous. Is it acceptable to permanently mess up some people's minds for the enjoyment of many? Strange how this is starting to sound like the NFL and the concussion issue. In the New Yorker interview, Obama had this to say about pro football and concussions:

"At this point, there’s a little bit of caveat emptor," he went on. "These guys, they know what they’re doing. They know what they’re buying into. It is no longer a secret. It’s sort of the feeling I have about smokers, you know?"

Do all these young people who are regularly using marijuana have a similarly informed view of what they're buying into?

On Bullying and NFL Culture

I have always been enthralled by NFL football. Growing up, I was amazed by the super-human strength, speed, and dexterity exhibited by its players, and how they seemed to (almost) always get up from bone-crunching hits and keep playing. Over the past decade though, it has become increasingly clear just what a physical and mental toll the game takes on its players, with the NFL's earlier attempts to deny links between concussions and lasting brain damage in the form of chronic traumatic encephalopathy at the forefront of recent reports.

For some observers, the NFL has definitely lost some of its luster. However, the league's popularity does not seem to be waning. The week-to-week dramas on and off the field have me convinced that the NFL is America's #1 reality show. What I wonder is whether this scrutiny can result in anything positive? Or will the NFL just take advantage of the increased attention, whether good or bad, for gain and profit? I think how the league handles the latest scandal will be instructive.

For the past week, there have been numerous news stories about Jonathan Martin of the Miami Dolphins, who left the team and checked into a hospital for emotional distress following alleged bullying by teammates. Martin, who graduated from Stanford, has made public some disturbing voicemails and text messages from Richie Incognito, a player who was kicked off two different college football teams.

What I haven't heard discussed much on sports shows is what exactly is bullying? The officially accepted definition is that bullying is unwanted, aggressive behavior that involves a real or perceived power imbalance, which is repeated over time. From this definition, it's quite clear that bullying was in fact what was going on. Incognito, an NFL veteran and a member of the team's player leadership council, is clearly in a position of power over the much younger Martin, and the abuse certainly was not a one-time incident, starting with Martin's rookie year and continuing into this season.

Watching the Fox NFL pregame show this morning, I was dismayed but not surprised by some of what I heard. Jimmy Johnson talked about how Martin was not drafted until the second round, meaning some teams must have thought there were some issues with him. Michael Strahan said that people only do to you what you allow them to, implying that Martin is somehow weak for not standing up for himself. Terry Bradshaw talked about how our culture has become too quick to judge. And then there was Jay Glazer's exclusive interview of Incognito, who admitted to sending insensitive messages, but denied being a bully or racist (link to ESPN's summary of the interview):

"When words are put in a context, I understand why a lot of eyebrows get raised," Incognito told Fox Sports during the interview, which aired Sunday. "But people don't know how Jon and I communicate to one another. For instance, a week before this went down, Jonathan Martin texted me on my phone, 'I will murder your whole F'ing family.'

"Now, do I think Jonathan Martin was going to murder my family? Not one bit. He texted me that. I didn't think he was going to kill my family. I knew that was coming from a brother. I knew it was coming from a friend. I knew it was coming from a teammate."
[…]
"You can ask anybody in the Miami Dolphins' locker room who had Jon Martin's back the absolute most, and they will undoubtedly tell you [it was me]," Incognito said. "Jon never showed signs that football was getting to him [or] the locker room was getting to him."
[…]
"All this stuff coming out, it speaks to the culture of our locker room, our closeness, our brotherhood," Incognito said. "And the racism, the bad words, that's what I regret most. But that's a product of the environment."

Now imagine a high school girl accused of bullying saying the same thing: "But I was her best friend! She said mean things to me, too! In the high school environment, that's just how we talk!" Not much of a defense, is it? Incognito is certainly right that the culture of the team played a role; he just clearly does not think that there's anything wrong with the culture. What the ESPN story does not include though, is the most important fact to come out of that interview: The one question that Incognito would not answer is whether his coaches had directed him to toughen Martin up.

The wisest thing any player has said about the situation has come from Brandon Marshall, a wide receiver who has experienced plenty of his own troubles, but who seems to have turned his life around after being treated for borderline personality disorder and courageously discussing his diagnosis in public.

