What’s Next in Mental Health?

 About a decade ago, one of the most influential psychiatrists of our time, started speaking out against over-medicalization and vested interests corroding the diagnostic system in psychiatry - a system he had helped pioneer. Professor Emeritus Allen Frances points to systemic biases with specialists pushing to expand their own speciality. Dr. Frances has protested that the pharmaceutical industry is capitalizing on this expansion and suggested that the exceptionally lucrative Diagnostic and Statistical Manual (DSM) be taken entirely out of the hands of the American Psychiatric Association. He also doesn’t see the World Health Organization’s corresponding system working any better.In this episode, we discuss with Dr. Frances, how the field of mental health became so medicalized and how the two diagnostic systems are produced.  We look at why specialists can be problematic evaluators when it comes to their own speciality and why a broader, less vested set of shoulders can be more appropriate for setting diagnostic criteria and treatment guidelines. Allen Frances chaired the task force that produced the fourth edition of the DSM (DSM-IV) and is Professor Emeritus at the Duke University School of Medicine where he chaired its department of Psychiatry and Behavioral Sciences. He is the author of the book Saving Normal: An Insider's Revolt against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life.Timestamps:0:00    Experts’ and Pharma’s interests in medicalization7:30    Creating diagnostic systems and APA’s DSM publishing interests9:54    Power balance between specialists vs. primary care13:31 Compensating treatment and therapy before or after diagnosis?17:00 Replacing APA as institution producing the diagnostic system20:25 Role of DSM, symptoms and the quest for biological understanding28:40 Becoming a public critic and witnessing the lack of progress for the severely illRelated episodes on What's Next in Mental Health? The Elephant in the Clinic: The DSM has Fallen Behind. Here is How Psychiatric Diagnosis Might Work in the Future. (with Dr. Colin DeYoung)Should We Stop Prescribing Antidepressants for Depression? (with Prof. Joanna Moncrieff)Other related materialsPreventing Overdiagnosis: Winding back the harms of too much medicine (Allen Frances, talk at Dartmouth College, 2013)Psychiatry & Big Pharma: Exposed (James Davies, lecture for The Weekend University, 2019)Anatomy of an Epidemic (Robert Whitaker, book)

Virtual reality technology has been used for exposure therapy for decades but has not yet become mainstream in clinical practice. Advances in the gaming industry and recreational applications for VR have, however,  made equipment increasingly affordable and available. In this episode we discuss VR exposure therapy with Dr. Andrew Sherrill who is Assistant professor and clinical psychologist at the Emory Healthcare Veterans Program at Emory University School of Medicine and specializes in VR therapy for anxiety. Dr. Sherrill guides us through what VR exposure therapy is like in practice, why it is appealing, what limitations it has and what he thinks the future will bring.Timestamps00:00 Virtual reality exposure therapy in practice18:00 Role of the clinician, self-help, telehealth and group therapy in VR26:46 VR therapy results and patient preferences 31:50 Range of virtual environments in VR therapy36:15 Fears and safety in VR exposure42:44 Disadvantages of VR therapy49:07 Future of VR therapyRelated materialNY Times: Virtual Reality Therapy Plunges Patients Back Into Trauma. Here Is Why Some Swear by It.Overcoming Clinician Technophobia: What We Learned from Our Mass Exposure to Telehealth During the COVID-19 Pandemic

Over the decades, the pharmaceutical industry and parts of the psychiatric profession lead us to believe that depression was caused by a chemical imbalance in the brain and that antidepressants helped correct it. Now a new effort is being made to say that antidepressants are effective, even if the biological mechanism is unclear. The problem is that both these narratives have been falling apart in the background for a long time. Surprisingly for many, the difference in efficacy between a placebo and antidepressant is so small that many drug trials don’t find it and most patients would be unlikely to really notice it. It’s not that change doesn't happen, it’s that it happens in the placebo groups too. And then there are the risks to take into account.In this episode, we discuss antidepressant drugs with Professor Joanna Moncrieff. She is Professor of Critical and Social Psychiatry at University College London. She is also the lead author of the impactful 2022 scientific review of the serotonin theory of depression. It is one of the 400 most shared scientific papers of all time out of the full 21 million tracked articles.This episode discusses the decades of efforts to find a biological basis for depression and issues with the diagnosis. We dive into the interpretations of the small difference between antidepressants and placebos and discuss the increasing awareness of the risks of long-term antidepressant use. Finally, we discuss the influence of the pharmaceutical industry, the professional interests within psychiatry and the research funding channels. Is the funding system protecting patient safety? How much should we curtail the indications for antidepressant prescribing? And finally, is the turning point for mass prescribing in sight? Episode timestamps:0:00   The search for a biological basis and problems with the diagnosis19:23 Disentangling placebo and antidepressant effects and emotional numbing33:33 Withdrawal problems44:05 Vested interests and high stakes55:05 Problems with research funding59:28 Finnish depression guidelines1:02:50 The future of antidepressantsRelated materials- Molecular Psychiatry: The serotonin theory of depression: a systematic umbrella review of the evidence- The Conversation: Depression is probably not caused by a chemical imbalance in the brain – new study- Psychiatry & Big Pharma: Exposed (Dr. James Davies, videolecture) - The Emperor's New Drugs: Exploding the Antidepressant Myth (Dr. Irving Kirsch, videolecture)- Royal College of Psychiatrists: Antidepressants- NICE Guidance: Medicines associated with dependence or withdrawal symptoms: safe prescribing and withdrawal management for adults- Anatomy of an Epidemic (Robert Whitaker, book description)

Psychedelic-assisted psychotherapy is an area of great research interest, widespread media coverage and increasingly also financial dimensions. In this episode, we discuss psychedelic research and everything related to it with Dr. Sandeep Nayak. Dr. Nayak is assistant professor at the Johns Hopkins Center for Psychedelic and Consciousness Research where he studies treating psychiatric disorders with psilocybin-assisted therapy. He also works as a clinical psychiatrist at Addiction Treatment Services (ATS) at Johns Hopkins Bayview Medical Center.Episode timestamps:00.00  A brief history of psychedelic research7.40    Where the funding is coming from10.10 Psychedelic-assisted therapy in practice20.55 “Bad trips” and mystical experiences27.39 Scientific results so far38.13 Non-specific effects, relationship effects and placebo44.43 Implementation in regular clinical practice46.22 Risks and harms55.45 Financial incentives and hype effects1.01.45 Expected timeline for FDA approvalRelated materials:Johns Hopkins - Center for Psychedelic & Consciousness ResearchMultidisciplinary Association for Psychedelic Studies (MAPS)Trial of Psilocybin versus Escitalopram for DepressionMDMA-assisted therapy for severe PTSD: a randomized, double-blind, placebo-controlled phase 3 studyPsychedelics, placebo effects, and set and setting: Insights from common factors theory of psychotherapyNew York Magazine: Cover Story (Podcast)