This image and one below is taken from the Sequencing.com website.  Will Powers got his PFS patients to get Whole Genome Sequencing done through sequencing.com.  He read the resulting information using gene.iobio.

The ‘system’ – ‘powers-that-be’ is/are unhappy with developments like this for several reasons. One concern is that our genetic data may reveal risks of future illnesses which, if the data fell into the hands of an insurance company, might lead to an increase in our insurance premiums.  Laws and regulations have been put in place to protect us against this.

Another concern is that a ‘cowboy’ reading of specialist data might lead to all sorts of extravagant claims on the back of which people take risks they should not take.  Again there are good grounds to worry about this.

All of this makes sense but it comes with a hazard. It also risks handing to others the power to interpret material that has come from us in a manner that may suit system interests rather than ours. At the end of the day, actions need judgement calls – decisions. Data doesn’t decide.  For us to decide, we need some familiarity with the ingredients going into a decision so we can decide rather than get forced to follow what someone else says.

Among the most striking features of the recent Enduring Sexual Dysfunction Congress was the extent to which Will Powers’ genetic findings supported what individuals affected by PSSD and PFS said about what happens them – details that no clinical trials or other research have so far supported.

Regulations, however, risk leading to Will’s studies getting closed down. We may need to find other ways to continue what he has begun.

Screening Genes

If you are like me, you know little or nothing about genes or about coding computers. But apparently among other things, AI has got to the point of being able to create Apps that can grapple with a lot things previously beyond the reach of ordinary folk like me.

The following post is taken from a set of comments by Peter Grace linked to last weeks Ending Enduring Sexual Dysfunctions post.

Peter Grace

I started thinking of ways to solve the DNA data privacy issue. It occurred to me that if we can’t have people shooting VCF files over gmail without moving operations to Kazakhstan, maybe we could make the data more abstract. Instead of looking at people’s genomes, is there an abstract way to just get a “show of hands” for variant lists of interest without seeing the bodies raising those hands. All that is shared is an integer, a count.

Searching around I found that this protocol already exists its called Beacon:  See also https://www.ga4gh.org/product/beacon-api/

It’s used by institutions but I thought perhaps there is no reason we couldn’t use the protocol.

How it might work specifically:

This proposal is for a small, simple system that lets the community ask and answer research questions like that at scale, while keeping every individual’s genome firmly on their own computer.

Someone in the community, I’m imagining it would be a researcher, curates lists of genetic variants worth investigating. They write up a simple text file containing those variants and post it on a suitable public platform, it might be a curated Github page, or any platform that can be curated. The file might be called something like “PSSD Variant list 14”.

Anyone who has their genetic data and wants to participate downloads the list and runs it through a small custom application on their own computer. The app loads their genome file, checks how many of the listed variants are present, and shows them a count: “You have 3 of these 12 variants.” That’s the moment the user decides whether to contribute. If they want to, they submit the number, just the number, “3”, to a public tally for that query. If they don’t, they close the app and nothing happens.

After enough people have submitted, someone tallies the responses and posts the aggregate finding: “Of 47 self-identified PSSD sufferers who ran Query 14, the average count was 1.8, with 31 people having at least one of the listed variants present.”

The assumption would be that self-selection pressure would ensure that mostly people who genuinely suspect they have the phenotype of interest will download the file and submit their count. You could further encourage this by providing clear instructions about the purpose of each list file and the phenotype it relates to on the website where the files are hosted.

No user information is shared, the researcher doesn’t see where the counts came from, they just see the raw tally.

Python has an existing library for parsing Variant Call Format (VCF) files and the application would be quite simple, just a GUI that lets users load up the list file, run the search and submit their count to the server. The only skills users would need would be the ability to download the application and enough of a clue to know which one the VCF file is. I could probably build such an application, not that I’m any great programmer but it doesn’t need to do much.

Beacon V2 has some extra safety rails to prevent accidental leaks: query rate-limiting and minimum-N suppression. Query rate limiting prevents a leak by a Guess Who/Celebrity Heads kind of situation where you leak by posing too many overlapping variant queries. But it might not be needed in our use case as we would be convenience sampling a population of unknown size rather than a fixed institutional database, that is provided the variant query files were hosted on a site accessible to the entire population, not just members of a Reddit or Facebook group. You can’t play Guess Who if you don’t know the number of faces on the board. Minimum-N suppression might still be needed but that is a no-brainer.

Of course it’s just one possible method of abstracting the data for privacy based on Beacon, we might be able to come up with something better. It is also possible an existing platform could be repurposed for this sort of use.

It may be that the moment you upload the VCF file to anything on the internet you then open up all the legal issues, but Gene.iobio is online and they apparently get around part of the legal issue by only streaming the parts of the genome that are being queried at any one moment so the whole genome is never stored “online” at once.

Depending on the institutional involvement we might not even need to be as careful as I am proposing. If a private individual posts a variant list online and another private individual runs the list against their own genome on their own private computer and then posts online that they had matches for this or that variant, has any privacy law been violated?

If its an instituition posting the variant lists and people are replying with their results to a practicing clinical researcher, that I think is more where the problem would be. But I think if you ask around between the tech savvy and legal savvy you’ll be able to find a way of going about it.

Just making it easier for people to run a variant checklist on their own computer might be helpful for people who can use a computer OK but don’t feel confident with tools like gene.iobio. It also prevents any confusion and people coming back saying “I looked and I have all of those genes!”. It might make it easier to roll out for controls as well, which we may still wind up needing.

Vincent Schmitt

Looking at PG’s comments said;

Yes it seems the right idea.  Some app running on the desktop/phone of the patient. He would be in control of his data and also the app.

Maybe the code for data extraction/computation from the data should be ”open” so that one can check there is no spying on confidential information.

But on the server side, if you want to collect data for stats, you should check the consistency of data.  Imagine one pharma company wanting to spoil your data…

[I can’t see why a pharma company would want to spoil the data – DH – PSSD is a problem that pharma would like to see go away].

Next Steps

I/We (many of us) need people who are much better versed in these things than we are to scrutinize the options laid out here and offer input on what might usefully be done.  Useful in the sense of what might empower us. Rather than useful in the sense of keep us safe (disempower us).

Given that all pharmaceutical companies, all regulators, all politicians and all health service companies shout from the rooftops that their number one priority is to keep us safe,  the assumption has to be that they really mean keep them safe from us.  There is no reason to think academic institutions, other bureaucracies or anyone has empowering us to keep ourselves safe as their number one priority.

I will attempt to run this by some institutions and see what comes back

Linked

This post links to

Calling Isotretinoin and SSRI Problem Solvers

Ending Enduring Sexual Dysfunctions

and on RxISK

Enduring Sexual Dysfunction Congress 

Love Making Actually

Feedback Loop Disorders

The post Grasping the Gene Genie first appeared on Dr. David Healy.

See below for an explanation of this image.

Will Powers work on Post-Finasteride Syndromes (PFS) has generated a lot of interest. It would be easy to misread the responses.

This post asks people with PSSD and PAS to get what are often called Dutch tests done.  The U in Dutch stands for Urine.

Can send your results to david.healy@rxisk.org – not to Dr. Powers.  He was swamped even before the recent Congress and is even more swamped with desperate people getting in touch unaware of the extent to which he is badly over-stretched.

This ask does not apply to Finasteride. Enough material has already been collected by or sent into Dr Powers for Finasteride.  His next step involves trying to figure out if the results he already has provide a basis for testing possible remedies – something that will undo the metabolic road-block people with PFS seem to have,

Will and RxISK are on the same page in viewing the enduring sexual dysfunctions as feedback loop disorders – See Enduring Sexual Dysfunction and Love Making Actually. This is not an effort to divert people away from Will – it’s an effort to avoid him burning-out.  We will be depending on him to shape any interpretations of the data being asked for here.

Dutch and Double Dutch Science

The response from researchers and mainstream medicine to the idea that Will’s work depends in part on Dutch Tests is that these are barely respectable tests likely to tell us little more about what is going on in people than reading the urinary output of the Kremlin or the Pentagon.  I had never heard of Dutch Tests 3 weeks ago.

A skeptical response is normally right but misses the sequence of events here.  Will didn’t start with Dutch tests. He began interpreting genomes where he noticed a pattern of gene findings involving the metabolic pathways for steroid and sex hormones that when combined with a drug like Finasteride that targets a key part of these pathways is almost certain to impact on how we metabolize these hormones more generally.

Problems can arise if we have a deletion in the relevant metabolic genes that normally offer a way to bypass a Finsteride obstruction. We can sail by on Finasteride with no problem if those genes are working fine in us.

Based on the deletion profile, Will predicted a set of likely results on Dutch tests. His prediction for PFS Dutch screens was broadly speaking right.

The PFS pattern is probably not going to hold true for PSSD or PAS for a few reasons.

Neither of these drugs directly impact on the metabolic pathways for these hormones the way Finasteride does.  An indirect impact, however, is possible, especially with PAS, which does have some metabolic overlap with PFS.

Unlike Finasteride both PSSD and PAS affect women just as much as men and to some extent this is likely to lead to differences.

We can only be sure of what Dutch tests might tell us if we do them.  Anyone getting a test kit, ideally needs to get a Dutch Complete Test – that includes dopamine metabolites.

There may be indirect routes to the same final result just as it looks like within the body there appears to be something that is leading PFS, PSSD and PAS folk to end up with a lot of clinical features in common.

It is worth nailing this down as these tests are simple and inexpensive and if the pattern doesn’t hold, it will steer any PSSD or PAS genome investigation in a different direction and perhaps offer hints on the best direction to follow.

There is another reason to move forward like this.  In terms of sheer workload, no-one is going to be able to get through all the work single-handedly especially if it involves in the case of PSSD going back to genome scratch.

The great advantage for PSSD sufferers is that PFS and Will Powers have laid down a template for the kind of problem we are dealing with – a feedback loop disorder – even if the details for PSSD and PFS differ.

Confronting a genome without a focus like this is like looking out on the vastness of the universe.  Finding something in a genome haystack is harder than finding a needle in a haystack – at least with the needle you have some idea what you are looking for.

It sounds great to hear that Will moved from genetic deletions to predicting Dutch test results.  Deletions are a finite number – aren’t they?  Not quite.  We all have tens of thousands of deletions – so we still need a way to separate the chaff from the wheat and even then the work is likely to be painstaking.

Where Will’s strength and medical input more generally comes in lies in interpreting how we might move from some protein change or change in a metabolic pathway to a final clinical symptom.

The plan also is to apply with Dr Powers and others for a research grant to move this forward and establish that it is not just in his hands alone that promising results materialize. This may mean running higher powered and more expensive genome screens. If need be we will use RxISK Prize money to get this going.

Live With or Die From

Is it worth going ahead to get genome screens at this point using sequencing.com and gene.iobio to read the results the way Will has done?

There are yesses and nos to this.

Yes, because we are rapidly moving into an era where this can be done and more and more people will likely take it up, perhaps reading their own and family genomes to understand more about ourselves.

There is a need to remember here that genomes are likely to be like post-mortems – able to show what people can live with rather than die from.

Finasteride and other drug induced problems are different to the cancers, minor strokes and heart attacks we can live with and perhaps barely notice.  They are more like a comet hitting the earth. These one off events offer a better chance of making a link to what has happened.

It’s likely that some people tinkering with genomes the way Will Powers did may come up with reasons why some of us have terrible problems stopping SSRIs or why SSRIs can increase blood alcohol levels for some or why anticonvulsants can weave their way into our nerves and close to become the problem we are trying to treat.

