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77. Dr. McFillin debates a Psychiatrist · Radically Genuine

• kel: Welcome to the radically genuine podcast. I am Dr. Roger McPhillon. I've put it out there for boy, about a year and a half, trying to get a psychiatrist on the podcast who is willing to broach these very controversial, nuanced and challenging topics, certainly around the value and the scientific foundations, safety, efficacy of psychiatric drugs. The DSM diagnosis. How psychiatrists are currently trained in practicing. Now we've had psychiatrists on this podcast previously but I don't think either one were willing to discuss some of these topics. They were really kind of considering themselves advancing the conversation with new science and new research including Dr. Christopher Palmer which we appreciate. But I'm honored today to welcome to the radically genuine podcast Dr. Doug Beach, who is a psychiatrist that's been in practice in Columbus, Ohio, beautiful area for 32 years. The last 24 and full-time outpatient practice where he specializes in individual psychotherapy and pharmacologic therapies. He is board certified in both general psychiatry and forensic psychiatry, and has served as an expert witness in both civil and criminal legal matters. He's also an independent psychiatric evaluator. for the Federal Aviation Administration. Dr. Beach attained his medical degree from Northeastern Ohio University's College of Medicine in 1990, after a bachelor's degree in integrated life sciences from Kent State. After an internship in pediatrics at Children's Hospital in Columbus, he completed his residency in psychiatry at Harding Hospital, where he also served as chief resident. After serving as medical director of a partial hospitalization program at Harding, Dr. Beach then served as chief psychiatry at Riverside Methodist Hospital in Columbus, where he was a member of the active medical staff from 1995 through 2015. He served as a consultant to Franklin County residential services for 25 years and to consumer support services of Licking County for 22 years. Both agencies serve adults with intellectual disabilities and in intermediate care facilities. He is a member of the clinical faculty at the Wexner Medical Center, Ohio State University Department of Psychiatry, where he serves as a psychotherapy supervisor for senior psychiatry residents. He is currently writing a book for the general public about mental health and various ways to apply the bio-psycho-social model. on Twitter at Dr. Beach. Certainly has a diverse background that I think adds to this conversation. Dr. Beach, welcome to the radically genuine podcast. doug_beech: Thank you very much. I appreciate kel: Speaking doug_beech: the opportunity kel: of which, doug_beech: to speak with you. kel: why did you decide to come on and have this conversation with me? doug_beech: Well, a number of reasons. You know, I first started to wade into the world of Twitter at the recommendation. I'm working on a book, as you mentioned. And some of the folks in this working creative group I was in said, what do you mean you're not on social media? So I ventured in. And in my background, as you kind of mentioned, I'm more of a psychotherapist. And I ventured my mission to be maybe similar to some of the themes that you There's too much over medicalization of mental health problems, the biological model versus a psychosocial model. And I pictured myself going on to defend, going on Twitter and interacting with folks to enlighten them to the importance of psychotherapy and a biopsychosocial model and to not think reductionist, reductionistically. But I was immediately kind of surprised to find there was so much... material on Twitter around people who have been harmed by psychiatric treatments and who were very critical of the medical model, which I feel has its place. But so much so that I paradoxically found myself defending the medical aspect of that biopsychosocial, the biological aspect, because there's an important place for that too. When some of your had come up, I had responded, and every now and then I would hear you say, well, why won't any of these Twitter psychiatrists? It's funny for me to think of myself that way, but come on my podcast and debate me, and I'm like, well, I'm not sure it's a debate, but I decided, you know, and I've, this isn't news to anyone, but you know, one of the things missing in our society more broadly is the ability to have constructive conversations, especially with people agree with or have different views for. And that's not good. And I said, in the spirit of that, I reached out to you and said, well, if we could have a civil, even if we disagree about some things, I think we do agree about some things. But maybe we can model a healthy conversation, even on the things we disagree and still be respectful and professional. And as I said, Tia, I trust your intentions. I think we're alignment with some things in terms of furthering a conversation. These are very complicated, nuanced matters, and I'm hoping I can add into that. kel: Sure. I hope so. And we've been talking on this podcast about the censoring of science, the restriction and limitation of information. I don't know if Twitter helps. I mean, Twitter is certainly a forum in, in which people have a voice. And I've learned a lot through the exposure to people on Twitter who've been harmed by the system. I've got 20 years experience myself, whereas, you know, it validates a lot of their, their concerns, but I agree with you. There, there, there's nuance. Um, And these are complex issues of an evolving science. And one of my greatest concerns is the reductionist model, and how a lot of what is now mainstream information in the Western world in the United States appears to be information that is certainly serving the interests of the pharmaceutical industry. And the alignment of contemporary psychiatry has led us down a path in which we've become more aligned with oversimplified diagnoses that have actually impaired our ability to be able to understand the complexity of the human experience. And then medical interventions and the medicalization of our culture has created a substantial drug-related problem. And so many, so much of the information that, I believe there's a robust science out there, is really certainly not available to the general public. And when you have primary care physicians, psychiatric nurses in a sick care model that is resembling more of an assembly line, I think we're seeing more and more people harmed. But I think you and I are going to agree on some of that. And I think it's more important for you to talk about where you oppose my mission or some of the things I'm discussing or putting out there on social media or on this podcast. Where are there some points of contention between the two of us? doug_beech: Well, if I may, I just wanted to propose that from the get-go, when we say there's nuance here and we're talking about science, in psychiatry there are no definitive answers almost by definition. That's not a redundant phrase. emotion and it doesn't have a concrete explanation, then it's a psychiatric problem. If it does have a definitive explanation, we don't think of it as a psychiatric problem. The best historical example of this that is often cited is neurociphalous. Ciphalous in its later stages affects the brain, but prior to us knowing what syphilis was or that there was an infection, those folks were in the psychiatric wards, the asylum model of the late 19th century, and accounted for 20% of admissions. But once it was discovered that that was an infection, that's no longer a psychiatric problem. That's an infectious disease. And thankfully we have treatments where we don't see that anymore with the advent of penicillin. So that's just an example. But so just by definition, when we're talking about disorder or problems or impairments in the emotional or... mental sphere, we're talking about things that don't have a definitive answer and that's where we're left to deal with. So it leaves a lot of blur. We'll put this visual in the notes I know, but I this chart here where we picture a linear continuum at one end we have illness or impairment, clearer illness. And at the other end we just have what we might call life problems, problems, both of which could manifest as disturbance in mood or thinking, behavior, etc. And what I would say, and this is kind of a segue or related to the diagnostic system, but there are the core, what I would call the core psychiatric disorders that predate psychiatry even and predate pharmacology. The things that have been written about for centuries. And you find in Greek medical literature, and you find in Shakespeare, in Melancholia, Mania, psychosis, the dementias. There are these, and that's not a complete list, obsessive-compulsive disorder, there are these core conditions that exist that are in some ways validly conceptualized as an illness. And there are also problems that that are not. And so what I would say is at either end of this spectrum, this continuum between life, normal life, and illness, on this spectrum, at either end, it's fairly easy to tell the difference. And there's not much disputing when a despondent adolescent has gone through a breakup and they can't sleep none of us kel: Oh, doug_beech: thinks kel: I would disagree. doug_beech: that person has a mental disorder. Ha ha kel: I can tell you doug_beech: ha ha. kel: from day to day experience that they will be identified with a mental illness and a disorder and even treated as such. doug_beech: Oh. Yes, well, yeah. And so again, I think you're correct. And that's where this problem comes in. But what I would say is that at one end of this spectrum, in reality, regardless of what gets done out there in practice, that's also a reality. But I'm just talking about from a conceptual point of view, you can tell the difference between a, quote, normal reaction in life and something that's temporary, likely to resolve on its own, or will respond kel: All right, doug_beech: to. kel: can I challenge doug_beech: support kel: you on some of this? doug_beech: and kel: Okay. doug_beech: at the up kel: So doug_beech: please kel: I'm just doug_beech: yeah kel: finishing up my doug_beech: yeah kel: research historically on what's considered manic depressive illness or today's identification of bipolar one disorder. So I agree with you. You can look back in the medical literature doug_beech: Mm-hmm. kel: dating back to Hippocrates that mania existed. And with some people after a manic episode, a drop into what we could describe as melancholia depth of depression. So the identification of that as an illness with unknown origin, I have no debate over. However, when I look at historical references, including research and medical texts, it was a very small percentage of the population. One could say that it's rare. Let's go back to pre-Lithium, for example. A manic depressive illness, first episode of manic depressive illness had high recovery rates. Upwards of 80% in the medical literature of those who had a manic depressive illness recovered without any additional episodes. The recovery rates were also quite strong, meaning even those who had a second or third episode. each episode, they were functioning at a fairly high level, including return to work, baseline functioning, ability to have families support themselves. And it is only within the modern conceptualization of the biomedical model and the drug model have we distorted scientific evidence to suggest these conditions are chronic. been identified as episodic. The major medical conceptualization and the drug treatment has created chronic disability. So you're talking about maybe 0.5 of the pop percent of the population, a prevalence rate of 0.5% being diagnosed bipolar one disorder. And then a drug error where 5 to 7% of the population is now diagnosed with bipolar disorder with the outcomes worsening. And so I, One of my contentions here in the modern conceptualization and treatment of these conditions is it's worsened them. It hasn't advanced the health care system. It's worsened and it's increased the prevalence rate. It's decreased the recovery rate. And you have physicians repeating information that's not based on sound science, but it was almost like a whisper down the alley that's been through the pharmaceutical industry in order to drive the sale of their drugs. Because when you're talking about short-term stabilization versus somebody being on drugs for life, that's significant in that financial model. [???] doug_beech: Well, absolutely. And that's where I'm leading with this, is go back to the historical manic episode. We can get a consensus about that and