Everything is Public Health
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Everything is public health and public health is for everyone.
So many things impact our health. The physical things around you, the social interactions, the policies you may never notice, are all quietly there, protecting our health and well-being in subtle ways everyday. This is the world of public health; a science of understanding the countless forces and designing solutions to help prevent or mitigate harm and improve the health and well-being of the people. Public health saved your life today, and you probably didn't notice.
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Website: https://www.everythingispublichealth.com/
Everything is Public Health
Mental Health is Public Health - Antidepressants Saves Lives
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There is nothing wrong with antidepressants. Anti-Depressants Are So Not A Big Deal.
Given all the barriers to access and stigma, it is more likely that there are people out there that would benefit from but are not taking these medication than people taking them when they don't have to.
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Welcome back to Everything's Public Health, a show about how everything is public health. And public health is for everyone. I'm MJ. And I'm Cass. Do you know a TV show called Crazy Ex-Girlfriend?
SPEAKER_01No. I say that highly like a little uncertain. I know for sure I have never watched it. I am sure at some point in my life I was aware that it was a show, but I've never watched it.
SPEAKER_00Is it a new show? No, it's old. I think it's at this point 10 years old. So it's been a while.
SPEAKER_01Oh, okay. I vaguely know of the show. Never watched it. Go ahead.
SPEAKER_00So, in my opinion, it is a brilliant musical comedy show from the mind of Rachel Bloom.
SPEAKER_01How did I not know that there was a musical comedy show?
SPEAKER_00If you love musical comedy show, you will love the show. I highly recommend it.
SPEAKER_01I love all things musicals. Did you not know this about me? If I could change one thing about my life, I would make my life a musical.
SPEAKER_00I know you love singing. I didn't know it was musical specific.
SPEAKER_01Oh my god, I love sometimes as cringy as they are, like any time a TV show does a musical episode, like the Buffy musical episode, loved it. Gray's Anatomy musical episode, loved it. I don't care if it's crap. I love it.
SPEAKER_00This show is a musical TV show. So every episode there's a song. So I think you would absolutely love this show. I'm glad I brought this to your attention. Your mouth is a gape.
SPEAKER_01I am so excited, and I am doing a staycation the week of Memorial Day, and you can bet your buckets that I'm gonna be watching some of this show. Thank you very much. You have made my weekend.
SPEAKER_00Well, let me know how you feel. It is a theater kids' fever dream of a show. The songs are oftentimes parodies of popular song. It's silly, funny, and satirical. The main character of the show, Rebecca Bunch, is a lawyer with various mental health issues who moved across the country to an awful suburb in Los Angeles to chase after her crush she dated 10 years ago for a few weeks in summer camp. That is the premise.
SPEAKER_01Okay, that's probably why I didn't watch it. Wait, are you turned off by this show now? No, I'm still going to watch it. Give it a chance. I'm still gonna watch it. But also, so it did it start 10 years ago or end 10 years ago?
SPEAKER_00It started 10 years ago.
SPEAKER_01Okay, well, I was gonna use the excuse that I was writing my dissertation and not watching television, but that's not true. I was done at that point. So anyway, moving on.
SPEAKER_00The show is 10 years old, but I can still wholeheartedly recommend it if you like musicals. A big theme of this show is mental health, and there is a song from the show called Antidepressants Are So Not a Big Deal. It's from season four. And do you want to guess what this song is about?
SPEAKER_01Gonna guess it's about the fact that antidepressants are not a big deal, that they can help you more than they will hurt you.
SPEAKER_00You are right! Yay! We could listen to the song together if you like. Yes, I would like. Okay, go to YouTube. We'll do this together. And you're just gonna type in crazy ex-girlfriend, antidepressants, so not a big deal. And it should be the first thing that comes up. It's on the channel called Rachel Does Stuff.
SPEAKER_01Okay, I got it.
SPEAKER_00Alright, let's press star at the same time. Three, two, one. Hello, post editing MJ here. Obviously, I can't play the actual clip or music for legal reasons, but I highly encourage everyone look up the show and particularly the song. It is very catchy and quite fun.
SPEAKER_01Okay, I got the gist.
