E116 - What are Mental Disorders? (with Dr. Awais Aftab)

Dr Awais Aftab is a psychiatrist in Cleveland, Ohio and Clinical Assistant Professor of Psychiatry at Case Western Reserve University. He is the author of Conversations in Critical Psychiatry - a 2024 Oxford University Press book, based on a series in the Psychiatric Times - https://www.awaisaftab.com/conversations-in-critical-psychiatry.html.  

He also writes Psychiatry at the Margins, a  substack newsletter exploring critical, philosophical, and scientific debates in psychiatric practice and the psy-sciences (https://www.psychiatrymargins.com/)

Our conversation today explores the role of philosophy in psychiatry, the nature of psychiatric diagnoses and their limitations, Dr Aftab’s view on mental illness as "medical conditions" and how biological, psychological and social factors contribute to mental health difficulties. 

Interviewed by Dr. Anya Borissova - Give feedback here - thinkingmindpodcast@gmail.com Follow us here: Twitter @thinkingmindpod Instagram @thinkingmindpodcast Tiktok - @thinking.mind.podcast 

Transcript

And that I think points to this kind of binary tendency that either a problem is a problem of biology, or we want to say that if the problem is not a clear biological problem or a problem of biological abnormality, then, you know, nothing, nothing much is to be gained by understanding the biological dimension of it.

Mental health problems, mental disorders, exist precisely in this middle ground where they are not. primarily problems of, uh, you know, biology gone wrong, mental health problems, or problems of behavior gone wrong, and, you know, psychological experiences gone wrong, but they, they nonetheless have a biological dimension, and then they're, you know, because they have a biological dimension, we can study that, we can intervene on that, um, you know, often in kind of, you know, remarkably effective ways at times.[00:01:00] 

Welcome back. Today we're exploring the question, what is the role of philosophy and philosophical thinking in psychiatry and mental health? And it's not actually me conducting today's conversation, but my co host, Dr. Anya Borisova. For those of you newer to the podcast, she's a clinical and academic registrar at the South London and Maltese Trust.

And today she's in conversation with Dr. Awais Aftab. Dr. Aftab is a psychiatrist working in Ohio in the US. And is also the clinical assistant professor of psychiatry at the Case Western Reserve University. Dr. Aftab is interested in philosophy and the history of psychiatry and writes about these topics on his Substack Psychiatry at the Margins.

He's also the author of the recently published Conversations in Critical Psychiatry. Today's conversation focuses on the philosophy of psychiatry, what assumptions and frameworks shape the field and how this impacts [00:02:00] things like diagnosis or decisions about treatment or understanding mental disorders.

They discuss what defines a mental disorder, how biological, psychological and social factors interact with mental health, the evolution of psychiatric diagnoses, And how these have shifted over time, the benefits and limitations of psychiatric medications, their potential harms, and some of the public relations challenges that psychiatry has faced and continues to face in the modern day.

As ever, it's really helpful if you can give us a rating or a comment or a review. We really enjoy hearing from you. And you can also give us feedback directly at our email at thinkingmindpodcast at gmail. com. This is The Thinking Mind, a podcast all about psychiatry, psychology, self development, and related topics.

We hope you enjoy. And as always, thank you for listening.[00:03:00] 

Hello, everyone. I'm very excited to be joined by Dr. Aves Afdab for this week's episode of the Thinking Mind podcast. Dr. Afdab, welcome and thank you for joining us. Thank you for having me. You are a psychiatrist and you write blogs. You do a lot of thinking about what the practice of psychiatry should be like and how it can be improved.

What got you thinking about this? What, what made this important for you? Um, I, I had been interested in, in philosophy for a long time even before I started med school I, I was interested in philosophy and, um, and in fact I was, I was Considering the possibility of going into philosophy as an, as an academic profession, uh, but I was in Pakistan at the time and, uh, you know, philosophy as a, as a kind of profession was just not really a viable option.

Um, so I ended up in medical school and in medical school I realized pretty quickly that [00:04:00] psychiatry was a subject that interested me. It felt a great fit for my temperament and also for, for my interests. Um, and so I started pursuing psychiatry, and, and to my delight, I discovered that there's this huge overlap between, you know, philosophy as a discipline and, and the subject matter of psychiatry, and there's this burgeoning field of philosophy of psychiatry, uh, which is inhabited.

by both by medical professionals, by psychologists, by, by philosophers. Um, so I, I started reading up on that and started getting familiar with the literature and, um, and I, I really got interested and curious about fundamental issues in psychiatry, um, various kinds of concepts that, that drive our clinical work and our scientific work.

Um, and, and I started realizing how, how fundamental they are to, to, clinical practice and scientific practice. Uh, so my, my profession, um, as a psychiatrist, my, my, my career as a psychiatrist, um, [00:05:00] I have used the opportunity to explore these basic questions, um, with the, with the help of the philosophical literature.

What as, as a quite a novice to philosophy, and I imagine a lot of our listeners are as well. Could, could you give us more of an idea of what kind of questions those are, even what philosophy means, particularly when applied to psychiatry? Um, yes. So in, uh, you know, the, the range of, of questions that, that are subject to philosophical analysis or philosophical inquiry is pretty broad.

Uh, but, but a helpful way to think about is. What are some of the assumptions and ideas that are guiding clinical work? And what, what are some of the, some of the basic concepts that, that we rely on in, in the field? So a basic concept that, that is ubiquitous is the idea of mental disorder or mental illness.

So we can ask about, um, when we characterize a behavioral [00:06:00] state as being disordered or when we characterize a behavioral state as being an illness or a medical problem in a certain sense, um, what kind of judgments are, are we making, um, to, to what extent are these judgments grounded in fact? About biology or facts about physiology, and to what extent are these judgments grounded in various values that that guide, um, uh, you know, human decision making.

To what extent are these values, social, cultural, in nature? Uh, to what extent are these driven by perceptions of, uh, distress and judgements of harm? Um. And, uh, when, what, what is the end, you know, end product of, of, of this confluence of, of, of, of judgments? Um, when we, when we classify conditions within the realm of, of mental disorders and within the realm of mental health problems, when we, let's say, uh, draw a line between depression as a syndrome and anxiety [00:07:00] as a syndrome, uh, what, what is the nature of that classification?

What, what exactly are we carving? Uh, are we, um, the, the kind of, categories that we have separated out? What is their metaphysical status? Do these categories present an essence, a unique singular category that is particular to or specific to that group? Or are these just, uh, for example, practical groupings, um, that we're using for our practical purposes and they don't necessarily capture the underlying structure of the problems or mechanisms of the, of the problem.

So, so these are metaphysical debates around what we call essentialism and pragmatism. And then when we look at the nature of psychiatric explanation and nature of psychiatric knowledge, uh, we can use a philosophy of science perspective and we can, we can think about how science progresses. How is it that scientific knowledge is generated?

What kind of, um, limitations, biases it is subjected to? to [00:08:00] what is the relationship between our theoretical understanding of a phenomena and the phenomena as it exists independent of human concerns or perceptions. So we can apply a lot of those philosophy of science questions about realism, anti realism, and epistemology and the basis of scientific knowledge to psychiatry as well and think about how is it that psychiatric knowledge is generated.

Uh, what, what is it that we are trying to study, what kind of inferences we we we can make, and we can also look at the methods of knowledge production. What kind of perspectives are being excluded, for example, from the way we currently generate psychiatric knowledge and what are the consequences of of of those things.