agree on that person's got a manic episode. And the blur is in between. And the DSM laid the groundwork in part for that expansion into the blurry between illness and life reactions. kept expanding and that's what you've got now. And another really important observation here is, you know, the pre... I mean, before lithium was 1970, beginning in the 1950s, antipsychotics medications were helpful for manic kel: The doug_beech: episodes, kel: debatable, doug_beech: but kel: debatable. doug_beech: a big shift, and this is based on... kel: That's debatable. doug_beech: say again? kel: When you say anti-psychotics are doug_beech: What's kel: helpful doug_beech: debatable? kel: for mania. So it's debatable, even that statement is debatable because you have similar evidence that would suggest that there's a natural recovery process that happens under certain conditions without the drug. So now if you're saying that there's doug_beech: Sure. kel: an effect for some short-term stabilization if someone's in danger to themselves or others when they are presenting with psychosis or mania, I'm with you. But when we say these general terms, anti-psychotics are helpful for mania. You can see how that general statement influences our listeners. If I am experiencing mania, which the modern conceptualization conceptualization of mania is not the same conceptualization of mania as it was back in 1960, then, uh, then a person might turn to anti-psychotics and think they need to be on anti psychotics for the rest of their life. So that's just the nuance that I want to make sure. that is clear. doug_beech: Yeah, and I would say that that cuts both ways. And one phrase I put out there a lot is, for some people. And so, anti-psychotics are helpful for some people with mania. And anti-psychotics are not helpful for some people. Mania will sometimes resolve on its own. A lot of what you look at in that older literature, though, and I think this is a really important shift that pharmaceutical influence, the SSRIs and all those other topics, the shift from inpatient care to mostly outpatient care. Resolve is on its own, well, that might be okay if someone can go into the hospital for a year or two, not unusual during that period of time. And beginning in the late 80s, early 90s, hospitalization, both public and especially private due to really aggressive managed care, very difficult to get admitted to a hospital. hospital. And so I think that that's a significant change in our capacity to monitor folks. It used to be if you wanted to start someone a medicine or switch their medicine, folks would just admit it to the hospital. You could call, I watched this go away. It was still present when I started, but a doctor from their office could call admitting and say, go walk to the floor. A person could walk right in the hospital and go on to the psych There's a moat around the hospital to get in. And I'm just saying that that affects practice significantly. That's a good example of the economic forces shaping medical practice. It's not unique to mental health. But mental health lends itself, because of its imprecision, to aggressive limitations on resources. So. I think the point I wanted to make though about that continuum from illness to life and it does lend itself in that blurring between, we have so much imprecision and in the face of imprecision those other forces often take over to diagnose, to prescribe a simple remedy. I agree with you that bipolar disorder is way over diagnosed. always include the caveat that some people really have bipolar disorder and a subset of them, yes, they'll have episodes and they can do well in between. A subset do benefit and require maintenance treatment. But again, all of that requires nuance, careful monitoring, and that's in shorter and shorter supply. The majority of people cannot afford what I would call optimal kel: So you started doug_beech: or ideal kel: this podcast doug_beech: treatment. kel: off talking about that until we understand the etiology of a condition that it can sometimes be mislabeled as psychiatric. And that's kind of where I think about mania and depression. So you call it bipolar disorder. And I understand. I doug_beech: Well, that's, I'm just following the kel: Yeah, doug_beech: current kel: well, doug_beech: standard kel: I mean, you did doug_beech: literature. kel: say that I believe bipolar exists and people require the drugs and it can help some people. Now, the way I look at it is there are doug_beech: Mm-hmm. kel: symptoms, there are presentations of menia, and then there are presentations of severe depressive episodes that exists. I think historically we'd say it's actually, the prevalence rate is very small, but they're of unknown origin. So, if we think about it brain condition that requires a drug to stabilize brain chemicals. And it's its own discrete illness. We are then miscommunicating that to the public. That is not accurate. And I think we are starting to advance the conversation around mental health symptom presentations, having some metabolic origin that can be treated with other interventions. Dr. Christopher Palmer's book on on brain energy, speaks to the science around that and how even a ketogenic diet has stabilized people. There are too many people that are told that they have bipolar disorder and that they require the drugs for life. There's good evidence that suggests maybe upwards of 50% of those individuals are just having a drug reaction to begin with. Because listen, we're living in the United States culture where this is a drug culture, not only from legal prescription drugs, but doug_beech: Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. kel: illegal illicit drugs. Cannabis, for example. I believe you have a five fold. in developing psychosis if you're a regular cannabis user. So psychiatric conditions or disorders that are communicated to the individual as a discrete medical illness, likely have other origins. And by communicating that these are discrete illnesses, we are doing a couple of things that I think are damaging. We are creating or manufacturing addition in which the person now views their symptoms through that lens and sees the only avenue towards health being use of that drug. I know you might not just, you might not agree with that statement, but that is certainly, we could agree that that is the conventional treatment and it's communicated in popular culture. It also, it also stops the research and investigation doug_beech: Sure. kel: of all these other variables or factors that would lead to that, that presentation. modern DSM and the conceptualization of disorders are more harmful than they are helpful. doug_beech: Well, it's just artificially reductionistic. And as you point out, it creates a narrative that just isn't accurate. There's a kernel of validity to conceiving of these things as condition, as illnesses. But then it gets expanded. And as you point out, in our world, we want a quick fix. When you use the phrase prescription drug culture, I'm always reminded of this Pepsi-D-C television commercials. at the late 80s, maybe early 90s, and it's a husband and wife in the kitchen. And you know, mom's making chili, and he sort of taps his belly and says, oh, sorry, I won't be able to have that, and she holds up the Pepsi Day C box. So, hey, don't worry, take this pill, you can eat whatever you want. But all of us, I'd say in all of us, we seek a simple solution for complicated matters. You know, this is where I would go back to the biopsychosocial model. feelings, emotions, behavior is always a mixture of lots of things all put together, always a dynamic. That goes for any kind of mood, mental, emotional state, happiness, anger, anxiety, psychosis, mania, depression, sadness. It's always a blend of things mixed together and we could think of that though all of those factors for purposes of talking about them, for purposes of thinking about them and conceptualizing, we could think of that as a pie graph that has three slices in it. And you have factors that are physical, like diet, like your genetic predisposition, like things such as exercise, medications, hormones, all those concrete physical things. You have the second slice in that pie. you might think of as social or situational factors, the events and circumstances affecting a person. And then the third slice is the psychological, and that's again the bio, psychosocial, our minds, our thoughts, our beliefs, our development, our personality traits and temperament, all those things mixed together to make up a person's state. And I would apply that model to understand when there's a problem, try to apply that model to it. And in that way of thinking, of it, no one in the whole world has what that particular person has. It's unique to them. What happens in the medical model is you do the opposite of that. You take what is a unique, complicated and nuanced individual, whom I would say their diagnosis would come kel: So doug_beech: in kel: a conceptualization doug_beech: several paragraphs, kel: instead doug_beech: not a kel: of a doug_beech: one kel: diagnosis. doug_beech: line. In the, exactly. That's right. A unique to that person. And I often say, you know, whatever is wrong with you is already with you. You walked in with it. I can't give it to you or take it away. And it's unique to you. No one in the whole world kel: The problem doug_beech: has what kel: with doug_beech: you kel: this, doug_beech: have. kel: right? I completely agree with you. You're sounding way too reasonable, Doug. Um... Um... doug_beech: Uh-oh. Your listeners is gonna go down. kel: The doug_beech: Listeners kel: problem doug_beech: ship kel: is that doug_beech: is gonna go down. kel: the label or the diagnosis can strip somebody of fundamental rights in this country. And it is communicated to the general public doug_beech: It can. kel: as if it's a mental illness that one would have potentially for life. And they need to be managed by drugs. don't have safety, strong safety and efficacy support through science. So I need to speak on behalf of people who have lost their rights because of a psychiatrist's diagnosis, not conceptualization, not the bio-psycho-social interaction with this person's very unique genetic background and vulnerabilities and connection with life experiences that have led to this complexity in which they're minutes and I am going to forcibly commit you into a hospitalization program where our outcomes generally worsen. You want to increase the likelihood someone's going to end their life, put them in a psychiatric hospital in the United States. So as reasonable as you're sounding, you are representing psychiatry and you doug_beech: Well. kel: are on the faculty of Ohio State University to follow this model. doug_beech: Sure. Well, and again, I hadn't finished with what happens in the medical model. We do the opposite of the biopsychosocial model. We reduce it down into something too simplistic and too narrowing, and that has a lot of negative implications. And I would say that's the story of psychiatry throughout its history. It's a mixture. It's a blend, and I think the lack of precision is where we've gotten into trouble, I think in mental health broadly. We find something that looks like it works in this group. And then we give that to everybody. We give everybody ECT. We give everybody psychoanalysis. Everybody gets 10 sessions of CBT. There's this one study that shows it helps. Okay, then everyone gets that. 15 minute Med checks. With this one study came out, anti-depressant, CBT. Everyone gets that. And again, largely driven by the reimbursement schedule. And so I know you go on quite a bit about the pharmacological, pharmaceutical industry influence. That in psychiatry, that's largely kind of come and gone, but it has left its mark, I agree with you. But that's not intensely present anymore. They've kind of given up. And as you point out, the psychoactive substances going on now have transcended organized psychiatry. Medical cannabis, recreational cannabis, There's a Ketamine clinic here in Columbus with a waiting list at $500 per treatment out of pocket. So what I'm agreeing with you on the undo focus, at the same time, I would still add for some people that diagnosis ends up causing them harm. For some people, the diagnosis is critical to them being able to get the help that they do need and do benefit from. They're qualified for services. be insured. So it's not a blanket approach. I think that's probably one of my principle objections to some of the things I hear you say. And as I pointed out to you in my communication, I think a little bit more qualification of, well, sometimes, even if it's most of the time, but it's not all the time. Very few