Random Notes on Psychiatry

Below is a collection of random notes on psychiatry I took at a random time in my life.

• When doctors get depressed, they prefer to call it “burnout” instead.

• Most people assume that everyone who has thoughts of suicide is in a major depressive episode and that the depression is making them “not think clearly”. While this may sometimes be true, this is not always the case. Some people are at rock bottom and they know it. They do not necessarily have to be “mentally sick” for wanting to end their pain.

• Statistical significance does not mean a drug works well, or at all. If we conduct a trial with 100.000 people, almost any minuscule difference will be statistically significant (but not necessarily clinically meaningful).

• Right now, in medicine and wider society alike, the term “depression” has taken on multiple meanings. The neurobiological process of depression (which is associated with a sharp drop in functionality due to a neural “program”) is called depression in the same way as a non-specific chronic state of unhappiness, “I hate my life”-ness, self-loathing, poor self-esteem, and low energy & excitement. People who claim “I’ve been depressed my entire life” usually do not have neurobiological depression but rather are of the latter type. Antidepressants usually do an okay job with the former, but not so much with the latter. Some help for sure, but in many cases only temporary until the hedonic treadmill turns its nasty gears (”The drug stopped working”). Also, clinical trials for antidepressants enroll participants who are currently in depressive episodes, not people who are chronically unhappy.

• Personality is also not as fixed as most personality psychologists and psychiatrists would like to believe.

• There is a dogma that stimulants make people anxious. This is sometimes true but sometimes also not. Esp. in people with clinical ADHD or “fast brains”, stimulants slow people down because they “stabilize” concentration, which decreases mind-racing. Furthermore, the increase in motivation, enthusiasm, and confidence through increased catecholamine signaling can also be quite anxiolytic.

• Many people with bipolar 1 develop a similar “dementia” as schizophrenics do (”residual negative symptoms”), perhaps because the brain was worn out by being in an overclocked amphetamine-like state for long periods of time. (I do believe that amphetamines may lead to similar issues down the line.)

• A comment by a patient that represents the current state of clinical psychiatry quite well: “I was never truly suicidal until I decided to commit myself to getting my mental health together, following all the psychiatrists’ advice, swallowing all the pills. Seroquel. Risperdal. I slept so much and died inside.” 

• Antipsychotics switch the disease from agitation & mania to sedation and emptiness, which by themselves are diseases (but they do not bother others as much).

• The current diagnose-and-drug strategy of psychiatry makes people feel more “crazy” than they are. Let’s say a patient comes in complaining of “depression”. 15 minutes of questioning later you tell him “No, you actually suffer from persistent dysthymia, social anxiety disorder, generalized anxiety disorder, ADHD, and have schizoid personality traits. ”

• Mirtrazapine is first and foremost a potent antihistamine.

• The label “treatment-resistant depression” is really bad because it fosters hopelessness (“it will never get better”) and helplessness (“there is nothing I can do about it”) and makes patients believe that they have “uncurable” depression – even though in many cases they either have something really bad going on in their life or their last psychiatrist was just incompetent (e.g., trying out an SSRI and then an SNRI if the SSRI did not work).

• Anhedonia also needs to be differentiated from a “schizoid” personality because being low energy & low excitement is just part of the way how some people are naturally, and there’s no way to “reverse” the symptoms because it is their natural personality.

• Industry-sponsored trials contain a sample that is so highly selected that only about 10-20% of psychiatric outpatients (and below 5% of psychiatric inpatients) would meet the selection criteria to participate in the trial.

• Giving out quetiapine as an antidepressant adjunct is ridiculous…and it happens ALL THE DAMN TIME. The only upside is that it is a sleeping pill.

• The people who don’t want to do anything except take pills are usually the patients who have been on 14 different medications and nothing ever seems to work – and if it does, drugs “poop out” quickly. While some people may indeed be neurobiologically screwed beyond repair, many people may not have “chemical imbalances” or “brain diseases” as much as they think but rather have a very shitty life situation. I am all for pills, but only if they actually help me to get up and change my life.

• Bupropion is not worse than other antidepressants when it comes to anxiety!

• Atypical depression does have many similarities with “adrenal fatigue”, for example, both have blunted HPA-axes, chronic low mood, fatigue, sleeping in, laying around all day, overeating, and being overly sensitive. In both cases, patients will feel better if they are given hydrocortisone.

