[mjburgess]

Before the sceptics get in:

1. The purpose of DSM/ICD is often to justify financing treatment:

> Chris Ferguson, a professor of psychology at Stetson University ... described the ICD as "the book of real diseases that you can get insurance payments for."

2. Treatment has to be mindful of the specific form of addiction:

> "These are co-morbid conditions," he said. "If you just treat the depression and not gaming, the gaming is likely to come back." This suggests it's a unique condition, he said.

3. No we are not "medicializing everything":

> But Ferguson argued that, if it is a disorder, it seems to be very rare.

NB.

Before criticizing modern psychiatry keep in mind:

1. mental health patients are extreme in their dysfunction, never common.

2. the operation of the brain (, nervous system, etc.) in its interaction with its environment is as liable to breaking as any other part of the body

3. modern clinical psychiatry is an evidenced-based, research-driven field which treats and forms diagnoses on the basis of decades of research into any particular condition. It isnt the 1950s.

[DanBC]

> Before criticizing modern psychiatry keep in mind:

> 1. mental health patients are extreme in their dysfunction, never common.

I agree with what you're saying, but the US does have a problem of over-testing, over-diagnosis, and over-treating illness. Not just mental ill health, but everything.

In the US about 10% of children have ADHD

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3489818/

> Based on the Heath Resources and Services Administration's National Survey of Children's Health, the percentage of children aged 4–17 years diagnosed with ADHD increased from 7.8% in 2003 to 9.5% in 2007, representing a 21.8% increase in just 4 years (Centers for Disease Control and Prevention 2010).

An estimates 3million US children take stimulant medication:

> Experts estimate that approximately 60% of children with ADHD are treated with prescription stimulants (Center for Disease Control and Prevention 2005a); therefore, approximately three million children in this country take stimulants for problems with focusing. At the same time, many studies have revealed the numerous adverse effects associated with prescription stimulants when they are used inappropriately.

These numbers are a bit worrying, especially if medication alone is being used, and it's not provided as a package of bio-psycho-social treatment.

[mjburgess]

Ahh, sigh. I was writing with ADHD in mind actually.

Up to 10% children really do have ADHD which is a delay in the development of the frontal lobe. Such a delay seems "somewhat common" amongst humans.

More than half catch up, leaving upto 5% of adults with some form of ADHD.

ADHD is serious. It is a severe impairment to planning, self-management, emotional regulation, etc. You are likely to be impoverished without substantial resources to rely on (family, etc.).

> are a bit worrying > it's not provided as a package of bio-psycho-social treatment.

ADHD researchers (serious neuroscientists & clinical psychiatrists) have for DECADES tried "biosocial blah blah". It has failed. ADHD is not a failure of child training (ie., parents "Raising Their Child Right!!!").

Overwhelmingly the effective treatment for ADHD is pharmocological. At this point comments like yours, along with the media hysteria, are doing real harm to children actually getting treatment.

The problem we have with ADHD is significant under treatment and under diagnosis.

It turns out all those "useless" people joked about in human history have not just been failures of character: in need of "social" intervention. They have had a physical impairment, a delay in their brain's development. Not Fixable by a good beating, or whatever the touchy-feely equivalent is.

The suggestion that a child with a broken leg not receive crutches would be absolutely outrageous. Or a person with cancer not receive a daily pill treatment. The very same outrage should be felt here in the suggestion that people with ADHD not receive medication vital to their ability to even pay attention to their lessons (goals, etc.). Vital to their ability to socailize (ie., control their frustation in ways that doesnt alientate other children). And therefore vital to their future success.

Yes there does need to be a fundamental reorganization to western education systems to, from the ground up, be aware of how wide-spread developmental issues are -- and to build in fundamental support structures.

However this isnt a "treatment" for ADHD. There is no cure. This is just bracing the crutches. Overwelmingly the research over the last 30 years has shown the only significant impact on ADHD is pharmocological.

[taneq]

Your points about ADHD requiring a pharmacological approach reminds me of the discussion here: http://lesswrong.com/lw/2as/diseased_thinking_dissolving_que...

Specifically, that the only distinction between 'disease' and 'character flaw' which makes sense is that you can't fix someone's disease by yelling at them.

[chiefalchemist]

> "...you can't fix someone's disease by yelling at them."