things kel: Okay, doug_beech: hold kel: and doug_beech: up kel: it doesn't doug_beech: to kel: always lend doug_beech: always. kel: itself in Twitter with limited character. So let's get into that discussion. I think the best way to walk down doug_beech: Yeah. kel: that path is doug_beech: Yeah. kel: antidepressants. Antidepressants are a multi, doug_beech: Mm-hmm. kel: multi-billion dollar industry. Despite questionable safety, questionable efficacy, and a large global community of harmed patients, these drugs are on the rise. I think you and I have a bit of a differing opinion on its overall value to society. I think doug_beech: Hmm. kel: we have a differing opinion on its efficacy and its overall safety. And I think we have to begin to get into the nuance of that. I think that's where you've probably been opposed to some of my positions. doug_beech: Yeah. Well, let's start at the beginning with this same issue that we have, and that's the, to try to study the efficacy of antidepressants requires some kind of consensus around the diagnosis of depression in the first place. So from the get-go, when you're trying, especially in a clinical study, where you're recruiting subjects into the study, you have to somehow create the illusion that all of the subjects in the study have the same problem. And in reality, just like we were talking a moment ago with the biopsychosocial model, all the people who get the diagnosis of major depression, they don't all have the same problem. They don't all have the same mix. So out of the gate, it's really, really difficult to study that efficacy especially when, as in the interest, especially pharmaceutical companies sponsored trials, they need subjects. They need people to meet the criteria. And as I know you've pointed out, you know, the depression rating scale, the Hamilton scale, 17 items, maximum 50 points, you've got to score in the 20s to get into the study. Well, what do we think that'll do to people who want to be in the study? Some of the studies you get paid, there's probably an artificial inflation of those scores, even if we granted some validity to track the condition. So, I think the questions about is the farther you are on this continuum toward illness, the more likely the medication is going to be efficacious. And the farther away you get from it, the less likely it's going to be. And that's where the risk benefit, it tilts based on where a person is on that conceptual continuum. So the studies for a variety of reasons are very difficult to rely on. And I don't think it's a great evidence base to defend. I would still go back that doctor-patient relationship or clinician-patient relationship. I think that can be teased out. I think you can get some reliability seeing a patient repeatedly. Can you do that in a 10-minute visit in a checklist? I doubt it. I don't want to rail on primary care providers. kel: I do. doug_beech: I try to put myself in their kel: I want doug_beech: shoes. kel: to rail doug_beech: I kel: on them. doug_beech: know, kel: And I will. doug_beech: well hold on. You shall, you have and you What I'm saying is I always want to put myself there like what were their alternatives? What were the other possibilities? We tried to refer for therapy. There's a six-week waiting list. We called their insurance. So again, I think majority of primary care providers are doing the best that they can, but it's lacking. It's not, as I said, I think the optimal care isn't available to most people. But not to, I want to stay on the track here. I would say antidepressants. Yes. not a good decision for a substantial portion of those who take them, but also very helpful to some of those kel: Okay. doug_beech: people who take them. kel: My rebut. There is no such thing as an anti-depressant. doug_beech: Okay. kel: Okay. That is a marketing term and it has influenced too many. I hate even using it, so I'm not going to use it today. An SSRI, which is the primary drug that is provided to anyone presenting with any... I don't even want to use this word, symptom of depressed mood. Now... and then and and anxiety. doug_beech: and anxiety. kel: The idea that there is a percentage doug_beech: Mm-hmm. kel: of the population that could benefit from antidepressants and the more severe that presentation, the greater the response, I do not agree that that is supported by any sound science. What I would agree is that the more severe the individual, the greater the decrease on a symptom checklist. We will observe. is a medical or professional interaction. Now I have looked at this every single way from every single angle. Okay. And there are multiple things that could influence why somebody would get better after an intervention. And I'm not denying that someone reports feeling better after an intervention, but there is this, uh, term. Hock ergo proctor Hock, right? After this, therefore resulting from this. And we know that that's a fallacy and that's why we have to have sound scientific doug_beech: Mm-hmm. kel: research. Now, the most important thing from the biopsychosocial model is the, is the mystery of the human mind, right? We are infants in that development as, as a mental health field and really understanding the mysterious nature of the human mind. The placebo effect is a great kind of reflection of what we don't know. And maybe our potential to heal ourselves with our own beliefs, our own mind. I think it's powerful. And we all know that there is a substantial portion of the clinical population that will report improvement conditions based on no intervention, just the belief that they received it. So that placebo arm of the randomized control trial, it can range from 30 to 45% in adults, up to 65% in younger people. It is substantial. Now, the drug companies certainly had a very difficult time being able to distinguish the drug-related group from the placebo group, probably because of, you know, that power of the mind. But I'm not denying that there is some reaction, some physiological response that someone would have to a psychoactive substance like an antidepressant, which is part of the problem because blind was broken. You know, the, the, the clinical researchers doug_beech: Mm-hmm. kel: and the patients themselves knew they were taking the drug. antidepressant, you know you're going to be on the antidepressant. People feel it. For a portion of the population, they report emotional flattening or numbing. Not everybody, but a portion of the population. That's the diversity and uniqueness of everybody genetically and how, and speaks to the point of why we can't always mass apply one intervention to the entire population. always conceded that emotional numbing or flattening for someone who is in high level of distress potentially could be viewed at least in the short term as a relief or as feeling better. That is not antidepressant and that is rarely discussed with the patients. Rarely are they told, listen, the best thing that's going to happen here is you're going to get some emotional. and a belief that this could alter your physiology because you believe you're genetically vulnerable to this illness. That's not what they're told. They're provided information that they use the words like antidepressant, which in itself is going to have an influence. But they're also not told that the emotional flattening and numbing could also lead to the numbing of the genitals and a permanent sexual dysfunction. They're not told that there's a percentage of the... of the clinical populations who take this are going to feel suicidal and might even want to end their life or experience acuthesia. It's usually very, very minimized. And so my point being is it's a serious drug intervention that might lead to some flattening of affect or blunting of emotion or even a sedative effect for somebody. Since the trials are only eight weeks, we don't really have great evidence to suggest that someone would have to be on them for life. We don't have any evidence of. some long-term positive effect to the drugs. Rarely is somebody placed on only one drug. It starts with that, then they add another, and they add another. Now it's a complete experimentation, but it's all under the disguise. There's this medical legitimacy to this drug that a marketing team said is anti-depressant. And so I do agree with you when you make a statement that says it's very difficult to determine what is actual depression, given everyone kind to how it's communicated and how it's being, how clients are currently being treated. So is there any debate with what I just said? doug_beech: Well, and I've heard, I've listened to several of your podcasts. I think I've listened to each one of that are specifically about antidepressants. So I've heard these claims. And you're pointing out a fundamental problem, and this gets back to the imprecision, not just in diagnosis, but, you know, the medications, we're hoping they affect a sort of narrow part of the brain. That's the ideal. Our nerves are all over our bodies, so there's a blanket kind of shotgun type of effect that all these different drugs have. I think antidepressant is just a convention, again, it goes back to, it's an unfortunate one, but it was capitalized and used as a marketing strategy, absolutely. You know, psychiatry broadly, you said I'm here representing, I don't feel I'm here representing psychiatry broadly, monolith, it's a diverse group of people that practice in a variety of ways. And I think the nuance, the terminology, there's a semantic element to emotional numbing because it suggests the lack of feeling. If someone's having panic or severe hopelessness, that in a way is a feeling we're hoping lesson. But here's how I say it to patients is we don't know if this medicine is going to work and even if you feel better we won't know it was the medicine. It could be you were going to get better anyway, it could be just because you're hopeful and I think we should just concede that to tolerate the ambiguity of not knowing. Those side effects you mentioned, certainly, I mean, you know, the list of side effects that comes with the drug would take an hour us, but the things that are common should certainly, the person should certainly be informed of. And I think the things that have gotten missed, like the withdrawal effects or the activation, those things should always be mentioned whenever prescribed. And I agree with you that I can't imagine that they are in the settings in which the majority of these medicines are prescribed. I think there's, it's likely that, I mean, there's variable, outcomes when you do this research, but the percentage of people who get diagnosed with depression and get treated with depression medicine, the majority of them never see a mental health professional. And in one study it was only a third did, and that doesn't mean the primary cares aren't recommending that they do, but the reality is many people say, well I'll try the medicine and see how I feel, and it's likely that a large percentage of those folks do call you and they would never call me. We're likely to see that people for whom medicine isn't a good idea or is not all of what they need and they probably should be doing other things. So that's, again, it just speaks to the vast pool. When you have 30 some million people taking a drug every day, it's about the same number that go to McDonald's, but that's, it's 30 sometimes mid 40s, but tens of millions of people take antidepressants just in the United States every day. huge group of people. I also would just like to mention the the word rare I mean if it's 1% or a half a percent it's still a lot of people. You know so how you point 5% of the American population would be around one and a half million people. One percent of our population would be three and a half million people. I just want to make sure we always tend to that group with what we say about things like brainwashing or the drug, you're being drugged, you're being told a lie. I mean, I want to make sure that when we say things like that, that we're speaking also to those people who, even if it's a small percentage, who do benefit. kel: Yeah, I mean, that's where that's where we're going to disagree. I, you know, I think the value of research is to protect the well being of people. That idea of benefit is somewhat nebulous. I don't know what you mean by that. The idea that someone who is the majority of people who are depressed walk into a primary care setting, walk out with a with a drug, and then they're just getting better so we don't ever see them. It probably speaks to your point earlier that that's the percentage of the population and never required to drug in the first place and our centers are overwhelmed like my center is absolutely