Um, and because psychiatry deals with, um, behavioral phenomena, but also deals with, you know, brain mechanisms and processes, we Inevitably come up with these philosophical issues around the mind body [00:09:00] relationship. Um, so what is the relationship between, uh, mental health symptoms, behavioral disturbance experiences with what is happening in the brain?

To what extent we can reasonably think of mental disorders as being brain disorders and, uh, what are the advantages and disadvantages of thinking of them in that kind of manner? Uh, what can conceivably be the limits of biology in explaining these problems. So that's just, you know, I'm going through a list of some of the, you know, questions that, uh, you know, psychiatrists interested in philosophy and others working in this area tackle, but it's just a subset of things that are being discussed.

I guess to go back to one of the specific examples, so you talk about, for instance, using a philosophical viewpoint to inquire around diagnoses like depression, anxiety, and to what extent these might be separate entities, to what extent they're categories that [00:10:00] are sort of pragmatic to use. What, I mean, what, what do you think about that question?

So the, uh, the, uh, kind of people involved in these philosophical debates, you'll, you'll hear them talk about natural kinds, social kinds, and practical kinds. Um, natural kinds are, are. categorizations that reflect the structure of the of the natural world as it exists independent of human interests. So a good example of that is the periodic table of elements in chemistry and physics.

It's, uh, it captures something genuine about the about the way elements exist and they're distributed. corresponds to the structure of the atomic nuclei. It has tremendous explanatory and predictive power. Um, we, we, you know, based on the position of the element in the periodic table, we can predict a lot of things about them and it is the, uh, it is the correct, objectively [00:11:00] correct way of, of categorizing and classifying elements as well.

Uh, if we imagine different, uh, chemists, you know, starting from different, different theoretical ideas about what elements are. If they do empirical work good enough, if they're doing scientific work correctly over time, they would all converge onto the same model. So it's, it's exists independently captures it's the, it's the, you know, uh, it has powerful explanatory value and independent of human interest versus in, um, think of.

So those are natural kinds. The complete opposite are social kinds. And, and these are categorizations and distinctions that are almost completely dependent on human interests. Uh, so a good example, um, uh, of, of this would be something like the political borders. They, they're, they're entirely dependent on human perceptions and human negotiations.

They, they exist in our, in our minds, so to, so to speak. There's nothing in the, in the [00:12:00] natural, you know, geographical landscape that corresponds to the, to the border itself. And if humans were to suddenly disappear, you know, the political borders would no longer exist. And, and as human conflicts occur, we, we change these.

you know, border space based on our negotiations. So, so that's an example of something that depends on human interests, you know, almost completely with no correspondence to the natural world. And in, in between natural and, and social kinds, there is this messy gray area of what we call practical kinds. Um, and, and, and these are, these are phenomena that that are enmeshed with human interest and that we, we have multiple ways of looking at this phenomena from different perspectives, different angles, uh, depending on what it is that we want to achieve.

And, and depending on what we want to achieve, we can make categorizations that, that are useful to us, but they are not the one objectively correct way of looking at it in the [00:13:00] same way as the, as the periodic table of, of elements is. So, uh, a lot of medic uh, a lot of classifications in, uh, in medicine and a lot of them in, in, in psychiatry, uh, tend to fall into this area of practical kinds.

Uh, now there, there are exceptions to it. So, for example, infectious diseases are, are a clear example of you know, natural kinds in medicine, uh, you know, whether some, whether a syndrome is, is caused by a spirochete infection, you know, we, we, we can identify, we can, you know, we can discover that it's a, it's a well defined entity and things like autosomal genetic disorders, uh, you know, can come pretty close to something like that too.

But for other conditions, um, like depression, anxiety, psychosis that are highly heterogeneous and, um, where we're kind of, you know, the boundaries are fuzzy and the actual distribution of symptoms is very dimensional [00:14:00] as well. Um, Any, any boundaries and thresholds that we draw and any distinctions that, that we make, um, they, they are not going to be the one objectively correct way of looking at it.

But rather it's kind of a question of what it is that we, that we want to achieve. Um, if we want to achieve, for example, a, a, a schema that corresponds to response to treatment. That is going to look very different from some classification that optimizes, let's say, genetic associations. And, and if you want to optimize something like neuro, neuroimaging findings, a schema based on neuroimaging finding is going to look very different from, you know, from clinical description, for example.

And then that's that's what we see. So, um, in, in, in, in, in, to tell, to speak of this in other terms, people talk of validators and convergence of validators. When, when we are dealing with natural kinds, the converge, the validators tend to converge. They all tend to [00:15:00] point in the same direction. Versus when we are dealing with practical kinds, there's a misalignment between different validators and different validators.

point or somewhat different things and um, and You know how to optimize that depends on what it is that we want to accomplish. So Uh, so there there is it's not so we cannot make things up. It's not it's not arbitrary, you know it but um the The optimal solutions will depend on goals that we have set for ourselves.

Okay. So how you think about depression as a psychiatrist or how you think about finding the boundary between depression and anxiety? will depend on whether you're, for example, thinking about what kind of treatments to prescribe versus how to explain that to the patient or how the patient might understand it themselves.

So, uh, so the, uh, so for the first thing to [00:16:00] note is that even in terms of, um, you know, symptoms themselves, uh, depression and anxiety share symptoms. So the, the boundaries between them are fuzzy for, you know, based on that, that reason alone. So, uh, so many, many. things like, you know, sleep disturbances, distractibility, irritability, um, you know, other, other changes can, can be seen in both.

And then, uh, depression and anxiety as syndromes are highly comorbid as well. People, people oftentimes, um, ha, ha, you know, have, have both of them. And, um, in fact, when you look at The way these symptoms cluster together, um, due to the heterogeneity and in high comorbidity, um, uh, depression and anxiety do not show up as distinct, uh, syndromes in the statistical sense in the, in the, in the psychometric sense, but rather they show up in kind of enmeshed together in the, in this larger sub factor known as the distress, distress sub factor.

[00:17:00] Um, uh, which is one of the, uh, you know, one of the. kind of dimensions in a classification known as hierarchical taxonomy of psychopathology. Uh, you know, which is based on statistical association. So, so even statistically speaking, they, they, they do not separate out as distinct uh, syndromes. Um, and it, another way to think about it is, uh, you can think of it, uh, of what happened in, in the United States in terms of diagnostic practices.

So, if you look at, um, nineteen, 1960s and 1970s, Um, anxiety disorders were, were kind of very commonly, were the most common kind of, you know, psychiatric diagnosis and, and, and, you know, utilized and given to patients and, and common treatments at that time were benzodiazepine medication. So, so people were getting diagnosed with anxiety and they were, they were, a lot of them were being prescribed benzodiazepines.

Um, And at that time, uh, psychiatrists were also [00:18:00] working with this general idea of neurosis, which kind of heavily, in which anxiety symptoms featured pretty prominently. When, when DSM 3 was published in 1980, um, DSM, the people behind the DSM 3 had a somewhat, uh, kind of anti psychodynamic bias, um, and As a result of that, they, they took the category of neurosis and they divided that up into several distinct anxiety disorders.

So general anxiety disorder became its own thing. Panic disorder became its own thing. Obsessive compulsive disorder became its own thing. And, and they set the criteria relatively conservatively. So for general anxiety disorder, you had to meet a threshold of six months, you know, in order to be diagnosed.

