#because if its both adhd and aspergers like she mentioned then that would explain A LOT

[mental-illness-bingo]

Content Warning: Venting about ableism against ADHD and Autism in a book; mentions of emotional abuse, repeated mentions of elitism within the autism community, "corrective" surgery for mental health disorders, demonizing of medication, encouraging young adults to refuse their medication etc. Note that I haven't finished the book yet, but I intend to, so I suppose it could get better, but what it's done already is abhorrent, and I'm grossed out.

Book in question: The Love Letters of Abelard and Lily by Laura Creedle

This. Book. Is. Killing. Me.

I saw this recommended as a "really good book about autism and ADHD" from someone but I *really* hate it so far (I'm on Chapter 27, about 2/3 way through the book) and it's honestly just blatantly ableist in so many ways. I do not know if Laura Creedle is autistic or has ADHD, but if so? Internalized ableism everywhere. If not then yet another neurotypical asshat who wrote an ableist ass book.

Context: Lily is diagnosed with ADHD and Abelard is diagnosed with "Asperger's".

And let's start there. This book was written in 2017, years after the switch from that N*zi doctor's name to Autism Spectrum Disorder. This is problem #1, and the reason is not that they use that word for it. I can and have enjoyed books while suspending my disbelief around the fact that they maybe didn't know because a significant number of people still don't in 2023.

However, Abelard is the poster child for elitism. He is this super smart kid who just so happens to have trouble with verbal conversation, being late, and sometimes being touched. He is worse than the savant trope because he is literally talked about like a genius. He is inhumanly good at chess, robotics, old literature, video games, just everything he touches, really. In fact, despite him supposedly having serious communication difficulties, when he is texting, he is suddenly able to communicate just like anyone else, with occasional long pauses between texts being the only issue he shows.

And his sole meltdown that has been shown is honestly so toxic and borders abusive to Lily. She is late to their date due to her ADHD, something any of us with it can relate to, and Abelard knows about her ADHD in advance as well as having had seen her symptoms multiple times in person. There is 0 way he didn't know about her having ADHD. Anyway, she's a little late (I think 20 minutes or something but I can't remember tbh with you) and he is visibly angry with her, and she immediately apologizes, explaining that her ADHD causes her issues being on time. Rather than be understanding of his girlfriend's disorder the way she has tried to be with his, he pretty much ignores her. His mother babies him about it, working on setting up everything for him and getting them into the movie wherein he seems to relax (but only after forcing his mother to go get popcorn right this instant because they're watching a movie and he needs popcorn). Then, after a bit, his father is trying to explain the movie to Lily and its history and Abe does NOT like people talking during movies. He yells at his dad, who continues to try and talk, and then has the meltdown in question. Lily tries to touch him to help comfort him and realizes immediately she shouldn't have when he makes a noise as though he is in pain. He begins slamming his head off the table, which is reasonably off putting to Lily, and she asks his father for help. His father mentions his mom would usually be here and that Lily "shouldn't have been late", basically accusing her of causing the meltdown even though he kept pushing when his son told him they were watching a movie. Lily panics and exits to the kitchen because she feels helpless and upset that she can't do anything for him.

All of this is relatively understandable behavior, I guess. I don't really love that he yelled at his father and mother both in this scene for normal things because it paints autistic people as unreasonable and irrational, but it is true that sometimes meltdowns are caused by people continually doing normal things that happen to really get under our skin. His parents should know his triggers and avoid pushing them because they are his parents. Lily, on the other hand, is a child and one with her own neurodivergent struggle, and should never in any way have been strapped with the blame both because it is not her job to tiptoe around a boy she has been dating for a few days with triggers no one warned her about, and because the issue at hand is a symptom of her own disorder and is equally as in her control as Abelard's reaction to her being late is in his.