"Look at it from this standpoint," Marshall said. "Take a little boy and a little girl. A little boy falls down and the first thing we say as parents is 'Get up, shake it off. You’ll be OK. Don't cry.' A little girl falls down, what do we say? 'It’s going to be OK.' We validate their feelings. So right there from that moment, we're teaching our men to mask their feelings, to not show their emotions. And it’s that times 100 with football players. You can't show that you're hurt, can't show any pain. So for a guy to come into the locker room and he shows a little vulnerability, that's a problem.

"That’s what I mean by the culture of the NFL. And that's what we have to change. So what's going on in Miami goes on in every locker room. But it’s time for us to start talking. Maybe have some group sessions where guys sit down and maybe talk about what's going on off the field or what's going on in the building and not mask everything. Because the (longer) it goes untreated, the worse it gets."

A T-group for NFL players, what an inspired idea! Marshall also addresses the role the head coach plays in shaping a team's culture:

“We [the Chicago Bears] look at rookies different,” he said. “You have to earn your stripes, earn your place on the team, earn your place in the NFL. But as far as crossing that line? Disrespecting guys? Demeaning guys? That just doesn’t happen here. Actually, Coach (Marc) Trestman did a great job of really going out of his way to make everyone feel comfortable from Day One.”

Will the NFL take advantage of this opportunity to change how coaches manage locker room behavior? Or will there be another flimsy attempt at a cover-up?

How to Combat Stigma, Part 2

This is part of of a series of posts on how to reduce stigma around mental health. Part 1 is here.

I'm working my way through Anthony Beevor's The Second World War, a one-volume history covering the major military events of World War II. To me, one of the most interesting aspects of the book is how much the author repeatedly describes the psychological effects of stress from war, which affected everyone involved from civilians to front-line soldiers to generals. One particularly striking passage described an infamous incident that occurred in Sicily in August 1943 when General George Patton was visiting hospitalized soldiers [page 498]:

Patton asked a soldier from the 1st Division, a young carpet-layer from Indiana suffering from battle-shock, what his problem was. 'I guess I can't take it,' the soldier replied helplessly. Patton flew into a blind rage, slapped him with his gloves and dragged him out of the tent. He booted him in the rear, shouting: 'You hear me, you gutless bastard. You're going back to the front!' A week later, Patton had another explosion when visiting the 93rd Evacuation Hospital. He even drew his pistol on the victim, threatening to shoot him for cowardice. A British reporter, who happened to be present, heard him say immediately afterwards: 'There's no such thing as shellshock. It's an invention of the Jews!'

I thought about this passage a lot as I was writing this post. In many ways, it does seem that the stigma of having a condition like post-traumatic stress disorder has greatly decreased. No general today would claim that PTSD does not exist or publicly berate a soldier suffering from it. However, the silence and shame surrounding mental conditions continues to be pervasive. There have been numerous articles and reports about the difficulties returning soldiers have in readjusting to civilian life or having access to appropriate treatment. Suicide rates, which used to be lower in the military than in civilian life, are now higher among members of the military.

I have not come across any good studies about evidence-based ways of decreasing stigma related to mental health, so what follows is my own intuition and opinion. I personally do not believe that talking about how common mental illnesses are would do anything to decrease stigma. Just look at the example of obesity, which despite skyrocketing rates, is still something that leads to kids being teased and bullied at school. Likewise, emphasizing that mental illnesses are biologically-based is unlikely to help. Everyone knows that those with intellectual disability have a brain-based condition. However, that did nothing to stop previous terms like "mentally retarded" and "idiot" from becoming pejorative. Below I'll discuss two broad areas that I think can help decrease stigma.

Normalizing the Expression of Emotion

In the U.S., when someone asks "How are you?", the answer is almost always some variation of "I'm okay," no matter what the truth may be. I believe that this cultural taboo against honestly discussing one's emotional states is one of the root causes of stigma. I have had countless patients apologize to me for crying as they describe the stress or trauma in their lives. The perception that it is somehow a weakness to be emotional or to talk about such difficulties leads to shame, which perpetuates stigma. When I ask about a family history of mental illness, one of the most common things I hear is: "I think my ___________ may have _____________, but my family never talked about it." Needless to say, those family members probably never got any sort of treatment for their suffering.