Now, Prior to dsm 3, uh, depression did not exist as a unified entity or a unified category in the dsm. In dsm 2 You see manic depressive kind of episode manic [00:19:00] depressive insanity depressive episodes You had psychotic depression separately. You had a depressive neurosis separately Um, and you even you even had a depressive personality kind of separate, you know separate um, and uh, then Involutional melancholia, which was kind of depression in old age that that that was a separate category and people sometimes spoke of this primarily as as being a distinction between melancholic endogenous styles of depression and and neurotic styles of depression, um, so but Depression was a, was fragmented across the manual in DSM 1 and 2.

In DSM 3, it is all brought together in the, in a unified category of major, major depression. And, and compared to anxiety disorders, the threshold is set relatively low. You just need two weeks of you know, peer, you know, symptom peer to, in order to meet depression criteria. And we, and, and 1980s is also when we, when we start seeing the development of antidepressant medications.[00:20:00] 

Prior to 1980, depression as a diagnosis was rare because it was only being given to people who had severe melancholic symptoms. And anyone who had milder forms, because they tended to have comorbid anxiety too, they were diagnosed with an anxiety disorder. Post 1980, we see this large shift that, you know, depression starts becoming a more common diagnosis.

People who would have been diagnosed with anxiety in 1960, 1970s are now being diagnosed with depression. And, and the treatment of selection also changes and becomes, you know, SSRIs are being developed and other, so antidepressants start getting utilized more. Now, The symptoms have not changed, you know, people were still experiencing the same mix of depression and anxiety as they as they were all the always experiencing, but our understanding and conceptualization of that changed dramatically, you know, the same person, you know, who would be classified as you know, anxiety disorder in one decade is [00:21:00] classified as, as depressive disorder in, in, in another decade with the same exact mix of symptoms.

And what has changed is what symptoms we are emphasizing, what thresholds we are, we are using and, and kind of, you know, how, how we are approaching, approaching the treatment. So that. That's a good example of how we're not dealing with some kind of objective essence of something that we are identifying through our diagnostic schemas, but rather different diagnostic approaches emphasize different cardinal symptoms, they emphasize different thresholds, and they, they emphasize the boundaries between these conditions in a different way.

So you could, you know, uh, divide up, you know, syndromes into smaller, you know, categories like as we did with anxiety disorders, or you could combine smaller things, previously smaller things into one big larger category, and suddenly a lot more people would fit into fit into that. Thanks a lot. What, what, what do you think about that?

And what do you think about the present in [00:22:00] terms of how depression is diagnosed? How anxiety is not, is often not thought about in people who have depression. What, what do you, what are your thoughts on that? Um, yeah, I think so. I think that the first thing we have to recognize are the, is the, is the fluid fuzzy nature of, of these diagnostic constructs, you know, we, we are working with these, um, symptom level descriptions and, and, and we, we have to recognize that these, these are highly heterogeneous.

you know, conditions different people present are presenting with very different, uh, combinations of, of, of symptoms. And, and so, and, and that is what we see in depression is that people, you know, present the, you know, um, with depressive states in a variety of ways. Some people have very severe psychomotor retardation, agitation, they have very Severe cognitive, uh, problems.

They have severe anhedonia, sometimes kind of, you know, severe, uh, severe existential flavor to [00:23:00] suicidality versus we see versus there are other people whose depression is very enmeshed with, with their life circumstances. They're experiencing a very stressful time. They're going through a divorce, they're, they're having, uh, you know, uh, job problems, or they, they have other, they have financial, you know, stressors or unstable housing.

And, and because of that excessive stress. You know that they're experiencing a lot of low mood and dys for dysphoria. Um, and then there are other situa, uh, you know, other, uh, situations where someone by their temperament is predisposed to high neuroticism. And that high neuroticism makes them vulnerable to experiencing low mood and adonia, um, at kind of various points in their life.

And perhaps they live with a certain amount of low mood and anhedonia that that. You know, fluctuates with life stressors, uh, but, you know, um, remains elevated at, at, at all times. So these are, these are very different styles of, of, of depression, you know, every, when, when manifesting, but in current diagnostic schemas, they're not, [00:24:00] uh, kind of sorted out very, very well.

And, and we, you know, everyone is being treated in a somewhat similar kind of manner. So. I think we have to recognize that our current schemas don't do justice to this heterogeneity and also the boundaries that we have made between kind of different conditions disorders at the symptom level. These boundaries are not respected at the mechanistic level.

The mishmash of mechanisms and processes that exist between, you know, it does not respect DSM or ICD boundaries. You know, we see this with genetics to the, you know, the genetic associations don't respect.

So we have to start thinking that our boundaries, whether, you know, they might be useful in terms of description in a certain, in a clinical context, but they're not going to be that particularly helpful when you're looking at things from a mechanistic standpoint, or when we are looking [00:25:00] at things from a, Psychological process standpoint, um, you know, that is why when we look at things from for example from a psychoanalytic or psychodynamic perspective The usual descriptive categories are less important and what matters more is the is the pattern of psychological, you know experiences So so being mindful of that, you know, we're dealing with a multi faceted phenomena and, and the boundaries we use from one perspective are not going to hold, you know, looking at things from another perspective.

And then secondly, we have to be scientifically smarter about, even at the descriptive level, about examining these things. If, if the traditional GSM ICD syndromes and boundaries, are, are kind of semi arbitrary in the sense that they, they are, they're, they're built on clinical impressions that people have had over years and there's a kind of semi consensus around them.

Uh, we have to look at other approaches about how, how we can, um, approach them in a sophisticated manner. [00:26:00] And, and that has been happening in the psychology psychopathology, where, where people are taking statistical data seriously. And, um, they are asking, you know, what happens if we look at the, at the covariation and co occurrence between symptoms if, you know, how do we, what kind of latent factors emerge, you know, in this classification?

And the answer first is that, you know, these, kind of the, the the, uh, dimensions. We see dimensions emerge rather than categories. So the phenomena are distributed in a population in a, in a latently continuous manner rather than there being discontinuities, um, one. And second, we see a hierarchy of dimensions where we, we have symptoms and traits as being narrow dimensions, you know, at the bottom that, that cluster together to form larger dimensions such as distress sub factor, fear sub factor, [00:27:00] that then cluster together to form things like internalizing disorders and externalizing disorders and thought disorders.

And then there's this very intriguing thing at the top called the general factor of psychopathology or the P factor that that seems to, statistically speaking, explain a, a, a, a shared variance among all mental, mental health disorders. And also kinda is a, is a reflection of the fact that all mental disorders are, are comorbid with each other at, at, at a certain level.

So, so just as all aspects of intelligence are. are, you know, in a sense, linked to each other such that we can talk about a g factor, a general factor of intelligence. Uh, all aspects of psychopathology are related to each other through mechanisms we don't understand very well, and we see a single statistic.

Factor emerge called the P factor. Um, and, and there's very interesting debate in the scientific literature around how to understand that whether, whether the P factor is just some statistical way of talking about things or [00:28:00] whether it represents some kind of, you know, set of processes, uh, that, that share, that confers some kind of general vulnerability to, to mental health problems.

Um, so, uh, so the thing I want, so I wanna emphasize is that we, we have to take, um, the. Kind of, you know, the pragmatic practical nature of our classifications seriously, which means being humble about their limitations and and looking at these things from a variety of different perspectives and optimizing our classifications for a variety of things.

