"Diagnosis Culture": Technology and mental health
Can you check my depression level? Oh my God [music: Dream Sequins by NMESH] Welcome to Ditto Nation, and I'm here with Professor Joanna Moncrieff You famously wrote an article about the serotonin model of depression, which has been very influential diagnoses now could be viewed as subcultures and people will identify themselves by their diagnosis, sort of siloing and algorithmic marketing, which clusters people together this search for new forms of identity kind of after identities formed by ethnicities and nationalities and music genres and that kind of thing I see this new subculture trend emerging that's based around, for example, ADHD, autism, borderline personality disorder is another big one So my work has been mainly about different ways of understanding the sorts of drugs that we prescribe for mental health problems like antidepressants the main point that I've been trying to make is that we have, we are misunderstanding what they do, and how they act and this misunderstanding is the idea that they work by targeting an underlying biological abnormality that produces the symptoms of the problem or the disorder that someone is said to have that model of how drugs work has been borrowed from the rest of medicine, where it is a fair description of how drugs work so in medicine, even if the drug doesn't target the underlying basis of the disease, most drugs act on the mechanisms that produce symptoms so if you think of your inhaler, your asthma inhaler, what that is doing is it's not curing the cause of asthma but it is dilating the passages in the lungs, which constrict during an asthma attack and cause wheezing and because it dilates those air passages, the wheezing is relieved. So that's how it works. It works on the biological mechanism that produces wheezing I've been suggesting that there is no evidence that any class of medication that we prescribe for mental health problems works in that way and that's partly because we have no evidence that for biological mechanisms, underpinning any mental health problems or symptoms but it's also partly because there's another way of understanding what drugs are doing when someone takes a drug and that is what I've called the Drug Centred Model of Drug Action and I've called it that to emphasise that drugs like antidepressants, for example, are drugs and drugs are chemicals that change the normal state of the body and the sort of drugs that are prescribed for mental health problems crossover into the brain, so they change the normal state of the brain Hey, guys, so I'm going to take you through the invisible illness lanyard I've been making so first off is my little fidget toy, little kitty then I've got my COVID certificate and my medications chronic fatigue syndrome, anxiety, borderline personality disorder, autism, depression, chronic pain, costochondritis, and ADHD and you can think of them really as being fundamentally quite similar to recreational drugs like alcohol so if you drink a lot of alcohol, and you're feeling sad, often you no longer feel sad anymore because the alterations produced by alcohol, the altered state that it produces, overrides your underlying feelings and we have a phrase for that in English, we talk about drowning your sorrows we also know that alcohol is good at counteracting social anxiety alcohol does that because the characteristic alterations it produces include the state of social disinhibition and that overrides, temporarily overrides feelings of anxiety that some people have when they're in social situations that is the Drug Centred Model and what I'm suggesting is that drugs like antidepressants, antipsychotics, or drug treatments for ADHD, for example work in that way as far as they work as far as they have a specific pharmacological effect because, of course, a lot of their effects is a placebo effect, we know that but as far as they have a specific pharmacological effect, it is likely to be because of these alterations that they produce and they will produce those alterations in anyone, regardless of whether they have an underlying disorder or not you know, alcohol produces the same sort of, of changes in everyone and one of the alterations that antidepressants produce is an emotional numbing effect people describe how antidepressants reduce the intensity of positive feelings like happiness and joy, as well as negative feelings that is obviously going to impact on someone who is feeling depressed, that's going to make their depressed feelings register as less [tourettes happens] So to be clear, in terms of depression, for example, or what you would now call bipolar what I was told when I was younger, for example, is that it's, you know, if you have depression, it's a chemical imbalance and what you're saying is that the drugs, which are being used to treat depression would have the same anaesthetising qualities or properties on anybody regardless of whether they were, you know, suffering or not it can be used to treat somebody who feels very sad, for example, but it would work the same way on somebody who didn't feel particularly sad Yes, absolutely. And there's just been a study of volunteers published a couple of weeks ago, that shows just that that shows an emotional numbing effect of antidepressants in volunteers in people who don't have a diagnosis of any mental disorder this idea that so many people were told that depression is caused by a chemical imbalance and people were being told this until a few months ago that idea is not supported by evidence as I showed in an umbrella review that I published with with a group of colleagues in the summer I've got 1000 voices just screaming in my head, I've got a sense of impending doom, and highly anxious What do you think causes depression? when I say depression, I'm using that in a fairly non scientific way. Because I think, you know, depression used to be the scientific term, then it became Bipolar, or Bipolar II but when I say depression, I mean, sort of chronic, feeling low. What do you think does cause that? Well, first of all, as you're implying, I think that the idea of asking 'what causes depression?' as if we're thinking of 'what causes liver disease?' is problematic, because it's different I don't think you, I don't