And how much is just idiots?
“How the US Mental Health System Makes Natives Sick and Suicidal,” by David Walker.
Important backstory: once upon a time, I made some offhand comments about mental health/psychiatric drugs that accidentally influenced someone else to go off their medication, which began a downward spiral that ended with them in the hospital after attempting suicide. Several years later, you could still see the words “I suck” scarred into their skin.
There were obviously some other nasty things that had nothing to do with me before the attempt, but regardless, there’s an important lesson: don’t say stupid ass things about mental health shit you know nothing about.
Also, don’t take mental health advice from people who don’t know what they’re talking about.
In my entirely inadequate defense, I was young and very dumb. David Walker is neither–and he is being published by irresponsible people who ought to know better.
To be clear: I am not a psychiatrist. I’m a dumb person on the internet with opinions. I am going to do my very damn best to counteract even dumber ideas, but for god’s sakes, if you have mental health issues, consult with someone with actual expertise in the field.
Also, you know few things bug me like watching science and logic be abused. So let’s get down to business:
This is one of those articles where SJW-logic plus sketchy research of the sort that I suspect originated with funding from guys trying to prove that all mental illnesses were caused by Galactic Overlord Xenu combine to make a not very satisfying article. I suppose it is petty to complain that the piece didn’t flow well, but still, it irked.
Basically, to sum: The Indian Health Service is evil because it uses standard psychiatry language and treatment–the exact same language and treatment as everyone else in the country is getting–instead of filling its manuals with a bunch of social-justice buzzwords like “colonization” and “historical trauma”. The article does not tell us how, exactly, inclusion of these buzzwords is supposed to actually change the practice of psychiatry–part of what made the piece frustrating on a technical level.
The author then makes a bunch of absolutist claims about standard depression treatment that range from the obviously false to matters of real debate in the field. Very few of his claims are based on what I’d call “settled science”–and if you’re going to make absolutist claims about medical related things, please, try to only say things that are actually settled.
The crux of Walker’s argument is a claim that anti-depressants actually kill people and decrease libido, so therefore the IHS is committing genocide by murdering Indians and preventing the births of new ones.
Ugh, when I put it like that, it sounds so obviously dumb.
Some actual quotes:
“In the last 40 years, certain English words and phrases have become more acceptable to indigenous scholars, thought leaders, and elders for describing shared Native experiences. They include genocide, cultural destruction, colonization, forced assimilation, loss of language, boarding school, termination, historical trauma and more general terms, such as racism, poverty, life expectancy, and educational barriers. There are many more.”
Historical trauma is horribly sad, of course, but as a cause for depression, I suspect it ranks pretty low. If historical trauma suffered by one’s ancestors results in continued difficulties several generations down the line, then the descendants of all traumatized groups ought to show similar effects. Most of Europe got pretty traumatized during WWII, but most of Europe seems to have recovered. Even the Jews, who practically invented modern psychiatry, use standard psychiatric models for talking about their depression without invoking the Holocaust. (Probably because depression rates are pretty low in Israel.)
But if you want to pursue this line of argument, you would need to show first that Indians are being diagnosed with depression (or other mental disorders) at a higher rate than the rest of the population, and then you would want to show that a large % of the excess are actually suffering some form of long-term effects of historical trauma. Third, you’d want to show that some alternative method of treatment is more effective than the current method.
To be fair, I am sure there are many ways that psychiatry sucks or could be improved. I just prefer good arguments on the subject.
“…the agency’s behavioral health manual mentions psychiatrist and psychiatric 23 times, therapy 18 times, pharmacotherapy, medication, drugs, and prescription 16 times, and the word treatment, a whopping 89 times. But it only uses the word violence once, and you won’t find a single mention of genocide, cultural destruction, colonization, historical trauma, etc.—nor even racism, poverty, life expectancy or educational barriers.”
It’s absolutely shocking that a government-issued psychiatry manual uses standard terms used in the psychiatry field like “medication” and “psychiatrist,” but doesn’t talk about particular left-wing political theories. It’s almost like the gov’t is trying to be responsible and follow accepted practice in the field or something. Of course, to SJWs, even medical care should be sacrificed before the altar of advancing the buzz-word agenda.