SPEAKER_00You wanna stop?
SPEAKER_01Yeah, we can stop. I got the gist.
SPEAKER_00First of all, what do you think? It's a fever dream. It's a theater kids fever dream of a show.
SPEAKER_01It fills me with such joy. I have had a giant smile on my face ever since I clicked played. I love it so much.
SPEAKER_00So you will watch the show. That's good.
SPEAKER_01I'm gonna go watch the show, yeah.
SPEAKER_00Do you want to describe to our listeners what the song is about, at least the first half of it?
SPEAKER_01Sure. So the the song starts because two folks are having a conversation about whether or not to start antidepressants, and the woman who sings the song is talking about how everyone is on them on some kind of medication, some kind of dosage that while we're all special and unique when it comes to being sad, like lots of people are sad. There's nothing special or unique about that, and there's a medication that can help. And, you know, it's not a big deal.
SPEAKER_00It's lovely, right? It's a nice little joyful number.
SPEAKER_01Normalizing mental health and the need for treatment. Exactly.
SPEAKER_00We love it. It starts as a conversation between Rebecca and her therapist. The woman in blue is the therapist about how antidepressant is okay and normal, but presented in an upbeat taps number. We didn't get to the tapshoe part.
SPEAKER_01Ooh, I look forward to it.
SPEAKER_00When the song aired, many people found this song incredibly relevant to them. Keep in mind that this was 10 years ago.
SPEAKER_01Well, it makes sense when we think about representation and the stigma around mental health, not just not just talking about mental health, but seeking treatment, whether that's therapy or medication, there's tons of stigma around that. And thinking about this being 10 years ago, like I think we have, well, maybe we've backslid a bit.
SPEAKER_00Yeah, we did.
SPEAKER_01I think we had made some progress. Like, I think about the Bipartisan Safer Communities Act that had a ton of money for mental health and crisis response. You know, we'd really been making some strides. So, you know, 10 years ago, if this song came out, I imagine probably even more stigma than we have now. But people resonating with seeing, oh, okay, like I'm not alone in this. And I will say what we see on social media is that everybody's happy and healthy and their lives are so perfect because the curated stuff we put online is not all of the ins and outs of our lives. And so people, I think, often feel alone and isolated if they aren't as happy as they see everybody else being on social media.
SPEAKER_00Yeah. And even with the term medicated, there's still stigma with just the term medicated. Like it's often used in a negative way. So it was a very popular song when it aired, and a lot of people found it very relatable. Unfortunately, we have to go to Bummerland a little bit. The inspiration for this episode is something that RFK Jr. said recently. Don't know if you saw this, but he said something about mental health and antidepressants. Did you see this news? Just one thing? There's multiple things. Yeah, you're right.
SPEAKER_01No, I know. Well, you said he said something as though it was like, I will say, I often disagree with his statements and positions. So we'll just leave it at that.
SPEAKER_00So he said this statement. I'm gonna read out to you. Today we take a clear and decisive action to confront our nation's mental health crisis by addressing the overuse of psychiatric medications, especially among children. End quote. How do you feel? Well, let me describe what her face is doing. Her eyes are closed, her mouth is scrunched up, and she is turning beet red.
SPEAKER_01I am processing. I have a lot of things that would like to come out of my mouth, and I am processing. I will say a couple of things. I don't know that there is any evidence to support the claim of overuse of psychiatric medications among any population, let alone children. In fact, we know that most people who need access to mental health treatments have a hard time gaining access. So if anything, we are underutilizing the range of treatments available to us, including psychiatric medication.
SPEAKER_00Keep this in mind.