think depression is a thing like liver disease that can be mechanically caused in the same way so I don't think that the fact that depression is not caused by serotonin abnormalities means that it must necessarily therefore be caused by some other sort of brain process depression is a mood which is a sort of prolonged emotional reaction emotional reactions are features of complex living organisms, mainly human beings, but to some extent, some other higher animals emotions are reactions to our circumstances they are a way of indicating actually, the situation is not good, or the situation is good, if it's a positive emotion depression, most of the time is a reaction to circumstances that people don't like; that are difficult and stressful and make people unhappy So I'm a media professional and I have been doing that for many years, for better part of a decade it was one of the top health and wellness media sites, it still is when you go and you Google things, any kind of ailments from you know, a sprained ankle to, you know, bipolar disorder, they are one of the top I was working alongside the content team who, you know, we're in charge of all the media from from top down all of all of the words published on the sites we were targeting Search Engine Optimization a whole lot. That's a standard practice for pretty much any digital media company at this point
when you are writing to the behaviours of people searching for things - so that's taking analytics from search engines, specifically Google they sort of like rule the entire internet that means that you're getting information on what people are searching for, how they're searching for it meaning the phrasing that they're using, different keywords, stuff like that you're creating content, articles, websites that those Google trawlers can kind of, like, pick up on, and then push your content to the very, very top of the Google search page so there was a really aggressive push over a couple of years to target some really specific things that people were searching for, especially in mental health the company was putting out articles that, that were very basic about, you know, what is Borderline Personality Disorder? What is Schizophrenia? What is Asperger's or Autism Spectrum Disorder? they're also doing a lot of quizzes in the mental health sphere, they had a whole landing page specifically for quizzes so you could sort of do these question and answer tests to see if you possibly were on the spectrum for Autism, or if you have ADHD the things that are really, you know, highly talked about right now online and of course, there was a lot of fine print that was associated with that work, like, you know, obviously "if you think you have one of these mental health conditions, you know, consult with an actual psychologist, psychotherapist, counsellor, et cetera" there's a lot of language like that on the site, but you know, it was definitely still kind of sensational to have those sorts of quizzes that a person could just do on their phone, or whatever if they were just curious about something, or paranoid or whatever, you know they were just really easily consumable, you know? this company in particular was very, very skilled with Search Engine Optimization, they're very good and they had some very smart people that were working on the team specifically for that, and it was very effective in terms of making the site extremely successful Exactly, this is why my whole polycule is autistic we fuck better I always thought that mental health disorders were a combination of environmental, historic and maybe genetic factors, that's an opinion shared by some and it feels like in the last sort of couple of decades, people have really been chasing after the biological factor or you know, the genetic factor, or whatever it is; the neuropharmacological factor because you can monetize that, and you can treat it in a very, you know I don't want to get too Marxist here or whatever, but that fits into a Capitalist structure quite well because you can target it, and monetise the cure of it whereas you can't do that so easily with environmental factors and you certainly can't do it with historical trauma and the treatment for trauma is probably far more difficult because it involves relationships with therapists and counsellors and that kind of thing Our emotions, including depression, are a response to our current circumstances, but the way that we respond to our circumstances is inflected by our past experiences and also probably, to some extent by our genetic makeup so yes, absolutely, I think that's right. and there's lots and lots of evidence that people who have had, you know, adverse events in childhood or been maltreated in childhood, are much more likely to get depressed than people who haven't as a whole, the mental health services have tended to focus on the biological origins of mental health problems, because well, for a whole variety of reasons partly I would agree with you, because it makes them easier to commodify it provides opportunities for various actors to make profit: the pharmaceutical industry, but also private health companies but I think there are other reasons, as well I think simplifying what are actually very complicated human problems in this way, is convenient for politicians the political system as a whole doesn't have to look at society and think, 'Oh, goodness, you know, so many people are unhappy and struggling, we need to make big changes' instead, they can just say, 'okay, we just need to increase funding for mental health services'. That's a lot - that's a much easier thing to do. and I think if you look at people themselves as well, there is sometimes a desire to want a quick fix to believe that this is a problem in the brain that can be solved by something as simple as a drug so I think there are all these factors that you know, sort of boost this idea that mental health problems are biological conditions that can be treated with drugs I take my meds every night as prescribed and I've woke up this morning, and I feel like I am disassociating. The other thing that a lot of psychiatrists do, I think, and psychiatric literature does, is to talk about theories most of them will admit that this is a theory, you know or they'll say things like, depression