“This federal agency doesn’t acknowledge the reality of oppression within the lives of Native people.”
and… so? I know it sucks to deal with people who don’t acknowledge what you’re going through. My own approach to such people is to avoid them. If you don’t like what the IHS has to offer, then offer something better. Start your own organization offering support to people suffering from historical trauma. If your system is superior, you’ll not only benefit thousands (perhaps millions!) of people, and probably become highly respected and well-off in the process. Even if you, personally, don’t have the resources to start such a project, surely someone does.
If you can’t do that, you can at least avoid the IHS if you don’t like them. No one is forcing you to go to them.
BTW, in case you are wondering what the IHS is, here’s what Wikipedia has to say about them:
“The Indian Health Service (IHS) is an operating division (OPDIV) within the U.S. Department of Health and Human Services (HHS). IHS is responsible for providing medical and public health services to members of federally recognized Tribes and Alaska Natives. … its goal is to raise their health status to the highest possible level. … IHS currently provides health services to approximately 1.8 million of the 3.3 million American Indians and Alaska Natives who belong to more than 557 federally recognized tribes in 35 states. The agency’s annual budget is about $4.3 billion (as of December 2011).”
Sounds nefarious. So who runs this evil agency of health?
“The IHS employs approximately 2,700 nurses, 900 physicians, 400 engineers, 500 pharmacists, and 300 dentists, as well as other health professionals totaling more than 15,000 in all. The Indian Health Service is one of two federal agencies mandated to use Indian Preference in hiring. This law requires the agency to give preference hiring to qualified Indian applicants before considering non-Indian candidates for positions. … The Indian Health Service is headed by Dr. Yvette Roubideaux, M.D., M.P.H., a member of the Rosebud Sioux in South Dakota.”
So… the IHS, run by Indians, is trying to genocide other Indians by giving them mental health care?
And maybe I’m missing something, but don’t you think Dr. Roubideaux has some idea about the historical oppression of her own people?
Then we get into some anti-Pfizer/Zoloft business:
“For about a decade, IHS has set as one of its goals the detection of Native depression. [How evil of them!] This has been done by seeking to widen use of the Patient Health Questionnaire-9 (PHQ-9), which asks patients to describe to what degree they feel discouraged, downhearted, tired, low appetite, unable to sleep, slow-moving, easily distracted or as though life is no longer worth living.
The PHQ-9 was developed in the 1990s for drug behemoth Pfizer Corporation by prominent psychiatrist and contract researcher Robert Spitzer and several others. Although it owns the copyright, Pfizer offers the PHQ-9 for free use by primary health care providers. Why so generous? Perhaps because Pfizer is a top manufacturer of psychiatric medications, including its flagship antidepressant Zoloft® which earned the company as much as $2.9 billion annually before it went generic in 2006.”
I agree that it is reasonable to be skeptical of companies trying to sell you things, but the mere fact that a company is selling a product does not automatically render it evil. For example, the umbrella company makes money if you buy umbrellas, but that doesn’t make the umbrella company evil. Pfizer wants to promote its product, but also wants to make sure it gets prescribed properly.
” Even with the discovery that the drug can increase the risk of birth defects, 41 million prescriptions for Zoloft® were filled in 2013.”
Probably to people who weren’t pregnant.
“The DSM III-R created 110 new psychiatric labels, a number that had climbed by another 100 more by the time I started working at an IHS clinic in 2000.
Around that time, Pfizer, like many other big pharmaceutical corporations, was pouring millions of dollars into lavish marketing seminars disguised as “continuing education” on the uses of psychiatric medication for physicians and nurses with no mental health training.
… After this event, several primary care colleagues began touting their new expertise in mental health, and I was regularly advised that psychiatric medications were (obviously) the new “treatment of choice.” ”
Seriously, he’s claiming that psychiatric medications were the “new” “treatment of choice” in the year 2000? Zoloft was introduced in 1991. Prozac revolutionized the treatment of depression way back in 1987. Walker’s off by over a decade.