BUT THEN while panicking in the kitchen, Lily breaks something on accident as she often does and tries to leave and Abe's mom makes a whole thing out of it. She becomes physically intimidating to Lily, smashing a glass on purpose to "help" the situation, which obviously makes Lily uncomfortable, and half-threatens her to go back into her son's room even though she wants to go. Throughout the entire next scene Lily mentions in her narration wanting to go home and while I think it's important that Lily learns coping skills outside of running away, it is equally within her right to be too stressed by Abe's reaction to her being late and choose to break up with him. Lily is not required to stay with Abe just because she's the only girl he has brought home, and intimidating her into staying is disgusting.

To Abe's credit, he mentions that his mother used his sob story to make Lily stay. Then he loses 100% of that credit in the most entitled scene I've read in a long time where Lily is pressured to not only stay in that house and in that relationship, but also promise to NEVER be late again even though it is a symptom of her own disorder. She mentions that this seems to be the only way to make him happy and that "promising to try harder is not enough". So, more or less, she is in a relationship where she cannot ever show symptoms of her disorder without him giving her the silent treatment, yelling at everyone around him, and smashing his head into a table.

No one ever mentions at any time during this or after that Abelard also should be learning positive coping skills or teaching her how to help with his meltdowns or anything like that. She should just be expected to never show a symptom of her own disorder so that he doesn't react in a very toxic/honestly kind of abusive way. Cannot stress enough that he does not treat her kindly again until she promises she will literally never be late ever again. Not try - NEVER late again.

Abe strongarms multiple people like this throughout the book. His mother with the popcorn, his father with talking during a movie, his robotics teacher where he literally stands there and repeats "I invited my girlfriend to robotics" over and over again until, despite safety concerns, the teacher gives up and allows Lily to stay if she signs a waiver (which she doesn't read and is not the legal age to sign anyway), and Lily when he wants to tell her something but tells her she is not allowed to speak until he has finished then gets visibly angry (as noted by Lily) when she answers a question he asked her out loud. His meltdowns are used as a threat of sorts to the people around him and a manner of controlling them. It is worth noting I have only in my entire life met one autistic person who did this and surprise surprise, they were abusive and had a history of using meltdown threats to R word multiple people. That is not autistic behavior. It is abuse being hidden behind the excuse of autism, and it's gross in every context, including this book.

So, onto Lily's ADHD. Lily is constantly breaking things, constantly late, runs out of any even slightly uncomfortable situation, does not care about the emotions of her mother or her sister, and is overall a really gross ADHD stereotype. But that's okay! Why? Because she will be fixed via corrective surgery. Yes, you read that right. But let's go into why medication didn't work for her first.

Lily lists throughout the book her hatred of her current and all past medications, of which there is a number she lost count of. Because the author treats this ADHD character like a goldfish who was just given access to a human body for the first time and therefore cannot remember anything (or walk two steps without smashing something valuable), that number could still be relatively small. The book doesn't treat it as a small number though, so we're going to assume she's tried most ADHD medications, and is currently taking an antidepressant as a manner of treating ADHD which is so far in the past as far as treatment goes that I don't even know which medication they're talking about.

The typical antidepressants (SSRI's) are not used to treat ADHD at all to my knowledge, and SSNRI's are only really used if every other form of ADHD medication has failed you and even then are rarely used as far as anyone I know with ADHD. Why? Because there are actual medications that help ADHD, and a good amount of them. Realistically, the concept that 0 of them worked for Lily is statistically improbable. The only antidepressant really used to treat ADHD actively is Bupropion, but the emotional blunting the surgeon Lily sees says is a side effect of her medication is not a side effect associated with Bupropion. In fact, Wellbutrin/Bupropion is often used for people either in combination with or as a replacement for other antidepressants to counteract the emotional blunting they cause.

The demonizing of medication in this book is dangerous. Lily hates every medication because all of them have stripped her of her ability to feel anything positive. The book does not mention any other ADHD character that tolerates medication well, or even speak about it as though it is just not working for her. It does not explain that if Lily went to the doctor and told them her side effects, that they would *immediately* taper and remove a medication that is causing emotional blunting and sui thoughts. The book doesn't mention that this is an abnormal side effect - in fact it's says it's a common side effect of antidepressants. It also treats medication as some sort of weird muzzle that is put on people with ADHD so their loved ones (in this case Lily's mom, sister, and teachers) can tolerate them. The book does not mention any positive effects of any medication for ADHD at all. I hate to think how many kids were made afraid of or resentful of their meds by this book.