Let me, let me give you another example. So, uh, take, take blood pressure, uh, you know, you know, blood pressure is a, it's a continuum. Everyone has a systolic blood pressure, you know, um, And there's nothing magical about our current threshold for essential hypertension as a diagnosis. So saying that, oh, a 140 millimeter mercury at the systolic blood pressure, you know, we're using the diagnostic threshold.

It's kind of semi semi arbitrary. There's no, you know, you could [00:29:00] have said 139 or 141 and it wouldn't be much different. So, but there's no natural discontinuity at 140 either. It's just, it's a smooth line. So why is it that we go with one 48 millimeter of mercury as a threshold. Uh, it's because we, we, we have looked at the data and we are interested in, um, reducing the risk of future cardiovascular negative events.

So we are reducing interest in reducing the risk of stroke. We're interested in reducing the risk of heart attacks and we're interested in reducing mortality. And if we look at, we, so we identify a. we look at the data and we say what kind of threshold would make the most sense to try to you know, optimize mortality reduction and that gives us the answer that if you want to achieve this then, you know, Try to keep the blood pressure lower than 140 and that also gives us the wiggle room to revise it So for diabetics, we know that even with 140, the mortality risk can be higher.

So for diabetics, we set the blood pressure threshold lower, [00:30:00] right? So our thresholds are going to be sensitive to what it is that we want to accomplish. The problem with DSM ICD is that they haven't had clarity on what it is that they're trying to optimize. Um, you know, let's say we have, we have the, you know, threshold for depression in DSM of five out of nine system, uh, symptoms for, for a two week period.

What is that threshold trying to optimize it? I mean, it doesn't optimize treatment response because, you know, people, people still respond to treatment even if they don't meet that criteria, it doesn't, it doesn't optimize, you know, neuroimaging finding as we know it, it doesn't optimize, you know, long course of illness.

So. Uh, you know, so what, you know, we, we have a variety of things in mind and, uh, we're, you know, we're going about them in a somewhat muddled manner versus if we had clarity on what, what was the practical aim, what was the clinical aim, a scientific aim, we can come up with different classification schemes that [00:31:00] optimize those goals and, and, you know, you know, make more progress, uh, you know, with, with that kind of clarity.

Is this something that you apply in your clinical practice at the moment, this kind of thing? Or does this kind of thinking modify how, how you practice? Um, in, in a, in a certain amount of way, um, in a certain, in a certain sense, I think one is that my conceptualization of what, what a person is going through, what they're experiencing is informed by that.

So I'm not just thinking in terms of, hey, you know, I'm gonna you know, this person meets XYZ, you know, DSM ICD criteria, and you know, and then I'm just going to blindly follow the treatment algorithm. But rather, I'm thinking in, you know, in this, all right, you know, what, what are the different ways in which I can conceptualize this person's problem?

And, and what way of thinking makes the most sense? you know, for this particular patient in this particular sense. And sometimes the diagnostic category, the DSM ICD diagnostic category is a very useful way of [00:32:00] talking about it. You know, for example, let's say, you know, ADHD or autism, sometimes it really, you know, really can be a life changing explanation for them to think of, think of their problem in that sense.

Versus in other cases, it's, uh, You know, whe whether I call this major depression with anxious distress, or I call this, you know, GAD, you know, it, it, that's, you know, it doesn't matter that much. 'cause the person's problem is very linked to a certain life circumstances and it's very linked to their personality and temperament and it's, it, it's much more fruitful for me to think about this person as having, Hey, this is a person who is high in neuroticism who is experiencing this acute life stressor and this interaction is generating a current.

You know, syndrome of distress for them. Um, so it, you know, it, so it, it allows me to adopt a kind of a flexible conceptualization. Uh, and then second thing is that, uh, I try to communicate that to, to patients as well, that do, do not attribute more reality to these [00:33:00] diagnostic labels. Then they actually possess, they, they, they are, you know, symptom level descriptions of, uh, you know, of, of these problems.

And they, they have. fuzzy boundaries and they can change over time and they don't, they don't capture some kind of essence that exists in your brain. Um, and, and even, even that, you know, a superficial level explanation can be very helpful for patients because the average lay person. Person. Uh, their understanding of these diagnostic categories is, is very, um, very reductive in biomedical, uh, you know, it's informed by decades of this language of chemical imbalance in brain diseases.

So, so they tend to think that these categories actually reflect. the structure of, you know, how brain functions or how brain goes wrong or, you know, or what happens neuroscientifically. So, so being clear about the nature of these diagnostic, uh, thresholds and diagnostic, you know, mappings, uh, can, can be very helpful for patients to understand their own problems in a, in, [00:34:00] in a better way.

And it's, it's a tricky point, uh, that, that you bring because It speaks to sort of a side of the debate around diagnosis that can become quite binary. And I can hear that in the explanations that you give to your patients, it's in trying to convey to them that a diagnostic category is not, it's not like a periodic table element that is a hard natural fact.

Um, but I think that can sometimes go into an area of the debate that says. Well, then these conditions just don't exist and actually they're not worth diagnosing at all. And. They, they aren't biological things in any sense of the word, and they are just social constructs. How, how do you tread that line?

Where, how do you think about those kind [00:35:00] of questions? And, and I think we, we, we have been seeing this, this, um, kind of dynamic play out in, um, in both. popular as well as academic discussions around around the nature of mental mental illness. And my whole that the direction of my academic and clinical work has been has been in challenging these binaries and in showing that this dichotomous way of thinking about mental health problems.

In fact, it doesn't even we do not apply very well to medicine. Um, you know, let alone to psychiatry and, and things are much more complicated that, you know, than that. And we, we have to be, we have to, um, you know, use better conceptual tools than, than thinking of this in, in this binary fashion. And again, I think the problem comes down to, um, the kind of biomedical reductive idea that people have about medicine generally.

Uh, the, the They tend to think of all medical diagnostic [00:36:00] categories as being in like infectious diseases or being like autosomal genetic disorders when in fact, most chronic conditions in medicine are highly multifactorial and you know, and can be, uh, you know, described and classified, you know, um, with, with, with, you know, some degree of kind of debate and wiggle room, uh, you know, things like that.

So the, uh, um, What happens is that if that is the conceptualization we work with, that uh, that medical diagnosis have essences that, that are neurobiological dysfunctions, um, then it it, you know, we, we either, we either fit a mental health problem into that kinda category or we just reject that understanding and we say that, oh, there's, you know, the.

Biology has nothing to do with this. This is, you know, kind of completely some kind of a psychosocial kind of issue that medical diagnostic terminology is completely unsuitable for this. [00:37:00] So it sets people up for this kind of flip flopping between two extreme views. Um. Versus, you know, um, if we understand that, you know, many problems exist in medicine that do not have, have an essence in, in the traditional, um, sense, um, and, uh, you know, we, we can identify.

uh, problematic behaviors, you know, based on the negative impact it has on a person's life. If, if a person is persistently and severely depressed, uh, to a point where they're unable to function, they, they, they are, um, let's say they're, you know, they, they are, they are so, um, uh, their, their psychomotor functioning has slowed down to a point they can barely get out of

that their appetite has gone down, and they're losing weight, that represents a significant state of impairment. And there [00:38:00] are many different biological, physiological ways in which that state can be present. produce or realize, which, which accounts for the mechanistic heterogeneity of it. So uh, there, there's not going to be, you know, there's no single singular cause or a final common pathway or a final, you know, or a common biological deficit, um, in all of that.

