Latest / Radically Genuine / 191. Heated Debate with Columbia University Professor of Psychiatry

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191. Heated Debate with Columbia University Professor of Psychiatry · Radically Genuine

• 00:00:03:15 - 00:00:25:13 ROGER MCFILLIN Welcome to the radically genuine podcast. I'm Doctor Roger McFillin. It's about a hundred degrees today in Bethlehem, Pennsylvania. So in our new studio, the air conditioning isn't exactly working as we would hope. So it's a little bit warm in here, but I'm so grateful for my guest today, Doctor Ragy Girgis. Welcome to the Radically Genuine Podcast. 00:00:25:15 - 00:00:33:20 RAGY GIRGIS Thanks for having me, Roger, and thanks for thanks for that. The directions, the hospitality, and also thanks to your team. 00:00:33:22 - 00:00:50:19 ROGER MCFILLIN Yeah, I mean, I'm really fascinated by your work. It's very difficult for a psychiatrist to come here and have a long form conversation with me. I've been asking for for years. So like, so incredibly grateful. Can we just start with a little bit about who you are personally and professionally in your journey into psychiatry? 00:00:50:21 - 00:01:11:08 RAGY GIRGIS Sure. Thank you. I went to medical school of the University of Pittsburgh. I really went into medical school not knowing anything about psychiatry. I had a great experience with the research during the summer after my first year of medical school, and then I had a great time on my psychiatry clerkship in the third year of medical school. After that, it was very clear to me that I needed to go into psychiatry. 00:01:11:10 - 00:01:23:14 RAGY GIRGIS I matriculated at the the adult residency program at Columbia. I completed the four year residency there, then a three year clinical fellowship. And I've been there ever since. 00:01:23:16 - 00:01:35:12 ROGER MCFILLIN So, when you first entered into medical school, did you have any intention of that time to maybe entering into another specialty area prior to psychiatry, really grasping your attention? 00:01:35:14 - 00:01:47:23 RAGY GIRGIS Right. Well, that's a good question. You know, I think I probably told people at the time that I was thinking of orthopedic surgery just because that's what I was kind of supposed to tell people. You know, I worked out at the gym. I was kind of a bro to some degree, even though that might not seem that way. 00:01:48:00 - 00:01:51:14 RAGY GIRGIS So I kind of told people I was probably interested in orthopedics, but I really wasn't. 00:01:51:16 - 00:01:57:02 ROGER MCFILLIN So in addition to your academic work at Columbia, do you actively see patients at all? 00:01:57:04 - 00:02:17:18 RAGY GIRGIS I used to, so what happens with, and also because I do clinical research. So my research involves patients, but in terms of having a pure kind of clinical component of my career, what happens and what I was told when I began my research career is that after residency, if you do end up doing research, I would I would have a private practice, which is typical for people at Columbia who do research for about ten years. 00:02:17:18 - 00:02:32:13 RAGY GIRGIS And then at that point, it would become too difficult for me to balance clinical and research duties. And that's exactly what happened after exactly ten years of having my clinical practice, like a private practice on the Upper West Side of Manhattan, I had to shut it down to focus completely on research. 00:02:32:15 - 00:02:50:01 ROGER MCFILLIN Okay, let's dive into that research. From what I understand, you've built something truly unique. The Columbia mass murder database with. I think there's over 2200 cases spanning more than a century. Is that accurate? That's right. Okay, let's start there. Well, your interest in this area and how you've built this. 00:02:50:04 - 00:03:10:03 RAGY GIRGIS Sure. I am a clinical schizophrenia researcher. I primarily conduct clinical trials, brain imaging studies that try to understand schizophrenia, ultimately with the goal of developing new medications to treat and, you know, potentially cure, but ultimately treat schizophrenia. Now, you know, we're all exposed to mass shootings and what the media says about mass shootings and potential relationship with mental illness. 00:03:10:03 - 00:03:32:04 RAGY GIRGIS And primarily psychotic disorders in mass shootings. Around 2019, a colleague of mine, Doctor Gary Preciado, came to me and said, you know, Roger, we need to put together a database that will allow us to as definitively as possible, answer the question of whether and how mental illness and again, primarily psychotic disorders, are related to mass shootings. And so that's what we did. 00:03:32:06 - 00:03:34:11 ROGER MCFILLIN Okay. Well, tell me about your findings. 00:03:34:13 - 00:03:59:13 RAGY GIRGIS Sure. So we put together this database with, like you said, 2200, cases of mass murder. We initially had 1600, and it's grown since then. We kind of put it together in 2019, 2020, and I want to even take a step back because the goal was ultimately to examine the the relationship between psychotic disorders and mass shootings. But to do that, we understood that we needed to understand more than just mass shootings. 00:03:59:13 - 00:04:27:00 RAGY GIRGIS So, for example, how research is done. And I imagine a lot of your listeners understand this, but how research is done is that we understand that no research can be perfect. We'll never have all the data that we need. So we understood we needed to control for these are referred to as biases or confounds. And so what we decided to do, and I think this is the most important decision we made when we decided how to construct the database, is that we decided to include both mass shootings, meaning mass murder involving at least one and more firearms and other types of mass murder. 00:04:27:00 - 00:04:47:11 RAGY GIRGIS So we would have at least one other comparison group that limits bias, limits, confounding, and those sorts of things. So we decided to construct a database involving all types of mass murder since 1900. So we could also examine events over time. We also included mass murder all over the world since 1900. So we can examine effects over time. 00:04:47:11 - 00:05:26:01 RAGY GIRGIS We can examine effects that are different between countries. We can examine differences between different when different types of methods are used. So that's how we started. And then we basically just looked online and found as many court records, police documents and other reliable media sources from which we could obtain data on any type of mass murder. And it's very reassuring to be clear that we define mass murder as three or more victim fatalities, not just injuries, certainly not just injuries, and also not including the perpetrator at any one time at any one place. 00:05:26:01 - 00:05:37:04 ROGER MCFILLIN So are you just looking at if like a psychotic condition was associated with that murder, or are you expanding, what is your definition of what is mental illness? 00:05:37:05 - 00:06:00:20 RAGY GIRGIS Sure. We looked at how different types of of every type of mental illness we could find, including substance use conditions. We also looked at neurological conditions. And then beyond that, we looked at see whether the mental illness, if it was if if the perpetrator had a mental illness, was actually motivated by their mental illness because, for example, in many cases, you would assume that the excuse me, the mental illness would be incidental. 00:06:00:22 - 00:06:24:03 RAGY GIRGIS So you probably imagine a lot of people on this podcast who listen to this podcast know that the the prevalence of mental illness in America, the lifetime prevalence at this point is around 40 to 45% if we include anxiety disorders and other sorts of conditions. So we examined not only the prevalence of mental illness, all sorts of mental illness, depression, psychotic disorders, etc., as well as in how many cases of mental illness. 00:06:24:03 - 00:07:07:10 RAGY GIRGIS Again, we're really talking about psychotic disorders was the motivating factor. In the perpetrators mass murder and killing of three or more people. So that's what we looked at. We had about 1617 hundred cases originally, like that's the number that we published in our original paper. And now we have 2200. What we found was that the percentage of people with, with a mental illness or specifically a psychotic disorder among people who perpetrated mass shooting was 8% that number among people who committed mass murder using another method, like any method besides a firearm, for example, knives, hammers, any sort of blunt object was 18%. 00:07:07:10 - 00:07:30:05 RAGY GIRGIS That difference was significant. The reason why examining differences between groups is important is, again, because there's a lot of bias and confounding in these numbers. For example, we can't be sure we have all of the information available about these people. We can't be sure that there are other reasons that might lead to an association between psychotic disorders and mass murder, or psychotic disorders, and something else, or not lead to this association. 00:07:30:07 - 00:07:51:21 RAGY GIRGIS So we had to compare groups that limits bias and confounding. And the groups needs to be as similar as possible. So 18% in the mass murder group, when a firearm is not used, 8% when a firearm was used. Those are also called mass shootings. The difference was significant. That speaks to specificity. Specificity is one of the nine. 00:07:51:24 - 00:08:13:08 RAGY GIRGIS Bradford Hill or people also know them as the Hill criteria of causation published I think by Bradford Hill in around I want to say 1968 or something like that. So to understand causation so to understand whether psychosis or mental illness actually causes mass shootings or there's any causative link between two variables, one needs to know more than just whether there's a correlation. 00:08:13:08 - 00:08:41:23 RAGY GIRGIS People know this as we understand this or have heard this as something along the lines of causation. Correlation does not equal causation. That's true. That comes from the Bradford Hill criteria. Correlation or association is one of the nine criteria. The other criteria. And I'm not going to remember all of them are things like specificity. So understanding that the relationship is specific to for example, psychosis in mass shootings rather than also psychosis and mass murder with other methods. 00:08:41:23 - 00:09:05:10 RAGY GIRGIS And again, in this point, in this, in this, in this, in this situation, we found that there isn't actually a relationship between psychosis and mass shootings, whereas there is a psychosis and other types of mass murder. Other criteria for causation include the strength of the relationship, whether there's like a dose response reversibility experiment, meaning whether you could produce this like in a lab, that's obviously not possible. 00:09:05:10 - 00:09:14:00 RAGY GIRGIS Some sorts of associations, there's coherence, plausible mechanism, all these sorts of criteria. So specificity was the one that we focused on. 00:09:14:02 - 00:09:47:06 ROGER MCFILLIN Okay. So you mentioned earlier about the large percentage of people that have been diagnosed with quote unquote, mental illness in the United States. I think you just mentioned over 40%. That seems quite high. Those who've been on my podcast before, we've addressed this subject, isn't that related? More to the expanded diagnostic, lowering the threshold and going from what amounts to 106, you know, mental illness diagnosis in the DSM from 1952 to, like, more than tripling it to today. 00:09:47:08 - 00:09:52:18 ROGER MCFILLIN So is mental illness actually a valid scientific construct that one can measure? 00:09:52:20 - 00:10:12:01 RAGY GIRGIS Yeah, definitely. You're right, there is a reason why there's so much more mental illness now than there was a 30 or 40 years ago. It might be less the number of conditions in the DSM and more things like earlier identification, less stigma, those those sorts of things, in a somewhat expanded definition. 00:10:12:03 - 00:10:32:05 ROGER MCFILLIN Well, they've lowered the threshold to obtain a diagnosis. I mean, let's, let's look at, major depressive disorder, right. So what's the difference between someone who meets those criteria in, let's say, three weeks versus, ten days? I mean, is there anything medically different from the two people? 00:10:32:07 - 00:10:54:24 RAGY GIRGIS Well, there are, well, I guess we'd have to go back to how these diagnoses are, are kind of understood and how they come to be. So basically the your, your listeners probably already already know this, but the DSM was developed based on or has been developed based on a lot of people getting together, reading the studies, consensus over. 00:10:55:01 - 00:10:58:17 ROGER MCFILLIN You know, clear, objective, objective measures and assessments. 00:10:58:17 - 00:11:22:12 RAGY GIRGIS Right. And yes, and then those the criteria that they develop are then subject to field trials. So they test the validity, reliability and other statistical parameters of these sorts of condition and that conditions. And that's that then is that then leads to kind of diagnoses that people feel comfortable with. And then and then makes sense. So it's not necessarily that they. 00:11:22:14 - 00:11:51:02 ROGER MCFILLIN Can I argue against that for a second. The fact that they're valid constructs has never been proven. In fact, there's dying diagnostic overlap in all of the conditions, like so many of them. So when you look at the DSM, it's a very clear that it's more of a categorical representation for communication purposes. It's it's I think it's expanded way beyond they're trying to identify it as discrete, identifiable medical conditions, but it doesn't have the science to necessarily support that. 00:11:51:02 - 00:12:11:21 ROGER MCFILLIN That's why you see so many people being provided so many diagnoses. Someone comes into my center, for example. It's very rare for me to see somebody who hasn't been in the medical system that doesn't have some label because that's required for insurance reimbursement, right? So there's a system here that works together. So someone comes in and they're just complaining about general symptoms. 00:12:11:21 - 00:12:45:10 ROGER MCFILLIN Maybe it's like inattention, difficulty focusing, lower mood, low motivation. Boom. All of a sudden they've got a mood disorder and ADHD. Right. Right on there. Just a categorization of symptoms that's different than saying we have this very clear, identifiable, discrete medical illness that, certainly can be reproduced over time. So that's like the challenges of, I think, saying that mental illness, the mental illness in itself doesn't lead to this or does lead to this because it's up in the air about what mental illness actually is. 00:12:45:12 - 00:13:14:00 RAGY GIRGIS I hear what you're saying, but there there are two points we need to bring up. First. I'll bring I'll, I'll address the second point first. The question of whether we can even say anything about a relationship or no relationship between mental illness and mass shootings in this case. First we can because. So if if that were the case, if the criteria for mental illness were were very weak, or if mental illness is really not a reliable construct, using a comparison group would account for that by. 00:13:14:00 - 00:13:19:17 RAGY GIRGIS That's the point of using a comparison, because that that limitation or that that's referred to a, that's one type of bias. 00:13:19:17 - 00:13:30:23 ROGER MCFILLIN All right. So what's the difference. So so if you're going to if you're going to label one of the groups as having mental illness, what criteria are they meeting and how are you gathering that information. 00:13:31:00 - 00:13:36:20 RAGY GIRGIS Right. We gather from police records, court records, media reports, those sorts of things. 00:13:36:24 - 00:13:39:10 ROGER MCFILLIN Is that valid? Is that reliable? 00:13:39:12 - 00:13:59:17 RAGY GIRGIS So you're right. That might the definitely and that just one of the limitations of here is that is not complete. Of course that's going to be less than 100% reliable valid and reliable. However, again, that is then the point of using the comparison group because that same bias like the same problems with validity, the same problems with reliability apply to the comparison group. 00:13:59:19 - 00:14:11:09 RAGY GIRGIS So that's why we use groups, because then that bias cancels out. Not perfectly, not completely. There's always bias. And this sort of bias and confounding and all the work that we do. But having the comparison group limits that. So so for example. 00:14:11:09 - 00:14:37:04 ROGER MCFILLIN I would argue that's not necessarily bias. There's not enough evidence to support a designation. So if you don't if you don't have clear discrete evidence, it's very hard to provide that person with a diagnosis. So for example, let's say the media reports that doctor Roger McFarland has, let's say, a potential neurological condition. Okay. But there's no scientific investigation into that. 00:14:37:06 - 00:14:45:12 ROGER MCFILLIN There's no hard objective data. Then how can you assume that is a valid representation of that diagnosis? 00:14:45:14 - 00:14:57:21 RAGY GIRGIS Sure. Well, that that is a limitation of that sort of method of determining someone's diagnosis. But again, that limitation, you know, the technical term is bias also applies to the comparison group. 00:14:57:21 - 00:15:04:21 ROGER MCFILLIN So it but I don't think it's bias. Bias would be having a preconceived notion about something. Right. 00:15:04:23 - 00:15:06:21 RAGY GIRGIS That's a that might be a personal bias. 00:15:06:21 - 00:15:19:05 ROGER MCFILLIN This is our other side. But this is about data gathering. So does it. Does it meet the scientific method. Is it can you scientifically scrutinize it when you don't have the objective data. 00:15:19:07 - 00:15:36:13 RAGY GIRGIS With that that yeah. No, I this might be a semantic issue bias. There's personal bias. I understand when most people hear the word bias, they think that, you know, this is my opinion or my kind of impression of things or my ideology or something like that. That is one type of bias that's like an investigator type of bias. 00:15:36:15 - 00:16:11:04 RAGY GIRGIS But any sort of noise that enters into a system can be considered bias or confounding. Confounding if it is, fundamentally, fundamentally related to the variables of interest, and is not introduced by the investigator or by the investigation. And then bias if it's in do if it's introduced by the investigator. So like my own personal bias, I don't think anyone to say because I think everyone has psychosis or a product of the investigation, such as limited means of collecting data and not collecting a full sample, etc., because we can't say all research has bias. 00:16:11:04 - 00:16:13:23 RAGY GIRGIS That's why we use comparison groups. 00:16:14:00 - 00:16:30:14 ROGER MCFILLIN But I mean, it's why we try to use like randomized controlled clinical trials, comparison to placebos. And so I mean that's a way to limit those, those variables and try to make it, you know, as as hard science as possible when we're trying to observe something. But if we're studying. 00:16:30:14 - 00:16:31:11 RAGY GIRGIS The best way. Exactly. 00:16:31:12 - 00:16:44:15 ROGER MCFILLIN That's if we're starting from the beginning. We have no way to confirm if somebody is mentally ill or not. How do you come to how would you come to a conclusion that say, mental illness doesn't influence violence, for example? 00:16:44:21 - 00:17:10:07 RAGY GIRGIS Right. Well, these are two separate points. I'll get to the validity of psychiatric conditions that that separate, but say, say psychiatric conditions have 10% validity that that's equivalent between the groups. So whether so we identified for example again, so if the lifetime prevalence of psychiatric conditions is 40%, regardless of the validity of the psychiatric conditions or the diagnosed, the ability to diagnose the psychiatric disorders. 00:17:10:12 - 00:17:30:11 RAGY GIRGIS And we identify 45 using the same criteria. There's a difference of 5%. And so we can say which is exactly what we found, that about 5% of mass shootings is related to, is related to mental illness, in particular psychosis. And that's exactly what we found. Now that that does speak directly to the validity of the psychiatric conditions. 