The book details specific ways to avoid taking your medication, and even how to hide it so you can (tw sui mention) take them all with vodka to hurt yourself. This is not something Lily attempts in the book, but was just thinking about, and therefore did NOT need to be described in detail. The book even acts like sui watch is stupid and unnecessary, and does not detail the dangers if Lily were to take all of these medications at once with alcohol. So basically they wrote in a non-precautionary sui method for kids with ADHD that also involves months or years of medication non-compliance. Great. /sarcasm

But like I said, that's not the worst of it. What upset me enough to write this whole rant is the next part. Lily's mother finally giving up on the neurologists (which... weird because everyone I know with ADHD was treated by a psychiatrist not ever a neurologist), and going to a literal brain surgeon for some sort of electrodes to be placed in her brain that is supposed to permanently change how her synapses fire.

This is the ableist buffet, and for a while Lily feels the same and by a while I mean 2-4 pages. Then she decides that she will see the doctor if her Mom does something for her, and forgets all about the upset of having her mother feel the need to cure her.

In fact, when Lily meets the doctor, it takes him almost no time to convince her that she not only needs but also wants the corrective surgery, spouting about how she could go to college right now if she does it, when college would not have even been an option before.

It is gross on every single level and I looked up this surgery and ITS FAKE ITS NOT EVEN REAL. This author literally made up a fake corrective surgery for ADHD, I wanna puke.

I literally do not even want to read this for the story anymore I just have to know how much worse it can possibly get. If it's bad maybe I'll reblog and add on to this.

Edit: HOW could I possibly forget Lily's Dad? A total deadbeat who cheated on her mother and ran off to Portland, who was only able to interact with his daughter while actively drinking when he still lived with them, who is constantly switching what he wants to do in his life to the point that he can't hold a job, and who refuses to talk to let alone see either of his daughters in the years since he's been gone because he "can't keep a phone". And why is he like this? As the books tells you very explicitly about 2/3 of the way in, he is like this because he also has ADHD. Lovely. He had this apparently entirely inspired, amazing, never-been-done idea for his dissertation in college. But then he more or less got bored and overwhelmed with the idea so he just dropped it, left college and his family, and ran away to Portland. All because he has ADHD, because the author thinks that's what this disorder is - an inability to have any responsibility or finish anything ever no matter what it is or how important. The author treats ADHD like it's a lobotomy and I hate it here.

Maybe don't read The Love Letters of Abelard and Lily.

Edit: see reblog. It got so much worse, not better.

[beaversatemygrandma]

Hmmm I was just given another option of how my year may go.  I Could always move up to NC for a while with my dad, where I’ll actually have somebody who will help me move forward and teach me how to be a real adult.  Coming out as transmasc will likely not happen tho, but at least i could be openly bi up there.  (read more bc im rambly thinking about this stuff)

Not to mention he’s willing to take like two days off, get me insurance, a license and a car right as i go up there. Like instantly. Instead of this argument with my mom about how i’m rushing to get my license (im fuckin 21 im not rushing, i Need one). Plus she says she’d be okay with me moving back in, but i’d be paying rent, and she doesn’t want me to yet. (apparently wants to remodel her bathroom first but idk what that has to do with me) Not to mention she’s wanting to bail on this state as soon as my sister graduates. Which is maybe in a year and a half?  So, if i do that, I might not be in FL for a long while (at least six months or so but if i like it there? maybe longer), but at least I’d have a car and be able to drive back as i please. I love long road trips, so that’s def not out of the option for the one of you wondering ;3 

It would be a good change of pace and after talking to the bf about it, he says it might be a good chance to move on and get to do what i want to do instead of just existing as i am. Which is a bit sad, but ik we weren’t going to be a forever thing. We’ve established that one a while ago. But heck, as of the end of may it would be my longest relationship at 2 yrs. I’d definitely still talk to him too.  i mean sure, i dont know anyone there bc i havent lived there since i was 7, but id at least have my dad, youngest sister, and grandma. It’s a solid idea and my dad even knows people working at NCU and i might be able to get in there and actually do college now that im not burnt out to extreme points.  Plus, he wouldn’t charge me rent. 