may be caused by low serotonin levels or, you know, sometimes they'll even preface it in advertisements by saying 'scientists don't know exactly but they think-' and that would it be okay, maybe, if they also presented different ways of thinking about these problems if they also said, well, actually, we don't have any evidence for this, it may be the case that depression is related to low serotonin but we could also think about depression in a completely different way, but no one ever does so all that is really offered to people is this narrow biological model is this idea that you know that depression is a chemical imbalance and in fact, I also have realised after the publicity that was surrounding the paper we published on serotonin, that many psychiatrists are just firmly convinced that depression is a brain problem that mental disorders are brain problems by and large and that if it's not serotonin, it must be something very similar and therefore it doesn't really matter whether you call it serotonin or not doesn't matter whether you say that it's not proven because something like that will be proven eventually I think there's quite possibly a genetic component to sensitivity, but there's going to be a huge influence of upbringing on sensitivity and it's probably, it's quite difficult to disentangle the influence of upbringing and sensitivity if you think that something has a biological cause then psychosocial influences are always going to be relegated to being just peripheral concerns, really if you're depressed and it turns out that you have a problem with your thyroid, and that's what's making you depressed, obviously, you need to get treatment for your thyroid problem and whether you're having problems in your marriage as well, or difficulties at work, are really not relevant if you're using that same model and saying that schizophrenia or depression are the same sort of thing, even if you're saying, 'yes, there are psychosocial influences' what you're also saying is the most important thing is the biology and reversing whatever biological abnormality is, you know, is going on, is taking place The stuff you were doing is helping to create the zeitgeist, you know if you make a tool, if you make a diagnostic tool, then make it readily available, you kind of amplify it algorithmically and you make it as, you know, metrically optimised as possible it's not a one way street. Do you know what I mean? people aren't just like hearing about it in one place, going directly to you and that's the end of the story that's then feeding back into culture During the years that I was there, it was pretty obvious that you know, something was happening in the digital space with that we had people who worked on social media teams and us ourselves as people who worked alongside content were always looking at social things like social media, these trends that were going on like TikTok became very, very popular at the time that I was there and there's an entire health space on TikTok, you know, not to mention, mental health space it would be negligent to say that it didn't, you know, feed into that loop, it obviously did the culture was really interesting, it was like nothing I had ever seen in a professional space before you know, I've worked for a lot of pretty big media companies and magazines in my career, and I have never seen anything like this where, um it was extremely utopian they really, really did a lot to create optics of this very idealised workspace and they did a good job too you know, as you kind of work there more and more, you started to kind of be very suspicious of it, I guess you could say and they were, you know, of course, very concerned with optics, with the whole 'woke washing' thing that kind of trickled down into the language that we were using there were some very odd things, in fact, actually just saw something turned into a meme from this particular website you couldn't say 'women' if you're talking about like pregnancy or like gynaecological things they literally have articles that say things like 'vagina owners', and 'uterus havers' it was bought by a company that was in the health space but not the media space I believe that it was a subsidiary of an insurance company who wanted to optimise our readership and wanted to direct them to health care so they specifically use language like 'we want to be healthcare disruptors' and this of course, goes into, like telemedicine and like telehealth this is all a trend that kind of spiderwebs off of the pandemic and things that kind of became commonplace in the industry like instead of going to a doctor, like you Zoom a doctor or whatever, stuff like that they wanted to create a pipeline where you could basically be Googling a disorder or Googling an issue whether it was you know, health or mental health, you would be sent to this page, you could read about it and they could further direct you to another professional or platform where you could be prescribed medications for things People who worked on the actual teams doing the content and doing the research on like, the lower level, were really, truly, like they really believed we're really making health accessible 'we're really making information accessible in this world where it used to be stigmatised a generation or two ago' or whatever, you know 'we're really helping people' Truth about star seeds and ADHD, that no one tells you the truth is that if you're a person with ADHD, you may think that there's something wrong with you but I can tell you, as someone who has ADHD, there's nothing wrong with you, you're just spiritually gifted and I'm talking in general, from my perspective ADHD stands for Accessing Directly Higher Dimensions and grounding the energy of higher dimensions into the 3D matrix so if you're someone with special needs, if you're someone who has been told the narrative, that there's something wrong with you it's time to flip the script and really go within and ask yourself what resonates for you? So the history of the DSM in particular is that it started life as a psychoanalytical manual, and a description of sort of loose clusters of symptoms or problem behaviours they were described as reactions. So you had 'depressive reactions' and 'schizophrenic reactions'