00:17:30:11 - 00:17:51:18 RAGY GIRGIS And then if we speak to the validity of the psychiatric conditions themselves, there are a number of ways to confirm the validity when they use the gold standard. And the gold standard was expert, basically not just opinion, but expert, expert diagnoses. Essentially. I'm never going back to the DSM, so they compared their criteria with expert diagnoses. And at some point, I mean, every gold standard is not going to be perfect. 00:17:51:18 - 00:17:53:21 RAGY GIRGIS But but that that's what they use. 00:17:53:22 - 00:18:03:07 ROGER MCFILLIN Is that like, you're going back in time and you're trying to like determine a diagnosis by reading what, like other people's accounts of it. 00:18:03:09 - 00:18:36:03 RAGY GIRGIS Now, with regards to the DSM field trials, they did this in a, in a very in a very rigorous way. Like they had the criteria, they had the they had the mental health practitioners, psychiatrists, psychologists and other people who, you know, had a lot of experience with certain people and they would have them then they would have people administer the DSM criteria or a or ask about or obtain the DSM criteria, and then compare that to the, the conditions or the diagnoses, obtained by or or or the determined by the experts. 00:18:36:03 - 00:18:37:10 RAGY GIRGIS And that's how they would come to. 00:18:37:11 - 00:18:43:17 ROGER MCFILLIN So you're saying that, that those persons never interviewed that particular person directly. So the people if they did, they did. 00:18:43:17 - 00:18:44:24 RAGY GIRGIS So of course, by definition. 00:18:45:04 - 00:18:55:23 ROGER MCFILLIN Okay. So everyone that you identify as having mental illness in your comparison groups was that person was interviewed by a psychiatrist and then was provided the diagnosis. 00:18:56:03 - 00:19:04:21 RAGY GIRGIS So, so right now I'm just talking about the DSM field trials. Like right now I'm just focusing on the validity of psychiatric diagnoses themselves and kind of how well, that. 00:19:04:21 - 00:19:14:18 ROGER MCFILLIN Doesn't make it that doesn't make it, valid. That just makes a, a doctor makes a subjective opinion based on established criteria that doesn't necessarily make it valid. 00:19:14:20 - 00:19:22:12 RAGY GIRGIS You know, they what they would do is so that the DSM teams would decide on their criteria based on all the studies. 00:19:22:12 - 00:19:50:18 ROGER MCFILLIN And I think I'm aware of that. I think what we will I think my listeners are been well-educated on this. We've had experts come on and and talked about the DSM at length. I guess our question is, is when there's a database of mass shooters and there's conclusions that are being drawn that a mental illness, a category, does not equate to any increase in violence to the general population, which I think essentially is what you're saying. 00:19:50:18 - 00:19:50:24 ROGER MCFILLIN Right? 00:19:50:24 - 00:19:53:10 RAGY GIRGIS There's no no, that's not what we're saying. 00:19:53:10 - 00:19:59:10 ROGER MCFILLIN Okay. Can you your conclusion on mental illness and violence is what compared to your comparison groups. 00:19:59:12 - 00:20:24:04 RAGY GIRGIS So the conclusion was that 5% of mass shootings is directly caused by psychosis. And that is an overrepresentation because, as you know, psychosis, the prevalence of psychosis in the background population is about 1 to 2%, depending on, you know, what, what criteria is, but it's certainly not 5%. Okay. So people with psychotic illnesses are overrepresented among mass shooters, there's no doubt about that. 00:20:24:06 - 00:20:41:17 RAGY GIRGIS But there's no doubt about that. But that's 5%. So the that 95% of mass shootings are not related to mental illness. They're not directly caused by mental illness. Now, mass murder when firearms or firearms are not used is much more so, a much greater degree caused by. 00:20:41:21 - 00:21:04:23 ROGER MCFILLIN All right. So I'm a little bit confused because you're you're using the same word to describe psychosis. Psychosis is mental illness. But then I asked you, you know, how do we define mental illness. You said it's broad 40% of the public. So are you just focused on psychotic conditions or did your research open itself up to anything that you could designate as mental illness? 00:21:04:23 - 00:21:06:24 RAGY GIRGIS All of them. Yeah. Okay. The major ones. 00:21:07:05 - 00:21:29:16 ROGER MCFILLIN All right. So in listening to you on other news shows or other podcasts, it appeared that what you were trying to present was that we don't have really good evidence that suggests that somebody who is mentally ill is more likely to engage in violence compared to, a non, clinical control group. Is that fair? 00:21:29:16 - 00:21:48:11 RAGY GIRGIS Yeah. That's not true. No, definitely. People with people with major mental illnesses are at higher risk for violence. I mean, there's no doubt about that. And by major mental illness, we're talking about schizophrenia. We're talking about by affective disorders, bipolar disorder, major depressive disorder and of course substance use disorders that that separate I mean, obviously substance use disorders, increased risk of violence. 00:21:48:13 - 00:22:10:00 RAGY GIRGIS We know there's a slight increase in violence among people with major mental illness, not anxiety disorders, that's for sure, and not other sorts of conditions. We're talking about affective disorders and psychosis. There's no doubt about that. Now. Only one condition, again, not including substance use disorders, increases the risk of murder in general. And that is schizophrenia to a very small degree. 00:22:10:00 - 00:22:36:07 RAGY GIRGIS But it is significant. And that is only among very early episode people who are unmedicated that's been shown, that's been replicated, there's no doubt about that. So that, that, basically replicates or is consistent with our data on mass murder, in which we find that the only condition associated with any sort of mass murder, mass shooting is psych is psychotic disorders, to a small degree, 5%. 00:22:36:13 - 00:22:54:20 RAGY GIRGIS When you compare that to the 1 to 2%, again, of psychosis among the general population, it's an overrepresentation. But that means that 95% of mass shootings in this case are not related to any mental illness, in this case, psychotic disorders. Now, again, if we're talking about other types of mass murder, the number jumps a lot again to it's about 18 to 20%. 00:22:54:20 - 00:23:00:10 RAGY GIRGIS So 18 to 20% of other types of mass murder are directly caused by psychotic illness. 00:23:00:12 - 00:23:03:19 ROGER MCFILLIN Okay. And are you coming to that conclusion from your database? 00:23:04:00 - 00:23:04:14 RAGY GIRGIS Yes. 00:23:04:14 - 00:23:09:24 ROGER MCFILLIN Okay. But there was no interview of those shooters. 00:23:10:01 - 00:23:10:13 RAGY GIRGIS That's right. 00:23:10:17 - 00:23:15:17 ROGER MCFILLIN So how are we able to provide a diagnosis when there's no medical evaluation? 00:23:15:21 - 00:23:33:24 RAGY GIRGIS Right. Well, that's the importance of the comparison group saying. So you have descriptive data. We'd like the 5% the 20% of whatever percent. Those are what we refer to as descriptive data, which are always going to be limited when you use a sample rather than a population, which is almost never available in any type of research. And that's why we use both. 00:23:33:24 - 00:23:57:13 RAGY GIRGIS We use the descriptive data, the 5% to 10%, like the prevalence data. That's what we refer to as descriptive data. But we also use the inferential and comparative statistics. That's when you compare groups. That's when you that's how you examine criteria like specificity, temporality. This experiment in some cases, in this case we the experiment would be the clinical trial, like you said, which can't be done in this case. 00:23:57:15 - 00:24:34:23 RAGY GIRGIS So that's why I mentioned the comparative data. So when you look at the comparative data, you see that again, thinking about causation. One of the criteria for causation that is which is specificity. There is no specific relationship between psychosis and mass shootings. It seems like that actually prefers other types of mass murder. When you look temporally, you find that, in fact, while the prevalence per capita of mass shootings and all types of mass murder is increasing over time, since 1900, the prevalence of psychosis being a cause for mass shootings and other types of mass murder over time is decreasing. 00:24:35:00 - 00:24:55:18 RAGY GIRGIS So yes, that the exact numbers the 5% to 25% whatever are probably a good estimation, but they can't be 100% accurate. That's that's impossible. That that never happens. And research would be impossible to have that in any type of research. But it's helpful. But that's why we also use the comparative comparison data. So you think about all that and you think, okay, it seems like there's less of a specific relationship. 00:24:55:20 - 00:25:14:00 RAGY GIRGIS And, you know, and of course there are other data sets suggest that. And for example, then we have the data that we examined on, I mean, the other day. So we also examined our data on female mass murder. So we looked at FEMA mass murders in particular because we wanted to, you know, tease apart this, tease apart these relationships. 00:25:14:05 - 00:25:46:18 RAGY GIRGIS So what we knew going into it was that, the effect of mental illness, especially psychosis and affective disorders on women in regards to perpetrating violence is much, is much greater than it is among men. The reason for that is because young men, like our 18 to 2025, are already very impulsive and tend to be more violent. Their base rate of violence is much higher, whereas the base rate of young women base rate of violence among young young women tends to be much lower. 00:25:46:20 - 00:26:14:08 RAGY GIRGIS So when psychosis or mental illness is involved, the relative change is is much higher. And women, when they perpetrate mass murder, almost never use firearms, they almost always use some other methods. So all these data together again kind of coalesce to the relationship between mass shootings and fire and psychosis rather is very small. People with psychosis are probably overrepresented to a small degree. 00:26:14:10 - 00:26:19:06 RAGY GIRGIS But again, the relationship was small. Again for someone other types of mass murder. Then we're talking about more of a relationship. 00:26:19:08 - 00:26:55:20 ROGER MCFILLIN Okay, I'm going to move on from the point that I was trying to make, and I think it was simply this is when there's controversy around the validity of a diagnosis to begin with, and then the manner in which that diagnosis is provided as a, as a variable that's being investigated, that if there's real methodological concerns with being able to draw any conclusions, because it's difficult to ascertain whether that person you legitimately even has some symptoms, because you have no way of being able to reference that other than case reports from somebody else, which is highly biased. 00:26:55:20 - 00:27:02:22 ROGER MCFILLIN Right? We're talking about I think it's overwhelmingly news media and reports from law enforcement. Correct. 00:27:02:24 - 00:27:07:21 RAGY GIRGIS It's it's exclusively media, law enforcement and and court records exclusively, of course. 00:27:07:23 - 00:27:12:24 ROGER MCFILLIN Okay. Yeah. So there's challenges, you know, with methodology to be able to come to those conclusions at all. 00:27:13:05 - 00:27:20:17 RAGY GIRGIS But that's that's a problem in all right. No research has 100% of it has 100% accurate valid. There's no such thing. 00:27:20:17 - 00:27:31:12 ROGER MCFILLIN Well, that's what science is a search for truth. But when you when your scientific experiment is set up with so many flaws, it's even less likely that you'll be able to obtain any, you know, legitimate data. 00:27:31:14 - 00:27:49:10 RAGY GIRGIS We. Yeah, but we're, you know, again, we deal with this by again, using using comparison groups that that deals with bias and confounding. We deal with this by examining multiple variants over time. So again we look at things like we look at the data in different ways temporality and specificity. 00:27:49:12 - 00:27:49:22 ROGER MCFILLIN All sorts. 00:27:49:22 - 00:27:50:04 RAGY GIRGIS Of things. 00:27:50:07 - 00:28:09:08 ROGER MCFILLIN And again doc, I know you you don't have to go through that again. But it always starts with a foundation is you have to have an established construct. Right? You have to have that's got to be observable. That has to be measurable. And that data has to be collected in a way that, you know, allows for us to try to confirm that to the best that we can. 00:28:09:08 - 00:28:43:22 ROGER MCFILLIN Right? So if we're going to, like, I don't know, measure the presence of a virus. Right. We need to be able to observe that virus. We have to be able to measure that virus. And, then we'd have to be able to compare it to someone who doesn't have a virus, for example, that already is not occurring when you're slapping on a diagnosis and then broadly saying it's mental illness because you can choose anything to be mental illness, then when 40% of the American public can be identified as having a mental illness at any time, that broad category allows an umbrella term for you to say anything with subjectivity is a mental illness, and then 00:28:43:22 - 00:28:56:14 ROGER MCFILLIN look at a comparison group and say, well, I'm going to choose not to provide a diagnosis there, even though you may not have enough evidence to be able to do that. That's not fair. 00:28:56:16 - 00:29:15:20 RAGY GIRGIS Well, I'm going to, it's I mean, I hear what you're saying, I will address this point. So, so I just want to make sure we don't conflate the two issues. One is the limitations of of the research that you're talking about, the validity of psychiatric conditions. I want to just that that is the second point, though. We've discussed the validity of the research itself, the limitations, bias and all sorts of things. 00:29:15:21 - 00:29:37:07 RAGY GIRGIS I won't mention that again. So yes, now definitely let's get to validity of psychiatric diagnosis. We kind of mentioned the DSM that they compared the gold standard with the criteria. This was the point of the field trials. And they determined things like sensitivity specificity and they get a positive predictive value that they would determine these statistical parameters. And usually they're in the 80% range, which is considered acceptable. 00:29:37:07 - 00:29:42:13 ROGER MCFILLIN You believe psychiatric diagnoses are scientifically valid constructs. 00:29:42:15 - 00:30:01:12 RAGY GIRGIS Definitely say that. And this is the point I want to get to. I understand we need to discuss this. This is the point I want to get to. So that was that's just the DSM. So generally, a diagnostic measure is considered relatively valid or clinically useful when it gets to about 80% in terms of sensitivity, specificity. 00:30:01:17 - 00:30:07:07 ROGER MCFILLIN So that's I yeah, I, I argue against that that's ever been achieved with a psychiatric diagnosis. 00:30:07:09 - 00:30:29:18 RAGY GIRGIS Well that's I hear and that's what we're going to discuss for sure I hear you definitely. No, I, I and I appreciate the I appreciate the back and forth and that we get to discuss these important issues. But but that's just just in general, 80% is about kind of the that the criterion or line we use in all of medicine to determine when a diagnostic test in particular is considered, you know, okay. 00:30:29:21 - 00:30:55:09 ROGER MCFILLIN And then let me challenge you on that. So what is the diagnostic test? That allows you to observe that in bipolar two disorder. What is the what's the test? What's the you know, how is that evaluating? How is how is bipolar two a valid construct, like so how would a physician be able to take the time to be able to observe, evaluate and identify that with accuracy? 00:30:55:15 - 00:30:55:24 ROGER MCFILLIN Sure. 00:30:55:24 - 00:30:59:18 RAGY GIRGIS Oh, well, that I'm referring to the DSM criteria. So I'm. Yeah. Now I'm just. 00:30:59:18 - 00:31:11:07 ROGER MCFILLIN Referring. So do you see how circular this gets it? I mean, it becomes circular reasoning, right? You end up saying, well, a psychiatric condition is valid. Why? Because the DSM exists. 00:31:11:09 - 00:31:16:16 RAGY GIRGIS But the DSM is based on something else. It's based on a gold standard, and that's how they identify you. 00:31:16:16 - 00:31:40:14 ROGER MCFILLIN Believe that you but you you believe the way that the DSM is constructed is gold standard science. Be honest. There's a lot of people listening. Definitely, because I think a lot of the people who actually were chair people of the DSM across very different, all of the, the different editions would clearly argue against that. Like Alan Francis, for example. 00:31:40:14 - 00:31:41:16 RAGY GIRGIS The DSM is. 00:31:41:20 - 00:32:10:15 ROGER MCFILLIN Is scientifically valid. It was never meant to be that. It was never meant to be. The identification of clear, identifiable, discrete medical conditions. It was always attempt to try to the best of their ability, and they failed horribly to try to cluster symptoms together for the purpose of research, classification and communication. And so it's not explanatory like someone has bipolar disorder. 00:32:10:15 - 00:32:28:10 ROGER MCFILLIN No one can say why they have bipolar disorder. Someone's depressed. The diagnostic criteria for major depressive disorder doesn't say why that person is depressed. It's just a label and it's poorly constructed label. Yeah. It's arbitrary right? I mean, it's this it's all it really is arbitrary. 00:32:28:12 - 00:32:29:20 RAGY GIRGIS I would disagree. 00:32:29:22 - 00:32:30:03 ROGER MCFILLIN You would. 00:32:30:03 - 00:32:53:21 RAGY GIRGIS Disagree. I believe the DSM is valid. So I mean we've test and that was that. This brings me to my next point. So in terms of statistical parameters, the DSM, you know, again the criteria, you know, especially for the major psychiatric conditions reach about those that 80, 80, 80% threshold. So but you're saying even with that these aren't valid medically valid or but maybe biologic valid or. 00:32:53:24 - 00:32:54:09 ROGER MCFILLIN Are you have. 00:32:54:09 - 00:32:54:20 RAGY GIRGIS Condition. 00:32:54:21 - 00:33:16:14 ROGER MCFILLIN Well both right. I first of all I don't I don't even believe they meet the very basic level of scientific scrutiny to say they're a valid construct because there's too much diagnostic overlap. I mean, it's very difficult for someone, even if you're going to use the diagnostic criteria. They're all experiencing multiple things amongst, a continuum. Right. 00:33:16:19 - 00:33:37:18 ROGER MCFILLIN And then you only get to a if if you're going to use observation, you're only going to use someone with observation in a very short, discrete period of time. So for example, if I unfortunately had to come to this podcast today on like two hours of, sleep two nights in a row because my kids are older, but let's say I had a crying baby and I'm sleep deprived, right? 00:33:37:20 - 00:34:05:06 ROGER MCFILLIN And I'm irritable and, I lash out at you because, you know, I don't believe some of the statements you're making. It could be very, like, could be easy for, a physician under those circumstances to draw conclusions that meet some threshold in the DSM. Increased irritability, decreased need for sleep, you know, behavioral manifestations of bipolar two. 00:34:05:06 - 00:34:33:10 ROGER MCFILLIN One might say he's hypomanic. There's no medical observation. There's no brain scan. There's no blood test, there's nothing with DNA. There's no serum levels conducted. It's just a subjective interpretation of human behavior without understanding cause. Right. So you're almost entirely going to determine the nature of that. Based on my own self-report. Right. And then which is very challenging because you're identifying somebody is like mentally ill. 00:34:33:10 - 00:34:59:11 ROGER MCFILLIN So somehow they're compromised. But then you're relying on the validity of their report to even make that such a diagnosis. So there's all types of concerns empirically. And since those diagnosis have so much weight and so much power in the medical system, in the legal system, for, for something with such great subjectivity that creates tremendous degrees of problems in the system. 00:34:59:13 - 00:35:03:03 ROGER MCFILLIN And so, are you aware of Coke's postulates? 