One of many Nos is that there are strict rules on holding genetic material. No one is allowed to hold other people’s genetic material unless it is a doctor or health system and then the holding is governed by strict rules aimed at protecting us from insurance companies finding our results and increasing our premium on the basis of our newly discovered risk profile.

In Will’s case, his work to date has been on his patients.  Expanding this to overseas requests for input becomes a lot more complex if it also means he is left holding the gene baby.

If we can get to a point where we have a somewhat clear idea about what we are hunting for, stand a chance of finding it and have ways to return all screens to the individuals they came from rather than hold onto them, this will be a lot safer all round.

The post Ending Enduring Sexual Dysfunctions first appeared on Dr. David Healy.

This picture comes from a meeting last week in Detroit aimed at tackling and solving the enduring sexual problems linked to Isotretinoin, SSRIs and Finasteride – See Enduring Sexual Problems World Congress.

This was a small but intense and exciting meeting. A great deal of the excitement was linked to some findings Will Powers, a Family Doctor, has come up with.

Everyone on the right hand side of this photo looks slightly shorter than they should and everyone on the left looks taller and bulkier.  Will has dark hair and is second from the right in the back row.

A few months ago, he began reporting on social media that he had some interesting findings from the genomes of people with Post-Finasteride Syndrome. This caused a stir. No one was sure what to make of him or of the findings he was reporting.

He lives in Detroit – so inviting him to the Congress gave a bunch of us a chance to get to grips with him and his findings.  The consensus was these are real findings, they make sense, and we could make progress by getting similar genome findings from people who have enduring sexual dysfunction after Isotretinoin and after SSRIs.

Lots of folk have been donating to PSSD Network and other Charities including RxISK’s charity to support research on these problems. In my opinion, at the moment money would be better spent on getting genomes – at least 10 to 20 Isotretinoin and 20 SSRI genomes to add to the Finasteride genomes Will already has.

We may also need genomes from some folk who have had Isotretinoin or SSRIs and have had no problems on these medicines.

Will has generated a Powers Genome Screening document linked here which is likely very different to anything you or most doctors have seen before.  He has gone out of his way to avoid making claims that you stand to gain from being screened but there is a real sense in which you do.

Even if there is no genetic link to be found to these sexual problems, having a Genome Wide Screen is very likely in the near future to offer useful health information and be a useful tool for all of us.

That said, there is a good chance what Will is doing will shed light on the sexual problems we are dealing with and will inform further research needed to find a cure – in addition to highlighting things that might make things worse and that we should not be doing in efforts to treat ourselves or as research projects. – See Enduring Sexual Problems.

Volunteers Needed

We need the following volunteers – not just to solve the injuries these drugs have caused but also because the findings shed a fascinating light on our sexualities and identities.  So even if you are not injured and not providing data as a control, you may find what this effort reveals made it well-worth supporting someone who is injured.

• 10 or more folk with Enduring Sexual Dysfunction Post Isotretinoin
• We will keep tabs on the people Will has and how more are needed.
• 20 or so folk with Enduring Sexual Dysfunction Post-SSRIs
• Will has genomes waiting – we will keep tabs on how many more are needed.

We will update you on the findings here.

The original post here mentioned a need for controls.  The genetic deletions found in PFS are rare. This means that finding 10 PFS cases each with one of these rare deletions is so improbable that controls are not needed – for PFS. Let’s see for PSSD and PAS.

Urinary Metabolites

In a follow up post – hopefully this week – I will lay out exactly what you need to do and where you can get it and roughly how much it will cost.

When Will did genome sequenced PFS patients, the gene profile predicted a lack of urinary testosterone and other metabolites.  He therefore now asks folk to check their urinary metabolites first of all and does the gene screening to confirm that there is a deletion causing their odd profiles.

It is not at the moment clear that PSSD and Isotretinoin genes will produce the same urinary metabolite profile as Finasteride. The PFS urinary metabolites are still a good starting point – but this may need updating as the gene profiles for SSRIs and Isotretinoin come in.

Costs

The costs are relatively modest – in total the urinary metabolites and gene screen should come to less than $500.  It takes Will 8 hours to read and interpret a new genome and he charges $1500 for this.

He recommends sequencing.com to screen. He then uses gene.iobio to read and interpret the results.  This can take 8 hours or more.  At present, he ill is backed up with genomes to screen. If there is anyone out there who can figures they might be able to use gene.iobio if people get screened, we can crowd-source thoughts on what urinary metabolites the results for PSSD genomes and PAS genomes might point to as tests of the findings.

If anyone is interested to get involved but simply does not have the funds for Will’s interpretation, contact me on David.Healy@rxisk.org and we’ll see what can be organized.  I can also put you in direct contact with Will.

If anyone knows how to help with genome interpretation, please get in touch.

The post Calling Isotretinoin and SSRI Problem Solvers first appeared on Dr. David Healy.

A distinguished colleague (C1) introduced last year’s word of the year – AI Slop – into last week’s The Prozac Liberation Front post.

As an unaccountable editor, I took the liberty to suggest that many of us seemed to figure – or would pretty soon get round to figuring – that AI was all too likely to go the way of the Internet as a potentially democratising force in healthcare.  If it can turn the Wine of decent human interaction into healthcare Water, the consequences for every other less intimate and personal domain of our lives were likely to be even worse.

At the heart of our dilemmas is that health has always been a Liberal and Socialist bastion in which people who cherish liberty on their own part, or on behalf of what the call the ‘people’, hold out against the powers that be – Can We Avoid Being Eaten.

The worry for some (Liberals) has been that the collective in the form of a bureaucracy (Now in US English called a Deep State) would squash individual liberty just as effectively as an aristocracy had or an oligarchy seems likely to do.

The bigger unnoticed worry is that the advent of effective pharmaceuticals, which looked like they might free us up to better live the lives we wanted to live, has enabled Companies (Deep State Corporate Bureaucracies) to effect an entry into the citadel of our liberties by means of a Horse –  Randomized Controlled Trials (RCTs).

T

These Averaging Machines not only get invaders into the city but get everyone to swallow the meds – not just those who might respond. RCTs are also the Gold Standard way to Average Hazards out of Existence.

Large Language Models (LLMs) are also Averaging Machines and with an algorithim or two inserted into screens here or there will ensure that only the messages from company RCTs get heard. It seems inevitable that LLMs will buttress rather than undermine Deep States.

Is there an Achilles Heel be found?  Perhaps not, but there is scope for amusement in the meantime.

Britain’s medicines regulator is MHRA, who you could say are the Still Heart of a Beating UK Healthcare World – just to be clear Hearts are still when dead.  But in their afterlife, bureaucrats will continue to seem to do something as a cover for doing nothing.  Hence a Document proclaiming a Revolution.

Project overview
Your health decisions matter. The information you receive about your medicines should be clear, accessible, and support informed conversations between you and your healthcare professional. The MHRA is committed to leading an inclusive approach to improving medicines information.

To achieve this, we have launched the Improving Patient Information project, to work closely with stakeholders across the health system including patient groups and charities to understand barriers and identify how information can be made more accessible, trusted, and future-fit.

Our aim is to ensure that patient information for medicinal products is clearer, inclusive, and easier to understand. This will be achieved by placing patients at the centre of the project.

A major focus of this work will be improving access to patient information leaflets in the UK through the use of digital solutions.

The Improving Patient Information project has a three-phase approach to delivery:

• Phase one (April 2025-March 2026): Scoping phase focused on engaging with stakeholders across the health system, understanding how patients access patient information and proposing an action plan
• Phase two (2026-2027): Establishing a multi-stakeholder governance structure and collaborating with partners across the healthcare system to deliver the action plan
• Phase three (2027-2028): Reviewing the impact of action plan, developing a strategy for implementation.

We have five design principles to guide our work: patient centred, accessible, trusted, innovative, and standardised.

Research reports
Woodnewton Associates was commissioned by the MHRA to conduct independent research on the role that patient information leaflets provide to informing patients. The findings and recommendations presented in this report are those of the researchers and do not necessarily reflect the views of the MHRA.

• Title  Research conducted on the role that patient information leaflets provide to informing patients
• Details  A research report defining the current baseline for patient engagement with and accessibility of patient information leaflets.
• This research was commissioned and funded by MHRA. Its aim is to provide evidence that will help inform future changes to patient information to make it more accessible, trusted, and fit for the future
• Our action plan is based on evidence we have gained through this research.

WN Report:  Research on the Role of Patient Information Leaflets in Meeting the Information Needs of Patients

Smile and the World Smiles With You

Ron Law, a Risk and Policy Adviser based in New Zealand – perhaps the most active person on another listserve on which Prozac Liberation ran – responded that ChatGPT could have its uses – for making cartoons. This is absolutely true as the recent set of 4 RxISK videos with 2 more to come shows.  He also figured, with a touch of guidance, it was good for Drafting Reports.

Knowing he loves nothing more than tackling regulators, I sent him the link to the MHRA document and was astonished to get a fabulous response within minutes.

A Most Welcome Commitment to Clarity

It is, of course, most heartening to observe the MHRA’s newly invigorated commitment to “clear, accessible, and trusted” patient information. One could scarcely object to an initiative so impeccably phrased, nor to the proposition—advanced with commendable solemnity—that patients ought, in principle, to understand the medicines they are invited to consume.

A Brief Encounter with Institutional Memory

However, for the more historically minded observer, this sudden institutional enthusiasm for transparency does invite a certain… reflective pause.

For it was not so very long ago that the same regulatory architecture appeared to exert itself with quite remarkable vigour in the opposite direction—namely, in the careful management, dilution, or deferment of information concerning potential harms associated with both COVID-19 vaccines and SSRI medicines. One recalls, for example, the rather strenuous reluctance to foreground adverse event signals in a manner that might have been considered “clear” or “accessible” to the uninitiated patient, let alone “conducive to informed decision-making.”

Indeed, the prevailing philosophy at the time might best be described not as patient-centred transparency, but as professionally mediated reassurance — wherein information was filtered through a series of interpretive layers designed to ensure that what reached the patient was not so much the unvarnished evidence as its more palatable administrative rendering.

The Damascus Conversion

In that context, the MHRA’s apparent road-to-Damascus experience is nothing short of remarkable. One is bound to admire the speed and completeness of the conversion. Yet it does prompt a delicate question regarding its precise point of origin. Was this newfound devotion to transparency born of accumulated evidence, external scrutiny, reputational necessity, or merely the natural lifecycle of regulatory fashion? The chronology, if one were unkind enough to examine it closely, may suggest that this enlightenment is rather more recent—and rather more convenient—than the rhetoric implies.

Trust, or the Management Thereof

The present declaration of intent—to place patients “at the centre of every stage” and to ensure information is “trusted” and “fit for the future”—thus carries a certain quiet irony. One is tempted to ask whether “trust” is here conceived as a product of fuller disclosure, or as the outcome of more sophisticated presentation.

Equally intriguing is the emphasis on “digital solutions,” which, while no doubt modern and efficient, may also offer unparalleled opportunities for the dynamic curation of information—allowing inconvenient complexities to be rendered, shall we say, less immediately conspicuous.