overwhelmed. It's not like it was the 80s or 90s and it was stigmatized to seek out mental health treatment. You know this mental health treatment is big business right now and there are lots of mental health professionals that exist and there is a such a large percentage of the population that is turning to drugs and diagnoses that would have never met that classification in previous generations. Now the drugs themselves, I don't have strong enough evidence to say they help some people outside the bounds of what is a natural recovery because most emotional problems are episodic, right? They're going to resolve themselves on its own by the by nature of life. You cope, challenges exist, you over overcome them, life is painful. Emotional pain is part of living. I don't see it as a symptom of, uh, of an illness. Now, if you're going to say that there's a percentage of the population that experiences a severity of depression that requires clinical intervention, I'm right there with you. The questions are then what are the safest interventions and have the greatest outcomes. And I think we would all agree that the safest interventions are interventions, but they've become front-line treatments in the American mental health system and our medical system. Front-line treatments without safety and efficacy. So when you say the percentage of people that it helps, well, I look at the long-term problems with these drugs, there's no doubt the longer you're on the drug, it increases the likelihood you're going to have a depressive episode. There are significant health effects, including metabolic illness, weight gain. We're just on the, I think we're on the, The front line opportunity to be able to understand the complexity of health from so many different perspectives. One of them is psychoneuroimmunology, right? That's biopsychosocial. And we're learning that this every thought, every experience has its own unique reaction and impacts your gut and gut microbiome and your nervous system and your immune system. And if we're talking about trying to disrupt natural processes with pretty serious psychotropic medications, with pretty serious adverse side effects, I don't think it's honest to the American people just to say, hey, it helps some people. Hopefully you're one of those people. And when there's millions and millions of people taking these drugs, and when we look at statistics in can say we're moving in a direction where we feel good about our culture, about our medical system. We're seeing increases in violence, mental health related conditions, suicide, death by despair. I don't think it's accurate to say, hey, they help somebody when we don't know that. When it could certainly be just a natural recovery, it could be the doctor-patient interaction. It could be the emotional blunting. It could be a placebo, effect. And so if we're going to advance the conversation, we have to move beyond the drug care model of the allopathic training of physicians in the Western world. And so, I mean, that's where my point is, I think many more people are harmed than helped. And I'm in a system here where every day we're seeing teenagers on three, four, five psychiatric drugs. And when these teenagers start experiencing things like intrusive thoughts, difficulties sleeping, feeling lethargic. The doctors, and it's a big hospital system in our area, and it's just growing. It's big, big business. The doctors are reporting that to be a symptom of their mental illness, and let's up this drug or let's add another one. And the parents don't know what to do. They don't, by their gut, they don't believe that their child is getting better. However, when you have a physician in our society with the degree of power that a physician will have, we become submissive to the medical authority without asking questions. And in some cases, the medical authority would say, if you don't follow my recommendations, well, then you are neglecting the needs of your own child. And that is the damage of the biomedical model and the training of psychiatry in the Western world. There's telling this is a discreet and medical illness with underlying causes just like diabetes and you must take these drugs or you are neglecting your child and you are even at risk of me contacting Child Protective Services. doug_beech: Yeah, I don't know who could try to defend that. And you're right that this is one piece in a large complicated system that has flawed in many, many ways. Again, what I would go back to is the one-to-one relationship, the elaborate, thorough discussion, and trying to understand what is problematic and difficult for an individual person. I think that's the ideal. I think the ideal is not available to most people. And that's a commentary on how our culture functions as well. Yeah, and I don't know what the fix is for that. I'm not sure what the alternatives are. And as I said, I think the bigger waves of societal change going on, in many ways, healthcare offerings, the medical model, what we offer in mental healthcare broadly, larger forces at play here, sort of usurping the influence of that narrow kel: had a pediatrician doug_beech: stripe. kel: in front of me a couple of weeks ago. And this was my opportunity. This is my opportunity to really understand what pediatricians are doing and why they are doing it. So as you know, about 80% of these psychiatric drugs are being prescribed in primary care settings. So it's not a psychiatry problem. It's a physician problem for the most part. And I got this individual to at least admit that he really has no sufficient background. and training in the assessment identification and the treatment of mental health related conditions. However, he feels pressured to have to follow guidelines by major medical organizations like the Academy of Pediatrics. Follow the money, take a look at some of these major medical organizations and how they are funded and they create these guidelines. So that there's fear for the practicing physician. If I have a teenager that's in for a medical, in front of me, and they report having suicidal thoughts, even though antidepressants can increase the likelihood of a suicide event compared to placebo in a teenager, because of these guidelines, the physician feels he has to prescribe that psychiatric drug, at least that SSRI to start, or if something would happen to this teenager, he could be held liable. Now, that's a big problem, problem because I do have an answer to some of the questions. Like you said, I don't know what do they do in these situations? Well, when watchful waiting is a more effective intervention than prescribing the drug, you don't do anything. You take it seriously and you follow up. Now, if you can get them to a mental health treatment provider, like a psychologist or a psychiatrist who does outpatient private practice and psychotherapy, which is rare nowadays, unfortunately, or even a social worker or, or even a counselor, that person can be observed over time and monitored. And you can take the time to evaluate what is happening within that individual's life. That's leading them to feel this way. And then we're not viewing those emotions as a symptom of an illness, but a natural reaction to events in one's life. Now, I think there's questionable when you start drawing the lines of like calling something an illness versus something not an illness. I certainly have concerns about that approach, especially when we look at, you know, just evolutionary biology. Like, I don't, in any way, discredit or disregard the complex reactions that we have physically in response to emotional stress. I just don't fall into the model that when somebody reacts, even if it's psychosis or even if it's mania, that's necessarily not some evolutionary adaptation to stress, or there's some underlying cause. not just is just unknown that we can't begin to treat more effectively with time. And I think time in these mental health conditions, especially depression. often is going to lead to positive outcomes. Now, it's not just time, but it's also time with support. It's also time with helping somebody cope. It's also time with validation. It's also with giving parents education. So, I mean, I can't even begin to tell you how many teens have been forced into hospitals in our region. And how many teens have been taking multiple drugs after following an event that traditionally we would view as quite normal for the teen experience and just another developmental milestone for them to overcome. And we've lost our conceptualization of what is normal, what are normal developmental challenges, and instead it's being slapped on with a diagnosis. And that diagnosis is being communicated as an illness. And so for the doctors in the primary care centers who are prescribing these drugs without the training, and they're doing it based on fear, going to let you off the hook. You have an ethical and legal responsibility. It also takes courage, high character, and morality to not provide an intervention that could be potentially harmful and is outside your boundaries of competence. So until we have good people, basically medical professionals, physicians who are able to stand up against this care, and status quo is creating harm. doug_beech: A few minutes ago you said the clear line between illness. My point was that there isn't a clear line. So I wanted to make sure that's, but in that practice world, you're correct that that provider is making a decision based on what they've got at the time. And I would say there's this subset of people who, yeah, it will resolve with time, it will resolve with support. There's a subset that it'll worsen too. kel: Do we have any data doug_beech: And that's there. kel: on that subset? Do we doug_beech: If kel: know doug_beech: the kel: that person or that percentage or under what conditions that would be? doug_beech: For the same reasons we've discussed, I don't think that research is available, but we do know from clinical experience. We have a base suicide rate. We have the clinical reporting of case reports, again, which are anecdotal, but it's still some evidence. And we have our own clinical experience. You know, we're all affected by the things we go through. carry with us those biases. I think you mentioned at the top the, you know, my time spent working in this group home setting for folks with intellectual disabilities was very influential to me because you had a controlled setting, you had people watching these folks around the clock, probably not subject to placebo effects because of sort of intellectual level, some of them not verbal even, but dramatic improvements in those core conditions of psychosis or severe OCD, OCD type syndromes are common in autism, they're common in Down syndrome, and dramatic improvements. So that affects and sort of biases me, I think, toward being able to see. These are folks I followed, some of which I followed those that entire 25 years, saw them regularly, and could track the improvements. And we also were mandated tri-reductions and dosages periodically, which again, I think is a good thing. But without that rapport and that ongoing relationship to monitor these reactions, both for the good and the bad, I think it's the model we have now where this care is being delivered. It's just, it's a wide open with more uncertainty than certainty. kel: Yeah, I think when I step back right now and I reflect on our discussion here, it seems like we widely agree. But you are saying there are some people that it helps. I don't know who they are. I don't understand under what conditions, but there are some people, so I'm not willing to go all the way in with where we've kind of advanced in the system. I've seen it help some people. And again, I think I don't disagree with the fact that a psychiatric intervention in the short term can be helpful. I've always, even on Twitter, I say psychiatric drug interventions should be rare and should be short term. And I think that fits the evidence along with informed consent. So the individual has to be aware of the risks. so poor. They have every right to take any intervention that's available to them on the current market. And if they are someone that can feel better even for a short period of time, then I'm a man of compassion. Yes, I support that. I've never said let's let's abandon all psychiatric drugs off the market and not have that as a as an available option. really should be, should be rare. And we should be open about what it's actually doing. It's not correcting an underlying abnormality. It's creating an abnormality. It's creating an imbalance. And that could have a sedative effect that could depress cognitive functioning. It certainly could allow somebody to sleep and not feel so