And not knowing people would give me a good chance to put myself out there again and not struggle with sifting through the friends i have in my mom’s town to avoid the relations to my ex. And maybe not be suffocated by being close to all the town’s stoners. Like i am now. Ish. I stopped talking to people and im starting to wonder if its even worth trying to go back to them because i might not have the friendship degeneration thing, but ik all of them do. (except like one and i will REGRET leaving them behind bc we still text like once a month and theyre so fuckin encouraging and sweet even if it is the much older stoner i hung out with back in the panera days) Besides, being with that group just led me into turning into a stoner myself and im breaking away from that one because holy hell that was a Ride start to finish. (my brain goes FAST again and its shocking like holy shit i can read still) A lot of regretful stuff happened, even if some of it was fun as hell, but not worth it in the long run if i want to be a functioning human being. 

Will i go up there and be one of those people on tinder looking for friends because they’re new to town? yeah probably. Will it work? I fucking hope so. I want to gather other like-minded people to hang out with so bad. Maybe some other nb people too. (and tbh maybe a gf because heck yeah) 

I’m liking this idea currently. It’d be a nice change of pace. Having a supportive parent around would also be a nice thing. And my little sister needs an influence from somewhere (even if the two of our ADHD issues goes berserk when together. I’ll do something impulsive, then she does and it’s usually worse bc she’s only 12 and Much Worse with focus even on meds.) And my dad supports meds, unlike my mom. So if i could get this adhd treated, things might just get easier too. (instead of self-medicating with things i shouldnt self-medicate with lol) 

Random unrelated thing, i actually ended up talking to my mom about the mental health screenings she got me as a child. Apparently 2 doctors said i was super hyperactive with adhd and another one said aspergers. So. I might have undiagnosed aspergers too. So that’s a thing. (no she never medicated me or went any further with testing. bc giving benzos to kids is bad which i can understand, but i didnt grow out of it like she thought i would and it causes me problems.) 

The only things im really worried about with going up there, is of course, leaving people behind, possibly having to take care of my extremely hyperactive sister who overwhelms me, and being in a big city.  Like Big City my dude. It’s Charlotte. I mean yeah sure, its where i was born, but i havent been in a big city since i was 7. Relearning how to drive during Their rush hour instead of the one here will be very overwhelming.  Perks though, would be real public transportation (they have trains and real buses, like holy shit), a parent who gives a shit, and the insane amount of decent paying job openings up there that wouldn’t be in a tourist trap where i’d get disrespected by rich white people all the time bc they think im stupid or smth. (no avoiding karens tho if i go back into customer service but if i can help it, im avoiding that) 

But i think just having a parent who encourages me and wants me to progress in life would be the biggest help. My mom seems to not want to see me getting ‘better than her’ bc the rest of the family looks down on her for not being successful (ig, i mean her sister’s a lawyer who stole my college fund to put her kids into private schools and accessed the will from my granddad way too early and all that shit when we’re the ones who needed that money bc we make less than 20k a year) but still, aren’t you supposed to be proud of your child if they’re going to potentially be in a better spot than you are?  Like my dad continues to remind me that i graduated with honors and a bunch of special stuff and how that isn’t common and how i have so much potential that i dont think i have and how i can actually qualify for a decent well paying job if i just go back to school. Plus, he’s got the connections to NCU. That’s a good school. I really wouldn’t mind actually getting some peace of mind for the future by getting what i need to done. And He’ll Help Me. (EDIT: It’s not NCU, it’s UNC. The Tar Heels. The blue one. In NC. Not Cali.) And he even knows how the world works a lot better than my mom seems to. He actually knows how to use those government help things and work around all the issues there instead of the blanant avoidance my mom has to it. (i havent had insurance since i was 17, like heck i need to go get myself checked out for A Lot of things and i cant afford to do that. She also doesn’t believe in credit cards. Real words she’s said. I shit you not.) 

