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Psychotropic Deprescribing Council retweeted
Before working with Marsha Linehan, I advocated for what I mistakenly thought was a broad 'bio/psycho/social' model of human nature & psych treatment.
She taught me it was far too narrow because it left out the 'spiritual' aspects of life- the human need to find meaning & hope.
Marsha perfectly embodied/practiced a fully rounded, 4 dimensional 'bio/psycho/social/spiritual' model.
Aaron Beck's last innovation was to add a spiritual component to CBT.
Psychotropic Deprescribing Council retweeted
Marsha Linehan spent her teenage years as the rebellious, self-hating ugly duckling of a highly successful family.
It took yrs of self blame & self mutilation before she had the spiritual revelation of radical acceptance that allowed her first to change herself & then change our understanding of & treatment for people suffering as she once did.
Psychotropic Deprescribing Council retweeted
One of the reasons why IV saline cannot be used as "placebo" in patients with POTS/dysautonomia/small fiber neuropathy. It creates temporary improvement from plasma volume expansion masking immunologic effects of IVIG.
onlinelibrary.wiley.com/doi/…
Psychotropic Deprescribing Council retweeted
Essentials of Marsha Linehan's DBT:
• Dialectics: Balancing acceptance & change
• Mindfulness: Staying grounded in the now
• Distress Tolerance: Problem solving exercises
• Emotional Regulation: Managing intense feelings
• Interpersonal Skills: Setting healthy boundaries
• Validation: Meeting yourself realistically but without judgment
Marsh Linehan has died.
Marsha was most impactful woman in history of psychology/her DBT is among best treatments ever developed/her life an inspiration of self healing & giving to others.
Marsha cured her first & toughest patient- herself- after a 2 yr hospital stay as teenager & then went on to help millions of people.
Marsha's special "dielectic" was to be the most validating of therapists, but also the most demanding. She gave patients more than anyone I've known, but expected them to work as hard as she did.
2 work things I'm proudest of are helping Marsha get her first NIMH funding/write her books. I think of Marsha & often will miss her always.
Psychotropic Deprescribing Council retweeted
I strongly disagree & prefer that psych trainees learn to tolerate the inherent uncertainty in our complex field than strive for artificial coherence/arrive at false certainty.
Psychiatry has no processes of clinical practice improvement. Each clinician is on their own, making it up as they go along according to their biases.
The shortage is of the quality of care that arises from understanding patients.
There are unfortunately no diagnostic solutions to institutional maladies in mental healthcare. If there is scarcity of relational care and no collaborative conceptualization and treatment planning, no tweaks to diagnostic language will substitute for what is actually needed.
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Psychotropic Deprescribing Council retweeted
Can universal help for teens about mental health make them more depressed?
A trial of 12,166 students in 153 English schools randomized them to:
• YAM, a 5-session program led by trained facilitators
• A 6-session teacher-led mental health literacy program (the Guide)
• Usual practice
YAM did not improve depressive symptoms. The Guide program increased help-seeking and knowledge.
But at 9 to 12 months, depressive symptoms were worse in both programs than with usual practice (SMD 0.08 and 0.09).
Effects are small, but consider rolling this out universally to millions of kids. From the authors: "these kinds of programmes may encourage rumination and self-labelling in such a way that it increases emotional distress."
Ref: 10.1192/bjp.2026.10667
We do know that psychiatric drugs, particularly antipsychotics, tend to derange metabolic functioning. How about carefully reducing to the lowest effective dose before adding another drug? Why is this not standard procedure in psychiatric drug treatment?
Terrific game changing news for people with severe mental illness who now have 20 yearr reduced lifespan.
New weight loss drugs dramatically reduce mortality & may even improve psych symptoms.
BUT terrible news: Ridiculously expensive & often inaccessible.
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Psychotropic Deprescribing Council retweeted
The thing that helped the most is time, or to be generous, time on the first antidepressant. Here's another terrific study, CO-MED, that suggest that mechanism if irrelevant and that that more drugs have more side effects. No one wants to talk about it.
psychiatryonline.org/doi/10.…
Psychotropic Deprescribing Council retweeted
@jack_goulder No history of psychiatry is complete without examination of the role of primary care in psychiatric diagnosis & treatment for the last 35 years. Powers-that-be claimed antidepressants were so safe & effective, no specialist training needed. Made billion$ for pharma.
"No placebo arm" is traditional in psychiatry research. You'd think the researchers wanted to find significant results for their experimental arm.
In 2017, the VA ran a large RCT (VAST-D) in 1,522 veterans with depression.
Three arms:
(1) adding the antipsychotic Abilify (aripiprazole)
(2) adding the NDRI Wellbutrin (bupropion)
(3) switching to Wellbutrin.