SPEAKER_01That's my first piece. The next thing I will say, there was a study that came out, I can't remember what it was now, but I use it. You may recall, MJ, I use it as a motivating example in my research methods class I used to teach in the opening lecture, talking about differences between randomized control trials and quasi-experimental and observational data, and how there was a paper that came out that said basically the takeaway was that young people on antidepressants had a 50% increase in suicide risk. There was a 50% increase in suicide risk among young people taking antidepressants. But if you look at it, and I what I'm about to say, I want to recognize that even one death or attempt at self-harm is too many, and we should absolutely be working to address that. So please don't take this as anything other than it was a 2% increase to a 4% increase in the risk of suicidal ideation in this population. So yes, it was a 50% or you know, a whatever increase, but it was not, we're talking very small magnitude. None of these studies were designed to measure suicidal ideation or suicide outcomes. It was only what was reported. And it was on only certain kinds of medications, not all medications, and they sort of had a blanket ban or black box warning on a whole bunch of antidepressants that actually weren't included in the study. So there's a lot of misinformation out about the risk of suicide among young people in particular related to antidepressants. So I just want to say I think this is there's nothing to support that statement from my slightly well-educated opinion.
SPEAKER_00I would say you're more than slightly well-educated.
SPEAKER_01I'm not a psychiatrist. I'm not a mental health epidemiologist. I certainly touch upon these things and I use them examples in classes that I teach, but I wouldn't say this is my primary area of expertise.
SPEAKER_00Sure. I remember that paper you used in class. Uh it was an example of what not to do, I suppose, in a paper. And I believe that paper also has selection bias.
SPEAKER_01There's tons of selection bias about who could be enrolled. These were all very short studies. They were not intended to track people long term. And when you actually looked at the data, the risk of suicidal ideation was much higher before they started the medication than once they started. So there were a lot of challenges.
SPEAKER_00Which is the important thing. Bad paper.
SPEAKER_01No, no, no. Not necessarily a bad paper because it was a they did a review of a bunch of papers.
SPEAKER_00Oh, that's right.
SPEAKER_01The interpretation of the findings in the review was problematic. We've been talking offline about communicating findings of research and the importance of clear communication and the way it was communicated led people to make the wrong decisions from my perspective.
SPEAKER_00And I fully agree with you there. Um, we'll do a full breakdown of this new quote unquote initiative, but let's talk about the psychiatric medication in question. Today's episode is all about meds, focusing on the most frequently prescribed one, like antidepressants, and why they are so important. And obviously, the obligatory question: why is this public health?
SPEAKER_01Hopefully, folks listening to this podcast don't need to hear this, but we'll say it anyway. Mental health is a part of health. It's important to have a healthy life, to have good mental health. Poor mental health can potentially lead to poor diet, lack of exercise, lack of social interactions. It can impact your ability to hold a job. Uh, it doesn't have to be depression-related. Manic episodes can also be harmful, like impulsiveness, risk-taking behaviors. Some folks who experience mental illness, particularly if they have a hard time accessing treatment, may self-medicate, which can also be negative for health. Depression is by some metric the leading cause of disability in the world. So if you're thinking about your ability to engage in sort of all aspects of life, that can be a disability. And the elephant in the room is obviously suicide. So mental health issues is one of the main risk factors for suicide, which is obviously a public health concern when people are dying from something that may be preventable if they're able to access appropriate treatment.
SPEAKER_00Yeah. Since mental health is critical to our individual and collective health, treating these mental health disorders is a good thing. Would you look at that? Like these psychiatric medications are a boon to humanity, similar to how artificial insulin saved the lives of diabetic patients. These medications dramatically improve the lives of people with major depressive disorder or bipolar or anxiety or ADHD, etc. Simply put, these medications save lives, or at the very least, improve people's lives dramatically.
SPEAKER_01There are lots of different kinds of medications. There are SSRI antidepressants, so selective serotonin reuptake inhibitors. It keeps serotonin around, helps with low mood. There are anxiety meds like benzodiazepines, where somebody may take the medication to help them feel less anxious or manage panic attacks. There are stimulants, for example, for ADHD like Adderall, something that can help you better focus or concentrate. And then there are mood stabilizers like gapapentin or lithium for people who may experience something like bipolar disorder, where you may have both depression and manic episodes.
SPEAKER_00Yeah, many different types. Um we will focus more on the common ones, which is the SSRI for today. So returning to the statement that RFK Jr. made, he is claiming that there's an overuse of psychiatric medications. Cass, you sort of touch on this already. You don't believe that this is true.