Actually, I think if you believe in neuroplasticity (sp?) that might not be accurate. True, yelling might not be the best approach. But it can still work if applied the right way - to some extent.

[wdewind]

I've read a lot of your posts on this thread and appreciate your perspective. I agree with a lot of it. Honest question for you though: isn't it a bit weird to label something as a disorder if 5-10% of the population has it? Isn't it just a fairly standard human existence then? I think that's where a lot of the discomfort comes from.

[maroonblazer]

Not the parent, and I don't mean this sarcastically, but isn't that akin to saying "Only 5-10% of people fracture a bone, so why bother treating it. It's just a standard part of human existence."?

[ed312]

Also poor eyesight, color blindness, partial deafness, &c. The reality all of these diseases/disorders are readily and inexpensively treated and not an issue in modern society.

[wdewind]

There is a wide difference in the prevalence, severity of condition and extremity of treatment in some of these conditions.

Poor eyesight afflicts a large portion of the population, but the severity of the issue and the extremity of the treatment are not high. It doesn't impact your ability to maintain social relationships, for instance, and the treatment is very well understood and has low/no side effects.

Color blindness, partial deafness etc., are readily and inexpensively treated, but they do not afflict 5-10% of the young and healthy population.

The issue comes in when we start saying 5-10% of the population has an extreme condition (ie: impacts ability to maintain work, social relationships etc.) with a relatively severe (ie: fairly large % of users experiencing side effects) treatment necessary. When you put that in the context of our massively volatile understanding of mental illness over the last 50 years, as well as the massive incentives for pharmaceutical companies to push a specific narrative, it is difficult for me not to see a red flag.

[FullMtlAlcoholc]

A significant amount of blacks worldwide had sickle cell anemia. In the past when humans lived in more isolated and homogeneous societies this was the standard existence. In fact, it conferred a resistance against malaria. Today, we have better treatments for that disease that don't carry the same side effects.

A more prescient and present example is that almost all humans are subject to cognitive biases. A wise man known as Citizen G'Kar once said "In the past, we had little contact with other races. Evolution taught us that we must fight that which is different in order to secure land, food, and mates for ourselves. But we must reach a point where the nobility of intellect asserts itself and says no, we need not fear those who are different. We can embrace those differences and learn from them."

[wdewind]

> In fact, it conferred a resistance against malaria.

I think this is one of my main points: if such a large percentage of the population has something that we think of as a large negative, it's probably a good time to take a step back and wonder if we aren't understanding the whole picture because evolution tends to take care of such low hanging fruit.

[TheCoelacanth]

Evolution takes care of things that stop you from reproducing, not things that make you unhappy.

[DanBC]

It's weird that you have such a strongly negative reaction to my post.

Especially this bit:

> > it's not provided as a package of bio-psycho-social treatment.

> ADHD researchers (serious neuroscientists & clinical psychiatrists) have for DECADES tried "biosocial blah blah".

Medication is the Bio bit. "Your children are not wilfully disobedient, please stop hitting them" is the psycho-social bit.

[mjburgess]

I'm half reacting to a reading of your post that many readers will have, even if it's not one you intended.

On the whole I appreciate you introducing the real prevalence of ADHD, etc.

However the lack of engagement with the reality of treating ADHD and the implied "concerns" is a very easy prelude to a rant about middle class mothers, and the medical establishment.

If I'm a little harsh to you, its only as a stand in for what your post would otherwise be used for: the occasional reader unthinkingly associating it with an attack on effective treatment.

[xena]

Honestly I think about half the problem is that psychiatric illnesses don't make people bleed, so there's no way to universally tell something is wrong.

[mjburgess]

The bane of society, I think, is mentally healthy people.

They run politics but have absolutely no appreciation for what works for non-healthy people. Which is all the people who acutally rely on politics/society.

I think conservatism as a personality is a symptom of good mental health: if you arent able to do something, its lazyness. So you must just need some motivation: either a beating or some money. etc.

That's true if you're mentally healthy. If not then the ways you are failing arent even imaginable from the POV of mental health. And they are as communicable as cancer, or any physical illness.

The last century is full of works by people who have recently taken acid telling everyone how "everything is now differnet" etc. How they couldnt even have imagined the things they took for granted in how their minds work were actually variable.