there were all sorts of challenges to psychiatry in the 1960s and '70s there was the Anti-Psychiatry Movement there was a perception that psychiatry had overreached itself and anyone could be diagnosed and there was competition for therapy from non medically qualified therapists and all those things combined to make the psychiatric professionals think that they had to model diagnosis much more closely on physical health conditions so the DSM III, which was produced in 1980, was produced with that idea and they got rid of the whole idea of mental health problems being reactions, and they brought in lots more disorders all these, all these so called diagnoses that are in the DSM and also in the modern international classification of disorders - the European system, or WHO system are not actually diagnoses in the sense that we think of diagnosis in the rest of medicine they are not identifying an underlying biological abnormality that explains the symptoms the diagnoses don't do any explaining, they are purely descriptive labels so they're just labels for collections of what have been called symptoms but what are actually the sort of complaints that people bring to psychiatrists or psychologists or other professionals Can I just cut in - so it's important though, that they are self reported? so unlike, for example, you know, if we were to use the example of a cancer, you know, I can take a biopsy and look at the cells but with anything to do with these diagnoses, you know, the symptoms that you're describing are self reported so they're coming from an individual They're reported by the individual themselves, or sometimes by other people, sometimes by their family or by the police the police might bring someone in saying, you know, 'They're behaving in a disorderly fashion. We think they're unwell' but, yes, they are subjective aspects of behaviour that have been subjectively identified to be abnormal so diagnoses in mental health are labels. They are not they are not explanations I think that's the most important thing because I don't think people always understand that they think that when they've been given a diagnosis, it explains something it doesn't explain anything. It's just the way that the doctor has decided to call the problems that you have described 12121212...
what? Woah. This is nice oh is those one of those dirt things? all right pick it up, now I throw it aw - don't - ok, I like that how long have I been out for? Oh a hole so where would I OK, I grab this, don't, oh, did it At the moment ADHD is a very common label among adults as well as children, of course it started off as a label given to children whose behaviour was disruptive at school, mainly partly because they hadn't matured at the same rate as other children were maturing there's evidence to show that children who get a diagnosis of ADHD are young for their school year, or more likely to be young for their school year another thing that's interesting about the label of ADHD is that the label of adult ADHD has very little in common with the label of childhood ADHD and even though we call it the same name, actually, we're probably pinpointing different sorts of difficulties The label of adult ADHD as a doctor writing in a UK newspaper recently took a test and found that he qualified as having adult ADHD anyone could identify themselves as having adult ADHD because the symptoms are things that we all experience and the criteria for getting the label is simply 'do these do these symptoms interfere with your life to a significant extent?' which of course, again, is a highly subjective judgement that is going to depend on all sorts of things it's going to depend on the individual presenting with a problem it's going to depend on the doctor and how he interprets what the individual is saying to him or her so other labels that have have interested me over the last few years have been Bipolar Disorder Bipolar disorder started off as something called manic depression: a serious condition that goes back for centuries, that involved people having periods of very dramatically disrupted mood, or arousal arousal would probably be a better way to describe it because people who experience are experiencing episodes of mania are over aroused and don't sleep and their behaviour becomes completely chaotic and disruptive and they usually end up in hospital, often picked up by the police, or something like that and then often after that period of mania, people will have a genuine sort of low period or they may just have a sort of reactive low period that is almost like a sort of come down from the manic episode so that's what Manic Depression consisted of then in the 70s, it was suggested that there was a milder version of this Manic Depression and that some people might have mild manic episodes, not end up in hospital and that depression would be a sort of bigger part of the picture that already started to become something that was really more, you know, more difficult to define and more difficult to distinguish from other people who had a label of depression because of course, we all have periods when we're you know, feeling better and getting on with things and a more active than usual and then the idea came along that there was, that bipolar disorder might consist of just rapidly changing moods: fluctuations of mood, emotional instability, or lability and this idea of the Bipolar Personality or Bipolar Spectrum Disorder was constructed and like ADHD, Bipolar Spectrum Disorder could be applied to anyone because the sort of symptoms that were suggested to define it, were things like, you know does your mood go up and down during the day? do you have good days when you're very productive and bad days when you're not very productive? so again, Bipolar Disorder went from being a very rare and quite characteristic and recognisable condition to being something that was really quite, quite vague and could be applied to almost anyone really I'm fucking bipolar, wait, no, I'm not, oh, shit, yes. some days I feel like I can conquer the world and other days I want to stay all day in bed sometimes I feel that nobody really fucking understands me because I literally have a fucking chemical imbalance in my brain, ain't that just dandy? whether I tell you to stay or to fucking go