But, but that state is clearly a state of impairment of harm of suffering. And If we have, you know, medical tools to alleviate that suffering, at least for some people, you know, in the form of medications and neurostimulation and psychotherapies, then withholding those tools simply because, you know, that condition does not satisfy some kind of abstract idea of what a, you know, what a medical disorder is, um, is just you know, uh, is this the wrong thing to do, uh, in, in my view?

So we, we have to expand our understanding of what it is that we mean when we call something to be a [00:39:00] medical condition. When we encounter states of suffering that, that are kind of clearly outside of the norms outside of our expected sociocultural norms and other norms of functioning. And they are amenable for, you know, to be described in, in, in medical clinical terms.

And then we have clinical ways of helping at least some people with, with, with that. Then in my view, that becomes a bona fide medical, medical conditions, which, which again, you know, emphasizes the kind of. pragmatic approach that that I have been advocating that that these things are pragmatic constructs when when we say that, uh, depression is a medical condition or anxiety is a medical condition.

We're not making a claim that, oh, there is some hidden medical cause behind these syndromes that is causing it. And that's what we're trying to fix. But we're rather simply making a very practical claim that that these are states of immense suffering that are out of the ordinary by some. [00:40:00] by some standard, and we have things we can do, uh, you know, um, uh, in our, in our medical toolkit that, that can help a person in that kind of state of suffering.

Do you think it's useful or necessary? to identify the brain basis for those states of suffering? I, I think it's, it's useful and, and in, in some, in some, some ways even necessary to try to have a scientific line of inquiry that seeks to understand what the brain mechanisms and processes involved are, um, because Uh, you know, acting on those mechanisms is one of the ways in which we can, you know, better improve the, you know, the, the, the, the lives for those individuals.

Um, and, uh, because we are in, you know, our minds are embodied, you know, we, we don't have free floating mental substance, you know, that exists independent, all of our behaviors are [00:41:00] mediated by, by the brain. So even extreme, um, impairing, disabling behavioral states. They, they are, they are, they are somehow the, you know, the brain processes through their, you know, in their complex attraction are somehow producing them.

And those states are somehow emerging in the ways that brains interact with, you know, with the environment and then the way that brains interact with other brains, you know, in our interaction with other people. So, so there's a, uh, a brain basis to that, you know, to be discovered and to be talked about.

Now, it's not going to eliminate the, the need for us to, you know, rely on psychological behavior language to describe stuff that is going on. Because when we, when we use psychological cognitive language, we, we are talking, we are describing, we're approaching these phenomena at a higher level. We, we are talking about how Uh, kind of, you know, the, you know, like, we're not just talking about a brain in isolation, but we are, we're talking about a brain in interaction with the environment.

We are talking about [00:42:00] multiple brains. So the, the language of neurology, for example, cannot capture those interactions because the language of neurology is focused on what is happening inside one brain versus the, the, the language of psychology and psychodynamics is, is, uh, captures those. Those higher level dynamics, a higher level interactions quite well, and many times behavioral health problems are, are linked with, with, with those higher, uh, you know, higher order, um, things.

Uh, we, we are dealing with our per, you know, how we are perceived by other people and things that other people say to us and our, our status within, you know, asserting a things and we're talking about. Things in the states that we have acquired through learning and behaviors, um, you know, so, so that all of that remains essential, but for certain, you know, for many of these conditions, learning more about how is it that You know, the brain mediates these behavior.

How, why is it that some people get stuck in certain [00:43:00] depressive states, you know, um, even when, when they desperately want to change their own behaviors that they're not able to? And what, what role, for example, do, does neuroplasticity play in that? Um, Why is it that in certain cases there's a very strong, um, family history of mental health problems?

And why, why is it in some people genetics seems to confer a huge degree of, of vulnerability? And the thing with genetics is that, uh, genetics, uh, factors cannot directly manifest in, you know, in, in, in psychological, uh, terms, you know, uh, any expression of genes has to go through cellular pathways and, you know, expression in brain network, et cetera.

So, uh, any link between behaviors and gene is going to be mediated to, to intervening neurobiological pathways, which means that there are, there are coherent things we can say about how is it. that, you know, um, uh, genes, for example, confer high [00:44:00] vulnerability to schizophrenia or bipolar disorder and understanding what those mechanisms are, you know, has, has the potential for us to, you know, develop new interventions.

Now, it does not mean that, that, that the reason a person, let's say, you know, uh, develops bipolar disorder or depression or schizophrenia is because they have abnormal genes. Uh, you know, that that's a very different thing. We are that that would be a false way of understanding this you know, it would be a mistake to say that oh, um that you know, bipolar disorder is a Disorder of abnormal genetics in the same way as huntington's disease is a disorder of abnormal genetics, you know That's a different kind of story, but it nonetheless remains the case that there is a genetic component to, to, you know, bipolar disorder, to schizophrenia, to a smaller extent even in depression, and that there are coherent ways in which that genetic contribution is being expressed.

And in [00:45:00] trying to understand that means that we better understand at the brain level what is happening to, to a depressed person. And then, you know, Hopefully, the hope is that that gives us more tools to, to understand, you know, more tools to intervene on, on, on, on, on that and, and, and help a person. Um, so I, you know, again, that I think points to this kind of, you know, this binary tendency that we want to say that either a problem is a problem of biology, you know, and that's why we would take biology seriously.

Or we want to say that if, if, if the problem is not a problem, clear biological problem or a problem biological abnormality, then, you know, nothing, nothing much is to be gained by understanding the biological dimension of it. And, and so, and, uh, you know, versus mental health problems, mental disorder exists precisely in this middle ground, where they, uh, mental health problems are not primarily problems of, uh, you know, biology gone wrong, mental health problems or [00:46:00] problems of behavior gone wrong.

And, you know, psychological experiences gone wrong, but they, they nonetheless have a biological dimension. And, and they're, you know, because they have a biological dimension, we can study that, we can intervene on that, um, you know, often in kind of, you know, remarkably effective ways at times. A couple of thoughts jump up, one of which is moving away from the conversation on depression, but I think you drew to some of the nuances that we can also use to think about diagnoses like bipolar, schizophrenia, because I think Sometimes we focus a lot of the conversation about the psychosocial contributors to, uh, to conditions like anxiety and depression.

I mean, I feel like the more that I work, the more patients that I see, it feels unignorable that patients who have conditions like schizophrenia have so many different stresses and factors in their lives that either contribute [00:47:00] to relapses over their lifetime. But also if when you see the story of the initial illness, it, it feels like you, you can't ignore the psychosocial aspect.

What, I guess, do you see that coming through more in psychiatry nowadays? Did it, did it used to be thought about more before and then biology took over for a time? What's, what's your view? Um, yeah, so I mean, I completely agree with you, uh, you know, psychosocial factors, you know, both, you know, in terms of, you know, individual psychological factors, um, in terms of their personality structure, in terms of their temperament, in terms of their psychological developmental history.

In terms of their, you know, the traumatic experience that they have had and their perceptions of, of those, you know, adverse experiences, um, as well as the, the larger, uh, societal organization around them, you know, their, their, their state of poverty, kind of financial stress, uh, you know, housing instability, you know, [00:48:00] access to food, uh, those kinds of things.

All of them are extremely important. The, the contributions vary from, you know, from person to person and, and case, you know, can, can I condition to condition. But the You they are absolutely vital and essential, and in many cases, the mental health problems and psychopathological problems, they are enmeshed with these psychological and social kind of stressors and issues.