00:35:03:05 - 00:35:04:03 RAGY GIRGIS I'm sorry, I'm not. 00:35:04:03 - 00:35:25:24 ROGER MCFILLIN Yeah. I mean, this is what's something that's really important to make some for, for an empirical threshold. Right? So Coke's postulate, very simple. Is there a specific biological abnormality? And it must be present in all cases. So if you're observing something, it must be present in all people who have that condition and then not present in people who don't. 00:35:26:01 - 00:36:07:20 ROGER MCFILLIN Right. This abnormality must be measurable and identifiable through some form of objective testing. There must be a clear causal mechanism, right, linking the abnormality to the symptoms. And it's got to be reproducible. Right. So those are for the kind of postulates if psychiatric diagnoses don't meet any of them. Right. Aren't we just saying it's our best way of trying to make sense of complex phenomenon versus saying, you know, it's this condition and there's 80% sensitivity and trying to communicate to the public that there's something legitimate and valid and scientific about it. 00:36:07:22 - 00:36:32:03 ROGER MCFILLIN And that's my major concern. And I'm going to let you speak in a second. Sure. My major concern is, are we honest with the public in the way we communicate scientific findings? Are we honest about the limitations of that? And we we clear and what we're saying? I don't know, we're doing the best we can, but it certainly doesn't meet some standard. 00:36:32:03 - 00:36:42:06 ROGER MCFILLIN And can we communicate it to the public in a way that I think meets, a bottom line threshold for informed consent and medical freedom? So I'll stop. 00:36:42:06 - 00:37:00:17 RAGY GIRGIS There. Yeah, well, there are a lot of points. I'm happy. I'm glad that you brought them all up. And I'm happy to address each one of them. So with regards to the DSM, the criteria. So there's this 80% level that's considered acceptable within medicine. Now the next point you brought up I think was about like how they're applied, whether they can be applied like within a session. 00:37:00:19 - 00:37:30:02 RAGY GIRGIS So we, psychiatrists, psychologists and, you know, all other mental health conditions do their best to, you know, examine to understand the criteria, the, you know, the nine above average depression, whatever. Over time, they don't ask about how someone's feeling after one day they, for example, for depression, make sure that the person is experiencing, you know, 5 to 9 symptoms for for at least two weeks, etc. they obtain collateral information, they observe them over time, and eventually they develop a relationship with them and they might see them for years. 00:37:30:02 - 00:37:35:01 RAGY GIRGIS And that's obviously less common. But please go ahead. 00:37:35:03 - 00:38:13:01 ROGER MCFILLIN Yeah. I mean, my first thing is you understand that that criteria is arbitrary. What makes what makes something a, a condition in two weeks is an arbitrary definition and that standards been lowered over time. Are you aware of the work of Charlotte Silverman? And she's a, she's an epidemiologist. I don't think she's currently living, but she she wrote the book The Epidemiology of Depression, I think early 1960s, where we went historically and identified, you know, the prevalence rate of depression throughout various, decades, in the early part of the 20th century. 00:38:13:03 - 00:38:39:22 ROGER MCFILLIN And so when you're talking about the identification of what was described as melancholy or depression was less than 1% in the population of the United States. And the people surveyed, the overwhelming majority of people who did experience that would achieve what's called natural recovery like. So it was a discrete period of time. They'd be able to overcome that, and it was almost always related to events in their life. 00:38:39:24 - 00:39:05:08 ROGER MCFILLIN Right. So I'm depressed because I'm struggling financially. My wife left me, I can't get work, you know, real legitimate conditions that would lead people to feel pretty bad and relatively temporary. Right. So again, there's, probably a threshold to be able to identify someone as a severe psychiatric condition that may be required, professional help back in that period of time. 00:39:05:10 - 00:39:35:03 ROGER MCFILLIN But over the years, we have expanded the definition of what is mental illness. We have slowly decreased the idea of what is normal. And now it can be widely applied very, very quickly. Now, you you absolutely spoke about what is the most ethical way to be able to provide a diagnosis, even under the current conditions of the DSM, which would be get collateral information, don't make a diagnosis haphazardly or quickly. 00:39:35:05 - 00:39:52:11 ROGER MCFILLIN Observe that person over a period of time. An empirical way. And I'm right there with you. But in clinical reality, that is not is what is happening. You said something very interesting to me when you came in here about, Bethlehem. What did you ask? 00:39:52:13 - 00:39:56:17 RAGY GIRGIS I asked, what sort of patient load you have. 00:39:56:19 - 00:39:58:11 ROGER MCFILLIN Yeah. Was it hard to find clients? Right? 00:39:58:12 - 00:40:00:13 RAGY GIRGIS Oh, yeah. Right. Yeah. 00:40:00:15 - 00:40:00:19 ROGER MCFILLIN And. 00:40:00:21 - 00:40:05:10 RAGY GIRGIS It being just to be clear to everyone, I'm from New York City. And some of you ever practice Bethlehem? Smaller than you are. 00:40:05:12 - 00:40:28:11 ROGER MCFILLIN Of course. Yeah. In comparison, I could see it, but it was maybe unaware of what's going on in our communities across the country. The overwhelming amount of people that are being placed on psychiatric drugs are doing so in primary care settings. Sure, sure. Where primary care docs are seeing these people for less than 15 minutes, and you know how they're making diagnoses of depression, including children and teenagers? 00:40:28:13 - 00:40:29:17 RAGY GIRGIS I'm not sure. 00:40:29:19 - 00:41:02:09 ROGER MCFILLIN A quick screening measure. I can't even remember the name of it. The, you're probably more aware of it. It's a Q, right? Right. Developed by Pfizer initially. Yeah, really to push more drugs. So we're getting an overwhelming amount of people on these drugs based on really quick screening measures in 15 minutes. Additionally, we're communicating which is, very strong marketing push that dates back to the early 90s when SSRI were first brought to market, about depression in a certain way. 00:41:02:09 - 00:41:26:01 ROGER MCFILLIN So we're influencing the collective consciousness. You can take this drug, you'll feel better regardless of cause. And so it's pushed a multitrillion dollar market. We have over 20% of adult females are now on this SSRI. So my point being is that when you reduce the threshold of a condition to enter into the realm of normality, what is normal for human beings to experience? 00:41:26:07 - 00:41:51:24 ROGER MCFILLIN You're going to increase the amount of people who identify as mentally ill, which goes back to my argument previously. Why it's problematic research is that when you are able to identify so many people with mental illness, and without a doubt this fuels an entire pharmaceutical industry as well as a medical apparatus that those conditions that identify those symptoms and the thresholds which have been decreased over time aren't based on science. 00:41:51:24 - 00:42:14:02 ROGER MCFILLIN Two weeks is arbitrary. There's there's no field study that says, okay, two weeks someone's severely depressed, but ten days they're not three weeks they are. You're continuously lowering it. Same with the five out of nine symptoms, like if you experienced five of these nine symptoms, regardless of cause, you know you can obtain the diagnosis. This is clearly trying to increase the number of people who identify with the diagnosis. 00:42:14:02 - 00:42:21:19 ROGER MCFILLIN And that's not scientific. That's political. That's and that's like industrial manipulation. 00:42:21:21 - 00:42:42:18 RAGY GIRGIS Right. I hear you, I so you bring up a lot of points and I want to be able to address all of them. And I certainly can address all of them. I'll suffice to say, for the sake of brevity and just to make sure I can get to everything. So the the criteria have been validated. But if we're talking about phenomenologically meaning symptoms in time, the criteria have been validated. 00:42:42:21 - 00:42:56:08 RAGY GIRGIS As we discussed this 80%, the DSM field trials. I'll leave it at that. Now that that two weeks time period, that's been pretty stable over time, I think. Now about the. 00:42:56:08 - 00:42:58:18 ROGER MCFILLIN What do you mean by that? 00:42:58:20 - 00:43:06:12 RAGY GIRGIS Like the, the, the two week criterion for major depressive disorder? I mean, that goes back many, many, many, many decades. I'm not sure that's changed much over. 00:43:06:14 - 00:43:10:22 ROGER MCFILLIN Do you understand why the threshold with the decrease, the two weeks. 00:43:10:24 - 00:43:36:09 RAGY GIRGIS Do I understand why? I mean, you told me why you think other people might want to, but I think I might be able to answer your question, though, by saying, I think maybe one point will disagree. Maybe about the most is, or maybe two is one. We have other evidence. This is kind of what I was. This is kind of how I was supporting, you know, our results with regards to the relationship or lack of relationship between mass shootings and mental illness. 00:43:36:09 - 00:43:53:08 RAGY GIRGIS Yes, that there there are other types of studies and other data that are consistent. What are they. So we have neurobiological data which support these these phenomenological or diagnostic constructs. Go ahead. And we have pharmacol data which support this. 00:43:53:10 - 00:43:55:10 ROGER MCFILLIN All right. Let's start with the neuro biological data. 00:43:55:11 - 00:44:10:02 RAGY GIRGIS Sure. And this gets to you know, like the attendees get to the coax postulates which are kind of kind of similar. So the neuro biologic data. So for example for depression for major psychiatric conditions the data are very clear. No I know we're going to disagree. 00:44:10:02 - 00:44:39:13 ROGER MCFILLIN You know, when you say things like data are very clear, that's where I feel like we'd be misleading the public. It's okay for you to say I you know, I believe this exists and you might want to cite it. Right. Because then I can include it in the show notes and then we can evaluate it, but I don't I don't think you're being completely transparent when you say the data is clear, when it's clearly controversial, very controversial. 00:44:39:18 - 00:44:48:16 ROGER MCFILLIN I'm okay with you speaking your position, but I'm very careful in this podcast by communicating things that we don't know to be true. 00:44:48:18 - 00:44:53:11 RAGY GIRGIS We would disagree about that. And that's okay. It's totally okay to disagree. 00:44:53:13 - 00:44:59:18 ROGER MCFILLIN What are the biological markers then for major depressive disorder that we use to make that diagnosis. 00:44:59:18 - 00:45:29:23 RAGY GIRGIS So well that those are two different things. So to to make a diagnosis is different then and then knowing that something is biological in nature, our understanding neurobiology for example, most medical conditions, even if they have a biological diagnostic marker, don't let me back up. We don't necessarily understand the biological cause of most medical conditions, even though in many cases we have a biological marker, say so. 00:45:29:23 - 00:45:44:11 RAGY GIRGIS For example, excuse me, blood pressure. I mean, you know, there's virtual I mean, the biologic, the diagnostic marker is different than, for example, the, you know, the biological cause, which is even totally understood. So it's just, I mean, this relationship that this is just how medicine works. I mean, we. 00:45:44:11 - 00:45:53:02 ROGER MCFILLIN Can't that's a biological. Yeah, but that's a biological marker that one can evaluate in a medical practice. Right. What's the biological marker for depression. But those. 00:45:53:02 - 00:46:14:11 RAGY GIRGIS Are different. Just to be clear. And I'm going to get to it. It's just I'm just saying that just because we don't have an adequate diagnostic marker, which actually is not because we actually do have diagnostic markers for most conditions, they just don't reach the statistical parameters sensitivity, specificity, all these sorts of things are better than phenomenology or diagnosing the DSM criteria. 00:46:14:11 - 00:46:32:10 RAGY GIRGIS That's why we don't use them. But we do have I mean, we could use any of the neuro biological markers as diagnostic markers. It's just that, again, they don't perform better than phenomenological, criteria like the DSM criteria. And then you have to consider cost and risk and those sorts of things which are very important. And again, this is common among medicine. 00:46:32:12 - 00:46:34:22 ROGER MCFILLIN But what you said about the use of neurobiology. 00:46:34:24 - 00:46:35:17 RAGY GIRGIS So then what. 00:46:35:17 - 00:46:39:09 ROGER MCFILLIN Are what's the consistent biological marker found in depressed. 00:46:39:09 - 00:47:02:07 RAGY GIRGIS Individuals. So there are many. There are many. But I think the one that most people think about or have heard about, and the one with which I'm most familiar, because this is, you know, one of my areas of research is the monoamine hypothesis or the monoamine markers of depression. Because obviously, you know, I deal with schizophrenia. So we talk about primarily dopamine and glutamate. 00:47:02:09 - 00:47:19:06 RAGY GIRGIS But in in depression, as we know, depression is, you know, reliably and validly related to again, it is complicated, but lower levels of mono means primarily serotonin, dopamine. And so the whole. 00:47:19:06 - 00:47:24:14 ROGER MCFILLIN Chemical, you're kind of going to talk to me about the chemical imbalance theory of depression. 00:47:24:16 - 00:47:32:18 RAGY GIRGIS That's that that term is used. It's the monoamine hypothesis, the lower levels of serotonin. And I mean, again, it's a little more complicated than that. But yes. 00:47:32:20 - 00:47:54:16 ROGER MCFILLIN Are you aware of the umbrella study in 2022? That was put out there. Yeah. Join a military. Sure. Yeah, sure. I guess one of the things that is challenging to me is that the idea that depression is related to low serotonin, or deficiencies in serotonin, was never reliably proven up to the point of when we pushed on antidepressants. 00:47:54:16 - 00:47:57:03 ROGER MCFILLIN And it's never been confirmed. The, 00:47:57:05 - 00:47:59:14 RAGY GIRGIS It has it has. 00:47:59:16 - 00:48:03:19 ROGER MCFILLIN Well, there's many people in your field to completely deny that. 00:48:03:21 - 00:48:15:16 RAGY GIRGIS So I want to be clear. I know we're disagreeing. It's okay. But I want to be clear. There's no there's there's virtually this isn't controversial in in in the field I understand. 00:48:15:16 - 00:48:33:02 ROGER MCFILLIN It's it's quite controversial. So I have a very large platform that is now in the top .05 percent related just to these ideas. And I've had plenty of other psychiatrist on here, where we've talked about this same thing. So what do you know about the Moncrieff Study 2022? The umbrella study on serotonin? 00:48:33:08 - 00:48:37:01 RAGY GIRGIS I, I know it well. I've read it multiple times. Okay. 00:48:37:03 - 00:48:40:10 ROGER MCFILLIN Can you tell us about to tell my audience about it and why you dispute it? 00:48:40:11 - 00:49:20:12 RAGY GIRGIS Sure. Well, first of all, again, I will. I very specifically, I will say, you know, we look at reproducibility among studies. This is one study. Again, and this is, this is this was that I think that you called in this correctly called like an umbrella review. It's actually a review of reviews, number one. So one potential limitation of reviews of reviews of any type of review is that even though meta analyzes and systematic reviews are considered maybe the highest kind of the most rigorous type of evidence they have to be, they have to be conducted in a certain way. 00:49:20:12 - 00:49:39:06 RAGY GIRGIS So and I'm not saying that Moncrieff did not conductor's in a certain way, but I will explain. So with mean Allison reviews say you you know, say a a findings for example low serotonin and depression. And I can explain more about what low serotonin actually means because it has more to do with serotonin receptors. But either way and transporters. 00:49:39:08 - 00:50:01:20 RAGY GIRGIS But basically the those sort of the low Sara the findings of low serotonin and low to me but low. So low serotonin are primarily observed in younger people earlier in the illness not on medications etc.. So you have a few of those studies, but then you have a lot of studies in which, like pet studies or studies examining serotonin levels in people with depression and people who have comorbid disorders. 00:50:01:20 - 00:50:16:18 RAGY GIRGIS Later in their illness on antidepressants. So if you put all of those together, you'll see nothing, because you'll have like a handful of studies that are, you know, positive or show that finding. And then you have many more that don't because they weren't, you know, quite were different than the other studies. That's how those things can. Yeah. 00:50:16:18 - 00:50:24:17 ROGER MCFILLIN Just just to be clear about their position, they say there's no relationship. I mean, it's a complicated neuro chemical that is impacts the entire. 00:50:24:17 - 00:50:47:14 RAGY GIRGIS But they say there's no relationship. So this is what I'm getting to I'm going to get to her. Moncrieff specific, findings. So if you look at the results, the results explicitly say that there is a relationship. The and so with I want to be so in in academia in research the most important thing is our credibility. 00:50:47:14 - 00:51:07:10 RAGY GIRGIS So that is that's like the reliability of the validity or our ability to cut the data to, to to put in the results and methods what we did and what we found. And then we can interpret the data in different ways. And that's totally okay. And that's what Moncrieff did. And I mean, they, I mean, they, they I think they very credibly reported the data both in the methods and the results. 00:51:07:10 - 00:51:29:01 RAGY GIRGIS So when I tell people when I learned how to like, read research studies and when I kind of helped my mentees learn how to read research studies, I always tell them just read the methods and the results. So if you look at the results, they say there's a, they said there's a relationship. And then in the discussion they say we're not can we're not convinced by the evidence. 00:51:29:01 - 00:51:46:09 RAGY GIRGIS And the evidence to us aren't consistent. But in the actual results, they say there is a relationship and that specifically with especially with regards to that, the Pet or positron emission tomography data examining relationships between serotonin. I believe it's transporters in depression. 00:51:46:11 - 00:51:59:16 ROGER MCFILLIN Okay, I don't want to speak for Johanna moncrieff, but would you be willing at any point to have a discussion on the podcast with myself, moderating it with the two of you, so you so you can just. Johanna moncrieff? Yeah. 00:51:59:18 - 00:52:06:00 RAGY GIRGIS I mean, I'd be I'd be happy to I mean quite yeah. I mean I'd be happy to. That'd be fine. I mean but that, that was her bit. That's. Those are her. 00:52:06:00 - 00:52:10:08 ROGER MCFILLIN No, I think so. I think you may be misrepresenting her position. And I think the burden. 00:52:10:08 - 00:52:13:22 RAGY GIRGIS Of her position was that the data aren't consistent or convincing. 00:52:13:24 - 00:52:14:19 ROGER MCFILLIN But exactly the. 00:52:14:19 - 00:52:19:21 RAGY GIRGIS Results she reported in a relationship. She mentioned there was a small, weak, but it was a relationship. 00:52:19:22 - 00:52:41:23 ROGER MCFILLIN Yeah. I think if and I don't want to speak for her, but I think if she was communicating that, she said, listen, when you when you identify, a causal relationship like low serotonin equals depression, and that drives the mass use of a pharmaceutical that targets that where we don't have long. I can get into the long term data problems, the concerns with this, even in aspects of violence. 00:52:42:00 - 00:53:05:01 ROGER MCFILLIN And there's no definitive proof that anyone who has a severe major depressive disorder has deficiencies in serotonin. We can't communicate that like that's that's an invalid way of being able to describe a relationship. It's on the the burden of proof is to prove definitively or clearly that there's a causal relationship because we're targeting it with a drug. 00:53:05:03 - 00:53:27:12 RAGY GIRGIS Well, so we can't prove anything like with 100% certainty what we're always in a gray area. That's just how science works. So again, I, I'm there's there other evidence connecting serotonin and depression. So and we just discussed the Moncrieff review. Only what was reported in the review. I mean I don't know what Moncrieff herself says, but I know what was reported in the review. 