Abilify did statistically better, but the raw numbers are not impressive, see graphic. Groups started with QIDS of 16.5–17 and ended 8.9-10.1.
Some took this to mean adding an antipsychotic beats Wellbutrin. There was no placebo arm, so we can't know whether any of these would do better than time and attention.
The authors: "augmentation with aripiprazole resulted in a statistically significant but only modestly increased likelihood of remission."
Also the meds had side effects:
• Abilify akathisia (14.9% vs 4.3%), sedation (14.5% vs 7.2%), weight gain (25.2% vs 5.2%).
• Wellbutrin anxiety (24.3% vs 16.6%), irritability (6.3% vs 1.4%).
Ref: Mohamed et al., 2017. JAMA, 318(2), 132–145.
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Psychotropic Deprescribing Council retweeted
We learned nothing from the disastrous #OxyContin tragedy.
Big Pharma/Venture Capital/Biotech startups are pouring billions prematurely hyping ketamine/psilocybin/MDMA.
Long term efficacy unclear & safe only in highly controlled/very expensive settings.
Result will surely be massive increase in very dangerous street use.
Researchers are optimistic about psychedelic drugs as potential treatments for depression and mood disorders, despite pushback having stalled the field
go.nature.com/4e1WDEM
As usual in psychiatric, the findings neglect the environments that might foster these attitudes in teens, such as interpersonal behaviors handed down in families, regional alcoholism, & neighborhood political leanings.
Fascinating findings show how teenage psych symptoms predict adult political preferences
1)Teenage depression/anxiety》Later left voting
2)Conduct disorder》Later right voting
Possible Mechanism
1)Depression/Anxiety may stimulate empathy
2)Acting out indicates early lack of it.
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Psychotropic Deprescribing Council retweeted
Week 7 of the Symptom Patterns Series (Series 4)
Mixed and Overlapping Patterns
Some withdrawal symptoms may fit one recognizable pattern. Others may span several — or fit none of them neatly.
Earlier weeks described patterns involving threat and arousal, autonomic symptoms, movement, and changes in thinking, sensing, and self-experience. In practice, these patterns can overlap.
A person’s picture may include fear and a racing heart (threat/arousal) alongside tremor and difficulty keeping still (motor). Or digestive upset and light-headedness (autonomic) alongside mental fogginess (thinking) and sound sensitivity (sensory).
Appearing together does not mean sharing one cause.
Some symptoms are harder to place — flu-like feelings, skin symptoms, or new intolerances. Others, such as what some people call “benzo belly,” may overlap several areas rather than fitting one pattern. Naming them does not explain their cause.
Overlap is not a flaw — it is part of the picture. These patterns are a shared language for patients and clinicians. They are not diagnoses and do not establish why symptoms occur.
New or changing symptoms deserve individual medical evaluation.
thebenzotaperdoctor.com/post…
#BenzoWithdrawal #NervousSystem #Neuroscience
New psychiatric diagnosis for people who become physiologically dependent on a prescribed opioid: complex persistent opioid dependence (CPOD). But not addicted - that's opioid use disorder (OUD).
hmpgloballearningnetwork.com…
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You, too, propofol? "Have you ever noticed that some of your critically ill patients become agitated & confused when their propofol infusions are being tapered or discontinued?"
Managing Propofol Withdrawal psychiatrist.com/pcc/manifes…
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This makes too much sense.
If we want to be evidence-based, as we should, then any clinical trial must follow the same scientific method: if "symptom relief" in the intervention group is high, but not higher than "placebo" (and we can argue what that placebo is or should be in various patient populations), then we can't call this intervention effective.
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Psychotropic Deprescribing Council retweeted
Dr. Ostacher, a recent article in Nature:
"What the field has not built, with equivalent rigor, is a science of what happens when the treatment stops."
Kim, B. (2026). The neuropsychopharmacology of treatment discontinuation. Neuropsychopharmacology. doi.org/10.1038/s41386-026-0…
Psychotropic Deprescribing Council retweeted
It would be great to have RCTs, but they're not a prerequisite for calling it "science." It's also worth remembering WHY we don't have RCTs--not because there's nothing worth investigating, but because of lack of funding. Most of science is done without RCTs, and for now we have to do our best to make inferences with available data. But it's also more than "conjecture and clinical experience."
The underlying biology aligns with with the clinical experience of many patients needing to taper to very low doses (ie hyperbolic dose occupancy curves) although the mechanistic picture is incomplete (here is where I plug @BShapiroMD and I's recent paper that you've seen as a next step). There is observational data as well, and much of what we do in psychiatry is based on observational data.
The fact that we know this issue affects many patients should prompt us to call for more research, but it shouldn't make us dismiss whatever evidence we do have. Good science is about making inferences with limited data, and we can't afford to sit back and wait for "perfect" data--too many patients are suffering for that!