SPEAKER_01I am highly suspect of any statement of overuse of psychiatric medication. I touched on this already, but just to reiterate the point, there are lots of people who need access to mental health services who cannot gain them for one reason or another. Lack of providers, lack of appointments, too far away, too expensive, whatever it might be. And so to claim with a blanket statement that there's general overuse, I find very hard to believe since we know there are so many people who can't even gain access in the first place to then have these overuse issues.
SPEAKER_00Absolutely. So let's break this down. After looking into this, I discover that this statement, and also the Maha space in general, is doing one of those tactics of wrapping lies around a kernel of truth. Like these half lies are the hardest to depunk because we need to get into nuances. And when you get into nuances, it takes more time to do so. But you know what? Let's do it. Let's get into the nuances. Let's break this down. To start, we'll start with a kernel of truth. There is an interest to understand psychiatric medication prescribing practices. Like what dose is appropriate, how much is appropriate, who qualifies for them, when discontinuation is appropriate, and long-term usage effect. There is a genuine interest in this space to figure out like, are we prescribing correctly in like a big question sort of way?
SPEAKER_01Which is a responsible thing to do. And I think we've talked about this before, but it's called practicing medicine because we're not always a hundred percent sure what the right thing to do is, right? And psychiatry in general, in case folks didn't know, is a particularly young field of science or medicine. And like any field of science, it's constantly trying to learn how to do better, right? If we aren't assessing whether what we're doing is working or not, we're not going to make improvements. And it's understandable that there's an interest to see if we are prescribing these medications appropriately. And researchers are calling for more research in this space. Also, mental health providers stress that an issue remains understaffing, inequity, access, all those sorts of things. But this does not mean that the field thinks there are blanket over-prescribing practices with regard to these medications. The consensus is still these drugs save lives. So it's important that we are assessing are we doing the right thing? But that doesn't mean that we are doing the wrong thing.
SPEAKER_00Correct.
SPEAKER_01And by we, I mean the field broadly, not me, because I'm not actually in it.
SPEAKER_00Right. And I digged a little bit into this, and some of the providers are saying that the nuance is really hard to parse out. So, for example, let's say someone is on a medication and you want to wean them off of a medication, that process is called tapering. However, tapering requires monitoring. The provider needs to monitor your progress over time as you taper, which means it requires resources. So if there is a understaffing or just a lack of human and material resources in that particular area, the provider is probably not going to taper you. They probably have like a huge caseload that they need to work through. So a lot of times, like the idea that, oh, people are getting prescribed when they don't need to, that is a systemic issue with being understaffed. Because it's a lot easier to give someone something than to like sit them down, assess them. What are the contexts that you're working with? What are your backgrounds? Like all that takes time. And when the provider don't have that time, sometimes they're just gonna err on the side of caution and be like, you know what? I'm just gonna prescribe you some SSRIs.
SPEAKER_01Well, then the frustrating thing is in general, a conservative talking point is that we need to address mental health. That, for example, gun violence is not a gun problem, it's a mental health problem. We love to talk about it. In the Bipartisan Safer Communities Act that was passed, there was all of this money for crisis intervention and school-based mental health centers and all of these things to address the very access issues that conservatives often talk about, but that has been gutted under the current administration. So all of the things you're talking about, these resources to understand are we giving people the appropriate amount of medication? Do we need to support them, change the medications, taper, et cetera? We've just made it that much harder to do by gutting all of these mental health resources that had been in Bisca.
SPEAKER_00So that's the kernel of truth. But however, as you alluded to, the Maha movement is still fundamentally lying. We know this because of everything else they have said about these trucks, specifically antidepressants. Let's debunk them one by one. Cass, tell me how you feel about each of these statements that RFK Jr. made. Statement number one. Americans have a dependency crisis driven by over-medicalization when it comes to psychiatric medications.
SPEAKER_01Okay, first of all, I don't really understand. I mean, I understand each of those words in the sentence, but together as a coherent thought, I'm struggling a little bit. So I will say I think that there can be a tendency to medicalize things that might not need to be medicalized. But that does not mean that people who have been evaluated by a mental health provider or physician of some kind and provided an appropriate medical treatment, which includes medication to address their mental health issues. That is not over-medicalization.
