Transcription
I'm Dr. Joseph. We're doing it today. I want to talk about, um, the negative consequences of the DSM and I think how it has led to, uh, some of the real errors in how psychiatrists treat patients in these days.
So, um, at around the, in around the 1970s, we kind of switched from DSM-2 to DSM-3. And this might not mean a lot to a lot of people listening out there, but it was a pretty big shift in psychiatry. Prior to this, psychiatry was very concerned with the reasons for mental illness. You know, where was it coming from? Was it coming from contextual stresses in your life? You know, was it coming from trauma and things like that? And that was reflected a lot in the earlier, um, in the early DSMs, one and two. When we went to DSM number three, a lot of that information got taken out, you know, and it became purely a descriptive nosology. And so, what that essentially means is the diagnostic system was divorced from a lot of speculation about, about the cause of it. Essentially, what it did was it just started listing symptoms. And I think, um, I think major depressive disorder, there's like kind of like nine key symptoms in there. If you have five of them, if it lasts for two weeks, then you have major depressive disorder. Um, there's no real, like, in-depth discussion about, you know, maybe, uh, the reasons that you might be depressed, you know, poverty, financial problems, relationship stresses, those types of things.
And it was done on purpose, essentially. It was done because there was a crisis in psychiatry whereby many different doctors were not agreeing on the diagnosis, you know. And so they said, you know, if we make this really standardized, if we just say, you know, it's kind of these sort of symptoms for two weeks, at least we'll have, um, statistically sound diagnosis, we'll have reliable diagnosis where, you know, if Dr. X says this is MDD, Dr. Y could say, you know, hey, you know, I'm going to ask about these nine symptoms and likely they'll get the same diagnosis. And that kind of leads better to sort of, you know, research and things like that. But where it really kind of messed up over time was that, um, it kind of led into, um, I guess, you know, that that kind of approach of not really seeing, you know, say depression as, um, something that's strongly linked to, you know, upstream factors, you know, whatever, you know, I think things that I've just, just mentioned previously. And really kind of sees it as just symptoms. I think it really harmed the way that physicians treated this condition over time.
So I'm going to take a step and talk a little bit about pharmaceutical drug development now and antidepressants. So this kind of criteria was pretty, uh, useful for, for drug research, you know, you could now have a, you know, a standardized idea of depression and, um, you know, you could trial a drug and they could be on that drug for, you know, as you may know, you know, eight to twelve weeks was the standard time to trial a new antidepressant initially. And, and then you could get, you know, if you're successful, and a lot of them were, you could get a label and you could say, you know, Prozac is indicated for the treatment of major depressive disorder and it could go off and be used. But the issue is that, um, people began to see antidepressants as kind of treating this illness, major depressive disorder. But major depressive disorder is not really an illness. I mean, it's a, well, not an illness in the way where we think of them in other parts of medicine where we have this kind of sound understanding of the biological underpinnings for, you know, something like diabetes. Where, okay, you know, you, um, you're not producing enough insulin, whether it's type 1 where it's genetic or it's type 2 and it's due to lifestyle factors, and you've just stopped producing insulin. Okay, that is a really kind of nicely understood biological deficit there. You know, no insulin, you need to supplement it, it fixes it. Infections, you know, okay, you've got, um, um, you know, uh, like a tuberculosis and there's a characteristic, um, um, finding, you know, on in microscopy where there is a, uh, bacteria which is causing it. And that's not the case with major depressive disorder. So, or, or depression, you know, there's no kind of unifying, uh, underlying biological abnormality.
So, um, and then it began, and so, and then the way we were describing it, you know, as I mentioned, it's if you have five out of those nine symptoms for two weeks, then you have it. And so we had this whole kind of scientific, um, machinery start up about, you know, studying, you know, studying it for those conditions. And it kind of over time, I think it morphed into this thing where it was like, okay, you know, major depressive disease, made, major depression is is like a bona fide illness. And it's really not like the other ones because it's symptomatic. And the problem with that was, you know, now you have these drugs for it, and they're being prescribed a lot by family medicine doctors. They can, they can almost use the same approach with their patients, but they could say, okay, well, let me give you this questionnaire on the way in. And okay, I can see you've got five out of the nine symptoms, that's been going on for two weeks. And, um, well, you know, that would, uh, qualify you to be on something like Prozac. And I'm going to go ahead and, you know, prescribe your Prozac. And I'm not really doing anything wrong. In fact, this is really in line with a lot of how these drug trials were done, you know, it was just descriptive. Okay, you've got it, you can take this medication, and I'll just check in with you. I'll monitor for some side effects. And, and that's about it.