i think i might do it. i dont see myself thriving back at my mom’s. she’d just keep me under her control and prob have me just at yet another standstill like ive been in since 2017. (fuckin pandemic really didnt help that. chose a bad year to get my shit together tbh because that didnt work, hell, neither did i lol)  Yeah sure, i got to move out and see what that’s like. Living on my own, working over 40 hours a week, seeing how poverty+ tastes... it tastes bad. I dont want to do that again. I learned some things. I’ve matured and have (mostly) processed what the actual fuck the trauma i got during high school was. (ahh the neo-nazi and the abusive jackass of a bf i had... hoooboy...)  Plus real seasons?? Sign me up. I miss seeing orange leaves in the fall and snow in the winter. And not suffering with daily 90+ degree weather. 

Even if i can’t (the transphobia is scary my guy) come out as transmasc, i’ll still likely get my hands on a binder and just go full gnc. More than i was before tbh. I’ve always been the ‘tomboy’ so it wouldn’t be so out of place doing that all of the sudden. Prob also going to cut my hair to have that fauxhawk that can be used in the most nb ways. It seems very nice and very versatile.  Might help the dysphoria that I’ve apparently had since 2015, likely longer. That’s just when i learned the word for it. Which has been Much Much worse lately due to the quarantine mane i still have going on. (mom wouldn’t help me just shave it off.... ;-;  Tho it is only shoulder length now with an undercut. Better, but still not good.) And the weight. Oh god and the weight. I miss my days of being flat as a board and having people unable to tell what i was. But nooo, i gotta be curvy. Doesn’t help that my mom makes me feel bad about it too. (thanks for the plus size clothes i got last xmas... im not that big. Damn.) Might also be the birth control... my body has more female hormones now than it knows what to do with. I could benefit from a break from it tbh. 

Also, who knew that if i stop self-medicating in a certain way, I’d get my will to live back? I sure wasn’t expecting it to hit so soon after quitting after hearing all the bs about how it was addictive and hard to quit (it’s not. At all. sure there’s a certain reliance your brain gets if you smoke for like four years straight all day everyday, i didn’t personally but it was a decent amount, but after like a day or two it’s gone. No headaches. No weird pain and mood swings. Whoever started the shit about it being so bad obviously never tried it. *glares at fuckin reagan and DARE and all the racial/criminal issues that come with it*) Though, I’ll still be happy that it’s getting legalized. (not fully in either of these states but still, it’s at least decriminalized in NC) It is a good thing in moderation, like giving a cat catnip. Just an extra plaything tossed into your enclosure sometimes so you don’t get bored and depressed. I haven’t done it in a good two weeks though and only really will if i end up hanging out with said stoner friends or to knock myself out if insomnia is kicking my ass, but that’s really it. I don’t want to anymore and that’s the end of that.  Not going back to embracing stoner culture like i did back in my apt and panera days tho. There’s some sketchy people who come around and its usually with drugs that actually are bad. (like that one tinder date who tried to bring coke into my apt and me and my roommate had to quickly shut him down. Never did hear from him again. Which is good. Not gonna associate with that shit that’s actually addictive and potentially dangerous.) Anyways, just glad im not too burnt out anymore to think and talk to people. This is definitely a step in the right direction. I think i could actually have a chance if i make the move this year. I definitely have enough savings to drop on the whole move and car and whatever else I’d need. (stimmies themselves pay for the car bc i never did spend them) 

Hopefully, this will end with me feeling good about myself for the first time ever and actually doing something with my life instead of sitting around depressed as hell. Could maybe be a real adult for once. Hell, I’m almost 22, i need to get onto this shit. My gap year may have been four years, but im getting there.  The positive influence from the bf and his family have been good for me and i think it was the kick i needed to get me started. The pandemic has given me a chance to breathe and process things. So, it hasn’t been all bad.  I just have to remember to pace myself so i don’t burn out again. It took way too long to recover from it. 