However, in some cultures, the more open expression of emotion seems to help people be more willing to seek treatment, as this CNN report on psychotherapy in Argentina shows. Even in the U.S., there are starting to be efforts to teach children emotional skills, which are increasingly recognized to be as important as intellectual or social skills. I believe that if children (and adults, but it's certainly easier with children) learn that it's acceptable to acknowledge and discuss their own feelings of sadness, anger, frustration, anxiety, etc., then they will have more compassion for others who are in emotional distress.

Of course, this does not address the stigma surrounding serious and chronic mental illnesses. Tellingly, the CNN article linked above contains the following:

One of the soon-to-be psychology graduates is Agustina, 31, who did not want her last name used because her future patients may Google her name.

Every member of Agustina's family goes to some kind of therapy, but, she's quick to add, "It's not that we are completely crazy or something. Nobody has big issues."

So what can be done for those with "big issues"?

Access to Care/Quality Treatments

I believe that as with other conditions like HIV/AIDS or Hansen's disease (a.k.a. leprosy), nothing stigmatizes more than having a group of suffers treated as outcasts and isolated from the rest of society. Having hundreds of thousands of chronically mentally ill people living homeless in the streets and millions more locked up in jails and prisons is terribly stigmatizing. Similarly, having managed care erect roadblocks to patients getting quality psychiatric care is stigmatizing, as it reinforces the idea that mental conditions are second-class citizens compared to purely physical ones. Despite passage of the Mental Health Parity and Addiction Equity Act in 2008, insurers are still unwilling to pay for many treatments.

Unfortunately, this is not going to get better until we as a society come to our senses and implement a better model for mental health treatment. As fellow blogger Dr. George Dawson has pointed out many times on his blog, managed care's focus on cost containment over quality has had a horrendous effect on the ability of clinicians to provide adequate care. Likewise, taxpayers are paying billions to keep mentally ill people locked up, when the same money could be used to much better effect to provide interventions such as stable housing, assertive community treatment, and vocational training.

It does not help that the NIMH continues to emphasize basic biological research above all else, or that the APA does little to challenge the managed care system, accepting it as fait accompli. But hopefully, with enough awareness and activism around these issues, meaningful change will eventually take place, and we as a society will make a bigger dent in the stigma related to mental health.

How to Combat Stigma, Part 1

The stigma associated with mental illness is something that leaders of the profession such as Dr. Jeffrey Lieberman, the current American Psychiatric Association president, often point to when fighting back against critics of psychiatry. Dr. Lieberman seems to believe that by moving psychiatry away from Freud's "brilliant fiction" and "into the mainstream of medicine," stigma will decrease and people will be more likely to seek treatment.

I think the truth is much more complicated. I believe that well-intentioned interventions can potentially have the opposite effect and increase stigma. I went to medical school in a city where HIV/AIDS was epidemic, and I was part of a medical student-run group that went to local middle schools to teach about HIV and AIDS. Our goal was not only to increase knowledge about the disease and how to prevent it, but also to decrease the stigma associated with HIV by having HIV-positive speakers meet with the students to share their stories. We also administered a quiz before the teaching and again a few months later, to assess for changes in the students' knowledge and their attitudes toward people with HIV/AIDs. Sadly, while their knowledge increased, their negative perceptions of people with HIV also seemed to increase.

An analogous situation is described by writer Ethan Watters in his 2010 book Crazy Like Us, which he excerpted in a NYTimes Magazine article:

In 1997, Prof. Sheila Mehta from Auburn University - Montgomery in Alabama decided to find out if the “brain disease” narrative had the intended effect. She suspected that the biomedical explanation for mental illness might be influencing our attitudes toward the mentally ill in ways we weren’t conscious of, so she thought up a clever experiment.

In her study, test subjects were led to believe that they were participating in a simple learning task with a partner who was, unbeknownst to them, a confederate in the study. Before the experiment started, the partners exchanged some biographical data, and the confederate informed the test subject that he suffered from a mental illness.