Every mental illness is its own unique form of acid. And unless you've been on an acid trip, or are very well informed medically, you've no idea what it is like.

[iamnothere]

This is an interesting perspective. I would add that there may be multiple "healthy" modes of being human that are quite different, and some of these modes may be a small minority. In a small tribe these cognitive differences may have been valued (depending on the tribe of course!), but in our modern, highly systematized society these people are often considered a social "misfit" for being unable or unwilling to play along.

For better or worse, the rules of society are designed by the neurotypical majority, who are often unable to see that the concept of "normal" is frequently just a fig leaf for the majority consensus. This can get wrapped up in politics through layers of metaphor but is rarely (if ever) engaged with directly in public debate.

[mjburgess]

> the rules of society are designed by the neurotypical majority

That's another way of putting it. I'm not sure the majority are neurotypical however.

I think, rather, "neurotypicality" is a background assumption of certain institutions because it's easier to design for an average even if it doesn't exist (no 1 human being is mean in every respect).

However those who experience life-long mental health, and esp. for most of their childhood, I think are overwhelmingly "conservative" in their personalities. And I think these sort do tend to find themselves in more elite/visible positions.

Political systems represent those who hold power. They do not represent a majority (power is the mechanism of representation, not mere existence).

In democracies, there is more "tending towards the majority". But still, it is very much a symptom of who can be elected, who is elected, etc.

[wdewind]

> I think conservatism as a personality is a symptom of good mental health: if you arent able to do something, its lazyness. So you must just need some motivation: either a beating or some money. etc.

This is a really cynical view of conservatism and I have a hard time seeing how you don't see half the country as evil if that's what you think.

Another view might be: this stuff is so complicated, and as you pointed out it's so difficult for political leaders to have real empathy for people in these situations, there is a high degree of chance we will screw this up and make it worse while trying to help. Example: homosexuality being in the DSM. Or really much of the history of how state institutions have treated the mentally ill, which has mostly had to do with keeping them away from the non mentally ill and not actually treating them.

[mjburgess]

I don't see it being cynical. I think it's the opposite of evil. It paints conservatives as entirely reasonable people making entirely reasonable suggestions but simply failing to appreciate difference.

A failure to appreciate difference is not evil, its part of how everyone acts in entirely well-intentioned ways.

Also, I dont think anywhere near half of any country has a conservative personality. Certainly the GOP are not today defined by their conservatism, whatever it is, it is radical.

I would say a fundamentally conservative personality is something most common in the vaguely upper-middle classes. It is present, to a degree, in the more traditional working class environments (eg. mom-and-pop store children, etc.).

It's all about seeing your success follow from your actions in a way that you control. It's about being able to plan, execute, and understand consistently -- for most of your life.

I think that's rarer than half, maybe 1/3? At a guess. And i think its not partisan: there are leftwing and rightwing conservatives.

[dragonwriter]

> The bane of society, I think, is mentally healthy people.

> They run politics

Assumes facts not in evidence.

[dec0dedab0de]

I dont think any mentally healthy person would want to work in politics.

[pantalaimon]

I think the conflict here is more in that way:

Do you want to give people medicine so they can conform to what society expects from them, or do you instead try to change society so it doesn't have this expectations in the first place.

With ADHD what a lot of people see is this: You are not being efficient, so that is a flaw that needs to be fixed. But where is the line? Should we really optimize for maximal productivity or are other forms of society possible?

[always_good]

You might be looking at ADHD too much through the lens of buying some Adderall before a uni exam so that you can nail it.

ADHD interferes with everything from social relationships to doing anything that you want to do. We have to be productive insofar as to pay for food and shelter, but you're addressing a very narrow aspect of what ADHD medication treats. For some people, it's the ability to socialize, finish a joke, and achieve their life ambitions.

[mjburgess]

Yes, this "Social" view of disability has I think, gone too far.

A dog with three legs is much worse at being a dog.

There is really something it is to be a human, and it isnt just defined by culture and present-day society.

We live on earth. We eat food. We socialize. We, by being human, do a very large number of things merely because we are human. And if you damage part of our body, we can't do those things. And doing those things is a fundamental part of what we do.

ADHD really is a neurological impairment on this scale. It isn't "being less productive". It is a torture, a trauma, an on-going alienating, destabilizing impairment.