00:53:27:12 - 00:53:47:04 RAGY GIRGIS And that's just kind of what I shared now. And again, that's just one paper. Now, if you look at the other papers, you focus on the studies done in people with early depression, less comorbidity, especially less personality disorders, no substance use? None. On its present medications, it's clear you have lower levels of the serotonin transporter, especially in kind of midbrain. 00:53:47:04 - 00:54:08:16 ROGER MCFILLIN No, I don't I don't think that that's clear. And prior to 2020, I did a a deep dive into this to try to create a position statement for my practice, just because we were seeing so many young people placed on, on the drugs. And, you know, I haven't been able to see anything that was a strong scientific study proving that hypothesis. 00:54:08:21 - 00:54:33:21 ROGER MCFILLIN In fact, there's just a lot of professionals in your field. Psychiatry has prominent psychologists that have moved far away from that idea in particular. Right. So, it's it's fine for you to say, you know, you still believe that there's some validity to that and take that position. But we have to be honest here about, how disputed that is generally in the field and how controversial this is. 00:54:33:23 - 00:54:39:19 ROGER MCFILLIN And there's a lot of data that, you know, contradicts those statements. We cannot say it's clear. Right. 00:54:39:21 - 00:55:02:07 RAGY GIRGIS Right. Well, that's that's my interpretation. But I am being honest. Those are those are what the data show to the majority of academic psych psychiatrist, for sure. I mean, certainly researchers within this field, within that, that kind of the the field, the scholarly kind of group within which I tend to work. There's do you. 00:55:02:07 - 00:55:25:17 ROGER MCFILLIN Think you might be in a bubble? Well my like Columbia University New York kind of the epicenter of group think. Right. I think it is certainly because, you know, Johnny Unitas is at Stanford. Sure. Yeah. So I mean, if he if he's here, he's going to be arguing against you, right, that there's this clear, chemical imbalance theory of depression and that. 00:55:25:22 - 00:55:27:11 RAGY GIRGIS He reported on that, I don't know. 00:55:27:11 - 00:55:38:22 ROGER MCFILLIN Yeah, he's he's discussed it at length, and I actually in fact, he argues that about 85 to 90% of the research that physicians and academics rely upon is unreliable. 00:55:38:24 - 00:55:40:02 RAGY GIRGIS And I know he said that. 00:55:40:06 - 00:56:14:08 ROGER MCFILLIN And, you know, Richard Horton, who's the editor in chief at Lancet, says the entire medical literature is pretty much encompassed by small sample sizes, tiny effects, invalid analyzes and conflicts of interest. And then there's Doctor Marcia Angell, who's a former editor in chief at the New England Journal of Medicine, who says simply, no longer is it possible to believe much of the medical literature on these clinical conditions published as can be relied upon because of the poor science that's being published and the conflicts of interest? 00:56:14:08 - 00:56:34:07 ROGER MCFILLIN Right. So when I bring on experts and they say I think it's clear or the research shows, then they're never actually, referring to the quality of that research. Right. And it might be exactly. The research is that that's funneled to you, you know, in the epicenter of all this, I think New York City is the epicenter of this. 00:56:34:07 - 00:56:49:19 ROGER MCFILLIN I mean, you're relying on media to, to to create credible research, like media reports are what you're using to communicate scientific findings to large scale organizations or media outlets like Fox News, for example. Right? 00:56:49:21 - 00:56:56:12 RAGY GIRGIS Right. Sure. Yeah. Let me be. So again, can I. Sorry. Go ahead. I don't want to cut you off, but I will I will address your points. 00:56:56:12 - 00:57:18:21 ROGER MCFILLIN But because it's it's still filters out to it filters out to popular culture. Right. And we start throwing out these words chemical imbalance, mental illness and violence. And we're start making all of these assumptions when it has not met, even like basic scientific thresholds. And there's large degrees of discrepancy, and debate. And that's what science is. 00:57:18:21 - 00:57:26:02 ROGER MCFILLIN It's a search for truth. Like, I don't even believe we have good evidence that the brain emits consciousness. 00:57:26:04 - 00:57:31:09 RAGY GIRGIS That's a no. I mean, that's a completely different quote. I can't address that question. I'm sorry. 00:57:31:11 - 00:57:42:07 ROGER MCFILLIN I know, but like, even coming out of I mean, there's good science coming out of Columbia. You know. Yeah. So, I mean, if we haven't been able to measure that. Right, like if. 00:57:42:12 - 00:57:42:15 RAGY GIRGIS Well. 00:57:42:16 - 00:58:05:04 ROGER MCFILLIN That's if there's no brain activity and consciousness exist now we're going to reduce the complexity of the human experience like mood and depression to like one neurochemical that we've been able to identify something as complex as serotonin, it almost seems like ridiculous to even talk about it. Like, what are they going to say 50 years down the line, looking back at conversations like this? 00:58:05:04 - 00:58:24:04 RAGY GIRGIS Yeah, I hear you, but but now I get I, I there are a lot of things to unpack here. We're combining too many things. So again that's that's with the assumption I know this is your premise that things like depression and schizophrenia, aren't you know, categorical biological conditions. So with that premise, I understand what you're saying, but. 00:58:24:06 - 00:58:29:10 ROGER MCFILLIN I think there's there's biological facts like, I'm not you know, I don't dispute that. Obviously. 00:58:29:12 - 00:58:49:00 RAGY GIRGIS So let me see if I can adjust consciousness. About the bubble. Columbia's in a bubble, but I think the bubble in which I live and work encompasses about 98 and 99% of of academia. Oh, of of neuroscience. I could I could do academic neuroscience. Academic psychiatry, for sure. 00:58:49:06 - 00:59:05:24 ROGER MCFILLIN I asked, I asked a neuroscientist once. I said, let's scale 1 to 1010 being like, we have full understanding of the human brain and consciousness, one being the brain is still a very, very mysterious organ. Do you know what number he identified? 00:59:06:01 - 00:59:09:03 RAGY GIRGIS Yeah, it's like 1 or 2. It's very small, there's no doubt about it. 00:59:09:03 - 00:59:41:19 ROGER MCFILLIN Yeah. So, I mean, it's so important, doc, that we're able not to speak in certainties, but to be able to identify where debate exists, where questions exist and be very mindful of saying things like it's, you know, it's pretty certain or it's proven or there's agreements. I can absolutely, assure you that there is not agreement on the subjects that we're talking about today, but it may there may be an agreement in that bubble that exists for you in academia, but globally, it certainly doesn't. 00:59:41:19 - 00:59:58:16 ROGER MCFILLIN And that's why I would love for you to do, I'll just a long form discussion with like Doctor Joanna moncrieff, who is doing the research on there, who has who speaks to this? I think in a nuanced way. I think she's very credible. She's better to speak for her findings than, I think either you or not. 00:59:58:16 - 01:00:19:21 ROGER MCFILLIN I are, you know, so if that opportunity arises, I mean, that's great for the general field. It's great for the American public because then we can really have nuanced, long form discussion where there's debate. I think the problem that's happened in our culture is that debate has been limited, and things have come in from like a bubble. 01:00:19:23 - 01:00:42:04 ROGER MCFILLIN And there's authority, bias, and we're just supposed to sit back and say, okay, well, a perceived authority says it's clear, right? And so you're a perceived authority, right? You're an academic at prestigious university. So we can just sit back and say, okay, you're the expert. You don't have to necessarily cite any research. You don't have to talk about the the details of that. 01:00:42:06 - 01:00:49:05 ROGER MCFILLIN The methodology or the strength of the evidence. You just have to say it's proven. And do you see where that's problematic? 01:00:49:07 - 01:01:08:09 RAGY GIRGIS Well, I hear you, but all I've been doing is talking about method and data. That's all I've been doing. I mean, that's exactly what I so I understand that I'm going to consider an expert in a third and these sorts of things, but I'm, I'm, I'm only talking about data and methods. It's completely what I'm talking about anyway. 01:01:08:12 - 01:01:17:04 RAGY GIRGIS But now so we can disagree about a lot of things, including the bubble. So you mentioned the, the 85% number. Oh yeah. The 85%. About. 01:01:17:06 - 01:01:19:12 ROGER MCFILLIN Yes, John, I and I know. 01:01:19:14 - 01:01:47:13 RAGY GIRGIS It's probably higher, but that's I'm talking about this for example, the serotonin finding is in the 15%. Sure. I've read it read any of my reviews. I've I've conducted reviews of on, you know, hundreds and hundreds of studies. I published one review maybe 3 or 4 years ago on. Experimental medication trials and schizophrenia. Yeah. I mean, even when studies are positive or negative, it almost doesn't matter. 01:01:47:13 - 01:02:06:03 RAGY GIRGIS I mean, basically out of like 500 studies, not, you know, not one of them ends up leading to anything, even though, you know, many were positive and many were negative. I mean, that's that's exactly the case, the serotonin finding. And I'll leave it at this. And I know we disagree and it's okay. The serotonin finding for the the clear reasons I mentioned is in that 15%. 01:02:06:03 - 01:02:25:06 RAGY GIRGIS But the reason we know that is because we don't just have the positron emission tomography and Spect studies like the brain imaging studies, which is again is what even Moncrieff reported. She also reported the trip to plan data from trip to tryptophan depletion. And then I think she she published or she reported that she reported for specific areas. 01:02:25:06 - 01:02:43:05 RAGY GIRGIS I think the the for the fourth was trip to fan depletion. I think the middle two are like imaging. And then the first one was on I think serotonin levels in your a pathological and biochemical samples like, like like brain biopsies and the like CSF levels etc.. And I think she found that the first and the fourth were completely negative. 01:02:43:05 - 01:03:11:19 RAGY GIRGIS But then there was association in a second and the brain imaging studies like transporter levels and whatnot. But we also have other, data that are consistent with the brain imaging studies suggesting the, you know, serotonin deficiency or chemical imbalance. So now we come to the medication studies. So the question is do medications work? So one premise of a lot of people is that medications that suck the serotonin reuptake inhibitors in particular don't work. 01:03:11:19 - 01:03:39:00 RAGY GIRGIS They cause a lot of side effects, etc.. But but they don't work. So again, going back to the nine criteria or eight causality criteria, experiments or reversibility or whatever, specificity would be one other criterion. So if a selective serotonin reuptake inhibitor were to be effective for depression, that would be, kind of consistent evidence of the serotonin imbalance theory. 01:03:39:00 - 01:03:40:13 RAGY GIRGIS Probably. Would you agree? 01:03:40:15 - 01:03:41:04 ROGER MCFILLIN No, I would. 01:03:41:05 - 01:03:47:08 RAGY GIRGIS If they were to work. Not I'm not. I do think they work. But if they were to work, well, you'd have to support. 01:03:47:08 - 01:04:05:23 ROGER MCFILLIN So you'd have to know. You'd have to define work. So let's of course, let's say let's say I create a drug that and again they're drugs not necessarily medicine. They're synthetic chemicals created in the factory. They influence, you know, brain function, consciousness. You know, number of things. Right. 01:04:06:00 - 01:04:16:12 RAGY GIRGIS So let's imagine the consciousness. I mean, I mean maybe some drug is doing it. It's set in a consciousness as we understand consciousness. They don't have a consciousness. They affect a lot of other things. But our consciousness. 01:04:16:14 - 01:04:17:17 ROGER MCFILLIN Oh, I would debate that. 01:04:17:19 - 01:04:22:13 RAGY GIRGIS But what do you mean by consciousness? Do you mean like they can make people tired, if that's what you mean? Well, yeah, of course some of them can do. 01:04:22:13 - 01:04:28:19 ROGER MCFILLIN They're not like they have been proven that they've induced psychotic episodes. 01:04:28:21 - 01:04:39:08 RAGY GIRGIS Well, I'm not sure that's the case, that that's not the case, but, that that's not if that's what you mean by conscious, if anything that happens when one is, well, awake by consciousness, then I know. 01:04:39:08 - 01:04:54:03 ROGER MCFILLIN Let's identify. I guess we have to identify what consciousness is. Our perception, our perception of reality, perception of our understanding of reality. Right is a form of consciousness. Our awareness. 01:04:54:05 - 01:05:04:21 RAGY GIRGIS It's a definite I don't know. I mean, certainly I SSRI rights definitely have effects on the brain. I guess we'll leave it at that. I just because I don't know enough about consciousness I, I shouldn't go down this. Yeah I don't know. 01:05:04:23 - 01:05:37:21 ROGER MCFILLIN So just very simply, if I create a drug in a factory that can induce some emotional blunting or sedation, and then I create a measure that accounts for that as if it's working well, then the answer would be yes. So it's just a little bit too complicated because if you make up the disease. Right. So if you arbitrarily identify the symptoms of the disease and you don't have any other biological markers to observe it from, so it becomes more subjective, you just create a series of symptoms. 01:05:37:21 - 01:06:05:16 ROGER MCFILLIN You can set up a trial very easily by creating, an outcome measure that is going to affect the effect of the drug. And of course, as you would know, when there's a randomized clinical controlled placebo controlled trial, that if you know you're taking the drug because it affects you psycho activity, then it breaks blind. So you're going to see you're going to see some increase in response where people identifying that they've taken the drug. 01:06:05:16 - 01:06:17:05 ROGER MCFILLIN There's so much interesting research I can get into. But it seems like you and I have a difference of opinion on what works and how effective the drug is, or how it's proven to be effective. Is that accurate? 01:06:17:07 - 01:06:34:21 RAGY GIRGIS I think they're effective, there's no doubt about it. There's no doubt. There's no doubt about the fact that they're effective. Not for everyone. Absolutely they haven't. They have a number needed to treat of about seven, which is among the best in medicine. I've, let's say very good in medicine, stimulants have the like the highest number needed to treat. 01:06:34:23 - 01:06:50:04 RAGY GIRGIS But SSRI is have a number need to treat of about seven which is considered very good psychiatric medications in general have a number needed to treat about seven usually, which is very good. Again a lot of points I can address all of them. I'm sorry if I'm missing points. 01:06:50:05 - 01:06:58:11 ROGER MCFILLIN I guess we have to. Actually, you seem very clear that you believe, an SSRI is proven to be effective. And that's exactly how you're taught. 01:06:58:11 - 01:07:00:23 RAGY GIRGIS Like, it's not a belief. It's. It's based on the data. 01:07:00:23 - 01:07:02:01 ROGER MCFILLIN It is. Absolutely not. 01:07:02:01 - 01:07:02:20 RAGY GIRGIS But I know you. 01:07:02:20 - 01:07:20:07 ROGER MCFILLIN And I are looking at the same data. I know my guest is I've probably looked at more data on this than you have, including looking at data from Freedom of Information Act, from court trials. I've done a deep dive. I've talked to government officials, I've talked to other psychiatrists, I've talked to experts around the world. Here's what I concluded. 01:07:20:07 - 01:07:38:11 ROGER MCFILLIN And you can debate this or not. If we look back at the original trials about how unnecessary SSRI came to market. Prozac 1987, right, was when it first came to to market. Are you aware of what happened in those clinical trials and what I happened to happen politically to get that just to market? 01:07:38:13 - 01:07:40:21 RAGY GIRGIS Probably not everything. No. Okay. 01:07:40:23 - 01:07:41:17 ROGER MCFILLIN 01:07:41:19 - 01:07:46:01 RAGY GIRGIS Is not necessarily relevant. And I will explain why, but feel free to share. 01:07:46:02 - 01:07:54:20 ROGER MCFILLIN How could that and how can clinical trials that were actually conducted by the drug companies themselves that led to the approval by the FDA to not be relevant. 01:07:54:22 - 01:07:58:14 RAGY GIRGIS Because we have many other types of data, again, supporting the serotonin. 01:07:58:16 - 01:08:14:23 ROGER MCFILLIN But they're not good studies, which is exactly what I was kind of referring to you when we're talking about the totality of this research, when it's poor, we can't say that proves it. We need valid long term evaluations. 01:08:15:00 - 01:08:17:19 RAGY GIRGIS Okay. We've had these medications for 70 years. 01:08:17:22 - 01:08:26:03 ROGER MCFILLIN Are you aware what. Well, for the market prescribed to the United States SSRI, it's post 1987. 01:08:26:05 - 01:08:34:17 RAGY GIRGIS Well, SSRI are just, just a form of medications we've had since the 50s, like tricyclic antidepressants. They're just another they're just another. 01:08:34:17 - 01:08:36:00 ROGER MCFILLIN They weren't successful then either. 01:08:36:00 - 01:08:36:08 RAGY GIRGIS Doc. 01:08:36:08 - 01:08:40:15 ROGER MCFILLIN Tricyclic, right. I mean, they're wise. Yeah, exactly. 01:08:40:17 - 01:08:41:15 RAGY GIRGIS I mean oxy. Yeah. 01:08:41:17 - 01:08:57:01 ROGER MCFILLIN I mean historically, if you look, first of all, very small percentage of people that we would prescribe them to very small come with a range of problems and not a, not a huge improvement in functioning. And there's a reason why the SSRI revolution came. It was because of those failures. 01:08:57:03 - 01:09:02:12 RAGY GIRGIS No, it was because the medications has have lots of side effects failures. 01:09:02:14 - 01:09:12:10 ROGER MCFILLIN Well, I mean, that's quality of life. We're talking about people with emotional conditions like depression, like what you call a side effect, is a strong adverse reaction that sometimes makes people want to kill themselves. 01:09:12:11 - 01:09:19:01 RAGY GIRGIS So antidepressants do not make people kill themselves. Again, this is I want to address all these. But it's so. 01:09:19:01 - 01:09:22:14 ROGER MCFILLIN Dark. This isn't a this is in the literature. I don't even know how you're making these statements. 01:09:22:16 - 01:09:26:05 RAGY GIRGIS In the literature. I know we need to address. I want to address each one of these is. 01:09:26:07 - 01:09:59:14 ROGER MCFILLIN There's a there's a there's a government black box warning, okay. Just for under the age of 25. And that is way too conservative because there's been data on adolescence that shows a 4 to 6 in fold fold increase in suicide compare in comparison to the placebo group. We have a government black box warning for inducing suicide. We have drug regulatory international drug regulatory warnings throughout the world, right. 01:09:59:16 - 01:10:07:05 ROGER MCFILLIN For increased suicide and violence. So why would they put those warnings out there if it didn't exist? 01:10:07:07 - 01:10:28:02 RAGY GIRGIS There's a lot of very good points. I didn't necessarily want to go go there, but we can go there. So the data. So if you go to the Moncrieff article and you read some of the comments, in response to the article, everything will be summarized there as a surprise. Antidepressants in general. None of the antidepressants increase suicide. 01:10:28:05 - 01:10:29:04 RAGY GIRGIS Now, there are. 01:10:29:08 - 01:10:35:16 ROGER MCFILLIN You know, many people I've met personally that talk about that exact causal relationship we need. Are they. 01:10:35:16 - 01:10:52:16 RAGY GIRGIS Lying? We need no, no, we need to talk about the data that we need to focus on the data. So the data are clear. Antidepressants decrease. I'm not familiar with that book. I'm sorry. The data are clear. Antidepressants decrease. Suicide. The data. 01:10:52:16 - 01:10:54:21 ROGER MCFILLIN You're doing it again. You're not a. 01:10:54:21 - 01:10:55:15 RAGY GIRGIS Popular. 