The confederate then stated either that the illness occurred because of “the kind of things that happened to me when I was a kid” or that he had “a disease just like any other, which affected my biochemistry.” (These were termed the “psychosocial” explanation and the “disease” explanation respectively.) The experiment then called for the test subject to teach the confederate a pattern of button presses. When the confederate pushed the wrong button, the only feedback the test subject could give was a “barely discernible” to “somewhat painful” electrical shock.

Analyzing the data, Mehta found a difference between the group of subjects given the psychosocial explanation for their partner’s mental-illness history and those given the brain-disease explanation. Those who believed that their partner suffered a biochemical “disease like any other” increased the severity of the shocks at a faster rate than those who believed they were paired with someone who had a mental disorder caused by an event in the past.

Of course, one study in college students is hardly conclusive, but I have had very many similar experiences with my own patients. Those who were told by previous doctors that they had biochemical issues going on in their brains often lost hope when the biological treatments did not help them feel better. I have had patients tell me that they felt like they were damaged or broken after they were told during psychiatric hospitalizations that they had "bipolar disorder" or "treatment-resistant depression."

I feel that many practicing psychiatrists are starting to come around, and I found hope in an unlikely place: the American Psychiatric Association's YouTube page. In particular, the following clip from this year's APA conference:



Below, I've summarized the responses of those interviewed:

1. Chester Swett, MD: As public becomes better educated, emotional issues are more accepted as a part of going through life; a certain percentage of people may have more trouble than the average person, and that is when we diagnose anxiety, depression.
2. Ravi Hariprasad, MD, MPH: Role model treating patients and families without stigma. Set a good example. Stigma is fought on individual one-to-one basis; best help is to help patients break their own stigma against themselves.
3. Darshan Singh, MD: Help patients learn they are not to be blamed, it is a health issue. There is not one cause, mental illnesses are not like diabetes. People should be encouraged to talk to social workers, nurses, mental health agencies, pastors, etc. to learn that they are not alone in their struggles.
4. Kerin Orbe, DO: Talk about psychiatry and psychological problems more naturally. Educate community about what mental illness means.
5. Marcos Liboni: Share advances in psychiatry. Show psychiatry nowadays is very different from the past. Historically, psychiatry was linked to prisoners and torture. Now brain diseases can be treated; psychiatry is a medical specialty not far from medicine. 
6. Laurie Wells, MD: Mental illness is universal, affects everyone. Treatment is whole treatment of mind and body, not just medication. Serving people we treat with respect and respecting autonomy de-stigmatizes them.

There is certainly a diversity of opinion, and I may not have captured the nuances of what each person was trying to convey. But what stands out to me is that only one of the respondents talked about biological advances in psychiatry, while several emphasized the importance of treating patients with respect and compassion. I think that's a good place to start.

What If the NIMH Succeeds? What Then?

Ever since National Institute of Mental Health (NIMH) Director Thomas Insel wrote his Transforming Diagnosis article on how the NIMH is moving away from the DSM to a new system called the Research Domain Criteria (RDoC) for future research studies, there have been countless articles and blog posts written about what this may mean for the future of mental health.

One of the most insightful perspectives comes from 1 Boring Old Man, who points out that the NIMH is trying to do the same thing as the DSM-5 all over again by focusing on "biology, genetics and neuroscience so that scientists can define disorders by their causes, rather than their symptoms" [quote is from the NYTimes article]. Dr. Allen Frances, the Chair of DSM-IV, thinks the new NIMH approach has merit, but he strongly criticized the NIMH for over-promising advances that won't arrive for a very long time, while ignoring the present plight of the chronically mentally ill.

Neuroskeptic likened the controversy to the Protestant Reformation, with the NIMH's RDoC (Protestantism) rising to rival the DSM approach (Catholicism), but in the end they worship the same God (biological psychiatry). This focus on the biological basis of mental illness troubles me, since I think it is terribly limiting. So much of a person's well-being is dependent on relational aspects and influenced by culture and society, as the Child in Mind blog pointed out. According to NIMH's mission statement:

The mission of NIMH is to transform the understanding and treatment of mental illnesses through basic and clinical research, paving the way for prevention, recovery, and cure. For the Institute to continue fulfilling this vital public health mission, it must foster innovative thinking and ensure that a full array of novel scientific perspectives are used to further discovery in the evolving science of brain, behavior, and experience. In this way, breakthroughs in science can become breakthroughs for all people with mental illnesses.