An Admirable Aim—In Need of Proof

None of this is to suggest that the initiative is without merit. On the contrary, it is admirable—indeed, exemplary—that the MHRA now seeks to engage patients, stakeholders, and the broader public in the co-production of medicines information. One can only hope that this commendable commitment extends not merely to the refinement of language and format, but to the substantive inclusion of material that has, in earlier iterations of regulatory communication, proven somewhat elusive.

Conclusion: Transparency in Practice

In short, transparency is a most splendid objective. Its true test, however, lies not in its declaration, but in its application—particularly when the information in question is awkward, contested, or inconvenient.

One awaits, with interest, the practical demonstration of this newly discovered virtue.

AI Whisperer

The RxISK Team fortunately has a gifted AI Whisperer – able to prompt AI systems to come up with imagery that has tranformed a set of just loaded videos into something much more loaded than they would otherwise have been. It’s worth enjoying these and getting a sense about what can be done that would have been impossible a year ago.

• Isotretinoin and Consent
• Finasteride and Consent
• Bad Trips on SSRIs
• No Sex – We’re on Antidepressants 

There are two more gems in the series to come.

• Good Trips on SSRIs
• Consenting to SSRIs 

Update

There is a great set of comments below which involve an interaction between Anon – a critic of AI Slop – and Ron who is defending what you can do with it.

Ron’s evidence lies in a 42 – page Chat GPT document linked here – its a much quicker read that you’d expect from 42 pages.

The post AI versus the Deep State first appeared on Dr. David Healy.

Chatting, recently, to two different friends of his separately, mentioning the possible role of SSRIs or other meds in the Tumbler Ridge shooting, a colleague (C1 – the first of 3 colleagues in this post) got blown away by both of them.  Conspiracy theories, they told him. Misinformation – you’re being ridiculous.

One of them – a decent scientist – sent him a ChatGPT read out, which dismissed the role of meds in events like Tumbler Ridge out of hand. Zero credibility.

This echoed my experience with gifted members of my extended family a few months ago, outlined in The Miracle of Artificial Intelligence.  They had just had or were about to have children. The issue of RSV vaccines taken while pregnant came up. Have or have not?  They’d all checked with ChatGPT – having the vaccine was absolutely a no brainer.

Looking at the RSV clinical trials around this time, the data indicates babies brains are exactly what’s at risk with these vaccines. Thanks to The Prozac Liberation Front, central to this post, there a ton of ways companies can hide the hazards. Chat GPT is the latest weapon in the Liberation Front armory.

Doing anything other than going along with the RSV or SSRIs are safe narrative risks pariah status. Forget Socratic questioning as a means of getting a friend or a family member to grapple with the basis of their beliefs. If ChatGPT has spoken, who needs to grapple?  There are instant infallible answers.

Is the Miracle of AI turning Wine into water?

AI and Homicide

Another colleague (C2)  found an Armed with Reason substack with a linked Gun Violence Pedia (GVPedia), who, deploying AI, seem to have a mission to brand any idea that homicides with a gun might be linked to psychotropic drug use as a complete (NRA sponsored) myth aimed at deflecting attention from the guns themselves.

See AI Tsunami for more.  There is a divide here that AI has the potential to make unbridgeable.  Megaphone diplomacy across divides never gets anywhere. Neither democracy nor science can survive in circumstances like these.

Artificial I

Only a few months ago, C3 faced an even more difficult challenge. Having been on the coalface of transgender debates in a listening capacity, he ended up trying to be Socratic in a conversation with his daughters who turned to ChatGPT to refute everything he was attempting to tell them about things he knew more about than Chat GPT.  See Artificial I.

While we once were able to think we had our own opinions because they differed from a friend, a child or a parent, we also used to know that newspaper X always gave us certain opinions while newspaper Y gave just the opposite and that to some extent we were tribal. We sometimes wore the tribal badge with pride.  Can there be other tribes with AI?  Grok might have a more risque sense of humor than Anthropic but they’re both going to dish up essentially the same stuff.

C 1 above figured he was (we are) up against AI Slop – last year’s word of the year. How can he get friends to engage again?

Have we just now ended up with the kind of unanimity featured in books like We, Animal Farm and Nineteen Eighty-Four – books that have been around for 60 years describing a then imminent future – starting in 1984. Or did this future start – 40 years ago?.

The Great Steal

.

The Great Seal of the United States – doctored. It normally reads E Pluribus Unum – out of many, one people.  The Latin Unum has been replaced with Mediocris – Latin for Average.

Averages are what both Randomized Controlled Trials (RCTs) and AI deliver. They are like meat mincers where you can’t distinguish what comes out the far end as human, cow or horse.  In the case of RCTs, you can put LSD, SSRIs, stimulants, antipsychotics, alcohol, benzodiazepines or nicotine into the mincer and they will come out the far end with almost identical rating scale changes.

They tell a doctor nothing about how to treat the person in front of them.

Just as meat mincers are a good way to hide a murder, so too with RCTs. They are the gold standard way to hide adverse events.

Who says all these things?  Austin Bradford Hill – the creator of RCTs.

Hill said to treat the person in front of you, you need to talk to them. You should not average them.  Back in 1965, he said we’ve been doing RCTs for 20 years and we should have learnt by now they’re not much use.

Everything Hill said was turned upside down in 1990 when Prozac was reported as causing suicide – See Bad Trips on SSRIs.  Eli Lilly, Prozac’s maker conjured up a Prozac Liberation Front (PLF).

The PLF took a rake of cases reported to the company in clinical trials – perhaps hundreds overall, some in healthy volunteers, all despite damping down SSRI effects with benzodiazepines – and put all these cases through their RCT grinder.

This was followed up with a borrowed and edited message taken from, you might have thought, an unlikely source. Just as on average it would be a slur on pedophiles to say that what they do harms people – you shouldn’t confuse the good intentions of pedophiles with anecdotes of unfortunate events.  See File under Phile.

Doctors swallowed this, gristle, viscera, bones and all. Yuck might be the appropriate word but doctors get outraged if, whatever about their good intentions, anyone, having looked closely at what is being served up, wants to pass on the dish.

The New Normal

Pharmaceutical companies write drug labels and are legally obliged to update these as new information becomes available. In the US, they routinely did so up to the turn of the millenium – with trickle down effects in Diego Britain, Europe, Australia, and Canada.

The legal obligation hasn’t changed.  But taking a cue from the PLF, company lawyers said we cannot argue in court that RCTs give gold standard knowledge of what drugs do, if company doctors continue to interview patients/doctors and add our drug caused X or Y to the drug label – How the Safety of Medicines was Destroyed.

So company doctors were told to stop. A new narrative emerged. Regulators are responsible for drug labels and we in the company can do nothing unless the regulators act.  Regulators don’t act because they would have to run RCTs to generate gold standard knowledge before changing anything.  Incorporating Anecdotes into the label is not an option.

Lawyers advised medical journals against publishing adverse event reports written by doctors – see Silencing Doctors Silencing Safety – on the basis that the PLF reclassification of these as Anecdotes – Misinformation, indicators of treatment hesitancy and pharmaphobia. Publication would risk a pharma lawsuit for damage to their product.

Medical insurers, who are supposed to make medical practice possible the way travel insurance makes travel possible, told doctors never to say a drug had caused a patient’s death at an inquest. If you can’t stomach this, let our lawyer blame the terrible illness for you – see Making Medicine Great Again and When Will Insurers Stop Killing people. .

Medical Guideline makers know they are incorporating fake or fraudulent results into their Guidelines but give their shoulders a ‘What can we do about it’ shrug.   See – The NICE Before Xmas.

The rubber really hits the road if treatment causes manslaughter or homicide. You will not be able to get a lawyer to fight in your not-guilty corner.  The third party to this injury, happy that the guilty party – you – has been sent down will never know what really happaned to a family member

The Sound of Silence

We are all now liable to be gaslit if injured. Our families are gaslit if we’re dead. When this has happened in cases where the only sensible way to explain things has been Drug X did it, activists fighting finasteride, isotretinoin and SSRI cases bamboozled by companies into thinking regulators count have laid siege to regulatory offices and forced label changes, which typically feel derisory given the gravity of the problems –

• Isotretinoin and Consent
• Finasteride and Consent 
• Bad Trips on SSRIs.

Health Activism was at its zenith in 1848 when it created social democracy and fed into liberalism – see Can We Avoid Bring Eaten.

Possibly stimulated by German demonstrations in the 1940s of just how horrific health systems out of control could be, health related political activism was still potent enough in 1968, mental health in particular, to be central to the Revolutions of that year.

Now, when health systems routinely sterilize and kill more than Germany did in the 1940s, health activism comes only from those injured by treatment and looks rather like a primitive Amazonian tribe pitted against a superpower. A fly pitted against an Elephant.

Conversations are a key marker to what has happened. They’ve stopped.  Central to Shipwreck of the Singular, which features in the image above, is the idea that if you want to understand the politics of our world, sit in a doctor’s office and you will see in microcosm what is happening outside.

The conversations have stopped.  We as patients used to train doctors, just the way we often say children train parents to be parents. They listened to and learnt from us – not from books. They brought their experience dealing with us and our differences to bear on the problems we brought them (they didn’t give us problems) but this experience is now written off as anecdotal and risks punishment.

As patients we are increasingly aware that our doctors aren’t listening to us.  Thinking Fast and Slow we can feel that there are Strangers in the Room who our doctors must listen to first.

When the Internet opened up, in the 1990s pioneers like Charles Medawar, who coined the idea of Pharmageddon, figured that it offered an opening for a democratization of medicine. But by 2010, he thought the Pharmageddon that threatened us had advanced so far and so fast that we were doomed.

For a brief few moments, some of the younger generation, who feature above, have been similarly enthused about the prospect that AI might level the playing field. Doctors would not be able to ignore the sheaf of LLM material we brought in to them.

Neither the younger generation nor doctors know that 4 years ago, Pfizer and GSK and friends were busy replacing their ghostwriters with AI.  Back when Cochrane was also a force for the good, one of the striking statistics was the companies used to produce up to 50 publications for every single trial done. This doesn’t mean that the bilge that pours into places an older generation used to swim in when young has now been cleaned up.

Just the opposite.  Anthropic and friends now produce clinical trial articles within days of an RCT finishing – with algorithms in place to ensure the right outcomes are reported, leaving little or no chance the company will be sued for fraud because there’s not be a scrap of intention, never mind intention to deceive, anywhere in the system on which to base a fraud charge.

Doctors rapidly became puppets through which the RCT averaging machine embodied in guidelines and a fraudulent medical literature spoke. We are now even more rapidly becoming artificial versions of us through whom Chat GPT speaks – echoing exactly what the doctor is also saying.

There will be no opening for conversations.

Health in the Cloud?  I’ve looked at Clouds from both Sides now – its Health’s Illusions I recall, I really don’t know Health at all.

At its heart, Science involves discussion about observables. After we take a prescription drug, an experiment starts and the observables are all in us. It’s as Lutheran – Here We Stand, We Can Do No Other – moment.

Our doctor is yoked to us and is obliged to have a real conversation with us.  But to adapt a phrase from Mahatma Gandhi:

How can those who think they possess absolute truth be scientific?

This post is a not-identical twin of Bad Trips on SSRIs.

The post The Prozac Liberation Front first appeared on Dr. David Healy.

Carney at Davos

Like or loathe his politics, unless I am missing something, Mark Carney, Canada’s Prime Minister and Liberal party leader, seems a decent man.  As the Canadian standing up to Donald Trump, whether you are pro- or anti-Trump, you are likely interested to see how this contact sport plays out. (Even Curling is close to being a contact sport these days).