But the problem with that is that the way, you know, Prozac and, you know, SSRIs and the other antidepressants are working is, you know, it's not like insulin for diabetes. I mean, they're having this kind of general, um, um, I guess, I guess mood-altering effect on your symptoms. It's not, you know, fixing anything. Rather, it's kind of putting on top of your, you know, your sadness or your anxiety, um, a new kind of mental state, you know. And this is typically one of, you know, emotional, um, constriction, maybe some numbing and some blunting. Which, which can be therapeutic. Here's the thing, it can be therapeutic, um, especially if you're crippled by anxiety. And, um, and it takes it down to a level where it's better to function. And that's great, and that's fine. And there's definitely a place for them there for people that have, or at least where I've decided people have pretty much severe depression and anxiety. I think, I think it makes sense.
But the issue was that you could actually get this diagnosis for a relatively minor major depressive disorder. I mean, you could have, I mean, some of the symptoms, low mood, anxiety, trouble sleeping, low appetite, difficulty concentrating, you know, um, decreased interest in things that you like doing. If you have five of those for two weeks, you could get it. And I mean, that's actually not that hard. You know, I think a lot of us could probably think about periods in our life, you know, where we've had challenges and, you know, we've been in that mental state. And so here's the issue with it. So when you're using a drug that just kind of treats symptoms, um, you want to know how that kind of therapeutic drug effect is affecting someone in all aspects of their life. Sure, if someone is crippled by anxiety at work and they're having a really hard time, you know, making decisions, um, and you give them something that's a mood constrictor like a Prozac, that could really help them, you know, it could make them more efficient. But just because it kind of helped them in that aspect of their life, it doesn't mean it's going to help them in other areas.
So, um, maybe they are a painter on the side, maybe they do music on the side. You might find that some of the more creative parts of them suffer. And you should probably ask about that. If they are in a relationship with others, um, there is the potential where if you're kind of more shut down emotionally than it used to be, that this is now kind of playing out in your marriage. It's playing out in the, in the relationships of the people that you care for, because you're not as able to kind of bring that level of connection and empathy. And maybe you're just not that bothered when there's this conflict going on, and you don't fight as hard as you used to. Um, and that is really kind of how I think these types of medications really ought to be used, and why specialists who's really looking at them in this way should be prescribing them. Because there can be a lot of really negative problems that can come from these things if someone is not watching them closely and keeping an eye on them. Um, I mean, we're talking about things like, you know, essentially, you know, having, having problems in your relationship. I mean, you could also in your work. I mean, if you get to this level of emotional constriction, um, it's easy to see how that might lead to some apathy, and you may not even perform at the level that that you should be. You may feel fine about it because, you know, things are kind of less stressful now, but it might hinder your performance. That's not going to be for everyone, you know, there are cases where it's going to improve your performance. But the point of it is, is that someone should be checking in with you about the, um, about the consequence of this kind of symptomatic approach to your treatments.
The other issue with major depression, you know, kind of often how it's spoken about today, is it's this illness. And then they'll kind of characterize it by saying, you know, it's a, it's a chronic illness, it kind of, it comes and it goes. You may have heard that a lot. And, you know, don't worry if you need to be on this medication long-term, it's this chronic illness. And that's kind of this broad over-characterization because obviously, you know, you can have, you know, five of those nine symptoms for things that are really time-limited sometimes. So you can have, you know, it's easy to think of things, financial problems, you know, you're overwhelmed, yeah, maybe you're a single parent, you're caring for children, you don't have a lot of support, you know, problems at work, problems in your relationship. And I don't know. And, and definitely for those people who have these contextual stresses where, and that's where the sadness is coming from, it's not really helpful for them to think about themselves as having this kind of chronic, relapsing, and remitting illness that will come and go throughout your life. Um, because that's not the message that really, um, is the most helpful for those types of patients. You know, they may want a more empowering message like, this is awful, you know, this is really hard that you've found yourself in this situation in life, you know, let's kind of think about how you get out of this relationship, you know, how you could get to a place of more financial stability. It's okay, you're going to do it, it's going to be really difficult for now. You know, if you want to try medication, we can have you on a medication for this period of time, it'll be time-limited, you can come off it, but we'll get you through this. And I mean, that is probably a much more empowering message, uh, to people. Um, and it's one that's lost.
