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Mel Remple's avatar

IMO this is the problem: “He does not feel comfortable seeing a therapist and would just like to start a medication.” Talking about our issues is key to feeling better and doing better. For decades society has stigmatized talking about emotions and mental health (especially for men) and promoted the quick fix of a ‘pill for every ill’ for everyone. Meditation, yoga, self-reflection and spending time in nature is very healing and has none of the nasty side effects of so many of our Western pharmaceuticals.

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Martin Greenwald, M.D.'s avatar

A timely and important topic.

A few thoughts:

1) A key different between SSRIs and stimulants is efficacy. For true, honest-to-Gosh ADHD, stimulants are one of the most effective medications psychiatrists have. While SSRIs can be truly helpful and even life-saving for a relatively small number of people, I don't think they can compare with stimulants in terms of efficacy.

2) The analogy between the two example patients is strained because psychotherapy for depression is often a reasonable monotherapy. I would argue that accepting the patient's "I don't feel comfortable with therapy" and just prescribing an SSRI is probably a mistake.

3) We absolutely need to be honest about cosmetic psychopharmacology as a way to help people who are basically already healthy, or at least aren't terribly impaired. Where do we draw the line? There doesn't seem to be an a priori reason to say that caffeine is OK whereas small doses of other stimulants like methylphenidate are not. I think there are genuine ethical and pragmatic dilemmas as to whether physicians want to get into the business of enhancement instead of treating illness.

4) Most of the talk of "depression" and "ADHD" these days is really the expression of basic human struggles—sadness, loneliness, lack of meaning, the disconnect between our evolved instincts and the demands of staying focused for long periods of time in modern life—but put into modern medicalized lingo. In a pre-scientific era this would probably have been considered some kind of mass spiritual crisis, which still seems like a fairly accurate description to me.

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