Now, as Scott Alexander says, beware the man of one study: you can visit Prozac and Zoloft’s Wikipedia pages yourself and read the debate about effectiveness.
Long story short, as I understand it: psychiatric medication is actually way cheaper than psychological therapy. If your primary care doctor can prescribe you Zoloft, then you can skip paying to see a psychiatrist all together.
Back in the day, before we had much in the way of medication for anything, the preferred method for helping people cope with their problems was telling them that they secretly wanted to fuck their mothers. This sounds dumb, but it beats the shit out of locking up mentally ill people in asylums where they tended to die hideously. Unfortunately, talking to people about their problems doesn’t seem to have worked all that well, though you could bill a ton for half hour session every week for forty years straight or until the patient ran out of money.
Modern anti-depressant medications appear to actually work for people with moderate to severe depression, though last time I checked, medication combined with therapy/support had the best outcomes–if anything, I suspect a lot of people could use a lot more support in their lives.
I should clarify: when I say “work,” I don’t mean they cure the depression. This has not been my personal observation of the depressed people I know, though maybe they do for some people. What they do seem to do is lessen the severity of the depression, allowing the depressed person to function.
” Since those days, affixing the depression label to Native experience has become big business. IHS depends a great deal upon this activity—follow-up “medication management” encounters allow the agency to pull considerable extra revenue from Medicaid. One part of the federal government supplements funding for the other. That’s one reason it might be in the best interest of IHS to diagnose and treat depression, rather than acknowledge the emotional and behavioral difficulties resulting from chronic, intergenerational oppression.”
It’s totally awful of the US gov’t to give free medication and health care to people. Medically responsible follow up to make sure the patients are responding properly to their medication and not having awful side effects is especially evil. The government should totally cut that out. From now on, lets cancel health services for the Native Peoples. That will totally end oppression.
Also, anyone who has ever paid an ounce of attention to anything the government does knows that expanding the IHS’s mandate to acknowledge the results of oppression would increase their funding, not decrease it.
Forgive me if it sounds a bit like Walker is actually trying to increase his pay.
“The most recent U.S. Public Health Service practice guidelines, which IHS primary care providers are required to use, states that “depression is a medical illness,” and in a nod to Big Pharma suppliers like Pfizer, serotonin-correcting medications (SSRIs) like Zoloft® “are frequently recommended as first-line antidepressant treatment options.” ”
My god, they use completely standard terminology and make factual statements about their field! Just like, IDK, all other mental healthcare providers in the country and throughout most of the developed world.
“This means IHS considers Native patients with a positive PHQ-9 screen to be mentally ill with depression.”
Dude, this means the that patients of EVERY RACE with a positive PHQ-9 are mentally ill with depression. Seriously, it’s not like Pfizer issues a separate screening guide for different races. If I visit a shrink, I’m going to get the exact same questionaires as you are.
Also, yes, depression is considered a mental illness, but Walker knows as well as I do that there’s a big difference between mentally ill with depression and, say, mentally ill with untreated schizophrenia.
” instance, the biomedical theory IHS is still promoting is obsolete. After more than 50 years of research, there’s no valid Western science to back up this theory of depression (or any other psychiatric disorder besides dementia and intoxication). There’s no chemical imbalance to correct.”
Slate Star Codex did a very long and thorough takedown of this particular claim: simply put, Walker is full of shit and should be ashamed of himself. The “chemical imbalance” model of depression, while an oversimplification, is actually pretty darn accurate, mostly because your brain is full of chemicals. As Scott Alexander points out:
“And this starts to get into the next important point I want to bring up, which is chemical imbalance is a really broad idea.