agitated. Now, does that mean it is curing obsessive compulsive disorder? a bipolar disorder? No, I would say no. You're inducing a chemical reaction or response, at least for the short term, that is going to provide that person relief and maybe stabilize a condition. We don't really have evidence that it's going to improve quality of life long term. As you know, the body and brain are going to adapt. You're going to need more and more of the substance to achieve some sort of what you would define as stability. but it also really appears to impair functioning in the long term. So if there wasn't those, that negative poor quality of life that's associated with those drugs, which are pretty clear, I think our evidence base is pretty strong on that, whether that's anti-psychotics or what is commonly referred to as mood stabilizers, the effects of that tend to really impair quality of life. And I just believe that in our field, when you talk about research, that we should be focusing on improving functioning and quality of life, not just decreasing symptoms that are in a temporary fashion, and then identify that or generalize that as recovery from a particular problem. doug_beech: Yeah, there's some quality of life research that, I mean, antidepressants fare better if you use quality of life measures actually compared to using the Hamilton scale. But I agree with that. Of course, that's what we should be striving for. And I didn't, at any point, say, I don't know who they're going to benefit. I see that as a one-on-one interaction, an ongoing dialogue with an individual, judgment with that individual trying to give them the information necessary to make a judgment about whether that particular treatment will be helpful for them. And again, admitting we can't know ahead of time who it's going to help, who it's not going to have an effect on, and who it's going to harm. We have some idea of the percentages. But as I said, the limitations of studying the effectiveness of antidepressant treatments is the very... The heterogeneity of the condition that is... called depression, and that's a weakness. And people who want a clear answer, they won't find it in the world of psychiatry. It's too ambiguous, almost by kel: Yeah, I asked you that doug_beech: definition. kel: question because I looked into some of the science on diminishing mutations and metabolizing genes of the CYP450 family. And these drugs are being prescribed without any genetic testing to determine who is unable to actually even metabolize these drugs. quote this from a paper based on mutations in the metabolizing genes for those who are prescribed an SSRI, sudden as opposed to slow withdrawal of serotonin-boosting antidepressants or other substances in an acuthesia suffer may make the problem worse and staying on them once acuthesia has developed is equally dangerous. It's the author's contention that prescribing antidepressants without knowing about the 50 genotypes is like giving blood transfusions without matching for ABO groups. And if this is going to be a science and psychiatry is a medical profession based on science, how do you prescribe a drug without even knowing that that person is unable to metabolize that drug and it could kill them? doug_beech: Well, there actually is genetic testing available, fairly readily available. It's not routinely done. I mean, the short answer to how do you do that practically, and remember, 40-ish million people are taking these medicines every day, is you start with a really low dose. And you are available to that patient if they've got a problem. You caution them. But you start with a really low dose. And that is one thing that comes out of the FDA. approval process is, you know, they test the drugs at wide ranges of doses that account for variabilities in both sensitivity to the drug and metabolic variability, which we know exists. And, you know, the person who has a dramatic reaction right away at the low dose, you can guess they're probably not metabolizing it properly. I'm not aware of any SSRI being lethal even an overdose of massive amounts. But yeah, you have to be sensitive to that, but practically you manage that through dosing very cautiously at first. And then again, quick follow up, not here's a prescription, let us know how you're doing, but let's talk later in the week or let's meet again next week. That's the proper way to do that. And it's, I think the evidence again, you have tens of millions of people taking these every day is that you don't see killing people by not being able to metabolize kel: disagree. doug_beech: them. kel: We had a gentleman on our podcast who, and this is what I mean by it being lethal, the gentleman on the podcast, 40-some-year-old male with no psychiatric history, had job-related stress. He was prescribed an SSRI. He fits the percentage of the population that can't metabolize that drug. He developed psychosis and And he was convinced that he was going to have to murder his young son. And he did. And this gentleman is now very open and trying to advocate for knowing the effects of your drugs. He was able to be acquitted with strong medical evidence that induced the homicide. And I think when we talk about the increase, it's at least two and a half times risk of suicide compared to placebo when we're talking about SSRI. So I would say those are fatal. Look at the school shooters or the violence that occurs and examine how many of them were on at least one psychiatric drug. So I just wanna be clear that I do see that these drugs are potentially Fatal and for all the families out there the parents I've I've spoken to whose Child ended their life by suicide when they weren't suicidal prior to the antidepressant Or you know the spouses who've lost their their wife or husband When again, they were placed on these drugs for sleep or anxiety or work with related stress And then they ended up ending their life We want to validate that these drugs are dangerous and wouldn't be so widely and easily prescribed haphazardly. Yes, we know a lot of people will not have that reaction. Most people will not. That does not justify us minimizing the risks. The risk is not the risk. The risk is not the risk. The risk is not the risk. The risk is not the risk. The risk is not the risk. The risk is not the risk. The risk is not the risk. doug_beech: But I didn't mean to minimize the risks at all. And I was speaking specifically when you brought the enzyme and the metabolism as the medicine itself causing a toxic lethal reaction. I'm not aware of that. As a separate matter, triggering people, being activating all that, that's a separate conversation. So again, that is, you brought up the two to three times the suicide risk. I think that is not accurate. And that is one of the things. you say repeatedly that I do kel: on the drug websites. doug_beech: object to kel: Yeah, doug_beech: because I kel: you know, go to the SSRI doug_beech: okay kel: websites doug_beech: well kel: by the doug_beech: yes kel: drugs and they will they will list it. doug_beech: I have kel: Now that doug_beech: They note, kel: Go ahead. doug_beech: hold on, please let me finish. They publish suicidality, which is a risk factor for suicide, no doubt. And in the FDA black box warning that you're referring to with 4,000 plus, this is, I believe, older adolescents, the incidence of suicidality was twice as high in the group on the drugs compared with the placebo. from 4% versus 2%. But so that is an increase in the risk for suicidality, which they in that study, or in the FDA's review, defined as increased in suicidal ideas, which is a risk factor for suicide, but it isn't proportional to suicide risk. It's a difference, it's an exponential difference, the incidence of suicidality versus the incidence of completed suicide. And so again, minimize the risk, I think that antidepressants in a subset of people who take them do get amplified and become more suicidal. That is the case. But that is not the same as a doubling of the risk of completed suicide. It's exponentially different. So I don't think it's accurate to say they double the risk of suicide. It's not even close to doubling the risk of suicide. It's possible that they increase it very slightly. What I would assert is that they increase it in a subset of that total group. They probably decrease it in another subset. But I don't think it's accurate to say they double the risk of suicide. There were no suicides in that group, zero. Now, if I could use another analogy that might illustrate this, and it's like the relationship between nausea and vomiting. If you ran a study, a drug, let's say for blood pressure, any other condition, if the group who took the drug had a 4% incidence of nausea and the group who took the placebo had a 2% incidence of nausea, we could say that the drug doubled your risk of nausea. But back to the antidepressants, what you're saying is that the drug doubled your risk of vomiting. accurate. And just try to think... step back and think about it broadly. Suicidal ideation occurs in... just in... if you study that on a survey, even in non-clinical populations, in 8 to 10 percent of the gross population, that's like millions of people have suicidal ideation. It is a risk factor for completed suicide. But the portion... the fraction of the total people who... who experience suicidal ideation, percentage will actually complete suicide. So again, I don't want to downplay the risk here, but I want to make sure you're defining what the risk is. If you tell someone your risk of suicide is double if you take the drug, that is not an accurate claim. kel: Yeah, I disagree. doug_beech: I'll give you a chance to respond. kel: I was just bringing up here. I think this is from the Lexa Pro website. Warnings. Suicidality in antidepressant drugs. Antidepressants increased the risk compared to placebo of suicidal thinking and behavior in children, adolescents, and young adults. And this is only in short-term studies. In short-term studies of major depressive disorder and other or any other antidepressant child, adolescent, or young adult must balance this risk with the clinical need. Now, um... I believe the risk is higher than two and a half times for younger people. doug_beech: of suicidality kel: I, doug_beech: or of kel: I doug_beech: suicide kel: come doug_beech: because they're not the same thing. Suicidal behavior is kel: I doug_beech: also kel: understand. doug_beech: not a completed kel: But doug_beech: suicide kel: in order to doug_beech: as kel: end doug_beech: they kel: your doug_beech: define kel: life, you have doug_beech: it. kel: to be suicidal first. So we can look... doug_beech: Yeah, that's a, I agree. That's, that's, I agree. That's a risk factor. It goes in that direction, just like you have to be nauseated first before you vomit. But the majority kel: So let doug_beech: of kel: me doug_beech: people kel: finish. doug_beech: who get nauseated do not vomit. kel: There is doug_beech: Okay, kel: a 45% increase in adolescent doug_beech: I'm sorry. kel: death by suicide in the last 10 years. So we can see that there is a dramatic increase in death by suicide in a population where those numbers historically were again, quite rare. We have to make sense of that, Doug. What's also increasing at the dramatic rate is an intervention that has a black box warning and it's not easy to have a black box warning. And it's not easy to have a black box warning. And it's not easy to have a black box warning. And it's not easy to have a black box warning. And it's not easy to have a black box warning. And it's not easy to have a black box warning. And it's not easy to have a black box warning. And it's not easy to have a black box warning. And it's not easy to have a black box warning. And it's not easy to have a black box warning. where it increases suicidality, right? So we don't know who is going to have increased suicidality. That's going to lead to a suicidal event versus who does not. It's probably around the quality of care and the home environment and access. So if you have increased suicidal thoughts and you wanna end your life and you're in good treatment and you have loving parents and you don't have access to the means their life doesn't mean that we don't talk about that suicidal, that increase in suicidal behavior as something that is critical in trying to understand what these drugs do. If you've ever looked at the NIMH study, the TAD study, 34 adolescents treated with Prozac had a suicide event compared to only three on placebo. We know this anecdotally as well. people will report feeling suicidal after the drugs when they didn't experience suicidality prior to taking the drugs. So I can understand that just because one experiences