You might say "well couldn't there be a society where ADHD was an advantage"... i'd say basically No, not without changing the human species.

Yes, maybe we could imagine one. A society perfectly designed for people with ADHD, but when you describe that society in detail, you'd discover its profoundly impairing to people without ADHD.

As in, imagine we all lived as if we had no arms. That would be an extreme oppression to the almost everyone who does. And that's because on-earth, doing the things human beings do, arms are inherently part of doing those things well. That is why not having arms is a disability, not a lifestyle choice.

Similarly for vision, hearing, etc.

ADHD is an impairment to advanced cognitive function. It's an impairment to your minds ability to "see" itself.

The moment we start to say, of children with ADHD, that they should have this impairment.. that it's our "culture" that decides this impairment is bad... I think that's a gross abuse of those children.

It's turning your own lack of dependence on pharmacology, your own health, into a trap for people who do need it.

[chiefalchemist]

> "...but the US does have a problem of over-testing, over-diagnosis, and over-treating illness. Not just mental ill health, but everything."

I'd argue this is a symptom. The root disease is the profits to be made from various testing positive.

I'd add that it's aided by the fact that most people believe the doc can (and should) script you a pill for just about everything. Prevention? That's not going to happen. The patients know it, the doctors know it, and the insurance company pays for it.

Do I think everyone should have access to healthcare? Yes. But everyone should also be mindful if personal health. That isn't the case. And since soneone else is always paying for it, and the med pro are too broken to push back, we get what we have.

Illness as a badget of honor.

[algesten]

> 3. modern clinical psychiatry is an evidenced-based, research-driven field which treats and forms diagnoses on the basis of decades of research into any particular condition. It isnt the 1950s.

But isn't modern clinical psychiatry marred by the same problems social or economic sciences are? Ultimately you are studying/interpreting human behaviour, which doesn't lend itself well to quantisation or categorising.

[mjburgess]

The most reasonable thing to think about any mental health disorder is whatever the consensus in clinical psychiatry is.

That is the point. It is so overwhelmingly well-researched, that even if its conclusions are wrong, no lay person is going to be in a position to have "an argument" that hasn't already been considered and researched and folded into the consensus.

This isnt the case with social sciences, and it isnt the case with macroeconomic policy. Both of these are about groups of humans, not individual humans, and are fundamentally about behaviour in the face of cultural/economic/social changes. That kind of analysis is purely speculative and historically accidental in the way that giving people adderall and measuring their cognitive performance isn't.

A man on the street may well have good reasons to speculate differently about the evolution of his society that those speculations produced in some university in a foreign country.

A man on the street can have no good reason to act against the consensus of research-based medicine. To do so is to fly blindly into an area of profound research depth and consideration.

We have a problem today of these domains being equivocated. About people believing they are experts because the "Experts" they see are really political speculators and commentators of macro-cultural changes. And so everyone thinks everything is speculation.

This is profoundly not the case for, let's say, what the best treatment plan for bipolar disorder, adhd, autism, clincial depression, psychosis, etc. etc. etc. is.

...which has folded in lifetimes of research on the way the brain works, the way that drugs work, CBT, social therapies, counselling, etc. etc. etc. ...

An opinion on what "should be done" about a family member with bipolar disorder may as well be an opinion about what should be done about their thyroid problem, carpal fracture, lymphoma, etc.

[xapata]

Sounds like you're not familiar with sociology nor macroeconomics literature.

[mjburgess]

My concern was to defend the topic at hand. Trying to distinguish between different forms of economics and sociology would muddy the waters a great deal.

For sure, no doubt, there is highly defensible macroeconomic and sociological work done.

There does seem to be a boundary where sociology meets macroeconomics meets english literature meets arsty-psychology wherein a huge amount of highly speculative work is done. Work which seems, as far as its truth apt, mostly false.

I don't think this work properly belongs to any of those subjects and is really a kind of speculative blogging that certain academics like to do that happens to get published somewhere. However that also tends to get seen more often than their detailed work on interest rates in the 1970s.

[whatshisface]

Macroeconomists often can't run experiments, and some kinds of "macro-sociological" theories can't be tested either. That puts them in a fundamentally different epistemological class.