• A lot of people blindly trust their doctors because as medical professionals they should know what’s best but, unfortunately, that is often not the case. In fact, most people trust doctors like they trusted their parents before they realized that quite often their parents were full of shit.

• For whatever reason, sertraline is known to have a particularly high rate of sexual dysfunction (compared to e.g., escitalopram) and also worse diarrhea than other SSIRs, earning it the appropriate nickname “squirtraline.” Other than that, sertraline is a fantastic SSRI because its affinity for the dopamine transporter.

• The main benefit of ketamine is a rapid reduction in suicidal ideation – which also serves the hospital/medical system a lot of money.

• Many times, patients claim that “the drug stopped working”. However, it is impossible to peer into alternate dimensions to see what would be happening to the person right now if they were not on the medication. They could e.g., be 30% more depressed and anxious. Also, many times people get so used to their mental state on the medication that they assume it had always been this way.

• The major antidepressant scores in clinical use (MADRS/HADS) have points about “loss of appetite or weight” and “insomnia” but not about “hyperphagia or weight gain” and “hypersomnia”. No wonder that quetiapine and other sedative drugs fare so well whereas stimulants (which lead to a reduction of sleep and a loss of appetite) usually do poorly.

• Antidepressants have a decent efficacy if they are dosed at very low doses (e.g., 2.5mg escitalopram) – which also reduces side effect burden. Unfortunately, most doctors never consider antidepressant doses in the “placebo” range. Furthermore, it also makes no sense to rapidly increase the dosage in every person – firstly, it is not much more effective, secondly side effects increase, and thirdly one cannot longer increase the drug when one needs to.

• Psychiatrists prescribe quetiapine like candy… It ruins many people’s lives and health. The major upside is that people stop being a danger to themselves and a burden to others.

• The lifetime prevalence of auditory hallucinations, especially hearing voices, has been estimated to be anywhere between 10-20%.

• When it comes to psych drugs, the response is highly individual. A billion randomized controlled trials and meta-analyses of randomized controlled trials cannot tell you if a medication is, or will be, effective and tolerable on an individual level. This is very different from most non-psychiatric drugs.

• There are some patients that obsess with neuropharmacology: “There has to be some neurotransmitter or brain region that explains why you are the way you are. You just need to dial the right dial and your life will fall into place.” More often than not, this is not the case.

• That vortioxetine does not cause sexual dysfunction is a myth. It definitely does, just less than other SSRIs. 

• It is a myth that bupropion should not be given to anxiously depressed patients. From the available data it seems that bupropion does not worsen anxiety (other than in the first week or so) and helps with anxiety almost as much as serotonergic antidepressants. 

• Almost everyone on SSRIs will have their sexual function impaired – though many just do not notice it. Vortioxetine is a little less likely than other SSRIs to cause this, though still well above placebo. Antidepressants that are neutral on sexual function are agomelatine, mirtazapine, reboxetine, and nefazodone. Antidepressants that improve sexual function are moclobemide, selegiline, buspirone, and bupropion. Unlike most of the the annoying side effects (diarrhea, anxiety, dry mouth, etc.) sexual dysfunction rarely goes away on its own.

• Opiates have not just wonderful physical-pain-killing properties, but are also excellent emotional painkillers.

• Why would I need therapy if depression is caused by a “brain disease”? Well, etiology and pathophysiology are not the same. I need antidepressants to change neurotransmitters, neurogenesis, and gene expression (pathophysiology), but I need therapy because some things in my mind or life are not the way they should be (etiology). I discuss this in more detail here: What Kind of Antidepressant Should I Choose?

• What most people mean when they talk about depression is a state of long-standing unhappiness with little joy, some anxiety, and just a general state of life dissatisfaction. This is quite different from a “major depressive disorder” as a biological mechanism or entity (characterized by a significant change in their baseline).

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The content available on this website is based on the author’s individual research, opinions, and personal experiences. It is intended solely for informational and entertainment purposes and does not constitute medical advice. The author does not endorse the use of supplements, pharmaceutical drugs, or hormones without the direct oversight of a qualified physician. People should never disregard professional medical advice or delay in seeking it because of something they have read on the internet.