On January 20, at a meeting of the rich and famous at Davos, Carney’s Speech, telling countries they need to get to the Table if they want to avoid being a Dish served up to the Great Powers, stood out.

Liberalism

Being at the Table was the key driver behind the nineteenth century birth of Liberal and Socialist politics.  It wasn’t safe to leave decision making to the nobles, the wealthy – the conservatives who didn’t want change.

Liberals and Socialists couldn’t easily argue against creating new factories, new jobs and wealth, especially in a world where if we don’t create them someone else will and will gobble us up.  The only effective response lay in the dead bodies or injuries happening in those factories. If they are too risky to work in, you won’t be able to compete against a motivated workforce.

Health was the Trump card.

Factories were like nations. At a time when the British didn’t give a fig about killing off millions of Irish, forcing them to emigrate or viewing them as vermin when they arrived in Britain, the French and Germans had realized that the nation with the most able-bodied mobilizable men was likely to win the Wars (contact sports) between them.

These considerations led to an alliance between Conservatives and Socialists in Germany in 1871 that, ironically excluding Liberals, set up a first ever national health insurance scheme.

Rudolf Virchow’s Liberals, meanwhile, installing sewage works in Berlin made it habitable and sustainable. Its population grew, and markets thrived demonstrating that public works could be good for business.

The history of these nineteenth century interactions between health and politics is outlined in Shipwreck of the Singular.

Born in the USA

Few Americans understand that, while communists wanted to destroy the Table, socialists in contrast wanted a seat at it.

After World War I, socialists and liberals in Germany soothed political tensions by expanding healthcare coverage for War related mental and physical injuries.  They also combined to put down a communist revolution, executing its leaders – See The Great Silence.

In America, Table dynamics played out most clearly during the 1980s AIDs crisis, when ACT-UP (AIDs-Coalition-To-Unleash-Power) took to the streets.

ACT-UP’s success hinged on getting people with AIDs to come out.  Some fabulously brave individuals, not afraid to stand up for their homosexuality, led the way.

Post-SSRI Sexual Dysfunction (PSSD), Post-Finasteride Syndrome (PFS) and Post-Retinoid Syndrome (PRS) are another pharmaceutical and sex saga that began in the 1980s. These are conditions that can permanently obliterate our ability to make love. They cause profound shame. Sufferers, however, weren’t facing an immediate death sentence with nothing to lose and have been slower to achieve what ACT-UP achieved. But this slower burning fuse has links to recent events in Tumbler Ridge.

An essentially political decision meant that AIDs was all over the media in the 1980s creating a platform for ACT-UP. Today’s political decisions, aimed at avoiding deterring people from seeking treatment, mean the public don’t hear about drug induced injuries like PSSD or the resulting deaths. Heaping Insult on Injury, the public get told the prior mental state of those damaged has been to blame.

Events like those in Tumbler Ridge recently offer a crack through which some light might get in.  It’s one thing not to deter people from seeking the benefits of a treatment that clearly saves lives but SSRIs, Finasteride and Isotretinoin lead to more loss of life than would otherwise be the case.  Is loss of life or loss of profits at stake?

Faced with almost no progress by the mid-1990s ACT-UP began to fracture. The ‘communists’ within wanted to take sledgehammers to the healthcare Table and start anew. The liberals and socialists clung onto a place at the Table from which they could shape what was happening.

Triple Therapy

Triple Therapy emerged just as the fracture was taking shape. Companies had made several ineffective antivirals. The epidemic would have killed a lot more people if companies had been left to market minimally effective meds and charge crazy prices for them. The initiative to combine several weak antivirals came from folk with AIDs. Clinical trials weren’t needed. People on Triple Therapy got up off death beds and walked.

Triple Therapy stands as one of the few pharmaceutical treatments from t1980 onwards that saves lives. It’s price is reasonable, because as Goldman Sachs noted – saving lives is a bad business model generating as it does immense pressure to lower the cost of treatment.

For more on this history of AIDs and politics – see Shipwreck.

Carney at Tumbler Ridge

Having had such an impact at Davos, Carney’s choice to pull out of an important Global Defense meeting in Munich a few weeks later surprised many.

Just before he was about to fly, at Tumbler Ridge, a small town near the British Columbia (BC) Alberta border, an 18-year old shot his mother and brother, 6 students in the local school, and himself.

Carney opted to attend a vigil at Tumbler Ridge rather than go to Munich. It looked like Canadians coming together in the face of a natural disaster. But it wasn’t a natural disaster.

Tumbler Ridge was even more of a man-made disaster than a fire at Crans Montana 3 weeks before Davos, when an accident with lighted candles set a club on fire killing 41.

Iron Cages

In 1919, Max Weber, many people’s favorite Liberal, said Liberals and Socialists had problems to sort out before they could collaborate at the same Table. While both had similar goals, the socialist impulse to systematize risked creating an Iron Cage of process.

Weber was referring to socialist success at the replacement of an aristocracy that figured they knew what was best for people with a set of impersonal procedures. With a bureaucracy that relentlessly codified what at one point might seem rational.  Without a good way to later undo what at one point might have appeared best for people, rather than helpful this would lead to politically correct but stifling tokenism and disaster – like he Holocaust some have since suggested.

For Weber this was not a specifically German problem. Iron Cage logic almost necessarily was totalitarian.

Denn heute gehört uns Deutschland und morgen die ganze Welt

Recognizing countries need bureaucracy, Weber stressed the need for political leadership.  He explained what he meant by saying Leaders would be like Doctors, professionals who when needed could ensure a people took what might be a necessary but not very pleasant medicine. Like doctors, leaders would make judgement calls and take responsibility for their calls rather than hide behind process.

He explicitly recognized that our developing medical capabilities would enable us to engineer births and death – putting medical assistance in dying (MAiD) on our Tables. Reading this now, many likely assume Weber figured doctors as leaders would not get locked into the Iron Cage of procedure.

Rather than seeing the Holocaust as a painting of our past, others have seen a window onto our present – onto Modernity.

Around 1940 German medicine, in particular psychiatry, led the world. Set a political goal to engineer the healthiest nation on earth, German health authorities cautioned against tobacco use before anywhere else did.

Without any coercion, German psychiatrists and other physicians sterilized roughly 360,000 men and women, terminated the lives of over 170,000, and ran dangerous medical experiments on over 15,000.  Close to all German doctors participated. None were coerced. None who refused to collaborate were sanctioned.

Canada now leads the world in mental health related MAiD – thanks in part to an erstwhile Liberal Senator, who also had a part in what led to Tumbler Ridge.

None of the Christian Churches that Marco Rubio, the US Secretary of State, presented in Munich as our saviors from civilizational erasure, raised a peep in the 1940s.

We Wanted You to Hear

About 6 hours before Rubio’s Valentine’s day speech, in Tumbler Ridge Mark Carney said:

We wanted you to hear that Canadians are with you. That we will always be with you. That whatever portion of your sadness that Canadians can bear to help ease your heavy load we will gladly do so   When some of you go back to quiet houses, to empty rooms, please know that you are not alone.

I have a colleague who knows a great deal about the harms psychotropic medicines have the capacity to cause.  Her daughter living in BC was recently killed by a man with a BC treatment history. Even though a proper assessment of the effects of his medication might mitigate his sentence or provide grounds for a not-guilty plea, she would like him assessed by someone capable of doing so. Not knowing what happened makes sitting alone in a quiet house more difficult.

Neither my colleague nor I know any physician in Canada with the forensic skills to make an assessment of the effects of this man’s drugs. It would mean going outside Canada.

Her request for an assessment to the prosecutor she is dealing with, for whom she has great respect, comes up against current procedures which make no accommodation for something as obviously sensible as this.

On the other side, even if this man could afford the best lawyers money can buy, and they were handed a report with good grounds to bring the medication he was taking into play, they almost certainly would not attempt to plead not guilty. They would pressure their client instead to accept a plea deal – his own lawyers in other words would make him a felon and downplay the hazards medication poses.

The doctor who prescribed the medicines will be told by his/her medical insurers than on no account can the medication be blamed for what happened.  S/he must blame the terrible illness and if s/he doesn’t feel capable of this, s/he needs to let the insurer’s lawyer make that case – See When Will Medical Insurers Stop Killing People.

The system in other words systematically conceals what is happening in cases like the one that drew Carney to Tumbler Ridge.

Another colleague lived with his two sons just over the BC border in Alberta. Unbeknownst to his father, one of his boys was put on an SSRI by a BC family physician, with the dose elevated to double the toxic levels. The first the father knew about any meds was when his son shot himself. This lack of knowing could not legally have happened if a BC child was prescribed treatment by an Alberta family physician.

For several years now, my colleague has come home to an empty house shorn of its shining light sensing that Canadians want nothing to do with his pain.

In France 16 year old Romain Schmitt was put on paroxetine by his doctor. When it was raised beyond toxic levels, Romain stepped in front of a high speed train.  His family have similarly had the light go out on their lives. Their case that paroxetine killed their son is compelling but just as in Canada it seems to be close to impossible to get a medical expert, even from among those who claim to be critical of the pharmaceutical industry, to agree to undertake a report.

French Experts claim not to have the expertise to write such a report, which begs the question as to whether they are fit to practice medicine – See Clinical Details Confuse Expert Doctors.

Homicides

Woody Witczak lived just over the Alberta border in Minneapolis with his wife Kim. He had no health problems of any sort. He and Kim had good jobs. They were planning a family and had booked trips away.

Woody went to a decent doctor in need of something for a few nights good sleep. He was given Zoloft, an SSRI. He became agitated and told Kim she wouldn’t believe the thoughts going through his head. In line with process based practice, his doctor told Woody to persist with treatment. Trusting his doctor, he did. Soon after, he hung himself.

After his death Kim learnt that killing her was among the thoughts in his head – Health, Care and Science in Real Life..

We have known for 70 years that for healthy people taking drugs acting on serotonin systems:

“the first few doses frequently made them anxious and apprehensive… they reported increased feelings of strangeness, verbalized by statements such as ‘I don’t feel like myself’… or ‘I’m afraid of some of the unusual impulses that I have”.

These reports come from people with no mental history being treated for raised blood pressure.

Companies making SSRIs have known for over 40 years that these drugs can cause healthy volunteers to become suicidal and commit suicide, as well as aggressive and homicidal and can obliterate sexual function permanently even after stopping in some cases.  Investigators on company trials, like me, were told not to ask about sex.

Everyone agrees the unusual impulses above included suicide. Cases like Woody’s make clear that while the drugs cause suicidality sometimes the suicides may be completed in order to avoid worse happening.

My colleague in Alberta and friends in France mourn the loss of a child without being aware that this loss may have been occasioned in part because of their children’s horror at what they might do to their parents. We cannot know if this was the case for these two boys, but it certainly can be the case, as might have been the case in Tumbler Ridge.

Asexual

Besides the direct drug induced suicidality, the two boys above were not told they would have a loss of sexual function while on treatment, with an impossible to ignore profound genital numbing. This is not the kind of thing a teenager can discuss with his parents. Did either wonder about homosexual or transgender issues? Did either find out from the web that this loss can be permanent?  Romain inexplicably smashed his phone before stepping in front of a high speed train.

The Eating Process

At present in Canada, SSRIs are de facto sterilizing more Canadians than German doctors did in the 1940s[1].  These drugs have almost certainly medically assisted more Canadian deaths than German doctors ever assisted.