01:10:55:17 - 01:11:08:22 ROGER MCFILLIN You're on a popular podcast and you're saying the data is clear. Again, I'm fine with you saying I, you know, I debate your premise. You can't come on a show like this and say the data is clear when your own field is going to dispute that. 01:11:08:22 - 01:11:31:00 RAGY GIRGIS No, I'm going to. I haven't finished my statement. So to address the black box warnings and what people perceive as the increase in suicide, it's not an increase in suicide for which there are equivocal data. The equivocal data are for an increase in suicidal ideation. There are no data suggesting antidepressants increase the violence. So the black box warning is only about suicidal ideation. 01:11:31:02 - 01:11:56:16 RAGY GIRGIS And they lump behaviors, not completions. So there's no doubt that antidepressants decrease suicide completions. They don't increase behaviors. But in the black box warnings and what people do is they sometimes add behaviors to ideation, because there are definitely some studies showing that, there's a relationship between SSRI and increased thoughts or ideation. There are those studies overall, the data are equivocal. 01:11:56:16 - 01:12:09:24 RAGY GIRGIS Now for those studies. Those studies like what we call registration studies in the in the, package inserts like for fluoxetine, for example, do you know, how many do you know how many, suicides there were in those trials? 01:12:10:02 - 01:12:13:14 ROGER MCFILLIN They withheld the data. They removed them from the data. Are you aware of that? 01:12:13:14 - 01:12:14:23 RAGY GIRGIS There was zero. 01:12:15:00 - 01:12:18:24 ROGER MCFILLIN Because they removed them and did not report them to the FDA. 01:12:19:05 - 01:12:19:13 RAGY GIRGIS There was. 01:12:19:19 - 01:12:47:11 ROGER MCFILLIN 1990. No, there were not zero. They were actually I want you to read the book Medication Madness The Role of Psychiatric Drugs in Cases of Violence, suicide and crime doctor Peter Brogan. I'm actually going to his house next month to be able to interview him. He's been a medical. He's a psychiatrist, he's been a medical expert in product liability cases, and he's been able to obtain through the discovery process, private memos. 01:12:47:13 - 01:13:14:11 ROGER MCFILLIN As well as the data from the drug companies that has proven that when people got became suicidal on the drugs, they either removed them from the final data count or they they placed they gave them tranquilizers. So 1994, there were so many lawsuits against Eli Lilly that a federal judge in Indianapolis combined 160 cases into a consortium called the Multidistrict litigation. 01:13:14:13 - 01:13:45:18 ROGER MCFILLIN And through the discovery process, Eli Lilly had hidden data that Prozac caused mania in patients who had never been manic previously. Additionally. Additionally, the stimulating effect was so pronounced in a portion of their trial patients. Eli Lilly's top scientist, Rafe Fuller, without informing the FDA, signed an in-house memo to prescribe tranquilizers to patients who were demonstrating a stimulating effect that ranged from hypomania to psychosis, and Agatha's idea and anesthesia appears to be a precursor to people wanting to kill themselves. 01:13:45:18 - 01:14:21:18 ROGER MCFILLIN So when I've either done evaluations myself or had people come on the podcast who've been able to describe what happened after they were prescribed the SSRI, they described these very experiences, including David Carmichael, who killed his own son after being, inaccurately prescribed Paxil. And due to the scientific data from these trials, you know, you're seeing, you're seeing these these, perpetrators, these homicide, these people who are on who are, who are on defense for homicide. 01:14:21:24 - 01:14:49:02 ROGER MCFILLIN They're being acquitted based on this data. So this was not reported to the FDA, and the drug would have never been approved if it was the West Becker case is another great example. Peter Bragdon was an expert witness. He reviewed hundreds of published studies concerning Prozac and in innumerable large storage boxes of sealed Eli Lilly memos, letters and studies concerning the development of and marketing of Prozac, some which were obtained through FOIA requests. 01:14:49:02 - 01:15:16:19 ROGER MCFILLIN That's Freedom of Information Act and the discovery process. So unless you're looking at that data, you can't come to that conclusion saying zero. Because after Joseph Spector's psychiatrist introduced Prozac, he exhibited psychosis, shot 20 people, killing eight, and himself. We see a number of cases across the world. 2001 Wyoming jury awarded $8 million to a family after a nonviolent grandfather went on a shooting rampage two days after starting an antidepressant drug. 01:15:16:21 - 01:15:32:15 ROGER MCFILLIN You know, you see this all over the case reports, and I'll just I'll just refer to the medical expert who's documented this. So it's fine for you to say, well, we've got alternative data. I've got another opinion. It's just we can't say it's clear. That's just not accurate and not fair. 01:15:32:16 - 01:15:49:23 RAGY GIRGIS I hear you. I'll stop using that, that word. But we have we have many other studies since the 90s or whatever. Again, I'm trying to go through all the data. We have many other studies showing that SSRI antidepressants in general decrease completed suicides. And so now again. 01:15:50:00 - 01:15:53:19 ROGER MCFILLIN You know, there's published studies that also say that that is wrong, that's inaccurate. 01:15:53:22 - 01:15:57:03 RAGY GIRGIS Completed suicide, suicidal behavior and ideation is. 01:15:57:05 - 01:16:05:10 ROGER MCFILLIN But do you understand the difference in a study those people are being monitored. So it's difficult to complete. Now we're trying to we're also trying to extrapolate this. 01:16:05:12 - 01:16:06:06 RAGY GIRGIS The opposite. 01:16:06:09 - 01:16:07:23 ROGER MCFILLIN Know you're being monitored in a study. 01:16:08:02 - 01:16:09:10 RAGY GIRGIS You're being. 01:16:09:12 - 01:16:09:24 ROGER MCFILLIN So when. 01:16:09:24 - 01:16:12:11 RAGY GIRGIS Some oh you mean complete suicide. Yes I see what you see. 01:16:12:12 - 01:16:31:04 ROGER MCFILLIN So like let's say you're in a you're in a trial. You take an antidepressant, you want to kill yourself. You're being I mean, you're being monitored very well and you're you have a, a physician or a researcher to report to. As soon as that happens, what we have to do is we have to try to extrapolate. What does that mean then in real life? 01:16:31:04 - 01:16:33:18 ROGER MCFILLIN Because that's not what is happening in our communities, but. 01:16:33:18 - 01:16:37:16 RAGY GIRGIS The data that the data in the clinical trials, 01:16:37:18 - 01:16:40:15 ROGER MCFILLIN Demonstrates increased suicidality. 01:16:40:17 - 01:16:43:15 RAGY GIRGIS So in some of them. That's right. So in terms of. 01:16:43:15 - 01:16:47:00 ROGER MCFILLIN Just all major ones, even ones from our government. 01:16:47:02 - 01:16:48:08 RAGY GIRGIS Just let me just. 01:16:48:10 - 01:16:48:21 ROGER MCFILLIN Study. 01:16:49:02 - 01:16:56:12 RAGY GIRGIS In terms of just completed suicide, the data, the data support that SSRI prevent in terms of completed suicide, I'm talking about. 01:16:56:14 - 01:17:04:24 ROGER MCFILLIN How how do you how do you determine how do you determine that? How do you determine that something prevents something? 01:17:05:01 - 01:17:07:12 RAGY GIRGIS Well, I mean, that's the point of the clinical trial. The. 01:17:07:14 - 01:17:19:24 ROGER MCFILLIN No. Because the clinical trials do not report that there might be some real world data that you're referring to. How how do you determine in a trial that a drug would prevent a future behavior? 01:17:20:01 - 01:17:27:14 RAGY GIRGIS Well, if there are less of those sorts of behaviors and the that that the in this case the SSRI group compared to the comparison, the. 01:17:27:14 - 01:17:28:22 ROGER MCFILLIN Placebo. 01:17:28:24 - 01:17:30:21 RAGY GIRGIS Or some sort of active. 01:17:31:00 - 01:17:32:04 ROGER MCFILLIN But a placebo group. Right. 01:17:32:04 - 01:17:33:01 RAGY GIRGIS That's a placebo. 01:17:33:02 - 01:17:37:17 ROGER MCFILLIN Well that's the well, if you're comparing it to another drug then you can't make that determination. 01:17:37:19 - 01:17:43:18 RAGY GIRGIS Now. It can be something. It could be therapy or something like that okay. Some sort of active compared okay. And to be an antipsychotic. 01:17:43:24 - 01:17:49:03 ROGER MCFILLIN And so why then will we have all these international drug warnings including our own country. 01:17:49:05 - 01:17:52:09 RAGY GIRGIS Yeah. I mean they're being conservative because I being conservative. 01:17:52:11 - 01:17:56:02 ROGER MCFILLIN But if there's no data and you're saying that a drug would prevent it. 01:17:56:04 - 01:17:57:12 RAGY GIRGIS Why would a different thing, why. 01:17:57:12 - 01:18:00:21 ROGER MCFILLIN Would there be international drug warnings? Why would there be a black box warning? 01:18:00:22 - 01:18:20:13 RAGY GIRGIS That's, clarifying. So with some we've now we're done with completed suicide. So suicidal ideation behavior, especially suicide. There are lots of studies showing or suggesting that antidepressants increase suicidal ideation. There are lots of ways to understand this. If you look at all the data, a lot of us think that those data are equivocal. So there are a lot of studies. 01:18:20:13 - 01:18:45:17 RAGY GIRGIS It's just that they decrease ideation. But a lot of studies suggest that they increase ideation. So it's safe to say it is safe to put a black box warning there. Another way that people think about it is that and again, this is with the understanding that antidepressants or the data showing that any presence decrease completed suicide. There's also the data that you of which you're probably aware or our understanding of how this works, that, there are multiple different types of suicidal ideation. 01:18:45:17 - 01:19:19:20 RAGY GIRGIS So when people are close to to wanting to take their own life, they won't report suicidal ideation as they improve. For example, when they take an antidepressant, for example, in a clinical trial, they will not want to act on their suicidal ideation and they'll be more likely to report it. So that's number one. And number two, I'll go back to kind of what you mentioned about how people are monitored more or less the people who are sicker ends up, especially if they're on an or if they're on antidepressant medication and experiencing more side effects, which we will get to because of course, this arise have more side effects than placebo. 01:19:19:22 - 01:19:39:07 RAGY GIRGIS They'll be seen more often and they'll have a chance to report suicidal ideation more often. And again, also, as you know, in many of these, especially the registration studies, the suicidal ideation was not systematically assessed. It was just kind of reported. So there's that's that's kind of how we understand that. Now, there also, just to be clear, there's no black box warning for violence or homicide. 01:19:39:12 - 01:19:41:03 RAGY GIRGIS There's no black box warning for that. 01:19:41:05 - 01:19:43:15 ROGER MCFILLIN In our country. Other other countries are. 01:19:43:17 - 01:19:44:11 RAGY GIRGIS That might be the case. 01:19:44:16 - 01:19:46:08 ROGER MCFILLIN I don't know the EU, for example, but. 01:19:46:08 - 01:19:52:24 RAGY GIRGIS There are no data suggesting that antidepressants increase. Certainly not murder or a homicide. 01:19:53:01 - 01:19:56:12 ROGER MCFILLIN Because they don't study it. 01:19:56:14 - 01:20:00:05 RAGY GIRGIS But but then how could they know that that increases violence. 01:20:00:07 - 01:20:26:04 ROGER MCFILLIN From clinical trials, case reports? They don't report it. So this is this is like probably the largest problem when it comes to our research letter literature. It's selective reporting. This is what happens when you have a drug company that's going to make billions, if not trillions from a drug that once they start observing things within their drug trials, they're incentivized to try to protect that. 01:20:26:07 - 01:20:27:05 RAGY GIRGIS They can't do that. 01:20:27:05 - 01:20:28:05 ROGER MCFILLIN They do, but. 01:20:28:05 - 01:20:28:17 RAGY GIRGIS They. 01:20:28:19 - 01:20:29:12 ROGER MCFILLIN This isn't. 01:20:29:14 - 01:20:31:05 RAGY GIRGIS This is a know I know this and I know this. 01:20:31:05 - 01:20:41:19 ROGER MCFILLIN Isn't speculation like there's been there's been millions and billions and dollars of government fines as well as court litigation. There's been product liability cases. 01:20:41:21 - 01:20:45:23 RAGY GIRGIS This stuff. You're right. This stuff comes out. There are case reports. Nothing is perfect. 01:20:45:23 - 01:21:16:21 ROGER MCFILLIN There's no they'll stop it with the nothing's perfect stuff. This is legitimate. This is legitimate information that you just can't dismiss by saying nothing's perfect. People die. Once we've started mass prescribing psychiatric drugs, which there is an absolute dramatic rise from the mid-nineties up until today, every measurable statistic from suicides to, increasing the amount of people identifying with mental illness, the number of people on disability for mental illness has risen dramatically. 01:21:16:23 - 01:21:50:08 ROGER MCFILLIN It's a failed paradigm of care, experimenting with drugs that clearly and obviously have a number of serious problems. So much so that there is a large and coordinated global community of harmed patients that are speaking out of this range from permanent sexual dysfunction to suicide to violence, to to becoming chronically disabled by their condition, polypharmacy, which is prescribing multiple drugs which have never been evaluated in in clinical directly, like. 01:21:50:10 - 01:22:25:13 ROGER MCFILLIN Combining multiple drugs at once that have never been evaluated with any, safety or evidence or efficacy data in a way that would demonstrate to us that that is healthy for a person. We see people go on drugs, have decreased quality of life, a number of metabolic conditions, and then we have the black box warnings. And then for other things, what I generally see from people who are being prescribed these drugs is almost, such a high degree of emotional numbness and detachment that interferes with a lot of areas of their lives that gets then misrepresented as mental illness. 01:22:25:15 - 01:22:42:11 RAGY GIRGIS I hear you can. I address again many important points, and I'm glad you brought them up. I'd like to address, try to go as quickly as possible. So many most studies now are are studies of multiple medications. And we have many medications approved for for for exactly that to be in. 01:22:42:11 - 01:22:52:05 ROGER MCFILLIN Combination with each other and their high quality studies. I mean, randomized clinical controlled trials long term, following the clients more than 6 to 8 weeks. 01:22:52:07 - 01:23:16:09 RAGY GIRGIS Of course, I conduct many of them myself. I mean, I that's what I do. I look at my review, I mean, just in schizophrenia, just among those I mean, there's so many papers, all these are all approved as I mean approved, not just studied, approved. So that's I mean, and then of course, these medications, like I said, Brown for 70 years, we have year long many, many, many year long years long studies of these medications. 01:23:16:13 - 01:23:18:20 RAGY GIRGIS And so that's now oh my gosh. 01:23:18:20 - 01:23:21:11 ROGER MCFILLIN You're saying you're you're years long. 01:23:21:11 - 01:23:28:15 RAGY GIRGIS Have these studies okay. I don't need those for initial approval. You are correct. But in almost every case we have those. 01:23:28:17 - 01:23:39:18 ROGER MCFILLIN Yeah it's up to the doctor can prescribe anything as long as a single drug is approved for use, a doctor can combine them, like. And this is what you're seeing. You're seeing like antidepressants. 01:23:39:20 - 01:23:53:06 RAGY GIRGIS Bad. That's that's true. But I mean, sometimes people need more than one medication. It's not always good. Less is more. One thing we learned in medical school, one of the first things with less is more. If you can do it, if you can do with less, always better than. 01:23:53:11 - 01:24:11:06 ROGER MCFILLIN You, you might not be observing what is happening in our communities because you're no longer in direct patient care. No, I do, but it's an absolute tragedy about the degree of which people are impaired on so many different drugs. Their quality of life has decreased to such an extent. I want to actually make another one more. 01:24:11:08 - 01:24:24:19 RAGY GIRGIS I want to address the point that I. I don't mean to interrupt, but I do want to address the points you made about what's happened since SSRI is came to market. So first is the rise are not much different than TCS. You know, they're just safer, but they're not much different this year. But but that's beside the point. 01:24:24:19 - 01:24:40:23 RAGY GIRGIS More importantly you mentioned the suicide violence rate. This the sorts of things. We don't you're right. We don't I don't think we've really studied the rise in violence much either way. But we have we do know about the rise in suicides. So we have the direct clinical studies, and we have cohort studies and all these sorts of studies. 01:24:41:00 - 01:25:05:21 RAGY GIRGIS We also have epidemiologic studies. So people say, I've heard this many times that since SSRI is the suicide rate is increase, all these things have increased violence. So actually if you look at if you look at the data, in the first 10 to 12 years after this rise came to market, the suicide rate in America decreased substantially. 01:25:05:21 - 01:25:08:11 RAGY GIRGIS And most people attribute that to SSRI. 01:25:08:13 - 01:25:09:08 ROGER MCFILLIN It did not decrease. 01:25:09:08 - 01:25:11:13 RAGY GIRGIS Substantially in the first 12 years. 01:25:11:13 - 01:25:34:23 ROGER MCFILLIN No, did not decrease. Know. This is the talking point. That psychiatrist say that's not backed up by hard data. There wasn't much there. I'm going to post this in the in the show notes to show the suicide rates. In the United States. I'll try to go back to 1900 if I possibly can, and we'll show the dramatic rises in suicide rates correlate directly with more prescriptions. 01:25:35:00 - 01:25:57:04 RAGY GIRGIS So, yeah, after 2000, we've had an increase in, prescriptions for rise hugely and a huge increase in the suicide rate. Yes. But again, we have combine that with what, you know, from the 1990s. Also what we know from data, from worldwide data since this, since the, development of SSRI is the worldwide suicide rate has decreased substantially. 01:25:57:04 - 01:26:18:24 RAGY GIRGIS So what makes America different in the last 25 years. And again, this is another kind of box that we're going to open. And I, I mean there's so much data to to to to go through. But the reason the suicide rate is increase over the past 25 years is, is strongly supported by the data. And that is the increase in firearm ownership. 01:26:18:24 - 01:26:20:07 ROGER MCFILLIN Oh come on with that. 01:26:20:07 - 01:26:23:15 RAGY GIRGIS Talking points are the data. These are the data. 01:26:23:17 - 01:26:25:23 ROGER MCFILLIN That's that's such that's such baloney. 01:26:25:23 - 01:26:29:05 RAGY GIRGIS It's not it's not just the firearm. Right. But it is. That is. 01:26:29:05 - 01:26:30:10 ROGER MCFILLIN Such that is such. 01:26:30:10 - 01:26:30:21 RAGY GIRGIS An ownership. 01:26:30:23 - 01:26:44:08 ROGER MCFILLIN That is such a political talking point. That is not no, it's not with data that's see, this is the problem with the authority bias and the expert. You can just say that's the data without strong evidence to support that case. 01:26:44:08 - 01:26:44:22 RAGY GIRGIS I mean. 01:26:44:24 - 01:26:51:18 ROGER MCFILLIN I can most state, you know, you don't even have to register like in Pennsylvania firearms. Do you think I have to register that firearm? 01:26:51:20 - 01:26:53:20 RAGY GIRGIS I'm not sure what you mean. So what's the point? 01:26:54:01 - 01:27:00:24 ROGER MCFILLIN You don't know. You're not able to determine who and how many people have firearms and whether that this goes back. 01:27:01:01 - 01:27:01:24 RAGY GIRGIS This goes back to your. 01:27:01:24 - 01:27:04:14 ROGER MCFILLIN Other data when it comes with identifying somebody who's mentally. 01:27:04:14 - 01:27:06:12 RAGY GIRGIS Ill. But we know. What do you. 01:27:06:12 - 01:27:09:20 ROGER MCFILLIN Mean we know? You just make it up and then you say the data is not perfect. 