SPEAKER_00You know what the sentence reminds me of? You know how some people they would use technical terms, they'll just sort of toss them in a sentence and just like jumble them around. And then we know these terms. So when we read this, it doesn't make sense to us. But you can see how this statement might appeal to someone who doesn't know what over-medicalization is or dependency is. And also, I don't like the dependency crisis because there is this insinuation that there's an addiction, which antidepressants are not addictive, these are not addictive compounds. So to use dependency crisis, I think is highly irresponsible. Next statement that he made too many patients begin treatment without a clear understanding of the risk and how long they will stay on these drugs or how to come off them. And that's not informed consent. We are going to fix this.
SPEAKER_01Okay, so there's so much going on. It's hard for me to imagine a provider prescribing a medication to a patient, like an antidepressant, and not having a conversation about the risks and benefits. That is standard practice for any treatment that a healthcare provider is giving. And there are often conversations about like, if you are going to stop this, we need to have a conversation about how to do that safely. You might not do it right in the moment, but you flag like you can't just stop taking it, right? It's important that we talk about it before you you stop taking it.
SPEAKER_00You need a taper, yeah.
SPEAKER_01And it's also like this is a throwing in informed consent is also muddies the water. Like, that's not really what we mean by informed consent. Like, yes, people should know the risks and they should know what they're taking and and all of those, like, yeah, of course, that makes good sense, but that's not really what we think of for informed consent. And like, there's also no comment about what is it that you're going to fix? We're going to fix it. Which part? There's like four things in this sentence, which part and how. So I I find this another form of I'm just gonna hand wave and say words, and then you aren't going to ask me any questions about it.
SPEAKER_00Yeah, same tactic. Throw in some terms in there, jumble it up with other words, and maybe this will fly over people's head. And for some people, it does fly over their head.
SPEAKER_01This also removes any kind of autonomy from the people who are being prescribed these medications, as though like someone is doing a thing to them and they have zero role or control in decision making or anything like that, which is not how this works either.
SPEAKER_00And also, if your complaint is that too many patients begin treatment without clear understanding, that is a resource issue. Right. They need more resource, right? You need more public health or sorry, mental health providers then if that's your worry, but you're obviously not doing that. All right, last one, I promise. We will support patient autonomy, required informed consent and shared decision making as shift the standards of care towards prevention, transparency, and a more holistic approach to mental health.
SPEAKER_01I mean, so on one hand, I support patient autonomy and informed consent and shared decision making. Like that is the basis of a healthy patient-provider relationship. Yeah, that all makes good sense. Like, I don't disagree with that. I don't think that's what they mean, particularly when they start to talk about shifting the standard of care towards prevention, because as we talked about, they're defunding all of these things that would help with prevention. And I like transparency, I find concerning because like transparency for who, by what? Like, there's all these all these concerns now about doctors being subpoenaed for their medical records. Like, I don't want the government to know the kinds of healthcare decisions I'm talking about with my provider. And like, that's not transparency for who, I guess, is my question. And we've talked before about holistic approaches to things and how that is sort of a concerning flag for like the wellness industry. And like that's where I worry about like over-medicalization. Like, there are all of these people who are like, oh, I you have this problem. I know how to solve it. If you just pay me $29.99, I will give you the solution to all of your problems and blah, blah, blah. Like that is what that flags for me more than like an effective strategy. And my concern is always, okay, so let's get into the details. How are you going to do this? What resources are you going to allocate to have prevention and transparency? And in general, theoretically, I support a holistic approach to mental health. Sure, medication isn't right for everyone, but that means you need to make equal access to mental health providers, to safe spaces for physical activity, all sorts of things that can improve people's mental health and well-being. But that requires dollars that, again, we have not seen this administration be willing to spend.