Like, some of these articles seem to want to contrast the “discredited” chemical imbalance theory with up-and-coming “more sophisticated” theories based on hippocampal neurogenesis and neuroinflammation. Well, I have bad news for you. Hippocampal neurogenesis is heavily regulated by brain-derived neutrophic factor, a chemical. Neuroinflammation is mediated by cytokines. Which are also chemicals. Do you think depression is caused by stress? The stress hormone cortisol is…a chemical. Do you think it’s entirely genetic? Genes code for proteins – chemicals again. Do you think it’s caused by poor diet? What exactly do you think food is made of?”
One of the most important things about the “chemical imbalance model” is that it helps the patient (again quoting Scott):
” People come in with depression, and they think it means they’re lazy, or they don’t have enough willpower, or they’re bad people. Or else they don’t think it, but their families do: why can’t she just pull herself up with her own bootstraps, make a bit of an effort? Or: we were good parents, we did everything right, why is he still doing this? Doesn’t he love us?
And I could say: “Well, it’s complicated, but basically in people who are genetically predisposed, some sort of precipitating factor, which can be anything from a disruption in circadian rhythm to a stressful event that increases levels of cortisol to anything that activates the immune system into a pro-inflammatory mode, is going to trigger a bunch of different changes along metabolic pathways that shifts all of them into a different attractor state. This can involve the release of cytokines which cause neuroinflammation which shifts the balance between kynurinins and serotonin in the tryptophan pathway, or a decrease in secretion of brain-derived neutrotrophic factor which inhibits hippocampal neurogenesis, and for some reason all of this also seems to elevate serotonin in the raphe nuclei but decrease it in the hippocampus, and probably other monoamines like dopamine and norepinephrine are involved as well, and of course we can’t forget the hypothalamopituitaryadrenocortical axis, although for all I know this is all total bunk and the real culprit is some other system that has downstream effects on all of these or just…”
Or I could say: “Fuck you, it’s a chemical imbalance.””
I’m going to quote Scott a little more:
“I’ve previously said we use talk of disease and biology to distinguish between things we can expect to respond to rational choice and social incentives and things that don’t. If I’m lying in bed because I’m sleepy, then yelling at me to get up will solve the problem, so we call sleepiness a natural state. If I’m lying in bed because I’m paralyzed, then yelling at me to get up won’t change anything, so we call paralysis a disease state. Talk of biology tells people to shut off their normal intuitive ways of modeling the world. Intuitively, if my son is refusing to go to work, it means I didn’t raise him very well and he doesn’t love me enough to help support the family. If I say “depression is a chemical imbalance”, well, that means that the problem is some sort of complicated science thing and I should stop using my “mirror neurons” and my social skills module to figure out where I went wrong or where he went wrong. …
“What “chemical imbalance” does for depression is try to force it down to this lower level, tell people to stop trying to use rational and emotional explanations for why their friend or family member is acting this way. It’s not a claim that nothing caused the chemical imbalance – maybe a recent breakup did – but if you try to use your normal social intuitions to determine why your friend or family member is behaving the way they are after the breakup, you’re going to get screwy results. …
“So this is my answer to the accusation that psychiatry erred in promoting the idea of a “chemical imbalance”. The idea that depression is a drop-dead simple serotonin deficiency was never taken seriously by mainstream psychiatry. The idea that depression was a complicated pattern of derangement in several different brain chemicals that may well be interacting with or downstream from other causes has always been taken seriously, and continues to be pretty plausible. Whatever depression is, it’s very likely it will involve chemicals in some way, and it’s useful to emphasize that fact in order to convince people to take depression seriously as something that is beyond the intuitively-modeled “free will” of the people suffering it. “Chemical imbalance” is probably no longer the best phrase for that because of the baggage it’s taken on, but the best phrase will probably be one that captures a lot of the same idea.”
Back to the article.