So any psychiatry that ignores them or minimizes them or neglects them is going to be a highly impoverished psychiatry and is not going to serve patients. patients very well. Um, what happened in the, in, in the 90s was that there was this, you know, tremendous exuberance around the potential for neuroscience and genetics.

And there was this tendency to just conceptualize these problems as these are brain diseases, these are genetic disorders. And there was this strong optimism that just any day now we're going to find out. [00:49:00] That in the in you know, that that hope did not can it was not successful, you know, by by early 2000s.

it became pretty clear that the, you know, biology is much more complicated, uh, than that. But it also became clear that that some of the kind of, you know, most important drivers and contributors of these problems are in fact things that are happening outside the brain. Uh, it is these childhood adverse experiences.

It is these, uh, you know, like, you know, terrible life circumstances, stressful life events, uh, that, that are happening. Um, And it's, uh, you know, in order to improve, uh, clinical outcomes, both at the individual level and at the, at the population level, we, we have to tackle those, uh, those kind of, you know, larger psychosocial, uh, psychosocial dynamics.

And medicine, I think, [00:50:00] has, has struggled to do that. Um, you know, psychiatry, psychiatry as well, but also, you know, medicine generally. And this is, uh, uh, I think as In order to take effective psychosocial action, we need a certain kind of political movement, we need a certain kind of political action, and, and we need, um, uh, buy in from, from, you know, social forces and social stakeholders, um, and, and the the political climate has not been conducive to the, you know, producing the kind of effective public health changes that people really, really need.

Um, and in fact, so the emphasis has been more and more on individual centric interventions. What, what can we do to improve the functioning of this particular individual while, you know, uh, leaving their, their, you know, environment and surroundings? Um, you know, as much, you know, intact as much as possible.

And, and, and this kind of basic dynamic, you know, shows up in, um, you know, in [00:51:00] all areas of, of medicine, you know, not, not just, not just in psychiatry. If you look at, um, kind of epidemiological data around metabolic disorders and cardiometabolic disorders, you see this tremendous, you know, association with social determinants of health with, with, um, poverty with access to food with access to quality of food with access to exercise, um, uh, you know, and so there's a, there's a, there's a case to be made that, you know, a public health approach, uh, is a necessary for, for all health, not, not, not just mental health or physical health, but it is certainly, um, you know, much more important in, um, in, in psychiatry than even it is in, in general medicine.

So that there's a difference of, degree but not a not a different uh, you know, kind of quality when it comes to these issues in in psychiatry versus medicine. I think the trick again is in holding both, accepting both at the same time. We can [00:52:00] acknowledge that yes, you know, there are factors within an individual and there are factors around both.

factors outside an individual and we have to tackle both. And worse than instead, we see this weird polarity in psychiatry where one group just tries to insist that, oh, well, you know, let's just focus on the individual and forget everything that's outside. And the other group said, let's just focus on the society and, you know, forget what's happening in the person.

And the reason this is important is that, um, again, you know, the, we, because these things are highly biologically heterogeneous. You know, we, we have not been very successful in mapping traditional D-S-M-I-C-D categories to specific biological processes. But if you look at, you know, what are some of the biggest predictors for the, for the development of these conditions and for, for the course, these are actually the, the kind of broader temperamental factors and personality factors like neuroticism.

That can heavily predict whether a person, for example, is going to [00:53:00] have depressive disorder, anxiety disorder, and other things now. And oftentimes, the contribution of personality factors like neuroticism tends to be greater than the contribution we see from adverse childhood experiences in general. So, at the very least, even if you put aside questions of, you know, biological mechanisms, we are seeing a very strong interaction between individual factors in the form of their personality structure and life events in the form of both childhood adversity as well as acute stressors later in life.

So any kind of binary that tries to split the two, that tries to say either we focus on the individual, either we focus on, you know, the society, is actually going to miss It's the, you know, the interaction that drives psychopathology to, to begin with. And I think the, that interaction feels very intuitive.

Probably to most people, you know, whether you practice in this field or if you know people [00:54:00] who have experienced difficulties with their mental health, what do you think is at the root of the fact that nonetheless, I guess we struggle with either biological empirical evidence for this or that we struggle to turn it into interventions that work for the majority of people rather than just, you know, 40, 50 percent of people.

Yeah, I think that the causes are, you know, complex and have a rich history. I think part of it is because the mental health field is professionally very fragmented. So it's not, it's not a Pure, you know, pure medical discipline. So for example, cardiologists, you know, when they're, you know, they're dealing with, with heart problems, um, and that they, they are the main specialty devoted to that versus for mental health problems, we, we have, uh, you know, people with psychiatric backgrounds.

So we, we have psych psychiatrists. you know, [00:55:00] who are into this. We also have general practitioners and family doctors in all of this. We have people from psychology background. So kind of, you know, people who have a psychology, psychology degrees, who might even have PhDs in psychology, you know, involved in this.

And then we have, um, uh, you know, social people with social work background, and especially in the U S. Um, uh, most people providing some form of counseling or psychotherapy actually have a social work background rather than a psychology background. So we, so we have multiple kind of, you know, different disciplinary backgrounds all, you know, in, in, in, engaged in, in trying to help people and working with people and, and they all bring.

different assumptions and different background ideas and different preferences and different methodologies. Um, and they're in, in, in a sense, they're all competing for, for resources that the system has to offer and they're competing for, for prestige that the system has to offer. And, and if there are asymmetries in, in how those [00:56:00] resources and how that prestige and how the, you know, the language that the public gets to hear, how, how those are distributed, then we, we set up the scene for conflict between different disciplines.

And we set up the scene for, um, kind of competition between disciplines for that, which ultimately ends up. Kind of hurting patients because they don't they don't get the integrated care. We need so especially I think in the in the uk with You know with the heavy reliance on nhs funding You know, there's a kind of zero sum mindset where you know, you have a fixed pot of money and it's It can either go here, it can either go here.

So people in that effort to try to obtain access to resources, they have to kind of bolster the narrative that they're offering. They have to kind of oversell, you know, what these problems are and they have to exaggerate And their side of their perspective, you know, so that they can secure, uh, the kind of funding and access to care that, that, that people need.

So I [00:57:00] think, so that sets up the scene where I think different stakeholders are incentivized to promote one side of the story rather than, you know, try to produce an integrated picture that recognize everything. And I think that the second thing is that. You know, uh, you know, at a philosophical level again, you know, because we're dealing with the mind body relationship and it is so easy For for people to fall into this mind body split tendencies and you know what cloakley you can call this dualism Um, and and it is so difficult to talk about uh, mind body in an integrated sense because you know the western world doesn't really have the language to to talk about that we we we have uh, uh, uh, we have to tackle this centuries of Uh bias towards dualism as well as reductionism that is very hard to a for a layperson.

So there are these kind of, you know, broader philosophical challenges that we face. And then finally, the [00:58:00] reliance on these symptoms, heterogeneous symptom categories, I think, has obscured the underlying complexity. It is so easy to just say, say, Oh, you have generalized anxiety and here, you know, we have medication or CBD for that, that, uh, you know, relying on just that, you know, actually ignores all the messiness and none of that really gets conveyed to the public and sometimes not even, not even to the clinicians.

And, and, and that has held back, you know, uh, uh, kind of appreciating the, the nuanced nature of, of, of these problems too. Because I guess in conducting, even just thinking to the very basics of conducting research, if you're recruiting people with, you know, recruitment will be people with a diagnosis of major depressive disorder as made by, you know, the clinical psychologist or the psychiatrist who's running the study.