SPEAKER_00Absolutely. You pretty much hit all the points that I wanted to make. And I think this statement is so insidious because they would often front-load a good thing and then sneak something towards the back and hope no one notices. The first part, yeah, absolutely. We care about informed consent, chair decision making. That's absolutely true. But then they start talking about prevention, and we have seen that they do not care about prevention. They have done nothing with their actions to show that they care about prevention. They don't really care about transparency. In fact, they care about surveillance, which is not transparency. And holistic approach, anyone else who said that, I would take them seriously. RFK Jr. said that. That's dog whistle for big wellness, unfortunately, given his track records. And we have found evidence that he is suggesting some Italian. Countryside wellness retreat to help wean people off SSRIs. Like that's like a serious thing that he's concerning.
SPEAKER_01I mean, don't get me wrong, I'd like to go to the Italian countryside, but I wonder who's making money off of all the folks who are going to that retreat.
SPEAKER_00Yeah, I wonder who's benefiting from all these things. All of the stuff that he said during that presser, I think, is very insidious because they're full of half truths, and half truths are a lot harder to debunk. You know that the Maha's attitude towards mental health is not a good one because they have made several statements about SSRIs specifically. They have claimed, with no evidence, that SSRI causes violence and mass shootings. Now, you know, gun violence researcher Cass.
SPEAKER_01No, that's not a thing.
SPEAKER_00They say they cause birth defects, also not a thing. They cause harm to children, which I'm always like, why are you so vague? What is harms to children? Do you care to elaborate? Like, what kind of harms to children? But they never say, and they say it causes lethal withdrawal symptom, which is also not a thing. This is an oversimplification of a very complex issue. To think de-prescribing is the magic bullet is concerning because as we talked about many times in this podcast, there is no public health magic bullet. You cannot get out of this quote unquote mental health situation by de-prescribing. It's just, it doesn't make any sense.
SPEAKER_01Right. Well, and the thing about public health is that it takes a multifaceted approach for prevention. For some people, medication might not be the right solution. And we don't want to force people to take medication if they don't want them. But for some people, it is the right strategy. And making this even more stigmatized than it has been in the past is problematic. Like people already are less likely to seek help if they're concerned about people knowing about it, all the stigma that comes around with it. And this is just going to make things worse for folks.
SPEAKER_00Yeah. I would say the conclusion is if anything, there is a lack of mental health resources. And a lot of people who should be on these drugs are not getting on these drugs.
SPEAKER_01Absolutely. And we talked about access, but cost is a really big really big thing right now. Like everything is more expensive than it was even a handful of years ago. And wages are not increasing. Cost of living is. And I am certain because we we see this often for a range of issues. There are people who have to choose between buying food and buying medications or paying their electric bill and getting their prescriptions. So it is a much broader and more complex issue than sort of simply saying, oh, we need to de-prescribe because we've over-medicalized a problem. From my perspective, if anything, we haven't medicalized mental health enough because we're not properly reimbursing. We aren't having more people trained to make sure that they can treat all of the people who need access to providers. We are very lucky that we have employer-based health insurance where we can get help when we need it, but there are lots of folks who don't. And it's a shame to frame it in a way that we're doing all of these bad things with medication when there are lots of people who could probably benefit.
SPEAKER_00SSR has saved lives. I think that's like a very clear thing that we've witnessed. Microgood time, maybe? R send a letter. You said that already though.
SPEAKER_01I know, but I think it bears repeating that like it's nice to open up the mailbox and have something that's not a bill to pay.
SPEAKER_00And or ads.
SPEAKER_01Find a fun sticker and send it to a friend in the mail. I love that. Drink water.
SPEAKER_00Yeah, buy some stamps. Vote. Of course. Keep up the pressure. Pressure does work. And don't fall into that space of like, oh, nothing matters. No, that's what they want you to think. Everything still matters. You have to believe that things still matter. Otherwise, we've lost.
SPEAKER_01Don't make it easy for them by giving up. That's what they want you to do.
SPEAKER_00Thank you for listening to Everything is Public Health. New episodes out every other week. If you like the show, please tell everyone you know about the show. That helps us out immensely. Commenting, subscribing, and leaving us a review helps us a bunch as well.
SPEAKER_01If you have any questions or think we missed an important perspective, you can reach out to us at everything ispublichealth at gmail.com. Follow our website, everything is publichealth.com for all show updates and bonus material. And remember, everything is public health.
SPEAKER_00Everything is public health.
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