The difference between the 1940s and today is that people are not dying in intentional medical experiments now. Their deaths are process driven, but the suffering inflicted on fellow citizens is no less excruciating.

Coercion and sanctions are more likely to brought into play today against physicians who refuse to adhere to our health service processes than was the case in Nazi Germany – See Gaslighting, Milgram, Madness.  While there may have been criminals among doctors in Germany, and there may be among doctors today, the root problem is political.

We have a process in which doctors and other healthcare staff, most of whom are decent and we have no reason to think weren’t decent in Germany in the 1940s, are trapped. Running fraudulent studies and portraying hearsay as evidence has been central to creating this process.

Stan Kutcher, a former Liberal Senator, has played a significant part in this process. He is listed on the authorship line of a ghostwritten article about Study 329, a GlaxoSmithKline (GSK) trial of paroxetine in adolescent depression, that transformed a statistically significant excess of suicidal and related behavioral events on paroxetine into a Safe drug. Documents indicating the article was fraudulent led New York State to take a fraud action against GSK and factored into a Department of Justice action against GSK that resulted in a USD 3 Billion settlement.

Paroxetine is almost certainly a pharmaceutical sibling of one of the drugs the Tumbler Ridge shooter was on, all of which have the capacity to cause homicide.

No one should assume that the medical literature on our medicines is anything but ghost-written and de facto fraudulent or shaped by the fact that medical journals are too scared to run anything other than material supporting treatment benefits. Even a former CEO of Britain’s NICE Guideline process recognized that the ‘evidence’ treatment guidelines involving psychotropic drugs is based on is deeply flawed but asked what alternative did guideline makers have?  See The NICE before Xmas.

I make these points as a physician convinced our use of SSRI and related medicines could not just be much safer, but their sensitive use also could reveal important aspects of our subjectivity, currently hidden, if, like Triple Therapy, their use is not bent solely to making a profit – See I Come to Praise SSRIs.

Healthcare needs Leadership. In a reversal to Weber’s metaphor, given that pharmaceutical companies believe few doctors have a thought in their minds not put there by them, Leadership seems unlikely to come from medicine.

Socialists sitting at the healthcare table are predisposed to gorging themselves on the edibles – refusing to let anyone deny them any of the 12 psychotropic drugs a day ‘their industry’ provides them with. As a result Western Life Expectancy and Healthy Life Expectancy is falling. This is not sustainable.

We have a probably then unforeseeable end-game to the dilemma Weber brought into view. Other than offer tasty soundbites, can a Liberal like Mark Carney do anything to stop us being served up as a Dish on Big Pharma’s Corporate Table?

Footnote

[1] SSRIs sterilize by depleting sperm counts and implantation hormones, through miscarriages and by causing neurodevelopmental delay in offspring – in addition to killing libido which may not recover to normal in up to 50% of us.

The post Can We Avoid Being Eaten first appeared on Dr. David Healy.

This image is from Wikipedia Gaslighting which gives the credit details.

The word Gaslighting comes from the 1944 movie Gaslight about a husband’s attempts to get his wife to doubt her sanity. It caught on slowly but as this graph shows in the last decade its use has taken off.

The greatest relative rise in its use may be in healthcare. Until recently it was inconceivable that patients would say their doctor was Gaslighting them. Now almost anyone suffering an adverse event on a drug reports medical gaslighting – see Gaslighting in Healthcare.

Authority

This image is from the Wikipedia entry on Milgram’s experiments.

In 1961, Stanley Milgram, an American social psychologist, recruited volunteers to participate in a study ostensibly about learning.  The teacher (T) had to shock a learner (L) if the learner gave the wrong answers to questions and was told by the Experimenter (E) to increase the doses of electricity in the event of wrong answers. While many volunteer Ts were agitated at what they were doing, two in three continued to do as they were told up to lethal levels.

Milgram’s experiment casts hypnosis in a new light. Supposedly only some of us are hypnotizable and do crazy things at the suggestion of a dominant other. But Milgram showed that most of us in response to Authority obey crazy orders.

Prior to World War II, few could have believed that Germany, perhaps the most cultured and scientifically advanced society in the world, with a large Jewish population contributing significantly to its culture and science, could possibly have descended into civilizational erasure.

Milgram, like all Americans, especially psychiatrists and psychologists, believed the Holocaust pointed to a fundamental flaw in the German character. It couldn’t happen Here. The psych view was that the Nazis were latent or closet homosexuals.  Psychoanalysis, a Judeo-German creation and immigrant to American shores, would make sure it couldn’t happen Here.

The recent movie, Nuremberg, based on The Nazi and the Psychiatrist by Jack El-Hai, outlines the encounters of US psychiatrist Douglas Kelley with Herman Goering that convinced Kelley it could happen Here. The dismissal out of hand of Kelley’s efforts after the War to tell Americans it could happen Here led to him developing an alcohol use disorder and to his suicide – 3 years before Milgram began his experiments.  It turned out that Germans, even concentration camp guards, were no different to Americans.

RxISK’s Guilty until Proven Innocent post dealt with prescription-drug abuses through the medium of sexual abuse. The injured need to follow the example of women who have got fed up being assaulted and have become more assertive, almost literally taking the law into their own hands. They, the women, and we, the drug abused, need to stop depending on the system, on authority, to be fair and deliver justice. The system is rigged. We are at risk if we fail to realize this.

The Magic of Medicine

While there have always been abuses in medicine especially in psychiatry, up until 1990 doctors behaved semi-decently. If we decided we had a problem, we brought it to ‘our’ doctor who even came to our house if need be.  They brought the magic linked to a wisdom borne from experience to bear on our problem.

From the 1950s, this magic came supplemented with new medicines. As the new drugs were viewed as unavoidably hazardous, they were made prescription only. Medical experience helped doctors bring good out of the use of these poisons by remaining observant and applying common sense.

Physicians then were professionals, which meant they prioritized our concerns – helping us to live the lives we wanted to live.  See  Getting Engaged to a Doctor and Who’s Afraid of Science. This was a forerunner of Relationship Based Medicine – more an experienced parent and inexperienced child then perhaps than the partnership of equals it needs to be now.

As professionals, physicians like lawyers were independent of Church, the First Estate, and State, the Second Estate (which had meant the aristocracy but increasingly came to mean a bureaucracy or Deep State) that from time immemorial had commonly wanted us, the third estate, to live the lives that suited them.  The Gutenberg Revolution followed by the French Revolution had brought a Fourth Estate into view – independent academic and lay media.

Doctors are still decent people, as are regulators, company people and the media, but they have now been recruited to a mass Milgram experiment and, in principle at least thanks to Milgram, we now know a lot more about what decent people are capable of.

Prozac 20 milgrams

With Prozac and other SSRIs, companies managed to relocate the magic of medicine into their pills. The poisons have become sacraments.

Any token magic left in doctors lies in their ability to write a prescription – not in their ability to engage with us

Rather than us taking our problems to an experienced doctor looking for help to live the lives we want to live, on pain of being denied coverage health systems summon us for screening and, giving us problems we didn’t know we had, administer ‘sacraments’ to us. On average now, we take more sacraments daily than any cloistered religious folk ever did.

The Fourth Estate has ceased to exist.  Doctors, regulators, and both academic and lay media are hemmed in by a ghostwritten, soon to be AI written flood of articles on the benefits of the sacraments.  Not even the most famous medical journals dare blaspheme and publish any hint, especially one written by a doctor, that one of the sacraments might come with hazards – Silencing Doctors, Silencing Safety.

Doctors have been forbidden to go by experience or use common sense. Their wisdom is dismissed as anecdotal – as misinformation.  The only acceptable truth about the sacraments comes from company publications, which extol their virtues to the point where Cardinals like Ian Hudson can tell juries that Evidence Based Medicine shows that paroxetine has no side effects whatsoever – See Gaslighting in Healthcare.

Guidelines rather than Angels bring us the Good News (Gospels) of Salvation.  Angels bearing Guidelines stand at the Gates of Heaven with flaming swords in hand – none who deviate from the Way, the Truth and the Light can enter here.  See – The NICE before Xmas.

The Angels bearing Guidelines take the place of Milgram. Doctors are caught between the patient whose body needs to learn to conform to the commandments and the Angels who insist the patient must stay on the treatment for at least 6 weeks and respond, or else the dose must be increased.

There are differences between the original Milgram experiment and now. For one, the patient (the learner) is real rather than an actor.

Another is that the electricity is real and rather than starting low and raising it in increments, the initial dose is at a lethal level – 20 milgrams of Prozac as the dose response curve below shows.

Lilly ran with a lethal dose of Prozac because it was proving very difficult to get Prozac licensed and they were taking no chances with their Golden Egg.  In order to run their trials at 20 milgrams they had to put a large number of subjects on concomitant benzodiazepines in order to damp down the agitation so much milgraming can cause.

Despite also running a trial of Prozac 5 milgrams and finding it just as good as 20 milgrams, Lilly did not bring the lower dose on the market. Why not? Because they figured it would be easier to capture the market if Prozac was the once a day antidepressant and doctors didn’t have to start low and go slow, monitoring their patients closely as they did.

Instead, once licensed, Lilly perversely encouraged us to use benzodiazepines to damp down the serotonin pick-up syndrome SSRIs cause. Perverse?  Well at the same time the central claim in SSRI marketing was the need to replace these hazardous benzodiazepines with safe antidepressants.

Thousands upon thousands of us are killed yearly because the system can now depend on decent doctors to do as they told. They gaslight their patients and in response to a real patient’s real agony right in front of them – not in a separate room as Milgram’s learner and teacher were –  they tell the patient they need to keep taking their SSRI, and keep raising the dose – 40 milgrams, 60 milgrams, 80 milgrams.

Family and friends, patients in mental health units and prisoners in prison can see the harm being done but decent doctors can’t.

Many of us have been bewildered by a script for an antidepressant from a decent doctor when, like Woody Witczak, we came in hoping for something to give us a few nights good sleep – See Are HealthCare and Science Compatible.

Bewildered too when finding that despite telling him that things were unimaginably bad on treatment he told us to persist.  Leaving everyone dear to us bewildered, when still operating on the basis of trust in a doctor they too perceived as decent, we did persist and ended up killing ourselves.

Worse again we have killed others. In cases like this, despite a cast iron not-guilty case, even with the resources to hire the best lawyers money can buy, there is no way to get a lawyer capable of fighting a not guilty case.  If things go wrong on the pills, we are Guilty without Hope of being Proven Innocent. It is becoming increasingly impossible to point the finger of blame at the Sacrament.

Premiers will skip meetings on the world stage aimed at preventing civilizational erasure, aimed at preventing us being eaten alive, but dare not question whether we are safe at the health service table or whether we have already become the food being served up.

Others have been seduced by marketing fantasies about being Better than Well, bringing out our inner Van Gogh, and were impervious to the advice of a doctor whose experience with these new wonder drugs counselled caution.

All too quickly, these doctors quietly adapted to a new reality – one in which they were forbidden to learn from experience.  When things go wrong for a patient like 15 year old like Dexter Johnson – In Memory of Dexter Johnson, whose doctor milgramed him up to 40 milgrams of Prozac  – or 16 year old Romain Schmitt – Clinical Details Confuse Expert Doctors – whose doctor milgramed him up to 40 milgrams of Paxil, doctors get told by their medical insurers never to blame the drug  – see Will Medical Insurers Stop Killing People and Tangled up in Bureaucracy and Who Will Make Medicine Great Again.