away, please don't take it personally before you throw me to the side and call me Jekyll and Mr. Hyde take the time and motherfucking get to know me That leads me on to a question about the diagnostic tool used in this country a lot, which is called the GAD-7 PHQ-9 or PHQ-9 GAD-7 which takes the form of a questionnaire and I think there's a statistic that medication is offered to around 80% of people who receive the questionnaire what can you tell us about that? So the GAD-7 and PHQ-9 are questionnaires that are used in general practice mainly to diagnose anxiety GAD-7 is an anxiety tool and the PHQ-9 is a depression tool, and the PHQ-9 was developed by a pharmaceutical company I can't tell you which one I'm afraid I can tell you which one laters guys, because I'm willing to take the hit Pfizer is the company it's a collection of nine symptoms if you get above a certain threshold, you're meant to be showing signs that you might have clinical depression it's very easy to score above that threshold as, as you're indicating so it's - it's setting a very low bar for the diagnosis of depression, which obviously, would be quite a good thing if you're selling an antidepressant Could you imagine seeing this questionnaire and reading like, how often have you been bothered by any of the following problems? and reading something like 'trouble relaxing' and answering 'not at all'? like, people like this exist? And you've never, you haven't at all been able to stop or control worrying? That's just something that hasn't happened in the past two weeks? I just cannot wrap my mind around it that people like this exist because I am not one You have something I want There are tonnes of things about -- like you mentioned -- Autism, ADHD, Personality Disorders were huge different modalities of therapy, different drugs, stuff like Psychosis, like what does Psychosis feel like? what's the difference between like hallucinating and experiencing Psychosis Dissociative Disorder? we worked with the DSM quite a bit, that was pretty much main source material when we're doing citations and things like that new symptoms and and things that you would need to get a diagnosis - like symptom lists. That was major You'd have like a new disorder dropping New symptoms dropping, let's commission article Yeah, that was another major part of it, too is updating existing content because that would change so much new discoveries, new drugs, new symptoms, new diagnostic guidelines And that could be useful information for somebody who wanted to get medicated Yeah, the content team was writing to people who may have family who are experiencing this kind of stuff but the contract was always written to get them to the doctor And now with this new thing they're building it will be 'click here to speak to a physician' Exactly. It's gonna be very easy
I came out as gay and everyone said 'we know'. and then I came out as bipolar. And everyone said 'we know' is there anything else y'all wanna tell me? Antidepressants come from numerous different chemical classes, they're all doing completely different things lots of drugs that are not considered to be antidepressants have similar effects to or equivalent effects to antidepressants in randomised controlled trials including things like opiates, and benzodiazepines, barbiturates the one common thing, the one thing they all have in common is that they are all psychoactive drugs that change the normal state of the brain and therefore the normal state of our of our thinking and emotions, et cetera drugs that do not have psychoactive effects have not been found to have antidepressant effects and there are a couple that have been tried. Folic acid was tried, for example for depression and a thing called substance P, and both of them failed so it looks as if giving someone something that makes them feel a bit different lowers their depression scores I think there are various explanations for that, I think the most likely explanation is it's an amplified placebo effect that people are experiencing so they're not meant to know whether they're getting the placebo or the antidepressant, but of course, many people can guess particularly people who are taking the antidepressant because they start to feel a bit different and that is likely to give people an amplified placebo effect because they think, 'Ah, I've got the active drug here, I haven't got the placebo, I've got the real drug' and so those people are likely to do a bit better than the people who just get the placebo That makes sense. Could an analogue be something like homoeopathy, where there is an argument that, you know - in randomised controlled trials with homoeopathy - the act of going to see somebody who will talk to you and give you a thing - that can be enough to help you with whatever it is you're suffering from so it's kind of irrelevant whether or not the substance works the fact that there is a process involved is enough to kickstart some kind of recovery or to act as a valid treatment is that kind of an analogue to the ethic, to the action that drugs are having? Yes, absolutely. I mean, lots of things happen when you go and see a doctor and you get a prescription for antidepressants, you give part of your problem to someone else by acknowledging it and acknowledging it publicly, other people are taking some of the burden from you you feel listened to you feel heard, someone offers you some support and then if you get a prescription, you know, you hope that that prescription is going to make you better and all those things are going to contribute to you improving but the other thing that that all these drugs may be doing is by making people feel different, somehow distracting them from their underlying feelings and that's maybe what I was saying about ECT. ECT basically shakes up the brain, obliterates someone's short term memory at least for a short period of time