suicidality after the drug intervention doesn't mean it's the drug intervention, but we're talking about no relevant history. So I mean, I do think if you're going to take the position that these drugs, don't significantly increase the likelihood that there could be a suicide event. Well, then that's when I think you're a little bit outside the mainstream. I think we can recognize that these drugs, four percentage of people, increase the likelihood of a suicide event. The most vulnerable are the young people. The most vulnerable are the young people. The most vulnerable are the young people. The most vulnerable are the young people. The most vulnerable are the young people. The most vulnerable are the young people. The most vulnerable are the young people. doug_beech: I'm glad you brought up the TED study, because I know you've spoken about it before, and that's usually what you've shared about it. But I didn't say it's not an increase in the risk. I didn't say that. But it is not double the risk. It's not kel: That's doug_beech: even kel: what doug_beech: close kel: the FDA doug_beech: to doubling, kel: reports. doug_beech: which is, I think, you're conf... No, there's a difference between risk of suicide versus risk of suicidal thinking and behavior, cutting, making plans, And you're right, means all those factors go into whether there's a completed suicide. I do want to address the prescription rate of antidepressants and the suicide rate because those two things right now in time are mapping together, again, worthy of scrutiny. Now are you aware of those factors in the 90s, the rate of antidepressant prescription and the rates of suicide? people because between 1990 and 2000, the rate of completed suicide in adolescents went down every year and especially in adolescent males. It went from I think the number 10, this is per 100,000 per population, down to about six. And during that same time, the prescription of antidepressants to that age group went up four to five fold, like four to 500%. Completed suicide, multi-factors, mostly socioeconomic that influence it, but I think if you're going to track the increases that you're seeing lately here, you think about broad societal changes. This correlation versus cause, I think, is one of the hardest things for people to grapple with. But the TAD study is very important, I think, and you have cited it. You've tweeted about it. And you mentioned on your pocket. as you just mentioned it now. But that's what you usually bring up. And now you do put out there that the TAD study is different in that it was funded by the NIMH, not by the drug companies. That's a score. It also was longer. It went on for nine months. It's rare kel: which we doug_beech: in kel: can doug_beech: studying kel: agree that doug_beech: treatments. kel: most people doug_beech: So kel: are doug_beech: the kel: placed doug_beech: treatment. kel: on the drugs much longer than nine months, and the clinical trials are approved in like eight weeks. doug_beech: Oh yeah, absolutely. Yes, no. And that's not because they want to hide it. That's because it's expensive, mostly. I mean, the sponsor is going to do the minimum the FDA requires, because kel: Yeah, they doug_beech: it's kel: don't doug_beech: very kel: have enough doug_beech: expensive kel: money. doug_beech: to run these trials. But you put the TADS study out there as an example of a different, funded by the NIMH, treatment of adolescent depression is the TADS acronym. And essentially, they started with four groups, three treatment groups and the placebo, the fourth group only ran for the first 12 weeks. But the comparison was Prozac Fluoxetine by itself versus CBT by itself with no medication and the combination of the two. And they ran that group for a total of 36 weeks. Again, a lot of limitations, dropouts, there's all kinds of things. kel: Yes, doug_beech: They excluded kel: I mean, doug_beech: severely kel: that's the doug_beech: suicidal kel: major, that's the major doug_beech: at risk, kel: point. I don't want doug_beech: folks. kel: you to leave this out. Like it's not like this was a great study. doug_beech: Well, I wouldn't. I've... kel: And a lot of, doug_beech: Well, kel: I think that doug_beech: it's kel: what doug_beech: one kel: stands doug_beech: that you kel: out doug_beech: point kel: is how doug_beech: out. kel: many kids became suicidal compared to the placebo group. That's what, that's what this stands out. I think that's what I think is the biggest thing doug_beech: Okay, but here's what else came out of the study that I think stands out that I haven't heard you say. 30% of the participants exhibited clinically significant suicidal ideation at baseline going into the study. Suicidal ideation decreased significantly in all treatment groups and showed the greatest improvement with the combination of CBT and fluoxetine therapy. So that's what the authors said. So this, and kel: Do doug_beech: even in the kel: you doug_beech: two kel: know doug_beech: groups kel: how doug_beech: that got kel: researchers doug_beech: the fluox, kel: can doug_beech: got kel: come doug_beech: the kel: to doug_beech: Prozac, kel: a significant result? How they can create statistical significance? Well, you're doug_beech: I'm not kel: the doug_beech: sure kel: conclusion doug_beech: what you mean. kel: is that there was a statistical difference with suicidality, right? Like improvement and statistical difference. Right. Um, doug_beech: as they kel: same doug_beech: were kel: thing doug_beech: measuring kel: with the drug trials. doug_beech: it, yes, kel: Do you know how statistical doug_beech: with its limitations, kel: difference, doug_beech: of course. kel: how easy it is to create a statistical difference? Go ahead, explain. doug_beech: I do, I do. Yes, kel: That's not a doug_beech: but kel: conclusion that doug_beech: what kel: gives doug_beech: I'm kel: us doug_beech: saying kel: any doug_beech: is is kel: real doug_beech: that kel: world doug_beech: when... You're kel: clinical relevant information. doug_beech: okay. Well, they recommended it. Hold on. There is no evidence from the TADS to suggest that fluoxetine induces mania or behavioral activation. Fluoxetine monotherapy delivered in the context of regular clinical management and careful monitoring will remain an important stopgap measure in patients in whom the earliest possible response is deemed clinically meaningful. This is the author's talking. And I'm not kel: So doug_beech: advocating kel: the data doug_beech: for this position kel: I have here is that 34 doug_beech: I'm referring... kel: adolescents treated with Prozac had a suicide event compared to only three on the placebo. doug_beech: But you have to look at the incidents of suicidal events prior kel: It doesn't doug_beech: to going kel: matter. doug_beech: into it too. kel: 34, so when you, one is provided a placebo, one is provided the drug. Now I'm not a great math guy. You might be better at math than me, but when you're looking about a sm... doug_beech: Hold on, the placebo was only the first 12 months. I'm sorry, first 12 weeks, the placebo group didn't do the whole study. You might be referring to the CBT group, which didn't have medicine and they went the whole way, but the placebo group was only for the first 12 weeks. They didn't continue the full 36 weeks. So you might be referring to the CBT group, again, the group that did not get the medicine, but they weren't getting a placebo. So, I'm sorry, I'm sorry, I'm kel: Well, doug_beech: sorry, I'm sorry, I'm sorry, kel: I'm doug_beech: I'm sorry, kel: going doug_beech: I'm sorry, kel: to doug_beech: I'm sorry, kel: post this with this episode and highlight this area of 34 adolescents compared to three. Now it's a small cohort, so it's a small number of people. You did recognize that a lot just dropped out, doug_beech: Yeah. kel: right? Um, some of the most severe cases just aren't able to be treated, right? doug_beech: Well, the most severe, well, they had to be treated. They couldn't be studied. The most severe, kel: Which is the population doug_beech: the most severe kel: that we're doug_beech: didn't kel: going to doug_beech: even kel: want to doug_beech: enter kel: work doug_beech: the kel: with? doug_beech: study. kel: That's where we care most about is... doug_beech: I agree, and that's one of the limitations kel: And doug_beech: of all kel: my statement doug_beech: this research. kel: here is that... There's no need for an adolescent to be on an SSRI with the data we have. It's real. I mean, they have such high placebo response reactions that are similar or if not outperform doug_beech: Mm-hmm. kel: the drug itself without the risks. There is really no reason to give a teenager or a young adult an SSRI, let alone a frontline treatment, that's insanity. That is absolutely insanity. And when we talk about, you know, all right, what is cognitive behavioral therapy. I don't know if it's cognitive behavioral therapy or any type of situation where somebody is going to sit down and listen to the person, take time and understand how and help them cope with the challenges that exist. Right? We say it's cognitive behavioral therapy. doug_beech: Of course, kel: What is that? doug_beech: no kel: Are doug_beech: argument kel: they going? doug_beech: there. kel: I don't even, I'm, I'm board certified in behavioral and cognitive therapy. And what people say is cognitive behavioral therapy is sometimes nothing even close to what I'm doing. But bottom line, it's the, it's, it's sitting with somebody. understanding their emotions in context, developing some emotional literacy and some coping. And that is so much safer than throwing a drug for a kid and saying what they experience is major depressive disorder with an underlying chemical abnormality and we should try them, we should place them on a drug. Now listen, you might have some debate on here around the difference between suicidality and a completed suicide. My guess is... doug_beech: What's debatable kel: they are doug_beech: about kel: two different doug_beech: that? kel: things. doug_beech: I mean, those are just two kel: But doug_beech: different kel: if doug_beech: things. kel: one intervention is going to increase suicidality, one common sense kind of response to that would, well, that's likely going to then also, you know, include a suicide event because one predates the other, right? You don't end your life unless you want to end your life. So wanting to end my life without ending my life, um, might be two separate constructs, right? But if you're going to end your life, what, what predated it? it is wanting to end my life. The problem with it, it's when we talk about an event doug_beech: Yes. kel: that's fatal, whether that's homicide or suicide, not always it's predating, not all that's suicidal ideation. Sometimes it is acuthesia. It's a delusion. Psychosis. doug_beech: Yeah, my dispute, I think, Roger, is not with the concept of an increase. It's with the number you're attaching to it. It's not kel: These aren't doug_beech: double, kel: my numbers, doug_beech: and it's not even kel: Doug. doug_beech: close to double kel: Doug, these doug_beech: the kel: aren't doug_beech: risk kel: my numbers. doug_beech: of completed suicide. No. Now, you're equating, you're conflating suicide with suicidality. Yes, they go together, but you can't, you can't apply the same number to the two. You couldn't apply the same numbers, the risk of higher cholesterol versus the risk of heart attack. They go together. but 94 million people have high cholesterol, kel: But Doug, we're doug_beech: only a few hundred kel: in doug_beech: thousand kel: a study doug_beech: will have kel: where doug_beech: a heart kel: somebody's doug_beech: attack. kel: closely monitored. That's a protection from that event. So, you know, they're being monitored, they're being monitored in a clinical, they're, yeah, they're being doug_beech: I kel: monitored doug_beech: agree. Yes, it is. kel: in a clinical doug_beech: That was part kel: trial, doug_beech: of their conclusions. kel: and then you're able to intervene so you're protecting the suicide event. But in real world settings, somebody can take this drug and they don't have those same protections. Nobody would deny that's going to increase that risk of suicide. There's too many parents that are listening to this doug_beech: And I'm not denying kel: podcast doug_beech: it either. kel: right doug_beech: I'm not kel: now. doug_beech: denying it kel: Their doug_beech: either. kel: mind is being blown with this type of discussion. It is risky. It is dangerous. doug_beech: But that, yeah, I don't know if you can hear me. I am not denying kel: Okay, then doug_beech: the kel: that's doug_beech: increased kel: enough. doug_beech: risk. kel: But then let's doug_beech: I'm kel: just doug_beech: just kel: leave doug_beech: saying kel: it at that, doug_beech: it is kel: right? doug_beech: not double. kel: There's an increased risk. And that's enough for us to recognize it as professionals. doug_beech: Yeah. All right. And there's an increased risk, which is also in the black box warning of not treating the depression, whether it's for medicine kel: of doug_beech: with kel: not, doug_beech: medicine kel: see, doug_beech: or anything kel: of not doug_beech: else. kel: treating the doug_beech: I always kel: depression. doug_beech: want to say that too. Yes. kel: That means doing, that means, that means doing doug_beech: Yes, kel: nothing. doug_beech: that's in the black box warning. No, I'm saying the black box warning, the FDA's warning includes that there are inherent risks to kel: Yeah, doug_beech: the condition kel: I think what doug_beech: itself. kel: we're talking about was what is effective treatment, right? So we're not, we're not saying that somebody becomes depressed doug_beech: Yeah. kel: and suicidal doug_beech: All right. kel: and we leave them alone. We're talking about what is the safest and more effective doug_beech: Yes. kel: and most effective kind of treatment. And certainly I don't think anyone's, yeah, no one's doug_beech: and kel: advocating doug_beech: that kel: you doug_beech: it kel: do doug_beech: is available. kel: nothing. I'm just saying you don't, we don't advocate for the intervention that's going to increase the risk. And so that's doug_beech: Does watchful waiting sometimes feel like nothing kel: They doug_beech: to kel: shouldn't. doug_beech: people or could people interpret it that way? Leaving their adolescent alone after school for hours till the parents get home, anything like that? I mean, kel: So watchful doug_beech: is that included? kel: weighting is actually taking the condition seriously, but not forcing an intervention. And since watchful weighting is going to result with a large percentage of population having natural recovery. So natural recovery is, it does, it means that the person feels really bad, but then they improve once the, whatever problem that they're facing resolves itself or they resolve it. So, um, we're talking about from the physician's perspective, intervention is a drug. So if, for the majority, so if doug_beech: for some, majority, yes. kel: the physician cannot get the teen in for therapy, seeing some form of therapist, then that clinical contact of meeting them every week or a couple weeks seems to have a therapeutic effect. And so I would say that's a doug_beech: Absolutely, kel: really important doug_beech: no kel: intervention. doug_beech: doubt. kel: So, all right, looks doug_beech: I agree. kel: like I'm going to lose my battery here for my Mac, and I might be losing you. I would have to get this plugged in somehow. So I think we're going to have to wrap this up, okay? I'm glad we had this debate on anti-depressants and danger at the end of this podcast, but I want to be able to give you kind of the last word because I ultimately think there's a lot of what we, about what we have is agreement. However, I have Kelly on the microphone. And he has some questions from our Twitter audience. So I'm gonna let him ask some questions. If I lose you on my computer, doug_beech: Oh wow. kel: I'm just gonna turn to Kelly's computer and we'll continue the conversation. Doug, first of all, you guys, it was really, really doug_beech: Bye. kel: thoughtful, meaningful discussion. So I really appreciate it. I just, there are quite a few questions. I'm not gonna ask you all of them, but doug_beech: Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. kel: a few of them. Yeah. doug_beech: May I ask, Kelly, did I assume these questions kel: Yeah, they. doug_beech: came in beforehand? Right. kel: No, doug_beech: You're not, kel: no, no, no, no, no. doug_beech: you're kel: No. doug_beech: not, we're not live. We're not broadcasting kel: I doug_beech: actually kel: think they're doug_beech: this kel: just doug_beech: month. kel: curious doug_beech: Okay. We're kel: because doug_beech: just, okay. kel: it getting doug_beech: All right. kel: us getting an act doug_beech: Okay. kel: of psychiatrists to come doug_beech: Sure. kel: on and have this debate. I think they were excited because we all want to see the, you know, both sides and both points of view. And you both did a great doug_beech: Mm-hmm. kel: job with this discussion today, but I feel like I think Roger promised, hey, you know, if you have questions, we'll do some. So if you're okay with it, I'll ask a couple. doug_beech: Oh, sure. kel: There doug_beech: Okay. kel: are a couple of doug_beech: Absolutely. kel: questions about doug_beech: I'll try to. kel: from antidepressants. So one just wants to know, have you had any consultees where you've successfully been able to deep prescribe from antidepressants and benzos and things like that? doug_beech: Oh, sure. That's absolutely. And it gets complicated. But I, again, trying to, the majority of people that I, through my career I end up seeing, have already been thoroughly treated. They often are on multiple medicines. They've had multiple medication trials. That's why I think the placebo responders, they get taken care of really early. And they often don't make it into a psychiatrist's office. But let's take the question separately. because the benzos and the antidepressants are two different categories. The benzodiazepines, I, without equivocation, I have taken more people off of benzodiazepines than I have ever put on and I try to prescribe it. Benzos only in very short-term limited situations. The example Australia or getting through a funeral. And here's five of them, you know, and I think, and they're great drugs for that, for a dental procedure, you know, not great management long term, even of anxiety problems and paradoxically, often will worsen an anxiety problem over time. And I've seen dozens of examples. The process of benzodiazepine withdrawal, there's the Ashton protocol that's out there. That's a generally good guideline, and the majority of people will do fine going at it that way. But there are some people who just really, really struggle, even with modest reductions. So you just have to go really slowly. A great resource that we have is we have, and I'm sure most metro areas have compounding pharmacies which can make micro doses of these different medications. You can take a 20 milligram capsule. or drug and then they'll make you a 19 milligram dose of it, you know, and do a gradual withdrawal. So the benzos, lots of experience doing that, a usual reduction, 10%-ish every two to three months, depending on how long a person has been on it. Some people have to do it even more gradually than that. And in the majority, doing it that way, you can be successful, but you have to take your time. some of the anticonvulsants protect, sort of put a ceiling on withdrawal symptoms in benzo deprescription. There are those, there is that minority that's out there though that really get into trouble early with low doses. I think that's the exception, but just like with antidepressants, when you have tens of millions of people being prescribed these drugs, even if a risk is low, frequency like 1%, it's still hundreds of thousands of people. The antidepressants, it's a different ball game and I think the difference here in half lives of the different drugs, I actually made a table but I don't have it here to show you because it's on my laptop. The difference in half lives among all the SSRIs and SNRIs compared with Prozac Fluoxetine. And don't quote me on all the numbers here. So remember, fluoxetine prozac was the first SSRI, came out in late 87 December, so effectively 88, 89. It was the only one for more than four years. Zoloft didn't appear until spring of 92. So those four years, prozac was the SSRI. Now half-life, that's the rate at which you clear a drug. You know, the amount of time that goes by where half of it will still be there, goes on and on. Half lives of Zoloft, Paxil, Selexa, Luvox, Lexapro are in the, at the low end, effects are especially as the lowest, it's like seven hours. And Lexapro and Selexa go up to 25, 30ish hours and I believe Paxil and Zoloft in between. I can actually, I have this tape already made, we'll send it and put it in the show notes. But Prozac and it's active, but Tablight, Prozac's half life is four to six days. It has an active metabolite with a half-life of 9 to 11 days. And the reason that's important is especially with these early side effects when you first start on SSRIs and SNRIs, effects are prestige and simbalta. A lot of the side effects and the agitating effect is because the drug level itself is going up and down rapidly, okay? And the shorter the half-life, the more that fluctuation is prominent. how it's affecting them, not only is the drug itself having an effect, but that change in the blood level adds to it. And also in the withdrawal symptoms, and I know that that's what the original question was, but I feel like this information is critical, the withdrawal symptoms when you try to reduce the dosage or come off of it, same thing, the shorter half-life drugs wreak havoc. And that's why Efex or vanilla faxin is one of the hardest because it has this short half-life, really hard to come off of. Prozac, kel: over six doug_beech: on the other kel: days, doug_beech: hand, kel: half a life, doug_beech: flat line, kel: that's the doug_beech: four kel: blood doug_beech: to kel: level doug_beech: six kel: of doug_beech: day kel: evil. doug_beech: half-life, kel: The doug_beech: the kel: cries doug_beech: blood level kel: of spirit doug_beech: is kel: gradually, doug_beech: even kel: the same doug_beech: and kel: thing, come doug_beech: rises kel: along. doug_beech: very gradually and same thing coming off of it. You could stop Prozac and a week later the level's gone down hardly at all. Now that doesn't mean people don't have withdrawal symptoms from Prozac, kel: It's still much, much, doug_beech: fluoxetine, kel: much less. doug_beech: but kel: So a common loop doug_beech: they're kel: in your doug_beech: much, kel: computer to do those doug_beech: much kel: things doug_beech: less kel: is to doug_beech: frequent. kel: switch to the first doug_beech: So a common kel: after. So doug_beech: move kel: watch, watch, doug_beech: when you're kel: watch, doug_beech: attempting kel: and tell. doug_beech: to kel: Get doug_beech: reduce kel: on the doug_beech: dosages kel: loop, watch, and you can get that. doug_beech: is kel: You can doug_beech: to kel: also connect doug_beech: switch kel: the doug_beech: to kel: device doug_beech: a different kel: here by taking a doug_beech: Prozac kel: switch from here doug_beech: first kel: to higher amount. doug_beech: from kel: Now, I'm going doug_beech: Zoloft kel: to switch doug_beech: selects kel: to the doug_beech: Alexa kel: second one. doug_beech: Pro. kel: I'm going to switch to doug_beech: Get kel: the third doug_beech: on kel: one. I'm doug_beech: the kel: going doug_beech: fluoxetine, kel: to switch to the fourth one. I'm going doug_beech: again kel: to doug_beech: I'm not kel: switch to doug_beech: offering kel: the fourth one. doug_beech: direct kel: I'm going doug_beech: advice kel: to switch to the fourth doug_beech: here, kel: one. doug_beech: but a switch, talk to your provider about could I switch to fluoxetine first and on average much less difficult to come off of kel: So doug_beech: and kel: I have doug_beech: reduce kel: to because doug_beech: it kel: we're doug_beech: gradually. kel: going to end this, but so I'm going to kind of combine the questions. A lot of people really want to know doug_beech: Thank you. kel: about doug_beech: Bye. kel: the myth of the chemical imbalance. There were quite a few questions on it. They want to know why a psychiatrist, that's just in general, never discourage patients from believing there was never a study that existed showing it. doug_beech: Well, can you give kel: Thank doug_beech: me kel: you. doug_beech: an kel: Bye. doug_beech: amount of time to respond? Because I do think this is important. I'll do a couple of minutes. First of all, disclaimer, I have never told a patient you have a chemical imbalance ever. I've been asked that hundreds, maybe thousands of times. And I have some anecdotes. So I don't think it's a helpful way to think about human experience and in terms of an imbalance. Okay, so I would never encourage someone to think of their problem as an imbalance of chemicals. Okay, I would also though I would not tell a patient you don't have a chemical imbalance because I don't for the