Side note: Holy fuck the covid case in NC are SO MUCH LESS than FL. Like less than half. Only about 1k vs like 6k a day. Another pro I guess. 

[douglasbergerpsychiatristto-blog]

Tests, testing, and tested – we need to critically evaluate the meaning of tests in psychiatry

Douglas M. Berger Meguro Counseling Center, Tokyo, Japan

A recent article entitled, “Perils of Newborn Screening”[1] led me to think of how we in psychiatry and our patients also have some perilous ideas about screening and testing. The article describes testing initiated in 2006 in New York State for Krabbe disease of the nervous system. Krabbe disease is a rare inherited disorder where lack of the enzyme galactocerebrosidase causes the myelin coating on the nerves to break down. Mental and motor development are affected, and muscle weakness, deafness, and blindness may occur.[2]

Out of the total one-million babies tested, 24 tested positive and out of 24, 4 developed symptoms. One family refused treatment and subsequently the child died; another child died from complications of the treatment; another’s illness is progressing despite treatment, and one baby who had been treated successfully has recently lost his ability to walk. Parents of babies who test positive, are described to be in a constant state of worry, some pursue risky tests, and the emotional trauma (not to mention the cost) incurred is likely to outweigh the benefits.

This example illustrates how one kind of test may have pros and cons. The pros and cons of ‘testing’ can also be seen in one’s daily practice of psychiatry. The following are personal experiences of my practice in Tokyo.

CLINICAL EXAMPLES

“My 8-year-old child is depressed, should they have psychological (psych) testing to determine if antidepressants are warranted?” A woman I have been treating for a few years for major depression told me about her 8-year-old son who is irritable, has been crying more, and has written some notes contemplating suicide. She first brought her son to a large local counseling center where they recommended in-person counseling with their staff psychologist, school observations, and psych testing (costing about $4,500), and told the mother that they could not recommend starting antidepressants until the psych testing was complete. The son could not finish the testing because he was unable to maintain concentration.

The mother eventually decided she couldn’t wait anymore and asked me to evaluate the child who clearly looked depressed. I explained that if the psych testing assessed the son having a depression, this affirms the obvious. If the psych testing assessed the son without a depression, we are still left with a depressed-looking child who is writing suicide notes, and with an anti-depressant responsive depression in his mother. Neither family dynamics nor school issues could explain the child’s depression.

We agreed that there was no logic for psych testing in terms of, ‘to treat’ or ‘not to treat’; and in tandem to a medical work-up for depression, we initiated 2.5 mg of escitalopram a day with a good response. Scales and tests for depression may indeed provide some helpful information; however, predictive value, sensitivity, and specificity are still far from perfect,[3] and the National Institute of Mental Health (NIMH) guidance only mentions medical examination and history of symptoms in the evaluation of depression.[4]

While no test can fully prove a psychiatric diagnosis, we understood that the medication can be construed to be both a treatment as well as a kind of diagnostic test, i.e., improvement on administration, and relapse on discontinuation would support the diagnosis of a major depression.

In addition, while the son was ill with depression, the other aspects of psych testing, i.e., personality or intellectual testing, would not properly reflect these areas of functioning. It would be like asking a person with pneumonia to run around a track, time them, and then make an interpretation of this person’s ability to run (not to mention the cost saving of the psych testing).

The next peril is the way the school authorities may use the results of his psychological testing, which may have a negative impact on the child’s education in the future. I opined that the school only needed to know that the son would get help, but did not need to know the diagnostic or treatment details.

“My 4-year-old has been tested and diagnosed with Asperger’s Disorder, can you counsel him?” This has been a more frequent inquiry in recent years. Some parents or adult patients almost seem to be proud to have this diagnosis, thinking that it portends high intelligence, but it may actually be a way to avoid a more uncomfortable mental illness diagnosis. Most of these parents do not realize that there is no test to prove that someone has Asperger’s, (the criteria for Asperger’s includes: Marked impairment in social relations, often with stereotyped motor movements, and a vast knowledge of some topic of esoteric or impractical value),[5] and that the incidence of Asperger’s is thought to be extremely low (about three in 10,000)[6] when compared with other disorders whose symptoms overlap with Asperger’s (i.e., attention deficit disorder/ attention deficit hyperactivity disorder (ADD/ADHD), which may affect up to 10% of children.[7]) Few of the patients who come in with a supposed diagnosis of Asperger’s actually fulfill the criteria for Asperger’s.