Walker states, ” Even psychiatrist Ronald Pies, editor-in-chief emeritus of Psychiatric Times, admitted “the ‘chemical imbalance’ notion was always a kind of urban legend.” ”
Oh, look, Dr. Pies was kind enough to actually comment on the article. You can scroll to the bottom to read his evisceration of Walker’s points–” …First, while I have indeed called the “chemical imbalance” explanation of mood disorders an “urban legend”—it was never a real theory propounded by well-informed psychiatrists—this in no way means that antidepressants are ineffective, harmful, or no better than “sugar pills.” The precise mechanism of action of antidepressants is not relevant to how effective they are, when the patient is properly diagnosed and carefully monitored. …
” Even Kirsch’s data (which have been roundly criticized if not discredited) found that antidepressants were more effective than the placebo condition for severe major depression. In a re-analysis of the United States Food and Drug Administration database studies previously analyzed by Kirsch et al, Vöhringer and Ghaemi concluded that antidepressant benefit is seen not only in severe depression but also in moderate (though not mild) depression. …
” While there is no clear evidence that antidepressants significantly reduce suicide rates, neither is there convincing evidence that they increase suicide rates.”
Here’s my own suspicion: depressed people on anti-depressants have highs and lows, just like everyone else, but because their medication can’t completely 100% cure them, sooner or later they end up feeling pretty damn shitty during a low point and start thinking about suicide or actually try it.
However, Pies notes that there are plenty of studies that have found that anti-depressants reduce a person’s overall risk of suicide.
In other words, Walker is, at best, completely misrepresenting the science to make his particular side sound like the established wisdom in the field when he is, in fact, on the minority side. That doesn’t guarantee that he’s wrong–it just means he is a liar.
And you know what I think about liars.
And you can probably imagine what I think about liars who lie in ways that might endanger the mental health of other people and cause them to commit suicide.
But wait, he keeps going:
“In an astonishing twist, researchers working with the World Health Organization (WHO) concluded that building more mental health services is a major factor in increasing the suicide rate. This finding may feel implausible, but it’s been repeated several times across large studies. WHO first studied suicide in relation to mental health systems in 100 countries in 2004, and then did so again in 2010, concluding that:
“[S]uicide rates… were increased in countries with mental health legislation, there was a significant positive correlation between suicide rates, and the percentage of the total health budget spent on mental health; and… suicide rates… were higher in countries with greater provision of mental health services, including the number of psychiatric beds, psychiatrists and psychiatric nurses, and the availability of training in mental health for primary care professionals.””
Do you know why I’ve been referring to Walker as “Walker” and not “Dr. Walker,” despite his apparent PhD? It’s because anyone who does not understand the difference between correlation and causation does not deserve a doctorate degree–or even a highschool degree–of any sort. Maybe people spend more on mental health because of suicides?
Oh, look, here’s the map he uses to support his claim:
I don’t know about you, but it looks to me like the former USSR, India/Bhutan/Nepal, Sub-Saharan Africa, Guyana, and Japan & the Koreas have the highest suicide rates in the world. Among these countries, all but Japan and S. Korea are either extremely poor and probably have little to no public spending on mental healthcare, or are former Soviet countries that are both less-developed than their lower-suicide brothers to the West and whatever is going on in them is probably related to them all being former Soviet countries, rather than their fabulous mental healthcare funding.
In other words, this map shows the opposite of what Walker claims it does.
Again, this doesn’t mean he’s necessarily wrong. It just means that the data on the subject is mixed and does not clearly support his case in the manner he claims.
” Despite what’s known about their significant limitations and scientific groundlessness, antidepressants are still valued by some people for creating “emotional numbness,” according to psychiatric researcher David Healy.”
So they don’t have any effects, but people keep using them for their… effects? Which is it? Do they work or not work?
And emotional numbness is a damn sight better than wanting to kill yourself. That Walker does not recognize this shows just how disconnected he is from the realities of life for many people struggling with depression.
“The side effect of antidepressants, however, in decreasing sexual energy (libido) is much stronger than this numbing effect—sexual disinterest or difficulty becoming aroused or achieving orgasm occurs in as many as 60 percent of consumers.”
Which, again, is still better than wanting to kill yourself. I hear death really puts a dent in your sex life.
However, I will note that this is a real side effect, and if you are taking anti-depressants and really can’t stand the mood kill (pardon the pun,) talk to your doctor, because there’s always the possibility that a different medication will treat your depression without affecting your libido.