Authority

Between 1800 to 1900 in creating modern healthcare, doctors created public health and then indecently manned barricades in France and Germany in the 1848 Springtime of the Nations.  Politics is nothing but medicine on a grand scale Rudolf Virchow said then.  See Shipwreck of the Singular.

Instead since prescription status gave doctors power beyond the dreams of oligarchs, the ability for a few of us to control the supply of drugs for all and bend pharmaceutical companies to our will, this Script of Power, our Precious, has like Sauron’s Ring transformed us into Gollums, Smeadics (Smeagol) in this case, creatures of the night – See One Script to Rule Them All.

One Script to rule them all
One Script to find them
One Script to bring them all
and in the darkness bind them
in the Land of Mordough where the shadows lie

Our doctors are now employees of health services, even when apparently not. They are model doctors where a model is a shrunken replica of the real thing, practicing model medicine.  They are not made of The Right Stuff.

They dish out Probity Blockers in a Transmedicine that increasingly pushes us to transition from members of the third estate into what in these days is more likely to be called Real Estate – something we can charge rents for and make money from.

The word Authority contains the word Author. In any theocracy, whoever has the power to write the script, the sacred text, whether a Holy or an A.I. Ghost controls the people.

We are not doing science. See Health Care and Science in Real Life. We have been swept up by a religious broom into a dustpan and risk like Road Kill being put out with the rubbish.

Rather than reading the Ghostly Books, doctors need to get back to recognizing that when we come to them, rather than when we are commanded to attend, we are the books they need to decipher.  These days the harms of the probity blockers they give us are the most likely reason we will reach out to them.  The harms of probity blockers are increasingly likely to be the cause of our death if they don’t intervene.

They need to start doing science and that can only be done cooperatively with us.

The post Gaslighting, Milgram and Madness first appeared on Dr. David Healy.

This post features Letters from Peter Scott-Gordon to Lade Smith – the originals are in the link.  Readers outside Britain should assume that the gaslighting here applies to regulators and medical bodies in their country also and should not be fooled by this apparently polite correspondence.

4 February 2026

Dear Dr Lade Smith,

PATIENT SAFETY

I wanted to write to you to say thank you for engaging with me as President of the Royal College of Psychiatrists in relation to a number of matters. I particularly wanted to thank you for your kindness and professionalism in this. I am aware that your period as president is coming to an end (how time passes!) and that a democratic process is underway to find the next College president.

You will doubtless be aware of a number of current inquiries, right across the UK, into serious matters relating to patient safety. In one recent example, Fred Mackintosh, KC, Senior Counsel to the Scottish Hospital Inquiry, said to BBC Scotland on 23 January 2026:

“Senior leaders effectively need to know that if they show wilful blindness or complacency or don’t ask questions when patient safety issues arise, in due course they will be held to account”.

Given this context it is important that the College does not ignore patient safety issues, including in its forthcoming election process which is likely to face wider public scrutiny than ever before.

I hope that the election process, including the hustings, will include consideration of patient safety issues. I appreciate that this may be challenging for the College as it is primarily a membership organisation and supporting the interests of its members is understandably its priority. However, there is a very real risk that a defensive approach interferes with, or indeed impedes, College acknowledgment of, and support for, patients harmed by psychiatric treatments. Given the recent warning issued by Fred Mackintosh, KC, the College has to be aware that its long-term reputation could be at risk. Psychiatry, like all branches of medicine, is dependent on the trust that patients have in it.

It is disappointing that the College has made no official response to the First Do No Harm Cumberlege recommendations which were published in the summer of 2020. This is a missed opportunity to accept accountability and demonstrate a willingness to learn. This apparent defensiveness by the College may be one of the reasons why over 1 million people in the UK are seeking support from Facebook and other social media groups in relation to prescribed psychiatric drugs.

The risks and benefits of social media use are issues affecting all of society and continue to be widely debated. In this environment it is more important than ever that the online behaviour of College members adheres to the highest possible professional standards. The College needs to remember that social media contributions, both past and present, of its office bearers are open to scrutiny.

Thank you again for taking the time to listen to my concerns and I wish you all the best for the future. I do hope that the College can demonstrate genuine engagement with patient safety issues and that these can be openly discussed in the election process for the next office bearers of the College.

Yours sincerely,
Dr Peter Scott-Gordon

Copied to:
[1] Sonia Walter, CEO of RCPsych
[2] Wes Streeting, Secretary of State for Health and Social Care
[3] Patient Safety Commission/Commissioners
[4] Marion Scott, The Sunday Post

6 February 2026

Dear Peter,

I hope this finds you well.

Patient safety and the quality of care provided to people is a paramount concern for the College. Everything we do, including supporting psychiatrists in their work, is aimed at improving outcomes for people with mental illness.

As you know, mental health services have been underfunded for many years and suffer from chronic understaffing. This affects access to care, as well as the ability of staff to provide excellent quality care for all their patients. This is something the RCPsych advocates about constantly.

With respect to individual practitioners, we expect that all will do their utmost to provide the best quality care that is safe. We provide guidance, education and training to support them to do this.

Regarding the Cumberledge report, the College updated our Sodium Valproate Position Statement in light of the recommendations and reviewed and updated this again last year.

The Cumberledge report looked at 3 medical interventions that were not specific to mental health, nonetheless, we contributed to and signed up to a statement put out by the Academy of Medical Royal Colleges, of which we are a significant member. The statement was released on behalf of all Medical Royal Colleges and can be found here. In addition, we were part of the development of the 2021 Guidance document on the use of sodium valproate for women and girls (here).

I hope this helps to reassure you that we take patient safety very seriously. The hustings will focus on questions from the membership. There are always questions about patient care and the quality of mental health services, because this is what our members care about.

With all good wishes,

Lade

Dr Lade Smith, CBE
President of the Royal College of Psychiatrists

Academy of Medical Colleges

Below is the full statement by the Academy of Medical Royal Colleges that Dr Smith mentions in her letter to me. I am not aware that there has been any update to this initial statement, particularly in relation to the final paragraph: “We will work with colleges and other stakeholders to ensure that agreed recommendations are implemented as quickly and effectively as possible.” I would have expected a follow-up statement but have been unable to find any.

Primodos, sodium valproate and Vaginal Mesh

Baroness Cumberlege’s report, ‘First, do no harm’ is shocking and does not make for comfortable reading for the medical profession or the health system as a whole. A system which ‘has failed to listen to their [patients] concerns and when, belatedly, it has decided to act it has too often moved glacially’ is not delivering patient centred care for women. But, the report sends clear and powerful messages for change.

We offer our sympathy to all those who have suffered from these three interventions. Others should not have to face what they have faced in seeking to have their concerns taken seriously.

The Academy Council will give the report full consideration when it meets on July 22 2020. We will work with colleges and other stakeholders to ensure that agreed recommendations are implemented as quickly and effectively as possible.

7 July 2020

In Another Part of Town

Peter is not responsible for what comes now, although he did introduce me to Harriet Vogt’s wonderful description of British Medical Bodies as the Royal College(s) of Carpet Fitters.

On the same day as Peter posted this correspondence, an email came from Two Old Geezers (TOG) – otherwise known as Carl Heneghan and Tom Jefferson who have recently been chasing safety aspects to Covid vaccines and GLP-1s – Wegovy and Mounjaro.

The TOG email included excerpts of the latest response they have had from Britain’s FDA equivalent – MHRA – from which they quote Alison Cave, MHRA’s chief safety officer, as saying:

“Patient safety is the MHRA’s top priority and we continually monitor the safety and efficacy of all licensed medicines. For the vast majority of patients who are prescribed GLP-1s, they are safe and effective medicines which deliver significant health benefits. The risk of developing these severe side effects is very small.”

The TOGs point out that every page of the MHRA’s Yellow Card Site (MHRA’s equivalent to FDA’s Medwatch), contains the statement:

“The existence of an adverse reaction report does not necessarily mean that the medicine or vaccine has caused the reaction.”

and comment that against a background of thousands of reports, many listing fatalities, these two statements sit uneasily together.

The TOGs failed to note that despite having a Chief Safety Officer title, Alison Cave is not a doctor and has no qualifications to decide whether a drug has the capacity to kill, maim or otherwise harm. Any reader taking a medicine, or their family and friends, is like Tom Kingston along with his family or friends, better placed to decide whether treatment is causing that person a serious hazard or not than Alison Cave is – Ants, Aunts and Regulators.

That patient safety is  MHRA’s number one priority is a soundbite not a reality. MHRA, FDA and EMA ‘look over’ (Cave into) drug labels that pharma companies write – companies who also claim patient safety is their number one priority.

Dr Ian Hudson was a Chief Safety Officer with GSK and later CEO of MHRA.  As a medical doctor he was better placed than Alison to decide if GSK’s paroxetine could cause serious problems – See Who Will Make Medicine Great Again – but despite almost certainly knowing what the results of Study 329 – a trial of paroxetine done in children – showed, in the Tobin v SmithKline Beecham legal trial Dr Hudson swore under oath paroxetine causes absolutely no side effects whatsoever.

It is difficult to imagine anything quite so psychotic as this.  The jury clearly thought so too.  MHRA and company personnel to this day, 25 years later, are just about obliged to parrot the same lines if called on to comment on safety issues in public or under oath.

After leaving MHRA, Hudson worked for the Bill and Melinda Gates Foundation, which brings the The Epstein Files files into the frame – Bill Gates has vigorously denied any link.

It appears Dr Hudson has had interests other than the safety of children.  See Former Head of UK Drugs Regulator Failed to Reveal.

Britain’s Guardian Newspaper, who have links to BMGF, refused to run this story.  The BMJ who, while also claiming patient safety is a priority, also opted not to cover the issue.  BMJ have mechanisms in place aimed at avoiding ever hinting a medicine might post hazards to patients – See Silencing Doctors, Silencing Safety.

Note

This post has put an emphasis on the role of doctors helping patients established what a drug has done or not done. There is no suggestion that you have to believe doctors.  Quite the contrary. They more than anyone have failed us – see Are Healthcare and Science Compatible.  To be Continued.

The post Gaslighting in Healthcare first appeared on Dr. David Healy.

This post was written 5 years ago.  It is a sequel to a lecture posted last week on RxISK with its comments – Are Healthcare and Science Compatible?  The comments brought out how we now have a system that gaslights both patients and doctors leading to tensions on all sides as this post illustrates.

It also links to RxISK’s – Guilty Until Proven Innocent – Prime Facie – this week.

Reducing Medication Burdens

Between February 2020 and 2021, I was one of four psychiatrists taking mental health referrals from 80 primary care physicians in an Ontario University city.

The most common referrals were people who were anxious or depressed, who had been on antidepressants for a decade or more. Some had started in their teens. For some the original drug had cascaded into cocktails.

Another group wondered if they had ADHD or Autistic Spectrum Disorder (ASD). This group included a number of people who could be described as extraverted or introverted in temperament rather than ill. Extraverts complain of lack of focus; introverts complain about too much focus. Extraverts take risks and are impulsive, introverts manage risks and ruminate.  Extraverts find the features of ADHD described in the lay media fit them perfectly. Many university students engineer ADHD or ASD diagnoses, believing the diagnoses or treatments can be used to good advantage.

Extraversion and introversion are biologically based elements that shape personalities. Medication can help but is not a cure and the treatment of ADHD by stimulants has been linked to an earlier onset of Parkinson’s disease.