On examination, most of these children have symptoms suggesting ADD or ADHD; some have depression or anxiety, and others a shyness or awkwardness that may be normal or may evolve into social anxiety disorder later in life. On rare occasion some do look like high-functioning autistic children, although it seems parsimonious and logical to assume that these children have the far more common diagnosis rather than a rare diagnosis if the symptoms overlap significantly.

The peril here is when the parents or an adult patient does not accept having a diagnosis or treatment other than that for Asperger’s. If a child also seems to have a comorbid ADD or ADHD, it needs to be treated first; to ascertain what Asperger’s symptoms may be left. Otherwise, it would be like making a diagnosis of asthma in a child with pneumonia (i.e., it is impossible to see if Asperger’s is there while the person is clearly impaired with ADD or ADHD).

In addition, once a child gets a diagnosis in their educational record, it tends to have a life of its own as definitive, and neither parents, educators, nor even psychologists or psychiatrists, endeavor to change the record.

“Cognitive behavioral therapy has been tested and proven to be effective for depression; can you give it to me?”

This is another situation where the use of the word ‘tested’ comes in and is an inquiry that can be a challenge for the psychiatrist to handle when the patient has vegetative symptoms, a strong family history, and a chronic course of depression because these patients usually require antidepressant medication in addition to any therapy.

Cognitive behavioral therapy (CBT) aims at repairing negative thoughts that are thought to cause depression.[8] Clinically, it is easy to observe; however, that negative cognitions improve when depressed mood improves, be it with antidepressants or the natural cycling course out of depression.[9] This is analogous to delusions improving, when one is given an antipsychotic, so that negative thoughts are more likely the result of depression rather than the cause, just like a runny nose and a cough are the result of a cold. If negative thoughts were the cause of depression, then this would be the only Diagnostic and Statistical Manual of Mental Disorders (DSM) Axis I condition where the symptoms are also construed to be the cause.

However, it can often be seen that CBT may help persons with depression function better. Degree of depression is usually evaluated by a rating scale that assesses both neuro-vegetative symptoms as well as misery (i.e., cognitive symptoms such as despair and helplessness). Giving persons hope and support can alleviate some of the misery symptoms decreasing depression scores. Allowing some time to pass where the persons improve by themselves or cycle out of depression can also decrease scores. In either case, the person functions better and their depression scores decrease over time. Even a few points lower on a depression test can result in a call of a “statistically significant difference” compared to a supportive therapy control group, but that does not mean the illness is really treated. For example, I broke my arm by falling on the ice. I had real pain and also misery because I couldn’t do things I normally liked to do. When my orthopedist told me, “I see many fractures like this, you will be fine in a few months,” all my misery disappeared, but the fracture did not change. Patients in misery can respond well to an authority figure which gives them hope.

A more important problem with using the word ‘tested’ is that it is not easy to study psychotherapy as a modality of treatment because the studies cannot be double blinded like a drug study that has a placebo arm—an extremely crucial point. A study on bias in treatment outcome studies concluded that the results of unblinded randomized clinical trials (RCTs) tended to be biased toward beneficial effects if the RCTs’ outcomes were subjective (as they are in psychotherapy studies) contrary to being objective.[10]

Patients and even professionals assume that the words “randomized and controlled” mean that the studies looking at a therapeutic modality are fully evidence based, even if they are not double blind. They may be single blinded, i.e., the rater may not know the treatment the patient received, but the patient themselves cannot be blinded to the type of therapy, thus potentially biasing the results. Depression studies notoriously have large random errors due to the wide variety of subjects many of which have mild forms of low mood, investigator and patient preference and economic incentive, or non perfect rating instruments, etc. Bias can lead to a result very far from the true value.[11]

A recent meta analysis[12] examined how effective CBT is when placebo control and blindedness are factored in. Pooled data from published trials of CBT in schizophrenia, major depression, and bipolar disorder that used controls for non-specific effects of intervention were analyzed. This study concluded that CBT is no better than non-specific control interventions in the treatment of schizophrenia and does not reduce relapse rates, treatment effects are small in treatment studies of major depression, and it is not an effective treatment strategy for prevention of relapse in bipolar disorder.