“A formal report on IHS internal “Suicide Surveillance” data issued by Great Lakes Inter-Tribal Epidemiology Center states the suicide rate for all U.S. adults currently hovers at 10 for every 100,000 people, while for the Native patients IHS tracked, the rate was 17 per 100,000. This rate varied widely across the regions IHS serves—in California it was 5.5, while in Alaska, 38.5.”
Interesting statistics. I’m guessing the difference between Alaska and California holds true for whites, too–I suspect it’s the long, cold, dark winters.
According to the American Foundation for Suicide Prevention,
“In 2013, the highest U.S. suicide rate (14.2) was among Whites and the second highest rate (11.7) was among American Indians and Alaska Natives (Figure 5). Much lower and roughly similar rates were found among Asians and Pacific Islanders (5.8), Blacks (5.4) and Hispanics (5.7).”
Hey, do you know which American ethnic group also has a history of trauma and oppression? Besides the Jews. Black people.
If trauma and oppression leads to depression and suicide, then the black suicide rate ought to be closer to the Indian suicide rate, and the white rate ought to be down at the bottom.
I guess this is a point in favor of my “whites are depressive” theory, though.
Also, “In 2013, nine U.S. states, all in the West, had age-adjusted suicide rates in excess of 18: Montana (23.7), Alaska (23.1), Utah (21.4), Wyoming (21.4), New Mexico (20.3), Idaho (19.2), Nevada (18.2), Colorado (18.5), and South Dakota (18.2). Five locales had age-adjusted suicide rates lower than 9 per 100,000: District of Columbia (5.8), New Jersey (8.0), New York (8.1), Massachusetts (8.2), and Connecticut (8.7).”
Hrm, looks like there’s also a guns and impulsivity/violence correlation–I think the West was generally settled by more violent, impulsive whites who like the rough and tumble lifestyle, and where there are guns, people kill themselves with them.
I bet CA has some restrictive gun laws and some extensive mental health services.
You know the dark blue doesn’t look like it correllates with?
Back to Walker. “Nearly one in four of these suicidal medication overdoses used psychiatric medications. The majority of these medications originated through the Indian Health Service itself and included amphetamine and stimulants, tricyclic and other antidepressants, sedatives, benzodiazepines, and barbiturates.”
Shockingly, people diagnosed with depression sometimes try to commit suicide.
Wait, aren’t amphetamines and “stimulants” used primarily for treating conditions like ADHD or to help people stay awake, not depression? And aren’t sedatives, benzos, and barbiturates used primarily for things like anxiety and pain relief? I don’t think these were the drugs Walker is looking for.
” What’s truly remarkable is that this is not the first time the mental health movement in Indian Country has helped to destroy Native people. Today’s making of a Mentally Ill Indian to “treat” is just a variation on an old idea, … The Native mental health system has been a tool of cultural genocide for over 175 years—seven generations. Long before there was this Mentally Ill Indian to treat, this movement was busy creating and perpetuating the Crazy Indian, the Dumb Indian, and the Drunken Indian.”
Walker’s depiction of the past may be accurate. His depiction of the present sounds like total nonsense.
” We must make peace with the fabled Firewater Myth, a false tale of heightened susceptibility to alcoholism and substances that even Native people sometimes tell themselves.”
The fuck? Of course Indians are more susceptible to alcoholism than non-Indians–everyone on earth whose ancestors haven’t had a long exposure to wheat tends to handle alcohol badly. Hell, the Scottich are more susceptible to alcoholism than, say, the Greeks:
Some people just have trouble with alcohol. Like the Russians.
Look, I don’t know if the IHS does a good job. Maybe its employes are poorly-trained, abrasive pharmaceutical shills who diagnose everyone who comes through their doors with depression and then prescribes them massive quantities of barbiturates.
And it could well be that the American psychiatric establishment is doing all sorts of things wrong.
But the things Walker cites in the article don’t indicate anything of the sort.
And for goodness sakes, if you’re depressed or have any other mental health problem, get advice from someone who actually knows what they’re talking about.