01:27:09:21 - 01:27:20:14 RAGY GIRGIS No, we do, but we know we for the most part, we know how many guns are sold because we have those records. And so we know by now I mean, well. 01:27:20:14 - 01:27:25:00 ROGER MCFILLIN There's there's more people like the population continues to increase per. 01:27:25:00 - 01:27:42:22 RAGY GIRGIS Capita. So we have about 4 to 500 million. I mean, it's a wide range, but I mean, we understand 4 to 500 million firearms in the US. We really don't know how many are, you know, legal versus illegal, but most are legal. And of course all illegal firearms come from I mean, they're produced by. So so the registration rate is about one. 01:27:42:22 - 01:27:46:24 ROGER MCFILLIN But people are I mean people have always had access to guns. 01:27:47:01 - 01:27:49:22 RAGY GIRGIS I understand that. And the rate of ownership is. 01:27:49:24 - 01:28:12:06 ROGER MCFILLIN What we should be interested in as mental health professionals is why would somebody want to end their life with a gun? So that is what has increased. The amount of people that want to die, they find their life very difficult to live in and the manner in which we're treating them in Western societies, United States in particular, has been an utter failure. 01:28:12:12 - 01:28:48:18 ROGER MCFILLIN There's some other and this is other data. The FDA or FDA has, an adverse event reporting system, right. There are 51,530 cases of homicidal ideation linked to psychiatric drugs. In that FDA data. But FDA admits there's only like 1 to 10% of side effects become reported. So this could represent, like in a given year, 30,000 cases. The FDA also added homicidal ideation as an official side effect for Effexor XR, which in 2005. 01:28:48:18 - 01:29:25:09 ROGER MCFILLIN So there is a relationship or there is identified by our government of homicidal ideation due to, to, a drug that we prescribe as an antidepressant, 31 prescription drugs disproportionately associated with violence. This is from the FDA, 25 year psychiatric drugs. So 80%. So there's there's something that there's some common sense, I think, that we have to come to in these conversations, what happens when we experimentally, alter states of consciousness on something, on our bodies and brains that have evolved over millennial in a discrete period of time. 01:29:25:09 - 01:29:53:22 ROGER MCFILLIN We start identifying, the emotional reactions and the behavior of human beings to be a brain condition. And then we experimented on a discrete period of time. In that time, we see an explosion of mental health related conditions, suicide and violence. Right? Right there. We have to ask ourselves, is the paradigm flawed? Forget about the the strength of the evidence around a particular drug. 01:29:53:24 - 01:30:14:01 ROGER MCFILLIN We can argue this for days, and I think we're just gonna end up boring the audience. I think what is clear is just the fact that you and I are having debate on this is it's not just acceptable, you know, it's acceptable conclusions that these drugs are safe or effective or they, decrease the rate of suicide. It is very, very complicated. 01:30:14:03 - 01:30:43:23 ROGER MCFILLIN There's a lot of data that is going to dispute exactly what you said. I know you can find studies that dispute what I said. I would just question the strength of the studies. There's tend to be a ton of methodological flaws. There's a lot of industry related corruption, conflict of interest. And as you know, many are talking about right now, if if doctors themselves and you actually, admitted to this point that the research that you're relying upon is highly flawed. 01:30:44:00 - 01:30:46:24 RAGY GIRGIS I'm not sure I said highly flawed. There are limitations and biases. 01:30:46:24 - 01:31:07:20 ROGER MCFILLIN Well, I think when I, when we were talking about, like Johnny Unitas and I said 85 to 90% of the published research is like very limited, highly flawed. There's often and this is his words. Yeah. There's conclusions that are drawn that it's it doesn't really assist practitioners in making evidence based decisions. And you said you agreed with that. 01:31:07:23 - 01:31:11:04 RAGY GIRGIS Academics figure that I mean, that's what I'm saying. Academics figure that out. 01:31:11:10 - 01:31:12:09 ROGER MCFILLIN He is an academic. 01:31:12:15 - 01:31:30:13 RAGY GIRGIS I know that's what I'm saying. But we figure that out based on that, the process of scientific communication and replication and all these sorts of things. And so what ends up happening is that, you know, I mean, you can go to clinicaltrials.gov right now and, and type in depression and, you know, you'll find hundreds and maybe even thousands of studies. 01:31:30:15 - 01:31:55:09 RAGY GIRGIS None, none, almost none of those will come to market. And that's that that represents that 85%. And we kind of just figure it out. That's how things work. Let me get back to suicide, violence. I'll be more succinct with my answers. Just to kind of you know, tie things in. So we'll wrap up kind of discussions and share kind of my, my, my, my side of thing or the side of things that the data that I, that I draw on. 01:31:55:11 - 01:32:20:15 RAGY GIRGIS So again, we, you know, I, I, my sense is that the data support that Intel presents are effective, that they decrease completed suicide, equivocal or otherwise suicidal ideation that is consistent with what we understand about the neurobiology of violence and suicide. Suicide is even more strongly related to lower levels of serotonin. Violence is also to some degree, that's John Mann, his work. 01:32:20:15 - 01:32:43:11 RAGY GIRGIS You can clearly, clearly see that in his work. We also just address a previous point of yours. You're saying that we don't also understand how the medications work, or we should expect some target engagement or biomarker. And in fact, we do actually have lots of those EEG measures. We have the pet of the pet, of course. Like we can see that the medications SSRI bind to the serotonin transporter, all those sorts of things. 01:32:43:13 - 01:32:56:17 RAGY GIRGIS So so we have all of that. And I'm just going to make one other point. And now it has escaped me. I was going to say I didn't realize this would be as much of a debate. I thought we were primarily going to talk about mass murder and mental illness and perhaps, you know, we. 01:32:56:17 - 01:32:57:06 ROGER MCFILLIN Kind of on this. 01:32:57:06 - 01:32:58:03 RAGY GIRGIS In the Bible. 01:32:58:05 - 01:32:59:04 ROGER MCFILLIN Well, we kind of aren't me. 01:32:59:09 - 01:33:07:18 RAGY GIRGIS Well, then let me address that one point about I guess, about violence and antidepressants, if that's okay. Would that be okay to bring up now? 01:33:07:20 - 01:33:09:08 ROGER MCFILLIN Sure, sure. 01:33:09:10 - 01:33:27:10 RAGY GIRGIS So the data show that there's only one psychiatric condition related to murder at all. I'm just starting with that. This is kind of one kind of foundational piece of violence. And that is, like I mentioned, early unmedicated psychosis, minor relationship. But it's there. And then we found something kind of similar in our mass. 01:33:27:12 - 01:33:28:24 ROGER MCFILLIN I know you're going you're going back to. 01:33:28:24 - 01:33:29:24 RAGY GIRGIS You now getting doc. 01:33:29:24 - 01:33:31:10 ROGER MCFILLIN You're going back to your you're talking. 01:33:31:10 - 01:33:32:10 RAGY GIRGIS Points. 01:33:32:12 - 01:33:53:10 ROGER MCFILLIN Now just hold on one second. You're going back to your talking points. But we probably went over this for the first 45 minutes. If we can't identify in that, in those research that you've conducted, that there is clearly an identifiable medical illness that unfortunately is just going to invalidate and dispute a lot of your statement. Why? Yeah. Why would we go back and do that? 01:33:53:14 - 01:33:57:03 RAGY GIRGIS I was just kind of summarizing what we had shown now specifically. 01:33:57:03 - 01:34:21:05 ROGER MCFILLIN But I don't want to I don't want to I don't want to go there because I don't think it's valid. And I made my argument on why I don't think it's valid. I don't think you can. I actually think it's dangerous to say that you can apply a blanket medical diagnosis without ever evaluating somebody, and then trying to trying to infer about who a person is from media reporting or even law enforcement. 01:34:21:07 - 01:34:43:18 ROGER MCFILLIN Prior to coming on this podcast, I interviewed, a few people in law enforcement about these very issues. When it comes to homicide, I want to know, like, to what extent are you do you order our toxicology reports, for example, ordered, and to what degree do we look at mental illness as being a major factor in completion of that? 01:34:43:20 - 01:35:12:01 ROGER MCFILLIN And I think from a law enforcement perspective, they're going to say, first and foremost, you know, we're trying to convict that person. So they're gathering evidence. It's not in their purview to order toxicology reports or even look into the role of any type of substances involved in that. That might be the defense, for example. So it's not something that's consistent, in being able to identify that there could be, you know, an unmedicated person or a medicated person. 01:35:12:03 - 01:35:36:08 ROGER MCFILLIN So I just have there's so many methodological problems with your work, I don't want to get into like a long form discussion to say, well, we know this, and we know this because that's what academics do. They're so used to saying, we know. And then you communicate it definitively, and then everyone passively accepts that information as if it's true and begins regurgitating it over and over. 01:35:36:09 - 01:36:09:08 ROGER MCFILLIN And it's same with this chemical imbalance nonsense and trying to reduce the complexity of the human experience to make one neurochemical. When you admit that maybe on a scale of 1 to 10, we understand a one. There's so much of contradiction in your statements when you just have to improve the way you deliver the information. If you improve the way you deliver the information to be more accurate, we have a safer culture, a safer society, because a lot of this is pseudoscientific nonsense being communicated with certainty. 01:36:09:10 - 01:36:30:09 ROGER MCFILLIN And that's my biggest problem because people deserve informed consent, there is no way we should have 1 in 4, 1 in 5 people on psychiatric drugs in the United States. Absolutely. No way. And if you want to make an argument that, you know there is a percentage of people in this country who truly, truly suffering, we're going to we're going to use this diagnostic criteria. 01:36:30:09 - 01:36:59:06 ROGER MCFILLIN We're going to refer to it as illness. We're going to put it under the medical system. And in some situations these drugs can improve a quality of life. Then I'm open for you, open with you. Because then we can talk about who, when, what, where, under what conditions. But that is not what's happening. United States, what's happening in the United States is there's a lot of propaganda from the pharmaceutical companies that was being spewed back to me today under the disguise, as if it's legitimate science, which is exactly what's happening to the primary care doctors. 01:36:59:08 - 01:37:28:24 ROGER MCFILLIN The primary care doctors are writing SSRI prescriptions because they're told exactly what you were told. There's no risk for increased suicidality. They're protective, against suicide. Ignore the black box warnings, as if the international community just somehow pulled that out of the thin air. To be conservative. No, that's not true. The data is absolutely overwhelming. The bigger the more you dig in to this with court documents, it's dark as hell. 01:37:29:01 - 01:38:00:01 ROGER MCFILLIN I mean, it's really, really dark. And when you talk about methodology like a pure scientists, like, I want to be a pure scientist because I, I believe in the search for truth. And when you create trials where there's a placebo washing period, when overwhelming amount of trials themselves show that the placebo group outperforms the drug group, and you don't have to publish those, well, then you have a crisis of credibility in research, because all of the totality of the data is not provided to our academics. 01:38:00:03 - 01:38:27:18 ROGER MCFILLIN And that's publication bias. And that in itself is indisputable. There's a clear problem with publication bias, being able to replicate data over and over again. And of course, there's a there's no doubt in mental health in the psychiatric field that there's a credibility issue around validity of psychiatric diagnosis. There overlapped 65, 70% of those on committees in the DSM received pharmaceutical money. 01:38:27:20 - 01:38:49:11 ROGER MCFILLIN So you have to be aware of what my listening audience and the global witness, audience that listens to this, they're aware of this information out. So our docs around the world, there are there are psychiatrists that are pulling themselves out of the system because of this. And they're funneling themselves into burgeoning new research opportunities and treatment opportunities. 01:38:49:13 - 01:39:17:14 ROGER MCFILLIN Functional nutrition or, you know, traditional psychiatry, for example, metabolic conditions, they're pulling people off the drugs and they're getting better. People are getting better when they're being pulled off the drugs safely. We didn't even get into the problem with what happens when someone abruptly stops the drugs when someone's tapered off too quickly, which is standard care in the United States, because we know violence and suicide increase under a number of conditions. 01:39:17:16 - 01:39:43:03 ROGER MCFILLIN Starting a new drug, increasing the dose of a new drug, decreasing the dose of a new drug, adding a drug. And the most dangerous is abruptly stopping a drug. And all of those are very, very dangerous conditions. And we prescribe these drugs to teenagers and kids. And my practice is overwhelmed because we see the results of this. They they decide to take their drug for a period of time and they just stop it. 01:39:43:08 - 01:40:08:00 ROGER MCFILLIN Then they have all those symptoms, which is the withdrawal effect of those drugs. They become suicidal. Maybe not because the drug induced suicide, but what happens to the brain? And when you abruptly stop that drug that can induce McCarthys fear, that can induce worsening mood, that has induce psychosis in a percentage of people? There's a lot of dangerous aspects to haphazardly prescribing powerful psycho agents like like this. 01:40:08:02 - 01:40:33:13 ROGER MCFILLIN And I it's just so important we do. We provide the public a service to make sure this is clearly identified and discussed, because as a practitioner in the community and someone who started a nonprofit around informed consent in medical freedom, it's my it's my duty, it's my calling to make sure that people understand the risks that are associated with medical interventions. 01:40:33:15 - 01:41:00:00 ROGER MCFILLIN And we just have to be so careful in the way we communicate. I understand how academics communicate because I got my doctorate in clinical psychology. So you're surrounded by academics and I go off to the various conferences, and I hear academics talk about how they present literature. It's the same language, right? We know this or this is pretty clear until it gets disputed five years down the line or ten years down the line with new evidence. 01:41:00:02 - 01:41:16:03 ROGER MCFILLIN Why would we want to use that language? We know this like this is the same thing that happened in in Covid that created so many problems across this country. By obtaining that this level of certainty, that's clearly not true. 01:41:16:05 - 01:41:37:02 RAGY GIRGIS There's some things with which, I, some things you mentioned with which I would agree for sure. I, you know, I think psychiatry is a specialty. I think specialists should prescribe a lot of these medications. I think discontinuing a medication, should almost always be done by a psychiatrist. I because of, you know, my. 01:41:37:02 - 01:41:44:08 ROGER MCFILLIN Role, but they don't know how to do it. Psychiatrists, they don't know how to taper off drugs. The overwhelming majority. 01:41:44:10 - 01:41:46:05 RAGY GIRGIS I don't know, because they're. I can tell. 01:41:46:05 - 01:41:51:12 ROGER MCFILLIN You they're following guidelines from the pharmaceutical industries. They're tapering people off too fast. I can guarantee you. 01:41:51:14 - 01:41:57:14 RAGY GIRGIS Well, I don't know about that. I can tell you that I am. I, doc. 01:41:57:14 - 01:42:00:21 ROGER MCFILLIN Are you are you aware? Are you aware what's going on in our communities? 01:42:00:23 - 01:42:05:14 RAGY GIRGIS I'm aware. I, I see, because I do still see patients. Just not part of a clinical practice. 01:42:05:14 - 01:42:12:14 ROGER MCFILLIN Are you aware of the, like, the, the Maudsley research on on drug tapering, hyperbolic tapering? 01:42:12:16 - 01:42:15:16 RAGY GIRGIS I probably understand the concept. I don't know exactly. See. 01:42:15:18 - 01:42:31:18 ROGER MCFILLIN And so that's the that's my point because there's this there's really good science and research that first start started kind of grassroots effort from communities of people who can't get off SSRI because of dependency. 01:42:31:18 - 01:42:42:00 RAGY GIRGIS But what do the data I wonder what what what is this whatever the modeling approach or whatever is, what exactly is that? I mean, I might I might know it in some other name, like I know how to. Yes. Or people off medication. 01:42:42:00 - 01:42:44:07 ROGER MCFILLIN How fast do you taper off someone from an SSRI? 01:42:44:10 - 01:42:47:11 RAGY GIRGIS Oh well, it totally depends on the person, of course, and what SSRI there are. 01:42:47:11 - 01:42:58:12 ROGER MCFILLIN But let's say let's, let's, let's say they were let's just first say they were on Prozac for ten years. Let's say they're on 40mg. How fast can they get off of it? 01:42:58:14 - 01:43:02:00 RAGY GIRGIS There's always individual variation, but they'd have to come off slowly. 01:43:02:03 - 01:43:04:01 ROGER MCFILLIN How slowly? 01:43:04:03 - 01:43:13:03 RAGY GIRGIS It does depend on a lot of considerations. For example, whether someone wants to get pregnant. These these are real things. That's not minor. I mean, a lot of people, you know, come off medications because they want. 01:43:13:03 - 01:43:19:10 ROGER MCFILLIN But let's say we wanted to reduce withdrawal symptoms and the dangers that could potentially come with protracted withdrawal. 01:43:19:14 - 01:43:24:00 RAGY GIRGIS Well, fluoxetine is is actually one of the better medications from which. 01:43:24:00 - 01:43:25:18 ROGER MCFILLIN To come off because of half life. 01:43:25:20 - 01:43:28:19 RAGY GIRGIS Exactly. Yeah. So it kind of self tapers. There are other ones. 01:43:28:19 - 01:43:40:18 ROGER MCFILLIN But it's still some point that they're it's removed like the drug is removed from the receptor. Right. And now the body's reacting to the absence of it even, you know at some point. Right. So what we're not. 01:43:40:18 - 01:43:50:05 RAGY GIRGIS Denying that medications have side effects. There's no there's no doubt about. And I'm also not denying a lot of the reports you're talking about the case reports your patients experiences. 01:43:50:07 - 01:43:53:21 ROGER MCFILLIN Yeah. That's not these aren't side effects withdrawal effect. 01:43:53:23 - 01:43:54:07 RAGY GIRGIS I'm. 01:43:54:13 - 01:44:05:07 ROGER MCFILLIN Also so in my community psychiatrist in my region. Here are our take getting people off three four psychiatric drugs in a 1 to 2 month period of time. They're getting believe. 01:44:05:07 - 01:44:06:03 RAGY GIRGIS You. Yeah. 01:44:06:05 - 01:44:07:20 ROGER MCFILLIN I mean and they're psychiatrists. 01:44:07:20 - 01:44:08:16 RAGY GIRGIS I understand, I. 01:44:08:16 - 01:44:30:03 ROGER MCFILLIN Understand and I'm a psychologist and I don't want anything actually to do with this, but I've been thrown into the conversation, obviously, because I'm having the conversations with people. So people around the globe contact me. Can you help me get off this drug? Is there someone you can refer to? Me and the overwhelming psychiatrist in the United States I have conversations like, are like this. 01:44:30:03 - 01:44:36:01 ROGER MCFILLIN You've never heard of the Maudsley approach or hyperbolic tapering, or even aware of the epidemic of withdrawal. 