This does not mean that CBT has no value, it only means that we need to consider CBT as an adjunctive modality to help functional impairment and suffering vs. an illness course-changing intervention. It is imperative that our field does not allow studies that are unblinded to be called “evidence based tests.” They need to be in a different category, i.e., “uncontrolled clinical data”, or “clinical impressions” (of CBT practitioners and/or their patients).

CONCLUSION

To the lay-person, the word “test” implies some absolute truth. The value of a test or a diagnosis given by an authority is very hard to evaluate by the average lay-person, and when it comes to testing of a therapeutic intervention, even most mental health professionals do not understand why it is crucial to control bias by double-blinding in a clinical trial of an intervention, whether psychotherapy or drug. The words “controlled” or “randomized” seem to carry more weight than they are worth if there is no placebo or double blind to back them up. We must also not avoid a critical discussion of the economic incentive to do a test or to “prove” the evidence base of a certain therapy.

{Ed.: Dr. Berger is in private practice in Japan and consultant on pharmaceutical clinical trials. Web page is at: www. japanpsychiatrist. com. This article is intended as a personal opinion piece and not a scientific analysis.}

REFERENCES

1. Bleicher A. Perils of newborn screening: Doctors may be testing infants for too many diseases. Sci Am 2012;307:16-7.

2. Pastores GM. Krabbe disease: An overview. Int J Clin Pharmacol Ther 2009;47(Suppl 1):S75-81.

3. Rivera CL, Bernal G, Rossello J. The Children’s Depression Inventory (CDI) and The Beck Depression Inventory (BDI): Their validity as screening measures for major depression in a group of Puerto Rican adolescents. Int J Clin Health Psychol 2005;5:485-98.

4. Available from: http://www.nimh.nih.gov/health/publications/men-anddepression/diagnostic-evaluation-and-treatment.shtml. [Last Accessed on 2013 Mar 30].

5. F84. Pervasive developmental disorder. International Statistical &ODVVL¿FDWLRQRI’LVHDVHVDQG5HODWHG+HDOWK3UREOHPVth (ICD-10) ed. World Health Organization (2006).

6. Fombonne E. Epidemiological surveys of pervasive developmental disorders. In: Volkmar FR, editor. Autism and Pervasive Developmental Disorders. 2nd ed. Cambridge: Cambridge University Press; 2007. p. 33-68.

7. Centers for Disease Control and Prevention. Summary Health Statistics for U.S. Children. National Health Interview Survey, 2002. March 2004, Series 10, No. 221.

8. Burns, David. Feeling Good, The New Mood Therapy. Avon Books; 1980.

9. Fava M, Davidson K, Alpert JE, Nierenberg AA, Worthington J, O’Sullivan R, et al. Hostility changes following antidepressant treatment: Relationship to stress and negative thinking. J Psychiatr Res 1996;30:459-67.

10. Wood L, Egger M, Gluud LL, Schulz KF, Jüni P, Altman DG, et al. Empirical evidence of bias in treatment effect estimates in controlled trials with different interventions and outcomes: Meta-epidemiological study. BMJ 2008;336:601-5.

11. Steven Piantadosi. Clinical Trials: A Methodologic Perspective. 2nd ed. Hoboken: Wiley-Interscience; 2005.

12. Lynch D, Laws KR, McKenna PJ. Cognitive behavioural therapy for major psychiatric disorder: Does it really work? A meta-analytical review of well-controlled trials. Psychological Medicine 2010;40:9-24.