Um, but to the, often to the exclusion of other diagnoses. Uh, or to [00:59:00] the ignorance of the other diagnoses, even though that is not necessarily the reality of that patient's existence in the world. You know, they will likely be experiencing, uh, obsessive thoughts that perhaps don't meet criteria for a diagnosis of obsessive compulsive disorder, but they might still be quite bothered by thoughts, uh, when they're feeling particularly.

distress, particularly on Edge, that they've left something turned on, or that something terrible is going to happen, or that Um, you know, if they don't take a certain action, they'll be responsible for all sorts of ills. But yes, so if, when research is so limited to, to doing the categories, and like you say, actually in large part, that's because of funding, you know, you get funding to research a disorder, uh, it's hard to move forward, I guess.

Yes, yeah. And that's why I think, you know, the scientific community has been realizing that too. And that's why there has been this big [01:00:00] push towards transdiagnostic dimensional research. Because people have realized that just having this methodology where you take one DSM ICD category and compare that to healthy controls, that's actually not the ideal, uh, kind of, you know, study design because, you know, heterogeneity and nonspecificity of the mechanisms, you know, both at psychological and biological level.

And that it makes much more sense to study these conditions at different levels of specificity. You know, looking at larger clusters of these problems, like in turn, like what it is that internalizing disorders all share with each other, and in some cases drilling down on specific symptoms, and why is it.

That for example, you know, anhedonia, uh, you know, what mechanisms might be involved in anhedonia versus psychomotor retardation versus just talking about a depression level syndrome. So, so looking at these things that, um, you know, at that, in a cross diagnostic manner and also at a kind of multidimensional manner, uh, is, is very important if you, if you wanna make progress.

And, and [01:01:00] right now it is the case that our, our. treatments have generally limited efficacy, this stands for both medical treatments and psychological treatments, you know, our psychotherapies and our medications are not as effective as we would like them to be. It would be great if we had more effective treatments, but you know, we're not there yet and it's important to be transparent with patients about that, that the tools we have right now are limited and somewhat imperfect and they come with, you know, a fair degree of risk.

And that they're not going to be a magic fix. They can, um, you know, for a lot of people that they can make the symptoms more tolerable in variable enough that, you know, there's an improvement in functioning and in a smaller subset of people experience more dramatic improvements. But for a lot of people, the symptoms are not going to go, go away.

They might get reduced to more a kind of variable functional levels. And that Uh, you know, we should not [01:02:00] over promise or we should not present a hyped up version of what our current tools can accomplish. And I think the problem has been that we have not been sufficiently humble as a profession. The narrative that we have told the public is quite disconnected from the scientific and medical reality, uh, of the, of the, of what we can actually accomplish.

Yeah, and I think it's refreshing and I think luckily, perhaps starting to become increasingly common to, to discuss this level of nuance in terms of the limitations of our treatments. Uh, and I think it's again, an area where binaries often arise in saying that if the treatments aren't helpful, then they aren't helpful at all.

Or, you know, how dare you say that the treatments aren't helpful. They're extremely helpful. They're only ever helpful. [01:03:00] There aren't any problems with them. I mean, can we, can we think about some of the, some of the issues that there are with treatments, both if we think in the group of depression, anxiety type conditions, but also conditions where people might experience disorders of thoughts, psychosis, what, what are some of the problems that you find and how do you manage them?

Yeah, I think so. It varies quite a, you know, quite a bit, especially with regards to the problems that people tend to experience in the short term or in the acute term, you know, when, when perhaps a medication is new or when it is being started versus when they have been on medications for quite a while.

for some time and, you know, and, uh, you know, they're in a more maintenance stage of treatment. And so, so the nature of problems can often, often differs, um, based on that. In, in the short term, we, we tend to see a variety of what you can call paradoxical reactions, [01:04:00] where let's say, you know, you have someone with depression and anxiety and you start them on an antidepressant and they'll suddenly have a.

flare up, their anxiety will get worse, uh, uh, you know, uh, soon after starting an antidepressant, they might experience states of agitation, they might experience states of irritability, uh, they'll have this intense dysphoria that, that can sometimes even, you know, uh, turn into suicidality, uh, at, at, at times.

So Um, So we have to be mindful of those that, you know, sometimes, you know, we start a medication and instead of things immediately started getting better, we get a paradoxical response where things suddenly get worse. Um, and, and so we have to be any kind of, you know, when we starting a new medication or we're increasing the dose, you have to be mindful for those possibilities.

Then we have to discuss them with patients that, you know, something like this happened beyond the, uh, you know, beyond the lookout for that. Um, and then there are various kinds of, um, physical, uh, side effects, you know, that that post tolerability challenge, uh, [01:05:00] challenges, uh, you know, with SSRIs, for example, you get a lot of gastrointestinal side effects.

Uh, people can have, uh, sexual dysfunction issues, uh, you know, with, with kind of, you know, ongoing use, um, that, that can become distressing. People can have things like headaches, other things. And so, so there are various kinds of tolerability issues that, that, that we need to be mindful of. When we start entering into the kind of long term maintenance therapy, then, then the metabolic effects start becoming problems.

So weight gain over time, increased risk of diabetes, increased risk of hyperlipidemia, um, And, and that often poses, uh, you know, a challenge that if, if a person has responded very well to a particular medication, but now six months later, they, you know, they have gained a lot of weight and they're kind of HbA1c is creeping up, you know, we, you know, we, we can't just leave it like that.

And, you know, and, and, you know, increase their [01:06:00] risk of cardiometabolic problems. So, the considerations change, so we have to do that. With antipsychotic medications, as you're well aware, the risk of mor you know, motor movement disorders becomes prominent, you know, kind of, like, you know, as we increase duration of treatment.

And then, the um. Something that has been generally neglected historically has been the risk of antidepressant withdrawal, um, you know, and discontinuation issues and, and not just with antidepressants but with other forms of psychotropics as well, uh, because people stay on these medications for years, um, you know, when, when, when they do decide to come off them, um, historically they were, they were being taken off very fast and then they would have severe, um, uh, withdrawal related effects.

And because we didn't have enough research investigating that, um, there was a general skepticism in the, in the medical community about whether these things even cause that, you know, that's where our protracted kind of withdrawal. So it [01:07:00] took a lot of effort by kind of service users and other, uh, other kind of patient communities who, who had been through really negative experiences and, and they raised enough of a hue and cry that, that.

you know, that the medical community began to pay attention and began to recognize this as a serious problem. So I think with, with all, uh, kind of psychotropic use long term, uh, withdrawal issues become pretty significant and we have to be mindful of them. Why, why do you think there was such a reluctance, uh, for, for professionals to hear the concerns of patients when it came to the issue of medication withdrawal?

It was a, I think it was a, it's a combination of, of different factors. Um, one was that, um, we did not have good research data on the, on this phenomena. Um, we, you know, there wasn't any. major funding [01:08:00] agency that was interested in exploring, you know, what happens with long term medication use, what kind of problems emerges.

So there was a big gap. For example, in the, in the U S uh, National Institute of Mental Health is the, is the biggest public funder of, of, of, of research. And, um, in the last three decades, they have been much more interested in doing basic Science research or are doing in in or developing innovative medical treatments and they have left clinical trials largely to pharmaceutical companies a Pharmaceutical companies obviously are more interested in developing a medication and studying its acute efficacy.