so people are distracted from their depression; from their low moods, they are sort of shaken out of it temporarily and what we know with ECT is although some people seem to get better for a short period of time, the effects wear off and in a few weeks time people are about where they would have been, anyway So I guess that leads us neatly into the current trend for hallucinogens and Ketamine therapy mood altering drugs or mind altering drugs have a similar effect on depression that means that Ketamine and hallucinogens, you know, Psilocybin, that kind of thing would work in a similar way So yes, I mean, that suggests that any psychoactive substance that makes people feel a bit different is going to have either a placebo effect or just an overriding effect and distract people from from their their depression hallucinogens have been used in a slightly different way, though the trend for Ketamine and for hallucinogens started out at least as this idea of psychedelic assisted psychotherapy so there was the idea that when you're under the influence of a psychedelic substance, you may have some insight into the nature of your difficulties and get some ideas about how you could progress and that a therapist might be able to bring out those insights so I have some sympathy with that model. I think it's potentially quite interesting, although I think it's been sort of overhyped a bit but I think it's potentially interesting. What worries me is that what's happened in the States with Ketamine is that the therapy is expensive [Ben: And Ketamine is cheap] And Ketamine is cheap and so actually the therapy, you know, quickly falls away, and it just becomes ketamine treatment. And people just turn up for their ketamine hit
you know, I don't think we should then call that a medical treatment Not a medical treatment. Julie joins us, and you've had a few of these treatments just in the last week, [Julie: two] right? [Julie: two] What was your experience like? and how are you feeling following that treatment? After my first treatment, I woke up the next morning and I had less heaviness in my throat and in my chest [Applause] Things would change also with the news, there was all that stuff with Johnny Depp and Amber Heard they were claiming she had some kind of personality disorder or whatever, they both did. That kind of stuff was real successful that was a very poised strategy in terms of kind of getting eyeballs on the page if there was something like that in the news people kind of automatically gravitate like we had stuff on what it's like to like, date a person with personality disorders. All those different keywords, like
what is love bombing? What is discarding? like these real common Cluster B kind of situations, you know, there would be ones that were really broad, where it was like you know, what is an eating disorder? and like, a rundown of what the DSM says, basically, maybe with some quotes from some actual physicians and stuff like that and then it would get very granular, and then it would say, okay, here are like, I think there's like eight or nine eating disorders in the DSM, if I remember and it would just, you know, just kind of spiderweb off into content about those specific things like Anorexia. Nervosa, Bulimia, Binge Eating Disorder really weird ones, like, like night eating, like sleep, eating and stuff like that and then it would get even kind of smaller and more granular based on what people were searching for and what they're interested in so stuff like 'can men have eating disorders?' they were doing a big project where they were gathering all of these different conditions and all of the content for each condition like under umbrellas like pages, like landing pages so there would be like a Schizophrenia page, there would be an Eating Disorders page, there would be an Autism, ADHD, you know, so on and so forth like literally everything that you can think of, and they would start with in production you know, they wanted to produce the ones that were the most popular first so it was those ones and just boom, boom, boom, here's an article on what the symptoms are here's an article on how a diagnosis is made here's an article on the different medications or different treatment plans that are used for this particular thing Would it be a really blunt thing to say that perhaps depression, Bipolar, you know however, we want to label it, these things probably have a variety of factors and at the moment, what we're using to treat them is basically an anaesthetic you know, we're sort of using this blunt tool to just sort of hammer down emotions to treat it we have been led to believe that there are neurochemical issues underlying but actually it's more likely that there are complex factors causing depression probably mostly environmental - as we were just talking about - and historical trauma, maybe some genetic, but that we're just using a one size fits all solution to that at the moment because the alternatives are too difficult or expensive But the social prescription is basically being prescribed, say, joining a cycling club, and they have been shown to be shockingly good for people but what surprised me is that it's not done as a matter of course, this is kind of portrayed as a radical idea Yes, yeah, I think the whole system is organised so that that is the result so you come in, you say what your problems are, they get translated into symptoms, you get a label, and then you get a drug for the label and in the process, what your actual problems are, and how to deal with them in a sort of creative or imaginative way that actually might produce a sustained solution, it gets lost it's not, it's no longer part of the conversation One of the arguments that I hear most often for the validity of, say, an ADHD diagnosis or Bipolar diagnosis is that it gives you access to help, you know, especially for children If they don't have that diagnosis, they don't have access to the help they need but it has this kind of cyclical effect, where we're creating more and more people who believe that they are an ADHDer, or a, you know, a kid with ADHD whereas actually, you know, they have been given that label to access help. You see what I mean? It becomes a vicious circle It's really problematic, it's really problematic, it's something I think we really desperately need to do something about you can completely understand if your child is struggling at school, and there is help available and to get that help, you need to label them, you're going to do it but there are negative effects from getting that label, because then that child may start to absorb this idea that there's something wrong with them something wrong with their brain, not just that, you know, they were struggling with this particular thing and it's the same with adults, often labels can help to, like you say, to access support to access, financial support, that can be really important but again, they feed into people's self image, and then people start to see the rest of their lives in these terms for the rest of their lives in terms of I'm a person with ADHD, I'm Bipolar. How's your day going? Oh, I woke up. And that was the first problem. And [sobbing]