And, you know, when I think about the nuances of the other thing, I'll add to that is, you know, you have a lot of these people that got started on these medications for relationship problems, financial stresses, things like that, and then they just get continued forever, you know. Um, they don't really get revisited. You know, the doctors don't say, you know, what's the impact this is having on your life? And so you have all these people walking around now, and I see a lot of them, I've been on the medications for five, ten years, something like that, and they go, you know, how's this helping you? And they go, honestly, I don't really know. You know, I got started on it a long time ago, I'm not really sure what it's doing. It's not really causing me any problems that I can think of. Um, but yeah, it just kind of kept on going. And, um, you know, they may try to come off of it and, uh, you know, if you've been on it for, you know, five years, something like that, you might have a really bad withdrawal reaction. Most of the research that kind of looks at like the severity of the withdrawal reactions in clinical trials, it's pretty short. You know, the longest some of these studies have been on is like, I think it's like a year in the double-blind phase, which is like a year of exposure to the medication. And then they'll taper them off over maybe like six months or something like that. So these are the limitations of clinical trials. Obviously, it costs a lot of money to do these things. And so the reality is, you're only going to have, you know, maybe data on what does a withdrawal reaction look like after about a year. And they're not that bad after about a year, you know, some people can come off, be on a drug for a year, come off over like six months, and they're okay. But it's not representative of what we see in clinical practice. We've got people 10, 20, 30, 40 years now on different combinations of medications. And so, you know, you have someone that got started for something that's really time-limited on the medication for 20 years now, they can't come off. You know, there's all these websites about these people who are struggling. And, and mostly, you know, what you see in the medical literature is, um, reference to these, to these clinical trials where they're all saying, well, it wasn't that bad there. But it's not representative, um, of, um, the populations that we're seeing now.
So, so how does this kind of play into, I guess, what I hear a lot about in kind of family practice, which worries me. And that is, you know, you go in and you see your family medicine doctor, and then, you know, do their screening tool. It's not just family medicine, can be psychiatry, it can be nurse practitioners. And, you know, the visits are so short, you know, 15-minute visits. And then you just, um, maybe you get five of those minutes, if that, you know, because they spend the rest of the time talking about cardiovascular disease or other things that are going on. Let's get these five minutes. And then they talk about your mental health. Okay, all right, you've got major depressive disorder. Let's start this medication. And you see them again in two months or three months. And they go, oh, yeah, how are you doing on the medication? Okay, good. All right, we'll just keep on going. And then maybe a year later, they don't even ask you, oh, you need a refill on that? That's fine. There's no kind of, I guess, respect for the idea that, hey, you're giving someone a drug that is changing their emotional state, um, and it could be playing out in all these ways in their life. Maybe you want to keep tabs on that. How's this going in your relationship? How's this helping you at work? Is this even doing anything for you anymore? Because the reality is, if it's not doing anything for you anymore, we should probably get you off. I mean, that is kind of safe medicine. I mean, when you look at the label and you look at the, you know, the metabolic effects, you know, the weight gain, and then some of these more serious things, which are really unpredictable, like post-acute withdrawal, PSSD. If the drug's not doing anything for you anymore, you should be coming off. But my impression is that people aren't really asking them about this. And the reason I think for that is, is essentially they're just like, oh, he's got a mate, he's got his major depressive disorder, he's got, he had his five out of nine, it's a chronic, relapsing condition. So I'm just going to keep it where it is, it's, it's fine. I got other things to look for.
This was a longer video. It's kind of my general download on, I guess, the problems with the DSM and I guess how it's led to kind of this, I'm gonna say, not very thoughtful prescribing, which can be pretty dangerous. Love to hear your comments about this. I mean, has this been your experience getting medications this kind of not very thoughtful, you know, rushed, maybe someone's not really asking you about what it's doing? Um, I'd love to hear about that. Maybe you've had a different experience, I'd like to hear about that as well. Um, so I hope you enjoyed this video and thank you so much for your time.