They're not interested in studying long term side effects so there was a Uh, we had this problem with incentive that no major research funder was really that interested in the question, you know ideally national institute of mental health should have been but you know They they they set their priorities kind of differently and in similar kind of ways I'm, i'm sure that you know in among [01:09:00] european funding agencies.

No one had really, you know made this a priority So because there was no research money going in that direction. It was never studied. So there was no general get on your knowledge base to link to and because these problems, you know, the severe versions of them were sufficiently severe, sufficiently uncommon that the average clinician was not seeing them.

So a person could treat hundreds of cases of depression and not come across a very severe case of withdrawal and the milder cases when they, when they would come across milder cases of withdrawal, they might just attribute that

So there was, um, uh, kind of, um, an inherent bias towards interpreting these symptom, withdrawal related symptoms as, you know, relapse terms rather than, rather than withdrawal terms. Um, So when, uh, when people did kind of start, [01:10:00] you know, raising this concern more fiercefully, um, you know, the physicians would look to their own experience and they would say, you know, I've been treating these patients.

I myself am not seeing this. And then they would look to the literature and like they were saying, you know, there's no, there are no studies on this. So they would, uh, They would start from a place of skepticism, given that, and the tendency would be to, you know, there's something unusual going on here, um, that, you know, but it's probably not the meds.

Versus the situation would have been quite different if, you know, if we had paid attention to long term, you know, effects from the very beginning, and if we had good scientific data from the very beginning, then people would have started from an informed place. Should there be a responsibility for pharmaceutical companies to study more than the acute effects of their drugs?

I, I think so. I would personally say, say so, but you know, uh, but forcing them, forcing them to do it, you know, it's going to, in places like the U. S. and also Europe too, would [01:11:00] require legislative action. And, and, and pharmaceutical companies have. Far, you know, stronger lobbying than, than, you know, most physicians.

And so the general, the general tendency is that pharmaceutical companies tend to only do what they're strictly obligated to do. But, you know, so for example, FDA requires, you know, you need to do large placebo control trials. So they, you know, they, they kind of, they're compelled to do it. If the, for example, if it was mandated that, you know, you have to do long term safety study to, you know, you know, things, and there, there are certain, there are certain minimal requirements, there are certain minimal post marketing requirements even now in the U.

S., but they were not strong enough to, to, you know, pick up, pick up these, uh, these kinds of issues. So there's certainly, I think, a responsibility, uh, you know, on the pharmaceutical company side, and, you know, we should look into, you know, getting them to do it, but I think at this you know, what I think we really need is a public funding agencies to make [01:12:00] iatrogenic harm a priority.

They, they need to recognize that this is getting to a point where this is a crisis in many different ways. It's a crisis of clinical care, but it is also kind of in a crisis of Uh, you know, uh, you know, you know, public relations too around, you know, around psychiatry, medicine, et cetera. Um, and there's genuine suffering.

So many people, you know, are dealing with this problem and feel abandoned by the, by the medical community. So this needs to be a funding priority in my view and by, you know, made a priority by, by, uh, by medical research organizations. With the public relations crisis in mind. And again, I'm, I think I'm thinking about topics that we've discussed on the podcast before and we, we aren't going focusing on today, but things like the, the debunking of the serotonin hypothesis of depression and, and other issues like that.

My question is how do you, how do you bear these iatrogenic harms in mind in your clinical practice? How, how do you [01:13:00] use these medications? Uh, and again, we're not focusing on other types of treatments, but But specifically, what, what is your approach and in your practice, but perhaps also more broadly to this public relations crisis?

Uh, yeah, my, my approach has generally been to, you know, talk about patients kind of in an open and transparent manner about, you know, about. you know, the nature of these problems as well as the nature of these treatments. So, uh, I, I try to convey to them that the, that the reason, for example, they are depressed or anxious is because of a confluence of different factors coming together.

You know, again, the, the contribution varies from person to person. So my formulation of what is going on in any particular case is going to be different. Um, but, but I emphasize the, you know, um, what are the different factors that we can identify that are, you know, leading a person to, you know, be in a depressed state or an anxious state and how this does not just involve biology, but there are these, you know, psychological factors involved, there are these life factors [01:14:00] involved, there are these developmental factors involved, and I, myself, do not use the language of chemical imbalances or brain disorders because I find that to be very misleading and deceptive.

And once in a while, a patient might themselves bring up the language of chemical imbalance and in that case, I kind of correct them, you know, this is actually, you know, it's not literally true. Sometimes people, you know, use it as a metaphor, but it doesn't represent the nature of the problem very, very well.

And so we talk about that. And then with regards to medication, um, you know, like in a way that they are not fixing, um, an abnormality in, in, in your brain, or rather, you know, we're using them to control symptoms and make these conditions more, you know, bearable for you and to improve your functioning or, or shift your emotional processing in a, in a prominent, you know, in a positive direction, or we're using it to control your body's state of arousal, et cetera, you know, whatever the specifics of, you know, [01:15:00] in, in, in, of the medication condition might be.

Um, But they're not, they're not going to be the magic fix. You know, they, you know, to the extent that the, your mental health problems are enmeshed with your life circumstances, with your, you know, psychological patterns, the medication would not change that. And, and those things required to be addressed through other means, either through psychotherapy, through lifestyle interventions, through other, other forms of, um, uh, you know, other forms of help.

And I think if we, if we take the time to have these honest, transparent conversations with the, with the patients, then they would not leave with these mistaken ideas about chemical imbalance or medications fixing a chemical imbalance or, or, or them having some kind of, uh, uh, you know, a biological disease in the same sense as diabetes, diabetes, a biological, uh, you know, dysfunction.

Um, so that, that's what I've been, I've been doing and, um, you know, emphasizing the. Uh, you know, a more sophisticated [01:16:00] conceptualization of problems as well as, as well as treatment. And again, I emphasize, medications are imperfect tools. They, they help, but they also have the capacity to harm. And, and the, and the balance is dynamic.

You know, if the, if the medication is helping you right now and you're not having a lot of problems with that, that's wonderful, but it does not mean that three years later, the balance will not shift. And if the balance ever starts shifting, that the medication is causing more problems than it is helping with, then we need to take action and, you know, either, you know, change treatments or, you know, figure out other non medication strategies.

And so, so I think patients being aware of the fact that, uh, benefit risk is a, is a dynamic thing over time is, is, is very important too. Dr. Aftab, thank you so much for that tour de force around these varied and complex topics. I'm really sad that we are running out of time, um, as I think I could probably carry on quizzing you for hours.

I'm just wondering if [01:17:00] there is anything that you would want to point people to in terms of your work, any other sort of important facets you'd like to highlight that I haven't brought out as yet today? Um, yeah, I think the, uh, you know, uh, over the past two and a half years or so, I've been working on a, on a Substack newsletter called Psychiatry at the Margins, um, so that's, um, uh, kind of a useful public facing resource that I've been working on that, that goes into some, uh, detail around these conceptual and scientific debates in the field.

field. So, so I'll refer people to that, that there, uh, there's also a recent book from Oxford University Press called Conversations in Critical Psychiatry, um, that is an edited collection of interviews that examines these issues in more detail too. And I think those would be useful, uh, resources for people, um, that are interested in exploring these questions.

Amazing. We'll definitely make sure to link to those in the show notes, um, as I've really enjoyed reading your work there as well myself, um, thank you so much for your [01:18:00] time. It's been a pleasure seeing you today and speaking to you. And thank you for having me. I enjoyed this. Thank you.