A third group were under work stress linked to the management culture in factory, university and healthcare settings. These referrals asked if the person is depressed or anxious – conditions that locate the problem in the person. A neutral diagnosis is burnout or adjustment disorder, which tread the line between securing a disability payment and not locating the problem within the individual.  Sometimes the management dysfunction was so clear, it had to be the diagnosis.

Few referrals had prior admissions for mental illness, even though some had up to six diagnoses and were taking nine psychotropic drugs in addition to other medication.

Mild to Moderate ‘Mental Illness’

The superficial dynamic in referrals from primary care physicians is that these referrals are for minor mental illness and a serious mental illness expert will find these cases easy.  Primary care problems are not in general continuous with traditional mental illnesses.

Severe mental illnesses are relatively easy to diagnose, and the treatment options are more straightforward than many primary care cases. Primary care throws up a lot of anxiety and distress stemming from existential, or social issues, as well as conditions where the appropriate response is diagnostic and therapeutic uncertainty.

Aside from a small number of cases that may evolve into mental illness in need of secondary care or have neuropsychiatric features that specialist input can help with or may require a turn to off-label therapeutic options, primary care physicians will usually know the person, their family and circumstances, better than a psychiatrist could on the basis of a single meeting and without contact with family members or the ability to see changes over time.

There is, however, pressure on family doctors to do what specialists recommend.  The image here is of a Judas Goat – whom companies use to get family doctors onside.  See Partialists and Generalists.

SSRI Burnout

Some of the main treatments for primary care nervous problems, like the selective serotonin reuptake inhibitors (SSRIs), are now 30 years old. While their use has largely been proper, and helpful, professional bodies like Britain’s Royal College of Psychiatrists now accept these drugs can cause dependence and can be difficult to stop. In practice, this means some of the nervous problems patients bring to their family physician will be breakthrough anxiety and depressive symptoms, which are confronting for all concerned.

Each family doctor may only have a few cases like this, but where several doctors refer to the same psychiatrist s/he may end with many cases and no easy solution to offer. Switching to other antidepressants or adding meds is not a reliable answer and often causes further problems.

It can be difficult to offer a clear management plan. The patient’s agreement to any plan is important especially if they are likely to be faced with withdrawal difficulties. Opening up a space, therefore, where the patient, supported by a family doctor, can disagree with the ‘expert’ is important in these cases.

Family Doctor Centred

Family doctors complain specialists rarely consult them on a case. With every referral, I messaged family doctors to let them know there was an entry in the medical record. These entries often called for their input and made clear I was willing to engage further. Some doctors phoned. Many messaged back thanking me for the entry to the record and in some cases explicitly agreeing where for instance I had not supported an ADHD diagnosis.

ADHD diagnoses were never turned down flat. An alternative – you are extraverted and creative and stimulants risk inhibiting this – was offered.

Nevertheless, some family doctors may have been concerned that a willingness to recognise adverse effects caused by prior treatments might cause them problems should there be a complaint.

There is a difficult area here between the pragmatic ‘give us a view that will help us move this case forward’ and the medico-legally concerned ‘give us a view that has a basis in guidelines that will give us cover should things go wrong’.

Bureaucratic or Person Centred

Family physicians globally say they do not read reports from psychiatrists other than the closing diagnosis and treatment. The only person interested to read the full report is the person referred.

For over 30 years in Britain, I provided all outpatients with copies of all reports on them. These were framed with the person in mind rather than their doctor. They were light on medical jargon and where possible used the person’s own words.  No doctor in 30 years complained about this and the letters were appreciated by patients.

In the new clinic, I emailed my entry to the electronic medical record (EMR) to both doctor and patient.  The reports supported the courses of action initiated by family doctors, even where these had stopped working. I made it clear to the patient I would likely have taken the same approach in the first instance. Having asked about the relationship between patient and referring doctor, I phrased the report accordingly. The report invited patients to research things that arose in the interview including possible drug options and check these and other issues with their family doctor.

During this period, the services were operating in lockdown, which meant phone or video supplemented consults in addition to in-person meetings. A patent attempting to arrange follow-up appointments with other colleagues could take weeks, which was a problem for anyone having medication change difficulties.

My patients had their reports half an hour after a consult and were able to email me any time if they had problems. They were seen within hours or days.  The normal bureaucratic wall between them and me was not there.

Medical Consumerism

Working two days a week, I saw over 300 referrals. I suggested a survey aimed at assessing what physicians and patients made of this new way of working.

Instead, at a meeting I only knew about 15 minutes beforehand, my input to the team was terminated. An undetermined number of doctors (2 that I know of) and patients (possibly only I), I was told, had been unhappy at an apparently insufficient offering of further diagnoses and treatments. There was no complaint of malpractice or investigation of any incident. A separate clinic at which I was working in the same way were happy for me to continue.

The system claimed to be unable to stream patients to me who might want this approach. I was told the system must have a standard approach, and at present at least some doctors and patients expect more diagnoses and treatments. The default is to medical consumerism and an adherence to guidelines for diseases rather than guidelines for people.  None of the management team showed an interest in the idea that in the light of current evidence the first point in a guideline for people might be that no-one should be on more than five drugs.

Despite, growing discussion about deprescribing in University Departments, and among clinicians, in addition to patients interested to explore this option, as of 2021 nowhere in Canada offered sustainable treatment as part of its mix.

Where once access to treatment was a privilege of wealth, public health systems are now geared toward increasing access to medicines. Being able to reduce a medication burden it appears has become a privilege of wealth.

In North America referrals increasingly come from people approaching a family doctor claiming they have ADHD, ASD, or the latest fashionable diagnosis, expecting to be referred to a specialist who will confirm the diagnosis and initiate treatment.

These diagnoses can suck people in the way cults do. While some doctors will try to persuade patients that consumerism and poisons (medicines) or mutilations (surgery) are not natural bedfellows, and some patients can be persuaded, an increasing number complain if they are not given what they want. ‘We have the rating scale score, where’s our drug’?

There is a case for saying what a person demands, a person should get, and in the case of terminations of pregnancy, gender reassignment and medical assistance in dying, Ontario Courts have said that doctors unwilling to support these options must make an effective referral or consider switching to a non-medical career – hairdressing has been mentioned.

If we standardize processes to the point where everyone gets the diagnosis they want, based on rating scales they self-administer, we will end up with diagnostic and prescribing cascades, as demonstrated in the following example.

A brief upswing of mood diagnosed as bipolar disorder will lead to a mood-stabilizer, ultimately several, one of which will be an antipsychotic. When asked in clinic how they are, any mention of loss of focus, which antipsychotics are designed to produce, risks leading to an ADHD scale and diagnosis and prescription of a stimulant. A dopamine agonist is now chasing a dopamine antagonist, and both can produce depressive symptoms, leading to further antidepressants.

This is not an invented scenario.  It was common in this clinic and a year it was splashed all over both The New York Times and New York Post.

Medical consumerism hinges on the idea that medicines are sacraments (can do no harm). On this basis, the managers who run health services are increasingly turning to cheaper nurse and pharmacist prescribers. We have reached a point where professional discretion is no longer valued.

Pandemic

The turn to virtual consults as a result of the Covid pandemic may aggravate these risks.  Gone is the feel for someone else from a look or body language that may convey a message at odds with a patient’s words, especially when treatment is going wrong. This is a good reason for increased liaison between specialist and a primary care physician who is more likely to have laid eyes on the person before and to know how much their demeanor and deportment now differs.

The switch to new ways of working triggered by the pandemic has already led to more prepping of patients with questionnaires that shape later clinical interactions and diagnoses. An increasing number of clinical evaluations and treatment recommendations come from out-of-state doctors often through phone apps.

Our oversight of who is delivering care and the conversations between family doctors, patients, and mental health personnel necessary to good care are slipping away.

Rotten Barrel?

This state of affairs would have been inconceivable a few years ago. It stems directly from a ghost-writing of the medical literature for on-patent drugs and a total sequestration of clinical trial data. This change has confirmed the medicines in common use as sacraments.  The magic of medicine once lay in the doctor who brought good out of the use of a poison, but the magic now lies in pills and doctors risk being swept away in the rush to get sacraments.

The traditional script for rooting out unethical practice will only make this problem worse by reassuring both doctors and patients that a problem has been found and the barrel is now safer than it was. We have a system problem with no clear solutions.

This wording of this post does not reflect how wild the scenario described was/is.  The wording is mild because it was important to get a peer reviewed article published and this was something new for any journal – See Reducing Medication Burden.

There are other things that were happening around this time, which it may soon be possible to say something more about.

These more hard-hitting RxISK posts touch on similar themes.

• The Future of Health App-ointments
• Over-Diagnosing or Under-Diagnosing
• Repairing Ruptures in Clinical Care 
• Challenging My Doctor to Disclose 

Standardizing Psychiatry

Later that year, I gave a talk at a Royal College of Psychiatry Meeting covering the History of Psychiatry from 1960 to 2010. This was based on a hard-hitting book chapter in Mind State and Society that the books editors seemed to appreciate.

The audience at this talk, that I gave by video-link from Canada, included some of the luminaries of UK psychiatry. They were not so appreciative.  I revisited  See:

• The Standardization of Psychiatry 
• The Nature and Meaning of Psychiatry

One of them said the talk posed a blood pressure hazard.  Looking back at it now, it seems very very mild.  Peter Selley thought so too and emailed this cartoon.

It may point to a difference between the Irish and the English.  The English put things between lines and into tones of voice. Something that sounds mild to others can be read by other English as savage. Something that seems mild to an Irish person like me can be read by an English audience as wild – and maybe a Canadian one also.

The question the talk ends with is – are we creating a generation of doctors who, like salt when it loses its savor, are only fit to be thrown out?

The post Health a Privilege of Wealth first appeared on Dr. David Healy.

Emil Kraepelin’s famous Textbook created modern psychiatry a hundred and thirty years ago.  After the World Wars, Freud’s influence grew and his thinking dominated the US mental health scene after World War II.  Nearly 90 years after Kraepelin established his framework, US psychiatry dramatically swept Freud away under the influence of a group of psychiatrists branded as Neo-Kraepelinians. Their arguments for a return to the medical model, and an end to an implicit psychoanalytic assumption that everyone is mentally ill, led to the Neo-Kraepelinian epithet. In 1980, this revolution was embodied in DSM-III, whose later editions, ironically, make it possible for virtually everyone to be viewed as mentally ill.  Kraepelin got by on 10 categories, DSM is heading toward 1000.

Psychiatric Drugs Explained was published a decade after DSM-III. Its introduction placed the voice of people taking psychotropic drugs front and central. It asked – could we all think about becoming Kraepelinians?  This was not an invitation to become a Neo-Kraepelinian. Instead the call was to do what Kraepelin had been doing before 1896, when he became the Gold Standard Psychiatrist. When along with Wilhelm Wundt and many early psychologists, he created Pharmacopsychology.

Modern psychopharmacology is about where drugs go, what receptors they bind to or neurotransmitter levels they change. If you don’t know what LSD can do to you, showing you where it goes (mostly in the body), binding to serotonin receptors (in the gut) for instance, is going to tell you very little about what to expect when you take it.

Pharmacopsychology is about reporting what we notice on a drug and doing tests to check the effects of the drug on how we are functioning. In the 1880s that meant caffeine, alcohol, cocaine and opioids.  Kraepelin and Wundt thought this new science would be an important part of our future.