[Grieverheart]

Most recent studies in psychiatry and social sciences that I have read, even those published in Nature, use sample sizes of around 50 people, which should be considered insufficient. Instead they use various cooked up formulas for correcting for gender/ethnicity etc. Instead, sample sizes should be much bigger. Of course this is not practical or even perhaps impossible. I find this to be a poor excuse, though.

The matter of fact is, we know very little about how the brain works. We certainly have some big picture on how the brain functions, but we are very far from grasping the chemistry.

[mjburgess]

psychiatry =/= psychology =/= social psychology

This is more "everything is the same" anti-expertism.

Clinical psychiatry is not about p-hacking groups of 50.

The treatment of bipolar disorder hasnt been decided on the basis of what happened to the last dozen undergrad students.

>The matter of fact is, we know very little about how the brain works.

Profoundly untrue. Even if it were truth, its very truth would preclude your ability to make this assertion. If we knew nothing, how are you estimating the nothing we know?

It is no mystery what happens when you give a person lithium. Nor some speculative game to know what the effect of MDMA on PTSD patients is. Nor hocus pocus to identify the effects of repeated trauma.

How are you deciding what percentage of "how the brain works" we need to know in order to do psychiatry in a reasonably well-informed way?

Suppose, even, we know now 0.1% of the entire story. Is this sufficient for an evidence-based treatment of psychosis?

It clearly seems to be. Since the treatment of schizophrenia is overwhelmingly more effective than anything based on a study of 50 people.

Your comment may very well apply to "journalistic science" ie., the increasingly prevent, "ive just had an idea, lets get 50 undergrads and a seminar room!".

That is a tiny percentage of science, even if it is the most commonly popularized.

[Grieverheart]

I had a look at this review on bipolar disorder, https://doi.org/10.1136/bmj.e8508 . According to a study referenced in it, 68 randomized trials where used to determine the effect of different drugs compared to placebo. Again the sample size is low and the statistical significance is also small, unless I'm missing something.

You are correct in saying that we don't actually know how much we know about the brain. But the brain is s much more complex than e.g. planets orbiting the sun. There are many components that can get affected by chemical compounds in the short term, but more importantly in the long term. I agree though that only through testing can we get a better understanding. It is just the way it's currently done that I disagree. I would gladly read some research you think is good and does not have the shortcomings I describe.

[dsacco]

> Most recent studies in psychiatry and social sciences that I have read, even those published in Nature, use sample sizes of around 50 people, which should be considered insufficient.

I disagree with your reasoning even if your conclusion is correct about the validity of those studies. Small sample sizes are not intrinsically bad and there’s no magic number to make sample sizes valid. It’s a sliding scale with statistical significance - with a large enough p value a relatively small sample size doesn’t mean the observed phenomenon isn’t there. In that case I would be more concerned about p value hacking or the researchers “presuming the conclusion from the outset” than the sample size.

[always_good]

You can't condemn sample size without also condemning the statistical methodology of an experiment.

"Small sample size thus irrelevant" does not make sense despite often being the top comment on Reddit.

[Grieverheart]

This is correct. Sample size should be dependent on the strength of the effect. As a rule of thumb though, a sample of 50 people is very little. If physics used these kind of sample sizes and confidence levels, we would have discovered multitudes of new particles.

[StanislavPetrov]

>3. modern clinical psychiatry is an evidenced-based, research-driven field which treats and forms diagnoses on the basis of decades of research into any particular condition. It isnt the 1950s.

Your post was okay until your last point. While it isn't the 1950s, its absurd to contend that "modern clinical psychiatry" isn't massively subjective in terms of both treatment and diagnosis. The fact is that the vast majority of psychiatrists reflexively shovel pills at those perceived to be afflicted with poorly-understood mental disorders. In reality, we are only beginning to scratch the surface when it comes to understanding how the brain works, let alone the human psyche. One of the most egregious illustrations of this fact are the over 1 million children under the age of 5 taking psychiatric drugs. We still don't know the long term outcomes of our tinkering with the developing brains of infants and small children, and its hubris (or worse) to pretend that we do.

https://www.cchrint.org/psychiatric-drugs/children-on-psychi...

[rendaw]

On the subject, I remember reading recently that most psychology studies are observational, and when attempts to duplicate the findings are made they mostly can't. I realize that GP's statement is qualified with 'clinical', and decisions based on observational studies are probably better than just making things up, but how much have we actually progressed?