01:44:36:01 - 01:44:50:18 RAGY GIRGIS That that that's different. Trust me. I know. I know how to use medications and and how to take people off medications. There's no doubt about that. Whether someone uses the Maudsley approach for their I don't even know what that means, but trust me, I know how to take people all right and put people on medic like taper and withdrawal, I think. 01:44:50:22 - 01:45:01:16 ROGER MCFILLIN I think psychiatrist how to put I think psychiatrists know how to put people on drugs. I don't think they don't know how to take them off. How long would it take for you to get someone off effects her again? 01:45:01:16 - 01:45:03:19 RAGY GIRGIS It depends on the dose. It depends on the person. 01:45:03:21 - 01:45:10:08 ROGER MCFILLIN Full dose ten years because this is what we're seeing. Ten people on effects are for ten, 15, 20 years. 01:45:10:08 - 01:45:22:16 RAGY GIRGIS Now see, what happens is you you start with the Effexor. So with Effexor what you would do is you, because of this low half life, you would generally first cross, titrate them to something like search for lean or fluoxetine. And that's how it works. 01:45:22:16 - 01:45:25:24 ROGER MCFILLIN Yeah that's what we're seeing. And that's and we're seeing horrible results from that. 01:45:26:01 - 01:45:30:17 RAGY GIRGIS But that's the listen nothing is perfect. But that's the way to do it. And I. 01:45:30:17 - 01:45:31:11 ROGER MCFILLIN Disagree sometimes. 01:45:31:11 - 01:45:34:18 RAGY GIRGIS It works and sometimes it doesn't work. But that's not good. 01:45:34:20 - 01:46:01:08 ROGER MCFILLIN That's not that's not good enough for the people who are harmed. It's not perfect sometimes. Sometimes it works. Sometimes it doesn't. When there's a better way, when there's a better way. Hyperbolic tapering is small reductions like 10% reductions in dose like a month, 10% reduction a month. And sometimes it takes years for people to get off the drug, including a reinstatement of a very low dose near the end of it. 01:46:01:14 - 01:46:20:20 ROGER MCFILLIN And we're seeing much better outcomes because what's happening is they're they're doing that psychiatrist are doing exactly what you describe, that you're prescribing another drug to get off of one drug. You're doing it fast. They're having withdrawal reactions. They come back into the office. The psychiatrist says, here's your mental illness returning. 01:46:20:22 - 01:46:21:20 RAGY GIRGIS I hear you. 01:46:21:20 - 01:46:26:13 ROGER MCFILLIN Do you understand that your colleagues, like your mental illness? This is why you need to be on the drug forever. 01:46:26:19 - 01:46:30:20 RAGY GIRGIS Patents are large. And trust me, I mean, I think you said that's hyperbolic. 01:46:30:22 - 01:46:33:18 ROGER MCFILLIN That's hyperbolic, and I'm not being hyperbolic. No, I. 01:46:33:18 - 01:46:43:18 RAGY GIRGIS Understand that's a standard of care. I hear you that that that's a phrase. I've never heard that phrase before, but that just describes slow tapering and that's that's fine. I mean, we're we're totally. 01:46:43:24 - 01:46:48:03 ROGER MCFILLIN It's a little bit more there's a, there's a curve in place and there's a process. 01:46:48:03 - 01:47:07:09 RAGY GIRGIS Involved there. But that's like how people on other pod not related to this podcast or maybe, I don't know, I haven't listened to every single one of our episodes, but many of them I actually appreciate a lot of what you do, but that's like how I hear in a lot of podcasts. People say that, oh yeah, medical students receive no training in nutrition, and it's at first you think. 01:47:07:12 - 01:47:08:14 ROGER MCFILLIN Very limited or. 01:47:08:16 - 01:47:10:02 RAGY GIRGIS No, but I mean or poor. 01:47:10:02 - 01:47:10:13 ROGER MCFILLIN Training. 01:47:10:14 - 01:47:11:16 RAGY GIRGIS But but then you. 01:47:11:16 - 01:47:14:00 ROGER MCFILLIN Realize I don't eat red meat like nonsense like that. 01:47:14:03 - 01:47:37:00 RAGY GIRGIS What's nutrition? Nutrition is biochemistry. I mean, medical students get more than enough biochemistry. I mean, that's what nutrition is. I mean, just because I don't know that something is called hyperbolic temperament doesn't mean I, I don't I'm not familiar with how to, you know, different methods for tapering people on, you know, discontinuing medications. But I wanted to get to, there was another important point. 01:47:37:02 - 01:48:10:05 RAGY GIRGIS Oh, gosh. Oh, yeah. Just in terms of the whole chemical imbalance theory, whether SSRI would work extra, I did want to mention people use tryptophan depletions, you know, decrease decrease serotonin and see whether that causes depression, that that's a relatively weak way of decreasing serotonin. If you actually decrease serotonin and dopamine using methyl partyers alphabet, the entire scene or you know what happens with people when after they use cocaine and LSD, they have a they have a crash, which is what happens when you have AMP. 01:48:10:07 - 01:48:32:12 RAGY GIRGIS You immediately become depressed. And so in most cases. So again, there there are lots of I'm on I'm just using this kind of these data to illustrate that there that there are lots of lines of evidence that support that SSRI would be effective or why they might be effective, why, you know, we we are pretty confident about the chemical imbalance theory and all these sorts of things. 01:48:32:14 - 01:48:46:23 RAGY GIRGIS There's so many other points I wanted to I've forgotten you made a lot of good points. Oh yeah. Yeah, I did want to mention I, I want to validate a lot of I mean, most of what you're saying, not all of it. I don't know as much as about, you know, pharmaceutical companies. I do know that all trials now are on clinicaltrials.gov. 01:48:46:23 - 01:49:08:19 RAGY GIRGIS And if they're not, you know, I mean, one wouldn't be able to certainly pharmaceutical company wouldn't be able to use it as a registration trial. But yeah, I want to validate, like you said, you're I totally 104, 105 patients are being prescribed psychiatric medications in the US. Many of them may be prescribed inappropriately. Most patients are prescribed sick in medications from their primary care physician, who may not know how to use the medications, as well. 01:49:08:19 - 01:49:14:21 RAGY GIRGIS As a psychiatrist, I understand that you feel that psychiatrists aren't maybe much better than primary care physicians. 01:49:14:21 - 01:49:17:00 ROGER MCFILLIN No, I mean, that's why it's backed up. I mean, there's we. 01:49:17:01 - 01:49:19:24 RAGY GIRGIS Figured I could make that. Yeah, I could claim that in. 01:49:19:24 - 01:49:21:13 ROGER MCFILLIN Some cases I. 01:49:21:15 - 01:49:21:19 RAGY GIRGIS Can. 01:49:21:23 - 01:49:26:11 ROGER MCFILLIN But in some cases, I'm just worried that it's it's worse. I hear you, and because. 01:49:26:11 - 01:49:26:23 RAGY GIRGIS You feel that. 01:49:26:23 - 01:49:28:00 ROGER MCFILLIN There's just so many as. 01:49:28:00 - 01:49:29:11 RAGY GIRGIS An incentive or something. 01:49:29:13 - 01:49:52:23 ROGER MCFILLIN Well, so first of all, that's your specialty area. Okay. If you had to acknowledge a lot of the points that I made today, and I think they're valid, I think they're grounded in evidence. I think there's a swell of, of harm to patients and real questions about the validity of our mental health system in the United States. 01:49:53:00 - 01:50:13:14 ROGER MCFILLIN You may be protected in a bubble in New York City. I'm aware of that. But it's such a swell that the tidal wave is going to overwhelm everybody. Right? And so we have to be aware of what is happening to harm patients across the globe. We have to be really focused on what works and what not, what does not work. 01:50:13:20 - 01:50:49:05 ROGER MCFILLIN We have to communicate scientific findings accurately, clearly, transparently. And that day of just blindly relying on some of this data coming out from very poor studies, even though they might be published in something like, The Lancet or the New England Journal of Medicine, like those days are now over and there's an awakening. And so I'm, I feel kind of bad because there's a lot of things you said today that I think are going to come back to hurt you, and I'm going to want you to come back on to be able to defend yourself because we're going to clip a lot of this, and I'm going to be honest about it. 01:50:49:05 - 01:51:12:14 ROGER MCFILLIN Like we're going to clip a lot of the statements that you made because they were very definitive. I think that's really problematic for where we are now as a nation and our health care and trying to communicate this effectively. There's also a lot of debate that exists from psychiatrists. So it's not this is not a Roger McMillan clinical psychologist debating a the psychiatry world. 01:51:12:20 - 01:51:32:03 ROGER MCFILLIN I think there's a lot of things that you said today that are up for debate and challenge, including Joanna moncrieff and a number of other medically trained doctors who either pulled herself out of the system or are focused on communicating this stuff directly, or are on the front lines of like drug tapering to get people off drugs. Because what we're seeing is people get better when they get off drugs. 01:51:32:05 - 01:51:58:07 ROGER MCFILLIN And I'm going to be clearly I'm going to clearly state this in my practice, clients are improving in front of our eyes when they safely taper off drugs, not with a lot of support and with other interventions, but the drugs themselves are really impairing quality of life. For many people. It is not a better life to be sedated or blunted emotionally. 01:51:58:09 - 01:52:25:08 ROGER MCFILLIN It does not in any way align with our historical understanding of emotion regulation. It doesn't. It does not in any way relate to a robust information on our ability to adapt to life circumstances like we are very, very resilient. You can go through a very hard time, meet the minimal criteria for what we label as clinical depression, and in all likelihood, you're going to move past that. 01:52:25:08 - 01:52:52:14 ROGER MCFILLIN And on the other side, there's a lot there's a lot of growth and transformation that occurs. But what happens when you start telling people that what they feel is an illness, it's genetic, it's outside their control. It's a brain disorder. You fundamentally impact their own understanding of their human experience. There's an invalidation process because there's a lot of people who are suffering, who are in very adverse conditions. 01:52:52:15 - 01:53:16:03 ROGER MCFILLIN It could be, you know, trauma, some of the worst of it, like when you see somebody, you know, in a really dangerous situation or young children in communities where there's violence and poverty and you start drugging them, what are the implications of that as a model, as a paradigm? Do they move through it and do they grow it? 01:53:16:03 - 01:53:48:06 ROGER MCFILLIN No, they don't. They become what happens psychologically is you end up getting an almost a war or a battle with your own emotions and thoughts. The idea of viewing them as symptoms of an illness is something that has consequences that we rarely talk about. So my clients become scared of their own emotions or scared of their own thoughts, which I think you would agree is fundamentally incompatible with living well and being well. 01:53:48:08 - 01:54:15:01 ROGER MCFILLIN And, and it's unfortunate what we're doing in this country because we're affecting generations and the consequences are really severe. You know, it's a lot gets blamed on Covid for the mental health crisis. But when you actually look at the data, it was on an upward trajectory of mental health problems. A practice like mine should not be as busy as it is as an industry, the therapy industry, the psychiatrist, there's way too many of them, right? 01:54:15:03 - 01:54:41:19 ROGER MCFILLIN It's not like, hey, this is a advancement in health. By having more therapists and more doctors prescribing drugs, and that is elite mental health care. That's the pinnacle of scientific supremacy. When you start comparing outcomes to other places in the world that don't have that same model, I mean, that's a whole nother podcast for another day. You know, you start seeing that the Western allopathic approach to mental illness is a failing paradigm. 01:54:41:21 - 01:55:02:10 RAGY GIRGIS Let me address some of these points. Yeah, we definitely disagree about the data and that that's okay. It's it's it's okay to have a debate. I didn't quite expect that we'd have a debate, but that's okay. We had a debate now to to back up a little maybe talk about something with which are about which we could agree a little more. 01:55:02:12 - 01:55:21:23 RAGY GIRGIS You know, I believe although we talk about medications, that is my that's certainly my area and I do near biological research. I fully believe, again, coming from Columbia, especially in the bio psychosocial model of, of psychiatric illness that strongly, you know, strongly, that, that. 01:55:22:00 - 01:55:22:21 ROGER MCFILLIN Is that a strong. 01:55:22:21 - 01:55:24:16 RAGY GIRGIS Emphasis on the psychosocial component. 01:55:24:18 - 01:55:27:14 ROGER MCFILLIN Is that is that a materialist perspective? 01:55:27:16 - 01:55:44:13 RAGY GIRGIS I'd have to know exactly what you what you mean by materialist. But I learned and I know Columbia is probably one of the few, one of the few programs in the country now that still teaches a lot of psycho dynamic theory and therapy. I think that one thing society's done, which is very unfortunate, is that we have I think. 01:55:44:13 - 01:55:44:24 ROGER MCFILLIN That's harmful. 01:55:44:24 - 01:55:50:14 RAGY GIRGIS To the baby out. You think psychodynamic therapy is psychodynamic theory is harmful? 01:55:50:16 - 01:55:55:17 ROGER MCFILLIN I think it can be. I think it's often misapplied, misunderstood and not that helpful. 01:55:55:19 - 01:56:15:04 RAGY GIRGIS Well, I think we've thrown the baby out with the bathwater that the bathwater being, you know, Freud psychosexual theory, which I guess a lot of people don't like. But the baby is all a psychological theory, I think. Not only is psychodynamic theory a great way of understanding people. See, I think your expertise is, if I'm not mistaken, CBT and eating disorders. 01:56:15:06 - 01:56:19:14 RAGY GIRGIS I think, I mean, there are no medications for eating disorders right now as far as a proof reading. 01:56:19:16 - 01:56:21:23 ROGER MCFILLIN They participate. They prescribe them now. 01:56:22:00 - 01:56:23:15 RAGY GIRGIS And well, there's a lot of co-morbidity. 01:56:23:21 - 01:56:26:18 ROGER MCFILLIN And no, they don't prescribe a necessary for and and or. 01:56:26:20 - 01:57:02:16 RAGY GIRGIS Therapy is also very helpful for people with depression and schizophrenia. I mean, almost all patients, not necessarily all, but almost all. I also really do if we're prescribing psychiatric medications to 60, 65 million Americans, or at least lifetime, maybe not at one time, they're going to be many examples or case reports or anecdotes of, excuse me, of, of of, you know, significant side effects, bad situations, a lot of those people, again, because you are diagnostic criteria only have 80 or so sensitivity and specificity. 01:57:02:16 - 01:57:17:20 RAGY GIRGIS They're going to be a lot of cases in which these medications don't work. Having a number needed to treat of seven, for example, means that you need to treat seven people with a medication to obtain, in this case, remission or relapse of depression. That means a lot of people are just not going to respond. 01:57:17:20 - 01:57:28:05 ROGER MCFILLIN Does not mean those numbers mean nothing when when we say when we set up the entire podcast and talk about the problems of published research, we can't just throw out numbers like that. That's ridiculous. 01:57:28:05 - 01:57:35:23 RAGY GIRGIS But the point is, is just that means that a lot of people are not going to respond. And so I understand a lot of people don't respond and we do our best. I can't speak to every psychiatry. Most people. 01:57:35:23 - 01:57:36:03 ROGER MCFILLIN Don't. 01:57:36:07 - 01:57:37:01 RAGY GIRGIS Prescriber. 01:57:37:07 - 01:57:40:16 ROGER MCFILLIN When you when you look at the absolute. But that's what I say when you when and. 01:57:40:21 - 01:57:42:08 RAGY GIRGIS If it's if it's. 01:57:42:10 - 01:57:43:03 ROGER MCFILLIN I don't even think that's. 01:57:43:03 - 01:57:46:04 RAGY GIRGIS Accurate. But even even that it's that means, you know. 01:57:46:04 - 01:57:48:07 ROGER MCFILLIN People get better on the placebo. 01:57:48:09 - 01:57:53:04 RAGY GIRGIS And what where those that number needed to treat I mean it incorporates placebo. That's what it means. 01:57:53:04 - 01:58:14:05 ROGER MCFILLIN But yeah, I mean the degree to what to to whether it's pain, mental health, the degree to which people get better, believing that they're taking a drug is so meaningful. This is why I asked about the materialist paradigm, because the materials paradigm is something it's going to start reducing, reducing everything down to the material, like there's a biological process. 01:58:14:05 - 01:58:42:07 ROGER MCFILLIN Eventually that's going to be causal in this, where the post material science is incorporating quantum physics, the bio field and energy healing, there's great work coming out of Columbia. I wish I had her, her name. I was trying to look for it. There's this whole new, evolving post materialist science that demonstrates, like, all these new ways or different ways that we have an effect on, on each other, unconscious isness on matter. 01:58:42:09 - 01:59:15:08 ROGER MCFILLIN Like, it's very, very complex with like a lot more a sound methodological studies than existing psychiatry. So like, if we fundamentally don't even understand things like the nature of consciousness or quantum reality or quantum physics, the bio field in medicine, if we don't have those type of conversations in mental health, then it's like getting in a time machine and going back to 1985 or earlier, 1990 and started saying things like the bio psychosocial model in psychodynamic therapy that. 01:59:15:08 - 01:59:34:13 RAGY GIRGIS I don't know, I hear what you're saying. Now, listen, we don't have to understand. We can understand 1% of the brain. We understand less than one. I mean, I'm I'm a fan of Neil deGrasse Tyson and he and Michio Kaku, they often kind of remind the listeners and I think appropriately and I appreciate this. They remind us the scale of the universe and how little we know. 01:59:34:14 - 01:59:53:13 RAGY GIRGIS Yeah, I forget which one says that for all of what we know and for how powerful we are, what we can't even do or understand, what one one cell of a of a, of a blade of grass can do, which is photosynthesis. We don't understand how that works, but that doesn't mean you throw out, I think what it. 01:59:53:15 - 01:59:55:11 ROGER MCFILLIN What it says is at least speaks to humility. 01:59:55:11 - 01:59:56:02 RAGY GIRGIS Of course. 01:59:56:07 - 01:59:57:00 ROGER MCFILLIN Right. 01:59:57:02 - 02:00:01:02 RAGY GIRGIS But naturally. But we work with what we have. I mean, it doesn't mean we just stop and we don't do. 02:00:01:02 - 02:00:22:08 ROGER MCFILLIN Anything, but we have more. And when you're in the bubble and you're reduced to the material paradigm, and you're in a profession that has aligned itself with the pharmaceutical industry, that's why I said, you take away these drugs and the role of the psychiatrist in the greater health care system disappears. You'd have to reinvent yourself. So there's such an inherent conflict that exists. 02:00:22:08 - 02:00:56:18 ROGER MCFILLIN You have to defend the drugs because you're prescribing them, because you're studying them, the researching them. You're communicating it from that paradigm. It you're the only psychiatrist that have these conversations with me are the ones who said, yeah, I know. And I left and there's and there's lots of them, you know, and there and there and I do believe I mean, I'm part of this is a profound disappointment because I think we need medically trained, physicians in the mental health realm because I think there's so much we can be doing with lifestyle. 02:00:56:20 - 02:01:06:18 ROGER MCFILLIN There's so much with innovative research around, like, light and metabolic health and nutrition. There's sleep like there's so many aspects of. 02:01:06:18 - 02:01:07:18 RAGY GIRGIS This. 02:01:07:20 - 02:01:31:18 ROGER MCFILLIN I know, but it's not it's not what's being provided as the standard of care in our country. And I bring in those physicians to have those conversations. But how we practice is stone ages. I mean, we're still pushing pharmaceutical drugs. And if you meet a like, you never meet a psychiatrist who thinks the same way around these drugs, like, I'll get like ten different patients. 