I think it's a bit like astrology, you know? I think if you have it in your head that, you know, I am an X, Y, Z, I'm a whatever star sign this is how or these are the behaviours that I should exhibit. I think people very much radically underestimate how powerful that is you know, and how hard it is to get those things out of your head, and how hard it is for other people not to prejudge you on the labels that we give ourselves so if I were to say, you know, I am a Sagittarius with ADHD, X, Y, Z, it doesn't really matter if anybody else knows that or not those are the narratives that I'll hold. And that's how I will define myself. Do you think that people underestimate the power of that? Yes, I do. I agree with you, I think it's really powerful and there have been some studies that show that people who believe for example, that depression is caused by a chemical imbalance are more pessimistic about their chances of recovery and less likely to think that anything that they do is going to improve their outcome so I think absolutely it has this, what Ian Hacking calls 'looping effect' that you, you know, you get the label, and then you start to interpret everything in terms of that label and everything therefore confirms the label for you. And he was writing about how people understand their behaviours and their problems through a concept that is offered to them
and I think this is probably what we're seeing with people having sort of ready access to the internet and sharing videos and sharing stories that people are picking up on different frameworks through which to understand their individual difficulties Go on, go on then! [Let me go out, let me go out this room please] I can't help it, my ADHD lad. I can't help it, my ADHD. [Put it down, put it down! Put it down then! Put your phone down! Put it down put your phone --] somebody got stabbed up to death 'cause you pissed me off, yeah? You're a little dickhead you're a little dickhead! Dickhead dickhead dickhead dickhead, yeah? man's hands all covered in blood, yeah? Man's gonna get loads of time for stabbing him up, yeah? and he was a nonce and loads of people were after him so I did the man a favour, innit? People are interested in things online you know, things become things sort of surface in consciousness in the zeitgeist, as you were saying those things then get searched for. The more that those things get searched for it becomes a kind of feedback loop and a self perpetuating kind of algorithmic mechanism where it kind of demands content, you know it sort of summons these things from the deep and then you know, people, you know, like the company that you're working for will then create these things in response to the searches rather than just give people the information, somebody has thought, you know, people have thought, 'okay, we can now plug this into a whole, you know, system of things, diagnosis' I don't know what a health coach is but, you know, it doesn't sound very professional if it's anything if it's anything like the UK, we now have online legal services, which is basically a warehouse full of 19 year olds and one lawyer you know, that kind of thing. I very much doubt that the system is full of veteran doctors or anything like that it's then being plugged into maybe insurance data, you know, insurance data is very valuable and diagnosis prescription, getting people on to medication When this was announced, there were some real concerns about the professionals involved and whether or not it was going to affect the editorial integrity we had a very rigorous system of having things medically reviewed across all the sites at this large company we were concerned that the actual, you know, veteran physicians and psychologists and counsellors and clinicians that were medically reviewing all of the content -- we were concerned that they were going to prefer to work with their own team of those people you know, these people had been really carefully hand selected and vetted over a number of years and had been doing the work for a long time [music plays] So can we talk about marketing techniques? How are these drugs being marketed historically? So once upon a time, drug companies were only allowed to market to doctors they swamped doctors with freebies with, you know, free mugs, and pens and calendars, and wined and dined doctors, took them out for meals, flew them off to ski resorts for so called conferences I remember a description of a conference where the different drug companies had set up installations almost like it was some sort of grand exhibition and one was an alpine mountainside and one was a circus, for example but something really important has happened in the last, well, since the 1990s the FDA in America allowed drug companies to start advertising directly to the public and because of the internet, and their ability to put material up on the internet - and even though direct to consumer advertising, as it's called, is only legal in America, and I think New Zealand - those messages get all around the world because of the importance of American culture so the sorts of things that drug companies will do for example with depression, they they produced a very famous advert with a with a blob a sort of sad looking blob and talked about how this sad looking blob had low levels of serotonin and then took some Zoloft so the brand name and suddenly perked up and looked a lot cheerier Side effects may include dry mouth, insomnia, sexual side effects, diarrhoea, nausea and sleepiness. Zoloft is not habit forming Endless, you know, pictures of nerve cells and chemicals going across them to try and impress on people this idea that depression is in the brain it's to do with your nerves and it's chemical and a drug can can put it right When you know more about what's wrong, you can help make it right The pharmaceutical industry has been really, really influential in publicising and popularising that idea that, that depression is a chemical imbalance and they, they had to go against people's common sense and sort of deep inner feelings about their emotions some psychiatrists in the UK did some research in the 1990s, into people's attitudes to depression and they found that most people believe that depression was caused by, you know, relationship difficulties, divorce, unemployment, child abuse the sorts of things that we know make people depressed they didn't think it was a brain problem. They didn't think it was due to a chemical imbalance