Though this statement does not explicitly constrain the NIMH to only fund studies looking at the biological aspects of mental illness, the language of "curing" someone obviously reflects a biological perspective. Dr. Insel is a quite a True Believer in the premises behind biological psychiatry, as shown in his TEDxCaltech talk:

“If we waited for the ‘heart attack,’ we would be sacrificing 1.1 million lives every year in this country,” he said. “That is precisely what we do today when we decide that everyone with one of these brain disorders, brain circuit disorders, has a behavior disorder. We wait until the behavior emerges. That’s not early detection, that’s not early prevention.”

As ridiculous as the above position sounds to me, let me play devil's advocate and future-think. Suppose the NIMH succeeds beyond anyone's—even Dr. Insel's—wildest dreams. What if their biological paradigm is able to elucidate at the brain circuit level (including all the circuits for positive/negative emotional valence, cognition, social processes, and attention/arousal) exactly what is happening when a person is depressed, or anxious, or hallucinating, and technology advances enough so that treatments can directly target those dysfunctional brain circuits, what then?

Well first, to make the diagnosis, there will have to be some kind of brain imaging examining the circuitry, likely coupled with obtaining a person's genetic profile. Given the complicated wiring in the brain, this will have to be done by a computer instead of a human. Treatments clearly won't be like today's medications that just target a receptor or set of receptors. To target a circuit, I can envision several methods: 1) The circuit would either have to be ablated using precise neurosurgery or interventional neuroradiology; 2) Some kind of medication would be used in conjunction with a device outside the brain that allows the medication to become active only in certain targeted areas of the brain; 3) Some sort of nanotechnology with tiny smart robots inside the brain reprogramming circuits. Because the brain is so plastic and easily influenced by the environment, a person will likely need repeated procedures or continuous treatment to prevent the circuitry from reverting to its previous state. And we haven't even talked about prevention, which seems to be Dr. Insel's goal. To do that, everyone would have to get brain-scanned on a regular basis and genotyped.

Certainly, new technologies will come along that I can't even imagine today. However, none of this will be cheap. Even certain cancer drugs today (which aren't that high-tech in the grand scheme of things) can cost hundreds of thousands of dollars per year. So once those super-expensive new brain treatments come out, who will get them? As we've seen with cancer treatment, rich people like Steve Jobs can get genotype-specific treatments and out-of-state liver transplants that ordinary folks cannot afford. Thus, it's hard for me to envision these advances in understanding brain circuitry doing much, if anything, for "public health."

Even trickier are the ethical issues that these new advances would pose for society. If you can correct the circuits causing a person's cognitive dysfunction and hallucinations, then you can certainly damage them as well. Who would we trust with such technology? Pharma? The government? China already locks up dissidents in mental hospitals; imagine if the Chinese authorities could rewire the circuits contributing to a person's desire to protest injustice. And what would happen if we no longer need any human contact, sunshine, exercise, or purpose in life to ward off depression or anxiety? Would we be content to live like the oblivious human batteries in The Matrix?

Before you accuse me of being a nutty conspiratorialist, consider this: If I were to time travel to the 1960's, and I told people that in 50 years time, everyone would have pocket-sized devices that would combine the functionality of TV, radio, telephone, telegraph, camera, newspapers, magazines, books, and myriad other games and diversions; that no one has to remember anything anymore because they can just ask an entity called "Google"; and that people would stare at this device for hours a day, even during social situations like group dinners, I think they would have put me in a psychiatric hospital.

Obviously, not much of what I am saying is new or original. Many science fiction authors have imagined such a dystopia. You can argue that it's the not the NIMH's job to consider all the potential consequences decades or centuries away, and you may be right. But I will say this: The risks of biological psychiatry are great, with uncertain payoffs. Directing those billions of dollars to address issues like transgenerational poverty, child abuse/neglect, interpersonal violence, and the housing of mentally ill in jails and prisons, while boring, will almost certainly reduce the burden of mental illness and help make our society a better place.