02:01:31:20 - 02:01:53:12 ROGER MCFILLIN They're all given the same diagnosis. They're all treated with so many different drugs over, you know, ten years. They're all horrible. Like they're doing really, really bad. But somehow they've been brainwashed to think, well, I've got this illness for life and I just have to keep taking these drugs. And so I do think we're inducing chronic mental health conditions, by the way, that we're treating them. 02:01:53:14 - 02:02:09:04 ROGER MCFILLIN And at some point, you know, in our communities that they'll be teenagers or young adults where a doctor will say, lay out a couple drugs and say, pick one like that. That's how bad that that's how bad that has gotten. The nurse practitioner. 02:02:09:04 - 02:02:28:12 RAGY GIRGIS I don't know about that, but I was I mean, I can't comment, I have not heard of that. Maybe it happens. I mean, listen, I don't know what to say about that, but what's happening in psychiatry, I you might not agree. I might not disagree with this. The state of research and whatnot in psychiatry is not much different than in other fields in medicine. 02:02:28:17 - 02:02:30:14 ROGER MCFILLIN Oh, it's much different. 02:02:30:16 - 02:02:32:04 RAGY GIRGIS No, it's very similar. I mean, we. 02:02:32:10 - 02:02:53:04 ROGER MCFILLIN How can you say that's. How can you say that when, when it's just it's subjective and we you can actually make statements here that we have a biological basis for this. But how much money has the NIH dumped into trying to identify mental illness as a brain condition, so much so that they've abandoned it. 02:02:53:06 - 02:02:54:19 RAGY GIRGIS That sure, they've abandoned. 02:02:54:21 - 02:02:55:15 ROGER MCFILLIN The dollars in. 02:02:55:15 - 02:03:04:11 RAGY GIRGIS Research on I'm funded to, you know, examine the pathophysiology like neurobiology of psych. I'm not sure. What do you mean, abandoned? 02:03:04:13 - 02:03:25:23 ROGER MCFILLIN Well, the the dollars aren't there in the way that it used to be. Now, now, there's certainly money that's being invested in various aspects of physiology and biology and mood and elsewhere. But like as far as like that, that decade of the brain and the amount of money that we devoted, 90s into like 2015, that paradigm is gone. 02:03:25:23 - 02:03:44:05 ROGER MCFILLIN Really. We've we've kind of moved away from it because it just hasn't produced results. It hasn't done anything to move the needle. In fact, if anything, you know, in my opinion, obviously it's much, much worse. But it's certainly hasn't reduce the burden of even severe mental illness in this country. 02:03:44:07 - 02:03:44:23 RAGY GIRGIS Sure it has. 02:03:45:03 - 02:03:45:24 ROGER MCFILLIN Oh my god. 02:03:45:24 - 02:03:49:15 RAGY GIRGIS Doc, no, no, there's no doubt about that. 02:03:49:17 - 02:03:55:03 ROGER MCFILLIN Doc. You think we've reduced the burden of mental illness in the United States? 02:03:55:05 - 02:04:03:19 RAGY GIRGIS So I would look at mental illness and this is what I was talking about. I would look at mental illness, the kind of way we look at cancer. So rates of cancer. 02:04:03:21 - 02:04:06:17 ROGER MCFILLIN That's a that's a problematic comparison. 02:04:06:19 - 02:04:09:09 RAGY GIRGIS No, it's my memory anyway that the rates of. 02:04:09:09 - 02:04:13:02 ROGER MCFILLIN Cancer because we're not really good at treating cancer either. 02:04:13:04 - 02:04:32:08 RAGY GIRGIS So the analogy is actually, I think pretty strong. So the rates of cancer are increasing. So the question is why have we have we failed our treatments for cancer. No. Good. Do they not work. They do work. And we have more treatments than we've ever had. And some of them are amazing. But cancer rates are rising. But we understand really why they're rising. 02:04:32:12 - 02:04:48:10 RAGY GIRGIS The rising for maybe 2 or 3 main reasons. Three I think. And this is actually maps it very well to mental health. Number one early identity, earlier identification. Number two people are living longer overall, I know in the past couple years has changed. But overall people are living longer. 02:04:48:10 - 02:04:52:20 ROGER MCFILLIN So but people are getting people are getting cancer younger now than any other point. 02:04:52:20 - 02:05:18:08 RAGY GIRGIS And maybe four and increase of rates of obesity, which is strongly linked, you know, to cancer of course. And then increased substance use you this four things psychiatry is not much different. So but we're able to treat cancer, you know, much better. Psychiatry is similar. We're able to treat more severe mental illness better. Remember rates of chronic hospitalization have gone down. 02:05:18:08 - 02:05:34:24 RAGY GIRGIS So severe mental illness they've gone down. While rates of mental illness have gone up. We can treat the most severe forms. We disagree about the data, but for example suicidality and stuff like that. And again, we can keep people out of hospitals so that severe mental illness or a severe kind of form so similar to cancer, that's what I'm saying. 02:05:35:03 - 02:05:57:12 RAGY GIRGIS They're very similar. And again, people do I just I can't go through every saying, I don't know every study. But, you know, if we compare mental health in general or depression in psychosis to that diabetes, you know, you have type one diabetes, which is very different than type two diabetes. Type one diabetes is like purely genetic. It's just I mean, that's it. 02:05:57:18 - 02:06:26:06 RAGY GIRGIS Type two diabetes is is mostly it has a female component, but it's very environmental and social. Right. Maybe to a larger degree than depression and psychosis, for example, there's a much stronger biologic component. There's a psychosocial component. There definitely is. But it's smaller than, for example, the environmental one. It's type two diabetes, which is almost exclusively related to overweight and obesity and those sorts of things. 02:06:26:08 - 02:06:36:13 RAGY GIRGIS So I mean, we do the best that we can. We have research methods, we have bias and limitations. And what we do, we try to address it. You know, we do the best we can. 02:06:36:15 - 02:06:47:12 ROGER MCFILLIN I want to give you credit. You are the first person who actually stated that we're actually doing a good job and we're reducing the burden of mental illness in this country. You're the first person I ever heard that. 02:06:47:14 - 02:06:51:10 RAGY GIRGIS Mental illness is increasing, but our ability to deal with. 02:06:51:12 - 02:06:53:19 ROGER MCFILLIN I said reduce the burden. 02:06:53:21 - 02:06:56:04 RAGY GIRGIS It. I guess we're just. There's more. 02:06:56:04 - 02:06:57:00 ROGER MCFILLIN I mean, I mean. 02:06:57:00 - 02:06:58:07 RAGY GIRGIS There is more mental illness. 02:06:58:09 - 02:07:05:03 ROGER MCFILLIN There's more people disabled by a mental illness diagnosis than in any other point in measurable history. 02:07:05:03 - 02:07:06:19 RAGY GIRGIS I'm agreeing with you. I'm agreeing. 02:07:06:19 - 02:07:13:09 ROGER MCFILLIN So I don't think we're reducing the burden. When people become disabled, they can't work there. 02:07:13:11 - 02:07:29:22 RAGY GIRGIS I'm agreeing with you. There's more. There's a lot more that we need to do, and we need to figure out what's going on. But it's not the medications crisis. But number two, you specifically, we were specifically talking about the severe forms, cancers increasing, mental illnesses increasing. There's nothing more people are affected by these things for sure. But I'm saying that we are I. 02:07:29:22 - 02:07:52:04 ROGER MCFILLIN Think we should quit. I think I think we should question the paradigm for both the manner in which we understand cancer, in the manner in which we understand mental illness. I think they're both great examples of how poorly we are in producing outcomes through Western medicine. I do agree with that comparison. I don't think we've reduced the burden of cancer. 02:07:52:06 - 02:07:58:11 ROGER MCFILLIN I don't think our outcomes have improved. I think there's more people developing cancer and younger. 02:07:58:17 - 02:08:01:07 RAGY GIRGIS That's that's true. I'm not I but I didn't say that that's true. 02:08:01:11 - 02:08:05:06 ROGER MCFILLIN And I don't. And I don't think our outcomes are strong at all. 02:08:05:08 - 02:08:18:00 RAGY GIRGIS They're getting better. So rate rates of death are decreasing as they are, for example, like I said. But if we're looking at the severe forms of the conditions they're improving. But yeah, the the overall burden is increasing. I'm agreeing with you. 02:08:18:01 - 02:08:39:00 ROGER MCFILLIN Yeah. I mean and same with mental illness. We have more people identifying with mental illness. I agree, we have more people disabled by mental illness. We have lower quality of life of people who are mentally ill during their life expectancy is is reduced. The drugs are factors in metabolic illness. So the weight gain. 02:08:39:00 - 02:08:39:23 RAGY GIRGIS Yeah they have in the. 02:08:39:24 - 02:09:02:04 ROGER MCFILLIN In the health related conditions that are associated with people who get placed on those drugs. In my opinion, many of these conditions that are drugs would have been episodic conditions that could have more safely helped move somebody through that condition and come out the other side. But we've just created this narrative in this country that mental illness is a brain condition. 02:09:02:04 - 02:09:17:11 ROGER MCFILLIN Once you have it, you can have it forever. And then you need to be on these drugs forever when we clearly don't have data that supports that. And so what we're doing is we're creating a burden of mental illness for a large portion of people that should have never been in the system in the first place. 02:09:17:13 - 02:09:29:19 RAGY GIRGIS Yeah. Mental illness for the most part, is episodic. That's right. We do have data that suggest that medications and they're actually approved for maintenance treatment, like the prevention of of relapse and those sorts of things. I mean. 02:09:29:19 - 02:09:34:12 ROGER MCFILLIN Horrible data, I mean horrible, horrible data, like, I mean, those things a clinical trial never. 02:09:34:14 - 02:09:37:24 RAGY GIRGIS I mean, I don't know what, you know, the clinical trials, I don't know. Yeah. 02:09:37:24 - 02:10:01:03 ROGER MCFILLIN I mean, this is why we're having this this is one of the reasons why, Bobby Kennedy is heading HHS, right? Because of being able to understand the corruption that took place in our government agencies and industry, that drugs got brought to market that should have never been brought to market because they didn't really meet baseline, safety and efficacy. 02:10:01:05 - 02:10:23:00 ROGER MCFILLIN And it becomes a it becomes a turnstile like of, FDA reviewers end up going and working and making big money in the pharmaceutical industries. Right? So just being able to say that because it received FDA approval from a trial that was conducted by the same company, that is going to benefit from that drug being to market is not is not the same thing as saying that means it's a it's effective and it's safe. 02:10:23:02 - 02:10:33:06 RAGY GIRGIS And know I was referring that that's just shorthand because we can't discuss every single trial. I can't even remember every single trial. But that's just shorthand for, for discussing the, the specific. 02:10:33:06 - 02:10:34:09 ROGER MCFILLIN Trials. Yeah. I mean when. 02:10:34:14 - 02:10:35:09 RAGY GIRGIS They're like a trial. 02:10:35:09 - 02:10:37:21 ROGER MCFILLIN We're in fundamental disagreement. 02:10:37:23 - 02:10:38:19 RAGY GIRGIS We do disagree. 02:10:38:22 - 02:10:40:07 ROGER MCFILLIN Fundamental disagree. 02:10:40:08 - 02:10:41:00 RAGY GIRGIS The value of. 02:10:41:00 - 02:10:41:19 ROGER MCFILLIN The about. 02:10:41:20 - 02:10:42:07 RAGY GIRGIS Studies. 02:10:42:12 - 02:11:07:17 ROGER MCFILLIN About the values of the studies about the health of this country, about the mental health system that we continue to fund from government that continues to expand while people continue to experience a higher burden of mental distress. I think we fundamentally have a different viewpoint of the human experience. One years is a relatively very small, short period of time in all of human history. 02:11:07:20 - 02:11:22:09 ROGER MCFILLIN We're talking about, you know, only a few decades of this, shift in paradigm that we can find a drug like insulin for diabetes and that we can cure these conditions. I mean, that was how it was discussed in the 90s. How old are you? 02:11:22:11 - 02:11:23:00 RAGY GIRGIS 45. 02:11:23:04 - 02:11:40:03 ROGER MCFILLIN I'm 49. So you and I kind of came through that era and, you know, that was really pushed. We're one of two countries with direct to consumer advertising. It really has been sold to the American public that you take this drug and it reduces the burden and like it's a standard of care and just accept it. Right. 02:11:40:03 - 02:12:09:01 ROGER MCFILLIN Take the drug. It's it's what's going to help you. And we've gotten therapies to to recommended therapies. You know nothing about this. It's like an absolute joke. You have like a 25 year old who just graduated and she's recommending like a 16 year old to go on an SSRI. I mean, it has become absolutely, fundamentally criminal. I don't know how well, I do know how we've gotten here, but one of the way we've gotten here is that, there's been too many experts who are repeating the narrative and actually selling the narrative for the pharmaceutical companies. 02:12:09:01 - 02:12:41:07 ROGER MCFILLIN It filters down from that area. So, I'm going to kind of try to close out the the podcast episode on you. And I have have two different perspectives, and we were able to passionately discuss that today. And I actually value that. And I'm passionate about this. I've had to sit with too many people harmed, and I'm part, kind of on the front lines of, of a movement trying to look at what have we done professionally to create this burden and this harm. 02:12:41:09 - 02:13:03:05 ROGER MCFILLIN And I'm past throwing myself into the data on this. I feel like I got a good grasp of it, its limitations and its challenges. But you willing to come on here and and have that discussion is meaningful to me. And I think it's meaningful to our to our listeners, because people can actually take a step back and say, all right, well, what do I think's going on? 02:13:03:05 - 02:13:21:15 ROGER MCFILLIN Like, how can I make informed, you know, decisions? What does he believe that shows strong evidence that we should support him versus what's doctor McFarland saying? And, you know, I feel like I have to challenge the expert, like, that's my job on this, but I have these same conversations behind closed doors. Obviously, you probably get that sense from sitting with me. 02:13:21:15 - 02:13:22:14 ROGER MCFILLIN I'll give you the final word. 02:13:22:14 - 02:13:41:06 RAGY GIRGIS Yeah. Oh, no worries. I appreciate you bringing me on again. I also appreciate, the work. The work with, if I can say his name. Your your colleague Ralph. Oh, yeah. I appreciate, you know, communing with both you and you are being so hospitable. I want to mention, again, I, I didn't, you know, quite be a debate, but I mean, that's okay. 02:13:41:08 - 02:14:00:17 RAGY GIRGIS Everything else, I think, you know, I think we we agree about the state of mental health. I think it's more about the, the, the cause of the state. And that's a health about which we disagree. But very clearly, if I can say that something is clear, the the etiology of where we are today is, is maybe what we disagree about the most. 02:14:00:19 - 02:14:05:10 ROGER MCFILLIN Yeah. No, I mean, listen, you're a standard trained academic psychiatrist. 02:14:05:10 - 02:14:06:08 RAGY GIRGIS I'm pretty traditional. 02:14:06:08 - 02:14:08:17 ROGER MCFILLIN In that sense. Yeah. Like extremely traditional, very. 02:14:08:17 - 02:14:10:13 RAGY GIRGIS Oh yeah. There's no doubt, professor, about that. 02:14:10:14 - 02:14:22:14 ROGER MCFILLIN Yeah. You are professor at the Ivy League school. You're at the epicenter of it, right? And so your willingness to drive down from, from New York and to be here and have this conversation, you probably know what you were walking into fully. 02:14:22:20 - 02:14:24:22 RAGY GIRGIS Not quite, but whatever. I mean, it's okay. Yeah. 02:14:24:22 - 02:14:45:20 ROGER MCFILLIN No, there's usually those who understand what I, what I do, you say I'm, I'm not going to enter into that conversation with you, which I think is a problem in our, in our field generally. Like we have to have these conversations, these debates have to have to happen. And I think it's an ethical, it's a legal and ethical mandate really. 02:14:45:20 - 02:15:19:14 ROGER MCFILLIN Because how how do you provide informed consent to patients? You know, let's say you're going to suggest an SSRI, you know, how do you communicate to that patient like what it does? What are the effects of that? What do you need to pay attention to? You know, you know, somebody is I probably said this last point, if somebody is going to be prescribed a drug and there's the probability they can have permanent sexual dysfunction, become suicidal. 02:15:19:16 - 02:15:28:12 ROGER MCFILLIN And I think you agree that taking the drug and compared to, to, a placebo has shown to increase suicidal ideation. Right. 02:15:28:14 - 02:15:33:11 RAGY GIRGIS In some sense, I think overall, I think the data are equivocal, but that has definitely been shown in some studies. 02:15:33:11 - 02:16:03:08 ROGER MCFILLIN Yeah. Like Lexapro, for example, was just published. I think it was 1 or 2 years ago. A study, for seven seven year olds to 18 year olds. So as children as young as seven, there was a six fold increase in the, in the, Lexapro group compared to placebo. About 10% of the kids became suicidal as young as seven versus, I don't know, 2%, you know, for the placebo group. 02:16:03:10 - 02:16:15:01 ROGER MCFILLIN So, I mean, those were staggering numbers. It's the data was clear. And you know, what the conclusions were by the study authors? Lexapro is safe and tolerable. 02:16:15:03 - 02:16:22:04 RAGY GIRGIS Right? I don't want to open up another kind of bag to going. I could address that. But, I'm not debating the. 02:16:22:05 - 02:16:23:13 ROGER MCFILLIN I mean, why would you why would you. 02:16:23:13 - 02:16:23:22 RAGY GIRGIS Study? 02:16:23:22 - 02:16:32:10 ROGER MCFILLIN I don't remember, I mean, why would you give a laxative? Why would you give a Lexapro to a seven, a seven year old who's anxious? I mean, then I would have been put on Lexapro at age seven. 02:16:32:10 - 02:16:42:10 RAGY GIRGIS Now, I believe the the veracity or validity of how you reported this study, that that that probably happened. Those are probably the data reported by the study. I believe you. 02:16:42:12 - 02:16:58:14 ROGER MCFILLIN Yeah. I mean, the big problem is the study authors were also receiving money from the pharmaceutical company that produces Lexapro. AbbVie. And that's a clear conflict of interest. Right. And those go into guidelines that like pediatricians use. 02:16:58:20 - 02:17:14:05 RAGY GIRGIS But just to be clear, I'm one and I don't want it. I don't want to get into too much. I know we're ending now and I appreciate it, but I actually enjoyed myself. I didn't, I didn't expect it, but I enjoyed myself. It was fun. I, I appreciated speaking with you. I've, not to extend things too much longer, but I've. 02:17:14:07 - 02:17:31:00 RAGY GIRGIS I first learned of you while I was watching you on Alphabet Stuckey's podcast. Oh, yeah? And you know what? I even though we, you know, clearly don't agree about a lot of things, I just for whatever reason, I appreciated your episodes. Oh. Thank you. I appreciate what you had to say. 02:17:31:02 - 02:17:42:19 ROGER MCFILLIN Yeah. So the next time, next time that you'll be on the podcast, will will be with, a couple other medical professional psychiatrists who disagree with some of your statements today, and we can agree on that. 02:17:42:21 - 02:17:45:17 RAGY GIRGIS I'd love yes, I'd love to meet Doctor Moncrieff. 02:17:45:18 - 02:17:46:08 ROGER MCFILLIN Okay. I'll get in. 02:17:46:08 - 02:17:48:00 RAGY GIRGIS Touch with me. She's very prominent. 02:17:48:03 - 02:17:51:15 ROGER MCFILLIN Yeah. No, she's doing. I think she's doing great work. 02:17:51:17 - 02:18:01:13 RAGY GIRGIS Her again, her style. She credibly reported the results. You have to. I mean, that was great. The results of the studies that she reviewed. 02:18:01:15 - 02:18:06:22 ROGER MCFILLIN Doctor Rocky Garcia, I guess I want to thank you for an absolute or radically genuine conversation article. 02:18:06:23 - 02:18:07:19 RAGY GIRGIS Yeah. Thank you.