and they also felt that taking a drug for depression was not a good idea, and that it would just numb people so people I think instinctively have that idea that actually, using a drug for an emotional problem is not a good idea it is like drowning your sorrows and alcohol, which, you know, certainly if you're doing day after day after day is is definitely not, you know, going to be good for you It's a bit analogous to Oxycontin, where you know, people know that, you know, if you give vulnerable people, opiates, they'll probably become dependent on them and it's not through their lack of morality, or their weak will but the narrative that was pushed by Purdue pharma, for example, was that anybody who was abusing their product, was, you know, they were at fault Ready to talk depression? and what are the vibes on that? that sweatshirt is very depression core hey, what's up? You guys? I'm here with my client who is deeply unwell and what's his sign? how does that make you feel? wait, that's like, so embarrassing. I'd be so stressed if I were you have you tried crystals? that's only 300 dollars Do you ever feel that you're a lone voice in this conversation or that you're shouting into the void or anything like that? I know that there are other people who are like minded who have the same views but when I published the serotonin paper in the summer, I realised that we live in our own echo chamber and that the vast majority of the population have never heard of my views on psychiatric drugs have completely accepted the idea that depression is a chemical imbalance that antidepressants are correcting that and were really shocked - the people who did hear the news of that paper - were really shocked to find out that actually, the evidence base isn't there the views of mainstream psychiatry are widely accepted and it's difficult to get a platform to challenge them and I also realised this because of the reaction to that paper, because it felt like we were being shut down we really should not be discussing these things It's interesting to hear you talk about them and to hear you describe them as 'views,' because to my mind, it's not a view or an opinion, it's evidence so in a world where, you know, we're describing a world, which is not evidence based, the DSM is not evidence based and the efficacy of the serotonin model and SSRIs the way that they work; none of it's particularly evidence based but what you're saying is for anybody who wants to read the paper, we'll link to it. But, you know, it's one of the most read research papers in modern times, for sure there's also a very popular article in The Economist, a very popular article in The Conversation but you know, even if a million people have seen that that's a drop in the ocean, for how many people are currently taking SSRIs, globally so why do you think people do perceive it as a view, rather than a fact? I think because so many people are so wedded to this idea that depression and mental health problems are brain based disorders, and they don't want to let go of that I think that's the bottom line it does make many psychiatrists uncomfortable, because - no one can deny that antidepressants, antipsychotics, et cetera, are mind changing drugs you know, that they do have effects on on animals and on normal volunteers that they do make people feel different and if they have those effects, then obviously those effects are going to impact on the symptoms and difficulties that we call mental health problems as you rightly say, it's not just my view, this is a fact about the nature of the drugs that, you know, that are being prescribed but I just hope that more people understand the evidence base and understand that this whole notion that mental disorders are brain problems, is not supported by evidence that there are other ways of thinking about mental health problems, that drugs are not targeting underlying biological mechanisms they're not normalising anything, they're actually creating abnormalities creating chemical imbalances, are altering your normal brain chemistry, then they might hopefully be more cautious about taking them as they should be we haven't done research into the consequences of taking these drugs day in day out for years and years and years we do not know that that's safe. So I just hope that that people get the message that these drugs do not do what people have been led to believe they do, have not been well tested
and we should be very, very cautious about using them I guess all of this is fascinating, because it's such a cyclical process, you know, and I guess all the time that you were working with this and it was for, you know, ad tech, you know, it was making money from advertising or whatever that's one thing but when it becomes, when it gets plugged into everything else it's doing something very interesting to the zeitgeist and the discourse around mental health you know, something gets mentioned in a court, in a court case. If you don't know that that hasn't been provoked by some trend on TikTok or whatever - you don't know where that's come from, and suddenly it's kind of directly plugged into insurance data and how people are medicated Yeah, that kind of seemed like the way that it was going. And it also seems you know, that this is not an unusual thing this is not anomalous to like healthcare media this is pretty much the direction that I that it seems that all of these big websites are kind of going to be going into, at least in some part like there's going to be some element of connecting the readership to some form of health care professional.