same reasons I don't think it's a helpful way to approach this. It's complicated. Now this is back to our need for something companies love it, they love that idea of if there's a chemical problem we've got a chemical solution. I think it's shorthand for a lot of doctors, it's an easier conversation to have, but it's just not a helpful way to think about it. Now there is some basis to infer that of course chemicals affect us. I mean everything we're talking about here, diet, sunlight, the medicines, hormones, these are all chemicals and our brain works through chemical signaling between It's electrical within the nerves, but it's chemistry. And the original data that brought up these observations were just based on, hey, these people are responding to this intervention, these people get depressed, these people look happier kel: What's going on? doug_beech: on kel: This doug_beech: this tuberculosis kel: is the full event doug_beech: drug. kel: I know. I just want doug_beech: What's kel: to doug_beech: going kel: make doug_beech: on there? kel: this doug_beech: This is kel: to doug_beech: before kel: be original. doug_beech: we even had identified these neurotransmitters. So the original hypotheses around the influence of chemical messengers, that data is all still there. I'm more interested in what people do with these ideas and misrepresent them than the ideas themselves. And that's where I think we get into trying. I mean, I think that's where what you're trying to do here in this podcast, you're trying to get at the nuance, but people are relying on us to talk about it sensibly. So I don't, you know, the Monkrieve paper didn't say there is no chemical imbalance. It said we didn't find, or a serotonin. kel: This doug_beech: We kel: is just doug_beech: can't kel: a business, doug_beech: nail that kel: I doug_beech: down. kel: don't think it's proper to doug_beech: It kel: say. doug_beech: didn't dismiss it, so kel: There doug_beech: I don't think kel: is doug_beech: it's kel: no doug_beech: proper to say kel: role for Sarah Connick, doug_beech: there is kel: so we doug_beech: no kel: can't do doug_beech: role kel: observation. doug_beech: for serotonin. kel: You get a Sarah Connick doug_beech: We kel: walk-in doug_beech: can, kel: agent. doug_beech: again, kel: Thank you. doug_beech: through kel: Thank you. doug_beech: observation, kel: Thank you. Thank you. doug_beech: if you give a serotonin-blocking agent, like reserpene, again, and this is early 50s, you see a change. If you give a beta blocker propranolol for high blood pressure, it blocks adrenaline and norepinephrine, people, a subset, get depressed. I kel: Doug, doug_beech: mean, kel: can I just correct you real doug_beech: it's more kel: quickly? doug_beech: how we talk kel: I think doug_beech: about it. kel: when it comes to science, what Dr. Monkreef is saying is we have no evidence that there's an abnormality in serotonin that creates depression. There are people who are depressed, who have normal ranges of serotonin, who when you try to attempt to test it in the blood, have more serotonin than somebody is not depressed. It's, there's no causal factor is what they're saying, doug_beech: Cause always the key. kel: but that's doug_beech: I agree. kel: not how it's been communicated to the Western doug_beech: Yes. .. kel: public. And so doug_beech: Eps, kel: obviously doug_beech: I agree, kel: all this is complicated. doug_beech: I agree. kel: I think you've done a really good job today of discussing that nuance and that complication. I mean, the difference between serotonin being measured somehow if we can measure it accurately, when if I got up, run in the morning sunlight versus after three days of sitting in my home on the couch watching Netflix eating bad food is going to be different. And so I think what you're, yeah, what you're speaking to is doug_beech: Fair enough. kel: that there is a, and I think this goes back to the, you know, the, the psycho neuro immunology research, right? Like everything kind of interacts with each other. So I mean, I can have a thought of gratitude and that has a chemical reaction. I think our field is saying that a chemical imbalance that's genetic is why you're depressed and we have to treat it like insulin for diabetes. doug_beech: I can't disagree with that. I'll go back and say the original paper, the SHILDOT paper in 65, catecholamine hypothesis had all those disclaimers. This is reductionistic. It isn't this simple. All these other factors are in play. But it's what we do with that in our need for simplicity. And I think that's a bigger problem than the kel: And doug_beech: actual kel: we should doug_beech: research, kel: alert doug_beech: as you point kel: the doug_beech: out. kel: listener to understand, you know, how that got out there into the American public. It was pharmaceutical funded. So doug_beech: Yeah. kel: they, they put psychiatrist, academic psychiatrist on the payroll, who went out into major conferences and they discussed this. They funded major news organizations. They bought spots or lines in American television and movies. infiltrated with the idea that we have found an abnormality that would lead somebody vulnerable to depression and we have drugs that will correct that abnormality. So I don't want to, you know, there's just too many Americans that are just who've been brought up in this culture and that's what they've been told and we don't want to gaslight them right now. I have a, when my daughter was in high school she sat through a class where the teacher said that if you have levels of serotonin. Now, it's not because people made that up, it's what they were told. And I can guarantee you today, we still have physicians that are suggesting the same exact. doug_beech: Yeah, no doubt. And I would not defend that. And I think Dr. Monkrieff, there were other authors, within the first couple of paragraphs of the paper, said, addressed it's a public perception problem. And I think her paper responded to that. But it is a, that kel: Go to doug_beech: belief kel: WebMD, doug_beech: is out kel: it's doug_beech: there. kel: still on there. doug_beech: It's one of many. kel: Yeah, right now you could probably Google WebMD and answer questions about why people have depression and they'll refer to it. So, yeah, I think that's it. I think that's it. I think that's it. I think that's it. I think that's it. I think that's it. I think that's it. I think that's it. I think that's it. I think that's it. I think that's it. I think that's it. I think that's it. I think that's it. I think that's it. I think that's it. I think that's it. I think that's it. I think that's it. I think that's it. I think that's it. doug_beech: Well, I feel lucky that my training director, who was later my boss, he did not own a prescription pad the first 10 years he was in practice. And I feel lucky to have been trained in that broader, more complicated view. And I hope we can spread that approach more informatively kel: So doug_beech: as you go kel: again, doug_beech: on. kel: there's so many questions for them, but I think we gotta kind of end that. I, you know, a lot of DSM questions, a lot of things that I think you can probably, they can maybe reach out to you doug_beech: Yeah. kel: and then, you know, you can kind of, but I really do appreciate being here today through my personal experiences that I told you in the beginning of this. I learned a lot and I really, both of doug_beech: Mm-hmm. kel: you, thank you for this thoughtful conversation. Yeah, Dr. Beecher might be, might be important for us to get together again in the future doug_beech: You. kel: to talk about some of the other issues we didn't get to. So, I'm going to start with a question. I'm going to start with a question. I'm going to start with a question. I'm going to start with a question. I'm going to start with a question. I'm going to start with a question. I'm going to start with a question. I'm going to start with a question. I'm going to start with a question. I'm going to start with a question. I'm going to start with a question. I'm going to start with a question. doug_beech: Yeah, let me put out a fun pitch to you when you recorded on Super Bowl Sunday. Well, I'm a lifelong Bengals fan and a Bengals Eagles Super Bowl is not, it's got decent Vegas odds for next year. Maybe make that the prompt kel: Yeah doug_beech: to talk again. I went to both AFC kel: Oh, great. doug_beech: Championship kel: I am, doug_beech: games last kel: I am an doug_beech: year kel: Eagles doug_beech: and this kel: season doug_beech: year kel: ticket holder. doug_beech: in Kansas kel: Um, doug_beech: City. Yeah. kel: don't go to as many games as I, as I used to, but we doug_beech: Thank you. Thank you. kel: are fanatical here in the greater Philadelphia region as you, as you well know. And the Cincinnati Bengals have a great young team and a great young quarterback. So. doug_beech: Well, he grew up in the area of Ohio where I did as well, and that's just been so gratifying to have sort of a homegrown Appalachian guy doing well. I sat behind his parents on the plane ride home from Kansas City just by almost accident, and I just congratulated them on raising such kel: When doug_beech: a kel: you doug_beech: fine kel: have the doug_beech: young kel: quarterback doug_beech: man. And they kel: in doug_beech: just kel: place, you know, you're doug_beech: stopped. kel: going to look at potentially a decade of opportunities to maybe get to the Super Bowl. doug_beech: Well, as long kel: True, doug_beech: as he doesn't get sacked eight kel: true. doug_beech: or nine times, kel: And, and I think both him and Jailden Hertz doug_beech: then break kel: are doug_beech: his other knee. kel: up for a substantial raise. And then that contract always influences team building. doug_beech: I would take less money and ask him to get some better linemen kel: So, doug_beech: if I'm Joe kel: Dr. Beach, you represent doug_beech: or kel: yourself doug_beech: Jaylin. kel: very well. I wish there were more psychiatrists like you out there. I think that your approach is one of safety, understanding the complexity of all those issues, and then viewing a range of options as a medical professional being able to intervene. I think you do, you know, you really do care about the clients that you are. that you work with. And that certainly comes through with how you discuss these complex issues today. Unfortunately, you know, certainly in my region, we do not have as many psychiatrists that function in the way that you function. And we're in a hospital based system of quick 10 minute checks and multiple drugs for developing brains and vulnerable people. And it takes conversations like this where we can move in a direction that we can help most people who are suffering. I think we step back and we say there's probably a lot more that's, we have an agreement than when what we oppose. And I'm sure a physician like yourself is going to be open to all the new innovative research that's going to be coming out, certainly around metabolic illness and different nutritional interventions that exist and trying to improve the overall well-being and lifestyle of patients who are struggling with their mental health. We can't separate the two. separate our physical well-being from our mental well-being doug_beech: Absolutely. kel: as well as, and, you know, my belief is that psychiatrists are critically important in the healthcare system, but not in the way that they're currently being provided. I wish, I wish that doug_beech: for the most part. kel: psychiatrists would take time with their patients and even rule out other conditions. Depression should be a rule out, bipolar disorder should be a rule out and be more aware of all other conditions that could influence why someone would be presenting that way, including drug reactions. And that's my hope for the future. doug_beech: I read Dr. Palmer's book. Yeah, I read it and I've listened to his podcast. Yeah, a lot of people are very interested. I've had some patients do very well with nutritional interventions. And again, we've got to find out what works for an individual. And not all money psychiatrists do want to have the broad view. I get to supervise residents at OSU. Come every week for an hour, two of them. And I've been doing that for 15 years. And we're just talking about therapy. We're not talking, their patients are being seen and we just do the therapy part. So, but you're right, they get into a system though that functions a certain way and reinforces a certain kind of practice and restricts kel: agreed. doug_beech: others. kel: Thank you for the radically genuine conversation, Dr. Beach. Yeah, thank you so much. I'm going to doug_beech: Thank