Pharmacopsychology & Psychopharmacology

In the early 1950s, the discovery of chlorpromazine, the first antipsychotic, appeared to put the future of Pharmacopsychology on solid ground.  Chlorpromazine and later imipramine, the first antidepressant, were discovered by noticing the effects they had on people when they had been given for something else.

For a decade after their discovery, the emerging neuroscience was in the hands of behavioural psychologists rather than physiologists or pharmacologists.  The science lay in paying heed to the functions chlorpromazine and diazepam and other new drugs affected and the possibility of using these changes to shape behaviour. It was possible to get the right dose of chlorpromazine or haloperidol by comparing the size of a person’s handwriting before and after starting on treatment.  It was possible to screen for new antipsychotics and tranquilizers by putting animals on the new drugs and monitoring the effects on their unconditioned and their conditioned reflexes these drugs had on their abilities to learn.

But starting in 1965, the Catecholamine Hypothesis of Depression and Dopamine Hypothesis of Schizophrenia side-lined pharmacopsychologists and brought psychopharmacologists into being.  Side-lined our understanding of what these drugs did and how best to use them. These hypotheses gave rise to the idea that if the person was not cured, something biological had not yet been fixed and the answer was to vastly increase treatment doses. It is no surprise that we have made virtually no progress in 60 years.

Our drugs now are replicas of the original antipsychotics and antidepressants – astonishingly given that we can screen thousands per day. The trouble is we put them in test tubes to see what they bind to or what epigenetic effects they have.

Our abilities to use them in a meaningful way have atrophied. Clinical practice has dumbed down.  We used to get good responses from haloperidol or flupentixol 1-2 mg per day but ended up giving them in doses over a 1000 mg per day

The Capsule in the Room

The introduction to Psychiatric Drugs Explained spelt out my astonishment at the disappearance of Pharmacopsychology. The book called on everyone taking medicines from healthy volunteers to patients to help restore it.

My astonishment then has given way to complete disbelief now that we cannot explain in plain language to the public or to patients what it is antipsychotics do and how this differs from what tranquilizers do and what these drugs do that differs from what SSRIs and anticonvulsants do.  These drugs are all anxiolytic in one sense of another, but they differ dramatically – anyone tested with one of them blind could tell you which it was.

The inscription reads your name may be forgotten but your work remains

Despite being immediately aware of differences between these meds, and despite the fact that so many people are taking them, no-one has been able to put in plain language what the key differences in the experience of taking these drugs are, what people can expect to notice if they take one or another and which of our multiple functions will be changed by them. We should be able to put people in a position to decide if they are getting this or that hoped for effect from a treatment so that they can tell us whether they are getting it or not. We should be able to put people in a position to decide whether what they have been told a treatment is likely to do in order to get them well, which might suit someone else, sounds like the right kind of thing to help them.

Putting people in a position to know what the mission is when taking this pill as opposed to that pill doesn’t just apply to mental health meds.  The same holds true for the different kinds of antihypertensives, hypoglycemics, cancer chemotherapies or other drugs along with non-drug options – See Why Depression IS like Diabetes (forthcoming).

Nobody can say No to a treatment we are assured will get us well.  But this is saying Yes to a lie. If the prescriber doesn’t know and can’t tell us how a treatment might help improve things, and help us to help improve things, the chances of it actually helping drop dramatically – well below 50:50.

A prescriber like this is locating the magic in the pill rather than in her or him and definitely not in US. S/he is dangerous and you should change prescriber.

Instead of a solid grounding in what we might expect, we have the appearances of science. Doctors increasingly hiding behind rating scales, blood tests or other measures.  The scales or tests generate figures which generate doctors who say this drug will get your figures back to normal – as if by magic without telling us what this drug will do to change the figures.

If we stuff stimulants, benzodiazepines, antipsychotics, SSRIs, drugs with no actions on serotonin, anticholinergics, nicotine, alcohol, microdosed LSD or mushrooms into clinical trials for nervous disorders, all can change rating scale scores to exactly the same extent. In the case of nicotine and alcohol, however, we know exactly what they can do to us and when that effect might be useful for us. We also know their hazards, but doctors can’t tell us a thing about what scientifically researched prescription meds specifically do.

E Pluribus Mediocris – as this doctored Great Seal of the United States says.  Mediocris is Latin for Average.  Clinical Trials are averaging machines – putting a pig, cow, horse or man through a mince meat grinder would produce a comparably similar outcome without us being able to tell one from the other.

Companies earn billions of dollars from these drugs every year but we who take them are none the wiser about how this drug as opposed to that drug might help us.  Our job is to just take them, without contributing from the position of a privileged observer on the question of whether the treatment is helping or not or what exactly it is doing.  This is a recipe for a doctor stubbornly sticking to the wrong treatment for us and perhaps doubling or tripling the dose in order to force ‘our’ figures to behave themselves.

Listening to us instead would be a recipe for changing this pill to a different treatment approach not just switch one SSRI for another – Most of the patients in the original Teicher group who became suicidal on Prozac, got better when switched to an MAOI.

Practicing What?

Bruce Springsteen in Born to Run gives better descriptions of akathisia, one of the most serious hazards of our meds, than any medical account has given since the 1950s when drug-induced akathisia was first described.  See I Come to Praise SSRIs for the description.  Most of our meds give rise to Akathisia, but here again we seem unable to pinpoint the differences between antipsychotic akathisia, SSRI akathisia and anticonvulsant akathisia.

Our 70 year fixation on dopamine and serotonin has shed no light on akathisia. We know antipsychotic akathisia can be pretty instant and can lead very quickly to suicide or homicide.  SSRI akathisia seems to have a slower onset and suicidal trajectory. Mirtazapine akathisia seems to have the same timeframe as SSRI akathisia, but it differs – we don’t know how – from SSRI akathisia.  Ditto Anticonvulsants. These are just as likely to lead to suicidality as SSRIs but over a much slower timeframe – giving us a much better chance to spot warning signs, except we have almost no sense what to look for or ask people about.

Shouldn’t it be possible to get us and our psychiatrists and psychologists to share insights on these issues.  The more people who have a sense of what might be going on, the better the chances we can save lives.  Doctors and psychotherapists knew far more 60 years than they do now. Their combined observations back then led to the creation of SSRIs.

A psychotherapist seeing a patient today might spot changes in their patient after being put on a drug but will generally not explore this with the patient for fear of an email turning up from a belligerent doctor telling them they are not licensed to practice medicine.

Whatever about practicing medicine, doctors who are not open to reports on medication – induced observables are not practicing science – See Narcissistic Doctor Disorder.

Material Me, Material Us

Behavioral pharmacology didn’t disappear entirely. It survived in an abuse colony few doctors ever want to visit – substance use disorders – where motivation is the big story.

Motivation sounds very personality or character based. Our appetites, however, the prototype of our motivations are body based rather than brain based.  Prompts from our circadian clock nudge us to imagine food and seek it out or to imagine sleep. Feeling chilly prompts heat-seeking behavior. Being driven by internal sensory signals like this led to a recognition of the importance of interoception – the ability to notice cues in a manner that enables us to manage them – See Intrepid Interoceptors Needed.

Homeostasis, the process of balancing our internal milieu, operates largely through small sensory nerves, which lay the basis for a Material Me, and the basis for a Material Us – many of our hormones readjust in the presence of others.

We have typically translated all this into a brain based biobabble about ‘Dopamine Hits’, almost all of which is badly wrong.  ‘Dopamine hits’ crop up in conversations about sex addiction or shopping addiction, as though our original sin was The Dopes need Hits.

The capacity of SSRIs to cause alcohol use disorder (AUD) helps illustrate the extent to which invoking dopamine side-steps the kind of work that needs doing.  Work?  Yep – talking to people.  Asking questions.

Even though the ability of SSRIs to cause AUD has been firmly on the radar for nearly a decade, we don’t know why or how SSRIs lead to AUD.  Nerds have looked at serotonin transporter genes to explain it, rather than ask people.  When you talk to people who have the problem, they offer several different explanations, each of which may be hold true for some of us but not for the rest of us.

1. When on an SSRI, or suffering from post SSRI sensory numbing, some folk claim not to be able to get drunk. They do end up blacking out so they do get drunk. Not being able to get drunk appears to mean they do not experience the sensory cues linked to becoming drunk. Giving a S-3 receptor antagonist can restore sensitivity to these cues. This muting is consistent with the core actions of SSRIs – I Come to Praise SSRIs.
2. Other folk, including medical doctors acting as healthy volunteers, have taken alcohol to subdue the akathisia or restlessness that psychotropic drugs can cause. Alcohol is one of the very best treatments for some forms of akathisia, possibly because it has diuretic properties which counteract the fluid producing effect of SSRIs, which is one candidate for a possible cause of akathisia. This happens because SSRIs are carbonic anhydrase activators leading to fluid production in confined spaces where it should not be giving rise to an abnormal irritating sensation.  See Psychiatric Drugs Explained.
3. Finally, another experience is more manic or closer to the traditional account of AUD disorder – I knew I didn’t want to do this, but it was there and I couldn’t stop. This echoes a ‘hypnotic’ effect SSRIs can have. When sensory muting reduces the flow of images to our brain, we are more vulnerable to one image becoming dominant and in control of our behavior.

There may be more SSRI effects that people with SSRI linked AUD can point to, but we aren’t going to know what these are unless we ask questions. At present we just lump everyone with an SSRI-linked AUD together and expect to find something in the genetics. This is not a recipe for finding something that may be there.

Sensory Power

It’s time to reinvent Pharmacopsychology.

Gen Z or Millennials, able to access SSRIs from online platforms like Hims and Hers, and uninhibited by prescribing doctors from noticing and sharing what these meds are doing to them are in a great position put this on the map.  Hundreds of millions of older folk, scared by their doctors, and not feeling entitled to research these drugs even though they are or have been in a positive of privilege to observe their effects, have been unable to do so.

Starting on very low doses will give the clearest signals. Sharing experiences is key but you have to bear in mind the differences among us.  Women may be hypersexual pre-menstrually or hyposexual  or just normal. If a variation like this can happen on our normal hormones, even greater variation can be expected with an explosive thrown into the mix.  It will take skill to map out what the drugs are doing. Given our brain bias, it will take great skill to notice all the bodily changes from smell to subtle visual effects that we have spent 30 years ignoring.

Emil Kraepelin and the early pharmacopsychologists would have died for drugs like the SSRIs. Through their effects on our sensory systems, SSRIs are extraordinary tools to explore our emotions (feelings) and subjectivity – even more than the psychedelics.

The science made possible by SSRIs needs doing has not been done.

Doctors are too hidebound by paperwork and scared by bureaucrats as well as just not curious about anything their prescribees might do or think or say, so the science won’t be done by them.  Millions of older folk are too scared of their doctors to say boo, so the science won’t be done by them either.  Governments are too rattled by pharmaceutical companies threatening to move their operations out of ‘your’ country, so they won’t support it.  Lawyers have advised medical journals that having anything to do with pharmacopsychology risks getting sued by drug companies.

It’s going to take a new and intrepid generation of explorers to open this Pandora’s box and let us see what is in there.  Time for Sensory Power to Flower.

This post links to to

• I Come to Praise SSRIs not to Bury Them
• Interoception needs Intrepid Interoceptors
• Treating Narcissistic Doctor Disorder

The post The Once and Future Pharmacopsychology first appeared on Dr. David Healy.